Fit to be Tied

Fit, spell, seizure, epilepsy, ictus are all terms that denote a seizure. Let's start with a definition. A seizure is a sudden neurological event caused by an abnormal excessive discharge of a group of neurons in the brain. The disease, epilepsy is recurrent seizures due to a chronic underlying process. Seizures are grossly divided into generalized and partial (focal).

Simple partial seizures do not lead to alterations in consciousness. The patient may have motor, sensory, automatic or psychic symptoms. Complex partial seizures include alteration in consciousness in addition to automatisms such as lip smacking, chewing, aimless walking or other complex motor activities.

Generalized seizures are either grand mal (tonic-clonic) or petit mal (absence). Have I ever mentioned that the French were the pioneers in neurology?

Grand mal seizures always present with a loss of consciousness and posture control. During the tonic phase there are marked contraction of muscles. Teeth clenching may lead to oral trauma and bleeding. The clonic phase of the seizure demonstrates rhythmic jerking of the body. There is usually a loss of control of the bladder and sometimes the bowels. A person having a grand mal seizure is not swallowing his tongue. One should not try and force anything into the patient's mouth. First aid is to remove any objects around the victim that they might cause injury and if possible to turn them onto their side.

Absence seizures are best described as a sudden brief impairment of consciousness without a loss of posture control. The typical petit mal seizure is 5-10 seconds of staring with minor motor twitching. The danger is that a petit mal seizure occurring while driving or performing any dangerous task could be disastrous.

Focal seizures involve only part on the body. Sometimes a single limb or side of the face, or more commonly a half of the body. Focal seizures are caused by anatomical abnormalities on the side of the brain opposite the side where the seizure activity is noted.

Some clonic movements may also be seen with many forms of syncope. Cardiac arrhythmias, vasovagal syncope, hyperventilation syncope may all show brief muscle twitching. In the ER psychogenic or pseudoseizures are part of the differential diagnosis in the seizure work up. Often patients with a true seizure disorder will have pseudoseizures. The lack of respiratory muscle involvement, the stylized movements and the lack of a postictal period of confusion and lethargy help to separate the psychogenic from the true seizure.

Seizures are often idiopathic, that is that there is no known cause. Genetics do play some role in idiopathic seizures. Tumors of the brain or metastatic tumors from other cancers, vascular anomalies such as AVM's (arteriovenous malformations), strokes and trauma to the brain are all anatomical causes of seizures. Many medications and abusable substances lower the seizure threshold and may lead to seizures. Isoniazid for tuberculosis, alkylating agents for chemotherapy, antimalarials (chloroquine and mefloquine), antipsychotics, antidepressants, alcohol, speed, cocaine, PCP, and methylphenidate are just some of drugs that may cause seizures.

In the patient with known epilepsy, a recurrent seizure work up will include an examination for any evidence of brain injury, infections, electrolyte abnormalities, and blood levels of the anticonvulsants that are prescribed for the patient. A drug and alcohol panel may also be done. Missed doses or simply stopping their medications are most often the cause of the recurrent seizure.

A first time seizure in an afebrile child or adult will lead to a more comprehensive work up. Besides blood and urine tests and a detailed history and physical exam, some type of imaging study will be performed. A CT or MRI of the head is part of the initial examination. An EEG will be done as soon as possible. Neurologists prefer that the patient not be started on an anticonvulsant until the EEG has been done. The ER doc must strongly admonish the patient that he or she is not to drive, operate machinery or engage in dangerous activities (scuba diving, climbing ladders, skiing, etc) until cleared by the neurologist. Seizures with fever especially in an adult may indicate a CNS infection such as meningitis or encephalitis and an LP will need to be performed.

Simple febrile seizures are a fairly common ER occurrence. In children from 3 months to 5 years, a seizure that is generalized, lasts less than 5 minutes and is accompanied by a fever is the usual presentation. The work up will depend on the individual patient's history and physical examination and height of the fever. About 80% of children who have a simple febrile seizure will not have any additional seizures. The EEG and use of anticonvulsants is rarely needed except for the 20% who return in the future with second or third febrile seizures. First aid as mentioned earlier is to protect the child from injury and to turn him on his side.

A newborn having a seizure, with or without fever, will be more aggressively evaluated with CT and LP almost always being part on the examination. Birth trauma and neonatal infection are the most common etiology of seizures in this patient population.

Status epilepticus is a life or death emergency in the patient with seizures. Status is the term used to describe a patient who has multiple seizure without a return to full consciousness or a patient who has continuous seizure activity. Untreated, status epilepticus will cause permanent injury to the brain or death. A recent patient of mine illustrates the difficulty in management of this condition.

The patient was man in his 60's who had had a hemorrhagic stroke in the past. He had a craniotomy to remove accumulated blood and was taking anticonvulsants. The injury to his brain had been on the left side. He presented to the ER with the paramedics and had been given IV lorazepam. This medication is a benzodiazepine and is a rapidly effective anticonvulsant. The patient was still having seizure activity involving the right side of his face and his right arm and leg. Blood tests and a CT did not show any obvious cause of his continued seizure activity. The patient was endotracheally entubated to protect his airway and multiple doses of ativan were given. He was given a loading dose of phenytoin, an additional anticonvulsant and paralytics to stop the motor activity. I arranged for urgent transfer to a tertiary care hospital as even when paralyzed the seizure activity of the brain could still be occurring. He needed continuous EEG monitoring. As he was about to be transferred I noticed a subtle twitching of his right eyelids. My parting shot was a loading dose on phenobarbital, a potent anticonvulsant.

Seizures are a frightening experience for the patient, their family and friends and even the bystanders who witness the ictus (from the Latin, meaning to strike). Historically, people with epilepsy were considered possessed. Exorcisms, trephinations (holes drilled into the skull) were perpetrated against these unfortunate patients. The psychic pronouncements of individuals with simple partial seizures may have been the basis for the oracles of mythology. As enlightened humans we should recognize that epilepsy in all its manifestations is diagnosable and treatable. There is no room in the 21st century for stigmatizing patients with epilepsy.

Knowledge leads to understanding.