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Epilepsy

An interview with Dr. D.G.A. Abeygunaratne - MBBS (Cey,), DCH (SL) DFM (SL) MCGP (SL) LRCP (Lond) MRCS (Eng).- Family Physician.

Q: How do you explain epilepsy?

A: In simple terms, epilepsy -or a fit - is an abnormal focus of sudden electrical activity in the brain. It is a discharge of a group of nerve cells of the brain detectable by the patient and the on lookers.

A single fit is not generally called epilepsy. For some one to diagnose epilepsy the patient should have had 2 or more unprovoked fits. In other words the term epilepsy refers to a tendency to suffer recurrent fits.

Q: What is the general prevalence rate?

A: A recent island-wide survey indicates that we have around 300,000 patients in Sri Lanka. The report also confirms that 85 per cent of them can lead normal lives with proper care and management. The incidence appears in 2 peaks, one in childhood under 15 years and the other in elderly over 60 years.

Q: Any specific causes?

A: There are number of causes implicated in epilepsy but in about two third of patients the cause remains unknown. Very small percentage of patients may associate with single gene inheritance but the majority considered to have any inheritance pattern is probably polygenic.

Among the major known causes of epilepsy are Strokes, brain tumours, malformations meaning structural lesions, head injury, brain infections and problems related to alcohol and other drugs.

Q: How would you diagnose an epileptic patient?

A: My diagnosis of the illness will depend mainly on the history provided by the patient and a person who has witnessed the actual incident. The investigations help establish the diagnosis, but more used in the management of the case.

Now, it is quite an easy diagnosis if some one has seen a person falling on to the ground with a cry and having fitting movements of the limbs and whole body, with froth coming out from the mouth. The patient had been unconscious at the time and later wakes up or recovers slowly. Unfortunately this pattern is not available most of the time as there are different types of the illness with major variations. Furthermore witnesses are not available all the time.

It is important that the witness exactly describes what he or she actually saw. It is also important if possible that the witness describes the circumstances around the time of the episode, what happened to the patient, whether he saw him fitting or frothing at the mouth.

Also of importance is to say whether the patient was incontinent of urine, or faeces, pattern of evolution of the symptoms and the behaviour before, during and after the fit.

The diagnosis of epilepsy can be mistaken for a number of other conditions. They include common fainting attack, hypoglycaemia (low sugar level in the blood), various cardio vascular problems (heart and circulatory problems), and other neurological or psychological disorders.

Q: Are there any different types of attacks?

A: The epileptic attacks are broadly grouped under two major categories. They are called generalized and partial seizures. However some partial seizures end up as generalized ones.

Generalized seizure involves whole brain and usually the patients are unconscious. This includes tonic clonic seizures, absence attacks, and myoclonic seizures.

To explain very briefly, tonic clonic seizure is most common.

It is characterized by a sudden loss of consciousness, followed by a sudden uncontrollable twitching and jerking movements.

The seizure lasts a few minutes and is followed by a deep sleep. In absence attacks the affected person suddenly becomes motionless and stares, lasting a few seconds.

Seizure ends suddenly with patient fully alert thereafter.

In a myoclonic seizure it will be sudden, brief, irregular involuntary contractions of limbs, usually without loss of consciousness.

Partial seizure involves only a part of the brain, and is further divided into simple partial and complex partial seizures. The patient with simple partial seizure remains conscious while the patient with complex partial seizures generally lose consciousness.

Q: Let us now talk about the treatment

A: There are a number of important objectives of the management of epilepsy. The physician attempts to make the patient take complete control of fits and prevent further recurrence with minimal side effects using anti epileptic medication.

He will explain the disease to the patient and the concerned relatives. The patients will be informed that the treatment is long term and the compliance is vital.

The physician will also identify the underlying treatable conditions and treat. Even though the diagnosis is made on the history provided by the patient and the witness of the fit, the patient will be examined carefully by the doctor.

This is important to give the patient confidence and also to exclude any underlying causes.

The investigations commonly asked by the family physician include full blood count, urea and electrolytes, blood sugar, liver function tests, serum calcium levels and E.C.G and chest X ray. EEG and neuro imaging (CT and MRI scans) comes under the remit of a neurologist.

Q: While on that point, there is also an opinion that an epileptic patient should best be treated by a neurologist. What is your idea?

A: Yes, ideally all the newly diagnosed patients should be referred to a neurologist with experience to confirm the diagnosis and initiate treatment.

The drug treatment is selected on the basis of type of epilepsy. Usually the drug is introduced gradually and increased slowly to get optimum results. Single drug treatment is considered to be best practice, though a second drug is added more often.

However, the ideal conditions are not practicable in our country because of the shortage of the specialists in that field. So the family physicians with experience in treating such conditions are expected to start the treatment.

Q: Can surgery help?

A: There is no doubt that the main stay treatment of the condition is anti- epileptic drugs. In certain circumstances however surgery seems to benefit for a selected few in refractory cases.

This kind of tedious treatment needs a dedicated specialized team who is prepared to monitor such patients and act accordingly. We really should be happy that there is such a specialized team in our own National hospital, in Colombo who have had some encouraging surgical results.

Q: Are there any category of patients needing special attention?

A: There are certain special problems which need to be considered in treating certain categories of patients. For example, Patients with refractory epilepsy, Children. Elderly, Pregnant and breast feeding women, women taking contraceptive pill and patients with learning disability (sub normal)

They all need careful treatment, and best managed by a specialist with experience in the field in communication with the family physician.

Q: Any preventive measures?

A: Prevention of fits can be controlled to a greater extent in most cases if the patients understand their illness and comply with the treatment. Doctor patient relationship is quite important. There are certain cases where the fits are difficult to control fully and named them as refractory cases.

This is particularly true in certain learning disability patients.

Fatigue, excitement, poor food intake, excessive alcohol consumption, are well known in precipitating an attack in vulnerable patients.

Q: What advice would you like to offer a epileptic patient?

A: Avoid any circumstance that has triggered a seizure previously. It is best to avoid operating heavy equipment, unsupervised swimming, heights and driving. Periodic visits to the doctor, every 3 to 6 months must be made to evaluate seizure control and side-effects to anticonvulsants.

Remember, anticonvulsant drugs can prevent most seizures and allow an almost-normal life.

- L.W.

STONE 'N' STRING

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