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Seizures and Teens Sorting Out Seizures


									Epilepsy Care — PART TWO


Seizures and Teens:                                                                                       should be very humble and not be “married” to

Sorting Out Seizures                                                                                      their first diagnosis. If a person is not doing
                                                                                                          well or as expected, one of the first questions
                                                                                                          should be “is the diagnosis correct?” Too often,
By Orrin Devinsky, M.D.                                                                                   once a diagnosis is made, people focus on the
                                                                                                          information that supports the diagnosis and
                                                                                                          don’t look carefully at information that may
Introduction                                          ion at an epilepsy center years later. VideoEEG     lead to a different answer. This aspect of
In adolescents, diagnosing seizures can be            monitoring recorded one of his typical              human nature can be dangerous, as mistaken
challenging and can lead to many pitfalls.            seizures in which his heart stopped for 15 sec-     diagnoses tend to persist under the care of dif-
Because seizures are episodic and unpre-              onds; a heart problem was triggering the            ferent doctors. There are many other health
dictable events, they usually do not occur in         seizures. Antiepileptic medicines were              problems that can masquerade as epilepsy.
the doctor’s office. Thus, a diagnosis of epilep-     stopped and a heart pacemaker was implant-          Table 1 summarizes some of the most common
sy is usually based on information presented          ed. Bob has been completely free of episodes        conditions mistaken for epilepsy.
by the person with seizures and their family.         for 15 years. A videotape of his spell was
Together with results of diagnostic tests, doc-       shown at a medical meeting during a lecture
                                                                                                          Table 1:
tors determine if the events are seizures and         on diagnosing epilepsy. The EEG and one
what type. Once a diagnosis of epilepsy is            channel of EKG were also shown. The audi-           Common Imitators of Epilepsy
made, sorting out whether the patient’s disor-        ence had five choices: complex partial seizure,
der can be classified into a defined group, or an     tonic clonic seizure, nonepileptic psychogenic      • Fainting spells or syncope
epilepsy syndrome, is done. Knowing the spe-          seizure and cardiac syncope. By chance, 20          • Migraines
cific epilepsy syndrome can help people               percent should have guessed the correct
understand the cause(s) of the epilepsy, what         answer, but less than 5 percent made the cor-
                                                                                                          • Movement disorders
other problems may be associated with the             rect diagnosis—even witnessing the episode.         • Heart rhythm disorders
seizures and what the prognosis or future may            Case 2 is Jennifer, 14 years old, who was
                                                                                                          • Sleep disturbances
be like. For example, some types of epilepsy          seen by a pediatric neurologist after having two
respond better to medicines than others. Some         tonic-clonic seizures in six months. The EEG        • Staring spells, daydreaming
epilepsy syndromes may be considered ‘benign’         showed spike activity on both sides, more in        • Attention problems
and tend to go away at a certain age, while oth-      the right frontal area, consistent with partial
ers are often difficult to control or require life-   epilepsy. She was started on carbamazepine          • Rage attacks
long treatment. This article discusses the chal-      and had the doses increased each time she had       • Other behavior problems
lenges of sorting out seizures, common seizure        another seizure. She was seen at an epilepsy
types and syndromes, and ways families and            center and her history revealed that all seizures
                                                                                                          • Anxiety or panic attacks
caregivers can observe and record seizures.           occurred within an hour after awakening. She           Correct classification is critical to know
                                                      also had brief jerking movements of both            what diagnostic tests may be needed and
Challenges and dilemmas                               shoulders while awake. Another EEG showed           establish an appropriate treatment plan. Just
How often do doctors make errors diagnosing           generalized spike-and-wave discharges. The          as historical information can be misleading,
seizures? Since there is no single test to diag-      diagnosis was changed to juvenile myoclonic         diagnostic studies can also lead to wrong
nose epilepsy, exact answers are not known.           epilepsy, a form of generalized epilepsy that       diagnoses, as shown in case 2 (see above). If
Yet clinical experience suggests that misdiag-        causes absence, myoclonic and tonic-clonic          the seizure type is incorrectly classified, the
nosis is more common than one might imag-             seizures. Carbamazepine can make this type of       underlying cause of epilepsy may not be rec-
ine. Consider the following situations:               epilepsy worse. She was changed to lamotrig-        ognized or an inappropriate medication may
   Bob was 17 years old when he developed             ine and has been seizure free for five years.       be selected. This could lead to unnecessary
episodes of staring, non-responsiveness and              All epilepsy means is that a person has had      side effects, incomplete control, or in some
slight shaking movements of the body. He was          two or more seizures that are not provoked by       cases, worsening of seizure control.
diagnosed with complex partial epilepsy and           a medical problem. Once epilepsy is diag-
was treated with carbamazepine and pheny-             nosed, the next steps are to identify the seizure   Types of Seizures
toin for years before obtaining another opin-         types and epilepsy syndrome. Clinicians             Seizures can be broadly separated into two

70 July 2006 • EP MAGAZINE/
groups: (1) primary generalized seizures and        have attention problems. Simple absence              duction, sometimes incorrectly described as
(2) partial seizures (Table 2).                     seizures are just “stares.” Complex absence          “foaming” at the mouth. The tongue or cheek
                                                    seizures mean that there may also be some            may be bitten. Loss of urine or, rarely, a bowel
                                                    change in muscle activity (e.g., eye blinking or     movement may occur. After the convulsion,
Table 2:
                                                    automatic hand movements), especially if the         the person is usually tired and confused for
Classifying Epileptic Seizures                      seizure lasts more than 10 seconds.                  minutes to hours and often sleeps. At times
                                                        There are two main syndromes of absence          the person can be agitated.
Primary Generalized Seizures                        epilepsy. Childhood absence epilepsy begins             PARTIAL SEIZURES. Partial seizures
• Absence                                           between the ages of four and eight years old         begin with an abnormal burst of electrical
                                                    with most children outgrowing the seizures in        activity from a restricted brain area. Most par-
• Myoclonic                                         their teenage years; very few will have tonic-       tial seizures arise from the temporal or frontal
• Atonic                                            clonic seizures. Juvenile absence epilepsy           lobes. Head injury, brain infections and prob-
                                                    begins in the early teen years (10-14 years old);    lems in the way the brain developed are com-
• Clonic
                                                    seizures often persist into adulthood and many       mon causes of partial seizures in childhood
• Tonic                                             develop tonic-clonic seizures. Children with         and adolescence. Often, no cause or family
• Tonic-clonic                                      absence seizures have normal development             history of epilepsy can be identified.
                                                    and intelligence, but may have higher rates of          Partial seizures are divided into two main
PARTIAL SEIZURES                                    behavioral, educational and social problems          types, depending on whether consciousness
                                                    than other children. The EEG is extremely help-      is fully preserved. During simple partial
• Simple Partial                                    ful in diagnosing absence seizures. In most          seizures the person is alert, able to respond to
                                                    cases, generalized spike-and-wave discharges at      questions or commands, and can remember
• Complex Partial
                                                    three-per-second or faster are recorded, espe-       what occurred during the seizure. During
• Partial seizures that                             cially during hyperventilation. Brain MRI is nor-    complex partial seizures, the ability to pay
  secondary generalize                              mal. Absence seizures may be confused with           attention or to respond to questions or com-
                                                    complex partial seizures (see below), however,       mands is impaired to some degree. Often,
   Primary generalized seizures begin with a        absence seizures are usually shorter and are not     there is no memory of what happened during
widespread, excessive electrical discharge that     associated with a warning (aura) or after effects    all or part of the seizure.
involves both sides of the brain at the same        such as tiredness or confusion.                         SIMPLE PARTIAL SEIZURES can cause
time. In contrast, partial seizures begin with an       MYOCLONIC SEIZURES are the most                  incredibly diverse symptoms and can be diffi-
abnormal electrical discharge that begins in        under-diagnosed seizure type in my experience.       cult to diagnose unless they also affect a per-
one area of the brain. Diagnostic tests and ther-   Myoclonic seizures occur as brief, shock-like        son’s awareness or include convulsive move-
apies can vary for these disorders, making cor-     jerks of a muscle or group of muscles.               ments. For example, isolated abdominal
rect diagnosis essential. A description of what     Myoclonus may occur in people who do not             (stomach) discomfort from a partial seizure is
happened before, during and after the seizure,      have epilepsy (e.g., sudden jerks when a person      likely to be attributed to a gastrointestinal or
as well as recordings of the brain waves, help      is falling asleep or benign nocturnal myoclonus)     anxiety disorder. Tingling in the little finger
the doctor to determine the type of seizure.        and in these situations is not considered epilep-    that spreads to the forearm may come from a
   IDIOPATHIC (PRIMARY) GENERALIZED                 sy. Epileptic myoclonus usually causes abnor-        seizure, migraine or nerve disorder. Motor
SEIZURES. The cause of most generalized             mal movements that involve both sides of the         seizures that cause jerking or stiffness are
seizures is unknown (also called idiopathic),       body (e.g., neck, shoulders, and upper arms) at      most likely to be recognized. Some partial
although genetic factors are suspected. The         the same time. Myoclonic seizures are the main       motor seizures cause weakness of one or
three most common types are absence,                seizure type in teenagers with juvenile              more body parts, including the vocal appara-
myoclonic and tonic-clonic.                         myoclonic epilepsy. In this syndrome, seizures       tus, which affects the ability to speak.
   ABSENCE SEIZURES (often called petit             most commonly occur within one hour after               SENSORY SEIZURES most often cause hal-
mal) are brief episodes of staring; the person      awakening. The attacks are usually well con-         lucinations, or episodes that are not really hap-
is not aware of what is going on and cannot         trolled with medication, which often needs to be     pening. The hallucinations may affect only one
respond. The episode begins and ends sud-           continued throughout the person’s life.              area of the body or environment, or spread to
denly, usually lasting less than 10 seconds,            TONIC-CLONIC (grand mal) seizures are            other areas. There also may be an illusion or the
but may last 20 seconds or longer. There is no      convulsive seizures. The person briefly stiff-       distortion of a true sensation. Hallucinations
warning and immediately afterward the per-          ens on both sides, loses consciousness and           and illusions can involve all types of sensa-
son is alert and able to pay attention. The         falls if standing. The stiffening (tonic phase) is   tions—touch, smell, taste, vision, hearing and
teenager may or may not be aware that a             followed by jerking (clonic phase) of the arms       vestibular (floating or spinning feeling).
seizure has occurred. Sometimes the person          and legs. The seizures usually last one to three        AUTONOMIC SEIZURES cause changes in
is thought to be daydreaming, confused or           minutes. There may be excessive saliva pro-                                       continued on page 72

                                                                                                     MAGAZINE • July 2006 71
Epilepsy Care — PART TWO                                                                                    Tips for Observing Seizure
                                                                                                            PERSON’S BEHAVIOR
continued from page 71                                ing the type of seizure, while the MRI or other
                                                                                                            BEFORE EVENT
nervous centers that automatically controls           brain scans can help look for possible causes.        • When event occurs
bodily functions (e.g., strange or unpleasant                                                               • Possible triggers
abdominal sensation, increased heart rate).           What Happens When Seizures
The area of the brain that controls emotions          Are Not Easily Controlled
                                                                                                            WHAT HAPPENS DURING EVENT
(limbic region) strongly influences autonomic         Approximately 30% of people with epilepsy             • Level of awareness, alertness
activity. This is why strong emotions are asso-       have seizures that are difficult to control despite   • Speech and understanding
ciated with changes in heart rate and breath-         one or more medications. These are referred to        • Thinking, remembering,
ing, feelings in the stomach or chest and why         as refractory seizures. In these situations, the
                                                                                                              feeling, perceiving
we say things such as, “I just have this feeling      first step is to make sure the diagnosis is right
in my gut.” When partial seizures arise from          and that medications were used appropriately.         • Sensations – see, hear,
limbic areas of the temporal or frontal lobe,         For example, if the medication was started at a         taste, smell, feel
autonomic changes are common.                         high dose and side effects were troublesome, it       • Facial expression
   PSYCHIC SEIZURES cause changes in the              is possible that slower increases would be better     • Muscle tone
brain that affect how we think, feel and expe-        tolerated. If seizures only occur within an hour
                                                                                                            • Movements – jerking, twitching
rience things. They can affect language func-         of awakening, then a higher dose of medicine at
tion, perception and memory (e.g., deja vu) or        bedtime may be more effective. Unfortunately,         • Automatic or repeated
cause sudden emotional feelings (e.g., fear or        despite the best medical care, seizures cannot be       movements
sadness). Other symptoms may include feel-            controlled in many people and other options           • Walking, wandering, running
ing as if one is not one’s self (depersonaliza-       such as brain surgery or the vagus nerve stimu-       • Falling
tion) or feeling as if the world is not real, or as   lator may be worthwhile considerations.
if one is in a dream (derealization).
                                                                                                            • Color of skin, sweating,
   During COMPLEX PARTIAL SEIZURES,                   Observing and Recording Seizures                        breathing
the person typically stares and is either             The first seizures can be a very scary time for       • Loss of urine or bowel control
unable to respond or responds incompletely.           teens and their families. People don’t know           WHAT PART OF BODY INVOLVED
Automatic movements (automatisms) occur in            what is happening, who to see and may not
most complex partial seizures and can                 even know what information to share with the          WHAT HAPPENS AFTER EVENT
involve the mouth and face (lip smacking,             doctor. Or maybe events have been going on            LENGTH OF EVENT
chewing, tasting and swallowing movements),           for a long time, but parents didn’t know they         • When returns to normal
hands and arms (fumbling, clasping move-              were seizures? When people don’t understand
ments), vocalizations (grunts, repetition of          what they are facing, expectations about
words or phrases), or more complex acts               seizures, treatment options and the future may        and whether any factors make the seizures bet-
(walking, running). These seizures usually last       not be realistic. Thus, the first steps in learning   ter or worse. For example, people whose seizures
from 30 seconds to two minutes. Auras (sim-           to manage seizures should focus on observa-           occur more frequently at times of stress would
ple partial seizures) often occur in the begin-       tion and recording of seizures and associated         want to record periods of stress along with times
ning and are actually the start of the seizure.       symptoms. What is seen or experienced by the          of seizures. Teens whose seizures occur at a spe-
After the seizure, people are usually tired and       teen, family members and caregivers on the            cific time of day or month should note if seizures
confused for 15 minutes or so and may not             front line (e.g. school nurse, pediatrician,          start occurring at different times than usual.
remember what happened during the event.              coaches or camp counselors) may affect all
   SECONDARILY GENERALIZED SEIZURES                   other decisions made. Table 3 offers examples         Next Steps
begin in one area but spread to become a tonic-       of what to look for during a seizure.                 This article provides an overview of diagnos-
clonic seizure. Secondarily generalized seizures         How seizures are written down is often a mat-      ing seizures in adolescents and stresses the
occur in more than 30% of children and adults         ter of personal preference. Some people like to       importance of first hand information from
with partial epilepsy. People may or may not          write full descriptions, others like to use calen-    others. Visit the Exceptional Parent magazine
recall an aura, and witnesses may first observe a     dars or checklists. Recording can be done on          website ( and
complex partial seizure that goes into the tonic-     paper or using technology such as personal dig-       ( for helpful links and
clonic seizure. A secondarily generalized tonic-      ital assistants or computer calendars. When the       resources, more detailed information on
clonic seizure may be difficult to distinguish        diagnosis is not clear, whichever system can give     seizure types and syndromes, as well as down-
from a primary generalized one, especially if it is   the most detailed information is usually best.        loadable tips for seizure observation and
not witnessed or occurs during sleep (most con-       Once the seizure type is known, a simplified ver-     seizure calendars. EP
vulsive seizures in sleep begin as partial            sion can be used to count how frequently                 Coming next – Seizure Emergencies—
seizures). The EEG is very helpful in determin-       seizures occur, if any changes have happened,         What to do?

72 July 2006 • EP MAGAZINE/

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