Professional Corner

Siezures or epilepsy

Debra L. Balke, M.D.

The following was a parent education seminar presented in San Luis Obispo county to address questions about seizures, epilepsy, medications and the latest research. It is printed here with permission from the presenter, Debra L. Balke, M.D.

What is the difference between a "seizure" and "epilepsy or epileptic syndrome"?

EPILEPTIC SEIZURES are classified as "partial (focal)" or "generalized"

Partial (focal) seizures (abnormal electrical activity occurs in one part of the brain only)

Simple partial seizures (the child is awake during the seizure)

Common examples include one arm twitching ("clonic movements") or one leg becoming stiff ("tonic stiffening").

Complex partial seizures (the child is not fully aware during the seizure)

There may be a warning ("aura") before it happens, then confusion with some repetitive automatic behaviors like chewing, blinking, picking ("automatisms".) Sometimes a simple partial seizure turns into a complex partial seizure as more of the brain tissue becomes involved with abnormal electrical activity. There is confusion for about 20 minutes or more after the seizure itself stops ("the patient -was post ictal 20 minutes.") Sometimes the electrical activity can spread to involve the whole brain and a generalized seizure can then occur ("the child has complex partial seizures that secondarily generalize about 30% of the time.")

Generalized seizures (abnormal electrical activity involves the whole brain)

Absence seizures (used to be called "petit mat seizures") These usually occur in otherwise entirely normal children. Brief, sudden onset staring spells, hundreds of times a day, lasting about a minute or less, with no confused period afterwards.

Atypical absence seizures These are sort of like absence seizures but can be slow to come on and to stop, and can have a confused period afterwards. They can have clonic (twitching) and/or tonic (stiffening) of the body during the seizure sometimes.

Myoclonic seizures Quick jerking movements, usually when the child is awake. This is a more rare type of seizure and can occur in a wide variety of circumstances.

Clonic seizures Whole body twitching

Tonic seizures Whole body stiffening. Usually seen in children with delayed development.

Tonic-clonic seizures (grand mal) Stiff for seconds then turns into twitching movement

Atonic seizures (drop attack) Child instantaneously drops to the ground. Usually the child has many other types of seizures as well and has delayed development.

EPILEPTIC SYNDROMES are classified as either "primary" or "secondary:'

The word "primary" or "primary generalized epilepsy" is used to mean that usually there is no known problem with the brain chemistry or brain structure. Obviously, there is a problem somewhere, but the only test that is abnormal is the EEG which shows a specific pattern. Many of the primary epilepsies run in families ("its genetic"') and the children tend to do well overall.

The term "secondary" or "secondary generalized epilepsy" is used when it is suspected that there is a problem with either the brain structure or brain chemistry. Often, we suspect this brain problem after seeing a certain type of EEG abnormality, MRI/CT abnormality, or just based on delayed or abnormal development of the child. "This child has many different types of seizures, developmental delay and an EEG that is consistent with a secondary generalized epilepsy."

NOTE: Do not confuse the term "secondary generalized epilepsy" which refers to an epileptic syndrome with the phrase "complex partial seizure that secondarily generalizes" which refers to a seizure that spreads to involve the whole brain. Secondary vs. Secondarily. Yes. terrible terminology, but I didn't invent it!......

With generalized seizures With partial seizures

Primary epilepsies Absence epilepsy Rolandic epilepsy (benign epilepsy with centrotemporal spikes)

Many generalized tonic- Childhood epilepsy with occipital clonic seizures spikes

Juvenile myoclonic epilepsy

Benign neonatal seizures

Secondary epilepsies Infantile spasms Temporal lobe epilepsy Lennox-Gastaut syndrome (also called psychomotor) Epilepsies due to brain malformations Epilepsies due to brain injuries such as after lack of oxygen to the brain Conditions with Reactive Seizures Febrile seizures Partial seizures occur when (abnormal reaction Most toxic and reactive seizures are superimposed of an otherwise normal metabolic induced on transient or preexisting non -brain to physiologic seizures epileptogenic brain injury, such as stress or transient Many isolated tonic- seen with head trauma, metabolic epileptogenic insult) clonic seizures abnormalities

Early posttraumatic seizures

Among people with Mental Retardation end Epilepsy, 25-30% have specific syndromes:

	Short Stature Tall Stature
	Frequent EpilepsyAngelman S Homocystinuria
	Chromosome 4p- S Sturge-Weber S
	de Sanctis-Cacchione
	di George S
	Fetal Varicella S
	FG S
	Generalized. Gangliosidosis, 1
	Lissencephaly S
	Menkes kinky hair S
	Pailister mosaic S (Tetrasomy 12p)
	Pseudo-Vitamin D deficiency S
	Schinzel-Giedion S
	Trisomy 4p S
	Trisomy 13 S
	Trisomy 21 S
	Zeilweger S
	Occasional Epilepsy Ataxia telangiectasia Klippel Trenaunay Weber S
	Cohen S Fragile X S
	de lange S Neurofibromatosis
	Geleophysic dysplasia Proteus S
	Hyperthermia-induced spectrum Ruvalcaba-Myhre S
	Hypophosphatasia Sotos S
	Langer-Giedion S
	Lowe S
	Maternal PKU effect
	Monozygotic twinning
	Prader-Willi S
	Robinow S
	Rubinstein-Taybi S
	Ruvalcaba S
	Sjogren-Larsson S
	Smith-Lemli-Opitz S

SEIZURE MEDICATIONS ("antiepileptic drugs" "anticonvulsants")

1. Ask the pharmacist for a handout on the medication. Every drug has scary side effects listed. Remember, in most cases, the risk of injury from the seizure problem is greater than the risk of the medication.

2. Potentially serious side effects:

	"aplastic anemia" which can manifest with fever, weight loss, pale looking skin, fatigue, easy bruising or bleeding. Very rare. Can look like the flu initially. The "CBC with differential, platelets" blood test screens for this and other related blood problems.
	' 'liver (hepatic) failure" which can start as yellow skin, vomiting, easy bruising or bleeding, fatigue. Very rare. Can start like the flu initially. The "chem panel or SCOT, SGPT blood test screens for this."
	"pancreatitis" which can start as the most severe abdominal pain. Very rare.
	"rash" a common side effect, but needs to be taken seriously.

3. Sometimes it is not possible to get rid of ALL of the seizures but to get rid of as many seizures as possible while still keeping the child functioning and alert as much as possible.

4. If the medication requires that "blood levels" be checked, do so first thing in the morning BEFORE the morning medicine is taken. This allows a measurement of the "trough" level, which is the lowest amount in the blood in a 24 hour period.

5. Don't suddenly stop seizure medications and don't run out. This can cause severe seizures in many cases. If you don't like the medication effects, call your doctor and inform him or her that you think it should be stopped and your doctor can give you a schedule of how to taper it off. Sometimes the side effects are only in the first few weeks and then wear off. Try not to forget doses.

6. Ketogenic diet. Best reserved for children who have not done well on several medications. Has potentially very serious side effects.

7. Surgeries are done to treat epilepsy. If one spot on the brain can be identified by looking at the EEG and the MRI scan as probably being the site/cause of the seizures, it is possible in some cases to remove that area to control seizures. This is often a last resort.

NEUROLOGIC STUDIES

	EEG (Electroencephalogram): Tests the electrical activity of the brain.
	With primary generalized epilepsies, the EEG is abnormal in as high as 95% of patients and shows a specific obvious pattern.
	With secondary generalized epilepsies, the EEG is abnormal in some cases, in others it may be entirely normal even though the patient is having many seizures.
	In children with developmental delay and multiple types of seizures, the EEG is abnormal nearly all of the time.
	In children with complex partial seizures, one EEG will show an abnormality only 30% of the time.
	MRI SCAN: This test requires the child to lie absolutely still for 30 to 45 minutes. No radiation is involved. This gives an excellent picture of the brain structure, which looks on paper as if you took out the brain and sliced it into Vi inch thick slices from top to bottom. This test is hard to get, cannot be done on an emergency basis. This is the best test to see the brain tissue to look for areas that are not formed correctly or tumors.
	CT SCAN: This test requires the child to lie still for a much briefer period of time. This test can be done on an emergency basis and gives an "OK" picture of the brain cut into slices. This is the best test to see sudden bleeding in the brain or hard calcium deposits. This test uses radiation.

SEIZURE BASICS

During a seizure:

1. Turn the child on his side so that if he vomits he won't choke.

2. Do not put anything into the mouth. He will not "swallow his tongue."

3. Call 911 unless your doctor has instructed you otherwise. In children with severe epilepsy, often their physician will give them rectal Valium or Ativan to administer at home first.

4. Pay attention during the seizure. Notice if the eyes are rolled up or to the right or left. Notice if the whole body is shaking the same or if just one limb is jerking or if just one limb is stiff. It can be tremendously helpful to know these details, especially if the observer can recall if it was really the right side or the left side. After the seizure ends, see if one side of the body is weak.

What should the emergency room or paramedics do?

If still seizing, oxygen is placed on the face and doses of Valium or Ativan are given IV or rectally. After two doses given about 5 minutes apart, IV Dilantin (phenytoin or fosphenytoin) or IV phenobarbitol or both are given. Sometimes the medicines make the child so sleepy that he forgets to breathe. In this case, a breathing tube is inserted while the doctors wait for the medicines to wear off a little.

Other things you should know:

1. What makes seizures worse: Anything! The big culprits are fever, colds, flus, sleep deprivation, street drugs, excitement such as a birthday party or going on a ftm trip, forgetting medication, suddenly stopping medication. So many things can make seizures worse that it is often NOT in your childs best interest to eliminate many of the items, such as fun events that the child enjoys and finds exciting.

2. Seizure log: Keep track on your calendar of what day the seizures occur, what time of day. Use this log to help yourself decide if the medicines are helping. Ask the doctor to explain how the medicines work, when they take effect and how long they last. For example, will switching from 3 pills twice a day to 2 pills in the morning and 4 pills at night help nighttime seizures? Don't make medication changes on your own, but use your log to make suggestions to your physician about medication changes which you think might be beneficial.

Prognosis

Extremely individual. In general, the primary generalized epilepsy syndromes tend to do well and "febrile seizures" tend to have an excellent outcome. The secondary generalized epilepsy syndromes can be more difficult to treat, but with newer medications, the ketogenic diet, and epilepsy surgeries, we have many treatment options which can improve seizure frequency and have less effect on behavior and level of alertness than some of the older medications

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