Dr. Yotin  Chinvarun. M.D. Ph.D. FAES

1) Disease overview

A seizure is a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements or feelings, and in levels of consciousness. If you have two or more seizures or a tendency to have recurrent seizures, you have epilepsy. There are many types of seizures, which range in severity. Epilepsy is a non-communicable disease that can be affected in every gender and age group. It is found approximately 1-1.4 % of the Thai population, a higher peak is found in children and in the elderly. If treatment starts early and is done correctly, epilepsy can be well-managed and treated in most patients. Approximately 70% of the cases became seizure free with proper medication. There are two major types of seizures are now called focal onset seizures and generalized onset seizures.

The causes of seizure

• Brain injury that occurs during child-birth 
• Central nervous infection (CNS) infection
• Complex febrile convulsions
• Developing brain disorder, genetic cause
• Brain tumor
• Stroke
• Abnormal blood vessel in the brain
• Systemic disease i.e. liver disease, kidney disease, blood sugar or electrolyte disturbance etc.
• Alcohol or drug abuse
• Degenerative brain disease, dementia

2) Signs and Symptoms

1. Focal onset aware seizure is a type of seizure in which the abnormal electric currents might affect the focal or regional part of the brain that controls certain body functions. It will exhibit certain symptoms while the patient is still aware, these seizures may alter emotions or change the way things look, smell, feel, taste or sound, but you don’t lose consciousness. These seizures may also result in the involuntary jerking of a body part, such as an arm or leg, and spontaneous sensory symptoms such as tingling, dizziness and flashing lights.

 2. Focal onset impaired awareness seizures These seizures involve a change or loss of consciousness or awareness. However, some patients might be having an aura or warning symptoms before impaired awareness. The patient is looked blank starring and not respond normally to your environment or perform repetitive movements, such as hand rubbing, chewing, swallowing or walking in circles. Patients will not be able to recall what happened during the event. Postictally, the patients could be experience confusion or may not be able to speak properly for a few minutes before gaining full consciousness.

3. Generalized seizure, it can start as focal onset seizures and then spreading to both sides of the brain (secondary generalized seizure) or they also can occur as “generalized onset (formally primary generalized seizure)” seizures in which seizure activity starts simultaneously over both sides of the brain. Generalized onset seizures usually start during childhood and are similar to a thermostat surge or a light flash abnormal regulation between parts of the brain causes the seizures. The most common seizure is the generalized seizure with motor involvement i.e. generalized tonic-clonic seizure (formally called grand mal), in which the patient had generalized tonic-clonic of both limbs, usually has grunting teeth, frothing sputum, eyes rolled up and the seizure usually lasted about 1-2 minutes. The patient will be extremely fatigued and will fall asleep after the seizure. Other generalized seizures are absence seizure, myoclonic seizure and atonic seizure. 

Absence seizure commonly found in young children, in which the patient has a brief period of blank staring usually with commonly rapid eye blinking without motor involvement of the limbs lasting for a few seconds. 

Myoclonic seizure, the patient presents with episodes of sudden jerking of both limbs with aware or impaired awareness and might be followed by secondary generalized tonic-clonic seizure. 

Atonic seizure or drop attack is another type of generalized seizure made the patient suddenly loss of tone of the muscles causing suddenly fall, and commonly with head trauma.  

3) Investigation and Diagnosis

The diagnosis was made from clinical history, seizure characteristics and further investigations such as proper neuroimaging technique and electroencephalogram (EEG) to confirm the diagnosis. 

Electroencephalogram (EEG): Two types of EEG

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1. Routine EEG; a half hour EEG study, usually done at the outpatient service, but it can be done up to 1-2 hours
2. The 24-hours video-EEG monitoring (VEM), this EEG is done as in-patient and has a substantial diagnostic yield and will lead to the detection of the majority of epileptiform abnormalities. In most of patients, the 24 hours video-EEG monitoring will lead to the detection of additional epileptiform abnormalities. 

MRI brain using 3T MRI with epilepsy protocol; 

MRI protocol for epilepsy is a group of MRI sequences put together to improve sensitivity and specificity in identifying possible structural abnormalities that underlie seizure disorders (e.g. mesial temporal sclerosis and malformation of cortical development). MRIprotocol for epilepsy revealed focal lesions in 85% of patients who previously had “nonlesional” standard MRI.

Other functional neuroimaging techniques; Ictal/Interictal Single Photon Emission Computed Tomography (SPECT) or Positron Emission Tomography (PET) scan used to identify the epileptogenic focus, commonly used as the presurgical tools for epilepsy surgery.

Neuropsychological tests. In these tests, doctors assess your thinking, memory and speech skills. The test results help doctors determine which areas of your brain are affected.

4) Prevention or Reduction of Risks

Prevention of seizures and other possible complications are part of a seizure management. 

Here are some tips to prevent seizures:

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1. Take the prescribed anti-seizure medications as directed. If the patient experiences untoward side effects or worsening symptoms, contact the prescribing physician. Do not abruptly stop taking medications.
2. Avoid stressors, learn stress management, and relaxation techniques.
3. Have adequate rest and a regular sleep schedule.
4. Avoid intake of alcohol and other substances.
5. Stay away from bright and flashing lights especially from TV and video games, if your seizure provoked by photic stimulation or photic sensitive.
6. Eat a healthy diet. In some cases, a low carbohydrate, high-fat diet known as ketogenic diet might be used to treat epilepsy, but needed to consult doctor how to use it properly.
7. Know about the seizure triggers and learn how to avoid and manage it.  

5) Treatments

• Medication; 

Most seizure disorders can be controlled with medication that will take approximately 2 – 5 years of continuous medication therapy. Approximately 70% of patients became seizure free when taking the antiseizure medication properly.

• Epilepsy surgery; 

Epilepsy surgery is alternative treatment option for the patients who became refractory to the medications, which account around 30% of cases. A comprehensive investigation will be conducted before considering surgery.  

• Neurostimulation 

This is a less invasive treatment option. It uses devices to treat drug resistant epilepsy and patients, who are not a good candidate for epilepsy surgery or failed epilepsy surgery. With neurostimulation, the goal is to reduce and a better control seizure. Two types of neurostimulations performed at the Phramongkutklao hospital and Bangkok hospital are: Vagus Nerve Stimulation (VNS) and Deep Brain Stimulation (DBS).

6) If untreated

Epilepsy treatment and management is essential in reducing the risk of having uncontrollable seizures. The seizure can cause serious injuries, accidents, and death. Prolonged seizures can result in brain damage, while recurring seizures can also have adverse effects on brain functioning affecting on the cognitive function and psychosocial ability.

Also, the patient and their family should know how importance of the proper treatment and closely follow up to reduce the risk of Sudden Unexpected Death in Epilepsy (SUDEP), which accounts for 8–17% of deaths in people with epilepsy.

7) Medical Emergency

Seizure first aid procedures:

1. When you see someone having a seizure, stay calm. Do not panic.

2. Let the patient lie on their side, facing the head to either side to prevent choking and the tongue to block the wind pipe.

3. Loosen their clothing.

4. Do not use your finger or any object to open the patient’s mouth during the seizure because it might cause harm to the patient and the person who trying to help.

5. After the seizure, the patient might still be confused. When the patient has not yet regained full consciousness, do not restrain because this might cause the patient to fight back violently

6. In case the patient falls asleep after the seizure, try to wake up. Do not feed or give any medication until they regain full consciousness to avoid chocking or aspiration.          

7. If the patient has a prolonged seizure or having relapse seizure and not regained consciousness, bring the patient to the hospital.