Epilepsy Treatment in Delhi, India

The most recent International League Against Epilepsy (ILAE) classification of epileptic seizures and epilepsies, published in 2010, revises past types using terminology and concepts appropriate for the modern era. Seizures are divided into three categories: generalised, focal (formerly called partial), and epileptic spasms. 

• Focal seizures originate in neuronal networks limited to part of one cerebral hemisphere.

• Generalised seizures begin in bilateral distributed neuronal networks.

• A seizure can start focally and later generalise. Seizures can originate in the cortex or in subcortical structures.

1. Focal seizures

   When consciousness is impaired during a focal seizure, the patient is unable to respond normally to verbal or tactile stimuli; the seizure is classified as dyscognitive (formerly called complex partial) seizures arising from the temporal lobe are often dyscognitive. Some seizures are preceded by an aura, a focal seizure wherein a patient retains awareness and describes motor, sensory, autonomic, or psychic symptoms. An aura precedes a focal dyscognitive or generalised seizure by seconds or minutes and is most often experienced by patients with temporal lobe epilepsy.

   Focal seizures can further be subclassified as those without loss of consciousness and seizures with altered awareness.

2. Focal seizures with no loss of consciousness

   Also known as simple partial seizures, as the name suggests, there is no loss of consciousness in these focal seizures. However, there may be an alteration in emotions or a change in the way things look, smell, feel, taste or sound. Sometimes there might also be an experience of déjà vu for the patient. Involuntary jerks in body extremities, that is, arms and legs, or spontaneous sensory alterations such as tingling, light flashes, or even dizziness are also known symptoms of focal seizures without loss of consciousness.

3. Focal seizures with altered awareness

   Also known as complex partial seizures, there is a change and/or loss of consciousness and/or awareness reported in these cases. Patients affected by these focal seizures may experience it as a dream. They may stare into space endlessly and not respond to environmental triggers. They may also indulge in repetitive movements, such as hand rubbing, chewing, swallowing, or walking in circles.

   Focal seizure symptoms may mimic other neurological disorders, migraine, narcolepsy, or mental illness, to name a few. A thorough examination and accurate diagnosis are needed to distinguish epilepsy from other disorders.

4. Generalised seizures

   The main subtypes of generalised seizures are absence, generalised tonic-clonic (GTC), myoclonic, and atonic. Absence seizures (formerly called petit mal) involve staring with unresponsiveness to external verbal stimuli, sometimes with eye blinking or head nodding. GTC seizures (formerly called grand mal) consist of bilateral symmetric convulsive movements (stiffening followed by jerking) of all limbs with impairment of consciousness.

   Myoclonic seizures consist of sudden, brief ("lightning-fast") movements that are not associated with any obvious disturbance of consciousness. These brief involuntary muscle contractions may affect one or several muscles; therefore, myoclonic seizures can be generalised or focal. Atonic seizures involve the loss of body tone, often resulting in a head drop or fall.

   Opposite to focal seizures, generalised seizures involve all areas of the brain.

These are further subclassified into six types-

1. Absence seizures

   Historically known as petit mal seizures, absence seizures are typically seen in children. A classical sign of absence seizure is that the patient stares into blank space, which may or may not be accompanied by subtle body movements, for example, eye blinking or lip smacking. These seizures typically last five to ten seconds. Absence seizures tend to occur in clusters. A frequency of as many as 100 times a day can be observed with this seizure, which may cause a brief loss of awareness.

2. Tonic seizures

   Stiffness of muscles and a loss of consciousness are typical signs of a tonic seizure. Muscle groups in the arms, legs, and back are the first to be impacted, leading to a loss of balance and a potential fall to the ground.

3. Atonic seizures

   These seizures cause a loss of muscle control and mostly affect the legs. This causes the patient to collapse suddenly. The seizures, therefore, are also known as drop seizures. 

4. Clonic seizures

   Clonic seizures classically show repeated or rhythmic muscle movements or jerks. The neck, face, and arms are the usual sites affected in clonic seizures.

5. Myoclonic seizures

   Sudden, brief jerks or twitches, usually affecting the upper body, arms, and legs, are termed myoclonic seizures.

6. Tonic-clonic seizures

   It can also be called the most dramatic of all seizures; tonic-clonic seizures were also known as grand mal seizures. Symptoms of this seizure include an abrupt loss of consciousness and body stiffening, twitching, and/or shaking. They may also affect visceral organs causing loss of bladder control or biting one's tongue.

Causes of epilepsy cannot be identified in half the people with the condition. However, the condition may arise due to various factors, including:

• Genetic influence

  Genetics may predispose one to certain types of epilepsy, categorised by the type of seizure experienced or the part of the brain that is affected. In these cases, it's likely that the particular epilepsy type runs in the family. Though genes are only a part of causative factors, researchers have linked certain kinds of epilepsy to specific genes. Some specific genes may predispose a person and make them more sensitive to environmental conditions that trigger seizures.

• Head trauma

  Injury to the head, as seen in road traffic accidents or other traumas, can also be a factor causing epilepsy.

• Brain abnormalities

  Brain abnormalities such as brain tumours or vascular malformations- arteriovenous malformations (AVMs) and cavernous malformations also contribute to epilepsy. In adults, especially over age 35, stroke is a leading cause of epilepsy.

• Infections

  Infections like meningitis, HIV, and viral encephalitis can cause epilepsy.

• Prenatal injury

  Even before birth, babies are sensitive to brain damage, and reasons such as infection in the mother, oxygen deficiency, or poor nutrition can lead to epilepsy or cerebral palsy. 

• Developmental disorders

  Developmental disorders such as autism are also contributing factors to epilepsy.

Other than the aforementioned causes, there are certain risk factors associated with epilepsy, such as:

• Age

  Children and older individuals are more prone to epilepsy. However, the condition can occur at any age.

• Family history

  A family history of epilepsy increases the risk of developing a seizure disorder.

• Lifestyle choices

  Intake of alcohol and smoking cigarettes can lead to vascular disorders that may eventually cause stroke or other blood vessel diseases responsible for epilepsy. Avoiding these triggers and eating a healthy diet and regular exercise can help reduce the chances of developing these diseases.

• Dementia

  Typically seen in older adults, dementia is also associated with epileptic attacks.

• Brain infections

  An inflammation in the brain, as caused by infections such as meningitis, may also increase the chances of developing seizures.

• Seizures in childhood

  Seizures are also seen in children who have had episodes of very high fever. This, however, does not always lead to epilepsy. The risk increases if there have been long-standing fever-associated seizures, an accompanying nervous system disorder, or a family history of epilepsy.

A seizure that starts in a specific part of the brain can cause different symptoms.

• If it starts in the back part of the brain (occipital lobe), it may cause vision changes.
• If it starts in the front part of the brain (precentral gyrus), it may cause rhythmic clonic or tonic motor activity (rhythmic muscle movements).
• If it starts in the middle part of the brain (postcentral gyrus), it may cause abnormal sensory sensations like paresthesia (tingling).

Diagnosis of epilepsy is made based on the symptoms and medical history. Evaluation is further confirmed by various tests, such as:

• Electroencephalogram (EEG)- One of the most common tests used to diagnose epilepsy. Here electrodes are attached to the scalp, which then records the electrical activity of the brain.

• High-density EEG- A variation of an EEG, high-density EEG has the electrodes placed more closely than conventional EEG. This helps in a more precise evaluation of the areas of the brain affected.

• Computerised tomography (CT) scan- structural abnormalities such as tumours, cysts, etc., in the brain can be seen on CT scans.

• Magnetic resonance imaging (MRI)- Similar to CT scans, an MRI gives a detailed picture of abnormalities in the brain.

• Neuropsychological tests- Thinking, memory, and speech skills are assessed using these tests. They help determine which areas of the brain are affected.

Accurate diagnosis is the first step toward effective treatment.

Treatment for epilepsy is usually started conservatively with medication. The choice of medication depends on the type of epilepsy and factors such as age and other existing medical conditions. In an event where medication does not provide relief from symptoms and seizure episodes, surgery may be recommended. Two major prerequisites usually looked into before deciding on the surgery are:

• The seizures should originate in a small, well-defined area of the brain.

• The area to be operated on should not interfere with vital functions such as speech, language, motor function, vision, or hearing.

If managed well, epileptic patients have known to have lived their lives to the full. It is important to have the correct diagnosis and complete treatment. 

There are several options for treating epilepsy, with the most common being anti-epileptic drugs, or AEDs. Up to 70% of people with epilepsy could have their seizures completely controlled with the right treatment.

Max Institute of Neurosciences offers the following options to get the best treatment for epilepsy.

A) Anti-Epileptic Drugs: This is usually the first treatment that the doctor will try to start to control the seizures. The aim is to control seizures as fully as possible, whilst minimising the side effects of the drugs.

B) The Ketogenic Diet: It is usually considered for children when AEDs have not had a good effect on controlling seizures. It involves strict control of fat, protein and carbohydrate levels, and should always be done with the supervision of a specialist dietitian.

C) Vagal Nerve Stimulation (VNS): This involves implanting devices to attempt to suppress the abnormal electrical activity that causes seizures. They can be considered for people when anti- epileptic drugs have failed to give control.

D) Surgery: This option is recommended for people with uncontrolled seizures. About 20 to 30% of people have poorly controlled epilepsy despite trying multiple medications. Surgery can practically cure epilepsy in such patients. The origin of seizures can be located by Video-EEG Monitoring and MRI. The small area of the brain responsible for seizures can be removed easily by surgery. Surgery has been very successful in such cases.

Seizures are not just about bouts of muscular stiffness and involuntary movements; they may also lead to complications that can potentially be fatal. Below mentioned are a few such possibilities:

• Falling- A fall during a seizure may result in head injury or fractures.

• Drowning- A patient with epilepsy is almost 20 times more at risk of drowning while swimming and/or bathing. This happens if the epileptic attack comes while the patient is in water.

• Car accidents- An epileptic patient is always at risk while driving. An attack when on the wheel can lead to loss of awareness and control, risking not just their life but that of others on the road too. A similar risk exists for those dealing with and operating heavy machinery.

• Pregnancy complications- Seizures during pregnancy are some of the trickiest ones. They pose a danger to the mother as well as the baby. What makes it tougher is that certain antiepileptic medications increase the risk of congenital disabilities and are not preferred as treatment. This does not rule out the possibility of a healthy pregnancy for an epileptic patient. A thorough discussion with the doctor, careful monitoring, and adjusted medication doses can help an epileptic patient in their pregnancy journey.

• Emotional health issues- Depression, anxiety, and suicidal thoughts are common mental health concerns seen in patients with epilepsy. These can be due to altered lifestyles and restrictions or also possible side effects of medication.

Other life-threatening complications, though uncommon, include:

• Status epilepticus

  A state of continuous seizure activity for more than five minutes or frequent recurrent seizures with loss of consciousness in between is termed status epilepticus. Patients with status epilepticus are at an increased risk of permanent brain damage, eventually leading to death.

• Sudden unexpected death in epilepsy (SUDEP)

  Certain seizures may impact the heart or respiratory conditions that may lead to sudden death during a seizure. Though the percentage of such cases is low, the possibility cannot be completely ruled out. High-risk groups include patients with tonic-clonic seizures or those patients where seizures are not controlled by medication.

Treatment for epilepsy is usually started conservatively with medication. The choice of medication depends on the type of epilepsy and factors such as age and other existing medical conditions. In an event where medication does not provide relief from symptoms and seizure episodes, surgery may be recommended. Two major prerequisites usually looked into before deciding on the surgery are:

• The seizures should originate in a small, well-defined area of the brain.

• The area to be operated on should not interfere with vital functions such as speech, language, motor function, vision, or hearing.

Max Institute of Neurosciences (MINS) provides comprehensive and compassionate care to adults and children with seizure disorders. Our team of highly experienced doctors and surgeons strive to ensure the best results that eventually bring good quality life to people. We provide super speciality tertiary care for all kinds of neurological disorders. Apart from an array of services like Advanced Brain Tumour Centre, Minimally Invasive Spine Surgery Centre and Stroke Centre, it has India's first BrainSUITE - the most advanced Neuro Operation Theatre.

We have highly-skilled neurosurgeons, neurologists, interventional neurologists, neuro anaesthetists, experts in critical care and specialised nurses who work together to deliver world-class services. They are supported by next-gen facilities such as a dedicated high-end Neuro ICU and HDU with 24x7 neurosurgery and neuro anaesthetist backup. Each member of the team brings expertise from years of experience and skills, all directed towards providing the highest standards of patient care.

The institute provides round-the-clock, comprehensive diagnostic and therapeutic neurology services, according to evidence-based protocols set as per internationally accepted guidelines. Our casualty services are available round-the-clock for diagnosis and early management of a wide range of neurological emergencies, including Status Epilepticus.

At Max Institute of Neurosciences, patients can receive a comprehensive evaluation and neurodiagnostic treatment services such as counselling, education, customised treatment plans, medication, physical evaluations, and psychological reports. It also provides elaborate presurgical evaluation and surgical treatment to those epilepsy patients whose condition cannot be controlled with medical treatment.

60%–70% of patients will see their seizures controlled by medication. In most cases, treatment is deferred until a second seizure occurs. Patients with no identified aetiology have a better outcome than those with structural, metabolic, or genetic aetiology.

Reviewed by Dr. Mukesh Kumar, Associate Director and Head (Parkinson's Disease Unit), Neurosciences, Neurology on 27-Mar-2023.

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