Epilepsy treatment with proper diagnosis, medication and surgery

Dr. Moradi, a neurologist

Epilepsy is a neurological condition (affecting the brain and nervous system) where a person has a tendency to have seizures that start in the brain. The brain is made up of millions of nerve cells that use electrical signals to control the body’s functions, senses and thoughts. If the signals are disrupted, the person may have an epileptic seizure.

types of Epilepsy in children

Epilepsy classification in children is due to the type of Seizure .

Generalized onset seizures

 These seizures affect both sides of the brain or groups of cells on both sides of the brain at the same time. This term was used before and still includes seizures types like tonic-clonic, absence, or atonic to name a few.

Focal onset seizures 

The term focal is used instead of partial to be more accurate when talking about where seizures begin. Focal seizures can start in one area or group of cells in one side of the brain.

  • Focal Onset Aware Seizures: When a person is awake and aware during a seizure, it’s called a focal aware seizure. This used to be called a simple partial seizure.
  • Focal Onset Impaired Awareness: When a person is confused or their awareness is affected in some way during a focal seizure, it’s called a focal impaired awareness seizure. This used to be called a complex partial seizure.

Unknown onset seizures

 When the beginning of a seizure is not known, it’s now called an unknown onset seizure. A seizure could also be called an unknown onset if it’s not witnessed or seen by anyone, for example when seizures happen at night or in a person who lives alone. As more information is learned, an unknown onset seizure may later be diagnosed as a focal or generalized seizure.

Causes Of Epilepsy 

Different epilepsies are due to many different underlying causes. The causes can be complex, and sometimes hard to identify. A person might start having seizures because they have one or more of the following.

  • A genetic tendency, passed down from one or both parents.
  • A genetic tendency that is not inherited, but is a new change in the person's genes.
  • A structural change in the brain, such as the brain not developing properly, or damage caused by a brain injury , infections like meningitis a stroke) or a tumour.
  • Structural changes due to genetic conditions such as tuberous sclerosis, or neurofibromatosis, which can cause growths affecting the brain.

Symptoms of Epilepsy in Children

  • Short attention blackouts, dazed behavior, memory gaps, mumbling or no response
  • Sudden falls, frequent stumbling or unusual clumsiness
  • Repeated, unusual movements such as head nodding or rapid blinking
  • Sudden stomach pain followed by confusion and sleepiness
  • Unusual sleepiness and irritability when woken up
  • Frequent complaints that things look, sound, taste, smell or feel "funny"
  • Sudden, repeated fear or anger
  • Clusters of (repeated) "jackknife" movements by babies who are sitting down
  • Clusters of grabbing movements with both arms in babies lying on their backs

How is Epilepsy Diagnosed?

Making a diagnosis involves identifying a condition or disease based on signs and symptoms. An epilepsy diagnosis is generally made when seizures occur more than once without an identifiable reason, such as fever or injury. Any child without a known diagnosis of epilepsy who experiences an unprovoked seizure needs immediate emergency medical attention and then have follow-up with her primary care pediatrician soon thereafter. If seizures reoccur, children should see a pediatric neurologist, a specialist who manages seizures and epilepsy. While every child's diagnostic process will vary, the major steps in the process typically include:

  • Detailed medical history: May include questions regarding the mother's pregnancy and delivery, any relatives with epilepsy, and if the child had a high fever, serious head injury and/or periods of staring, inattention or breath-holding.
  • Detailed account of the seizure: The person(s) who were present at the time of the child's seizure should communicate with the doctor.
  • Physical examination: Assessment of cardiac, neurological, and mental status.
  • Blood test: To identify potential causes and or other significant illnesses.
  • Computerized Axial Tomography (CAT) or CT Scan : Can be used to determine whether a seizure was caused by an acute neurological lesion or illness.
  • Electroencephalogram (EEG): Can be used to assess the risk of seizure recurrence and may help determine seizure type and epilepsy syndrome.
  • Magnetic Resonance Image (MRI): Preferred brain picture when evaluating children with new onset seizures or seizures that may have started in a particular part of the brain.

After the exam, tests, and a period of observation, a doctor determines whether a child has epilepsy.

First aid after epileptic seizure

First aid for children having a seizure is usually aimed at keeping the child safe and as comfortable as possible. To those ends, there are a few basic things to remember :

  • Realize that most seizures last only a few seconds to a few minutes and are not life-threatening. Stay calm, and speak reassuringly to the child having a seizure, both during the seizure and afterward.
  • If a child has a generalized tonic-clonic seizure, first make sure they are safe. Prevent injury to the child by removing any sharp objects from the area or items that could be pulled down on top of the person during a seizure. If the child seizing is at risk for falling, help guide them to the ground or to a comfortable chair. Protect their head from hitting the floor by placing a folded-up piece of clothing beneath it.
  • Make note of the time. If the seizure is more severe than usual, the child is injured or choking, or the seizure goes on for more than 5 minutes, call your doctor.
  • Don’t try to hold a child down during a seizure. This won’t stop the convulsions, and you risk injury to yourself and to them if you try to restrain them.
  • If the child is walking during a seizure, help to guide them away from dangers like traffic, heights, or the edges of subway or train platforms.
  • Do not put anything in the mouth of someone having a seizure! Doing so increases the risk of choking. To help prevent choking on saliva during a tonic-clonic seizure, roll the child onto their side so their mouth is pointed toward the ground.
  • After a seizure, stay with the child until they feel normal or feel able to contact someone else who can help them.

Treatment for children

 

Anti-epileptic drugs

Most people with epilepsy take anti-epileptic drugs (AEDs) to control their seizures. The paediatrician can discuss with you whether AEDs are the best option for your child. Although AEDs aim to stop seizures from happening, they do not stop seizures while they are happening, and they do not cure epilepsy. Most children stop having seizures once they are on an AED that suits them. Like all drugs, AEDs can cause side effects for some children. Some side effects go away as the body gets used to the medication, or if the dose is adjusted. If you are concerned about your child taking AEDs you can talk to their paediatrician, epilepsy nurse, GP or pharmacist. Changing or stopping your child's medication without first talking to the doctor can cause seizures to start again or make seizures worse. Although AEDs work well for many children, this doesn’t happen for every child. If AEDs don’t help your child, their doctor may consider other ways to treat their epilepsy.

Ketogenic diet

For some children who still have seizures even though they have tried AEDs, the ketogenic diet may help to reduce the number or severity of their seizures. The diet is a medical treatment, often started alongside AEDs and is supervised by trained medical specialists and dietitians.

Who is the diet suitable for?

The diet may not work for everyone but is suitable for many different seizure types and epilepsy syndromes, including myoclonic astatic epilepsy, Dravet syndrome, infantile spasms, and those with tuberous sclerosis. It can be adapted to all ethnic diets, as well as for children who are allergic to dairy products (although this can limit the food choice). The dietitian will calculate the diet and try to include foods your child likes. If your child has feeding problems or has a condition where a high fat diet would cause problems, the diet may not be suitable.

What is the ketogenic diet?

The ketogenic diet (KD) is a high fat, low carbohydrate, controlled protein diet that has been used since the 1920s for the treatment of epilepsy. The diet is a medical treatment and is usually only considered when at least two suitable medications have been tried and not worked.  The ketogenic diet is an established treatment option for children with hard to control epilepsy. Dietary treatments for epilepsy must only be followed with the support of an experienced epilepsy specialist and dietitian.

Epilepsy surgery

It may be possible for some children to have epilepsy surgery depending on the type of epilepsy they have and where in the brain their seizures start. Epilepsy surgery involves removing a part of the brain to stop or reduce the number of seizures a child has.

After surgery

Immediately after the surgery your doctors will monitor your recovery. For the first few days you may feel very tired and need to sleep, as it can take a while for the anaesthetic to completely wear off. Some people who have brain surgery will have seizures within the first week of surgery - but this doesn’t mean the surgery has not been successful. Seizures after surgery can happen because of the direct stress the brain experiences in surgery, rather than because a person has a history of epilepsy. How long you may need to spend in hospital will depend on the type of surgery you have had and how the doctors feel you are recovering. Generally your doctors might expect you to be back to your normal activity about six weeks after your surgery, but this is very individual.

What are the possible risks of surgery?

For any type of surgery, there are possible risks relating to how the person responds to anaesthetic, or to any complications that happen during the operation. Risks for epilepsy surgery will vary depending on what type of surgery a person has. The most common type of epilepsy surgery is removal of part, of the temporal lobe. Possible risks of this type of surgery include problems with memory, a partial loss of sight, depression or other mood problems. These risks will vary from person to person, and may be only temporary in some cases. For some people, their memory and mood could improve after epilepsy surgery. Therefore the chance to ask your medical team questions before surgery is very important, to help you understand what the specific possible risks are for you.