Jun
17
2011
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SURGICAL APPROACHES TO EPILEPSY: SURGERY FOR PARTIAL (FOCAL) SEIZURES – RISK-BENEFIT DISCUSSION WITH YOUR PHYSICIANS

SURGICAL APPROACHES TO EPILEPSY: SURGERY FOR PARTIAL (FOCAL) SEIZURES – RISK-BENEFIT DISCUSSION WITH YOUR PHYSICIANS
Discussion of the possibility of surgery and its risks and benefits should be an ongoing process. Having identified a focus and its location, surgery can become a more serious consideration, and a more detailed discussion of its risks and benefits is possible. The risks will depend on the area to be removed. Surgery is most often performed to remove a focus from the frontal or temporal lobes of the brain, areas from which large amounts of tissue can usually be safely removed without major complications.
As with any operation, there is, of course, a risk of dying or suffering major complications of anesthesia. While the consequences of such a complication could be great, the chances of a major anesthetic complication’s occurring are in the range of less than one per one thousand. Infection also is always a risk; so is bleeding or clotting of a blood vessel. All these are potentially serious and capable of causing additional brain damage. Fortunately, these complications occur infrequently.
Generally, as noted, frontal and temporal lobe removals are considered by neurologists and neurosurgeons to be “safe” procedures, but as with any decision-making process, the risks and their magnitude must be weighed against the possible benefits and the chances of those benefits occurring. What are the benefits of the focal operations? The maximum benefit would be freedom from seizures for your child—freedom from taking anticonvulsant medicine and freedom from neurologic deficit due to the surgery. This is everyone’s goal. What are the chances of that occurring? Surprisingly, it is difficult to give numerical answers to this question. Surgical centers often quote 60-75 percent “good outcomes.” This means that perhaps 50 percent will be cured of their seizures, another 10—25 percent will have substantial decrease in the frequency of their seizures, and about 25 percent—one in four—will not be helped at all.
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Discussion of the possibility of surgery and its risks and benefits should be an ongoing process. Having identified a focus and its location, surgery can become a more serious consideration, and a more detailed discussion of its risks and benefits is possible. The risks will depend on the area to be removed. Surgery is most often performed to remove a focus from the frontal or temporal lobes of the brain, areas from which large amounts of tissue can usually be safely removed without major complications.
As with any operation, there is, of course, a risk of dying or suffering major complications of anesthesia. While the consequences of such a complication could be great, the chances of a major anesthetic complication’s occurring are in the range of less than one per one thousand. Infection also is always a risk; so is bleeding or clotting of a blood vessel. All these are potentially serious and capable of causing additional brain damage. Fortunately, these complications occur infrequently.
Generally, as noted, frontal and temporal lobe removals are considered by neurologists and neurosurgeons to be “safe” procedures, but as with any decision-making process, the risks and their magnitude must be weighed against the possible benefits and the chances of those benefits occurring. What are the benefits of the focal operations? The maximum benefit would be freedom from seizures for your child—freedom from taking anticonvulsant medicine and freedom from neurologic deficit due to the surgery. This is everyone’s goal. What are the chances of that occurring? Surprisingly, it is difficult to give numerical answers to this question. Surgical centers often quote 60-75 percent “good outcomes.” This means that perhaps 50 percent will be cured of their seizures, another 10—25 percent will have substantial decrease in the frequency of their seizures, and about 25 percent—one in four—will not be helped at all.
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Written by admin in: Epilepsy |
Feb
28
2011
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MEDICAL TREATMENT OF SEIZURES: COMMON QUESTIONS ABOUT BLOOD LEVELS

MEDICAL TREATMENT OF SEIZURES: COMMON QUESTIONS ABOUT BLOOD LEVELS
Physicians and parents have become enamored of tests and often give them greater importance than is proper. Despite scientific advances, the proper use of anticonvulsants remains an art, not always a science. We are often asked questions by both physicians and parents.
“My doctor says that my child’s blood level is slightly low and wants to increase his dose. What should I do?”
If you ask us this, we would ask if your child is still having seizures. If he is, then the dose should be increased. If he is not, then we would leave the dose alone; the current level may be sufficient to control his seizures. The question of increasing a dose often comes up in a child whose seizures are controlled. As the child grows and increases in size, the blood level will, of course, decrease if your doctor doesn’t increase the dose. But we suggest keeping the dose the same as the child grows and gains weight, unless he is having seizures. If the dose is kept the same, then the blood level gradually falls over the months or years. If the child does not have another seizure, it will be easier and safer to take him off his medicine when he has been free of seizures for two years. If he has a seizure, then you know that he needs to stay on the medication longer.
“My daughter’s blood level is at the upper end of ‘normal,’ and she is still having seizures. My doctor wants to try another drug. Is that the proper thing to do?”
We would suggest first that he try increasing the dose even further, but slowly, since your daughter is close to the point where many people show toxicity. Sometimes seizures will be controlled with a little more drug without any toxic problems. The upper level of the therapeutic range is like a sign post, “WARNING”; it suggests that you and your physician should be watchful for signs of toxicity.
“Rachel’s blood level is ‘high,’ and my doctor wants to lower the dose. I think that she is doing just fine, and she hasn’t had any seizures since that last Increase in dosage. What should we do?”
We would recommend that you leave the dose alone. If Rachel isn’t having any seizures and has no signs of toxicity, then perhaps this is the level she requires. However, since the level is above the usual range, we would suggest that you keep a close eye on her and on her school performance to be sure that the drug is not interfering and that you stay alert for other signs of toxicity.
“Billy’s blood level is right in the middle of the ‘range.’ Is that good?”
The answer to this question is, “It depends.” If Billy is not having any seizures and shows no signs of toxicity, then that level is fine and should not be changed. If he is still having seizures, then the level is too low for him, and he needs more medication. If he is too sleepy, too irritable, or having problems in school, then it is important to find out why. There are many causes for problems such as these. Obviously, you should be sure that he is not having seizures. If the level is not high, then the drug is a less likely cause. However, if you can’t find another cause, then lowering or discontinuing the drug may be worth trying. If the problem disappears, then it may have been due to the drug.
To summarize, the therapeutic range is a guide and nothing more. It will suggest to you and your physician when it may be appropriate to increase the drug and when to look more closely for signs of toxicity. The range does not tell you when the child is taking too much or too little. Control of seizures and signs of toxicity are the only things that tell that.
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Physicians and parents have become enamored of tests and often give them greater importance than is proper. Despite scientific advances, the proper use of anticonvulsants remains an art, not always a science. We are often asked questions by both physicians and parents.
“My doctor says that my child’s blood level is slightly low and wants to increase his dose. What should I do?”
If you ask us this, we would ask if your child is still having seizures. If he is, then the dose should be increased. If he is not, then we would leave the dose alone; the current level may be sufficient to control his seizures. The question of increasing a dose often comes up in a child whose seizures are controlled. As the child grows and increases in size, the blood level will, of course, decrease if your doctor doesn’t increase the dose. But we suggest keeping the dose the same as the child grows and gains weight, unless he is having seizures. If the dose is kept the same, then the blood level gradually falls over the months or years. If the child does not have another seizure, it will be easier and safer to take him off his medicine when he has been free of seizures for two years. If he has a seizure, then you know that he needs to stay on the medication longer.
“My daughter’s blood level is at the upper end of ‘normal,’ and she is still having seizures. My doctor wants to try another drug. Is that the proper thing to do?”
We would suggest first that he try increasing the dose even further, but slowly, since your daughter is close to the point where many people show toxicity. Sometimes seizures will be controlled with a little more drug without any toxic problems. The upper level of the therapeutic range is like a sign post, “WARNING”; it suggests that you and your physician should be watchful for signs of toxicity.
“Rachel’s blood level is ‘high,’ and my doctor wants to lower the dose. I think that she is doing just fine, and she hasn’t had any seizures since that last Increase in dosage. What should we do?”
We would recommend that you leave the dose alone. If Rachel isn’t having any seizures and has no signs of toxicity, then perhaps this is the level she requires. However, since the level is above the usual range, we would suggest that you keep a close eye on her and on her school performance to be sure that the drug is not interfering and that you stay alert for other signs of toxicity.
“Billy’s blood level is right in the middle of the ‘range.’ Is that good?”
The answer to this question is, “It depends.” If Billy is not having any seizures and shows no signs of toxicity, then that level is fine and should not be changed. If he is still having seizures, then the level is too low for him, and he needs more medication. If he is too sleepy, too irritable, or having problems in school, then it is important to find out why. There are many causes for problems such as these. Obviously, you should be sure that he is not having seizures. If the level is not high, then the drug is a less likely cause. However, if you can’t find another cause, then lowering or discontinuing the drug may be worth trying. If the problem disappears, then it may have been due to the drug.
To summarize, the therapeutic range is a guide and nothing more. It will suggest to you and your physician when it may be appropriate to increase the drug and when to look more closely for signs of toxicity. The range does not tell you when the child is taking too much or too little. Control of seizures and signs of toxicity are the only things that tell that.
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Written by admin in: Epilepsy |
Dec
09
2009
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THE FACTS-THE FIRST SEIZURE AND THE DIAGNOSIS OF EPILEPSY: OTHER CAUSES OF IMPAIRED OXYGEN SUPPLY TO THE BRAIN-DROP ATTACKS AND JUMPING LEGS (MYOCLONIC JERKS; HYPNIC JERKS)

These affect only middle-aged women, and then often only for a year or two. The story is striking. The woman complains that, while walking along, she suddenly finds that her legs have given way. She may land on her knees or pitch forward on her face. In either case she is always adamant that she is fully aware of what is happening, and equally adamant that she does not trip. The condition is variously assumed to be due to some weakness of the thigh muscles, or to a disturbance of blood flow in the brain-stem, interfering with postural reflexes. Whatever the mechanism, neurologists are confident that there is no association with epilepsy.

Jumping legs (myoclonic jerks; hypnic jerks)-About 80 per cent of the adult population, at some time in their lives, are conscious of a sudden jerk of one or other leg, usually in the twilight stage of drifting off to sleep. The jerk is associated with, or may cause, a sudden arousal. Some people have a great number of jerks, so many that their spouse, being bruised by the kicks, will refuse to share a bed with them. These jerks must represent some sort of paroxysmal discharge of nerve cells, not necessarily in the brain. They are therefore in this way close to epilepsy, but are not so regarded because of their near universality in the population, and their lack of association with frank epileptic seizures. Specifically, there is no relationship between these jerks and the morning myoclonic jerks associated with typical absence or tonic-clonic seizures.

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Written by admin in: Epilepsy |
Dec
09
2009
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THE FIRST SEIZURE AND THE DIAGNOSIS OF EPILEPSY: OTHER CAUSES OF IMPAIRED OXYGEN SUPPLY TO THE BRAIN-LOCALIZED REDUCTION IN CEREBRAL BLOOD FLOW

The changes in blood flow that we have considered so far affect all parts of the brain equally. In older people, arteriosclerotic changes take place in the arteries in the neck and head. There may be a temporary blockage of an artery to one part of the brain by a fragment of chalky deposit or thrombus swept downstream from a larger artery by the flow of blood. Neurologists call these blockages ‘transient ischaemic attacks’. In some of these short episodes, muscle weakness or tingling in one or other limb may slightly resemble partial motor or sensory seizures. However, although focal motor seizures may arise in the scarred brain in the territory of a permanently blocked artery after a stroke, transient ischaemic attacks are associated with transient paralysis rather than convulsions.

In younger people, localized (focal) neurological phenomena occur in migraine. In the first stage of a classical migraine attack, arterial spasm occurs, reducing cerebral blood flow focally. It is unclear whether this is primary or secondary to some depression of nerve cell activity. The occipital area is the region most often affected. This results in a hallucination of distorted vision or flashing lights, rather than the formed visual hallucination which may be part of a partial seizure arising in a temporal lob. Occassionally spasm affects the motor or sensory areas of the brain, producing short-lived paralysis or disturbance of sensation, without convulsions, on the opposite side of the body.

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Written by admin in: Epilepsy |
Dec
09
2009
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THE FIRST SEIZURE AND THE DIAGNOSIS OF EPILEPSY: REFLEX ANOXIC SEIZURES AND BREATH-HOLDING ATTACKS

These are a type of syncope, but deserve a particular mention as the attacks are frequently misdiagnosed as epileptic seizures. Reflex anoxic seizures (also called pallid syncopal attacks) usually affect young children between 12 months and 4 years of age, but can affect older children and even adults. The attacks are always provoked by either a sudden fright, or unexpected pain. This unpleasant experience then stimulates a nerve (the vagus nerve) which causes the heart to slow down or even stop for a few seconds. As a result of this the child becomes pale, then limp, and may even have a brief clonic convulsion. Almost immediately the child will recover, may cry, and then appear sleepy. Within a few minutes the child is usually back to normal. These attacks do not damage the brain or heart, do not need treatment, and usually stop by the age of 5-10 years.

Breath-holding attacks-These attacks occur only in young children, aged usually between one and three years. The typical story is of a child who is frustrated, told off, or spanked. The child becomes angry or upset and will hold their breath. After a few seconds the child becomes blue (cyanosed) because of a lack of oxygen in the blood and loses consciousness, and becomes limp. Because of the reduced oxygen supply to the brain (as the child is not breathing) the child may have some clonic (jerking) movements and wet themselves. The child always starts breathing again and is back to normal within a few minutes. These breath-holding attacks usually stop by the age of 4-5 years.

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Written by admin in: Epilepsy |
Dec
09
2009
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THE CAUSES OF EPILEPSY: CONGENITAL MALFORMATION

Some congenital abnormalities (present at birth) are not inherited. For example, the abnormalities in the limbs of the children whose mothers had taken the drug thalidomide during pregnancy are congenital and will not be passed on to their children, as the thalidomide affected the developing cells in the limbs without, (although there continues to be some debate), causing any mutations in the baby’s own ovaries or testes. Other congenital abnormalities may have an inherited basis.

One congenital abnormality relevant to epilepsy is a maldevelopment of blood vessels known as an angioma. The abnormal vessels may be either arterial, venous, or capillary. Sometimes a clot or thrombus forms in one or more of the abnormal vessels, exacerbating the situation. One type of capillary angioma of the brain is associated with a similar malformation of blood vessels in the skin of the upper part of the face—the Sturge-Weber syndrome. Children with this particular combination of angiomatous abnormalities have a high probability of developing seizures.

More common than angiomas as a cause of epilepsy are disorders oi migration of nerve cells during fetal development, so some end up in the wrong place, the wrong layer of the brain, or with the wrong connections. They are congenital abnormalities, but unlike a harelip, for example, externally invisible. The causes of such disorders are not known, but some probably have a genetic basis. This sort of abnormal brain development may cause seizures and fits in the first few weeks or months of life, including infantile spasms (West’s syndrome).

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Written by admin in: Epilepsy |
Dec
09
2009
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THE DIFFERENT TYPES OF EPILEPTIC SEIZURE AND OF EPILEPSY SYNDROMES

Area indicates a number of nerve cells in the cortex (the name given to the layers of nerve cells on the surface of the brain) which are in some way abnormal, tending to discharge paroxysmally. They may drive other nerve cells to follow their abnormal patterns of discharge. The paths of influence of the discharging nerve cells are indicated by the arrows. As long as the discharge remains in one part of the brain, the seizure is said to be a partial seizure and its cause

location-related. What happens during a partial seizure depends upon the exact site and pattern of discharge of abnormal nerve cells. Temporal lobe seizures are of this type.

The abnormal discharge may spread through the connections linking the two halves of the brain, or, by affecting poorly identified central collections of cells, initiate a generalized seizure discharge, in which case the seizure is said to be a partial seizure with secondary generalization (to a convulsive seizure—grand mal). These are also known as tonic-clonic seizures).

The second main class of seizure. In this class of seizure, central collections of nerve cells are in some way abnormal in their behaviour—even though they may appear to be perfectly normal under the microscope. Because of their central position, and the direction and power of their transmissions, a seizure discharge generated within them spreads more or less simultaneously to all parts of the brain. Such a seizure is generalized at onset. Typical absences (often known as petit mal), and some grand mal seizures, are of this type.

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Written by admin in: Epilepsy |
Dec
09
2009
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EPILEPSY: THE FACTS

There are all sorts of problems about epilepsy. Epilepsy is the name given to recurrent ‘seizures’ (also known as ‘fits’, or ‘attacks’), of which the fairly well-known grand mal convulsions are only one type. A whole variety of brain disorders can cause epilepsy, which should perhaps be considered no more than a stereotyped reaction of the brain to a variety of stresses. It is not generally known that, in spite of the most modern methods of investigation, an underlying cause can only be identified with certainty in about one third of people with epilepsy. The good news that has emerged from research studies over the last twenty years is that the long-term outlook for the cessation of seizures is very much better than was previously considered to be the case, as earlier research referred only to people with epilepsy whose seizures were the most difficult to control.

People with epilepsy have many worries. Children with epilepsy may be upset or worried about telling their friends and what will happen to them in the future. Women with epilepsy are understandably concerned about the possible effects of anti-epileptic medication when pregnant. Not everyone understands the impact of epilepsy upon the eligibility to hold a driving licence. Many employers understand little about epilepsy, and people with epilepsy may not have the same possibilities of employment, or of career advancement.

Epilepsy can begin at any age in life, but is particularly likely to begin in early childhood. One of us is a paediatric neurologist with a particular interest in epilepsy, and the other works with adults with epilepsy.

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Written by admin in: Epilepsy |
Dec
09
2009
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QUALITY OF LIFE OF CHILDREN AND PEOPLE WITH EPILEPSY

Until comparatively recently, the emphasis of neurologists and paediatricians has been on obtaining complete control of epilepsy. The child or person’s own feelings have not been taken into sufficient account, nor has the effect of epilepsy on aspects of their life such as choice of career, employment, social and leisure activities, and family life. The stigma which is associated with epilepsy, and the relatively poor medical understanding and management of epilepsy has contributed to patients with epilepsy experiencing a poor quality of life. This is now changing. Favourable factors are:

• an increased understanding about how epilepsy is caused;

• an increased medical awareness of the condition at all levels of undergraduate and postgraduate medical training;

• the development of more effective and safer drugs, and of surgical treatments leading to improved control of seizures;

• the development of clinics and facilities, both locally in general hospitals and nationally in major specialist centres;

• the appointment of specialist nurses in epilepsy whose role is to support and counsel patients of any age, and their families; and

• an expansion of local and national voluntary associations to provide advice and information to all patients and professionals who are involved with epilepsy.

The introduction of epilepsy clinics and specialist nurses in epilepsy are, in our view, as (if not more) important than the discovery of new anti-epileptic drugs in improving the quality of life of patients who have epilepsy.

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Written by admin in: Epilepsy |
Dec
09
2009
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PROBLEMS FOR WOMEN WITH EPILEPSY

The effect of menstruation on seizure frequency. The interaction between anticonvulsant drugs and oral contraceptives. The effects of anticonvulsant drugs on the fetus.

Some mothers report that their seizures become more frequent, others less frequent during pregnancy, and others have seizures which remain more or less unchanged in pregnancy. There seems no way of predicting what is going to happen in the first pregnancy, except that those with very frequent seizures are unfortunately, likely to get worse. By and large, subsequent pregnancies in any one mother follow much the same pattern. An unexpected and totally unexplained finding has been that those pregnant with a male baby are rather more likely to have more frequent seizures. Although epilepsy may start for the first time during pregnancy, this usually seems to be coincidental, and there is no good evidence that pregnancy itself is a

particularly potent event in inducing seizures. One possible reason for an increase in frequency of seizures during pregnancy is that the body processes anticonvulsant drugs differently. The interactions between pregnancy and drug metabolism may be complex.

Some anti-epileptic drugs pass through the placenta into the fetus. Phenobarbitone is perhaps the best-known example. After delivery the baby’s serum phenobarbitone falls, and during the early days after birth the baby may be much more fractious and irritable than most new-born babies.

Many mothers on anti-epileptic drugs wonder whether they can breast-feed their babies. Careful studies have been made on this point, and only small quantities of the drugs are secreted into milk, so it is quite safe to breast-feed.

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Written by admin in: Epilepsy |

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