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The fit makes the patient fall down senseless; and without his will or consciousness presently every muscle is put in action; as if all the powers of the body were exerted to free itself from some great violence. In these strong and universal convulsions, the urine, excrements and seed, are sometimes forced away, and the mouth is covered with foam, which will be bloody, when the tongue is bit, as it often is in the agony.
WILLIAM HEBERDEN (1710–1801)
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Epilepsy is defined as a ‘tendency to recurrence of seizures’. It is a symptom, not a disease. A person should not be labelled as having epilepsy until at least two attacks have occurred.1 Epilepsy is common and affects about one person in 50. Both sexes are about equally involved, and some forms run in some families. Famous people who have had epilepsy include Julius Caesar, Thomas Edison and George Frideric Handel.
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The most important factors in the management of epilepsy are the accurate diagnosis of the type of seizures; identification of the cause and appropriate investigation; the use of first-line drugs as the sole therapy of some weeks; and adjustment of the dose, according to clinical experience and plasma levels, to give maximum benefit.
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To be accurate in diagnosing seizures the diagnosis must be based on:2
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the patient’s memory of the seizure
the patient’s history (e.g. family history, toxin exposure, accidents, febrile convulsions, eclampsia)
the observation of a witness to the seizure
a general and neurological examination
an EEG, although this has considerable limitations
a CT scan or preferably MRI (especially if the EEG is focal and a tumour is suspected)
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Long-term ambulatory EEG recording now provides more information and, coupled with video monitoring, provides a permanent record of the seizure which can be reviewed at will. The CT or MRI scan is necessary to exclude a focal cause (such as a cyst, tumour, malformation or abscess) which might be treatable by surgery. The MRI scan can indicate developmental migration disorders.
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The scan may identify mesotemporal sclerosis (an abnormality in the hippocampus due to birth hypoxia), thereby making some ‘idiopathic’ seizures into secondary seizures from a known cause.
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Epilepsy usually starts in early childhood.
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Optimal management includes adequate psychosocial support with education, counselling, advocacy and appropriate referral. Advice about appropriate lifestyle using the NEAT approach (see CHAPTER 7) is important.
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An underlying organic lesion becomes more common in epilepsy presenting for the first time in patients over the age of 25 years, and thus more detailed investigation is required.1
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Secondary causes of seizures include:
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trauma—head injuries
postcerebral surgery
metabolic (e.g. calcium and sodium electrolyte disturbances, hypoglycaemia, uraemia, hepatic failure)
drugs and other toxins (e.g. alcohol, amphetamines including withdrawal)
intracerebral infections (e.g. meningitis, ...