Neurology

Epilepsy: symptoms, diagnosis, treatment

Updated: 08 November , 13:37
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Christian E. Elger

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Causes and symptoms of epilepsy

Epilepsy is considered a functional brain disorder, which manifests itself in the form of seizures, during which neurons produce sudden and short-time uncontrolled impulses.

The overall risk of having epilepsy is 3-5%. In developed countries this is a growing trend, associated with population aging. Most often, children or people over 50-60 years old are affected, although epilepsy can start at any age. In industrialized countries, the incidence is 5-9 cases per each 1000 people.

The causes of epilepsy are varied: congenital or acquired abnormal changes in the brain; metabolic disorders (diabetes, thyroid disease, etc.); genetic mutations, including hereditary ones. Combined, genetic and structural-metabolic cases of epilepsy are also known: the symptoms of an inherited disease appear only as a result of a significant trigger – a stroke, meningitis, poisoning, etc. In some cases, the cause cannot be established, so they are referred to as idiopathic.

The main symptoms of epilepsy

The main signs of epileptic seizures are well-known and include a fixed gaze, hypertonia, loss of consciousness, rhythmic, sometimes asynchronous convulsions, wheezing, biting the tongue. The attack ends with drowsiness and mental confusion. Such episodes often occur upon awakening, and last no longer than 90 seconds (they should not be mixed up with psychogenic seizures which can last for several minutes). Still, not every physician can make the correct diagnosis of epilepsy. The reasons include the variety of the disease forms, as well as of the intensity and frequency of symptoms. When an attack occurs, it is important to get the advice of a competent specialist as soon as possible. First, the expert will be able to distinguish the true symptoms from signs of other disorders with similar manifestations. These can be cerebrovascular events, drug or heavy metal poisoning, meningitis, concussions, or metabolic disorders. Second, the fastest possible examination does not only ensure a correct diagnosis, but also increases the treatment effect.

The Importance of the Anamnesis in Diagnosis-Making

The correct diagnosis largely depends on comprehensive anamnesis taking. The highest risk of an epileptic seizure hides itself behind previous manifestations: the probability of relapse increases to 70% after two unprovoked episodes without convulsive symptoms. It is important not to miss "harmless" cases. The most typical causes of misinterpretation are panic attacks or behavioral disorders that are not associated with epilepsy. However, generalized motor manifestations may be underestimated.

The most common (11-50%) diagnostic errors occur in patients with psychogenic non-epileptic seizures. Often the mistake is revealed when patients report a long-term lack of effect from taking antiepileptic drugs. Although experts are well aware of a number of significant differences:

- after an epileptic attack the patient is lethargic, almost non-responding to stimuli, while in a state of psychosis the patient can start speaking a foreign language or imagine living at a different age;

- in contrast to psychogenic ones, true epileptic seizures are characterized by slow head movements to the sides.

Patients with resistance to antiepileptic drugs should contact specialized centers, as the consequences of improper treatment can be extremely severe. Mortality in such patients is statistically 2.5 times higher than in those receiving the correct treatment.

Another important symptom is the time needed for the patient to return to a normal state after an attack. With a short-term loss of consciousness, this time is one to two minutes. With epilepsy, the patient needs 15-30 minutes to recover from an attack.

What exams should be done to confirm epilepsy?

In addition to a case history, special tests and imaging studies are necessary. They allow to identify possible abnormal changes.

Electroencephalography in the diagnosis of epilepsy

Electroencephalography (EEG) is recommended to be performed within half an hour after the attack, at the latest within 24 hours. According to most experts, the presence of epileptic potentials is most reliably recorded during this period.

A study involving 170 patients, completed in Germany in 2020, indicates that the most reliable EEG results were obtained within the first 16 hours. This allows to decide on the appropriateness of antiepileptic drugs.

If an antiepileptic drug is administered within 48 hours following an attack, the risk of relapse within the next five years constitutes 32%, but if therapy starts later, the risk is 48%.

In daily practice, the correct interpretation of EEG findings is of key importance.

Incorrect assessment of normal variants based on EEG results can lead to misdiagnosis and, subsequently, to incorrect treatment. In particular, the so-called Wicket spikes, which are similar to the epileptic potentials of temporal lobar epilepsy with symptoms of drowsiness, should be considered as variants of normal.

Video monitoring as an important study option

For a more comprehensive examination, a 1-3 day EEG with video recording is performed. A video of the patient taken at the time of the attack can significantly help in the correct diagnosis. Only an experienced epileptologist can interpret such data correctly.

In Germany, EEG assessment belongs to areas requiring high expertise, so physicians engaged in it should be board-certified in neurophysiology.

Epilepsy MRI scans

Timely performed MR imaging in conjunction with EEG makes it possible to confirm the presence of structural abnormalities. In such cases, the probability of recurrence exceeds 60%. If there are no structural changes, the risk of recurrence is significantly lower, namely, from 19 to 26%.

The choice of a hospital to diagnose epilepsy is critical. To avoid both false positive, and false negative results, a combination of the epileptologist’s clinical experience and the appropriate technical facilities is required. It is important to perform both standard and long-term EEG with video recording, as well as cranial MRI with detection of epileptology zones.

Treatment prospects

Epilepsy is not curable. The goal of therapy is to reduce the frequency and intensity of seizures as much as possible. Some patients can experience single episodes of the disease that do not require treatment.

The first-line therapy involves medications. If it is ineffective, surgery can be considered.

Drug treatment

Recurrent seizures require therapy with anticonvulsants. The regimens should be determined by specialized health care facilities, where the drug type and dosage can be selected carefully, taking into consideration a whole range of factors. One of the most important ones is drug tolerance.

In 50% of patients, the initially suggested plan is successful in getting rid of seizures. If a drug causes side effects, it can be replaced with a better-tolerated one. The substitute medications are effective in the next 20% of patients.

However, the best results are often achieved by a combination of several medications. Only a highly qualified specialist with appropriate expertise can suggest an effective treatment regimen and determine the treatment duration. In certain cases, therapy can be lifelong.

When prescribing antiepileptic drugs, the following factors are taken into account:

     • physical condition, weight and cognitive abilities;

     • personal life goals, such as the desire to have a child;

     • comorbidities and medications taken to manage them.

Neurostimulation

If medicines fail to prevent epilepsy attacks, neurostimulation may be used. This method is not exactly perfect, since it does not guarantee complete suppression of epileptic activity either, but it may bring some improvement. The most common procedure types are:

Vagus nerve stimulation. The method uses a pacemaker implanted subcutaneously in the collarbone area and connected to an electrode that is attached to the vagus nerve area in the neck. The device generates regular electrical impulses to suppress seizures.

Deep brain stimulation also involves electrical impulses, but in this case, they are generated by electrodes implanted in certain brain areas. The aim is the same, that is, the suppression of epileptic activity.

Antiepileptic surgery

If conservative therapy fails, the remaining option is surgery. As a rule, it is performed if the condition is associated with focal brain lesions, since with a generalized form it is impossible to identify abnormal areas to be removed. Indications for surgical treatment are determined by epileptologists together with neurosurgeons and radiologists. Decision-making involves the assessment of surgical risks; in particular, the chances that intervention may result in partial or complete loss of speech, mental activity, and other functions.

There are two types of epilepsy operations:

     • resective (with curative effect): the seizure-initiating zones are removed completely, eliminating the disease cause. Preliminary testing is carried out to assess the possible consequences of lesion resection. For example, if the temporal area is affected, doctors evaluate the chances to spare the memory function.

     • Non-resective (palliative) operations do not result in complete relief from seizures. Such interventions prevent frequent and severe attacks and help reduce the use of anticonvulsant medications. The goal is not to remove a lesion, but to cut the connections between brain areas, which interrupts the transmission of an attack provoking impulse.

Scientific Research Perspectives

The University of Bern Department for Diagnostic and Interventional Neuroradiology in Switzerland is currently investigating possible areas of functional brain damage in patients with primary unprovoked seizures. The purpose of the study was to identify biological markers of epilepsy. Experts proceed from the fact that brain areas with the same structure may be functionally interconnected.

In particular, one of the studies revealed that in patients with the temporomandibular form of the disease, the fixed structural relationships in the EEG, which did not detect abnormality, differed from the EEG of healthy patients. The research team was able to use MRI to determine which hemisphere of the brain was affected.

Thus, the study of such relationships gives a chance to identify biomarkers relevant both for diagnosis and classification of epilepsy.

References:

  • Baumgartner C, Galmetzer P, Piker S et al.: EEG-Muster, die mit epileptischer Aktivität verwechselt werden können. Thieme 2011. DOI: 10.1055/b-0034-36721.
  • Llaurado A, Santamarina E Fonseca E., et al.: How soon should urgent EEG be performed following a first epileptic seizure? Epilepsy behav. 2020; 111 (107315). DOI: 10.1016/j.yebeh.2020.107315
  • Fisher RS Acevedo C, Arzimanoglou A, et al.: ILAE official report: a practical clinical definition of epilepsy. Epilepsia 2014; 55 (4): 475-82. DOI: 10.1111/epi.12550.
  • Watson E, Ryan EG, Jones M, et al: psychogenic nonepileptic seizures treated as epileptic seizures in the emergency department. Epilepsia 2021; 62 (10): 2416-25. DOI: 10.1111/epi. 17038.
  • Pohlmann-Eden B, Beghi E, Camfield C, et al: The first sezure and ist management in adults and children. BMJ 2006; 332 (7537): 339-42. DOI: 10.1136/bmj.332.7537.339.
  • Elger, C. Bei therapierefraktärer Epilepsie Op erwägen. InFo Neurologie 23, 27 (2021).
  • Randi von Wrede, Christian E. Elger Diagnostik und Therapie bei Patienten mit epileptischen Anfällen
  • Image source: Free Stock photos by Vecteezy
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Дмитрий Попов
Дмитрий Попов

Благодаря медикаментам эпилептические приступы у моей жены бывали очень редко, не чаще, чем раз в год. Потом вдруг она стала терять сознание по пять раз за ночь, но совсем не так, как при эпилепсии. На ЭКГ каждый раз фиксировалось нарушение сердечного ритма. У нас теперь очень большая проблема с тем, какие медикаменты принимать. Слышали, при аритмии энтиэпилептические средства могут быть небезопасными. Очень надеемся на вашего консультанта профессора Эльгера.

Кристина Подольская
Кристина Подольская

Насколько опасны хирургические операции на головном мозгу для лечения эпилепсии? Как они могут повлиять на дальнейшую жизнь?

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