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Epilepsy

A seizure is a clinical manifestation of abnormal firing of brain cells termed neurons. We can all be susceptible to a seizure with the proper provocation such as excessive lack of sleep, head trauma, or a severe metabolic disturbance such as very low blood sugar, low blood sodium or low blood calcium. An isolated seizure does not constitute a so-called ongoing seizure disorder termed epilepsy. However, an ongoing susceptibility to having seizures that requires some form of therapy is termed epilepsy. For example, if someone suffers a severe blow to the head and has a seizure but recovers quickly with a normal exam, a normal brain scan and a normal brain wave test (EEG), then they do not necessarily require medication to prevent seizures unless further seizures follow. On the other hand, a number of individuals, perhaps up to 1% of the general population, have epilepsy which requires that they be very attentive to prescribed treatment and that they follow strict precautions in terms of level of activity until it is determined that it is safe for them to drive, per state law, as well as engage in activities such as swimming, operating heavy equipment, and climbing a ladder. Causes of seizures can include genetic (familial) susceptibility, head trauma, stroke, brain tumor, brain infection and neurodegenerative disease. At least 50% of seizure patients have so-called idiopathic epilepsy which means there is no clearly defined cause. It is, obviously, better to fall in an idiopathic class of epilepsy than to have a brain tumor. However, patients tend to be particularly perplexed when they experience a seizure “out of the blue” and then find out that they have an ongoing predisposition requiring medication or other intervention as well as restrictions on their level of activity.

There can be a number of forms of seizures with the public most aware of the person who falls out with generalized body tightness and then body jerking termed generalized tonic-clonic (grand mal) epilepsy. Other forms include the staring spells seen in children termed petit mal or absence seizures. These are often self-limited with the child outgrowing them after being on medication for a period of time. However, this is not always the case and some patients require ongoing treatment into adulthood. There can be confusional spells with alteration of the senses which has been termed partial complex seizures as opposed to partial simple seizures in which there is some altered neurological function, such as jerking on one side, but without loss of awareness of what is happening.

The evaluation of epilepsy usually requires brain imaging with an MRI brain scan, with and without contrast, being the imaging modality of choice assuming there are no contraindications to the performance of this type of scan such as a cardiac pacemaker. This allows assessment for potential causes of the seizure such as pre-existing scar tissue of the temporal lobe of the brain, termed mesial temporal sclerosis, as well as to look for evidence of stroke, trauma, a brain tumor or an infection. The electroencephalogram (EEG) can help to determine if there is an ongoing seizure tendency and there are characteristic patterns that can be seen on the EEG such as a 3 per second generalized spike and wave pattern, often promoted by hyperventilation, that is characteristic of

Epilepsy is very treatable and there is an increasing armamentarium of therapeutic choices. The older anti-seizure medications are no longer as popular as they use to be and these include phenytoin (Dilantin), carbamazepine (Tegretol) and valproic acid (Depakote). Newer agents such as levetiracetam (Keppra), oxcarbamazepine (Trileptal) and zonisamide (Zonegran) are often better tolerated than the older agents and do not necessarily require blood test monitoring to ensure that there are no serious side effects potentially affecting the blood counts, the liver or renal function. Furthermore, there are potential interactions of medications that are less of a problem with the newer agents such as an effect on birth control pill efficacy or on chemotherapy agent efficacy. In addition, one must be particularly attuned to a potential effect on the fetus if a woman of child-bearing potential were to become pregnant. This is of particular concern with an agent such as valproic acid. Certain anticonvulsant medications, such as valproic acid and pregabalin, are not uncommonly associated with weight gain which can be troublesome for a particular patient. On the other hand, agents such as topiramate and zonisamide can be associated with weight loss. All of the anticonvulsants have some concern about an adverse effect on the mood and patients need to be carefully assessed in terms of potential worsening of an underlying depression

The Epilepsy team at Tulane includes the Director of EEG at Tulane Hospital, Dr. Jeff Nicholl. Other neurologists actively involved in epilepsy care at Tulane include Drs. John FreibergPatricia Colon, Angela Traylor, Roger Kelley, and Morteza Shamsnia. Services include inpatient EEG telemetry when indicated to determine why a patient is experiencing poor seizure control or in preparation for possible epilepsy surgery which can be quite effective in removing the potential for ongoing seizures in certain patients.

 

Tulane University, New Orleans, LA 70118 504-865-5000 website@tulane.edu