LEARN ABOUT DIFFERENT TYPES OF EPILEPSY AND THEIR MANAGEMENT!
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DIFFERENT TYPES OF EPILEPSY AND THEIR MANAGEMENT
Epilepsy refers to a spectrum of disorders involving recurrent episodes of seizures. A seizure is defined as a transient occurrence of signs and symptoms due to abnormal excessive and synchronous firing of cortical neurons in the brain.
Neurons are nerve cells that form the functional basis of our central nervous system. People often confuse seizures with epilepsy and use them synonymously which isn’t true. Seizure refers to an isolated episode of abnormal activity in the brain which may occur due to several reasons whereas epilepsy refers to the recurrent occurrence of such episodes. There are many types of epilepsies depending on the seizure types, their
severities, and their causes. Though epilepsy is a brain disease, the repercussions on the patient are manyfold. These occur because many of these patients may suffer neurodevelopmental delay, defects in higher functions of the brain, and may also present with comorbid depression and anxiety.
While prescribing medications, doctors should consider these factors so apart from seizures the associated problems can also be taken care of. The ultimate goal of any treatment plan is to improve the quality of life (QOL) of the patient.
The prevalence of epilepsy has increased in recent times. Because of this, increased attention is being focused on the management of epilepsy. This condition is usually present since childhood and hence its management with minimal side-effects assumes considerable significance. But there are some disturbing facts associated with epilepsy.
Researchers have found that despite having a good prognosis concerning control in seizures, these patients have a mortality rate that is 2 to 3 times that of normal patients and have a reduced life expectancy.
The increase in mortality is attributed to several reasons including sudden unexpected death in epilepsy (SUDEP). The exact reasons causing SUDEP are not known but recent evidence points to disturbance of cardiorespiratory mechanism. SUDEP accounts for up to 15% of all epilepsy-related deaths! However, seizures are not always associated with epilepsy but can be caused by a variety of reasons. These include factors like drug overdoses, alcohol abuse, barbiturate or benzodiazepine withdrawal, brain hemorrhage, or systemic illnesses like hypocalcemia, hypoglycemia, uremia, or eclampsia. High fever can also precipitate seizures in some patients.
There are different types of epilepsies depending on seizure type. These include focal, generalized, and unknown onset epilepsies. Focal seizures are caused due to focal problems in the brain which means it originates from a specific area of the brain. These seizures are further classified into motor onset and non-motor onset.
Depending on the type of seizure, different symptoms are manifested in different patients. Motor onset seizures present with some motor signs like twitching and jerking eg. myoclonus, stiffening, or automatic movements like smacking lips, rubbing hands, or picking at clothes. The patients also experience a phenomenon called aura which is defined as the symptomsexperienced at the beginning of a seizure. Recently, the use of this term has been discouraged.
Generalized onset seizures are those that occur due to the involvement of both hemispheres of the brain. These are always accompanied by impaired awareness and major motor symptoms generally referred to as tonic-clonic. The seizure is accompanied by loss of consciousness followed by muscle stiffening and a period of rigidity and clonic movements. This is often described as jerking of arms and legs. Crying or moaning by the patient during a seizure is normal as laryngeal muscles are activated.
The patient can also experience bladder or bowel incontinence due to loss of sphincter control and may also bite his/her tongue. Once the patient regains consciousness, he/she may experience confusion, drowsiness, lack of coordination, soreness throughout the body, and amnesia (loss of memory) of the event.
Seizures of unknown onset are classified based on the presence of motor or non-motor symptoms. In some cases, it may become impossible to classify the seizure at all; this is a rare occurrence and is referred to as an unclassified seizure.
The treatment of most epilepsies consists of only managing the symptoms as there is no cure as of now. And since as mentioned earlier, most epilepsies are childhood diseases, their medical management assumes utmost importance.
The mainstay treatment is the use of antiseizure drugs (ASDs). Many drugs are used for this purpose and are prescribed depending on the kind of epilepsy and the amount of period the patient has been suffering for.
Chief medications that are used include conventional ones like carbamazepine, phenobarbital, primidone, and phenytoin which are used to treat focal seizures, and ethosuximide and clonazepam which are used for generalized seizures. Valproate is a conventional drug that is used both for focal and generalized seizures.
The new generation drugs include brivaracetam, eslicarbazepine, ezogabine, lacosamide, perampanel, rufinamide, tiagabine, and zonisamide which are used for the treatment of focal seizures. Lamotrigine, levetiracetam, and topiramate are new-generation drugs that are used both in focal and generalized seizures.
The patients in whom seizures cannot be controlled by drugs require non-pharmacologic interventions. These include diet modifications, vagus nerve stimulation (VNS), and sometimes, even surgery. The use of diet modifications has shown inconclusive results which are not reproducible.
A vagal nerve stimulator is an implanted medical device approved by US FDA. It is used as adjunctive therapy in reducing the frequency of seizures in adults and children above 12 years of age having partial-onset seizures that are refractory to ASDs. It can also be used in the treatment of refractory primary generalized epilepsy.
Though the mechanism of VNS is unknown, clinical studies point to changes in concentrations of inhibitory and excitatory neurotransmitters in cerebrospinal fluid. Increased blood flow to specific areas of the brain responsible for the generation or regulation of cortical seizure activity also seems to play a role in the anticonvulsant activity.
Locus coeruleus, a sky-blue set of spots found in the brain stem, the place where the base of the brain connects to the spinal cord, may also be responsible for the anticonvulsant effect of VNS. It has also shown very good results in patients where changes in mood and behavior are of concern.
Side effects experienced are minimal and include voice changes or hoarseness, mild difficulty in breathing at night, little indigestion, and feeling of nausea. Surgery is generally advised in patients who have refractory focal epilepsy, especially in whom seizures originate from the temporal lobe.
Epilepsy is a disease that encompasses a multitude of factors and affects different patients differently. It needs to be managed through drugs which usually need to be taken regularly for the whole life.Thus, it becomes very important to constantly monitor these patients and apply subtle changes to get the desired result with minimal side effects. Epilepsy can have a detrimental effect on the social life of the patient as it can cause neurological problems. The clinician treating a patient should be compassionate and take care of these factors.
Counseling of the patient forms an integral part of the treatment plan. As research increases, more modalities will come forth that can help patients to fight this disease. In recent times, seizure dogs are employed to help patients. These are specially trained dogs that alert the patient before the onset of a seizure and help him/her to get to safety or alert other people about the help needed. Thus, we have come a long way in managing epilepsy. Future developments will surely help to better handle this disease and improve the quality of life (QOL) of these patients.
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