Sunday, 24 July 2011

Epilepsy - Can it be Cured

Published in Panorama

Can seizures cease for good?

Six year old Rupesh was happily playing with his teddy when he suddenly began staring vacantly into space, fiddling with his toy at the same time. His mother called out to him but he seemed unaware of her calls. "Well that's him and his day dreaming," shrugged his mother.

"It is petit mal, seen mainly in children and can occur several times a day," explains Dr. Rajni Ashok, Specialist, Internal Medicine, Zulekha Hospital, Sharjah. "This is a typical situation when the child is not arousable. Without being unconscious, he is cut off from his surroundings. It may not be day dreaming at all and could in fact signal an underlying seizure problem! Left untreated, as the child progresses through school, there is a definite scholastic dropping, probably because of the recurrent attacks.”

Similarly, Abdul did not know what happened to him for a few seconds when he was driving. "I was fine upto some point but after that I just don't know what happened. I blanked out, but I was okay again. I don't remember what happened in those few seconds." Abdul was confused and had a transient loss of idea about that event, what we call as amnesia, says Dr.Rajni. When a patient comes to you with this kind of a symptom, it definitely needs investigation to rule out a seizure disorder or a transient decrease in blood supply to the brain."

What are seizures and how does one identify an epileptic? Epilepsy or 'Fits' , to a common man, explains Dr.Rajni, is when a person loses consciousness and he has jerky movements of the extremities, may be all four or one side, with frothing of the mouth, uprolling of the eyeballs and sometimes without his knowledge, passage of urine or motion and an associated injury because of the vigorous movement. This injury could be in the form of a tongue bite or an injury to the head sustained in the fall.

Dr.Rajni clarifies, "a person who has developed a seizure movement cannot be called an epileptic since a single convulsion does not make him an epileptic. When the common factor is seizure, the deciding factor is only the number of episodes. Also, not every case of seizure need follow this pattern of symptoms, as happened in the cases of Rupesh and Abdul.

There are small types of seizures which are also serious in nature, which may not come with these jerky movements; they can be complex partial seizures, as in the case of Abdul. The event itself may be very insignificant and escape the notice of the patient, his friends or relatives. Alternatively, it may be noticed and confused for some other symptom, but when probed by a medical personnel, it may indicate an underlying seizure disorder. Also, convulsions may occur during sleep for which there is no eyewitness account and if such cases are left untreated, the patient may choke on his secretion while in sleep."

Irrespective of the type of fit, whether it’s the full blown jerky type or transient confusion type, the post ectal confusion (jerky movement followed by an episode of confusion) is a very important symptom to diagnose a patient as being epileptic. This is particularly important, emphasizes Dr.Rajni, “since very often it can be mistaken for a pseudo seizure which I see here, both in children and adults. The jerky movement associated with fit is something than can be enacted by anyone and everyone as you see on screen. In fact, a hysterical patient can continue jerking his limbs for hours with no other accompanying problem associated with true epilepsy. He may finally get fatigued out and just blow up into an overt hysteria.”

To differentiate between a pseudo seizure and true seizure assumes greater importance when appropriate medication is to be administered, says Dr.Rajni. For, over medication may bring with it complications of drug therapy.

Does an epileptic have any warning signals of an impending attack? Some patients do get them but not very often, says Dr.Rajni. Some have an aura, they may get dizzy, see flashes of light, get some smell, have a block in their ears, experience transient blindness, blurring of vision and then they may pass out. Such patients can avoid physical injuries to themselves by seeking to rest in a safe spot, thereby averting injury from fall during an attack.

What then are the factors predisposing one to fits? While no concrete cause may be attached to the attacks, certain categories of people face the risk of epileptic attacks, says Dr.Rajni.

These include:
1. Children who had some birth problem and had asphyxia immediately after birth.
2. A child who had febrile convulsions in childhood.
3. Persons with metabolic defects involving calcium.
4. Head injuries, strokes, brain tumors, infections and genetic conditions are potential causes of many cases of epilepsy.
Factors precipitating an epileptic attack are keeping late nights, undue stress, monthly cycles in ladies and drug interactions.

The first attack of epilepsy can occur at any age and there is no age predisposition, according to Dr.Rajni. Epilepsy primarily affects children and young adults, although anyone can get epilepsy at anytime. “In my practice,” says Dr.Rajni, “30% of my patients have neurological problems and of these, 10% of cases come up with seizure disorders.”

What is the mode of diagnosis? Electro Encephalogram (EEG) is the primary diagnostic tool for epilepsy. However, emphasizes Dr.Rajni, “It does not imply that a normal EEG indicates a normal brain function and vice versa. The EEG report has to be always clinically correlated. EEG is not a goal standard investigation for seizures but it is more of a screening tool. But every patient who has come with a history of seizures, major or minor, or with a history of transient dysfunction of the brain, should go for an EEG, else you can be missing a seizure disorder which is a treatable condition.

An EEG is generally followed by a CT or MRI Scan. Dr.Rajni explains, “We do a CT scan to rule out a structural lesion in the brain. This has to be done because if the person has a structural lesion and we keep pumping him with anti epileptic medication, it does not treat him. We have to remove, as far as possible, as much as possible of the lesion, without causing much of a damage for the patient.”

What is the treatment modality for epileptics? Once the clinical assessment point to a classical history of fits, three possibilities emerging from EEG and CT Scan reports need to be considered for purposes of treatment, according to Dr.Rajni. The first group of patients may have both their EEG and CT Scan show up normal; the second group may have an abnormal EEG and normal CT while the third group may have both EEG and Scan showing abnormalities. Depending on these results, each group is approached differently for treatment purposes.

In the first group of patients who had both EEG and CT normal, they are treated with anti seizure drugs for a period of two years. If after two years, they are seizure free and a repeat EEG shows up normal again, the dose of medication is tapered and gradually stopped.

The second group of people with abnormal EEG and normal scan are also candidates for consideration after two years, opines Dr.Rajni. “If the patient remains symptom free, we repeat the EEG and it is normal and the previous abnormalities have disappeared, no new ones have come up, we will consider reducing and stopping the medication gradually. However, if the seizures have not appear for two years but the EEG still shows abnormal, we will treat the EEG, in the sense, continue to give the anti epileptic medication, because even if you are having one attack after this two year period, you are causing a little brain dysfunction. So we prefer not to take chances if the EEG shows abnormal.”

Dr.Rajni explains, “It is very unlikely that the CT is abnormal and the EEG is normal unless the lesions in the brain are very deep seated and hence the EEG is not able to pick it up. In the 3rd group of patients, even after two years of medication they are likely to have both EEG and CT, abnormal. These patients will most probably need life long treatment with anti epileptic medication.

Will treatment with anti seizure drugs effect permanent cure? Dr.Rajni is unequivocal, “Every type of seizure, major or minor can be treated, but not cured. It’s like hypertension or diabetes. If you stop your medicine, it can come. Even after completion of treatment, if it does not come for some time, it does not mean you’re cured because you can still get it. We never give a patient a clean chit and declare that he’s cured of it. We always educate him and tell him that he could get it!”

Is it possible for patients to get an attack while on medication? Certainly, under certain circumstances, emphasizes Dr.Rajni. “There are three groups of patients in whom this may happen. First, where the prescribed dose falls short of an increasing body weight. Second, these patients may have taken some other medicine for some other ailment which has reacted with the anti epileptic medication to reduce its drug level. Third, the patients might have missed a dose of medicine. Missing even a single dose can cause the attack to occur.”

Dr.Rajni emphasizes the importance of educating patients for long term therapy since epilepsy is a problem which can recur. Further, there are problems of therapy, problems from the attack itself as the disorder is long standing.

What side effects can anti-seizure drugs bring on? Drowsiness and scholastic backwardness in school going children may be the commonest adverse effects, says Dr.Rajni. “Eptoin, a commonly used drug can cause a lot of gum hyperplasia and consequent cosmetic problems. An overdose of medication can cause problems in walking and groggy feeling. Another group of medicines, Tegretol can lead to patients having an acute fall in their blood count which in turn predisposes them to recurrent infections, or a liver problem which is a manifestation of allergy in the form of skin rash. That is why we tell the patients to come back to us after taking the medication for three months, to monitor these factors. Sodium Valproate, another class of anti seizure drugs can cause an acute fulminant liver damage. Patients on this drug may be doing well on the fit but one fine day they may come with a full blown attack of jaundice which can be fatal. The other thing about this sodium compound drug is that it may cause water retention anywhere in the body. So a patient put on this drug may gain body weight. In such cases, we’ll have to give him diuretics to flush out the sodium or if the problem is beyond this, we may have to change the drug.

Allaying the fears of parents of school going children and girls who are victims of seizure disorders, Dr.Rajni clarifies, “If the child showed no scholastic backwardness and till getting the attack was performing normally in school, he or she should continue to study in the same grade. I emphasize this because some parents want to know if the child should be allowed to study one year behind his age. There is no need to treat the child separate because when the parents give more importance to the fit than to the child, the incidents of pseudo attacks are more. What is important is to educate the child so as not to misuse the illness to his advantage.”

“Similarly, girls can lead a normal married life and bear children, because, very often the seizure attacks may not go to the child if it is not associated with an inherited disorder.

However, it is better if the seizure-affected women do not take oral contraceptives after marriage since these drugs can interfere with the anti epileptic drugs. Again, the anti seizure medication should be continued even through the period of pregnancy and delivery. The most important aspect of patient education is to drive home the point that the foetus may not get damaged due to the anti epileptic drug, but if by stopping the drug, the mother gets an attack, that hypoxia or temporary loss of oxygen can damage the foetus. Also, seizure – affected mothers can safely breast-feed their children.”

Myths Associated with Epilepsy:
1. Marriage can cure epilepsy.
2. Acute managing will help.
3. It indicates a ‘possessed’ person and has something to do with witchcraft.
4. Shoving a key, iron bar and other things into the mouth and hands of a patient who comes down with an attack, will cause the seizures to cease. This is a very wrong thing to do, says Dr.Rajni. “An attack that is a jerky movement has two phases. The tonic phase in which the tone of the muscles is increased, causing stiffness. In this state of stiffness you should not try to do anything with the patient because what you are doing is forcing him to open his hands against a very high resistance. This may cause more damage to him. People have the wrong notion that by forcing these things into his hands or mouth, you cause him to relax. However, the convulsions are time limited, they stop on their own.”

1. During an attack, bystanders should see to it that the patient does not get aspirated, that is, get choked over his own secretion. Turn the patient on his side to prevent his tongue from falling back.
2. Loosen his clothing.
3. Take medication as prescribed by the physician without missing a single dose.

1. Dr.Rajni particularly cautions patients in the UAE and neighbouring countries, “Do not stop anti epileptic drugs during Ramadan because fasting predisposes seizure patients to convulsions and also the altered sleep patterns make them more vulnerable to the problem. Neither should they miss a dose nor compensate for a missed dose by taking more at another time. It is important to stick to the prescribed pattern of medication.
2. Alcohol use should be avoided by epileptics.
3. Avoid late hours and activities involving undue stress.
4. Driving is not safe for seizure-prones since they are a dangers to others as much as they are to themselves.
5. Known cases of seizures should avoid swimming and hiking in hilly regions, not because these exercises by themselves will cause harm. An attack while in the pool can be fatal. Similarly should an attack get onset while hiking at heights, the patient’s fall and consequent injury could be fatal.
6. Whenever seizure patients need to go in for any investigative procedures or take medication for other problems, they need to be aware of drug interaction. They should not purchase OTC drugs without consulting their physician.


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