Epilepsy and Seizures

1. Epilepsy and Seizures Nicholas G. Avgeropoulos, M.D. January 2009

2. Epilepsy - Scientific Background • When the brain functions normally, millions of fluctuating, simultaneous, tiny electrical charges go from the nerve cells to all parts of the body. • People who have seizures / epilepsy have these normal electrical “patterns” interrupted by sudden and relatively intense bursts of electrical energy that may affect consciousness, body movements, and sensation.

3. Signals are electrochemical • Neurotransmitters can be excitatory or inhibitory

4. Epilepsy -Scientific Background • Nerve cells normally transmit electrochemical signals and maintain a balance of excitatory and inhibitory neurotransmitters as well as sodium, potassium, and other factors critical to energy stability. • When this balance is changed, a seizure may result.

5. POLL QUESTION 1 • Do you know the difference between seizures and epilepsy?

6. Epilepsy vs. Seizures • A seizure is defined by release of excessive and uncontrolled electrical activity in the brain. Seizures themselves are not a disease, they are an event. • Epilepsy (seizure disorder) is a neurological condition, that in different times produce brief disturbances in the electrical functions of the brain. Seizures are a symptom of epilepsy.

7. Seizures • Seizures can cause different symptoms based on the location of the source of and where the abnormal electrical activity spreads. • Seizures can range from tingling in a finger to grand mal (generalized) seizures, during which people lose consciousness, become stiff, and jerk. • Not everything that looks like a seizure is a seizure. And not every seizure is an epileptic seizure. Fainting, collapsing, and confusion can also result from other disorders or even from emotional stress. Withdrawal from alcohol or addicting drugs can also cause seizures.

8. EEG Montage

9. EEG Depicting Seizure

10. Poll Question 2 • T or F: Epilepsy is a relatively uncommon event

11. Facts About Epilepsy • There are over 2.5 million people diagnosed with epilepsy in the United States. • Epilepsy affects more people than other serious conditions such as cerebral palsy, cancer, tuberculosis, muscular dystrophy, and multiple sclerosis combined. • The leading cause of epilepsy in adults is automobile accidents

12. Facts About Epilepsy • All other things even, people who have epilepsy have the same abilities and intelligence as everyone else • The leading cause in children is birth trauma • The leading cause for the elderly (people over 65) is strokes

13. Causes of Seizures by Age(Brain Tumor trends indicated in BLUE)

14. Epilepsy and Brain Tumors • Any type of brain tumor can cause seizures • Slowly or quickly growing primary tumors • Multiple metastases • Tumors near the Rolandic fissure, temporal lobes / insular cortex more seizure prone. Tumors in the cerebellum and brainstem are not. • Seizures are the second most common presenting symptom reported in brain tumor patients, with 33% of patients reporting a seizure before the dx was made.

15. Classification of Seizures • Seizures are classified into partial and generalized • Partial seizures are divided into • Simple partial - Consciousness is not impaired • Complex partial - Consciousness is impaired • About 2/3 of people with epilepsy have complex partial seizures

16. Different Types of Seizures • Generalized seizures - Can be convulsive or non-convulsive • Absence seizures - Typical vs. Atypical • Typical absence seizures - Non-convulsive with muscle tone preserved. The seizure usually lasts less than 10 seconds. • Atypical absence seizures - Convulsive, longer in duration, loss in muscle tone, and tonic/clonic movements are observed.

17. Different Types of Seizures • Tonic-clonic seizures (grand mal) - Generalized convulsion occurring in the tonic phase and the clonic phase. Often this is preceded by an aura. • Tonic phase - Muscles stiffen up, person loses consciousness, body grows rigid. • Clonic phase- Body extremities jerk and twitch. • Secondary generalized tonic-clonic seizures begins locally with partial seizures

18. Tonic and Clonic(Most often, these alternate)

19. Different Types of Seizures • Photosensitive seizures - These are very rare, even for people with epilepsy (<5%). A light related stimulus may trigger this seizure, hence the warning labels on electronic devices, theme park rides, and even video games. • Atonic seizures - Sudden lack of muscle tone, causing the inability to sit and stand. They are also called akinetic seizures. These are very rare in adults.

20. Poll Question 3 • True or False: Status epilepticus can be a life threatening event

21. Status Epilepticus • Status Epilepticus - A state of recurring seizures when consciousness does not return between seizure events. • Can be very serious and at times fatal. This is a seizure that lasts for about 20 minutes, and can cause serious brain damage, if not aborted. • Benzodiazepines like diazepam or lorazepam may be given to patients in the hospital for treatment.

23. Treatments • Keppra - Binds to the surface of the vesicles which contains neurotransmitters, and may inhibit some of the release of neurotransmitters to the neuron. May also stop hypersynchronized electrical releases. • Dilantin - Is mainly used for treatment of tonic-clonic seizures and complex partial seizures. It works in part by reducing electrical conductance between brain cells and by stabilizing the inactive state of voltage gated sodium channels. Sodium channels are co-transporters, which offer facilitation of neurotransmitter movement.

24. Treatments • Valproic acid - Include drugs such as Depakote, Depakene, and Valrelease. Valproate affects the sodium channels in the brain, helping prevent the release of abnormal brain signals. Valproic acid increases gamma-aminobutyric acid (GABA), which is a natural brain chemical that stops or slows down other brain signals. Valproate is usually prescribed for complex partial or complex absence seizures but has many other utilities.

25. Treatments • Lamictal - Many of these medicines are similar in how they work, and Lamictal works by blocking sodium channels. However, lamotrigine also lessens the flow of glutamate (an excitatory neurotransmitter). • Topamax - Works very similar to valproic acid with respect to GABA stimulation. Mainly prescribed for tonic-clonic and partial seizures. • Tegretol - The generic name is Carbamazepine. Helps block sodium channels like the others. Has many uses.

26. Common Side Effects • Nausea, drowsiness, confusion, dizziness, skin rash / severe allergy, weight gain, liver damage, altered white blood cell and platelet counts and function amongst many others. • Consult with a doctor to make sure other drugs do not interact negatively as different medicines work for different people. Make sure there is no allergic reaction history to a related compound.

27. Poll Question 4 • True or False: Once a person has had a seizure, they can never drive again

28. How do Seizures/Epilepsy Affect You? • Seizures may restrict driving, working, and social opportunities and also affect self-esteem. But remember, you can influence how epilepsy will affect you. • Most people’s epileptic seizures can be controlled. Some people end their seizures with the first medication they try. Others will need to partner with their Neuro-Oncologist or epileptologist to find the right dosage and combination of medications, especially as brain tumors can change geometry and location.

29. Take Control of Managing Seizures • Understand your epilepsy, including your seizure type • Make sure to talk to your Neuro-Oncologist or epileptologist about all available treatment options • Fill out a medical history and seizure calendar, so you can become involved in your medical care • Learn how to communicate well with your neurologist and his or her staff

30. Take Control of Managing Seizures • Bring your epilepsy medications or a detailed printed list to each Neuro-Oncology visit Take your medication regularly. • Linking this to a routine may be helpful (when you brush your teeth, prepare for bed, etc.). • There are also devices that can help like a watch that beeps when your dose is due or special blister packaging that is pre-dosed Get enough sleep- lack of it can bring on epileptic seizures

31. Download • Questionnaire and informational handout regarding seizure control.

32. Common Myths • Epilepsy is contagious • People may swallow their tongue during a seizure • Putting things in people’s mouths (like wallets or a stick) while seizing is a good idea • Ambulance should be called immediately • If the seizure lasts longer than 5 minutes, it is their first seizure, they request an ambulance, or have multiple seizures in a row

33. Summary • In most instances, there is a zero-tolerance policy for seizure control but there are exceptions • Most commonly, we have to strike a balance between seizure control and toxicity of medications • Seizures are often a frightening experience which in turn can make them tricky to discern from emotional repercussions such as panic, abnormal movements such as from spasticity, etc. As usual, knowledge gives us power to gain control over even the toughest situations

34. Work Cited • http://www.epilepsyfoundation.org/about/faq/index.cfm • http://www.umm.edu/ency/article/003200.htm • http://www.epilepsy.com/101/ep101_epilepsy • http://healthlink.mcw.edu/article/921725959.html • http://professionals.epilepsy.com/page/seizures_classified.html

35. Work Cited • http://www.epilepsy.ca/eng/content/types.html#anchor126332 • http://www.keppra.com/pc/about_keppra/how_keppra_works.asp • http://www.vhi.ie/hfiles/hf-066.jsp • http://ca.geocities.com/epilepsy911/epilepsyfacts.html

36. Work Cited • http://epilepsy.emedtv.com/valproic-acid/valproic-acid.html • http://www.tiscali.co.uk/lifestyle/healthfitness/health_advice/netdoctor/archive/100001450.html • http://www.netdoctor.co.uk/medicines/100002607.html • http://www.bellaireneurology.com/seizure/epil_trt_tegretol.html