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Overview |
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Definition |
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Seizures are a temporary neurologic event that results from abnormal,
hypersynchronous discharges from neurons in the central nervous system (CNS).
Seizures can be variously characterized according to behavioral and
electroencephalographic (EEG) changes. Recurrent seizures from one of many
chronic processes are considered epilepsy; however, a single seizure or
recurrent seizures from a correctable cause (e.g., febrile seizures) are not
considered epilepsy.
The International League Against Epilepsy published a Classification of
Epileptic Seizures in 1981 in which all seizures were classified according to
clinical features and EEG changes. The three major categories of seizures are:
partial, generalized, and unclassified.
Partial (or focal) seizures can be isolated to certain areas of the cerebral
cortex and are further classified as simple-partial seizures (consciousness is
preserved), complex-partial seizures (consciousness is lost), or partial
seizures with secondary generalization.
Generalized seizures usually involve both cerebral hemispheres and are
further classified as absence seizures (petit mal—brief
loss of consciousness), generalized tonic-clonic seizures (grand
mal—tonic contractions followed by unresponsiveness),
atonic seizures (transient loss of muscle tone), and myoclonic seizures
(transient muscle contractions).
Unclassified epileptic seizures include neonatal seizures, West syndrome
(infantile spasms), Lennox-Gastaut syndrome, juvenile myoclonic epilepsy, and
reflex epilepsy (e.g., seizures resulting from certain stimuli such as a
flickering light). |
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Etiology |
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- CNS infection (e.g., bacterial meningitis, encephalitis)
- Drug toxicity or withdrawal (e.g., alcohol or illicit drug
use)
- Genetic mutations (e.g., myoclonic epilepsy with ragged red fibers
[MERRF])
- Head trauma
- Electrolyte or metabolic derangements
- Drugs that lower the seizure threshold
- High fevers
- Brain abnormalities (e.g., tumors, stroke)
- Hypoglycemia and
hypocalcemia
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Risk Factors |
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- History of febrile seizures
- Family history of seizures
- History of stroke
- Alzheimer's disease
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Signs and Symptoms |
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The physical presentations of seizures are varied in duration, severity, and
characteristics. Signs may include the following.
- Prodrome of generalized seizures (aura), including lethargy,
depression, irritability, myoclonic jerks of limbs, abdominal pains, pale
complexion, headache, constipation, or diarrhea
- Loss of consciousness
- Total or partial body muscle spasm (tonic contractions)
- Apnea (cessation of breathing)
- Cyanosis (bluish coloring) of skin and mucous membranes
- Dilated pupils that are unreactive to light
- Bowel or bladder incontinence
- Increased pulse and blood pressure
- Increased salivation and sweating
- Deep coma, postictal confusion, and deep
sleep
Repeated seizures over a long period of time may result in:
- Absentmindedness
- Automatisms (e.g., lip smacking, chewing, fumbling)
- Declining school or work performance
- Loss of postural muscle
tone
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Differential
Diagnosis |
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- Stokes-Adams attack
- Transient ischemic attack
- Syncope
- Hysterical (psychogenic) seizures
- Metabolic disturbances (e.g., delirium tremens)
- Migraine syndromes
- Sleep disorders (e.g., narcolepsy)
- Movement disorders (e.g.,
tics)
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Diagnosis |
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Physical Examination |
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Initially, providers must attend to the seizure patient's respiratory and
cardiovascular status and vital signs. After the patient is stable, a detailed
history must be taken from family members, witnesses, and the patient (if
possible) to determine definitively whether the patient actually experienced a
seizure. Precipitating events (e.g., head trauma) and risk factors (e.g., family
history of seizures) must be considered. The presence or absence of "auras,"
which are experienced by up to 60% of seizure patients, automatisms, myoclonus,
postures (i.e., whether or not the patient fell), continence (loss of bowel
function), and postictal confusion must be noted. These signs can help to
differentiate the type of seizure experienced. |
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Laboratory Tests |
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Laboratory values are often normal in seizure patients.
- Complete blood count to diagnose metabolic disorders and as a
baseline before treatment
- Urine and blood toxicologic screens to determine any underlying drug
use
- Serum electrolytes and liver function tests for baseline values
before beginning treatment
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Pathology/Pathophysiology |
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In many cases, the brains of patients with generalized seizures appear
normal; however, some seizure disorders have definable lesions: hamartomas,
vascular abnormalities, areas of neuronal loss, fibrosis, scars, and tumors. In
addition, traumatic (e.g., cortical contusions) or hypoxic (e.g., degeneration
of Purkinje cells) effects can result from the seizures themselves.
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Imaging |
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- Magnetic resonance imaging (MRI) to diagnose cerebral lesions (e.g.,
tumors, vascular malformations)
- Computed tomography (CT) to diagnose CNS infection and cerebral
lesions when MRI is not available
- Positron emission tomography (PET) to localize epileptogenic areas in
cases refractory to medical treatment
- Single photon emission computed tomography (SPECT) to localize
epileptogenic areas in cases refractory to medical
treatment
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Other Diagnostic
Procedures |
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- An EEG is the primary diagnostic tool used to categorize seizures.
The epileptiform abnormalities (spikes and waves) on the EEG are recorded in 60%
to 90% of patients.
- Lumbar puncture—to diagnose meningitis,
encephalitis, and human immunodeficiency virus
- Closed-circuit television EEG (CCTV/EEG) for long-term monitoring in
a hospital setting to localize epileptogenic foci for resective
surgery
- Ambulatory EEG for long-term monitoring at home, school, or work to
localize epileptogenic foci for resective
surgery
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Treatment Options |
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Treatment Strategy |
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Treating the seizure patient can be challenging. It includes diagnosing and
treating any underlying condition (e.g., surgical removal of cerebral lesions,
focal brain resection, temporal lobectomy, lesionectomy, hemispherectomy) that
may be causing the seizure activity. Precipitating events (e.g., lack of sleep,
alcohol ingestion) should be identified and then avoided. The goal of therapy is
to stop the seizure without adverse side effects, to prevent recurrences, and to
help patients readjust to their home life and work environment.
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Drug Therapies |
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Ideally, patients should take only one medication. However, many patients
need several medications for complete seizure control. Approximately 30% to 70%
of seizure patients will have a second seizure within 1 year. Side effects from
seizure medication are experienced by over 50% of patients. These include
gastrointestinal complaints, gingival hypertrophy, weight gain or loss, hair
loss or hirsutism, coarsening of facial features (especially children),
drowsiness, impaired memory and concentration, depression, mood swings,
insomnia, dizziness, tremor, headache, ataxia, dermatitis, hepatotoxicity, bone
marrow suppression, aplastic anemia, thrombocytopenia, lymphadenopathy, and
osteomalacia.
- Carbamazepine (Tegretol), 600 to 1,800 mg/day for tonic-clonic and
focal-onset seizures
- Phenytoin (Dilantin), 300 to 500 mg/day for tonic-clonic and
focal-onset seizures
- Valproic acid (Depakote), 750 to 2,000 mg/day for tonic-clonic,
absence, myoclonic, and focal-onset seizures
- Phenobarbital (Luminal), 60 to 180 mg/day for tonic-clonic and
focal-onset seizures
- Primidone (Mysoline), 750 to 1,250 mg/day for tonic-clonic and
focal-onset seizures
- Lamotrigine (Lamictal), 150 to 500 mg/day for focal-onset seizures
and Lennox-Gastaut syndrome
- Gabapentin (Neurontin), 900 to 2,400 mg/day for focal-onset
seizures
- Ethosuximide (Zarontin), 750 to 1,500 mg/day for absence
seizures
- Clonazepam (Klonopin), 1 to 12 mg/day for absence and myoclonal
seizures
- Felbamate (Felbatol), 2400 to 3,600 mg/day for focal-onset seizures
and Lennox-Gastaut syndrome
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Complementary and Alternative
Therapies |
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Some mild cases of seizures may be controlled by alternative therapies,
specifically nutrition, the cornerstone of alternative treatment. Herbal
treatment may be helpful if low blood sugar and/or stress are initiating
factors. Precautions regarding sudden cessation of drugs must be adhered to as
there are currently no adequate replacements to drug therapies and/or surgical
interventions. |
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Nutrition |
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- A ketogenic diet (high fat, low protein, low carbohydrate) produces
ketones in the bloodstream, which may help control the frequency of seizures,
especially if low blood sugar, or skipping meals, is a trigger. Some studies
have shown a connection with food allergies and seizures in children. Avoid
alcohol, caffeine, and aspartame.
- Taurine: 500 mg tid, neuroinhibitory amino acid that inhibited
experimentally induced seizures
- Folic acid: 400 mcg/day, depleted during seizures and in some persons
with seizures, although higher doses than 400 mcg may actually precipitate some
seizures. Should take with B12
- B12: 100 to 200 mcg/day
- B6: 20 to 50 mg/kg, especially in children may help control seizures;
depleted in phenytoin therapy. However, B6 may inhibit phenytoin's
effects.
- Magnesium: 500 to 750 mg/day (should be in a 1:1 ratio in persons
taking calcium) for normal muscle and neuronal function
- Manganese: 5 to 15 mg/day, depleted in epileptics, especially in
children
- Zinc: 30 mg/day, may be depleted by some medications, some concern
that excess zinc may disrupt zinc/copper ratios and increase seizures,
especially without sufficient taurine
- Dimethylglycine: 100 mg bid, anecdotal evidence for decreasing
medication requirements
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Herbs |
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Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. of herb per cup of hot
water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes
for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination
as noted.
- Passionflower (Passiflora incarnata): to both prevent and
treat seizures, may be effective without side effects, especially where stress
is a precipitating factor. Dose is 30 drops tid to qid.
- Skullcap (Scutellaria lateriflora): antispasmodic and
calmative herb, with historic use for epilepsy
- Valerian (Valeriana officinalis): spasmolytic, sedative,
historically used for epilepsy, large doses may cause lethargy or
gastrointestinal upset that resolve with discontinuation
- The above herbs may be used singly or in combination at 1 cup tea tid
or 30 to 60 drops tincture tid. In addition, use milk thistle (Silybum
marianum) to protect the liver from ill effects of some medications (70 to
210 mg tid).
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency. For acute
prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours
until acute symptoms resolve. If symptoms persist consult with an experienced
homeopath.
- Artemesia vulgaris for convulsions after exertion and/or visual
stimulation
- Oenanthe for violent seizures, especially exacerbated
menstrually or after a head injury
- Bufo for convulsions accompanied by delayed
development
- Cicuta for violent seizures with arching of the back,
especially with a long postictal drowsiness and/or after head injury
- Cuprum metallicum for seizures with mental dullness and/or
difficulty breathing
- Causticum for seizures during menses or after a fright or
receiving bad news
- Belladonna as general remedy, especially for convulsions
followed by nausea
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Physical Medicine |
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Chiropractic, osteopathic, or naturopathic manipulation may be quite helpful,
especially in children with seizures or seizures appearing after a head
trauma. |
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Acupuncture |
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Acupuncture may be helpful with specific acupressure points that have been
used to stop seizures. |
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Patient Monitoring |
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Because of the toxicity of the antiepileptic therapy, patients must be
monitored closely for myriad side effects, the most serious of which include
hepatotoxicity, bone marrow suppression, aplastic anemia, thrombocytopenia,
lymphadenopathy, hirsutism, osteomalacia, and ataxia. In addition, determining
the correct dosage or drug combinations is an inexact science at present; thus,
patients must be monitored closely for many months until seizures are under
control and side effects are tolerable. Starting and stopping antiepileptic
medications must be done slowly, often by overlapping drugs for several weeks.
Monitoring should continue regularly to ensure patient compliance with the drug
schedule. |
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Other
Considerations |
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Prevention |
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Some patients can identify events that seem to trigger seizures such as
alcohol, lack of sleep, stress, and, in certain individuals, visual or auditory
stimuli (e.g., video games, music). Thus, these situations must be avoided.
Also, strict compliance with the drug schedule is mandatory to ensure
therapeutic blood levels. Dangerous activities such as swimming, operating
equipment, working at heights, and driving are contraindicated initially, and
perhaps forever, depending on the seriousness of the seizure disorder and the
success of treatment. |
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Complications/Sequelae |
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- The diagnosis of a seizure disorder can drastically alter a person's
outlook and restrict their productivity; in addition, patients may face
occupational discrimination and loss of independence if they are unable to
drive. Depression or other psychological disturbances may result.
- Serious injuries are often sustained with the first seizure and in
seizure disorders that are refractory to treatment. Head injuries and broken
bones are common sequelae.
- The long-term effects of antiepileptic drugs on the growth and
development of children is unknown.
- Generalized status epilepticus is characterized by a series of grand
mal seizures without regaining consciousness. This must be treated as a medical
emergency as irreversible neurologic sequelae are common.
- Absence status is characterized by absence seizures that may last for
hours. This may be labeled inattention or daydreaming by young schoolchildren
who may fall behind developmentally if the seizure disorder is not diagnosed.
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Prognosis |
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Approximately 60% of adults who have successful therapeutic treatments and
are seizure-free for two to five years can stop taking their medication. The
exact point at which a drug-free trial should occur is unknown, but often
providers make a first attempt after two years. Seizures that are refractory to
drug therapy (20%) may respond successfully to surgery if they fit the criterion
for a good surgical candidate. The diagnosis of a seizure disorder can
drastically alter a person's outlook and restrict their productivity.
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Pregnancy |
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While it is not uncommon for women with a seizure disorder to have a normal
pregnancy and delivery, there may be changes in the frequency of the seizures,
which can have a teratogenic effect. Also, women who experience grand mal
seizures while pregnant are more likely to experience premature labor,
spontaneous abortion, toxemia, and abruptio placentae and hypoxia. In addition,
infants of women who are taking antiepileptic drugs have malformations two to
three times as often as healthy women. These malformations include cleft lip and
palate, cardiac abnormalities, anencephaly, and neural tube
defects. |
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References |
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Adams RD, Victor M, Ropper AH. Principles of Neurology. 6th ed. New
York, NY: McGraw-Hill; 1997:313-341.
Bartram T. Encyclopedia of Herbal Medicine. Dorset, England: Grace
Publishers; 1995:170-171.
Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrison's Principles
of Internal Medicine. 14th ed. New York, NY: McGraw-Hill Book Co;
1998:2311-2325.
Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal
Medicines. Montvale, NJ: Medical Economics Co; 1998:1128, 1135, 1204,
1219.
Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms.
Albany, Calif: Hahnemann Clinic Publishing; 1993:46, 76, 111-114, 124,
146-147, 276.
Murray MT. Encyclopedia of Nutritional Supplements. Rocklin, Calif:
Prima Publishing; 1996:84.
Murray MT. The Healing Power of Herbs: The Enlightened Person's Guide to
the Wonders of Medicinal Plants. 2nd ed. Rocklin, Calif: Prima Publishing;
1998:40, 91.
Rowland LP. Merritt's Textbook of Neurology. 9th ed. Media, Pa:
Williams & Wilkins; 1995:845-868.
Werbach MR. Nutritional Influences on Illness. New Canaan, Conn: Keats
Publishing, Inc; 1987:189-193. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |