Diagnosis and
investigations
The history from
a witness is crucial. The onset, setting, and stage of attacks are of importance.
Neurological examination may be normal or point to a clinical diagnosis (e.g.
hemiparesis and papilloedema in a hemisphere tumour).
General medical
screening, including serum calcium and an EEG should be carried out. The differential
diagnosis is from other attack of disturbed consciousness.
Electroencephalography
The EEG remains a useful test, despite limitations. It should be performed
after a first fit.
(1) During a seizure the EEG is almost invariably
abnormal, because spikes reach the brain surface.
(2) EEG evidence of
seizure activity is shown typically by focal cortical spikes (e.g. over a temporal
lobe) or by generalized spike-and –wave activity.
(3) Hz spike-and-wave
activity occurs specifically in petit mal. This is always present during an attack
and is frequently seen in between attacks.
(4) A normal EEG between attacks
(interictal) does not in any way exclude epilepsy. Many people with epilepsy have
normal interictal EEGs.
(5) EEG videotelemetry is used to study attacks
of uncertain nature (e.g. non-epileptic).
(6)
An abnormal interictal EEG does not prove that one particular attack was epileptic
and should not be used to make a diagnosis.
Ct or mr imaging
The
trend is towards sophisticated imaging of all new cases of epilepsy when resources
permit. In practice, CT is a reasonable screening test in most adults to diagnose
unsuspected mass lesions.
MR is used for detailed study, particular
in the selection of cases for epilepsy surgery.
Treatment
Emergency measures
When faced with a seizure it is best
simply to ensure that the patient comes to as possible, and that a the airway
is maintained both during a prolonged seizure and in postictal coma. Wooden mouth
gags tongue forceps and physical restraint cause injury.
Most seizures
last only minutes an end spontaneously. A prolonged seizure-longer than 3 minutes-or
repeated seizure outside hospital are best treated with rectal diazepam (10mg),
or intravenous diazepam. if there is any suspicion of hypoglycaemia, take blood
for glucose and give i.v.glucose.
Serial epilepsy describes repeated
seizures with brief periods of recovery. These may lead to status epilepthicus.
Sudden death in a seizure is usually but does occur.
Status
epilepticus
This medical emergency means continuous seizures without
recovery of consciousness. It should be assumed if prolonged serial seizures (two
or more) occur with incomplete recovery of consciousness.
Status has
a mortality of 10-15% from cardiorespiratory failure. Over 50% of cases occur
without a previous history of patients with apparent refractory status has pseudostatus
(non-epileptic attack disorder): the iatrogenic morbidity of inappropriate treatment
in these patients is significant.
Management.
Focal status also occurs. In absence status, for example, status is non-convulsive-the
patient is in a continuous, Distant, stuporose state. Epilepsia partialis continua
is continuous seizure activity in one part of the body, such as a finger or a
cortical neoplasm or, in the elderly, a cortical infract.
Anticonvulsant
drugs
Drugs are indicated when there is a firm clinical diagnosis
of recurrent seizure, or a substantial risk of recurrence. Anticonvulsant use
carries the stigma of epilepsy.
Acceptance
by patients is essential, and their understanding of potential unwanted effects.
For both partial and generalized seizures, prescribe monotherapy with an established
anticonvulsant of proven efficacy.
The
dose is increased until seizure control is achieved a second drug is added. Many
new anticonvulsants have been marketed in the 1990s.unfortunately there different
views about the most appropriate drugs for each variety of seizure.
