SEIZER - EPILEPSY HOMOEOPATHIC REVIEW

A seizure is any abnormal clinical event caused by an electrical discharge from the brain, whilst epilepsy is a tendency to have seizures. Major seizures cause loss of consciousness, with the patient falling to the ground and presenting with a history of 'blackouts'. Minor seizures causing alteration of consciousness, without the patient falling to the ground .

Pathophysiology:
 In the normally functioning cortex, synchronous discharge amongst neighboring groups of neurons is limited by recurrent and collateral inhibitory circuits.
 Inhibitory Transmitter
GABA
 Excitatory Neurotransmitters
Acetylcholine, Amino acids glutamate and Aspartate.

 'Epileptic' cerebral cortex exhibits hypersynchronous repetitive discharges involving large groups of neurons.

 Cells undergoing repetitive 'epileptic' discharges undergo morphological and physiological changes which make them more likely to produce subsequent abnormal discharges ('kindling').

 The chief division of seizure types on physiological grounds is between Partial (focal) Seizures and Generalized Seizures


Clinical features
 Tonic clonic Seizures
 Complex Partial Seizures
 Absence Seizures
 Partial Motor Seizures
 Partial Sensory Seizures
 Versive Seizures
 Partial Visual Seizures

Trigger factors for seizures
 Sleep deprivation
 Alcohol (particularly withdrawal)
 Recreational drug abuse
 Physical and mental exhaustion
 Flickering lights, including TV and computer screens (primary generalised epilepsies only)
 Intercurrent infections and metabolic disturbances
 Uncommonly: loud noises, music, reading, hot baths

EPILEPSY
 Epilepsy means a tendency to have seizures and is a symptom of brain disease rather than a disease itself. A single seizure is not epilepsy but an indication for investigation.

Types of epilepsy
The classification of epilepsy is best achieved by separately considering the clinical events (the seizures), the abnormal electrophysiology,the anatomical site of seizure genesis and the pathological cause of the problem.

Classification of epilepsy
Seizure type:
 Simple partial
 Complex partial
 Absence
 Tonic clonic
 Tonic
 Atonic
 Myoclonic

Electrophysiology:
 Focal spikes/sharp waves
 Generalised spike and wave

Anatomical site:
 Cortex
 Temporal
 Frontal
 Parietal
 Occipital
 Generalised (diencephalon)
 Multifocal



Primary Generalised Epilepsies:
 The primary or idiopathic epilepsies are a group of disorders which make up some10% of all epilepsies, including some 40% of those with tonic clonic seizures. Onset is always in childhood or adolescence. No structural abnormality is present and there is often a substantial genetic predisposition.

Secondary Generalised Epilepsy:
 Generalised epilepsy may arise from spread of partial seizures due to structural disease or be secondary to drugs or metabolic disorders. Epilepsy presenting in adult life is almost always secondary generalised.

Causes of Secondary Generalised Epilepsy
 Genetic:
 Inborn errors of metabolism
 Storage diseases
 Drugs:
 Antibiotics: penicillin, isoniazid, metronidazole
 Antimalarials: chloroquine, mefloquine
 Cyclosporin
 Cardiac anti-arrhythmics: lignocaine, disopyramide
 Psychotropic agents: phenothiazines, tricyclics, lithium
 Amphetamines (withdrawal)
 Alcohol (especially withdrawal):
 Cerebral birth injury:
 Hydrocephalus:
 Cerebral anoxia:
 Metabolic disease:
 Hypocalcaemia
 Hyponatraemia
 Hypomagnesaemia
 Hypoglycaemia
 Renal failure
 Liver failure
 Infection:
 Meningitis
 Post-infectious encephalopathy
 Inflammatory disease:
 Multiple sclerosis (uncommon)
 Systemic lupus erythematosus (SLE)
 Diffuse degenerative disease
 Alzheimer's disease
 Creutzfeldt-Jakob disease

Partial epilepsy
 Partial seizures may arise from any disease of the cerebral cortex, congenital or acquired and frequently generalise.

Causes of Partial Seizures
 Idiopathic:
 Benign rolandic epilepsy of childhood
 Benign occipital epilepsy of childhood
 Focal structural lesions:
 Genetic Tuberous sclerosis, neurofibromatosis, van Hippel-Lindau syndrome
 Infantile hemiplegia
 Dysembryonic Cortical dysgenesis, Sturge-Weber syndrome
 Mesial temporal sclerosis (associated with febrile convulsions)
 Cerebrovascular disease Intracerebral haemorrhage, cerebral embolus, arteriovenous malformation
 Tumours
 Trauma (including neurosurgery)
 Infection
 Cerebral abscess (pyogenic), toxoplasmosis, cysticercosis, subdural empyema, encephalitis, HIV
 Inflammatory disease
 Sarcoidosis, vasculitis

Investigations
 Electroencephalography (EEG)
 Brain imaging
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Investigation of Suspected Epilepsy
 Epileptic nature of attacks?
 Ambulatory EEG
 Video telemetry

 Type of epilepsy?
 Standard EEG
 Sleep EEG
 EEG with special electrodes (foramen ovale, subdural)

 Structural lesion?
 CT
 MRI head

 Metabolic disorder?
 Blood urea and electrolytes
 Liver function tests
 Blood glucose
 Serum calcium, magnesium

 Inflammatory or infective disorder?
 Blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)
 Chest radiograph
 Serology for syphilis, HIV, collagen disease
 CSF

Indications for Brain Imaging in Epilepsy

 Epilepsy onset after the age of 20 years
 Seizures with local features clinically
 EEG shows a focal seizure source
 Control of seizures is difficult or deteriorates

Management
 It is important to explain the nature and cause of seizures to patients and their relatives, as is the instruction of relatives in the first aid management of major seizures. Many people with epilepsy feel stigmatised by society and may become unnecessarily isolated from work and social life. It should be emphasised that any brain can develop a seizure, that epilepsy is a common disorder which affects just under 1 % of the population, and that good or complete control of seizures can be expected in more than 80% of patients.

Immediate care of seizures
 Little can or need be done for a person during the time

 A major seizure is occurring except first aid and commonsense manoeuvres to limit damage or secondary complications.

 First aid (by relatives and witnesses).

 Move person away from dangerl (fire, water, machinery, furniture)
 After convulsions cease, turn into 'recovery' position (semi­prone)
 Ensure airway is clear
 Do NOT insert anything in mouth (tongue-biting occurs at seizure onset and cannot be prevented by observers)
 If convulsions continue for more than 5 minutes or recur without person regaining consciousness, summon urgent medical attention
 Person may be drowsy and confused for some 3D-60 minutes and should not be left alone until fully recovered

Immediate medical care
 Ensure airway is clear
 Give oxygen to offset cerebral hypoxia
 Give intravenous anticonvulsant (e.g. diazepam 10 mg) ONLY if convulsions are continuous or repeated (if so, manage as for status epilepticus)
 Take blood for anticonvulsant levels (if known epileptic)

Restrictions
 Until good control of seizures has been established, work or recreation above ground level, with dangerous machinery or near open fires or water should be avoided.

 atients should take only a shallow bath and then when a relative is in the house, and should not lock the bathroom door.

 Cycling should be discouraged until at least 6 months' freedom from seizures has been achieved.

 Recreations requiring prolonged proximity to water (e.g. swimming, fishing or boating) should always be in the company of someone who is aware of the chance of a seizure occurring.

 Any activity where loss of awareness might be very dangerous (e.g. mountaineering) should be discouraged.
STATUS EPILEPTICUS
 Status epilepticus exists when a series of seizures occurs without the patient regaining awareness between attacks, Most commonly this refers to recurrent tonic clonic seizures. (major status) and is a life-threatening medical emergency.

Management of Status Epilepticus

 Immediate care
 Secure I.V. access
 Draw blood for glucose and electrolytes and save for future analysis (drugs etc.)
 Transfer to intensive care area, monitoring neurological condition, blood pressure, respiration and blood gases
 Investigate cause

HOMOEOPATHIC REVIEW
References
 DEVIDSON’S “principles and practice of medicine”, 17th edition,churchil and laving stone,London.
 KENT.J.T, “Repertory of Homeopathic Materia Medica’ reprint edition,B.Jain publishers,New delhi.
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 http--pet_radiology_uiowa_edu-webpage-Research-CaseStudies epilepsy_jpg_files\imgres_files.