Epilepsy

Epilepsy: Excerpt from Professional Guide to Diseases (Eighth Edition)

Epilepsy, also called seizure disorder, is a condition of the brain marked by a susceptibility to recurrent seizures — paroxysmal events associated with abnormal electrical discharges of neurons in the brain.

Causes and incidence

In about half the cases of epilepsy, the cause is unknown. However, some possible causes of epilepsy include:

❑birth trauma (inadequate oxygen supply to the brain, blood incompatibility, or hemorrhage)

❑perinatal infection

❑anoxia (after respiratory or cardiac arrest)

❑infectious diseases (meningitis, encephalitis, or brain abscess)

❑ingestion of toxins (mercury, lead, or carbon monoxide)

❑tumors of the brain

❑inherited disorders or degenerative disease, such as phenylketonuria or tuberous sclerosis

❑head injury or trauma

❑metabolic disorders, such as hypoglycemia or hypoparathyroidism

❑stroke (hemorrhage, thrombosis, or embolism).

Alcohol withdrawal can cause nonep-ileptic seizures.

Epilepsy affects 1% to 2% of the population. However, 80% of patients have good seizure control if they strictly adhere to the prescribed treatment regimen.

Signs and symptoms

The hallmarks of epilepsy are recurring seizures, which can be classified as partial or generalized (some patients may be affected by more than one type).

Partial seizures arise from a localized area of the brain, causing specific symptoms. In some patients, partial seizure activity may spread to the entire brain, causing a generalized seizure. Partial seizures include simple partial (jacksonian) and complex partial seizures (psychomotor or temporal lobe).

A simple partial motor-type seizure begins as a localized motor seizure characterized by a spread of abnormal activity to adjacent areas of the brain. It typically produces stiffening or jerking in one extremity, accompanied by a tingling sensation in the same area. For example, it may start in the thumb and spread to the entire hand and arm. The patient seldom loses consciousness, although the seizure may progress to a generalized seizure.

A simple partial sensory-type seizure involves perceptual distortion, which can include hallucinations.

The symptoms of a complex partial seizure vary but usually include purposeless behavior. The patient experiences an aura immediately before the seizure. An aura represents the beginning of abnormal electrical discharges within a focal area of the brain and may include a pungent smell, GI distress (nausea or indigestion), a rising or sinking feeling in the stomach, a dreamy feeling, an unusual taste, or a visual disturbance. Overt signs of a complex partial seizure include a glassy stare, picking at one’s clothes, aimless wandering, lip-smacking or chewing motions, and unintelligible speech; these signs may last for just a few seconds or as long as 20 minutes. Mental confusion may last several minutes after the seizure; as a result, an observer may mistakenly suspect intoxication with alcohol or drugs or psychosis.

Generalized seizures, as the term suggests, cause a generalized electrical abnormality within the brain and include several distinct types:

❑Absence (petit mal) seizures occur most commonly in children, although they may affect adults as well. They usually begin with a brief change in level of consciousness, indicated by blinking or rolling of the eyes, a blank stare, and slight mouth movements. There’s little or no tonic-clonic movement. The patient retains his posture and continues preseizure activity without difficulty. Typically, each seizure lasts from 1 to 10 seconds. If not properly treated, seizures can recur as often as 100 times per day. An absence seizure may progress to generalized tonic-clonic seizures.

❑A myoclonic (bilateral massive epileptic myoclonus) seizure is characterized by brief, involuntary muscular jerks of the body or extremities, which may occur in a rhythmic fashion and may precede generalized tonic-clonic seizures by months or years.

❑A generalized tonic-clonic (grand mal) seizure typically begins with a loud cry, precipitated by air rushing from the lungs through the vocal cords. The patient then falls to the ground, losing consciousness. The body stiffens (tonic phase) and then alternates between episodes of muscular spasm and relaxation (clonic phase). Tongue-biting, incontinence, labored breathing, apnea, and subsequent cyanosis may also occur. The seizure stops in 2 to 5 minutes, when abnormal electrical conduction of the neurons is completed. The patient then regains consciousness but is somewhat confused and may have difficulty talking. If he can talk, he may complain of drowsiness, fatigue, headache, muscle soreness, and arm or leg weakness. He may fall into deep sleep after the seizure. These seizures may start as facial seizures and spread to become generalized.

An akinetic seizure is characterized by a general loss of postural tone (the patient falls in a flaccid state) and a temporary loss of consciousness. It occurs in young children and is sometimes called a “drop attack” because it causes the child to fall.

Status epilepticus is a continuous seizure state that can occur in all seizure types. The most life-threatening example is generalized tonic-clonic status epilepticus, a continuous generalized tonic-clonic seizure without intervening return of consciousness. Status epilepticus is accompanied by respiratory distress. It can result from abrupt withdrawal of anticonvulsant medications, hypoxic encephalopathy, acute head trauma, metabolic encephalopathy, or septicemia secondary to encephalitis or meningitis.

Diagnosis

Clinically, the diagnosis of epilepsy is based on the occurrence of one or more seizures and proof or the assumption that the condition that led to them is still present.

Diagnostic information is obtained from the patient’s history and description of seizure activity and from family history, physical and neurologic examinations, and computed tomography scan or magnetic resonance imaging. These scans offer density readings of the brain and may indicate abnormalities in internal structures. Paroxysmal abnormalities on the EEG confirm the diagnosis by providing evidence of the continuing tendency to have seizures. A negative EEG doesn’t rule out epilepsy because the paroxysmal abnormalities occur intermittently. Other tests may include serum glucose and calcium studies, skull X-rays, lumbar puncture, brain scan, and cerebral angiography.

Treatment

Generally, treatment of epilepsy consists of anticonvulsant therapy to reduce the number of future seizures. The most commonly prescribed drugs include phenytoin, carbamazepine, phenobarbital, gabapentin, or primidone administered individually for generalized tonic-clonic seizures and complex partial seizures. Valproic acid, clonazepam, and ethosuximide are commonly prescribed for absence seizures. Gabapentin and felbamate are also anticonvulsant drugs.

A patient taking anticonvulsant medications requires monitoring for toxic signs: nystagmus, ataxia, lethargy, dizziness, drowsiness, slurred speech, irritability, nausea, and vomiting.

If drug therapy fails, treatment may include surgical removal of a demonstrated focal lesion to attempt to stop seizures. Emergency treatment of status epilepticus usually consists of diazepam (or lorazepam), phenytoin, or phenobarbital; dextrose 50% I.V. (when seizures are secondary to hypoglycemia); and thiamine I.V. (in chronic alcoholism or withdrawal).

Special considerations

A key to support is a true understanding of the nature of epilepsy and of the misconceptions that surround it.

❑Encourage the patient and his family to express their feelings about the patient’s condition. Answer their questions, and help them cope by dispelling some of the myths about epilepsy, for example, the myth that epilepsy is contagious. Assure them that epilepsy is controllable for most patients who follow a prescribed regimen of medication and that most patients maintain a normal lifestyle.

Because drug therapy is the treatment of choice for most people with epilepsy, information about medications is invaluable.

❑Stress the need for compliance with the prescribed drug schedule. Reinforce dosage instructions and stress the importance of taking medication regularly, at scheduled times. Caution the patient to monitor the quantity of medication he has so he doesn’t run out of it.

❑Warn against possible adverse effects — drowsiness, lethargy, hyperactivity, confusion, and visual and sleep disturbances — all of which indicate the need for dosage adjustment. Phenytoin therapy may lead to hyperplasia of the gums, which may be relieved by conscientious oral hygiene. Instruct the patient to report adverse effects immediately.

❑When administering phenytoin I.V., use a large vein and monitor vital signs frequently. Avoid I.M. administration and mixing with dextrose solutions.

❑Emphasize the importance of having anticonvulsant blood levels checked at regular intervals, even if the seizures are under control.

❑Warn the patient against drinking alcoholic beverages.

❑Know which social agencies in your community can help epileptic patients. Refer the patient to the Epilepsy Foundation of America for general information and to the state motor vehicle department for information about a driver’s license.

The primary goals of the health care professional and family members caring for a patient having a seizure are protection from injury, protection from aspiration, and observation of the seizure activity. Generalized tonic-clonic seizures may necessitate first aid. Show the patient’s family members how to administer first aid correctly:

❑Avoid restraining the patient during a seizure. Help the patient to a lying position, loosen any tight clothing, and place something flat and soft, such as a pillow, jacket, or hand, under his head. Clear the area of hard objects. Don’t force anything into the patient’s mouth if his teeth are clenched — a tongue blade or spoon could lacerate a mouth and lips or displace teeth, precipitating respiratory distress. However, if the patient’s mouth is open, protect his tongue by placing a soft object (such as a folded cloth) between his teeth. Turn his head to provide an open airway. After the seizure subsides, reassure the patient that he’s all right, orient him to time and place, and inform him that he’s had a seizure.

❑Don’t restrain the patient during a complex partial seizure. Clear the area of any hard objects. Protect him from injury by gently calling his name and directing him away from the source of danger. After the seizure passes, reassure him and tell him that he has just had a seizure.

Book Source Details

• Book Title: Professional Guide to Diseases (Eighth Edition)
• Author(s): Springhouse
• Year of Publication: 2005
• Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Professional Guide to Diseases (Eighth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2005 ISBN: 1-58255-370-X

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