brain, spinal cord, and nerve disorders
Seizure Disorders
Treatment of Seizure Disorders
Elimination of the cause if possible General measures Medications to control seizures Sometimes surgery or other procedures if medications are ineffective If the cause of the seizures can be identified and eliminated, no additional treatment is necessary. For example, if a low blood sugar (glucose) level ( Hypoglycemia ) caused the seizure, glucose is given, and the disorder causing the low level is treated. Other treatable causes include an infection, certain tumors, and an abnormal sodium level. If the cause cannot be eliminated, general measures plus medications are usually sufficient to treat seizure disorders. If medications are ineffective, surgery may be recommended. Exercise is usually recommended and social activities are encouraged. However, people who have a seizure disorder may have to make some adjustments. For example, they may be advised to do the following: Eliminate or limit their consumption of alcoholic beverages Not use illicit drugs Refrain from activities in which a sudden loss of consciousness could result in serious injury, such as bathing in a bathtub, climbing, swimming, or operating power tools After seizures are controlled (typically for at least 6 months), they can do these activities if adequate precautions are taken. For example, they should swim only when lifeguards are present. In most states, laws prohibit people with a seizure disorder from driving until they have been free of seizures for at least 6 months to 1 year. A family member or close friend and coworkers should be trained to help if a seizure occurs. Attempting to put an object (such as a spoon) in the person’s mouth to protect the person’s tongue should not be tried. Such efforts can do more harm than good. The teeth may be damaged, or the person may bite the helper unintentionally as the jaw muscles contract. However, helpers should do the following during a seizure: Protect the person from falling Loosen clothing around the neck Place a pillow under the head Roll the person over to one side If a pillow is unavailable, helpers can put their foot or place an item of clothing under the person’s head. People who lose consciousness should be rolled onto one side to ease breathing and help prevent them from inhaling vomit or saliva. Inhaling vomit or saliva can lead to Aspiration Pneumonia and Chemical Pneumonitis (a lung infection caused by inhaling saliva, stomach contents, or both). People who have had a seizure should not be left alone until they have awakened completely, are no longer confused, and can move about normally. Usually, their doctor should be notified. Putting a spoon or other object in the mouth of someone having a convulsion can do more harm than good. Antiseizure medications (also called anticonvulsants or antiepileptic medications) reduce the risk of having another seizure. Usually, they are prescribed only if people have had more than one seizure and if reversible causes, such as low blood sugar, have been ruled out or completely corrected. Antiseizure medications are usually not prescribed when people have had only one generalized seizure. Most antiseizure medications are taken by mouth. Antiseizure medications can completely stop seizures in about one third of people who have them and greatly reduce the frequency of seizures in another third. Almost two thirds of people who respond to antiseizure medications can eventually stop taking them without having a relapse. However, if antiseizure medications are ineffective, people are referred to a seizure center and evaluated for surgery. There are many different types of antiseizure medications. Which one is effective depends on the type of seizure and other factors. For most people, taking one antiseizure medication, usually the first or second one tried, controls seizures. If seizures recur, different antiseizure medications are tried. In such cases, determining which medication is effective may take several months. Some people have to take several medications, which increases the risk of side effects. Some antiseizure medications are not used alone but only with other antiseizure medications. Doctors take care to determine the appropriate dose for each person. The best dose is the smallest dose that stops all seizures while having the fewest side effects. Doctors ask people about side effects, then adjust the dose if needed. Sometimes doctors also measure the level of antiseizure medication in the blood. Antiseizure medications should be taken just as prescribed. People who take medications to control seizures should see a doctor regularly for dose adjustment and should always wear a medical alert bracelet inscribed with the type of seizure disorder and the medication being taken. Antiseizure medications can interfere with the effectiveness of other medications, and vice versa. Consequently, people should make sure their doctor knows all the medications, supplements, and illicit drugs they are taking before they start taking antiseizure medications. They should also talk to their doctor and possibly their pharmacist before they start taking any other medications, including over-the-counter medications. After seizures are controlled, people take the antiseizure medication until they have been seizure-free for at least 2 years. Then, the dose of the medication may be decreased gradually, and the medication eventually stopped. If a seizure recurs after the antiseizure medication is stopped, people may have to take an antiseizure medication indefinitely. Seizures usually recur within 2 years if they are going to. Seizures are more likely to recur in people who have had any of the following: A seizure disorder since childhood The need to take more than one antiseizure medication to be seizure-free Seizures while taking an antiseizure medication Focal-onset seizures or Abnormal EEG results within the previous year Structural damage to the brain—for example, by a stroke or tumor Antiseizure medications, although very effective, may have side effects. Many cause drowsiness, but some may make children hyperactive. For many antiseizure medications, blood tests are done periodically to determine whether the medication is impairing kidney or liver function or reducing the number of blood cells. levels, increasing the risk of Osteoporosis . People taking antiseizure medications should be aware of possible side effects and should consult their doctor at the first sign of side effects. For women who have a seizure disorder and are pregnant, taking an antiseizure medication increases the risk of miscarrying or of having a baby with a birth defect of the spinal cord, spine, or brain ( Neural Tube Defects and Spina Bifida —see table All women who are of childbearing age and taking an antiseizure medication should take folate supplements to reduce the risk of having a baby with a birth defect. Emergency treatment to stop the seizures is required for Status epilepticus (seizures that last more than 5 minutes) Large doses of one or more antiseizure medications (often starting with a benzodiazepine, such aslorazepam) are given intravenously as quickly as possible to stop the seizure. The sooner antiseizure medications are started, the better and the more easily seizures are controlled. Measures to prevent injuries are taken during the prolonged seizure. People are monitored closely to make sure breathing is adequate. If it is not, a tube is inserted to help with breathing—a procedure called intubation. If seizures persist, a general anesthetic is given to stop them. If people continue to have seizures while taking two or more antiseizure medications or if they cannot tolerate side effects of the medications, brain surgery may be done. These people are tested at specialized epilepsy centers to determine whether surgery can help. Testing may include MRI of the brain, video-EEG monitoring, and the following: Functional MRI : To determine which areas in the brain are causing seizures (called seizure foci) Single-photon emission computed tomography (SPECT) (SPECT): To check for areas with increased blood flow around the time of a seizure, which may indicate which areas in the brain are causing seizures EEG combined with magnets used for imaging (magnetic source imaging): Also to help determine which areas in the brain are causing seizures If a defect in the brain (such as a scar) can be identified as the cause and is confined to a small area, surgically removing that area can eliminate seizures in up to 60% of people, or surgery may reduce the severity and frequency of seizures. Surgically cutting the nerve fibers that connect the two sides of the brain (corpus callosum) may help people who have seizures that originate in several areas of the brain or that spread to all parts of the brain very quickly. This procedure usually has no appreciable side effects. However, even if surgery reduces the frequency and severity of seizures, many people need to continue to take antiseizure medications. However, they can usually take lower doses or fewer medications. Before and after surgery, a psychologic and Neurologic Examination may be done to determine how well the brain is functioning. If people cannot undergo these surgical procedures, other procedures, such as stimulation of the vagus nerve or brain, may be done. Electrical stimulation of the 10th cranial nerve (vagus nerve) can reduce the number of focal-onset seizures by more than one half in about 40% of people who have focal-onset seizures. This treatment is used when seizures continue despite use of antiseizure medications and when surgery is not a possibility. The vagus nerve is thought to have indirect connections to areas of the brain often involved in causing seizures. For this procedure, a device that looks like a Keeping the Beat: Artificial Pacemakers (vagus nerve stimulator) is implanted under the left collarbone and is connected to the vagus nerve in the neck with a wire that runs under the skin. The device causes a small bulge under the skin. The operation is done on an outpatient basis and takes about 1 to 2 hours. The device is programmed to periodically stimulate the vagus nerve. Also, people are given a magnet, which they can use to stimulate the vagus nerve when they sense that a seizure is about to begin. Vagus nerve stimulation is used in addition to antiseizure medications. Side effects of vagal nerve stimulation include hoarseness, cough, and deepening of the voice when the nerve is stimulated. The responsive neurostimulation system is a device that looks like a Keeping the Beat: Artificial Pacemakers . It is implanted within the skull. The device is connected by wires to one or two areas in the brain that are causing the seizures. This system monitors the brain's electrical activity. When it detects unusual electrical activity, it stimulates the areas of the brain that are causing the seizures. The aim is to restore normal electrical activity in the brain before a seizure can occur. The responsive neurostimulation system is used in addition to antiseizure medications. It is used when adults have focal-onset seizures that are not controlled by medications. It can reduce the frequency of seizures in these people. Surgery to implant the system requires general anesthesia and typically takes 2 to 4 hours. Many people can go home the next day. Some need to stay in the hospital for up to 3 days. Many people can return to their daily activities within a few days and return to work in 2 to 4 weeks. People cannot feel the device or the stimulation, and the device can be removed if needed. 