Seizures
Ruth Estes, Ph.D.

Seizures are the most common medical complication following traumatic brain injury. Approximately five percent of persons with brain injuries develop seizures following injury. This is twice the incidence found in the general population. When the brain injury is severe, risk of seizures is substantially increased, with incidence at 15-20%. The presence of a skull fracture and intracranial hemorrhage increases the risk further. Approximately 50 percent of those who sustain a skull fracture and a severe brain injury develop seizures. Therefore, seizures are an important issue in the management of traumatic brain injury.

Post-traumatic seizures are classified as immediate or impact (within the first 24 hours), early (24 hours to seven days after injury), or late (more than seven days after injury). An immediate seizure does not increase the risk for later seizures. Early seizures, however, do correlate with increased incidence of late seizures. Of those individuals who develop late seizures, approximately 25% will do so after the first year post injury.

Defining Terms

What is a seizure? A seizure is a change in perception or in a behavioral state that results from abnormal electrical activity in the brain. In normal brain function, millions of tiny electrical charges pass from nerve cells in the brain to all parts of the body. In persons with seizures, this normal pattern is interrupted by sudden and intense bursts of electrical energy, which may affect a person’s consciousness, bodily movements, or sensations. Given the right set of circumstances anyone can experience a seizure. The point at which there is enough physiological or pharmacological stress to cause a seizure is called the seizure threshold. There are individual differences in seizure thresholds. Seizure thresholds are affected by genetics, brain trauma, medications, drugs and alcohol, body temperature, fatigue, metabolic variables, hormones, nutrition, illness, stress, and a variety of other factors. If a seizure occurs as a result of some acute precipitating physiological disturbance such as a high fever or drug toxicity, the person may not experience another seizure when the precipitating cause is resolved. A single seizure does not equal epilepsy.

What is epilepsy? Epilepsy is the tendency to have recurrent seizures. This may also be referred to as a seizure disorder. Epilepsy is not a disease; it is a symptom of a neurological disorder that affects the brain. It is conventional to speak of someone having epilepsy, but it is more accurate to think in terms of one of the sense of a breeze on the skin, unusual sounds, voices that are not really there, unpleasant tastes, strange smells, and distortions in the way things look. A room may seem narrower or wider. Part of the body may appear to change in size or shape. If the area of the brain involved with memory is affected, there may be disturbing visions of people and places from the past. Time may seem distorted as well. The comfortable sense of familiar things and places may be disrupted by a simple partial seizure. Well-known places may look unfamiliar. New places and events may seem familiar as if they’ve happened before. This type of seizure usually lasts several minutes, but can be more prolonged.

A Complex Partial seizure causes an individual to have a change in level of consciousness, without loss of consciousness. This type of seizure may be referred to as a Psychomotor or Temporal Lobe seizure because the abnormal electrical activity often occurs in the temporal lobe of the brain. The seizure may last minutes during which the individual displays repetitive, non-purposful acts such as lip smacking, picking at things, fidgeting with objects, and/or moving around in an unorganized, restless manner. The person may appear confused and disoriented and cannot interact normally with others. Persons are not aware of their behavior, even though they do not lose consciousness. Like Simple Partial seizures, Complex Partial seizures are often associated with unusual sensations such as unusual smells, seeing or hearing things that are not there, or a sense of déjà vu. Several minutes of confusion usually follow the episode. The person is unable to recall what happened during the seizure and may be amnesic for events just preceding and following the seizure. As described above, Simple and Complex Partial seizure can produce a wide range of behavior depending on the part of the brain involved. What an individual does or feels during a seizure, however, is likely to be similar each time the person experiences a seizure.

Diagnosis
Diagnosis is critical to the appropriate management of epilepsy. Physicians must not only differentiate between epilepsy and other similar attacks but also must identify correctly the type of seizure or in some cases, the syndrome, a person has. Persons may experience more than one type of seizure.

The most commonly used tool to assist in diagnosing epilepsy is the electroencephalograph (EEG). The EEG measures electrical activity in the brain using small sensors, called electrodes, which are attached to various areas of the individual’s scalp. Only approximately 30-50% of persons with epilepsy have epileptiform abnormalities on the first EEG because electrical misfiring may not occur during the short testing period of a waking EEG. For that reason, when seizure activity is suspected, the physician may order a 24-hour continuous EEG or multiple recordings may be made to increase the diagnostic value of the EEG.

In addition to EEG, descriptions of the episode obtained from the person having the seizure or eyewitnesses are critical in making an accurate diagnosis. The questions listed on page 25 will help a physician make an accurate diagnosis and assist in treatment planning.

Treatment
Anticonvulsant or antiepileptic medication has been the primary treatment for epilepsy for more than 80 years. Choosing the best drug treatment for a person with epilepsy involves art as well as science, even in this age of evidence based medicine. The goal of treatment is to control seizures completely without causing unacceptable side effects.

The first step is accurate diagnosis. This cannot be overemphasized. Inaccurate diagnosis can result in treatment that not only does not reduce seizures, but may, in fact, worsen the condition. After a diagnosis is made, selection of an antiepileptic drug that is appropriate for the particular type of epilepsy and the specific individual is the priority. More than twenty medications are available to treat epilepsy and several medications may be effective in treating a particular type of epilepsy. The physician’s task is to find a medication that is effective in controlling seizures, while minimizing side effects. With substantial individual differences in responses to medications, a physician may have to try several medications to find one that is effective for a particular individual. It may also take some time to customize the dosage to maximize effectiveness and minimize side effects. Factors such as cost and dosing frequency may be taken into account when more than one medication is found to be effective.

In the past several years, a number of new antiepileptic drugs have become available, and more will likely be released. These new agents offer physicians expanded treatment options for persons with epilepsy. The wide range of treatments now available offers many persons seizure control without unacceptable side effects and provides the minority who have refractory epilepsy with a chance of achieving better control.

Unfortunately, despite these advances, many people with epilepsy are not getting the medication most appropriate for them. Common and potentially avoidable problems in treatment include: incorrect or incomplete identification of seizure types, resulting in inappropriate choice of treatment; selection of a drug appropriate for the seizure type, but not appropriate for the specific individual; correct diagnosis and choice of drug, but medication dosage that is too low or too high; no change in treatment despite substantial and bothersome side effects; or, failure to return to a specialist when treatment is ineffective.

Persons with epilepsy must advocate with their physicians to ensure that problems such as those described above do not prevent them from obtaining the most effective treatment available.

When medication does not control seizures or medication side effects are intolerable, additional treatment options may be considered. These options include surgery, vegas nerve stimulation, and restrictive diets.

Surgery to remove part of the brain where seizures are known to originate or to stop the spread of seizure activity from one side of the brain to the other has been an accepted form of treatment for over 50 years. Because of new surgical and imaging techniques, these operations are now being done with greater success.

Vagus nerve stimulation is another treatment option. This treatment is currently approved for use in persons over age12 who have partial seizures that resist control by other methods. The therapy is designed to prevent seizures by sending regular small pulses of electrical energy to the brain via the vagus nerve, a large nerve in the neck. The energy is delivered by a flat, round battery, about the size of a silver dollar, which is surgically implanted in the chest wall. The battery is programmed by the health team to send a few seconds of electrical energy to the vagus nerve every few minutes. If the person with the system feels a seizure coming on, he or she can activate the discharge by passing a small magnet over the battery. In some people this has the effect of stopping the seizure.

The ketogenic diet may be recommended for in children with hard to control seizures. The diet uses food to produce a change in the body’s chemistry called ketosis, which has the effect of controlling or reducing the frequency of seizures. The diet is very high in fat, low in carbohydrates, with restricted calories and no sugar. The ketogenic diet must be carefully tailored by a dietitian and strictly followed which requires substantial involvement of the child and family. The diet must be monitored by a physician just as medications are monitored. The diet is usually used to treat children for a limited period of time, after which the diet may be slowly tapered and regular food slowly reintroduced. If seizures return, the diet may be re-instituted. Studies are under way to see if the ketogenic diet is effective for some adults.

In addition to the treatment options described above, it is important to note that lifestyle management can go a long way toward reducing the frequency of seizures. Stress, sleep deprivation and fatigue, inadequate food intake, alcohol or drug use, and failure to take antiepileptic medication can result in an increase in seizures.

Conclusion
For optimal seizure control to be achieved, persons with seizures and family members must be active members of the treatment process.
Physicians should be contacted when there is new or increased seizure activity or when new symptoms, including possible side effects of medications, develop. Physicians cannot identify the best treatment unless they are given accurate information about seizure occurrence and medication side effects. Good communication and new treatment options make seizure control a realistic expectation.

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Types of Surgery Performed When Medications Are Not Effective in Controlling Seizures

Lobectomy: An operation to remove all or part of the lobe of the brain from which seizures emanate.

Hemispherectomy: An operation to remove all or almost all of one side (hemisphere) of the brain. Used in rare cases in children who have severe brain disease on just one side of the brain that produces uncontrollable seizures and paralysis on the opposite side of the body.

Corpus callosotomy: An operation that interrupts the spread of seizures by cutting some or all of the nerve fibers (corpus callosum) connecting one side of the brain to the other.

Multiple subpial transection: An operation in which small incisions which interfere with the spread of seizure impulses are made in specific areas of the brain. Used when seizures originate in or spread to parts of the brain that are responsible for critical functions, making it inadvisable to remove that area of the brain.

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Healthy Habits to Reduce the Frequency of Seizures

Take antiepeleptic medications every day, on time, as prescribed

Do not skip meals and drink plenty of fluids

Limit caffeine intake

Get adequate rest and sleep

Avoid all night study or work sessions

Learn and use basic relaxation stress management techniques

Discuss alcohol use with a physician and follow recommendations

Do not use street drugs

Check for possible drug interactions before starting a new
prescription or over the counter medication

Communicate with your physician

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When to Seek Emergency Medical Care
An uncomplicated seizure in someone who has epilepsy is not a medical emergency. It stops naturally after a few minutes. Some circumstances, however, require that you go to the emergency room or call the local emergency number. These situations include:

If a seizure lasts longer than 5 minutes

If it is the first time the person has had a seizure

If there is no medical I.D. and no way of knowing if this is a first seizure

If the person is pregnant, injured, or diabetic

If a second seizure starts shortly after the first has ended or before the person has recovered

If consciousness does not start to return after the shaking has stopped

If the person has difficulty breathing after the seizure

If the seizure happened in water

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For Further Information:

Epilepsy Foundation of America
Provides information to people with epilepsy, their families, researchers, educators, and caregivers in order to enhance quality of life.
1-800-EFA-1000
www.efa.org

MedicAlert
A non-profit membership organization that provides emergency medical alert information service. Members purchase medical alert bracelets which may alert emergency medical professionals to health/medical conditions.
www.medicalert.org

National Institute of Neurological Disorders and Stoke
The nation’s leading supporter of biomedical research on disorders
of the brain and nervous system.
www.ninds.nih.gov

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