What are seizures

Seizures also known as fits, are symptoms of a brain problem caused by rapid and uncoordinated electrical firing in the brain that often causes alternating stiffening and jerking of the arms and legs, and a loss of consciousness or altered consciousness level. Seizure can vary widely and cause a wide range of symptoms. A person having a seizure may lose consciousness during the seizure, or between several seizures. Others may become very rigid and have a fixed staring expression on their face or rolling eyes. Some people with seizures simply stare blankly for a few seconds during a seizure, while others repeatedly twitch their arms or legs. Having a single seizure doesn’t mean you have epilepsy. In general, a person is not considered to have epilepsy until he or she has had two or more unprovoked seizures separated by at least 24 hours.

Seizures can affect people in different ways, depending on which part of the brain is involved. Some seizures cause the body to jerk and shake (a “fit”), while others cause problems like loss of awareness or unusual sensations. They typically pass in a few seconds or minutes.

Seizures can occur when you’re awake or asleep. Sometimes they can be triggered by something, such as feeling very tired.

Seizures happen because of sudden, abnormal electrical activity in the brain. When people think of seizures, they often think of convulsions in which a person’s body shakes rapidly and uncontrollably. Not all seizures cause convulsions. There are many types of seizures and some have mild symptoms. Seizures fall into two main groups. Focal seizures, also called partial seizures, happen in just one part of the brain. Generalized seizures are a result of abnormal activity on both sides of the brain.

Most seizures last from 30 seconds to 2 minutes and do not cause lasting harm. However, it is a medical emergency if seizures last longer than 5 minutes or if a person has many seizures and does not wake up between them. Seizures can have many causes, including medicines, high fevers, head injuries and certain diseases. People who have recurring seizures due to a brain disorder have epilepsy. At least two unprovoked seizures are generally required for an epilepsy diagnosis. In contrast, seizures can be caused by epilepsy but there are other causes, including very low blood sugar, fluctuations in electrolyte levels, high fever, acute traumatic brain injury, nervous system infections or recreational drugs, for example. The brain controls everything you do by sending messages — like little electrical signals — to and from your body to make you move, feel, think or react. A seizure occurs when the brain cells send mixed-up messages, which stops a person’s body from working properly for a short time.

Figure 1. Recovery position

When are seizures not epilepsy?

While any seizure is cause for concern, having a seizure does not by itself mean a person has epilepsy. First seizures, febrile seizures, nonepileptic events, and eclampsia (a life-threatening condition that can occur in pregnant women) are examples of conditions involving seizures that may not be associated with epilepsy. Regardless of the type of seizure, it’s important to inform your doctor when one occurs.

First seizures

Many people have a single seizure at some point in their lives, and it can be provoked or unprovoked, meaning that they can occur with or without any obvious triggering factor. Unless the person has suffered brain damage or there is a family history of epilepsy or other neurological abnormalities, the majority of single seizures usually are not followed by additional seizures. Medical disorders which can provoke a seizure include low blood sugar, very high blood sugar in diabetics, disturbances in salt levels in the blood (sodium, calcium, magnesium), eclampsia during or after pregnancy, impaired function of the kidneys, or impaired function of the liver. Sleep deprivation, missing meals, or stress may serve as seizure triggers in susceptible people.

Many people with a first seizure will never have a second seizure, and physicians often counsel against starting antiseizure drugs at this point. In some cases where additional epilepsy risk factors are present, drug treatment after the first seizure may help prevent future seizures. Evidence suggests that it may be beneficial to begin antiseizure medication once a person has had a second unprovoked seizure, as the chance of future seizures increases significantly after this occurs . A person with a pre-existing brain problem, for example, a prior stroke or traumatic brain injury, will have a higher risk of experiencing a second seizure. In general, the decision to start antiseizure medication is based on the doctor’s assessment of many factors that influence how likely it is that another seizure will occur in that person.

In one study that followed individuals for an average of 8 years, 33 percent of people had a second seizure within 4 years after an initial seizure. People who did not have a second seizure within that time remained seizure-free for the rest of the study. For people who did have a second seizure, the risk of a third seizure was about 73 percent by the end of 4 years. Among those with a third unprovoked seizure, the risk of a fourth was 76 percent.

Febrile seizures

Not infrequently a child will have a seizure during the course of an illness with a high fever. A temperature of 100.4°F (38°C) or above may cause febrile seizures in children. A febrile seizure can be frightening for any parent or caregiver. Most of the time, a febrile seizure does not cause any harm. The child usually does not have a more serious long-term health problem. Febrile seizures occur most often in otherwise healthy children between ages 6 months and 5 years. Toddlers are most commonly affected. Febrile seizures often run in families. Most febrile seizures occur in the first 24 hours of an illness. It may not occur when the fever is highest. A cold or viral illness may trigger a febrile seizure. Antiseizure medications following a febrile seizure are generally not warranted unless certain other conditions are present: a family history of epilepsy, signs of nervous system impairment prior to the seizure, or a relatively prolonged or complicated seizure. The risk of subsequent non-febrile seizures is low unless one of these factors is present.

Results from a study funded by the National Institute of Neurological Disorders and Stroke suggested that certain findings using diagnostic imaging of the hippocampus may help identify which children with prolonged febrile seizures are subsequently at increased risk of developing epilepsy.

Researchers also have identified several different genes that influence the risks associated with febrile seizures in certain families. Studying these genes may lead to new understandings of how febrile seizures occur and perhaps point to ways of preventing them.

Febrile seizures prevention

Because febrile seizures can be the first sign of illness, it is often not possible to prevent them. A febrile seizure does not mean that your child is not getting the proper care.

Occasionally, a provider will prescribe a medicine called diazepam to prevent or treat febrile seizures that occur more than once. However, no drug is completely effective in preventing febrile seizures.

Febrile seizures symptoms

A febrile seizure may be as mild as the child’s eyes rolling or limbs stiffening. A simple febrile seizure stops by itself within a few seconds to 10 minutes. It is often followed by a brief period of drowsiness or confusion.

A febrile seizure symptoms may include any of the following:

• Sudden tightening (contraction) of muscles on both sides of a child’s body. The muscle tightening may last for several seconds or longer.
• The child may cry or moan.
• If standing, the child will fall.
• The child may vomit or bite their tongue.
• Sometimes, children do not breathe and may begin to turn blue.
• The child’s body may then begin to jerk rhythmically. The child will not respond to the parent’s voice.
• Urine may be passed.

A seizure lasting longer than 15 minutes, is in just one part of the body, or occurs again during the same illness is not a normal febrile seizure.

The health care provider may diagnose febrile seizure if the child has a tonic-clonic seizure but does not have a history of seizure disorders (epilepsy). A tonic-clonic seizure involves the entire body. In infants and young children, it is important to rule out other causes of a first-time seizure, especially meningitis (bacterial infection of the covering of the brain and spinal cord).

Febrile seizures diagnosis

With a typical febrile seizure, the examination usually is normal, other than symptoms of the illness causing the fever. Often, the child will not need a full seizure workup, which includes an EEG, head CT, and lumbar puncture (spinal tap).

Further testing may be needed if the child:

• Is younger than 9 months or older than 5 years
• Has a brain, nerve, or developmental disorder
• Had the seizure in only one part of the body
• Had the seizure last longer than 15 minutes
• Had more than one febrile seizure in 24 hours
• Has an abnormal finding when examined

Febrile seizures treatment

The aim of treatment is to manage the underlying cause. The following measures help keep the child safe during a seizure:

• Do not hold down the child or try to stop the seizure movements.
• Do not leave the child alone.
• Lay the child on the ground in a safe area. Clear the area of furniture or other sharp objects.
• Slide a blanket under the child if the floor is hard.
• Move the child only if they are in a dangerous location.
• Loosen tight clothing, especially around the neck. If possible, open or remove clothes from the waist up.
• If the child vomits or if saliva and mucus build up in the mouth, turn the child to the side or on the stomach. This is also important if it looks like the tongue is getting in the way of breathing.
• Do not force anything into the child’s mouth to prevent biting the tongue. This increases the risk for injury.

If the seizure lasts several minutes, call the local emergency number, to have an ambulance take your child to the hospital.

Call your child’s doctor as soon as possible to describe your child’s seizure.

After the seizure, the most important step is to identify the cause of the fever. The focus is on bringing the fever down. The provider may tell you to give your child medicines to reduce the fever. Follow instructions exactly on how much and how often to give your child the medicine. These medicines, however, do not reduce the chance of having febrile seizures in the future.

It is normal for children to sleep or be drowsy or confused for a short time right after a seizure.

Febrile seizures prognosis

The first febrile seizure can be frightening for parents. Most parents are afraid that their child will die or have brain damage. However, simple febrile seizures are harmless. There is no evidence that they cause death, brain damage, epilepsy, or learning problems.

Most children outgrow febrile seizures by age 5.

Few children have more than 3 febrile seizures in their lifetime. The number of febrile seizures is not related to future risk for epilepsy.

Children who would develop epilepsy anyway will sometimes have their first seizures during fevers. These seizures most often do not appear like a typical febrile seizure.

Non epileptic seizures

An estimated 5 to 20 percent of people diagnosed with epilepsy actually have non-epileptic seizures, which outwardly resemble epileptic seizures, but are not associated with seizure-like electrical discharge in the brain. Non-epileptic events may be referred to as psychogenic non-epileptic seizures (PNES), which do not respond to antiseizure drugs. Instead, psychogenic non-epileptic seizures are often treated by cognitive behavioral therapy (CBT) to decrease stress and improve self-awareness.

A history of traumatic events is among the known risk factors for psychogenic non-epileptic seizures. People with psychogenic non-epileptic seizures should be evaluated for underlying psychiatric illness and treated appropriately. Two studies together showed a reduction in seizures and fewer coexisting symptoms following treatment with cognitive behavioral therapy. Some people with epilepsy have psychogenic seizures in addition to their epileptic seizures.

Other non epileptic seizures may be caused by narcolepsy (sudden attacks of sleep), Tourette syndrome (repetitive involuntary movements called tics), cardiac arrhythmia (irregular heart beat), and other medical conditions with symptoms that resemble seizures. Because symptoms of these disorders can look very much like epileptic seizures, they are often mistaken for epilepsy.

Are there special risks associated with seizures?

Although most people with epilepsy lead full, active lives, there is an increased risk of death or serious disability associated with epilepsy. There may be an increased risk of suicidal thoughts or actions related to some antiseizure medications that are also used to treat mania and bipolar disorder. Two life-threatening conditions associated with the epilepsies are status epilepticus and sudden unexpected death in epilepsy (SUDEP).

Status Epilepticus

Status epilepticus is a potentially life-threatening condition in which a person either has an abnormally prolonged seizure or does not fully regain consciousness between recurring seizures. Status epilepticus can be convulsive (in which outward signs of a seizure are observed) or nonconvulsive (which has no outward signs and is diagnosed by an abnormal EEG). Nonconvulsive status epilepticus may appear as a sustained episode of confusion, agitation, loss of consciousness, or even coma. Sometimes termed subtle status epilepticus, the motor movements of this type of nonconvulsive status epilepticus may only be nystagmoid eye movements, facial twitching, extremity twitches, or in some cases, no motor movement at all ¹.

Any seizure lasting longer than 5 minutes should be treated as though it was status epilepticus. There is some evidence that 5 minutes is sufficient to damage neurons and that seizures are unlikely to end on their own, making it necessary to seek medical care immediately. One study showed that 80 percent of people in status epilepticus who received medication within 30 minutes of seizure onset eventually stopped having seizures, whereas only 40 percent recovered if 2 hours had passed before they received medication. The mortality rate can be as high as 20 percent if treatment is not initiated immediately.

Researchers are trying to shorten the time it takes for antiseizure medications to be administered. A key challenge has been establishing an intravenous (IV) line to deliver injectable antiseizure drugs in a person having convulsions. A National Institute of Neurological Disorders and Stroke-funded study on status epilepticus found that when paramedics delivered the medication midazolam to the muscles using an autoinjector, similar to the EpiPen drug delivery system used to treat serious allergic reactions, seizures could be stopped significantly earlier compared to when paramedics took the time to give lorazepam intravenously. In addition, drug delivery by autoinjector was associated with a lower rate of hospitalization compared with IV delivery.

Sudden Unexplained Death in Epilepsy (SUDEP)

For reasons that are poorly understood, people with epilepsy have an increased risk of dying suddenly for no discernible reason. Some studies suggest that each year approximately one case of Sudden Unexplained Death in Epilepsy (SUDEP) occurs for every 1,000 people with the epilepsies. For some, this risk can be higher, depending on several factors. People with more difficult to control seizures tend to have a higher incidence of SUDEP.

Sudden Unexplained Death in Epilepsy (SUDEP) can occur at any age. Researchers are still unsure why SUDEP occurs, although some research points to abnormal heart and respiratory function due to gene abnormalities (ones which cause epilepsy and also affect heart function). People with epilepsy may be able to reduce the risk of SUDEP by carefully taking all antiseizure medication as prescribed. Not taking the prescribed dosage of medication on a regular basis may increase the risk of SUDEP in individuals with epilepsy, especially those who are taking more than one medication for their epilepsy.

Types of seizures

Seizures are divided into two major categories – focal seizures and generalized seizures. However, there are many different types of seizures in each of these categories. In fact, doctors have described more than 30 different types of seizures.

Focal seizures

Focal seizures originate in just one part of the brain. About 60 percent of people with epilepsy have focal seizures. These seizures are frequently described by the area of the brain in which they originate. Many people are diagnosed with focal frontal lobe or medial temporal lobe seizures.

In some focal seizures, the person remains conscious but may experience motor, sensory, or psychic feelings (for example, intense dejà vu or memories) or sensations that can take many forms. The person may experience sudden and unexplainable feelings of joy, anger, sadness, or nausea. He or she also may hear, smell, taste, see, or feel things that are not real and may have movements of just one part of the body, for example, just one hand.

In other focal seizures, the person has a change in consciousness, which can produce a dreamlike experience. The person may display strange, repetitious behaviors such as blinks, twitches, mouth movements (often like chewing or swallowing, or even walking in a circle). These repetitious movements are called automatisms. More complicated actions, which may seem purposeful, can also occur involuntarily. Individuals may also continue activities they started before the seizure began, such as washing dishes in a repetitive, unproductive fashion. These seizures usually last just a minute or two.

Some people with focal seizures may experience auras – unusual sensations that warn of an impending seizure. Auras are usually focal seizures without interruption of awareness ( e.g., dejà vu, or an unusual abdominal sensation) but some people experience a true warning before an actual seizure. An individual’s symptoms, and the progression of those symptoms, tend to be similar every time. Other people with epilepsy report experiencing a prodrome, a feeling that a seizure is imminent lasting hours or days.

The symptoms of focal seizures can easily be confused with other disorders. The strange behavior and sensations caused by focal seizures also can be mistaken for symptoms of narcolepsy, fainting, or even mental illness. Several tests and careful monitoring may be needed to make the distinction between epilepsy and these other disorders.

Generalized seizures

Generalized seizures are a result of abnormal neuronal activity that rapidly emerges on both sides of the brain. These seizures may cause loss of consciousness, falls, or a muscle’s massive contractions. The many kinds of generalized seizures include:

• Absence seizures may cause the person to appear to be staring into space with or without slight twitching of the muscles.
• Tonic seizures cause stiffening of muscles of the body, generally those in the back, legs, and arms.
• Clonic seizures cause repeated jerking movements of muscles on both sides of the body.
• Myoclonic seizures cause jerks or twitches of the upper body, arms, or legs.
• Atonic seizures cause a loss of normal muscle tone, which often leads the affected person to fall down or drop the head involuntarily.
• Tonic-clonic seizures cause a combination of symptoms, including stiffening of the body and repeated jerks of the arms and/or legs as well as loss of consciousness.
• Secondary generalized seizures.

Not all seizures can be easily defined as either focal or generalized. Some people have seizures that begin as focal seizures but then spread to the entire brain. Other people may have both types of seizures but with no clear pattern.

Some people recover immediately after a seizure, while others may take minutes to hours to feel as they did before the seizure. During this time, they may feel tired, sleepy, weak, or confused. Following focal seizures or seizures that started from a focus, there may be local symptoms related to the function of that focus. Certain characteristics of the post-seizure (or post-ictal) state may help locate the region of the brain where the seizure occurred. A classic example is called Todd’s paralysis, a temporary weakness in the part of the body that was affected depending on where in the brain the focal seizure occurred. If the focus is in the temporal lobe, post-ictal symptoms may include language or behavioral disturbances, even psychosis. After a seizure, some people may experience headache or pain in muscles that contracted.

Absence seizures

Absence seizures are brief seizures that cause someone to lose awareness and stare into space for a few seconds. It’s important to see a doctor if your child has an absence seizure but has not had one previously. The International League Against Epilepsy Classification of 2017 defines absence seizures as “generalized non-motor seizures” ². However, this term is not entirely precise, because, motor manifestations of absence seizures are frequently seen ³.

Absence seizures are brief seizures characterized by a behavioral arrest that correlates with generalized 3-Hertz spike-and-wave discharges on electroencephalogram (EEG) ². Absence seizures occur in multiple idiopathic/genetic generalized epilepsies including childhood absence epilepsy, juvenile absence epilepsy and juvenile myoclonic epilepsy. Atypical absence seizures have been reported in up to 60% of patients with Lennox-Gastaut syndrome ².

An absence seizure is a type of seizure that affects the whole brain at once. They cause the person to stop what they are doing and stare into space. People may think the person is daydreaming or not paying attention. Absence seizures can happen many times a day.

Absence seizures mostly affect children and adolescents. This can cause problems with the child’s learning, so it’s important to get treatment.

Absence seizures used to be called ‘petit mal’ seizures. They are a form of epilepsy, a condition that disrupts the electrical activity in the brain, causing the seizure.
Absence seizure symptoms

In a typical absence seizure, the person temporarily loses awareness and stops what they are doing. The seizure comes on abruptly and stops as quickly as it started.

When someone is having an absence seizure, they won’t respond to you and they lose their facial expression. Sometimes their eyelids may flutter, or their eyeballs may roll back.

An absence seizure normally lasts from 5 to 30 seconds. Then the person’s awareness quickly returns to normal.

There are other, less common types of absence seizure with different symptoms:

• atypical absence seizure, which can be more gradual and may involve the person also slumping or jerking.
• myoclonic absence, where the person rhythmically jerks their shoulder or arms or twitches their face.
• absence with eyelid myoclonia, where the eyelids jerk and the eyes roll upwards.

Absence seizure diagnosis

If your child has an absence seizure, see your doctor. They will examine them and organize for them to have tests, including an electroencephalogram, or EEG, to measure the electrical activity of their brain, a brain scan, and blood tests. A pediatrician (child specialist) or neurologist (brain specialist) will probably care for your child.

It’s a good idea to video an absence seizure on your phone, if you can. Seeing exactly what happens during the seizure can help your doctor to make an accurate diagnosis.

Absence seizure treatment

Many people with absence seizures don’t need treatment. It depends on how often they are having the seizures.

If a child is having a lot of absence seizures, it can affect their learning and development. In this case, they may be given medicine to prevent the seizures from happening.

The first-line treatment for absence seizures is ethosuximide ². A randomized controlled trial performed in 2010 that included 446 children with childhood absence epilepsy showed that ethosuximide and valproic acid were superior to lamotrigine. However, this study had a low seizure-free rate with 53% of patients in the ethosuximide group, 58% on the valproic acid group, and 29% of patients taking lamotrigine. The group that received valproic acid had significantly lower scores on attentional measures as compared to the ethosuximide and lamotrigine groups. For this reason, ethosuximide is the preferred agent for treatment of absence epilepsy ⁴.

The most frequent side effects of ethosuximide are abdominal pain and nausea. For this reason, ethosuximide should be taken with meals. Other medications that can be used for management of CAE include valproate, lamotrigine, and topiramate. Second-line medications that can be used as adjunct therapy include zonisamide and levetiracetam.

It is important to note that some sodium channel blockers like phenytoin, carbamazepine, gabapentin, pregabalin, and vigabatrin can worsen absence seizures.

It’s important to avoid things that can trigger an absence seizure. These may include flashing lights, getting very tired or hungry, or watching television. Eating regular meals, getting enough sleep and exercising can reduce the chance of another seizure.

If your child has absence seizures, you must always supervise them when they are swimming, in the bath or doing an activity at a height. Your doctor will be able to advise you about what is safe for them.

Simple partial seizures

Partial seizure refers to abnormal neural activity localized to one area of the cerebral hemisphere and having a discernible focal or localized onset ⁵. When there is no associated impairment in consciousness, it is called simple partial seizure, and when it is associated with impairment in consciousness, it is called a complex partial seizure. When a partial seizure becomes generalized, it is referred to as a “partial seizure with secondary generalization.” New terminology for a simple partial seizure is “focal onset aware seizure” ⁶.

Patients with simple partial seizure remain awake and aware throughout the seizure, and some patients can even talk during the episode ⁵. It may be difficult to distinguish them from complex partial seizure in infants and patients with cognitive and speech difficulties, as impairment in consciousness can be difficult to assess in these patients.

After the first year of life, partial seizures are the most common seizure type in patients with epilepsy ⁵. The incidence of all partial seizures is approximately 20 cases per 100,000 population between the age of 1 to 65 years in the United States. It is estimated that around 6% to 12% of patients with epilepsy have simple partial seizures; these are frequently associated with other types of seizures. There is no reported predilection for gender, race, or ethnicity. Incidence has been increasing in older people, especially those with cerebrovascular disease ⁷.

The term “aura” refers to signs and symptoms that occur with a seizure before consciousness is lost and for which memory is intact afterward. Auras that are not followed by seizure should be considered focal aware seizures or simple partial seizures ⁶.

Depending on clinical signs, symptoms, and EEG localization, focal seizures can be further subdivided into four types: (1) focal motor seizures, (2) focal sensory seizures, (3) autonomic seizures, and (4) psychological seizures.

Focal motor seizures

Focal or partial motor seizure occurs due to an epileptogenic lesion on the contralateral frontal lobe. Motor symptoms constitute the primary clinical manifestation. Typically, consciousness is not impaired in seizures of discrete motor areas. They usually originate from the supplementary motor area and cause turning movements of head and neck to the opposite side and sometimes tonic contractions of the limbs and trunk on the same side. This may or may not be followed by generalized clonic movements. Subdivisions of ictal motor symptoms include elementary (tonic, clonic, dystonic, versive) and automatism (coordinated, repetitive motor activity like lip smacking, tapping, and swallowing). Another classification based on clinical symptomatology uses the terms like focal clonic, focal tonic, or versive seizures.

Focal motor seizures are more common on the face, hands, and toes because these areas have disproportionately large cortical representation. The excitatory focus is usually around the rolandic (motor) cortex. If there are accompanying sensory symptoms, the focus may be on post-rolandic convolution. Temporal lobe origin seizures sometimes have head-turning movements on the same side followed by the forceful contraversive turning of the head and body.

• Clonic seizures refer to repeated, short contractions of various muscle groups characterized by twitching movements or rhythmic jerking that recur at regular intervals of less than 1 to 2 seconds. These seizures are brief, lasting less than 1 to 2 minutes. In focal clonic seizures, there is epileptic activation of a restricted area of the precentral gyrus.
• Tonic seizures refer to sustained contractions that last for more than 5 to 10 seconds and result in the posturing of the limbs and whole body. Focal tonic seizures refer to tonic contractions restricted to a part of the body on one side. Focal tonic seizures are attributed to activation of Brodmann area 6, particularly mesial frontal region. There may be some involvement of the premotor areas in some cases.
• Versive seizures consist of sustained, forceful, involuntary turning of head and eyes to one side due to tonic contraction of head and eye muscles. Usually, they are accompanied by loss of consciousness, but occasionally patients may be aware of the forced involuntary eye and head turning. The version can result from seizures originating from various locations and spreading to premotor cortex.

Following convulsions with predominant focal motor symptoms, patients may have transient, functional, and localized paralysis of the affected limbs. This is known as Todd paralysis and can last minutes to hours, usually in proportion to the duration of the convulsion. This postepileptic paralysis occurs due to persistent focal dysfunction of the affected epileptogenic area and is the signature of a focal seizure. It has significant clinical value in lateralizing the hemisphere of seizure onset ⁸.

Jacksonian march seizure

Jacksonian march seizure starts with tonic contractions in one hand or on one side of the face or the muscles of one foot. This is followed by clonic movements in these parts and sometimes a series of clonic movements with increasing frequency that builds up to a tonic contraction. These movements may spread (“march”) from the muscles affected to the other muscles on the same side of the body. In classic Jacksonian march, the seizure spreads from hand to arm to face and then down the leg ipsilaterally, or if it started in the foot, then seizure marches up the leg, down the arm, and then to the face. This typically happens over a short time (20 to 30 seconds). There can be other associated symptoms like automatism (lip smacking or tapping movements), hallucinations, muscle cramping, head-turning, etc. Symptoms are usually mild. These seizures rarely become generalized, and typically consciousness remains intact. Jacksonian march seizure can be mistaken for a transient ischemic attack, migraine, or other condition ⁹.

Focal somatosensory seizures

Sensory seizures present as numbness, tingling, crawling sensation, “pins and needles” feeling, and rarely, as pain or thermal sensations. They can be focal or can march to other ipsilateral body parts and usually have focus in or around post-rolandic convolution of the contralateral cerebral hemisphere.

• Visual seizures are rare but have localizing significance. Visual hallucinations and visual loss are typical of occipital lobe epilepsy but sometimes can occur with seizure foci in anteromedial temporal and occipitotemporal regions.
• Auditory hallucinations are a rare initial manifestation of seizure and have sometimes been noted with lesions in posterior temporal lobe on one side.
• Olfactory hallucinations often occur with a lesion in inferior and medial parts of the temporal lobe.
• Gustatory hallucinations can occur in temporal lobe disease with lesions in the insula and parietal operculum.

Autonomic seizures

Autonomic seizures manifest with predominantly altered autonomic function. Some common autonomic signs and symptoms include diaphoresis, shivering, piloerection, rising sensation in epigastrium, nausea, changes in blood pressure and heart rate (commonly tachycardia), and pupillary changes. Autonomic features are common in several nonepileptic conditions, making autonomic seizures harder to diagnose.

Some specific epilepsy syndromes with prominent autonomic features include neonatal seizures, epilepsy of infancy with migrating focal seizures, Dravet syndrome, benign epilepsy with centrotemporal spikes, and early-onset benign occipital epilepsy ¹⁰.

Psychological seizures

Psychological seizures manifest with affective and cognitive symptoms like memory flashback, dream-like events, Deja Vu feeling, hallucinations, anxiety, agitation, and uncontrolled laughter or crying. They arise commonly from the temporal area rather than extratemporal.

Simple partial seizure diagnosis

Diagnosing a simple partial seizure can be difficult, especially when sensory, autonomic, or psychic symptoms are predominant. Suspicion of simple partial seizure is based on typical history and reproducible patterns with known simple partial seizure types. A neurological examination may or may not show subtle focality. Some patients may have postepileptic paresis (Todd paralysis). Examination during a seizure is helpful to assess consciousness. The patient should be able to follow simple commands and remember the events postictally to make a diagnosis of simple partial seizure. Simple commands like moving extremity on both sides, repeating a two syllable command will help assess responsiveness. Some patients with motor manifestations may not be able to perform a motor task but remember the instructions postictally; this should be interpreted as intact responsiveness.

Symptoms depend on the area involved.

• Temporal lobe focal aware seizures can cause autonomic and/or psychological symptoms. The most common symptom is an epigastric rising sensation. Sometimes sensory symptoms like auditory and olfactory hallucinations can be present.
• Frontal lobe simple partial seizures are usually short but can have a rapid generalization. They have prominent motor manifestations like twitching or stiffness in one muscle group on one side.
• Parietal lobe focal aware seizures present with predominantly sensory symptoms. They may have a feeling of tingling or numbness that may or may not spread in a Jacksonian manner. Head, arm, and face are most commonly involved. They can also present with visual metamorphopsia, loss of awareness of a body part, vertigo, and sometimes language disturbances.
• Occipital lobe seizures usually have visual manifestations like scotoma, amaurosis, or flashing lights. They also can have visual hallucinations and perceptive illusions in which objects appear distorted ¹¹.

Clinical data alone is often not enough to precisely diagnose and localize focal seizures. Scalp and intracranial EEG may be needed to diagnose accurately. EEG done after the suspected seizure episode may be normal or nonspecific. MRI head is required to identify the underlying etiology

Seizure characteristics that favor an epileptic diagnosis include younger age at onset, stereotyped patterns of movements, shorter duration of seizures, nocturnal occurrence and presence of MRI, and EEG abnormalities.

Simple partial seizure treatment

In general, patients suffering from partial seizures of unknown etiology or of structural origin should be treated with antiepileptic drugs.

Focal seizures caused by non–neurological pathologies like infections and electrolyte imbalance are managed by treating the underlying etiology. It is important to know if the seizure fits into a particular type of epilepsy or epilepsy syndrome in order to decide treatment and determine prognosis.

Medications

Appropriate seizure medication is chosen based on the type of seizure, side effect profile of the medication, the age of the patient, use of other medications and co-morbid medical conditions. Carbamazepine and lamotrigine are the first-line antiepileptic drugs (AED) for simple partial seizures. Alternative first-line drugs include valproate, oxcarbazepine, and levetiracetam. One of these medications should be considered if the other two are not tolerated or can not be used. If the first antiepileptic drug is ineffective or not tolerated, then another antiepileptic drug of these five drugs should be considered. If the second antiepileptic drug is also not effective, then adjunctive therapy is added. Adjunctive therapy for focal seizures includes carbamazepine, lamotrigine, levetiracetam, oxcarbazepine, sodium valproate, gabapentin, topiramate, and clobazam. If adjunctive therapy is also not effective or not tolerated, then referral to a tertiary epilepsy center should be considered, where other antiepileptic drug may be tried.

Ketogenic diet

Antiepileptic drugs can control seizures in about two-thirds of epilepsy patients. The ketogenic diet can help control seizures in some children. It is a specialized high fat, low carb and controlled protein diet, that should be considered in children with intractable seizures when at least two antiepileptic drugs have been ineffective.

Vagus nerve stimulation

Vagus nerve stimulation involves an electric stimulator inside the body that connects to the left vagus nerve in the neck. It helps to calm down the irregular electrical activity in the brain. It can reduce the frequency, severity, and length of seizures. Vagus nerve stimulation therapy should be considered in patients whose seizures are not controlled with antiepileptic drugs and are not candidates for surgery. Antiepileptic effects of vagus nerve stimulation therapy may take up to two years, and antiepileptic drug should always be used along with it. If vagus nerve stimulation therapy is effective, it may be possible to reduce the medications slowly.

Surgery

Surgery should be considered for refractory seizures where a specific area of the brain is responsible for causing seizures. Surgery involves removing or separating the specific area of the brain causing seizures.

Simple partial seizure prognosis

Patients with partial seizures have a higher risk of seizure recurrence than those with generalized seizures. However, recurrence rates of simple and complex partial seizures appear to be the same. Risk of seizure-related complications like aspiration, and overall morbidity and mortality are lower in simple partial seizures than in those where consciousness is impaired.

Simple partial seizures can result in falls and trauma. Uncontrolled or poorly controlled seizures can cause chronic neurological and cognitive impairment. Prognosis of simple partial seizure is believed to be similar to that of complex partial seizure and is dependent on the underlying etiology of seizures.

Complex partial seizures

Complex partial seizures refer to focal seizures that start in one hemisphere of the brain and are associated with impairment in consciousness ¹². The characteristic feature of complex partial seizure (focal impaired awareness seizure) is impaired awareness, referring to decreased overall arousal and responsiveness. These seizures most commonly arise from the temporal lobe. Simple responses like visual tracking may be preserved in complex partial seizures. However higher-order processing tasks like a verbal response, decision making are profoundly impaired.

Complex partial seizures are now preferably called as “focal impaired awareness seizure” or “focal onset impaired awareness seizure” ¹². International League Against Epilepsy (ILAE) 2017 classification has categorized seizures based on three key features: the location of seizure onset, level of awareness during a seizure, and other features of seizures.

After the first year of life, complex partial seizures are the most common seizure type in patients with epilepsy. It is estimated that around 36% of people with epilepsy have complex partial seizures. It affects all ages. Incidence is highest in children and older adults. No predilection for gender or race is known ¹².

Complex partial seizures occur more often than simple partial seizures, although most complex partial seizures start as simple partial seizures. Partial seizure refers to abnormal neural activity localized to one area of the cerebral hemisphere and having a discernible focal or localized onset ⁵. When there is no associated impairment in consciousness, it is called simple partial seizure, and when it is associated with impairment in consciousness, it is called a complex partial seizure. When a partial seizure becomes generalized, it is referred to as a “partial seizure with secondary generalization.” New terminology for a simple partial seizure is “focal onset aware seizure” ⁶.

Focal seizures refer to epileptiform activity starting in one area on one side of the brain. If awareness is impaired or affected at any time during the seizure, it is called focal impaired awareness seizure. Focal seizures are further classified into motor onset (automatisms, atonic, clonic, myoclonic, tonic, epileptic spasms, hyperkinetic) and nonmotor onset (autonomic, emotional, sensory, cognitive, behavior arrest) types. A seizure that starts on one side or one part of the brain and then spreads to both sides, earlier referred to secondarily generalized seizures, is now preferably termed as “focal to bilateral seizure” ¹³.

Focal seizures with impaired consciousness can present with or without an aura. Auras can last from a few seconds to as long as 1 to 2 minutes before the consciousness is impaired. Consciousness is maximally impaired in the beginning typically. Most of the seizures with automatisms last longer than 30 seconds, up to 1 to 2 minutes and sometimes can be as long as 10 minutes. Absence seizures can sometimes present with same symptomatology however ictal EEG will show generalized 3-Hz spike-wave complexes. Symptoms of focal seizures with impaired awareness depend on the area of the brain it is arising from. Most of the complex partial seizures arise from the temporal lobe. Extratemporal origin has been reported in at least 10% to 30% of patients ¹⁴.

Temporal lobe seizures

Temporal lobe seizures also called temporal lobe epilepsy, is the most common epilepsy syndrome with focal seizures. Temporal lobe seizures are often associated with auras of nausea, emotions (such as déjà vu or fear), or unusual smell or taste. The seizure itself is a brief period of impaired consciousness which may appear as a staring spell, dream-like state, or repeated automatisms. Temporal lobe seizures often begins in childhood or teenage years. Research has shown that repeated temporal lobe seizures are often associated with shrinkage and scarring (sclerosis) of the hippocampus. Hippocampal sclerosis consists of neuronal loss and gliosis in the dentate nucleus and pyramidal layer of the hippocampus. Mechanism of damage in hippocampal sclerosis is glutamate discharge during the seizure episode. The most frequent site of damage is in the CA1 area of the hippocampus. It is controversial whether hippocampal sclerosis is a result of localized asymptomatic seizure activity over years or a cause of seizures. The hippocampus is important for memory and learning.

Stereotyped automatisms occur in about 40% to 80% of patients with temporal lobe epilepsies. Seizures with predominantly oral and manual automatisms in addition to some other motor manifestations are highly suggestive of temporal lobe origin. About 60% of temporal lobe seizures have a secondary generalization. Gradual recovery after several minutes of confusion occurs postictally in most patients, however, in some patients automatic behavior like running, walking about, the nondirected violent behavior may occur. Temporal lobe focal impaired seizures can have features similar to frontal seizures, but temporal lobe focal impaired seizures typically have slower onset and progression, and more pronounced confusion. Certain features can help in localizing the seizure onset to one hemisphere. Ictal vomiting, ictal speech, urinary urge, and automatisms with intact consciousness suggest seizure onset in the non-dominant hemisphere, and speech disturbance postictally is suggestive of seizure onset in the dominant hemisphere. Upper limb dystonia lateralizes seizure to the opposite hemisphere.

In young children with focal seizures of temporal lobe onset, behavioral arrest and unresponsiveness are common. Oroalimentary automatisms tend to occur in children older than age 5. In younger children, symmetric motor movement of the limbs and head nodding is typical. In infants, these seizures may be subtle with few automatisms. In very young infants, central apnea can occur. Temporal focal impaired seizures can be confused with absence seizures as both may have automatisms, but temporal seizures are usually longer in duration and are associated with postictal confusion.

Seizures arising from mesial temporal lobe are characterized by auras such as epigastric sensation, deja vu, a feeling of fear, and unpleasant smells. Autonomic features like tachycardia, flushing, and pallor are common. Auras may be followed by impaired awareness and manual and oroalimentary automatisms. Automatisms in the upper limb and /or pupillary dilatation unilaterally may lateralize seizure to the ipsilateral hemisphere. Dystonia in the upper limbs and head and eye version on the opposite side can occur.

Lateral temporal seizures may have vertigo, auditory (buzzing, ringing), or visual symptoms as initial aura symptoms. Auditory aura in only one ear may lateralize seizure to contralateral hemisphere. Initial aura is usually not prolonged, and impaired awareness is an early feature. Seizures are of shorter duration and progression to bilateral convulsions is more common than those arising from mesial temporal lobe ¹⁵.

Frontal lobe seizures

Frontal lobe seizures also called frontal lobe epilepsy, is a common epilepsy syndrome that features brief focal seizures that may occur in clusters. Frontal lobe seizures can affect the part of the brain that controls movement and involves seizures that can cause muscle weakness or abnormal, uncontrolled movement such as twisting, waving the arms or legs, eye deviation to one side, or grimacing, and are usually associates with some loss of awareness. Frontal lobe seizures usually occur when the person is asleep but also may occur while awake.

Up to 30% of the patients with focal epilepsy have seizures arising from the frontal lobe. Frontal lobe seizure is the most common extratemporal type. Seizures are accompanied by loss of consciousness in about half of the patients with frontal lobe epilepsy. Focal impaired awareness seizures can arise from various locations within the frontal lobe, except the rolandic strip. These seizures typically are brief, lasting about 30 seconds, occurring in clusters, multiple times a day, are often nocturnal occurring during sleep and have minimal postictal confusion. Motor symptoms are predominant and range from hypermotor thrashing episodes like pelvic thrusting, bicycling movements to asymmetric tonic posturing. Sexual automatisms, bizarre behavior, and vocalizations are common. These seizures often have a stereotypical pattern for each patient. Nocturnal frontal lobe seizures may be mistaken for parasomnias. The ictal EEG may be difficult to interpret because of movement artifacts. Identification based on semiology alone and differentiating from mesial temporal lobe epilepsy may be difficult, however earliest signs and symptoms and their order of appearance may help in distinction. Seizures with hypermotor features are more likely to have ictal focus in the orbitofrontal and frontopolar regions. Temporal lobe seizures have more oroalimentary automatisms, gesturing and fumbling semiology.

Epileptiform activity in frontal convexity can cause clonic seizures, and in the supplementary motor area can cause tonic seizures. Unique semiology of supplementary sensorimotor cortex includes deviation of head and eye to the side contralateral to seizure onset, the asymmetrical posturing of upper limbs with an extension of arm contralateral to the side of seizure onset and flexion of ipsilateral arm. Orbitofrontal region seizures are automotor type and manifest prominently with autonomic phenomena like flushing, vocalization, and automatisms. Anterior cingulate gyrus seizures have predominant motor manifestations like hypermotor seizures and complex motor seizures. Posterior cingulate cortex epilepsies predominantly have altered consciousness and automotor seizures as main clinical manifestations. Antero-lateral dorsal convexity seizures may manifest with auras such as dizziness, epigastric sensation, behavioral arrest and speech arrest.

Parietal lobe seizures

Seizures arising from parietal lobe may be difficult to diagnose because of their subjective nature. Positive and /or negative sensory features are common. Sensorimotor phenomenon and vestibular hallucinations suggest onset in the parietal lobe. Paresthesias, visual hallucinations, visual illusions, somatic illusions, vertiginous features can occur. Seizures arising from the dominant hemisphere can cause receptive language impairment. Parietal lobe complex partial seizures can have auras like epigastric sensations, visual hallucinations, panic attacks and behavioral arrest. Often there is involvement of other lobes as the seizure spreads. When focal seizures from parietal lobe spread and involve the temporal lobe, loss of consciousness and automatisms may occur.

Occipital lobe seizures

Seizures with ictal origin in the occipital lobe are characterized by a visual aura and are difficult to diagnose especially in young children. Visual auras, typically of elementary sensations, ictal blindness, versions of the head and eyes to opposite side, rapid and forced blinking, oculoclonic activity are some features suggesting occipital lobe as an origin of focal seizure with impaired consciousness. Seizures from primary visual cortex can cause bilateral loss of vision in the form of white-out or black-out. Shorter duration of visual aura (less than 2 minutes) can help to differentiate from migraine aura which is typically longer (5 to 15 minutes). Complex, formed visual hallucinations like pictures of people, animals, etc. are associated with seizure onset in the extra-striate cortex. Other symptoms may result from spread to temporal or parietal lobes.

Insular lobe seizures

Seizures arising from the insula can mimic frontal, temporal, parietal lobe seizures. Origin from the insula is suspected when viscerosensitive symptoms (nausea, vomiting, salivation), motor symptoms (tonic, hypermotor or generalized tonic-clonic movements), and/or sensory symptoms (numbness, tightness, vibration, pain, vertigo) occur at seizure onset ¹⁶.

Complex partial seizure diagnosis

As with other types of seizures, diagnosis of focal impaired awareness seizure is based on clinical history. As with any other seizure, it is most important to make sure that the episode is truly a seizure. Obtaining a detailed history from the patient and family members is important. A detailed description of the spell, for example, the sequence of events, nature of onset, loss of consciousness, any motor or convulsive activity, bilateral involvement, tongue bite, incontinence, stare, automatisms, eye movements, postictal confusion, recovery, and duration of events are very important to elicit. It is important to elicit a detailed medical history to identify possible risk factors.

Some specific features associated with focal seizures can help in lateralizing the seizure origin to one hemisphere. These features provide a good clue for lateralization but can be falsely lateralizing.

• Dystonic limb posturing: Unilateral dystonic posturing is the most reliable lateralizing sign in the temporal lobe automotor seizures. Unilateral hand/arm dystonic posturing in conjunction with automatisms of the opposite limb and head-turning is highly suggestive of temporal lobe onset contralateral to the dystonic upper extremity.
• Head version: Classical head version (defined as tonic, unnatural, forced lateral gyratory head movement) is highly suggestive of seizure onset to the contralateral side. It can occur in both temporal and extratemporal seizures. Seizures spread to the premotor areas may be the cause.
• Automatisms: Oroalimentary automatisms like lip-smacking, chewing, or swallowing may occur without loss of consciousness at seizure onset in temporal lobe seizures with seizures confined to the amygdala and anterior hippocampus. Most automatisms are usually accompanied by impaired consciousness and have no lateralizing value, but preserved responsiveness during automatisms lateralize to the nondominant hemisphere. Eye blinking or fluttering at seizure onset may indicate occipital lobe onset. Aversion of the eyes to the opposite side suggests seizures arising from the occipital region. Focal seizures with impaired consciousness arising from mesial frontal and orbitofrontal regions can cause bicycling or pedaling movements of the leg. Mimetic automatisms and crying have been reported in focal seizures with impaired consciousness arising from the non-dominant temporal lobe. Vomiting during seizure lateralizes to the non-dominant hemisphere. Sexual or genital automatisms (like pelvic thrusting, masturbation) can occur in focal seizures with the impaired consciousness of frontal lobe origin and temporal lobe origin.
• Postictal nose wiping: Postictal nose wiping that occurs within 60 seconds of the seizure occurs in about 50% to 85% of temporal lobe epilepsy patients and is performed with the ipsilateral hand in a majority of the cases ¹⁷.

Clinical data alone is often not enough to precisely diagnose and localize focal seizures.

• A comprehensive metabolic profile, complete blood count (CBC), urine analysis, urine toxicology screen is usually checked initially to rule out metabolic causes and infections.
• EEG is an important test for evaluating patients with seizures, although not essential for diagnosis. Some patients may require video EEG or prolonged EEG monitoring.

Interictal EEG: Thirty percent to 40% of the patients may have normal interictal findings on a single routine EEG recording. Temporal intermittent rhythmic delta activity is predictive of temporal lobe epilepsy. Bitemporal sharp wave foci may be noted in 25% to 30% of the patients. Intermittent rhythmic slowing may be the only clue as mesial temporal spikes may not be seen well at the surface. The amplitude of mesial temporal spikes is maximal at the anterior temporal scalp electrodes, and nasopharyngeal and sphenoidal electrodes when used. Sharp wave foci are seen in the mid-temporal and posterior temporal regions less frequently. Extratemporal focus (most commonly frontal lobes) is seen in 10% to 30% of patients with focal seizures with impaired consciousness. Interictal discharge may take the form of a bifrontal spike and wave discharge in some patients with mesial frontal foci.

Ictal EEG: Ictal EEG is abnormal in about 95% of the patients with focal impaired awareness seizures. About two-thirds of the patients with focal seizure with impaired consciousness have an electrodecremental pattern at the onset. A prototype pattern consisting of 5 to 7 Hz rhythmic theta discharge in the temporal regions is seen in about 50% to 70% of patients with temporal lobe epilepsy. This pattern has shown high accuracy in localizing the onset to the ipsilateral mesial temporal structures on depth electrode studies. Lateralization from scalp EEG is usually satisfactory however localization within a lobe may sometimes be incorrect. Scalp ictal changes are difficult to appreciate with some frontal lobe seizures because of movement artifacts.

Neuroimaging is often needed to rule out structural causes.

MRI head is a very sensitive and specific imaging technique for localization-related epilepsy. Use of high-resolution MRI and specific seizure protocols can enhance detection of abnormalities like hippocampal atrophy. Likelihood of finding an epileptic focus on neuroimaging studies is higher in patients with focal seizures than in generalized seizures. Common MRI findings are mesial temporal sclerosis, congenital anomalies, brain tumors, sequelae of head injury, vascular lesions, neurocysticercosis. Many MRI findings may be nonspecific and should be interpreted in clinical context.

Sometimes further imaging with PET scan, ictal and interictal SPECT may be utilized to identify ictal onset zone, especially in patients with refractory seizures ¹⁸.

Complex partial seizure treatment

Antiepileptic medications are the mainstay of treatment, but other approaches are available for refractory seizures.

Medications

Except for ethosuximide, all other currently available antiepileptic drugs can be used in the treatment of complex partial seizures. Choice of medication depends on the patient’s preference, comorbid conditions, drug interactions and side effect profile of the drug. Monotherapy is preferred initially. An increased dose of a single agent may be required to achieve seizure control before adding another agent. Classical antiepileptic drugs used for complex partial seizures include carbamazepine, valproate, phenytoin, and phenobarbital. Newer agents available are levetiracetam, topiramate, lamotrigine, gabapentin, oxcarbazepine, zonisamide, felbamate, tiagabine, pregabalin, and lacosamide. Most common first-line drugs are carbamazepine, phenytoin, valproic acid, and oxcarbazepine.

More than half of the patients with complex partial seizures will require more than one antiepileptic drug. Use of more than one antiepileptic drug creates a potential for drug interactions, often necessitating constant monitoring and adjustment in doses. Seizures are considered refractory when two or more antiepileptic drugs have failed to control the seizures. Only about half of the patients with complex partial seizures have epilepsy fully controlled with medications.

Ketogenic diet

The ketogenic diet is a specialized high fat, low carb, and controlled protein diet that should be considered in children with intractable seizures when at least two antiepileptic drugs have been ineffective.

Surgery

Surgical intervention is considered for refractory complex partial seizures. Resective surgery is considered when the seizure focus is localized and solo. An ideal candidate for respective surgery is a patient with refractory complex partial seizures who have failed trail of at least two or three antiepileptic drugs, have features suggesting mesial temporal onset and MRI shows mesial temporal sclerosis. Surgical procedures for refractory complex partial seizures include amygdala-hippocampectomy, temporal lobectomy, and gamma knife radiation.

Vagus nerve stimulation

Patients with refractory seizures who are not candidates for surgery should be considered for implantation of vagal nerve stimulation device. Response rates of 35% to 45% have been reported with vagal nerve stimulation therapy. Antiepileptic drugs should always be used along with it. If vagal nerve stimulation therapy is effective, it may be possible to reduce the medications slowly ¹⁹.

Complex partial seizure prognosis

Patients with focal seizures have a higher risk of seizure recurrence than those with generalized seizures. Recurrence rates of simple and complex partial seizures appear to be the same. Loss of consciousness can cause trauma, aspiration, burns, and accidents. Associated anxiety, limitations in work, and driving add to significant morbidity. The mortality rate in patients with epilepsy is 2 to 3-times higher than the general population. Most deaths are due to underlying etiology and accidents. Sudden unexpected death in epilepsy (SUDEP) is more in patients with medically intractable seizures.

Baby or infant seizures

The neonatal period is limited to the first 28 days of life in a term infant. For premature infants, this term usually is applied until gestational age 44 weeks; ie, the age of the infant from conception to 44 weeks (i.e., 4 week after term).

Most neonatal seizures occur over only a few days, and fewer than half of affected infants develop seizures later in life. Such neonatal seizures can be considered acute reactive (acute symptomatic), and therefore the term neonatal epilepsy is not used to describe neonatal seizures ²⁰.

Seizures in neonates are relatively common, with variable clinical manifestations. Their presence is often the first sign of neurologic dysfunction, and they are powerful predictors of long-term cognitive and developmental impairment.

Most seizures in the neonate are focal, although generalized seizures have been described in rare instances.

What have been termed “subtle seizures” are more common in full-term than in premature infants. Video electroencephalogram (EEG) studies have demonstrated that most subtle seizures are not associated with electrographic seizures. Examples of subtle seizures include chewing, pedaling, or ocular movements, these movements are thought not be epileptic in nature and more commonly are an epi-phenomena of severe encephalopathy ²¹.

Baby or infant seizure classification

Clonic seizures

These movements most commonly are associated with electrographic seizures. They often involve 1 extremity or 1 side of the body. The rhythm of the clonic movements is usually slow, at 1-3 movements per second.

Tonic seizures

These may involve 1 extremity or the whole body. Focal tonic seizures involving 1 extremity often are associated with electrographic seizures.

Generalized tonic seizures often manifest with tonic extension of the upper and lower limbs and also may involve the axial musculature in an opisthotonic fashion. Generalized tonic seizures mimic decorticate posturing; the majority are not associated with electrographic seizures.

Myoclonic seizures

These may occur focally in 1 extremity or in several body parts (in which case they are described as multifocal myoclonic seizures).

Focal and multifocal myoclonic seizures typically are not associated with electrographic correlates. These movements are thought to be non-epileptic in nature and a reflection of severe encephalopathy.

Baby or infant seizure causes

Seizures occur when a large group of neurons undergo excessive, synchronized depolarization. Depolarization can result from excessive excitatory amino acid release (eg, glutamate) or deficient inhibitory neurotransmitter (eg, gamma amino butyric acid [GABA]).

Hypoxic-ischemic encephalopathy

Another potential cause is disruption of adenosine triphosphate (ATP) ̶ dependent resting membrane potentials, which cause sodium to flow into the neuron and potassium to flow out of the neuron. Hypoxic-ischemic encephalopathy disrupts the ATP-dependent sodium-potassium pump and appears to cause excessive depolarization. It is an important cause of neonatal seizures ²².

Seizures resulting from hypoxic-ischemic encephalopathy may be seen in term and premature infants. They frequently present within the first 72 hours of life. Seizures may include subtle, clonic, or generalized seizures.

Hemorrhage

Intracranial hemorrhage occurs more frequently in premature than in term infants. Distinguishing infants with pure hypoxic-ischemic encephalopathy from those with intracranial hemorrhage often is difficult.

Subarachnoid hemorrhage is more common in term infants. This type of hemorrhage occurs frequently and is not clinically significant. Typically, infants with subarachnoid hemorrhage appear remarkably well.

Germinal matrix-intraventricular hemorrhage is seen more frequently in premature than in term infants, particularly in infants born prior to 34 weeks’ gestation. Subtle seizures are seen frequently with this type of hemorrhage.

Subdural hemorrhage is seen in association with cerebral contusion. It is more common in term infants.

Metabolic disorders

Metabolic disturbances include hypoglycemia, hypocalcemia, and hypomagnesemia. Less frequent metabolic disorders, such as inborn errors of metabolism, are seen more commonly in infants who are older than 72 hours. Typically, they may be seen after the infant starts feeding.

Genetic disorders

“Early-onset epileptic encephalopathy” refers to a syndrome in which seizures are refractory to medications and severe cognitive/developmental issues are present. In those patients in whom structural and metabolic causes have been ruled out, genetic mutations are increasingly recognized. These mutations occur in genes that code for ion channel subunits (such as SCN1A, SCN8A, KCNT1) and other nueronal proteins and enzymes (such as CDKL5, STXBP1) ²³.

Intracranial infections

Intracranial infections (which should be ruled out vigorously) that are important causes of neonatal seizures include meningitis, encephalitis (including herpes encephalitis), toxoplasmosis, and cytomegalovirus (CMV) infections. The common bacterial pathogens include Escherichia coli and Streptococcus pneumoniae.
Malformation syndromes

While most cerebral malformations present with seizures at a later age, major malformation syndromes are important to consider. Lissencephaly, pachygyria, polymicrogyria, and linear sebaceous nevus syndrome can present with seizures in the neonatal period.

Benign neonatal seizures

Benign neonatal seizure syndromes can be characterized by familial or idiopathic seizures. Benign familial neonatal seizures typically occur in the first 48-72 hours of life; the seizures disappear by age 2-6 months. A family history of seizures is usual. Development is typically normal in these infants.

Benign idiopathic neonatal seizures typically present at day 5 of life (ie, fifth day fits), with the vast majority presenting between days 4 and 6 of life. Seizures are often multifocal. Cerebrospinal fluid (CSF) analysis is usually unremarkable.

Baby or infant seizure treatment

Acute neonatal seizures should be treated aggressively, although controversy exists as to the optimal treatment for them ²⁴.

When clinical seizures are present, a rigorous workup to determine an underlying etiologic cause should be initiated quickly. Electrolyte imbalances should be corrected through a central venous site. Hypocalcemia should be treated cautiously with calcium, since leakage of calcium into subcutaneous tissue can cause scarring.

When an inborn error of metabolism is suspected, discontinue feeding, since feeding may exacerbate the seizures and encephalopathy. Institute intravenous solutions.

Once these issues have been addressed, antiepileptic drug (AED) therapy should be considered. Phenobarbital is the initial drug of choice. If seizures persist, the use of phenytoin should be considered.

Patients with seizures resulting from intracranial hemorrhage should have head circumference measurements performed daily. A rapid increase in head circumference may indicate hydrocephalus.

Baby or infant seizure prognosis

Prognosis is determined by the etiology of the neonatal seizures. If the EEG background is normal, the prognosis is excellent for seizures to resolve; normal development is likely ²⁵.

Severe EEG background abnormalities indicate poor prognosis; such patients frequently have cerebral palsy and epilepsy. The presence of spikes on EEG is associated with a 30% risk of developing future epilepsy.

The prognosis following neonatal seizures that result from isolated subarachnoid hemorrhage is excellent, with 90% of children not having residual neurologic deficits.

Neonatal seizures are a risk factor that markedly increases rates of long-term morbidity and neonatal mortality. The presence of neonatal seizures is the best predictor of long-term physical and cognitive deficits. Complications of neonatal seizures may include the following:

• Cerebral palsy/spasticity
• Cerebral atrophy/Hydrocephalus ex-vacuo
• Epilepsy
• Feeding difficulties

Seizures in children

Seeing your child have a seizure or convulsion can be frightening. Simple first aid can help keep them safe. About 1 in 20 children will have a seizure during childhood. For most, it’s a one-off seizure – very few have epilepsy.

Seizures can be described in different ways.

They can be described by how much of the brain they affect. For example, focal seizures happen in one part of the brain, whereas generalized seizures happen all over the brain.

Seizures can also be described by the symptoms they cause.

Tonic-clonic seizures (previously called grand mal seizures) are a type of generalized seizure. They’re also known as fits. Someone having a tonic-clonic seizure might fall down, be unconscious, go stiff or jerk, lose bladder or bowel control, and be sleepy or confused afterwards.

Absence seizures (previously called petit mal seizures) are also generalized seizures. Someone having an absence seizure is not aware of what is happening or responsive to interactions with people. They might stare, blink their eyes or make chewing movements with their mouth.

Some people have focal seizures where they display automatic movements and behaviors like picking at clothing, chewing, swallowing, staring, picking up objects or running on the spot.

The common thread is that the person can’t control what happens.

What should I do if my child has a seizure?

If your child has a seizure, you should stay calm and:

• gently protect their body and head
• if they’re in water, keep their face out of the water and call for an ambulance
• time the seizure
• don’t put anything in their mouth
• after any convulsion ends, roll them on their side
• lay them on their side if there is fluid in their mouth
• make sure they are breathing normally afterwards

Take your child to see a doctor or go to a hospital emergency department if:

• your child’s seizure lasts more than 5 minutes, or they have more than one seizure
• they had a seizure with food or liquid in their mouth
• they’re unconscious or not breathing normally
• it’s their first seizure
• the seizure happened in the bath or a pool
• they’re unconscious for more than 5 minutes afterwards, or not breathing normally
• your child also has an injury
• you’re unsure whether they need help

What causes seizures in children?

A high fever (above 100.4 °F or 38°C) can sometimes cause seizures in young children. These are also called febrile convulsions.

Children can also have a seizure because of:

• an infection
• a brain injury
• a lack of oxygen to the brain

Certain triggers, such as flashing lights, can also lead to seizures in some children.

Can seizures be prevented?

The good news is that many children grow out of seizures or epilepsy.

Febrile convulsions can’t always be prevented, and can happen before a fever is obvious.

Your child should avoid anything that is known to trigger their seizures.

If your child is on medication for seizures, it is important to avoid missing doses. Getting a good night’s sleep and regular meals can also help.

Risks and complications of seizures

Most children recover well after a seizure, although they might be sleepy and confused for a short while. It’s rare to die from a seizure, but there are risks if the seizure goes on for a long time (30 minutes, for example, or more) or if the child chokes on water or vomit.

How are seizures diagnosed?

A doctor will assess your child. You should describe the seizure (how your child looked and behaved) to the doctor, or show them a video of the seizure, if possible.

If your child had a febrile convulsion, they may not need to undergo any tests, but they should still see a doctor.

However, if your child had a seizure, and especially if they had more than one, they might have tests such as an electroencephalogram (EEG), which is a reading of the electrical activity of the brain, or a brain scan (such as a CT scan or an MRI).

Treatments for seizures in children

Following any seizure, perform first aid. Where a seizure continues for an extended period of time (more than 5 to 10 minutes), it might be necessary for a health professional to give medication to stop it.

Febrile convulsions aren’t usually harmful, but it’s a good idea to see a doctor to make sure your child doesn’t have a serious infection. However, children who have a febrile convulsion can be prone to having a seizure again in the future.

If a child experiences multiple seizures, regular medication might be needed, but this may not be necessary for a one-off seizure with a clear cause, such as a febrile convulsion. However, several different medications might need to be tried to find one that is effective. Other treatments, such as surgery, are sometimes used.

What causes seizures

Nerve cells (neurons) in the brain create, send and receive electrical impulses, which allow the brain’s nerve cells to communicate. Anything that disrupts these communication pathways can lead to a seizure.

Causes of seizures can sometimes be difficult to find. Some known causes of seizures include the following:

• Epilepsy. The most common cause of seizures is epilepsy. But not every person who has a seizure has epilepsy.
• Illegal (recreational) drugs
• Alcohol
• Extremely low blood sugar
• High fever
• Head injury
• Infection. The most common cause of epilepsy in developing countries and overall worldwide is infectious. Infections can cause both acute seizures and epilepsy. Tuberculosis, neurocysticercosis, cerebral toxoplasmosis, HIV, cerebral malaria, subacute sclerosing panencephalitis (SSPE), and bacterial and viral meningoencephalitis are some infections known to cause seizures.
• Brain tumors or other medical problems, including stroke.
• Developmental abnormalities
• Vascular lesions/AV malformations
• Meningitis/focal encephalitis
• Hypoxic brain injury
• Postsurgical changes
• Electrolyte imbalance like hyponatremia or hypocalcemia
• Endocrine disorders
• Metabolic: Several inherited enzymatic disorders like GLUT-1 deficiency, cerebral folate deficiency, among others can cause seizures.
• Medications and toxins
• Genetic/chromosomal abnormalities: Several chromosomal disorders (e.g., AKT3, Fragile X syndrome) and gene defects (e.g., Down’s syndrome, Klinefelter’s syndrome, Angelman syndrome) have been associated with epilepsy.

The cause cannot be determined in more than half of all individuals with epilepsy. Congenital anomaly is the most common known cause in children, and head trauma in young adults. In people, age 35 to 64 years, head trauma, tumors, and vascular disorders are common causes. In people age 65 years or more, cerebrovascular disease, and degenerative disorders are most common known causes.

Seizures can be brought on by certain situations or triggers. Some common triggers include tiredness and lack of sleep, stress, alcohol, fever, acute medical illness, substance abuse, hormonal changes and medication noncompliance ¹⁷ . The triggers should be avoided wherever possible.

Common triggers include:

• flashing or flickering lights
• lack of sleep
• stress
• alcohol
• missed medication taken for seizures.

A common cause of seizures in childhood is a perinatal hypoxic brain injury. In adolescents, seizures are most commonly caused by head trauma and encephalitis. Brain tumors are the most common cause of seizures in middle-aged adults, and vascular dementia and encephalopathies are the most common etiology in older adults ²⁶.

Important: Anyone taking prescribed medicines for seizures should always take the correct dosage and make sure they do not miss a dose.

Symptoms of seizures

With a seizure, signs and symptoms can range from mild to severe and vary depending on the type of seizure.

Most seizures last for less than two minutes and will stop on their own, without any treatment. The person is usually unconscious for 10 to 20 seconds, and then will start having convulsions.

Seizure signs and symptoms may include:

• Temporary confusion
• A staring spell
• Uncontrollable jerking movements of the arms and legs
• Loss of consciousness or awareness
• Cognitive or emotional symptoms, such as fear, anxiety or deja vuconfusion
• A headache
• Aches and pains around their body
• Tiredness.

Doctors generally classify seizures as either focal or generalized, based on how and where abnormal brain activity begins. Seizures may also be classified as unknown onset, if how the seizure began isn’t known.

Focal seizures

Focal seizures result from abnormal electrical activity in one area of your brain. Focal seizures can occur with or without loss of consciousness:

• Focal seizures with impaired awareness. These seizures involve a change or loss of consciousness or awareness. You may stare into space and not respond normally to your environment or perform repetitive movements, such as hand rubbing, chewing, swallowing or walking in circles.
• Focal seizures without loss of consciousness. These seizures may alter emotions or change the way things look, smell, feel, taste or sound, but you don’t lose consciousness. These seizures may also result in the involuntary jerking of a body part, such as an arm or leg, and spontaneous sensory symptoms such as tingling, dizziness and flashing lights.

Symptoms of focal seizures may be confused with other neurological disorders, such as migraine, narcolepsy or mental illness.

Generalized seizures

Seizures that appear to involve all areas of the brain are called generalized seizures. Different types of generalized seizures include:

• Absence seizures. Absence seizures, previously known as petit mal seizures, often occur in children and are characterized by staring into space or by subtle body movements, such as eye blinking or lip smacking. These seizures may occur in clusters and cause a brief loss of awareness.
• Tonic seizures. Tonic seizures cause stiffening of your muscles. These seizures usually affect muscles in your back, arms and legs and may cause you to fall to the ground.
• Atonic seizures. Atonic seizures, also known as drop seizures, cause a loss of muscle control, which may cause you to suddenly collapse or fall down.
• Clonic seizures. Clonic seizures are associated with repeated or rhythmic, jerking muscle movements. These seizures usually affect the neck, face and arms.
• Myoclonic seizures. Myoclonic seizures usually appear as sudden brief jerks or twitches of your arms and legs.
• Tonic-clonic seizures. Tonic-clonic seizures, previously known as grand mal seizures, are the most dramatic type of epileptic seizure and can cause an abrupt loss of consciousness, body stiffening and shaking, and sometimes loss of bladder control or biting your tongue.

Warning signs

Some people who have seizures may get warning signs, such as a change in body temperature, visual problems or a strange taste in their mouth for example. These signs are also called ‘auras’. If these warnings occur, try to get to a safe place or position if possible.

Sometimes, other people can tell if someone they know is about to have a seizure. They may look different, their pupils may change size or they may act out of character. Again, if this happens, try to guide the person to a safe location.

People who have seizures should take precautions when swimming, driving or bathing.

Seizures complications

Having a seizure at certain times can lead to circumstances that are dangerous for you or others. You might be at risk of:

• Falling. If you fall during a seizure, you can injure your head or break a bone.
• Drowning. If you have a seizure while swimming or bathing, you’re at risk of accidental drowning.
• Car accidents. A seizure that causes either loss of awareness or control can be dangerous if you’re driving a car or operating other equipment.
• Pregnancy complications. Seizures during pregnancy pose dangers to both mother and baby, and certain anti-epileptic medications increase the risk of birth defects. If you have epilepsy and plan to become pregnant, work with your doctor so that he or she can adjust your medications and monitor your pregnancy, as needed.
• Emotional health issues. People with seizures are more likely to have psychological problems, such as depression and anxiety. Problems may be a result of difficulties dealing with the condition itself as well as medication side effects.

Seizures diagnosis

After a seizure, your doctor will thoroughly review your symptoms and medical history. Your doctor may order several tests to determine the cause of your seizure and evaluate how likely it is that you’ll have another one.

Tests may include:

• A neurological exam. Your doctor may test your behavior, motor abilities and mental function to determine if you have a problem with your brain and nervous system.
• Blood tests. Your doctor may take a blood sample to check for signs of infections, genetic conditions, blood sugar levels or electrolyte imbalances.
• Lumbar puncture. If your doctor suspects an infection as the cause of a seizure, you may need to have a sample of cerebrospinal fluid removed for testing.
• An electroencephalogram (EEG). In this test, doctors attach electrodes to your scalp with a paste-like substance. The electrodes record the electrical activity of your brain, which shows up as wavy lines on an EEG recording. The EEG may reveal a pattern that tells doctors whether a seizure is likely to occur again. EEG testing may also help your doctor exclude other conditions that mimic epilepsy as a reason for your seizure. Depending on the details of your seizures, this test may be done as an outpatient in the clinic, overnight at home with an ambulatory device or over a few nights in the hospital.
• Computerized tomography (CT). A CT scan uses X-rays to obtain cross-sectional images of your brain. CT scans can reveal abnormalities in your brain that might cause a seizure, such as tumors, bleeding and cysts.
• Magnetic resonance imaging (MRI). An MRI scan uses powerful magnets and radio waves to create a detailed view of your brain. Your doctor may be able to detect lesions or abnormalities in your brain that could lead to seizures.
• Positron emission tomography (PET). A PET scan uses a small amount of low-dose radioactive material that’s injected into a vein to help visualize active areas of the brain and detect abnormalities.
• Single-photon emission computerized tomography (SPECT). A SPECT test uses a small amount of low-dose radioactive material that’s injected into a vein to create a detailed, 3-D map of the blood flow activity in your brain that happens during a seizure. Doctors also may conduct a form of a SPECT test called subtraction ictal SPECT coregistered to MRI (SISCOM), which may provide even more-detailed results. This test is usually done in a hospital with overnight EEG recording.

Imaging and Monitoring

An electroencephalogram, or EEG, can assess whether there are any detectable abnormalities in the person’s brain waves and may help to determine if antiseizure drugs would be of benefit. This most common diagnostic test for epilepsy records electrical activity detected by electrodes placed on the scalp. Some people who are diagnosed with a specific syndrome may have abnormalities in brain activity, even when they are not experiencing a seizure. However, some people continue to show normal electrical activity patterns even after they have experienced a seizure. These occur if the abnormal activity is generated deep in the brain where the EEG is unable to detect it. Many people who do not have epilepsy also show some unusual brain activity on an EEG. Whenever possible, an EEG should be performed within 24 hours of an individual’s first seizure. Ideally, EEGs should be performed while the person is drowsy as well as when he or she is awake because brain activity during sleep and drowsiness is often more revealing of activity resembling epilepsy. Video monitoring may be used in conjunction with EEG to determine the nature of a person’s seizures and to rule out other disorders such as psychogenic non-epileptic seizures, cardiac arrhythmia, or narcolepsy that may look like epilepsy.

A magnetoencephalogram (MEG) detects the magnetic signals generated by neurons to help detect surface abnormalities in brain activity. MEG can be used in planning a surgical strategy to remove focal areas involved in seizures while minimizing interference with brain function.

The most commonly used brain scans include CT (computed tomography), PET (positron emission tomography) and MRI (magnetic resonance imaging). CT and MRI scans reveal structural abnormalities of the brain such as tumors and cysts, which may cause seizures. A type of MRI called functional MRI (fMRI) can be used to localize normal brain activity and detect abnormalities in functioning. SPECT (single photon emission computed tomography) is sometimes used to locate seizure foci in the brain. A modification of SPECT, called ictal SPECT, can be very helpful in localizing the brain area generating seizures. In a person admitted to the hospital for epilepsy monitoring, the SPECT blood flow tracer is injected within 30 seconds of a seizure, then the images of brain blood flow at the time of the seizure are compared with blood flow images taken in between seizures. The seizure onset area shows a high blood flow region on the scan. PET scans can be used to identify brain regions with lower than normal metabolism, a feature of the epileptic focus after the seizure has stopped.

Medical History

Taking a detailed medical history, including symptoms and duration of the seizures, is still one of the best methods available to determine what kind of seizures a person has had and to determine any form of epilepsy. The medical history should include details about any past illnesses or other symptoms a person may have had, as well as any family history of seizures. Since people who have suffered a seizure often do not remember what happened, caregiver or other accounts of seizures are vital to this evaluation. The person who experienced the seizure is asked about any warning experiences. The observers will be asked to provide a detailed description of events in the timeline they occurred.

Blood Tests

Blood samples may be taken to screen for metabolic or genetic disorders that may be associated with the seizures. They also may be used to check for underlying health conditions such as infections, lead poisoning, anemia, and diabetes that may be causing or triggering the seizures. In the emergency department it is standard procedure to screen for exposure to recreational drugs in anyone with a first seizure.

Developmental, Neurological, and Behavioral Tests

Tests devised to measure motor abilities, behavior, and intellectual ability are often used as a way to determine how epilepsy is affecting an individual. These tests also can provide clues about what kind of epilepsy the person has.

Seizures treatment

Not everyone who has one seizure will have another one, and because a seizure can be an isolated incident, your doctor may not decide to start treatment until you’ve had more than one.

The optimal goal in seizure treatment is to find the best possible therapy to stop seizures, with the fewest side effects.

Medications

More than 20 different antiseizure medications are available today, all with different benefits and side effects. Most seizures can be controlled with one drug (called monotherapy). Deciding on which drug to prescribe, and at what dosage, depends on many different factors, including seizure type, lifestyle and age, seizure frequency, drug side effects, medicines for other conditions, and, for a woman, whether she is pregnant or will become pregnant. It may take several months to determine the best drug and dosage. If one treatment is unsuccessful, another may work better. Benzodiazepines such as diazepam, midazolam, or lorazepam are accepted as the first line medications for continuing seizures.

Many medications are used in the treatment of epilepsy as first-line or add-on. They can be grouped based on their mechanism of action. Sodium channel blockers (carbamazepine, oxcarbazepine, eslicarbazepine, phenytoin, fosphenytoin, lamotrigine, lacosamide, and zonisamide), potassium channel opener (ezogabine), agonist of GABA receptor (benzodiazepine and barbiturates), GABA reuptake inhibitors (tiagabine), inhibitors of GABA-transaminase (vigabatrin), multiple mechanisms (gabapentin, pregabalin, valproic acid), glutamate antagonists (topiramate, felbamate, perampanel), and binding to synaptic vesicle 2A protein (levetiracetam, brivaracetam).

If the patient has noncompliance with a medical regimen and has returned to normal mental status, medications may be resumed. Testing for medication levels may be appropriate if available for the particular medication.

Table 1. Seizure medications

In June 2018 the U.S. Food and Drug Administration approved cannabidiol (Epidolex, derived from marijuana) for the treatment of seizures associated with Lennox-Gastaut syndrome and Dravet syndrome for children age 2 and older. The drug contains only small amount of the psychoactive element in marijuana and does not induce euphoria associated with the drug.

For many people with epilepsy, seizures can be controlled with monotherapy at the optimal dosage. Combining medications may amplify side effects such as fatigue and dizziness, so doctors usually prescribe just one drug whenever possible. Combinations of drugs, however, are still sometimes necessary for some forms of epilepsy that do not respond to monotherapy.

When starting any new antiseizure medication, a low dosage will usually be prescribed initially followed by incrementally higher dosages, sometimes with blood-level monitoring, to determine when the optimal dosage has been reached. It may take time for the dosage to achieve optimal seizure control while minimizing side effects. The latter are usually worse when first starting a new medicine.

Most side effects of antiseizure drugs are relatively minor, such as fatigue, dizziness, or weight gain. Antiseizure medications have differing effects on mood: some may worsen depression, where others may improve depression or stabilize mood. However, severe and life-threatening reactions such as allergic reactions or damage to the liver or bone marrow can occur. Antiseizure medications can interact with many other drugs in potentially harmful ways. Some antiseizure drugs can cause the liver to speed the metabolism of other drugs and make the other drugs less effective, as may be the case with oral contraceptives. Since people can become more sensitive to medications as they age, blood levels of medication may need to be checked occasionally to see if dosage adjustments are necessary. The effectiveness of a medication can diminish over time, which can increase the risk of seizures. Some citrus fruit and products, in particular grapefruit juice, may interfere with the breakdown of many drugs, including antiseizure medications – causing them to build up in the body, which can worsen side effects.

Some people with epilepsy may be advised to discontinue their antiseizure drugs after 2-3 years have passed without a seizure. Others may be advised to wait for 4 to 5 years. Discontinuing medication should always be done with supervision of a health care professional. It is very important to continue taking antiseizure medication for as long as it is prescribed. Discontinuing medication too early is one of the major reasons people who have been seizure-free start having new seizures and can lead to status epilepticus. Some evidence also suggests that uncontrolled seizures may trigger changes in the brain that will make it more difficult to treat the seizures in the future.

The chance that a person will eventually be able to discontinue medication varies depending on the person’s age and his or her type of epilepsy. More than half of children who go into remission with medication can eventually stop their medication without having new seizures. One study showed that 68 percent of adults who had been seizure-free for 2 years before stopping medication were able to do so without having more seizures and 75 percent could successfully discontinue medication if they had been seizure-free for 3 years. However, the odds of successfully stopping medication are not as good for people with a family history of epilepsy, those who need multiple medications, those with focal seizures, and those who continue to have abnormal EEG results while on medication.

There are specific syndromes in which certain antiseizure medications should not be used because they may make the seizures worse. For example, carbamazepine can worsen epilepsy in children diagnosed with Dravet syndrome.

Contraception and anti-seizure medications

Some anti-seizure medications can alter the effectiveness of birth control (oral contraceptive) medication. If contraception is a high priority, check with your doctor to evaluate whether your medication interacts with your oral contraceptive, and if other forms of contraception need to be considered.

Ketogenic diet

Dietary approaches and other treatments may be more appropriate depending on the age of the individual and the type of epilepsy. A high-fat, very low carbohydrate ketogenic diet is often used to treat medication-resistant epilepsies. The diet induces a state known as ketosis, which means that the body shifts to breaking down fats instead of carbohydrates to survive. A ketogenic diet effectively reduces seizures for some people, especially children with certain forms of epilepsy. Studies have shown that more than 50 percent of people who try the ketogenic diet have a greater than 50 percent improvement in seizure control and 10 percent experience seizure freedom. Some children are able to discontinue the ketogenic diet after several years and remain seizure-free, but this is done with strict supervision and monitoring by a physician.

The ketogenic diet is not easy to maintain, as it requires strict adherence to a limited range of foods. Possible side effects include impaired growth due to nutritional deficiency and a buildup of uric acid in the blood, which can lead to kidney stones.

Researchers are looking at modified versions of and alternatives to the ketogenic diet. For example, studies show promising results for a modified Atkins diet and for a low-glycemic-index treatment, both of which are less restrictive and easier to follow than the ketogenic diet, but well-controlled randomized controlled trials have yet to assess these approaches.

Surgery

Evaluation of persons for surgery is generally recommended only after focal seizures persist despite the person having tried at least two appropriately chosen and well-tolerated medications, or if there is an identifiable brain lesion (a dysfunctional part of the brain) believed to cause the seizures. When someone is considered to be a good candidate for surgery experts generally agree that it should be performed as early as possible.

Surgical evaluation takes into account the seizure type, the brain region involved, and the importance of the area of the brain where seizures originate (called the focus) for everyday behavior. Prior to surgery, individuals with epilepsy are monitored intensively in order to pinpoint the exact location in the brain where seizures begin. Implanted electrodes may be used to record activity from the surface of the brain, which yields more detailed information than an external scalp EEG. Surgeons usually avoid operating in areas of the brain that are necessary for speech, movement, sensation, memory and thinking, or other important abilities. fMRI can be used to locate such “eloquent” brain areas involved in an individual.

While surgery can significantly reduce or even halt seizures for many people, any kind of surgery involves some level of risk. Surgery for epilepsy does not always successfully reduce seizures and it can result in cognitive or personality changes as well as physical disability, even in people who are excellent candidates for it. Nonetheless, when medications fail, several studies have shown that surgery is much more likely to make someone seizure-free compared to attempts to use other medications. Anyone thinking about surgery for epilepsy should be assessed at an epilepsy center experienced in surgical techniques and should discuss with the epilepsy specialists the balance between the risks of surgery and desire to become seizure-free.

Even when surgery completely ends a person’s seizures, it is important to continue taking antiseizure medication for some time. Doctors generally recommend continuing medication for at least two years after a successful operation to avoid recurrence of seizures.

Surgical procedures for treating epilepsy disorders include:

• Surgery to remove a seizure focus involves removing the defined area of the brain where seizures originate. It is the most common type of surgery for epilepsy, which doctors may refer to as a lobectomy or lesionectomy, and is appropriate only for focal seizures that originate in just one area of the brain. In general, people have a better chance of becoming seizure-free after surgery if they have a small, well-defined seizure focus. The most common type of lobectomy is a temporal lobe resection, which is performed for people with medial temporal lobe epilepsy. In such individuals one hippocampus (there are two, one on each side of the brain) is seen to be shrunken and scarred on an MRI scan.
• Multiple subpial transection may be performed when seizures originate in part of the brain that cannot be removed. It involves making a series of cuts that are designed to prevent seizures from spreading into other parts of the brain while leaving the person’s normal abilities intact.
• Corpus callosotomy or severing the network of neural connections between the right and left halves (hemispheres) of the brain, is done primarily in children with severe seizures that start in one half of the brain and spread to the other side. Corpus callosotomy can end drop attacks and other generalized seizures. However, the procedure does not stop seizures in the side of the brain where they originate, and these focal seizures may even worsen after surgery.
• Hemispherectomy and hemispherotomy involve removing half of the brain’s cortex, or outer layer. These procedures are used predominantly in children who have seizures that do not respond to medication because of damage that involves only half the brain, as occurs with conditions such as Rasmussen’s encephalitis. While this type of surgery is very excessive and is performed only when other therapies have failed, with intense rehabilitation, children can recover many abilities.

Devices

Electrical stimulation of the brain remains a therapeutic strategy of interest for people with medication-resistant forms of epilepsy who are not candidates for surgery.

The vagus nerve stimulation device for the treatment of epilepsy was approved by the U.S. Food and Drug Administration (FDA) in 1997. The vagus nerve stimulator is surgically implanted under the skin of the chest and is attached to the vagus nerve in the lower neck. The device delivers short bursts of electrical energy to the brain via the vagus nerve. On average, this stimulation reduces seizures by about 20 – 40 percent. Individuals usually cannot stop taking epilepsy medication because of the stimulator, but they often experience fewer seizures and they may be able to reduce the dosage of their medication.

Responsive stimulation involves the use of an implanted device that analyzes brain activity patterns to detect a forthcoming seizure. Once detected, the device administers an intervention, such as electrical stimulation or a fast-acting drug to prevent the seizure from occurring. These devices also are known as closed-loop systems. NeuroPace, one of the first responsive stimulation, closed-loop devices, received premarket approval by the FDA in late 2013 and is available for adults with refractory epilepsy (hard to treat epilepsy that does not respond well to trials of at least two medicines).

Experimental devices: not approved by the FDA for use in the United States (as of March 2015)

• Deep brain stimulation using mild electrical impulses has been tried as a treatment for epilepsy in several different brain regions. It involves surgically implanting an electrode connected to an implanted pulse generator – similar to a heart pacemaker – to deliver electrical stimulation to specific areas in the brain to regulate electrical signals in neural circuits. Stimulation of an area called the anterior thalamic nucleus has been particularly helpful in providing at least partial relief from seizures in people who had medication-resistant forms of the disorder.
• A report on trigeminal nerve stimulation (using electrical signals to stimulate parts of the trigeminal nerve and affected brain regions) showed efficacy rates similar to those for vagal nerve stimulation, with responder rates hovering around 50 percent. (A responder is defined as someone having greater than a 50 percent reduction in seizure frequency.) Freedom from seizures, although reported, remains rare for both methods. At the time of this writing, a trigeminal nerve stimulation device was available for use in Europe, but it had not yet been approved in the United States.
• Transcutaneous magnetic stimulation involves a device being placed outside the head to produce a magnetic field to induce an electrical current in nearby areas of the brain. It has been shown to reduce cortical activity associated with specific epilepsy syndromes.

Pregnancy and seizures

Women who’ve had previous seizures typically are able to have healthy pregnancies. Birth defects related to certain medications can sometimes occur.

In particular, valproic acid — one possible medication for generalized seizures — has been associated with cognitive deficits and neural tube defects, such as spina bifida. The American Academy of Neurology recommends that women avoid using valproic acid during pregnancy because of risks to the baby. Discuss these risks with your doctor. Because of the risk of birth defects and because pregnancy can alter medication levels, preconception planning is particularly important for women who’ve had seizures.

In some cases, it may be appropriate to change the dose of seizure medication before or during pregnancy. Medications may be switched in rare cases.

Lifestyle and home remedies

Here are some steps you can take to help with seizure control:

• Take medication correctly. Don’t adjust the dosage before talking to your doctor. If you feel your medication should be changed, discuss it with your doctor.
• Get enough sleep. Lack of sleep can trigger seizures. Be sure to get adequate rest every night.
• Wear a medical alert bracelet. This will help emergency personnel know how to treat you correctly if you have another seizure.
• Be active. Exercising and being active may help keep you physically healthy and reduce depression. Make sure to drink enough water and rest if you get tired during exercise.
• Make healthy life choices. Managing stress, limiting alcoholic beverages and avoiding cigarettes all factor in to a healthy lifestyle.

Personal safety

Seizures don’t usually result in serious injury, but if you have recurrent seizures, injury is a possibility. These steps can help you avoid injury during a seizure:

• Take care near water. Don’t swim alone or relax in a boat without someone nearby.
• Wear a helmet for protection during activities such as bike riding or sports participation.
• Take showers instead of baths, unless someone is near you.
• Modify your furnishings. Pad sharp corners, buy furniture with rounded edges and choose chairs that have arms to keep you from falling off the chair.
• Consider carpet with thick padding to protect you if you do fall.
• Display seizure first-aid tips in a place where people can easily see them. Include any important phone numbers there, too.

Coping and support

If you’re living with a seizure disorder, you may feel anxious or stressed about what your future holds. Stress can affect your mental health, so it’s important to talk with your health care professional about your feelings and seek ways you can find help.

At home

Your family can provide much-needed support. Tell them what you know about your seizure disorder. Let them know they can ask you questions, and be open to conversations about their worries. Help them understand your condition by sharing any educational materials or other resources that your health care professional has given you.

At work

Meet with your supervisor and talk about your seizure disorder and how it affects you. Discuss what you need from your supervisor or co-workers if a seizure happens while at work. Consider talking with your co-workers about seizure disorders — you can widen your support system and bring about acceptance and understanding.

You’re not alone

Remember, you don’t have to go it alone. Reach out to family and friends. Ask your health care professional about local support groups or join an online support community. Don’t be afraid to ask for help. Having a strong support system is important to living with any medical condition.

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