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Epilepsy is the most common serious neurological condition affecting people of all ages. A prevalence rate of 0.5% (1in 00) is usually quoted as a minimum prevalence for the UK This would mean that there are at least 50,000 people with epilepsy in this country.
Anyone can develop epilepsy; it occurs in all ages, races and social classes. Seizures tend to start in infancy or by late adolescence, but the incidence rises again after 65.
The causes of epilepsy are different at different ages and the mechanisms are largely not fully understood.The wide range of causes, and the variety of effects, highlights the importance of research in this area. New drugs and other therapies are constantly being sought, as is the answer to why it happens.
Frontal Lobe - movement
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Parietal Lobe - sensory control
Occipital Lobe - vision
Temporal Lobe - language and memory
The human brain is an enlarged and highly organized mass of nervous tissue located in the skull. It is the control center for the nervous system. The brain is divided into sides known as hemispheres; these hemispheres are in turn divided into lobes. Different regions of the brain are known to control different tasks i.e. vision, speech, movement. Damage to the nerves in a particular region will directly affect the task that it controls.
The basic unit of the nervous system is the individual nerve cell - the neuron. Nerve cells operate by generating electrical signals and passing them from one cell to another and by releasing chemicals called neurotransmitters to communicate to other cells.
The anatomical junction between two nerve cells is called a synapse. It is here that the cells communicate with each other by releasing neurotransmitters. These chemicals then bind to receptors on the neighboring cell to affect its activity. Cell activity can be altered in two ways - excitatory or inhibitory. Excitatory messages enhance the cells activity whereas inhibitory messages dampen it.
In epilepsy there is a problem with the way in which the cells are communicating with each other leading to the occurrence of seizures. When the inhibitory pathways are removed the cells become over excitable and fire incorrectly. As the nerves of the brain are connected in complex patterns this can lead to a number of cells exhibiting inappropriate behaviour. The outcome of these abnormal circuits are very varied, depending on the region of the brain they affect, hence the multitude of epileptic syndromes.Before treatment is initiated patients are usually evaluated with the aid of EEGs. This helps determine the type of seizure the patients experiences. EEGs show the activity of the brain and allow any abnormalities in brain function to be pin-ponited.The first line of treatment in Anti-epileptic Drugs. Epilepsy can be effectively controlled with AEDs in around 70% of all patients.When medication fails some patients may be put forward for surgery. Typically good candidates for surgery are those whose seizures are focal and not close to regions controlling important brain functions such as language
WHY RESEARCH?
Professor Alan Richens, Chairman of the Epilepsy Research Foundation says
Although we know a lot about how the brain works, we still dont know what exactly happens when a seizure strikes. Through careful research, we are beginning to understand how genetics causes some of the inherited problems affecting nerve cells and how we can control seizures with drugs.
ERF helps the best UK scientists push forward the frontiers of our basic knowledge about epilepsy. In addition, it promotes the more practical aspects of our knowledge and treatment of epilepsy by supporting research into its prevalence, improving the diagnosis by brain scanning and developing better neurosurgical treatments.
As epilepsy frequently begins in childhood, particular stress is put on promoting research in this age group. However, as we enter old age, epilepsy becomes common once again and, with the rising proportion of elderly people in the population, it is an increasingly common problem.
A great deal of research is still to be done before we can say that we have conquered epilepsy.
TYPES OF SEIZURES
As the brain is responsible for a wide range of functions, seizures can take many forms.
The International Classification of Seizures (published by the International League Against Epilepsy) is the most commonly used to determine the type of seizures a patient has.
Generalized Seizures
These seizures involve the entire brain and there is loss of consciousness. There are various subclasses of Generalized seizures.
a) Tonic Clonic (previously grand mal) - the person will become rigid and may fall if standing up when the seizure occurs. The muscles relax then tighten rhythmically causing the person to convulse. Breathing will become laboured and the person may become incontinent.
b) Tonic - there is generalized stiffening of the muscles without any rhythmical jerking
c) Atonic (also known as drop attacks) - there is a sudden loss of muscle tone
d) Myoclonic - abrupt jerking of the limbs is observed
e) Absence (sometimes know as petit mal) - brief interruption of consciousness without any other signs, except perhaps for a fluttering of the eyelids. Commonly seen in childhood and adolescence when it may be mistaken for daydreaming.
Partial Seizures
In Partial Seizures the disturbance in brain activity begins in a localized region. These are also known as focal seizures.
There are main types of Partial Seizures
a) Simple - There is no loss of consciousness. The seizure is confined to either rhythmical twitching of one limb, or part of a limb, or unusual tastes or sensations. They can often develop into complex seizures and can be known as auras
b) Complex - With this seizure type consciousness is impaired. They usually involve the Temporal lobe but can also be seen in the Frontal and Parietal Lobes. The seizure may be characterized by a change in awareness as well as semi-purposive movements such as fiddling with clothes.
c) Secondary Generalized - these seizures occur when either of the above seizures spread to involve the whole brain.
Antipileptic Drugs
Why to attacks need to be suppressed?
Epileptic seizures need to be controlled for several reasons. Apart from prevention of injury caused by falling, biting of the tongue etc. in major attacks, frequent seizures may impair memory and academic performance. The unpredictable nature of seizure onset can also have repercussions on employment and family life. A driving license, for example, is only permitted after a person has been completely seizure free for a year or a pattern of purely nocturnal seizures has been established over at least years.
How do drugs prevent seizures?
Most of the drugs used in treating epilepsy today were discovered to have anti-epileptic properties by chance. However there is now a more systematic search for new AEDs under way, based on research progress in understanding how neurons talk to each other and an increasing knowledge of the structure and function of neuronal membranes.
Which drug?
The type of AED chosen by a doctor depends on many factors
1) the type of epilepsy
) possible side effects
) anticipation of pregnancy
4) other medication
First line drugs are those which are prescribed alone when anti-epileptic medication is started. Second line drugs are usually prescribed as an addition to an existing first line therapy when seizures are difficult to control. Each drug has names - the generic/chemical name ( for example sodium valproate ) and the trade name ( for example Epilim ). Doctors may write a prescription using either name. If the doctor has used the generic name the pharmacist may supply the trade or generic drug, however if the doctor uses the trade name, the pharmacist must provide that drug. Below is a brief description of a few of the most commonly used AEDs. The dosage levels quoted are for a otherwise healthy adult.
Surgical treatment depends on main principles
1) presence of a local abnormal area of the brain which can be entirely removed without interfering with normal brain function
) the spread of generalized epilepsy can be prevented by cutting the nerve fibres that carry the electrical message
As well as intensive assessments to pinpoint the region of the brain responsible for the epilepsy, patients will undergo a number of psychological tests to determine where in their brain language and memory are processed - to ensure that these regions will not be damaged during surgery. It is also vitally important that surgery will not affect the bodies motor control.
There are 4 main type of surgical procedure
a) removal of a large, identifiable tumour or cyst
b) removal of entire cerebral hemisphere
c) removal of a small/large lesion which has been identified on the basis of EEG recording and imaging as being responsible for the epilepsy
d) resection (cutting) of nerve fibers
In patients undergoing surgery, 60-70% will become completely seizure free following the procedure, and another 10-0% will see marked improvement in seizure frequency and duration. The phenomenon of sudden unexpected death in epilepsy (SUDEP) is by definition a death for which no cause has been found except for the individual having had a history of seizures. It has been found that the majority of such cases occur whilst the individual is asleep and it is estimated that there are approximately 500 cases of SUDEP in the UK a year.
During a seizure, patients may display a number of symptoms. These include apnoea (temporary cessation of breathing), tachycardia (increase in heart rate above normal) or bradycardia (slowing of heart rate above normal), hypertension (high blood pressure) or hypotension (low blood pressure) and hyperpyrexia (rise in body temperature above 41.1degrees C). Despite this the vast majority of patients fully recover from a seizure, because of the bodys ability to regulate these unconscious processes (homeostasis). When sudden unexpected death occurs, it might be assumed that this homeostatic regulation has been interfered with to a sufficient degree to result in heart and/or lung failure. The Epilepsy Research Foundation felt that this was an important area of research to be funded. It has awarded two grants to ascertain possible risk factors and mechanisms of SUDEP. Dr Michael Hennessy from Kings College Hospital, London studied the effect of sudden withdrawal of the antiepileptic (AED) drug, carbamazepine, on 1 patients with severe partial epilepsy. He found an increase in activity of the sympathetic nervous system (responsible for increasing heart rate and blood pressure) during sleep. The activity of the sympathetic nervous system whilst sleeping is normally low, and it therefore appears conceivable that this increased activity might be responsible for provoking alterations to the normal rhythm of the heart (cardiac arrhythmia) during a seizure. This study suggested that AED non compliance (not taking the drug at the correct time and in the appropriate quantity) may have on predisposing to SUDEP. It also highlights the importance of slow AED withdrawal, and suggests the need for additional medication at the time of drug withdrawal to counteract this sympathetic nervous system activity. This study now needs to be repeated on a larger number of patients and to examine the effect of withdrawal of other antiepileptic drugs on the sympathetic nervous system. Dr Yvonne Langan from the Institute of Neurology, London undertook an exploratory case control study to examine the influence of a number of factors on the risk, for an individual with epilepsy, of SUDEP. These included the epilepsy syndrome, seizure type and control, treatment history and compliance, alcohol intake, gender, age, electrocardiogram (ECG) changes and supervision at night.
The following passage is a summary of her work presented at the ERFs 10th Birthday Metting in October 001
Sudden Unexpected Death in Epilepsy (SUDEP) a case control study--The mortality rate of those suffering from epilepsy is - times higher than that of the general population. SUDEP has a reported incidence of between 1100/yr and 11000/yr. The exact mechanisms underlying SUDEP are unclear so risk factors were identified from descriptive epidemiological studies. This group carried out a case control study of SUDEP to identify risk factors. 154 cases were identified, the majority of whom had been found dead in bed and with evidence of a recent seizure.
Following completion of her year grant, Dr Langans research supports the belief that SUDEP is a seizure related event. It also suggests that better seizure control may play an important role in preventing these deaths. Her work would suggest that a witnessed seizure is less likely to be fatal and therefore it is conceivable that SUDEP may be prevented by paying closer attention to recovery and positioning following a seizure.
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