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Epilepsy is usually treated with medication prescribed by a physician;
primary caregivers, neurologists, and neurosurgeons all frequently care for
people with epilepsy. In some cases the implantation of a stimulator of the
vagus nerve, or a special diet can be helpful. Neurosurgical operations for
epilepsy can be palliative, reducing the frequency or severity of seizures; or,
in some patients, an operation can be curative.
Responding to a seizure
In most cases, the proper emergency response to a generalized tonic-clonic
epileptic seizure is simply to prevent the patient from self-injury by moving
him or her away from sharp edges, placing something soft beneath the head, and
carefully rolling the person onto his or her side to avoid asphyxiation. Should
the person regurgitate, the material should be allowed to drip out the side of
the patient's mouth by itself. If the seizure lasts longer than 5 minutes,
Emergency Medical Services should be contacted. Prolonged seizures may develop
into status epilepticus, a dangerous condition requiring hospitalization and
emergency treatment.
Objects should never be placed in a person's mouth during a seizure as this
could result in injury to the person's mouth or obstruction of the airway.
Despite common folklore, it is not possible for a person to swallow their own
tongue during a seizure.
After a seizure, it is typical for a person to be confused, disoriented, and
possibly agitated or sleepy. It is important to stay with the person until this
passes; people should not eat or drink until they have returned to their normal
level of awareness, and they should not be allowed to wander about unsupervised.
Many patients will sleep deeply for a few hours after a seizure; this is not
dangerous. In about 50% of people with epilepsy, headaches may occur after a
seizure. These headaches share many features with migraines, and respond to the
same medications.
Pharmacologic treatment
Some medications can be taken daily in order to prevent seizures altogether or
reduce the frequency of their occurrence. These are termed "anticonvulsant" or
"antiepileptic" drugs (sometimes AEDs). All such drugs have side effects which
are idiosyncratic and others which are dose-dependent; it is not possible to
predict who will suffer from side effects or at what dose the side effects will
appear.
Some people with epilepsy will experience a complete remission when treated with
an anticonvulsant medication. If this does not occur, the dose of medication may
be increased, or another medication may be added to the first. The general
strategy is to increase the medication dose until either the seizures are
controlled, or until dose-limiting side effects appear; at which point the
medication dose is reduced to the highest amount that did not produce
undesirable side effects.
Serum levels of AEDs can be checked to determine medication compliance and to
assess the effects of drug-drug interactions; serum levels are generally not
useful to predict anticonvulsant efficacy in an individual patient, though in
some cases (such as a seizure flurry) it can be useful to know if the level is
very high or very low.
If a person's epilepsy cannot be brought under control after adequate trials of
two different drugs, that person's epilepsy is generally said to be 'medically
refractory.'
Various drugs may prevent seizures or reduce seizure frequency: these include
carbamazepine (common brand name Tegretol), clobazam (Frisium), clonazepam (Klonopin),
ethosuximide (Zarontin), felbamate (Felbatol), fosphenytoin (Cerebyx),
flurazepam (Dalmane), gabapentin (Neurontin), lamotrigine (Lamictal),
levetiracetam (Keppra), oxcarbazepine (Trileptal), mephenytoin (Mesantoin),
phenobarbital (Luminal), phenytoin (Dilantin), pregabalin (Lyrica), primidone (Mysoline),
sodium valproate (Epilim), tiagabine (Gabitril), topiramate (Topamax), valproate
semisodium (Depakote), valproic acid (Depakene, Convulex), and vigabatrin (Sabril).
Other drugs are commonly used to abort an active seizure or interrupt a seizure
flurry; these include diazepam (Valium) and lorazepam (Ativan). Drugs used only
in the treatment of refractory status epilepticus include paraldehyde (Paral)
and pentobarbital (Nembutal).
Bromides were the first of the effective anticonvulsant pure compounds, but are
no longer used due to their toxicities and low efficacy.
Surgical Treatment
Surgical treatment can be an option for epilepsy when an underlying brain
abnormality, such as a benign tumor or an area of scar tissue (e.g. hippocampal
sclerosis) can be identified. The abnormality must be removable by a
neurosurgeon.
Surgery is usually only offered to patients when their epilepsy has not been
controlled by adequate attempts with multiple medications. Before surgery is
offered, the medical team performs many tests to assess whether removal of brain
tissue will result in unacceptable problems with memory, vision, language or
movement, which are controlled by different parts of the brain. Resective
surgery, as opposed to palliative, successfully eliminates or significantly
reduces seizures in about 80% of the patients who undergo it. Many patients
decide not to undergo surgery owing to fear or the uncertainty of having a brain
operation.
The most common form of resective surgical treatment for epilepsy is to remove a
portion of either the right or left temporal lobe, depending on where the
seizures are occurring. A study of 48 patients who underwent this operation,
anterior temporal lobectomy, between 1965 and 1974 determined the long-term
success of the procedure. Of the 48 patients, 21 had had no seizures that caused
loss of consciousness since the operation. Three others had been free of
seizures for at least 19 years. The rest had either never been completely free
of seizures or had died between the time of the surgery and commencement of the
study[4].
Palliative surgery for epilepsy is intended to reduce the frequency or severity
of seizures. Examples are callosotomy or commissurotomy to prevent seizures from
generalizing (spreading to involve the entire brain), which results in a loss of
consciousness. This procedure can therefore prevent injury due to the person
falling to the ground after losing consciousness. It is performed only when the
seizures cannot be controlled by other means. Resective surgery can be
considered palliative if it is undertaken with the expectation that it will
reduce but not eliminate seizures.
Hemispherectomy is a drastic operation in which most or all of one half of the
cerebral cortex is removed. It is reserved for the most catastrophic epilepsies,
such as those due to Rasmussen syndrome. If the surgery is performed on very
young patients (2-5 years old), the remaining hemisphere may acquire some
rudimentary motor control of the ipsilateral body; in older patients, paralysis
results on the side of the body opposite to the part of the brain that was
removed. Because of these and other side effects it is usually reserved for
patients who have exhausted other treatment options.
Other Treatment
Ketogenic diets may occasionally be effective in controlling some types of
epilepsy; although the mechanism behind the effect is not fully understood,
shifting of pH towards a metabolic acidosis and alteration of brain metabolism
may be involved. Ketogenic diets are high in fat and extremely low in
carbohydrates, with intake of fluids often limited. This treatment, originated
as early as the 1920s at Johns Hopkins Medical Center, was largely abandoned
with the discovery of modern anti-epileptic drugs, but recently has returned to
the anti-epileptic treatment arsenal. Ketogenic diets are sometimes prescribed
in severe cases where drugs have proven ineffective.
There are several downsides to what initially seems a benign therapy, however.
The ketogenic diet is not good for the heart or kidneys and medical problems
resulting from the diet have been reported. In addition, the diet is extremely
unpalatable and few patients are able to tolerate it for any length of time.
Since a single potato chip is adequate to break the ketosis, staying on the diet
requires either great willpower or perfect control of a person's dietary intake.
People fed via gastrostomy or young children who receive all their food in the
presence of a caregiver are better candidates.
Vagus nerve stimulation is a recently developed form of seizure control which
uses an implanted electrical device, similar in size, shape and implant location
to a heart pacemaker, which connects to the vagus nerve in the neck. Once in
place the device can be set to emit electronic pulses, stimulating the vagus
nerve at pre-set intervals and milliamp levels. Treatment studies have shown
that approximately 50% of people treated in this fashion will show significant
seizure reduction.
Some people with epilepsy receive a special dog which has the rare talent of
sensing the onset of a seizure and is trained to alert the human so they can
reach a safe location before their seizure puts them in danger. Other epilepsy
care dogs do not sense seizures, but serve as companions and guardians during
the loss of consciousness accompanying a seizure.
The Institutes for The Achievement of Human Potential promulgate a home program
consisting of a healthy diet, clean air, and respiratory training. This
alternative approach is regarded as unscientific by most medical practicioners.
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