Seizures

Clinical Approach to Seizures What is Seizure?

• Seizure refers to the abrupt, abnormal and excessive electrical discharge in the brain; depending on the area where this occurs, the manifestations can vary. If it is in the motor cortex there will be involuntary movement of a part of the body corresponding to the area affected. If it occurs in occipital lobe there will be visual hallucinations, if it occurs in temporal lobe there can be an acute onset of abnormal behavior.

What is Convulsion?

• Convulsion refers to the motor manifestation (involuntary movement) of the seizure discharge.

What is Epilepsy?

• Epilepsy is seizures occurring repeatedly for months or years due to an underlying structural or metabolic problem, which cannot be completely eradicated. Very often no obvious structural or metabolic abnormalities are detectedand they are called as idiopathic epilepsy. The fact is there is an epileptogenic focus which might have developed in utero or at birth or afterwards, as a result of some trauma, ischemia or infection. These low threshold areas are triggered by further metabolic or structural insults resulting in seizure discharge.

Causes of Seizures

• Metabolic causes

* hypoglycemia

* hyperglycemia

* hypocalcemia

* hyponatremia

* hypomagnesaemia

* porphyria/lead poisoning

* alcohol related

* sleep deprivation

• Idiopathic seizure disorder
• Structural disorders of the brain

* ICSOL

* CNS infections (Encephalitis, meningitis, brain abscess)

* AV Malformations

* Scars due to ischemia, injury, infection in the past

• Many patients with seizures have multiple problems.

Investigations

• Blood sugar: To look for hypoglycemia or hyperglycemia as in hyperosmolar non-ketotic state
• Urea: Elevated urea can suggest uremia as the underlying disorder
• Sodium: Hyponatremia as in SIADH or in hypovolemic states
• Ca++/Mg++: Whenever hypocalcemia or hypomagnesaemia are suspected to be the only cause or precipitating factor for the seizure
• Urine porphobilinogen whenever there is an unexplained seizure ECG to look for arrhythmias, chamber enlargements and ischemic changes, all can suggest a cardiac source of embolism. Moreover, evidence of complete heart block can suggest SA attack as the cause for seizure
• X-ray chest when required to look for cardiac and respiratory problems associated with seizures
• CT scan is asked for, only when secondary causes are likely. It is not necessary to do CT scans in every patient with seizure. Good clinical evaluation can very often obviate the need for CT scan.
• Electroencephalogram (EEG) is often misused in patients with seizures.
• CSF: CSF study may be useful when one suspects an infection as the cause of seizure, very often meningeal signs are present in such cases, but there may not be any meningeal sign in some patients with CNS infection and meningeal involvement, e.g. elderly, septicemia, neonates
• Other investigations depending on the clinical setting.

Summarized Steps in Management of Seizures

1. Control seizures
2. Control of precipitating factors: infection/fever/metabolic anomalies/cerebral edema/ICSOL/abscess

Care of the comatose: airway/secretions/oral hygiene, I/O balance, nutrition/bowel/bladder/skin.

Classification of Seizures

1. Control seizures
2. Control of precipitating factors: infection/fever/metabolic anomalies/cerebral edema/ICSOL/abscess

Care of the comatose: airway/secretions/oral hygiene, I/O balance, nutrition/bowel/bladder/skin.

Anticonvulsants

• Simple partial (Focal)
• Partial with secondary generalization
• Complex partial
• Primary generalized
• Tonic-clonic(grand mal)
• Petit mal
• Primary atonic
• Myoclonic seizures.

Long-term Management of Seizures

• Tab Dilantin 100mg (Phenytoin Sodium) 5-10 mg/kg/day
• Tab Phenotone 30 mg 0r 60 mg (Phenobarbitone) 3-5 mg/kg/day
• Tab Tegral (Carbamazepine) 5-20 mg/kg/day (100 mg, 200 mg)
• Tab Neogab (Gabapentin) 100mg/ 300mg

Adjuvant Measures in Management of Seizures

• Duration of treatment: If it is a single seizure, first episode in life with a definite precipitating factor identified, it may be possible to stop the treatment once that risk factor is avoided.
• But if the risk persists or if seizures recur, continue the anticonvulsant drugs for a minimum period of three years. If the patient remains seizure free for at least three years one can attempt at withdrawing the medication. On withdrawing, if there is recurrence, drugs may have to be continued lifelong.

• Diet

Diet should be a balanced one containing all the essential nutrients in appropriate amounts to avoid deficiency of Ca, Mg, Pyridoxine, and all other vitamins and minerals and to prevent hypoglycemia, timely intake of food is very important. When necessary vitamin supplementations may be given.

• Oral hygiene

Daily brushing before going to bed and if possible after every meal will prevent aspiration of infected material into lungs in case a seizure develops. Moreover, good oral hygiene can prevent gum hypertrophy in those who are on phenytoin sodium.

• Preventive measures

Avoid sleep deprivation, alcohol intake, smoking, fasting and emotional upset.

• Psychological support

To get over the feeling of inferiority complex arising out of the handicap, Yoga, meditation and other relaxation techniques may be useful.