Epileptic seizures occur when abnormal and excessive brain electrical activity prevents the brain from working normally. Seizures can cause a variety of symptoms ranging from unusual sensations (auras) to bland unresponsiveness to uncontrolled convulsive body movements and loss of consciousness. Seizures can be focal, affecting only a small part of the brain, or generalized affecting most of the brain. They can occur in isolation or as part of an epilepsy syndrome with other symptoms. Epilepsy is the term for having recurrent, unprovoked seizures. It currently affects about 1% of our population, or more than 3 million people in the U.S. and 65 million people world-wide. About 1/3 of patients have seizures that are not adequately controlled with medications. Seizures can result in permanent injury and even death. Epilepsy has a socioeconomic impact, and can be disabling by limiting your ability to work or drive.
In Connecticut, there is no specific period of seizure freedom required by law before you are allowed to drive. This varies in neighboring states, as Massachusetts has a 6-month restriction, New York has 1 year, and Rhode Island requires you to be seizure-free for 18 months before resuming driving. Your physician may recommend that you should not drive for a period of 3 to 6 months after a seizure for safety reasons. Get more information from the Epilepsy Foundation on driving information for other states.
There are many causes for seizures. Almost any injury to the brain can result in a seizure. This includes head trauma, toxins, alcohol, medication use or withdrawal, tumors, strokes and infections. The tendency to have seizures can also be inherited, and a number of genetic disorders or subtle brain malformations can cause seizures. In many cases, however, we cannot find a specific cause.
Seizures come in two major categories. Focal seizures start in a part of the brain (and were once known as “partial seizures”) and can cause either a strange experience (unusual smell, numbness/tingling, visual hallucinations, butterflies in the stomach or a sense of déjà-vu) that is called an aura. They can also cause loss of awareness and unconscious chewing or picking movements known as automatisms. These types of seizures will sometimes progress to a generalized tonic-clonic (GTC) seizure (also called grand mal seizure) with stiffening of the arms and legs followed by rhythmic jerking, usually lasting about 1-2 minutes and often followed by sleepiness, confusion, and sometimes tongue biting or bladder incontinence. GTC seizures can also occur without an earlier focal seizure.
The second category of seizures is generalized, as these appear to start all over the brain rather than in a single location. A GTC without focal onset is considered a type of generalized seizure. Other types of generalized seizures include absence seizures which have bland staring without the automatisms seen in focal seizures, as well as myoclonic seizures (brief jerks of the arms or head), tonic seizures (whole body stiffening with arms thrown upward) and atonic seizures (whole body loss of tone causing a fall). Some of these seizures types occur with specific syndromes and have other symptoms as well. Since the seizure type frequently determines which medication is most helpful, your doctor will need a very good description of each type of spell you have as well as any precipitating factors. We will also want to know about any family history of seizures, whether you have had a severe head injury, convulsions with a high fever during early childhood, or a brain infection like meningitis or encephalitis.
An electroencephalogram (EEG) can help identify, localize and classify seizures due to changes in the brain activity. You do not need to have a seizure during the recording in order to detect these changes. An CT scan or MRI of the brain can determine whether seizures are due to a structural lesion. Seizures can also occur with abnormalities in blood chemistry, and blood tests can sometimes detect systemic factors that can lead to a seizure.
There are now almost 30 different seizure medications that can help control seizures. Your doctor will select a medication that is appropriate to your seizure type and other factors in your medical history. You can find out more about each of these medications at the Epilepsy Foundation. Sometimes several medications must be tried before seizures are fully controlled, and more than one medication may be needed. If your seizures do not respond to several different medications, vagus nerve stimulation or epilepsy surgery are possibilities.
Please call 1-84-GET-UCONN or request an appointment online with one of our epilepsy specialist and discuss the best care for your seizures. You can find more information on the Epilepsy Foundation of America. For information about local support and resources, we encourage you to contact the Epilepsy Foundation Connecticut chapter.
Electroencephalography (EEG) is a test that records the electrical activity of the brain. It can be done in either the outpatient clinic or in the hospital. In preparation for the test, you should have clean hair and not put any oils on your hair or scalp. The technician will ask you to sit back in a chair and will measure and mark your head with a crayon-like marker so the electrodes will be placed in the right positions. The scalp is prepared by mild rubbing with a paste, and then electrode cups with wires attached are placed on the 20 spots on the head. There may also be electrodes stuck on near your eyes, and an ECG electrode on the chest to record your heart electrical activity. Once the wires are in place, you lie back and relax, mostly with eyes closed, so we can record the brain electrical activity. The patterns can show whether you are awake or asleep, whether there has been damage to a part of the brain, and whether there is a tendency to have seizures. You don’t need to have a seizure at the time of the recording for to detect seizure-related discharges. Usually the recordings last for 25 to 60 minutes, but your doctor may have asked for a longer study with video if the goal is to record a spell or seizure. It is helpful to see your brainwaves in both awake and sleep states. You may be asked to count to 10 or do another mental task to show what your brain waves look like when you are most alert. You may also be asked to hyperventilate (breathe fast and deep) for several minutes, which also changes the brain waves, and a flickering strobe light may be used to stimulate the visual parts of your brain at different frequencies. After the test, the paste will come out with washing your hair. EEGs can be done on critically ill patients in the hospital to help predict recovery after a severe brain illness, or to diagnose brain death.
If you have spells or seizures, your doctor may request ambulatory EEG monitoring. This begins like a regular EEG with the wires being placed on your head, but instead of paste, a type of glue is used to keep the wires in place for several days. You will take a small recording device home with you that records your brain waves 24 hours a day for 1 to 3 days. You will also be given a diary so you can record any typical spells that occur during the recording, and the time they occur, so we can match the event to the brain waves that were happening at the time. At the end of the time assigned for recording, you bring back the recording device and diary, and the electrodes will be removed with a chemical solvent. It is important not to pull off the electrodes since the glue could hurt your skin. The study will be read by one of our EEG epilepsy specialists and you will find out the results within a few days (if any changes in your medications need to be made) or at your next neurology clinic appointment.
Long-term video-EEG monitoring (LTM) is performed to help diagnose the type of seizure, to monitor for seizure activity, or to localize the seizure discharges in the brain in preparation for possible epilepsy surgery. LTM is performed in UConn John Dempsey Hospital, where you will be admitted to one of our epilepsy monitoring rooms for continuous recording of both your brain waves and video of your activity during the day and night. Electrodes will be applied to your head using a glue as with ambulatory monitoring, and you will be connected to an EEG recording system via a long cable that allows you to move around the room. Video cameras will record your activity in the room (but not in the bathroom!). If you are on anti-seizure medicines, we may ask you to reduce or stop them just prior to the study or upon arrival at the hospital. You may need to stay for up to 4 or 5 days depending on how many spells or seizures are recorded. Since we cannot predict when spells will occur, we usually do not know in advance how long the monitoring will last. You will need to stay in your room the entire time of the admission so we can record your brain activity and any spells that occur. If you are a smoker, this is not allowed in the hospital, and we can provide a nicotine patch to reduce your craving to smoke. We may try to keep you awake overnight on selected nights to increase the chances of recording a spell. We realize that no one likes to have seizures, but having one in the hospital is the safest place since we have people watching you at all times, and access to medications and equipment to ensure your safety. Sometimes seizures or spells do not occur despite removing medications. If this happens, we will resume your seizure medicines and discharge you home. We may need to try again at a later date if spells continue. You can find more information on LTM at the Epilepsy Foundation of America.
Vagal Nerve Stimulation (VNS) has been used to improve seizure control since the mid-1990s. The VNS device is a small stimulator (about the size of a silver dollar) that is implanted under the skin below the collarbone, which is connected with a wire electrode to the vagus nerve in the neck. The device is implanted by a neurosurgeon as an outpatient surgical procedure. The battery for the device now lasts from 3 to 10 years depending on the amount of stimulation used, and replacement of the stimulator/battery can be done without changing the electrode in the neck. Stimulation is well tolerated by most people. A common pattern of stimulation is 30 seconds of pulses followed by 5 minutes of no stimulation, occurring 24 hours a day. After a quick period of adjustment, most people do not notice the stimulation. It is possible to give additional stimulation by passing a magnet (provided) over the stimulator, which can sometimes help abort a seizure in progress. The main side effect is a slightly hoarse voice when the stimulator is activated. If you sing in a choir or other group, you can tape a magnet over the stimulator during singing to prevent the stimulation from occurring during that time. About half of people who get VNS will have a 50% or greater reduction in seizures, and most have some improvement, but few people become seizure-free with VNS. It has also been used to treat other conditions including severe depression. You can find more information at the Epilepsy Foundation of America or from the company that makes the device, LivaNova. If you are interested in VNS for uncontrolled seizures, request an appointment online.
If seizures are not adequately controlled by medication, brain surgery may be a good option. The work-up for epilepsy surgery begins with admission for video-EEG monitoring so that seizures can be recorded to determine where they originate in the brain. Additional tests include brain MRI, neuropsychometric testing, PET scans and others to confirm that the site of seizure onset is correct before surgery. For patients who have seizures coming from one temporal lobe, surgical removal of that lobe has a 70 to 80% chance of curing the seizures. If your seizures have not responded to medications, your doctor may discuss with you whether you might be a candidate for epilepsy surgery. You can find out more about the process at the Epilepsy Foundation of America.