Blog #47: Epilepsy in Developed vs. Underdeveloped Nations

(This blog was originally posted on June 25, 2014)

 

Premature death is more likely to occur in underdeveloped, low-income countries, than in the developed world. Significant causes of these early deaths include deficiencies in education, nutrition, sanitary conditions, perinatal care and access to medical services. More than 85 percent of people who have epilepsy—approximately 70 million people worldwide—reside in areas of the world with limited health-related resources (1). Epilepsy-related deaths in these countries seem to be associated with falls, burns, drowning and status epilepticus, or uncontrolled continuous seizures lasting many minutes to hours to days without stopping. 

The data is staggering. Ngugi, et al, published a study in Kenya, Africa. It showed that the death rate of those with active convulsive epilepsy is more than six times that of a comparison group without active convulsive epilepsy (2). Important factors contributing to this high mortality associated with epilepsy include lack of appropriate anticonvulsant medications and nonadherence to their anticonvulsant medication regimen (commonly associated with long distances from medical providers, traditional animistic beliefs about epilepsy and cognitive impairment). More than half of all deaths in this study were directly related to epilepsy with a high incidence of prolonged seizures and status epilepticus. The researchers concluded that access to basic medical management of seizures would have saved lives.

Conversely, death due to epilepsy is far less common in the developed world. Sudden Unexplained Death in Epilepsy (SUDEP) is a known cause occurring in approximately one out of one thousand people who have epilepsy (see my Blog # 13, November 14, 2011: Sudden Unexpected Death in Seizures). It is imperative that people with epilepsy: follow medical treatment advice; prevent drowning—do not swim alone and don’t bathe or shower unless the bathroom door is open and someone is at home, if at all possible; and don’t drive unless epilepsy is controlled.

The underdeveloped world’s tremendous challenge is to serve their populations by improving the quality of life for all of their people and to prioritize healthcare.

 

1.      Newton CR, Garcia HH. Epilepsy in poor regions of the world. The Lancet 2012; 380: 1193-1201.

2.      Ngugi AK, Bottemly C, et. al. Premature mortality in active convulsive epilepsy in rural Kenya. Neurology 2014; 82: 582-589.

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. DINGS is his first novel. It is a mother’s dramatic story that teaches epilepsy.

Blog #37: Status Epilepticus

(This blog was originally posted on September 3, 2013)

 

Approximately 1 to 16 percent of people with epilepsy experience seizures that last five or more minutes. This prolonged seizure is referred to as “status epilepticus,” and the seizure will be characterized by either convulsions (tonic-clonic seizure, See Blog #33) or periods of blanking out (complex partial seizure, See Blog #35). Each event originates in a different area of the brain and can last many minutes or even several hours.

·         Tonic-clonic status epilepticus: This type of seizure emanates from the central depths of the brain, but it can spread to both hemispheres and affect the whole brain. This form of epilepsy can be lethal if it goes on for too long because the convulsions impede/prevent breathing. If someone is convulsing for more than several minutes, it is important to get the patient medical help as soon as possible: intravenous anti-seizure medications can be given to help stop that seizure. If this fails, general anesthesia is used to try to stop the seizure and to preserve the brain cells that have not already been damaged by oxygen deprivation that occurred during the seizure.

·         Complex partial status epilepticus: This seizure begins in the temporal lobe, and occasionally in the frontal lobe. It may last several minutes, many hours or even days. To the uninitiated observer, someone who is in this state may appear to have a psychiatric problem, where the patient has “freaked out” and just acts strangely. The patient may even be referred to psychiatrists because of the unrecognized seizure. As oxygenation is not compromised in complex partial status epilepticus, anti-seizure medications may be administered orally or intravenously, as per the medical team’s judgment.

·          Subclinical, non-convulsive status epilepticus is believed to be the cause of coma in many seriously ill, unresponsive patients in the intensive care unit (ICU). These patients lie still, without responsiveness, yet they can be having continuous seizure activity seen if an electroencephalogram (EEG) is done. A routine eye examination with an ophthalmoscope at the bedside could diagnose this condition. I have occasionally been surprised to find that the optic disc—a structure in the back of the eyeball—is jerking back and forth in comatose patients. This may be the only part of the body demonstrating epileptic activity, which will be confirmed on the EEG.

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. DINGS is his first novel.

 

Blog #13: Sudden Unexpected Death During Seizures

(This blog was originally posted on November 14, 2011)

 

 

Sudden death without obvious cause in epilepsy is an uncommon danger that is not often discussed with patients. This phenomenon is known as “sudden unexpected death in epilepsy” (SUDEP). Dr. Orrin Devinsky, Professor of Neurology at New York University, reviewed SUDEP in the November 10, 2011 edition of the New England Journal of Medicine.

Each year, sudden unexpected and unexplained death is reported in fewer than one in one thousand epilepsy patients. SUDEP tends to occur among patients whose tonic-clonic seizures are poorly controlled; it occurs more in adults than in young children.

SUDEP is diagnosed when an autopsy reveals no other known cause for the death, such as drug intoxication, heart attacks, uncontrolled continuous seizures, i.e., status epilepticus, or other identifiable diseases/abnormalities. Many SUDEP incidences involve patients who go to sleep and then are found dead in bed. Most of these cases are thought to occur after a seizure, although this cannot always be proven. It is believed that seizure activity affects the brain’s regulating centers for breathing and heartbeat, which can result in pulmonary edema, a common finding at autopsy in these patients. Pulmonary edema is a congestion of the lungs that can be lethal by impairing breathing.

We still do not know how to prevent SUDEP. Closely following medical advice and treatment guidelines to control seizures seems to offer the most benefit.

 

 

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. DINGS is his first novel.