What is Seizure and Epilepsy?

                                                                                                                                                          * Dr. Suman Bhattarai

Seizure: Seizure is defined as a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain. This means that a seizure is a sudden event resulting from excessive electrical discharges in the brain, which can manifest in various ways, depending on the area of the brain involved.

Epilepsy:

Epilepsy is a disease of the brain defined by any of the following conditions

1. At least two unprovoked (or reflex) seizures occurring >24 h apart
2. One unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years
3. Diagnosis of an epilepsy syndrome

• It is typically diagnosed when a person has had two or more unprovoked seizures that are separated by more than 24 hours

How does seizures occur?

• Seizures often begin with high-frequency bursts of action potentials and hyper-synchronization of neuronal populations. This leads to sustained neuronal depolarization and a burst of action potentials
• The seizure spreads as surrounding neurons are recruited, leading to a loss of inhibitory control. This process involves mechanisms like increased extracellular potassium, enhanced neurotransmitter release, and activation of excitatory receptors

This abnormal electrical activity can be caused by various factors, including:

Mechanisms of Seizure occurrence

1. Abnormal Electrical Activity: Seizures are fundamentally caused by disruptions in the normal electrical communication between neurons in the brain. This can result from an imbalance between excitatory and inhibitory signals.
2. Medical Conditions: Conditions such as epilepsy, brain infections (e.g., meningitis, encephalitis), brain tumors, and stroke can lead to seizures
3. Neuronal Communication: Normally, neurons communicate through electrical impulses. Any disruption in this communication can lead to seizures. This disruption can be caused by various factors such as head injuries, infections, or genetic conditions
4. Seizures Initiation and Propagation: Seizures often start in a discrete region of the brain and can spread to other areas. This spread occurs when there is sufficient activation to recruit surrounding neurons, leading to a loss of surrounding inhibition
5. Paroxysmal Depolarizing Shift: At the cellular level, seizures involve sustained neuronal depolarization, leading to bursts of action potentials. This is followed by a rapid repolarization and hyperpolarization phase, known as the paroxysmal depolarizing shift

Types of Seizures

1. Focal Onset Seizures: starts from one part of limbs/body
2. Generalized Onset Seizures
3. Focal Onset with Bilateral Tonic-Colonic Seizures
4. Unknown Onset

Causes of Seizures

1. Idiopathic/Genetic
2. Infections/Inflammations: Meningitis, Encephalitis, Neurocysticercosis
3. Structural Brain Damage: Head injuries, Stroke, Brain tumors
4. Metabolic: Hyponatremia, Hypoglycemia, Hyperglycemia, Hypocalcemia
5. Substance use and withdrawals: Use of illicit drugs like cocaine, amphetamines, withdrawal from alcohol or certain medicines
6. Medical conditions: Eclampsia, Degenerative disease of brain

Risk Factors for Seizures

1. Non-compliance with medications
2. Lack of sleep, dehydration, extreme stress
3. Hormonal changes
4. Exposures to bright flashing lights
5. Fever and illness
6. Physical exertion
7. Hypoglycemia

Treatment

1. Anti-seizure medications
2. Epilepsy surgery including minimal Invasive procedures: MRI guided laser ablation and Focusses ultrasound
3. Devices and Therapies: Vagus-nerve stimulation (VNS), Responsive brain stimulation (RNS), Deep Brain stimulation (DBS), Transcranial Magnetic stimulation (TMS), Transcranial Direct Current Stimulation (tDCS)
4. Dietary: Ketogenic diet, Modified Atkins Diet and Low glycemic index diets

Facts and Myths About Epilepsy

Facts

1. 3/1000 populations affected by epilepsy in Nepal, about 50 million people worldwide, one of the most common neurological disorders
2. Seizures can present in different ways: convulsion (focal/generalized)/non-convulsions/staring
3. Treatment is available in forms of Anti-seizure medications(ASMs), Epilepsy Surgery/ Minimal invasive procedures/Devices/Dietary therapies

Myths

1. Seizures/Epilepsy is contagious
2. All seizures involve convulsions
3. People with epilepsy are intellectually disabled
4. There is no treatment for epilepsy
5. People with epilepsies cannot participate in physical activities
6. Put something in mouth (eg. Fingers, spoon)
7. Smelling shoes/socks (Jutta/moja sughaune)
8. People with epilepsy are mentally ill or emotionally unstable
9. Women with epilepsy cannot or should not get pregnant
10. People with epilepsy will pass it to their kids
11. You cannot live a full and normal life with epilepsy

Epilepsy Resolved

1. Individuals who either had an age-dependent epilepsy syndrome and are now past the applicable age
2. Individuals who have remained seizure free for the past 10 years and off seizure medicines for 5 years

Do’s and Don’ts in Epilepsy

Do’s

1. Adhere to prescribed anti-seizure medicines
2. Identify and avoid seizure triggers (e.g.. Stress, lack of sleep, alcohol, smoking, flashes of lights etc.)
3. Maintain healthy lifestyle (regular sleep schedule, healthy and balanced diets), regular physical activity, Maintain good hydration
4. Safety precautions:
5. Inform about your condition and triggers to those around you
6. Take precautions in situations where there is risk of injury during seizures-e.g. swimming, operating machinery
7. Wear protectives during seizures that could lead to injuries
8. First Aid:
9. Learn what to do during seizure and how to provide first aid:
   • Know the signs of seizures and when to seek medical attention
   • Stay calm and assist person during seizure
   • Cushion Pearson’s head during seizure
   • Do not restrain the person during seizure
   • Do not put anything in person’s mouth during seizure
   • After seizure: stay with person until fully alert and oriented and communicate with your doctor about your epilepsy

Don’t’s

1. Maintain adherence to anti-seizure medicines, do not take other medications without consulting your doctor
2. Do not ignore known seizure triggers and do not engage in activities that could trigger your seizure
3. Do not put anything in mouth during seizures
4. Do not restrain person during seizure
5. Do not leave person alone during seizure

Role of Government

1. Traditional healers can play an important role in the management of epilepsy. Training them to provide basic epilepsy care, correcting harmful practices, and developing productive collaborative working relationships that encourage the referral of people with active epilepsy may be useful for people living in remote areas that are difficult to reach with conventional health care
2. Stigma/Myths associated with epilepsy is very common. National epilepsy awareness campaign for the general public can help
3. Nurses, community health workers, and community leaders, such as teachers and priests, can help identify people with epilepsy and reach them through community-based epilepsy education programs.
4. Policies to improve care should be tailored to the situation in each country based on epidemiological data, local resources, local beliefs, behaviors, and cultural practices
5. Well-designed epidemiological studies to identify health priorities and other education and service needs
6. Laws to promote equal access to health- care services and community integration
7. Organize comprehensive epilepsy care throughout a country (educational, economic, and research aspects)
8. Develop local epilepsy care at a primary care level (closely integrated with specialist epilepsy departments- identify epilepsy patients and guarantee access to AEDs and other basic needs)
9. Specialist training in epileptology in specialized centers
10. By training primary care physicians and health workers to diagnose and treat patients with epilepsy
11. Feasible to reach as many patients as possible and sustain the process in time
12. Local communities should also be involved in the planning and implementation of this process
13. Well-organized referral network
14. Enable local healthcare workers to consult patients with more complex diseases and
15. May ensure routine availability of inexpensive Anti-epileptic Drug

*Consultant Neurologist

National Neuro Center

Maharajgunj, Kathmandu