Epilepsy

Question 1

What are the different types of generalised seizures?

Answer 1

• Tonic-clonic seizures
  
  • Tonic-clonic seizures produce sudden loss of consciousness, with the person commonly falling to the ground, followed by stiffening (tonic) and then rhythmic jerking (clonic) of the muscles. Shallow or ‘jerky’ breathing, bluish tinge of the skin and lips, drooling of saliva and often loss of bladder or bowel control generally occur. The seizures usually last a couple of minutes and normal breathing and consciousness then returns. The person is tired following the seizure and may be confused.
• Absence seizures
  
  • Absence seizures produce a brief cessation of activity and loss of consciousness, usually lasting 5-30 seconds. Often the momentary blank stare is accompanied by subtle eye blinking and mouthing or chewing movements. Awareness returns quickly and the person continues with the previous activity. Falling and jerking do not occur in typical absences.
• Myoclonic seizures
  
  • Myoclonic seizures are sudden and brief muscle contractions that may occur singly, repeatedly or continuously. They may involve the whole body in a massive jerk or spasm, or may only involve individual limbs or muscle groups. If they involve the arms they may cause the person to spill what they were holding. If they involve the legs or body the person may fall.
• Tonic seizures
• Tonic seizures are characterised by generalised muscle stiffening, lasting 1-10 seconds. Associated features include brief cessation of breathing, colour change and drooling. Tonic seizures often occur during sleep. When tonic seizures occur suddenly with the child awake they may fall violently to the ground and injure themselves. Fortunately, tonic seizures are rare and usually only occur in severe forms of epilepsy.
• Atonic seizures
  
  • Atonic seizures produce a sudden loss of muscle tone which, if brief, may only involve the head dropping forward (‘head nods’), but may cause sudden collapse and falling (‘drop attacks’)

Question 2

What is a focal seizure?

Answer 2

Focal seizures occur when the seizure arises in a localised part of the brain, usually on one side. Focal seizures used to be called partial seizures. Consciousness may or may not be impaired. The manifestations of a focal seizure depend on the part of the brain involved with the abnormal brain cell activity. Focal seizures used to be classified according to whether there is impairment of consciousness or not.

Question 3

What are the different kinds of focal seizures?

Answer 3

• Focal seizures without impaired consciousness
  
  • Formerly called simple partial seizures, these arise in parts of the brain not responsible for maintaining consciousness, typically the movement or sensory areas. Consciousness is NOT impaired and the effects of the seizure relate to the part of the brain involved. If the site of origin is the motor area of the brain, bodily movements may be abnormal (e.g. limp, stiff, jerking). If sensory areas of the brain are involved the person may report experiences such as tingling or numbness, changes to what they see, hear or smell, or very unusual feelings that may be hard to describe. Young children might have difficulty describing such sensations or may be frightened by these.
• Focal seizures with impaired consciousness
  
  • Formerly called complex partial seizures, these arise in parts of the brain responsible for maintaining awareness, responsiveness and memory, typically parts of the temporal and frontal lobes. Consciousness is lost and the person may appear dazed or unaware of their surroundings. Sometimes the person experiences a warning sensation or ‘aura’ before they lose awareness , essentially the simple partial phase of the seizure. Behaviour during a complex partial seizure relates to the site of origin and spread of the seizure. Often the person’s actions are clumsy and they will not respond normally to questions and commands. Behaviour may be confused and they may exhibit automatic movements and behaviours e.g. picking at clothing, picking up objects, chewing and swallowing, trying to stand or run, appearing afraid and struggling with restraint. Colour change, wetting and vomiting can occur in complex partial seizures.
  • Following the seizure the person may remain confused for a prolonged period and may not be able to speak, see, or hear if these parts of the brain were involved. The person has no memory of what occurred during the complex partial phase of the seizure and often needs to sleep.
• Focal seizures becoming bilaterally convulsive
  
  • Focal seizures may progress due to spread of epileptic activity over one or both sides of the brain. Formerly called secondarily generalised seizures, bilaterally convulsive seizures look like generalised tonic-clonic seizures.

Question 4

What is a generalised seizure?

Answer 4

Generalised seizures occur when epileptic activity begins all over the brain simultaneously. Consciousness is always impaired in generalised seizures.

Question 5

What is the treatment of generalised vs focal seizures?

Answer 5

generalised = sodium valproate

focal = carbamazepine

Question 6

What is the reason for performing tests in a child with seizures?

Answer 6

• not to diagnose epilepsy - epilepsy is a clinical diagnosis

Tests are generally performed to:

• confirm a clinical suspicion,
• determine the type of seizure or epilepsy,
• determine the underlying cause of a child’s epilepsy,
• assess the severity or monitor treatment of a child’s epilepsy,
• assess associated medical or psychological problems,
• or determine the most appropriate treatment of a child’s condition.

Question 7

Investigations for first episode of seizure?

Answer 7

• BSL
• UEC - calcium, sodium, magnesium
• EEG
• MRI
• may require lumbar puncture
• metabolic testing of urine
• genetic tests

Question 8

Information for parents on what to do in a major seizure?

Answer 8

• Convulsive seizures with major movement manifestations
  
  • eg: tonic-clonic, tonic, myoclonic, atonic, and partial motor seizure
• Stay calm
• Check for medical identification
• Protect the person from injury by removing harmful objects close to them. Loosen any tight clothing or restraints. Place something soft under their head.
• Stay with the person and reassure them. Do not put anything in their mouth and do not restrain them.
• Time the seizure
• When the seizure is over, roll the person onto their side to keep their airway clear
• Treat any injuries
• Consider if an ambulance needs to be called (see below)
• Stay with the person and reassure them, they may be sleepy, confused or combative after the seizure

Question 9

Information for parents on what to do in a minor seizure?

Answer 9

Seizures with staring, impaired consciousness or unusual behaviour e.g. complex partial seizures and absence seizures

• Stay calm
• Check for medical identification
• Protect the person from injury by removing harmful objects close to them
• Stay with the person and reassure them
• Time the seizure
• If a tonic-clonic seizure develops, follow major seizure management
• Stay with the person and reassure them, they may be sleepy, confused or combative after the seizure

Question 10

When to call an ambulance if your child is having a seizure?

Answer 10

• The seizure lasts longer than 5-10 minutes
• Another seizure quickly follows
• The person remains unconscious after the seizures ceases
• The person has been injured
• You are about to administer diazepam or midazolam
• You are unsure
• The seizure happens in water
• The person is pregnant or a diabetic
• The person is not known to have epilepsy

Question 11

“Other” treatments for epilepsy

Answer 11

• rectal diazepam or intranasal/buccal midazolam, for treatment of prolonged seizures and seizure clusters
• new antiepileptic medications, available in clinical drug trials or through special access schemes
• epilepsy surgery
• ketogenic diet
• vagus nerve stimulation
• alternative therapies