Neurologists are diagnosing epilepsy sooner and providing better treatments, but many patients are still not seizure free and do not receive adequate medical care. The next 20 years hopefully will shrink this number. But much is still not understood about the condition, including the specific cause in too many patients.
There has been an evolution of different terms for the
various forms of epilepsy but the seizures themselves are unchanged, i.e., how they
spread in the brain and their electrical activity.
A once common cause of complex partial seizures, aka
temporal lobe epilepsy and psychomotor epilepsy, was mesial temporal
sclerosis (depicted as inner temporal lobe atrophy on brain imaging scans).
Currently this specific brain atrophy is less commonly seen. Why this is
so is a mystery. A leading epileptologist, Dr. Jacqueline French, speculates
that a particular type of illness that caused it is no longer prevalent. Alternatively,
could it be that more anti-inflammatory medications are currently used in
children that usually develop it and these effectively minimize this seizure
disorder? 1
Neurologists note that nearly one-half of all
comatose patients in Intensive Care Units (ICU) were having electrographic
seizures on the EEG but 90% had covert seizure manifestations that were not
obvious. When I personally examined motionless comatose patients I have
been surprised by occasionally noting a “jumping” of the eyeballs, called
nystagmus, when I would focus my ophthalmoscope on structures in the rear of
the eyeballs. These movements are compatible with unsuspected seizures. In
recent decades skill using ophthalmoscopes at the bedside that could
detect this finding has been lost by younger clinicians; they depend
on brain scans, but scans are not capable of showing epileptic activity.
Newer deep-brain stimulation can effectively detect
electrical onset of seizures and then “short-circuit” the abnormality
thus halting seizures as they begin. Brain surgery to remove identified
abnormal seizure foci has become common and is very effective in minimizing the
frequency of seizures. Surgery can even cure epilepsy. Robots can place
brain electrodes or even function to remove brain tissue under neurosurgeons’
control.
The past 2 decades have seen development of newer
anti-seizure drugs but none, to date, are able to eliminate seizures
completely. Still, half of all the 1% of people afflicted with epilepsy will
have excellent seizure control when put on the best anti-convulsant for them.
Genetic studies can help to diagnose epilepsy syndromes in increasing numbers.
Specific gene patterns in individuals (their genomes) are now found to be associated
with epilepsy that guides the best medication choice for that person’s
condition.
Formerly, Sudden Unexplained Death in Epilepsy (SUDEP)
was incorrectly believed to be rare, however, it is not rare; effective
anti-convulsants that prevent or minimize a person’s seizure frequency has been
very effective in lowering SUDEP.
The ability to track your seizures by implanting
electrodes has been a very significant advance in epileptology. It is hoped
that this will enable patients to predict when a seizure will occur and gain
better control over their lives.
1) Fallik D. Then and Now:20 Years Later. Neurology Today. September 2, 2021; p.14.
Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is a family medical drama told from a mother’s point of view. It is his first novel. It teaches epilepsy. DINGS is now available in eBook, audiobook, and soft and hard cover editions.
