Seizures — What you must know.
By Anne Kellog
Seizures can be caused by something as simple as becoming dehydrated, and do not always indicate epilepsy. However, they always can be dangerous … even life threatening. We spoke with two neurologists on the subject, one of whom shares her experience of experiencing seizures as a result of a metabolic epilepsy disorder.
“A seizure indicates abnormal brain wave activity,” according to Mateja de Leonni Stanonik Spindler, M.D, M.A., Ph.D., of Vita Medica Institute. “I liken it to a sort of ‘electrical earthquake’ in the brain,” she says. “That description speaks to what it’s like for patients with these electrical discharges.”
Seizures can vary greatly in their degree and causation. Some are barely noticeable, while others are dramatic to witness.
Dr. de Leonni notes, “The general public should understand that seizures are far more common than we are led to believe, and that the least common type we see are the stereotypical grand mal seizures (with violent muscle contractions and sometimes unconsciousness).”
Some patients develop seizures in infancy — in most cases because of an epilepsy disorder — but even people who never have had a seizure in their lives can have one.
Imagine you’re at Wildcat football game on a hot, sunny day, and perhaps you have consumed several beers while tailgating. You’re having a terrific time but suddenly you feel a little peculiar, start convulsing and drop to the ground. What happened? You’ve never had a seizure before, so what gives?
In many cases, a seizure can be a one-time thing or multiple seizures can occur even in a nonepileptic patient due to a combination of triggering factors.
“On a biochemical level, usually we discover there’s an imbalance between the sodium and potassium ions in the brain cells, which cause electrical abnormality between nerve cells,” Dr. de Leonni states. “Certain medications, for example, can disturb the balance of sodium, potassium, and sometimes calcium in the brain, which can bring on a seizure.
“Let’s say you get very dehydrated and don’t sleep well that night, or maybe had an infection going on — that’s a perfect storm to bring on a grand mal seizure. Those who have consistent seizures have epilepsy or an epileptic disorder, for which they often are genetically predisposed.”
An epileptic seizure can be presaged by an “aura,” or perceptual disturbance such as flashes of light or an unpleasant smell. These auras often give the patient enough warning that he has time to avoid injury.
“I will ask the patient to keep a diary that includes their sleep patterns, daily diet, stress levels and any seizure activity.” — Mateja de Leonni StanonikSpindler, M.D., M.A., Ph.D.
Diagnosing the Cause of the Seizures
Job one for the neurologist is to help the patient reduce or even stop the seizures altogether, if possible. The neurologist will take a patient history, do a full physical workup, and perform an electroencephalogram (or EEG), to look at the brain’s electrical activity. “There are definitive signs in the brain waves that indicate to the neurologist that a seizure has occurred, or is about to occur,” Dr. de Leonni explains. “We always perform imaging tests as well, such as magnetic resonance imaging (MRI), to look at the brain’s anatomy and check for structural anomalies or scarring from a stroke or injury.”
Depending on the severity and frequency of the patient’s seizures, the neurologist may have the patient wear an EEG monitor for several days at home, or he’ll be put in the hospital and observed 24 hours a day for several days. In that way, a certain course of medication can be tried and the EEG closely monitored to see how he responds. In a patient with an epilepsy disorder who has many disruptive seizures, it may require trying several different types of medications before an optimal match is found,
“I will ask the patient to keep a diary that includes their sleep patterns, daily diet, stress levels and any seizure activity,” Dr. de Leonni notes. “Sleep, or lack thereof, is extremely important in seizure patients, so I always address sleep issues, as well as any coexisting mood disorders (i.e., anxiety or depression).
“I also check the patient history for any type of heart issues, such as any history of arrhythmia or atrial fibrillation. The heart and the brain are connected electrically, and when atrial fibrillation or arrhythmias occur in the heart, a seizure can be brought on, and vice versa. When seizures occur, the incidence of heart arrhythmias — particularly ventricular arrhythmias, the most dangerous ones — is higher, and death can be imminent.”
Seizures in Infants and Children
“Seizures that start in babies and small children — unless caused by high fever or other trigger — usually indicate they’ll have epilepsy in adulthood,” Dr. de Leonni contends. “Sometimes the child can outgrow it.
“It is believed that in some cases the area of the brain causing the childhood seizures has its etiology in abnormal development of the brain, either in utero or shortly after birth. Those areas can serve as focal points for abnormal brain wave activity. With imaging techniques such as functional MRI, we’re better able to detect those areas and, in some cases, surgical excision of those areas can be curative. Epileptic surgery is a fairly new and very much evolving field.
“In babies who die of Sudden Infant Death Syndrome, we believe that at least half, if not the majority, actually are caused by a heart rhythm abnormality that then translates into a brain wave abnormality as well.”
Seizures in Older Adults
As one ages, shrinking of the brain is inevitable — it’s a normal part of aging. However, many seniors also suffer from chronic conditions like high blood pressure, diabetes, or high cholesterol. “That predisposes you to have hundreds or possibly thousands of transient ischemic attacks (TIAs), or mini-strokes, over time,” says Dr. de Leonni. “These TIAs leave scars in the brain that serve as foci for seizures. I have many older patients who are on medications for some or all of these ailments. There may come a time when they’ve become dehydrated, are running a fever or are stressed, and boom, they can have a seizure.
“If the patient is someone who already has had a stroke or TIAs, the likelihood of their having a seizure can be higher than 80 percent. If the patient is someone without these risk factors for stroke (such as high cholesterol, diabetes, hypertension, obesity), the percentage is probably lower.”
If a patient is diagnosed with epilepsy, the number and severity of their seizures, combined with test results, will dictate the medication the neurologist may choose. In the majority of those with epilepsy disorders, their seizures can be brought under control with medication and they go on to live relatively normal lives. Dr. de Leonni notes that some epilepsy disorders are typified by “intractable” seizures, meaning that medications do not bring the condition under control. In these cases, neurosurgery may be the answer, especially if the epilepsy only affects one side of the brain, such as in refractory partial epilepsy. A surgeon can remove the area of the brain that’s responsible for the seizures.
In those patients without epilepsy, a seizure can be a one-time thing, caused by specific triggering factors, such as our example of the football fan. These incidents can occur more than once.
Seizure triggers can include:
• Jet lag, sleep deprivation
• Electrolyte disturbance (usually caused by dehydration)
• Withdrawal from overuse of alcohol. Other illicit drugs also can produce seizures, such as cocaine, heroin and even marijuana, if it is ingested in toxic levels
• Some prescription meds will lower the seizure threshold, for example Tramadol (a pain management medication) and certain antibiotics to which the patient is sensitive.
• Specific foods can trigger seizures in individuals who are sensitive to them, such as honey, carbohydrates and artificial sweeteners.
• Certain metabolic issues such as liver or kidney problems
• Any infection that produces high fevers
• Flashing lights — even the slight fluctuations in fluorescent lights
• For women, the changing blood levels of estrogen and progesterone right around their periods
• A drop in blood sugar below 70, and especially below 50
• Excess caffeine
In addition to medications and trigger avoidance, neurologists have a number of other less conventional methods in their arsenal to help prevent seizures, even in those with epilepsy disorder.
“We’ve discovered, especially with kids, that a ketogenic diet is very helpful in helping to abate epilepsy,” observes Dr. de Leonni. “We also counsel our adult patients that carbs can make seizures worse. High-protein diets can help even in very severe genetic seizure disorders.
“The Academy of Neurology and the FDA have approved medical marijuana as a treatment in intractable epilepsy. And we’ve even been incorporating aromatherapy with our patients. These are multifaceted and complicated issues, and they require all of our efforts to help reduce seizure incidence.”
Seizures: A First-Person Account
Louann Carnahan, D.O., is a board-certified neurologist and a fellowship-trained Epileptologist treating adult patients at the Center for Neurosciences.
Here, she shares her experience with seizures related to a unique clinical syndrome called Myoclonic Epilepsy with Ragged Red Fibers.
“I had my first generalized convulsive seizure when I was 17 years old, during a high school calculus test, in a classroom full of students and everything!
“What is it like to have a seizure? Some people, like myself, have no warning, it’s just boom — I lost consciousness.” — Louann Carnahan, D.O.
“I took the seizure in stride, and went about my business, not too concerned about having another. The second one occurred nine months after the first while I was on a plane going to Indonesia. We were over the ocean when it struck. I was with my brother, and because he knew my history he got on the phone back home, and they got hold of a neurologist. By the time we landed in Japan, my family had arranged for a doctor to meet the plane. I spoke with a young doctor for a quick assessment, and my home neurologist already had shipped my medicine to Indonesia, so it was there when we finally arrived.
“The cause of my seizures is a bit more complicated than traditional epilepsy. It’s part of a syndrome of mitochondrial disorders — a systemic disorder that can affect multiple parts of the body. It is called Myoclonic Epilepsy with Ragged Red Fibers, or MERRF syndrome. Ragged Red Fibers pertains to the microscopic muscle cell appearance, and it causes weakness and nervous system issues that started to affect me a few years later when I was beginning medical school.
“A doctor asked me later if I’d ever had any jerks or twitches in my arms, and I’d actually had them all the time since I was 14. That is textbook for my kind of epilepsy, and those were myoclonic seizures, which is a common presentation.
“What is it like to have a seizure? Some people, like myself, have no warning, it’s just boom — I lost consciousness. My classmates and, later, the people on the plane, witnessed my stiffening and convulsions. Seizures by their classical definition, are very short — a couple of minutes or less on average.
“Relatively speaking, I’m very lucky that I’ve had only three seizures in my life. My third one occurred during medical school the morning of an exam! I woke up on the floor, and discovered I was on the phone with my classmate. He knew I was in the habit of sleeping in, so he had called to make sure I made it to the test. I was confused and had a huge headache, I’d bitten the inside of my mouth pretty badly, and all I could think was, “I’ve got to get to that test! I did end up passing it….
“So I ended up back in the neurologist’s office in a new city. He was the first physician to put together that my epilepsy syndrome was consistent with the myoclonic type.
“I got on the proper medication, have had no further arm jerks or generalized convulsions, and I’ve passed my 12-year anniversary of being seizure-free.
“The Center for Neuroscience treats both children and adults, but I am an adult neurologist. Treatments are the same for kids and adults, and seizure activity is the same in terms of the electrical storm in the brain … it’s the same pathophysiology.
“The majority of patients, 65-70 percent, can be controlled with medication if they take it as prescribed, and follow up with their doctor. I’d say successful treatment relies half on medical treatment and half on self care of the patient. Many times, the struggle is the patient being noncompliant. In my own situation, the seizure I had in medical school led me to realize how very disruptive my epilepsy was. I couldn’t drive for six months, and I hated that. So, I finally complied, and took my meds.
“Symptomatic management and treatment of epilepsy is largely the same as it has been: medications and Vagus nerve stimulation.
Deep Brain Stimulation modulation recently has been approved in the U.S.; it was approved in Europe going on 10 years, but wasn’t FDA approved. They had Deep Brain Stimulation for intractable movement disorders such as Parkinson’s, but the approval never crossed over to the area of epilepsy. Experts are still learning the correct amount of stimulation for epilepsy, so this is still on the horizon for generalized use.
“Quite honestly, I’ve never looked on the epilepsy part of my condition as a disability. I just take my pill and forget about it.
“Statistically speaking, the majority of patients who are controlled go on to live normal lives.
“There are triggers that can cause a breakthrough seizure, such as sleep deprivation, stress (the top two triggers), illness or running out of meds. Lifestyle management is important.
“The seizures were what sparked my interest in neurology. I already had an interest in becoming a doctor and thought I wanted to become a surgeon, but during my med student rotations when I got to neurology I loved it!
“The other side of my condition, the Ragged Red Fibers, started manifesting early in medical school, and that causes a visible, physical disability from muscle weakness. I’ve had to use electric mobility aids. When I started my clinical rotations, my legs were too weak to walk the entire distances. It has been a challenge, and I’ve been fortunate that my advisors and co-workers have been willing to work with me to develop accommodations for my muscle weakness, such as electric scooters. I was introduced to people who understand, because I chose the field of neurology.
“My goal is that my patients return to normal life, that they’re seizure-free, able to drive and work where they wish. Understanding, education and awareness are key for patients being treated for epilepsy. When dealing with patients who won’t take their medication, I’ll ask them, ‘How much do you want to live confidently? What is it worth to you?’”
This article is by no means meant to be an exhaustive study on, or medical advice for, seizures and epilepsy.
Readers always should obtain medical help immediately if they suffer a seizure.