Definition of Epilepsy.
• Brief recurrent disorder of cerebral function that is usually associated with disturbance of consciousness and accompanied by a sudden, excessive electrical discharge of cerebral neurones. EEG is of high voltage relative to the background.
• Clinically, epilepsy is defined as a condition characterised by recurrent (two or more) unprovoked seizures.
•Focal (Partial) seizures- the seizure activity starts focally in the cerebral cortex and may or may not spread to rest of the brain.
•Primary generalised seizures- the seizure activity appears abruptly and involves entire brain simultaneously.
• Epilepsy is due to a population of abnormal hyperexcitable neurons. Such neurons are subject to excitatory and inhibitory influences from other sources. Excitatory transmitters depolarise and inhibitory transmitters hyperpolarise the neuronal membrane. The discharge is governed by the balance between these two opposing factors.
• Acetylcholine is the excitatory transmitter.
• GABA is the inhibitory transmitter.
• Epilepsies maybe primary or secondary (symptomatic).
• In majority of cases, epilepsy is idiopathic and the cause is not known. There maybe a positive family history, onset is in childhood and has a genetic background.
• Any intracranial disease like cerebral tumours, head injury, cerebrovascular accidents and CNS infections.
• Hypoglycaemia and hyperglycaemia.
• Uraemia, heart block.
• Ingestion or withdrawal of alcohol or drugs.
Primary Generalised Seizures.
• Electrical abnormality occurs simultaneously over the entire cerebral cortex and is recognised clinically and electroencephalographically.
• There is an altered consciousness at the onset that maybe associated with an epileptic cry. Fit starts simultaneously with generalised tonic state that lasts for few seconds to minutes. Patient is unconscious and cyanosed, does not breathe (as glottis is closed and respiratory muscles are in tonic contraction) and pupils are dilated. Heart rate changes and may even stop. This is followed by clonic state where rhythmic jerks appear and lasts for one to few minutes. Tongue maybe bitten and urinary or bowel incontinence may occur. (Tonic state occurs during continuous discharge from the cortex when synchronous continuous excitatory activity starts. Clonic phase indicates appearance of inhibitory influence that breaks the continuous discharges to intermittent pattern).
• This is followed by postictal phase where patient passes off into sleepy state and may have headache and vomiting. At initial few minutes, he is not arousable and maybe totally flaccid. Plantar response is extensor and heart rate maybe slow. On gradual recovery he maybe confused and show automatic behaviour. Whole phase may last from a few minutes to 1-2 hours.
Diagnosis of Epilepsy
• Attempt should be made to find out:
• Whether an attack is really an epileptic fit or some other brief disorder of consciousness or disorder of CNS, e.g. syncope, migraine, transient ischaemic attack, psychogenic non-epileptic seizures, etc.
• Type of fit-primary generalised, focal or secondary generalised (presence of aura, change in consciousness and details of the fit by a reliable observer).
• Cause of epilepsy (primary or symptomatic) by type of fit, age of onset, family history, presence or absence of neurological deficit, systemic abnormalities and by laboratory investigations, as and when necessary.
Determining the Cause of Epilepsy
• Any person having fit with focal onset or a fit starting for the first time after the age of 25 years (late onset) should be investigated for symptomatic epilepsy. • Causes of seizures vary according to age
• Anoxia (or post-anoxic) • Hypocalcaemia • Hypoglycaemia • Hyponatraemia • Fever (febrile seizures) • Meningitis, birth trauma
• Genetically determined metabolic disorders of brain • CNS infections • Idiopathic
Late childhood and adolescence
• Idiopathic (genetically determined) • Sequelae of previous injury • Infections • Drugs and toxins including lead poisoning
• Tumours • Current or previous brain injury (traumatic or post-operative) • CNS infections, including HIV • Metabolic • Drugs and toxins (cocaine, amphetamines, theophylline, alcohol, organophosphates); alcohol or benzodiazepine withdrawal • Idiopathic
• Metabolic • Tumours • Current or previous brain injury (traumatic or post-surgical) • lschaemia to the brain • Drugs and toxins
• A first seizure provoked by an acute brain disturbance is unlikely to recur (3-10%), whereas a first unprovoked seizure has a recurrence risk of 30-50% over the next 2 years.
• A first seizure mandates individual counselling about the risk of recurrence, pros and cons of the drug treatment and the impact on lifestyle.
• Tide over the stigma by proper explanation. • Children not to cycle on public roads. • No swimming. • Adopt an occupation at which neither the patient nor society is put to risk. • Avoid exposure to moving machinery and working at heights. • Driving only as per regulations (free of attacks for 2 years). ' • Adequate sleep. • Avoid hyperpyrexia, flickering lights and emotional disturbances.
During a Fit
• Protect from injury by moving the patient away from fire, sharp and hard objects.
• Padded gag inserted within teeth.
TREATMENT AT DR. SOHAN LAL CLINIC
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