Epilepsy

International Classification (ICD)	G40.-
Symptoms	twitching in the arms and legs, involuntary sounds, Biting one's own tongue, urination or defecation, Unconsciousness, involuntary eye, head and mouth movements, Automatisms
Possible causes	Disease of the central nervous system, genetic alterations of ion channels and transmitter receptors
Possible risk factors	Brain tumors, Brain and meningitis, Alcohol abuse, drug and medication abuse, Metabolic diseases and/or genetic disorders, Poisonings, Sleep Deprivation, Flickering light on television or in a disco, Hyperventilation, Withdrawal from alcohol and medication, Shift in the mineral balance of the body, Deformities of the brain, Traumatic brain injury, Infarction or bleeding, Birth Complications
Possible therapies	Anticonvulsants, surgical procedure
disease.indicated_substances	Levetiracetam

Basics

The word epilepsy is derived from Greek and means something like "seize", "attack" or "assault". The word origin is explained by the fact that epilepsy and epileptic seizures used to be understood as being caused "from outside" (gods, demons). Epilepsy can also be translated as "falling sickness" and is often referred to in colloquial language as a cerebral seizure disorder. The condition involves a malfunction of the brain in which sudden synchronized impulses are fired and discharged. This process is triggered by nerve cells. Sometimes only a few muscles twitch during an epileptic seizure, but the entire body can also convulse. In addition, affected persons may lose consciousness in the course of a seizure.

Doctors speak of epilepsy when:

At least two unprovoked seizures have occurred within 24 hours.
If, after an unprovoked seizure, the risk of having another seizure within the next 10 years is more than 60%.
A diagnosis of epilepsy syndrome has been made (e.g., Lennox-Gastaut syndrome).

The 1-year prevalence for epilepsy in Central Europe is approximately 7.1 per 1000 population. Men and women are affected by the disease and epileptic seizures at about the same rate. The probability of developing epilepsy increases particularly in the first years of life, and then only again from the age of 65. In general, however, people of any age can develop epilepsy. If a person suffers a single seizure, this does not necessarily mean that he or she will suffer from seizures for the rest of his or her life.

If an epileptic seizure lasts longer than five minutes, it is also referred to as "status epilepticus". Status epilepticus" is a medical emergency and should be treated immediately by a doctor or with medication. Even if several seizures occur within a short time of each other, this is an emergency.

Menschliche Neurone (iStock / K_E_N)

Die Einteilung

Epileptic seizures are divided into focal (beginning in one cerebral hemisphere) and generalized (beginning in neurons of both cerebral hemispheres) seizures. Focal seizures can be further divided into conscious and nonconscious forms. Both of these forms can have a motor and a non-motor onset. If a focal seizure spreads to the other brain hemisphere, it is also called a "bilateral tonic-clonic seizure". Between the individual seizures, however, people with epilepsy usually have no physical symptoms.

Causes

The human brain is composed of billions of neurons. These neurons communicate with each other using chemical and electrical signals. Individual areas of the brain are responsible for motor functions, while others are responsible for speech or vision. During an epileptic seizure, the interaction of these neurons either does not function for a short period of time or is disrupted. In Europe, about 0.7 to 0.8 percent of the total population is affected by epilepsy. In some families, epilepsy occurs more frequently, which is why a genetic component of the disease is also suggested.

Even healthy people can be affected by a seizure under certain circumstances. These circumstances include:

Sleep deprivation
Flickering lights on television or in a disco
Accelerated breathing (hyperventilation)
Withdrawal from alcohol and medications
Severe shift in the body's electrolyte balance

Idiopathic epilepsy:

The triggers of this form of epilepsy are, for the most part, still unknown. Conjecture suggests that genetic changes in ion channels and transmitter receptors generally play a role in the development of epilepsy.

Affected individuals with idiopathic epilepsy, by definition, do not have other neurological disorders (e.g., traumatic brain injury). Imaging examination procedures (computed tomography, magnetic resonance imaging) also show no pathological changes.

Symptomatic epilepsy:

This form of epilepsy is triggered by a disease of the central nervous system. Causes that may be triggers include such things as:

Brain malformations
Brain damage triggered by pregnancy or birth complications, mainly in premature babies, by brain hemorrhage, lack of oxygen supply to the brain (birth complications) or by brain inflammation.
Brain injury (e.g., traumatic brain injury).
Stroke (infarction or hemorrhage)
Brain tumors: Therefore, especially in young people, the cause of first seizures should be clarified immediately by means of CCT (computer tomography of the brain) or MRI (magnetic resonance imaging).
Brain and meningitis
Alcohol abuse, drug and medication abuse
Metabolic diseases and/or genetic disorders
Poisoning

Symptoms

Epileptic seizures can be divided into two main groups:

Focal seizures: This type of seizure occurs in a circumscribed region of the brain and is confined to one area of the body. However, a focal seizure can also progress into a generalized seizure.
Generalized seizure: Generalized seizures affect the entire brain from the beginning or at least parts of both cerebral hemispheres at the same time. The seizure then usually affects the entire body.

Focal seizure:

Focal seizures occur in a specific area of the brain. Depending on which area of the cerebral cortex is affected, affected individuals experience different symptoms. For example, there may be a twitching of the leg (motor seizure) or sensory disturbances (sensory seizure). If visual symptoms occur, such as flashes of light, the origin of the seizure is probably close to the visual cortex. In a focal seizure, the affected person is often in an awake, oriented state and is clearly conscious. However, some forms of focal seizures limit attention or even consciousness. If only a focal seizure occurs initially, it can also spread to the entire brain and lead to secondary generalization.

Generalized seizure:

Generalized seizures always affect both hemispheres of the brain. They are generally no more severe than focal seizures, but more often result in unconsciousness and muscle twitching throughout the body.

Generalized epileptic seizures present as follows:

Tonic: The extremities tense and become stiff. The seizure usually passes quickly. There is not always a clouding of consciousness.
Atonic: Muscle tension suddenly decreases in one part of the body. For example, the legs may buckle and one falls. A brief loss of consciousness is also possible.
Clonic: Muscle groups in the arms or legs twitch in a slow rhythm. In most cases, the affected person loses consciousness.
Myoclonic: Individual muscle groups twitch very quickly. The affected person usually retains consciousness.
Tonic-clonic ("grand mal"): The entire body cramps and twitches. In addition, affected persons often lose consciousness.

Absences: This type of seizure is characterized by brief pauses in consciousness. It is considered a "mild form" of an epileptic seizure.

Diagnosis

First, the patient is questioned in detail (anamnesis). It is particularly important to find out whether there are any known cases of epilepsy in the patient's family. After that, a neurological examination is usually performed.

Eine EEG-Untersuchung (iStock / luaeva)

An epileptic seizure is always assessed by the type of seizure pattern (seizure history). For this reason, it is good if another person has observed the seizure and can describe it. In addition, epilepsy must be distinguished from other diseases that may cause similar symptoms, such as psychologically induced seizures. Furthermore, structural brain changes (e.g. tumor) should be excluded as a possible cause of symptomatic epilepsy.

The following examination methods are available:

Electroencephalography (EEG)
Computer tomography (CT)
Magnetic resonance imaging (MRI)
Blood tests

In certain cases, tests of the cerebrospinal fluid (CSF) are also performed.

Therapy

Epilepsy is treated by a specialized neurologist.

Basically, seizure prophylaxis and therapy of epilepsies consists of three pillars:

Elimination of the cause in symptomatic epilepsies.
Medication for seizure prophylaxis
Avoidance of trigger factors (e.g., sleep deprivation, alcohol)

Drugs against epilepsy (anticonvulsants) increased the pathologically lowered seizure threshold in epilepsy patients. The indication for therapy is given if two or more seizures occur within 6 months or after a seizure if there are additional findings characteristic of epilepsy in the EEG or MRI (e.g., spike-wave pattern). In the absence of therapy, there is a risk that seizure frequency will increase.

Antikonvulsiva (iStock / Attila Barabas)

For seizures with focal onset, the drugs lamotrigine and levetiracetam are first-line agents. Second-line drugs include carbamazepine, phenytoin, and topiramate.

For seizures with generalized onset, the drug valproic acid is usually the first choice. Second-line drugs are lamotrigine and topiramate. If valproic acid alone does not provide sufficient protection against seizures, combination therapy with another anticonvulsant should be started.

With the help of correct drug treatment, the majority of epilepsy patients can lead a seizure-free life. The therapy has the task of ensuring seizure freedom without undesirable side effects or with tolerable side effects. The dosage of the medication must be precisely adjusted and adapted to the patient.

Initially, therapy should be carried out with an anticonvulsant as monotherapy. If the seizure prophylactic effect is not sufficient, monotherapy with another agent should be started. An end of therapy should only be considered after 2-5 years of seizure-free time with an inconspicuous EEG.

Principle of drug therapy:

Anticonvulsants are designed to reduce the hyperexcitability of neurons through various mechanisms, or even to enhance the brain's inhibitory mechanisms. Medications are often administered that interfere with gamma-aminobutyric acid (GABA) metabolism, for example (e.g., valproate), because GABA is the most significant seizure-inhibiting transmitter in the brain. In order for therapy to show success, it is important to take it regularly and keep medical checkups.

Seizure calendar:

In order to tailor therapy precisely to the patient, the seizure situation must be assessed. For this reason, patients should keep a seizure calendar. The frequency and severity of the epileptic seizures should be noted in this calendar. This enables the attending physician to regularly obtain a picture of brain activity (EEG monitoring) and seizure frequency in combination with the level of medication in the blood.

In some patients, medication alone is not sufficient. In these cases, surgery may also be considered. Epilepsy surgery usually shows very good results in terms of seizure freedom after surgery, especially in temporal lobe epilepsy, but surgery can only be performed if the seizures always originate from the same region of the brain. The location in the brain must be able to be removed without danger or disadvantage to the patient.

Another possibility of epilepsy treatment is the implantation of an electrical device that causes the excitation of a specific nerve (vagus nerve) in the brain. As a result of stimulation of this nerve, the number of seizures can be reduced.

Forecast

In general, about 50% of people with epilepsy have a single seizure, while the remaining 50% experience a second seizure. Consequently, the risk of another seizure also increases. Approximately 70% of patients who have already had at least two seizures experience another seizure within a year. People in whom the epileptic seizure was caused by an underlying condition such as traumatic brain injury are particularly at risk. Here, the risk of further attacks is twice as high as in epilepsy patients in whom the cause is based on a genetic predisposition or there is no known cause.

It is often possible to maintain a good quality of life and prevent seizures in the long term by selecting the right medication. However, 3 out of 10 sufferers continue to experience seizures, making epilepsy a significant cause of suffering.

Tips

In order to maintain as high a quality of life as possible despite epilepsy itself, sleep hygiene (sufficient sleep with regular times to fall asleep) can be helpful. Some forms of epilepsy are triggered by certain trigger factors (e.g. flickering light, alcohol, sleep deprivation, looking at a checkerboard pattern). These triggers should be avoided entirely, if possible.