Mark A. Granner, MD
University of Iowa Department of Neurology
Peer Review Status: Internally Peer Reviewed
Creation Date: November 2003
Last Revision Date: November 2003
1. What is epilepsy?
Epilepsy, also known as "seizure disorder", is a neurological condition defined by the occurrence of repeated, unprovoked seizures. A number things can cause epilepsy, including head trauma, brain infection, stroke or tumors. Some people are born with the tendency to have epileptic seizures (i.e. a genetic cause), but may not begin having seizures until later childhood or teenage years. Epilepsy can begin at any age, and in fact, after childhood, epilepsy most commonly begins after age 60. The main symptom of epilepsy is a seizure, which may take on many forms (ranging from a purely subjective feeling to a convulsion, and many other types in between). It is estimated that 3% of all Americans will have epilepsy at some point during their life.
2. What do I do if I see someone having a seizure?
The goals of first aid for a seizure are to allow the seizure to finish on its own, call for medical assistance if it does not, and help keep the person as safe as possible until it stops. You should lead the person away from dangerous items such as stoves and machinery, help them to the floor so they do not fall, roll them to their side (in case they vomit) and loosen any tight clothing (such as neckties). Most seizures stop on their own in less than 2 minutes. If a seizure lasts more than 5 minutes, it is less likely to stop on its own and medical assistance (e.g. the EMTs) should be called. After a seizure, the person may be confused. Try to talk to them in a calming voice, but do not try to restrain them unless they approach dangerous equipment it is usually best to just let them "walk it off."
3. How is the diagnosis of epilepsy made?
The diagnosis of epilepsy depends on taking a careful medical history, performing a neurological exam and, often, performing diagnostic tests. The two most helpful tests in the diagnosis of epilepsy are the electroencephalogram (EEG) which displays the brains electrical activity and the magnetic resonance imaging (MRI) scan which shows the brains structure or appearance. Other tests may include blood tests, Neuropsychological (memory) testing and, in certain cases, functional brain imaging such as PET or SPECT scans. When seizures are difficult to diagnosis, or do not respond to common treatments, admission for prolonged video-EEG monitoring may be useful.
4. What things other than epilepsy can cause seizures?
Most people who have a seizure do not have epilepsy. Called an "acute symptomatic seizure," these are often caused not by brain dysfunction or injury, but by some other factor affecting the brain such as overwhelming infection or metabolic disturbance, a reaction to prescription or over-the-counter medication or stimulant recreational drugs, severe sleep deprivation, or intoxication with or withdrawal from alcohol. Psychological conditions are another common cause of seizures that look and sound very much like epileptic seizures, and may in fact be treated ineffectively for years with anti-epilepsy medication. Commonly referred to as "pseudoseizures" (more so because they mimic or look like epileptic seizures, not because most patients "fake" them), these usually involuntary seizures do not have the same electrical EEG changes as epileptic seizures, and usually require video-EEG monitoring to make the correct diagnosis and assign the more appropriate therapy.
5. What is an epileptologist?
An epileptologist is a neurologist with a dedicated interest and subspecialty practice in the field of epilepsy. Epileptologists have received additional fellowship training beyond their neurology residency learning the art of epilepsy care and electroencephalogram (EEG) interpretation, with particular emphasis on video-EEG interpretation and the clinical management of patients with epilepsy and spells, including optimal treatment with a broad range of antiepileptic drugs, vagus nerve stimulation (VNS), and epilepsy surgery. Epileptologists may be adult or pediatric neurologists. All ICEP epileptologists are board-certified in clinical neurophysiology and electroencephalography (EEG).
6. What is an EEG? Why is it important for me?
An electroencephalogram (EEG) is a recording of brain wave activity. This test may help your doctor better understand your seizure type, by revealing transient irritable brain wave patterns that serve as a marker for epilepsy. These irritable brain wave patterns are called spike or sharp wave discharges. When localized over one brain lobe or region, spikes are considered "focal" and may signal that the seizure type is consistent with partial epilepsy (seizures that start in one part of the brain). If spike-wave discharges are generalized over the entire scalp, they usually correlate with primary generalized epilepsy. These distinctions are important since they can inform you and your physicians about prognosis and the most appropriate types of medication, or whether you may potentially benefit from consideration of other treatments such as epilepsy surgery or the vagus nerve stimulator.
7. Ive been scheduled for an EEG. What can I expect?
During an EEG test, an EEG technologist will apply electrodes to your scalp (don't worry, they do remove them when the test is over!). You may be asked to hyperventilate to try to activate spike discharges during part of the study if this is safe for you medically, and flashing lights will be used similarly during the test. Often, recording during sleep or after sleep deprivation may also help to activate spike discharges, so most tracings are obtained with attempted sleep. Most EEGs can be run in about an hour or less, and results are generally available to your physician within one week.
8. What is video-EEG monitoring?
Routine EEG is often too brief to capture seizures or rare spike discharges, or may show unrelated findings. Recording actual seizures is still the best test for understanding seizure type and location of onset when other information does not allow a definitive diagnosis. Video-EEG monitoring, performed on either outpatients (hours long) or inpatients (days long), is a specialized form of EEG testing, in which typical events are recorded. This permits the physicians to learn more about your seizures by directly viewing them. If you and your physician are considering epilepsy surgery, video-EEG monitoring is a vital piece of the puzzle, for ensuring the diagnosis of epilepsy and allowing an accurate estimation of the seizure onset region in the brain.
9. Ive been scheduled for video-EEG monitoring. What can I expect?
Video-EEG monitoring can be arranged as either an inpatient or outpatient test. If spells are frequent enough (on the order of multiple times per day), then a few hours or one day of outpatient recording may be sufficient to capture the spell. However, in most instances, admission to the hospital is preferable when spells are less frequent (such as only a few times per week or month). Spells that are infrequent (e.g. one every few months) might be impractical to record. Depending on how quickly seizures occur, monitoring may be as short as a few days, or as long as one to two weeks. You will have EEG electrodes applied to the scalp at admission and wear them throughout your hospital stay. Patient rooms are either private or semi-private, and a day room lounge provides a comfortable retreat with activities such as television, video games, and movies. Exercise may be prescribed, with nursing supervision. Continuous video camera recording of behavior will be done to enable correlation of the seizure behavior to the EEG. Epilepsy monitoring technologists will ensure the recording is performed accurately daily, and an EEG board-certified physician will review your information on a daily basis with the inpatient hospital team. Depending on monthly assignments, you may or may not see your epilepsy clinic physician while in the hospital. You will receive inpatient care from the neurology hospital service, a team of physicians who will explain the test findings and suggest changes in therapy or the need for further necessary testing. By the time of discharge, the neurology hospital service team physicians and epileptologists will coordinate a plan of treatment together based on results of your testing.
10. What is epilepsy surgery? How do I know if Im a candidate?
Epilepsy surgery is an extremely effective treatment for some individuals whose seizures have failed to come under control with multiple medication trials. The process involves (1) identification of a single brain region causing your usual seizures, (2) determination if that region can be safely removed without damage to vital brain functions, and (3) brain surgery to remove the area generating seizures while safely preserving important brain functions. Success of therapy can usually be predicted after trials of no more than 2 or 3 medicines seizures that continue after such trials suggest the presence of medically resistant (or "intractable") epilepsy. Many patients who may be ideal candidates for surgery cycle though multiple medications without success for years before finally being considered for an operation.
While the idea of epilepsy surgery may sound scary at first, and while any brain surgery carries risk, the risk of poorly controlled seizures must also be considered, and the potential to improve a patient's quality of life considered. If seizure freedom can be achieved, many patients can be restored to more functional lifestyles, permitting driving and improved work opportunities. Sometimes palliation, or prevention of injurious seizures, can also be a reasonable goal of surgery when stopping seizures completely is not possible.
Determining if a patient is a suitable candidate for epilepsy surgery is a journey. It requires establishing a trusting relationship with a treating epileptologist, ensuring that appropriate medication options have been exhausted and that a patient's quality of life is affected by seizure burden or that the patient is at risk of harm from seizures, and pursuing many tests to evaluate brain structure, function, and pinning down a single brain region generating seizures. Necessary testing includes expert MRI performance and interpretation with a specific seizure protocol (examining the temporal or relevant extratemporal brain regions capable of generating seizures carefully for pathology that can cause epilepsy), brain PET (demonstrating brain function rather than structure alone), neuropsychological testing to evaluate memory and language performance, visual field testing, and most importantly, seizure recording during inpatient video-EEG monitoring.
This information will be reviewed at the ICEP epilepsy surgical conference, an interdisciplinary clinical conference held bi-weekly. This meeting is attended by epileptologists, epilepsy nurses, neurosurgeons, neuropsychologists, neuroradiologists, epilepsy monitoring and EEG technologists, who together decide upon the best course of treatment for each individual patient.
11. What is invasive video-EEG recording?
In some individuals, even scalp video-EEG recording is not sufficiently localizing to decide on epilepsy surgery. For example, seizures may not localize well on scalp EEG, may start in one area then quickly spread to another area, or may appear to arise from more than one area. In such instances, your physician may recommend additional seizure recording after the neurosurgeon performs an operation to place electrodes inside the head. Video-EEG monitoring is then performed to confirm the precise site of seizure onset. In most cases, this area of onset is found and an operation can be offered, but the performance of this testing does not guarantee that seizure surgery will ultimately be possible.
12. Ive been diagnosed with pseudoseizures. What does that mean?
Pseudoseizures, or psychogenic nonepileptic spells, may closely resemble epileptic seizures by history and even observation, but they do not have an epileptic cause and typically do not respond well to treatment with antiepileptic drugs. Although the true cause of such spells remains unknown, they are usually found to be associated with emotional disturbance, acute or chronic life stressors, mood disorders, alcohol or drug use/abuse history, or a personal history of abuse of many forms (physical, emotional, and sexual). Often, such spells may not even have an obvious acute triggering factor, but patients are found to have a history of psychiatric or psychological problems. While sometimes antiepileptic drugs may be used to augment treatment of pseudoseizures to help stabilize mood or reduce pain, they generally have little direct effect on the spells themselves, and psychological counseling and psychiatric medications are the preferred treatments. Video-EEG monitoring is the most helpful diagnostic test for pseudoseizures. Pseudoseizure behavior may closely resemble epileptic seizures, but no accompanying EEG abnormalities are seen. Care must be used in interpretation, as some epileptic seizures may have minimal EEG abnormalities. ICEP epileptologists will review video-EEG data to determine whether a diagnosis of pseudoseizures is accurate. Once diagnosed, the patient is most often referred for psychological or psychiatric care.