Blog #106: LEARN ABOUT THE FEBRILE SEIZURE

            Young, healthy children can have seizures when they get high fevers such as with ear and upper respiratory infections. These seizures are more likely if family members have had them. Four percent of young children in the United States experience febrile seizures.

            The typical age range is 3 months to 5 or 6 years. The peak incidence of febrile seizures is between 18-22 months of age. They occur during the rising phase of fever and during the first day of the illness. Only one febrile seizure that day is typical. Seizures that occur later in the febrile illness suggest some other condition. Only 2 percent of youngsters who have had a febrile seizure go on to develop epilepsy by age 7 years.¹  The possibility of developing epilepsy later in life is increased if there is a prior neurologic developmental abnormality; if the convulsion lasts longer than 3-5 minutes; if convulsive jerking involves just one part of the body (focal) rather than a generalized convulsion; and if the EEG (electroencephalogram) is abnormal.

            Convulsions that occur with fevers after age 5 or 6 years should not be considered benign febrile seizures. These children should receive a thorough evaluation to search for some causative condition and if none is found, then epilepsy is likely. Children who have benign febrile convulsions are not considered to have epilepsy (epilepsy is defined as more than one seizure often due to no identifiable cause).

            Among children who experience their first febrile seizure before their first birthday, half will have at least one more. Among children who are older than 1 year when the first febrile seizure occurs, about 1 in 4 will have more. The overall prognosis, however, is excellent.

            Febrile convulsions are diagnosed when no other condition is present that can cause high fevers and the seizures occur before age six years. Meningitis and encephalitis must be considered. Clinical judgment determines if the spinal fluid is to be examined by a lumbar puncture. Serious causes of a convulsion associated with fever are considered if the convulsion occurs after the initial fever-peak or if there are multiple convulsions. Convulsions associated with a vaccination-induced fever are typically benign febrile seizures unless confused with a rare encephalopathic reaction to the immunization.²

            Acute treatment of the convulsion is usually not necessary unless it lasts 3-5 minutes. Diazepam (Valium) can be administered intravenously, intramuscularly or per rectum. Treatment should be given if it is a prolonged seizure.

            Prophylactic treatment (i.e. daily antiepileptic medications), can be used if the child under 6 years old experiences frequent convulsions during the rising phase of fevers. Daily administration may be indicated because seizures can occur before the fever is detected and then administration of the drug is too late. If prophylaxis is chosen it’s usually continued 1-2 years after the last febrile convulsion and then tapered off over 1-2 months. The problem with prophylactic treatment is that only one-third of the population of young children will experience another seizure with a subsequent febrile illness. There is no evidence that prophylaxis reduces the risk of future epilepsy.

            Risk factors for future epilepsy diagnosis in children who experience febrile seizures includes a family history of non-febrile epileptic seizures, pre-existing neurological conditions or developmental delay, seizures lasting longer than 3-5 minutes, focal localized seizures and multiple seizures in one day.

1.      Nelson KB, Ellenberg JH: Predictors of epilepsy in children who have experienced febrile seizures. N Engl J Med 295:1029, 1976.

2.      Engel, Jr J: Seizures and Epilepsy. Philadelphia, PA: F.A.Davis Co. 1989, p 181-183.

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, now available in eBook, audiobook and soft cover editions.

Blog #105: TRAINING SEIZURE DOGS

      The Epilepsy Foundation visited trainers and staff of Canine Partners for Life, Cochranville, Pennsylvania. This is what they learned about training these amazing seizure-alert dogs:

• Certified seizure-dog trainers do not require a specific educational degree. However, some states require licensure and others have voluntary certification programs for the dogs. Other states have accredited college and community college programs to train service dogs for various disabilities. 

•  Seizure-dog resources can be found on line: www.epilepsy.com/learn/seizure-first-aid-and-safety/seizure-dogs/perspective-training-seizure-dogs

•  Seizure-dogs are trained to help or to alert for help when their human partner is having a seizure. Some animals can even predict a seizure within minutes or an hour before it occurs and warn their handler. How dogs do this is not precisely known. Do they pick up some signal? Do they detect a smell? Can they be trained to detect an imminent seizure or are they born with that ability? Barking and licking are anecdotal tales of dogs responding to seizure-warnings, but even trainers cannot guarantee the dog will predict every seizure.

•  One facet of training can be to expose the dog to a person who has active epilepsy. That person can judge if the dog reacts in any way prior experiencing an aura or seizure. However, ambulatory EEGs running continuously in a patient with the seizure-dog nearby often show no response in the dog.

•  Dogs are trained to alert, respond and retrieve items in interacting with their human partner. While any dog can potentially be trained to become a seizure-dog, favorite breeds include Labrador and Golden Retrievers and Collies. Dogs start their training with organizations that provide seizure-dogs as puppies where they are assessed for temperament and personality. Serious specialized training begins around 14 months of age. Dogs are trained to: fetch, push buttons, open doors, turn off lights, pay a cashier and carry things. In harness they can help balance and support their handler. The dogs are placed in their partner’s home to build bonds during training and to learn what their partner needs.

•  Another useful website to acquire a seizure dog is: assistancedogsinternational.org.

•  Anyone over 11 years of age and who can communicate at least at a sixth-grade level is eligible to be partnered with a seizure dog because certain levels of maturity/ability are required. The cost of training a dog is around $26,000. Donations subsidize many dogs. The cost to the person with epilepsy ranges from free to $20,000 depending upon ability to pay. 

 

    The impact a seizure dog can have on an individual or family can be life changing. The dog can bring a sense of relief with more safety, independence, confidence and love.

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, now available in eBook, audiobook and soft cover editions.

Blog # 104: DINGS Excerpted from Dr. Lance Fogan’s medical mystery novel, DINGS.

     Chapter 22, Part 2 (Part 1 was in Blog # 95, June 25, 2018)

Sam snored softly in his sleep. I tossed, turned and then gave up. Quietly, I rose in the darkness and slid into my slippers and bathrobe. I tiptoed down the hall. Madison’s and Conner’s still forms and the sounds of soft, regular breathing comforted me.

The study doorknob felt cold as I closed it. I switched on the desk lamp. It illuminated the sheets of notes I had already made on my seizure research.

I drummed my fingers on the desk as I looked out into the cold, clear, indigo March night sky. I loved the color the sky was now. An occasional wind buffeted the windows. I shivered and wrapped my robe tighter around me as the computer screen came to life. The desktop screen showed my favorite picture of the kids taken last summer. They smiled in their vegetable garden out back. I clicked on the Internet Explorer icon. It was time to find out about Conner’s neurologist.

I typed “Hal O’Rourke.” The screen filled with pages of references for those key words. I scrolled down until I found a link for the neurologist’s website. The homepage displayed a photograph of a smiling, avuncular, clean-shaven middle-aged man. He wore a white doctor’s coat over a blue buttoned-down shirt and a bright blue, red and yellow-striped bowtie. I smiled. One didn’t see bowties very often. I leaned in.

Dr. O’Rourke was a full professor of neurology. He had been in practice for more than twenty-six years. He had done a tropical-medicine fellowship in Papua New Guinea as a medical student. I wondered if there were cannibals and headhunters over there. Conner would be intrigued by this. He and his friends were always watching TV shows about exotic animals and people who lived in jungles.

The next page showed several pictures of Hal O’Rourke as a young medical student in a primitive world doing medical things and tramping around tropical forests. In one photograph, he posed with a large white parrot on his arm. In another, he held a huge hypodermic needle stuck in the side of a native lying on a table in a mud-floored, jungle operating room. I squinted at the monitor. I was horrified to see that there were no screens on the windows. People leaned through them to watch. I guessed that was how they lived there. I would be dead in a week without modern conveniences.

The bibliography of Dr. O’Rourke’s research papers went on for several pages. I read a list of his research articles. They were about headaches and other unfamiliar medical conditions published in medical journals.

What followed was a little astonishing: a section called “Shakespeare and Neurology.” It listed Dr. O’Rourke’s articles about that great dramatist. If he was doing all of these other things—and this literature research—did he have enough time to be a really good doctor? Did he know enough about seizures? According to the article, Dr. O’Rourke had studied every neurological symptom that had ever been mentioned in Shakespeare’s works. 

The English major in me was immediately fascinated. As I continued to read my confidence in this neurologist returned. Othello and Julius Caesar had epilepsy. King Lear had delirium and “an epileptic visage.” Juliet’s nurse got migraines. Shakespeare even described how alcohol’s damage to the liver affected thinking. A character in another play had double vision. Others were incontinent and a few were demented. I laughed quietly. This was wild.

The last page listed awards and some lectures he had given at medical conferences around the world.

My gut instinct—a mother’s instinct—spoke to me. My Conner would like him. Dr. O’Rourke could be the man to make everything all right again. He had been doing this for a long time, after all. One more day and then we would get some answers.

My eyelids drooped and my head started to nod. I leaned back and closed my eyes. Once again, haiku images coalesced: huge waves roaring in—crashing over jagged rocks—a swimmer reached home.

 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, now available in eBook, audiobook and soft cover editions.

                                                                                                         

Blog #101: EPILEPSY—FIT TO DRIVE?

The United States codifies legal restrictions regarding seizures and driving, but only six states have laws requiring physicians to report patients with seizures to the state authorities: California, Delaware, Nevada, New Jersey, Oregon and Pennsylvania. The other states depend on the patients reporting their epilepsy diagnosis and status themselves and/or ceasing to drive. A common restriction-determination used by some states is the person should be free of seizures for three to twelve months but other states may have different requirements. Researchers found it made little difference if states used a three-month seizure-free period or a six-to twelve month time frame.¹

           

Seizure triggers such as missed medications or sleep deprivation are more commonly associated with collisions. Crashes attributed to generalized epilepsy are often preceded by the vehicle going out of control from the onset, whereas those with focal epilepsy, e.g., complex partial seizures, seventy-five percent of these crashes had a prior movement of driving straight ahead and then veering off the road.² This latter pattern is suggestive of a brain focal aura followed by the spread of the epileptiform activity throughout both cerebral hemispheres resulting in the generalized convulsion.

Potential actions that could help prevent driving-related seizures include optimizing morning antiseizure medication blood levels, especially if seizures tend to occur then. Driving with a passenger who is aware of the driver’s epilepsy and who could take control of the wheel would help. Driverless cars offer hope, also.²

Only 1 percent of the population has epilepsy, yet people with seizures had 2.3 times the rate of fatal driver crashes as compared to people with heart or blood pressure problems and 4.6 times the rate for patients with diabetes.²

But, non-health problems cause most fatal driving accidents. Between 1995-1997, an average of 86 drivers with epilepsy died per year. Alcohol is the biggest problem accounting for 31 percent of fatal driving accidents claiming 13,400/year on average. "The total number of deaths due to alcohol-related fatal crashes is 6.6 times greater than the number of fatal crashes associated with medical conditions and 156 times greater [than] those associated with seizures." ² Young drivers aged 16-24 were at the wheel in 24 percent of all fatal crashes.

 Fatal driver crashes due to seizures are uncommon and this supports the current public policy of permitting patients whose seizures are controlled to drive.³

1.   Drazkowski JF, Fisher RS, Sirven JI, et.al. Seizure-related motor vehicle crashes in Arizona before and after reducing the driving restriction from 12 to 3 months. Mayo Clin Proc 2003;78:819-825.
2. Sirven JI, Payne ET. Seizure-related crashes. Neurology; 2018: 91: 543-544.
3. Sheth, S. Neurology, September 2004; vol 63: pp 1002-1007.

 

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, now available in eBook, audiobook and soft cover editions.

Blog #102: Reflex Epilepsies

            Last month’s blog, PHOTOSENSITIVE EPILEPSY (# 101), posted December 26, 2018 on LANCEFOGAN.COM, introduced the reflex epilepsies. This reflex epilepsy is seizures initiated by exposure to flashing and flickering lights. Other reflex epilepsies are seizures that develop in response to a specific motor, sensory or cognitive stimulus. Most are uncommon, some are rare. 

•             In susceptible people, certain thoughts―the cognitive stimulus—can trigger a seizure. An example can be sequential decision-making. Reflex seizures may be generalized, or focal, and they can be associated with, or without, impaired consciousness. If consciousness is impaired it’s a ‘complex’ focal seizure. If consciousness remains intact during the seizure it is a ‘simple’ focal seizures. Reflex epilepsy can be caused by: 1) a genetic trait and some specific genes are known; if a causative gene hasn’t been recognized, it’s idiopathic reflex epilepsy, i.e., of unknown cause; or 2) symptomatic reflex seizures which are due to a structural brain abnormality such as tumor, stroke, infection, or traumatic scar. Photosensitive epilepsy is the most genetic, i.e. hereditary. The other reflex epilepsies’ causative genes are elusive and run less in families.

•             Eating epilepsy is very rare. It occurs in fewer than one person in 1000 people with epilepsy. It is not associated with particular foods, rather, the seizure seems to come on during the act of swallowing. Additionally, some people develop seizures if they visualized, smelled or even thought of, a particular food.

•             Musicogenic-evoked epilepsy can be associated with certain music themes or music notes. The seizures can be even be precipitated by singing voices. It was found that some singers' voices, but not other singers’ voices, were particularly epileptogenic in the sensitive person afflicted. Additionally, some songs, but not others, would precipitate a seizure in these sensitive individuals.

•             Movement-induced epilepsy starts with certain movements in that person.

•             Auditory-evoked epilepsy is when a seizure is evoked with startling sounds.

 
 

           We await research to reveal more about how stimuli such as these above can induce seizures.

 

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, now available in eBook, audiobook and soft cover editions.