Epilepsy

Epilepsy is a chronic neurological condition which causes chronic or recurrent unprovoked seizure, affecting our movement, behaviour and level of consciousness. Epileptic episodes can be anything from a brief lapse in attention (absence seizures) to uncontrolled muscle movements (tonic-clonic seizures). 

Epilepsy is also common worldwide, affecting about 50 million people globally. Although there is no cure for epilepsy, the condition can be treated and managed properly, allowing patients to have a good quality of life.

What is epilepsy?

Epilepsy is a condition characterised by recurrent episodes of seizure, which are often unprovoked or not triggered by external stimuli. A seizure is the main symptom of epilepsy — a temporary occurrence of synchronous and overactive neuronal activity in the brain [1].

What’s the difference between a seizure and epilepsy?

Seizures are defined as the transient episode of symptoms caused by the abnormal activity of the neurons, while epilepsy is defined as the disease or disorder that causes frequent or recurrent episodes of seizure, often unprovoked.

	Seizure	Epilepsy
What is it?	Symptomatic episodes caused by abnormal and excessive activity of the neurons in the brain.	A disease or disorder that causes recurrent seizures.
What causes it?	Infections (meningitis, encephalitis), traumatic brain injuries, brain tumours, genetics, malformations of brain development during childhood [1].	Unprovoked
How often does it happen?	Episodes can be triggered by an isolated event, such as infections, brain injuries, substance withdrawals, or hypoglycaemia [1].	Two or more unprovoked seizures at least 24 hours apart [1].

What are the signs and symptoms of epilepsy?

Epileptic seizures can present the following symptoms:

• Mental confusion
• Uncontrollable movements, such as jerking, twitching, and loss of muscle tone
• Blank stare or staring spells
• Loss of consciousness or awareness
• Problems with speech or understanding speech
• Changes in vision, hearing, tasting, and smelling
• Numbness and tingling sensation
• Psychological symptoms can include fear, anxiety, or deja vu
• Rapid heart rate

Symptoms of an epileptic seizure can vary from person to person. However, each person with epilepsy typically experiences the same type of seizure hence will have the same/similar symptoms with each episode of seizure. 

What causes epilepsy?

The seizures in epilepsy are caused by abnormal synchronous neuronal activity in the brain, which can affect part of the brain, or throughout the entire brain. That said, the exact causes or triggers of epilepsy may vary among patients. 

Typically, genetic and developmental issues contribute to epilepsy in children, while accumulation of brain injuries, such as trauma or tumours, are seen to contribute to epilepsy in the elderly [1]. Epilepsy can be broadly classified into several types, depending on the type of seizure onset experienced [2]:

• Focal – Focal onset refers to the seizures that involve only a localised part of the brain. Most patients experiencing focal onset seizures often remain conscious and alert, and may remember the episode. Focal seizures can also involve altered awareness or impaired awareness. Focal seizures can also be categorised according to the part of the brain where the seizure originates:
  
  • Temporal lobe seizures – The temporal lobes are responsible in processing emotion, patients with temporal lobe seizures may have psychological symptoms such as deja vu, fear, or even joy.
    
  • Frontal lobe seizures – The frontal lobes are responsible for movement, hence patients may present with motor symptoms.
    
  • Occipital lobe seizures – The occipital lobe is responsible for vision and visual processing, patients may experience visual symptoms such as hallucinations and loss of vision, or blinking and eye movements.
    
• Generalised – Generalised onset involves neuronal networks across both sides of the brain (bilateral). Generalised onset seizures often lead to the loss of consciousness and uncontrollable muscle movements such as jerks and twitches. Generalised seizures can also be further categorised to different types of seizures:

• Absence seizures – Absence seizures are characterised by brief episodes of blank stares and unresponsiveness, usually lasting between 2 to 15 seconds.
  
• Tonic seizures – Tonic seizures are characterised by stiffened muscles, usually involving the back, leg, and arm muscles.
  
• Clonic seizures – Clonic seizures are characterised by jerking movements.
  
• Myoclonic seizures – Myoclonic seizures are similar to clonic seizures, but they typically only involve the arms or upper body muscles, the patient can also be fully conscious while this happens.
  
• Atonic seizures – Atonic seizures are characterised by the loss of muscle tone, which can cause the patient to fall or drop their head.
  
• Tonic-clonic seizures – Tonic-clonic seizures are a combination of tonic and clonic seizures with symptoms from both types, the patient usually loses consciousness, followed by stiffening of the muscles/falling, and jerking motions. Other symptoms that may occur also include cyanosis, tongue-biting, foaming at the mouth, and incontinence. Tonic-clonic seizures are also known as grand mal seizures.
  

• Combined generalised and focal – Combined generalised and focal can occur as a focal seizure that spreads from one part of the brain to both sides of the brain, which can be referred to as focal to bilateral tonic-clonic.
  
• Unknown – Unknown onset seizures are typically classified when there is insufficient information on the nature of the onset of seizure. They can be further classified as unknown-onset motor seizures and unknown-onset non-motor seizures.

Seizures can be caused by varying different factors, one of which is epilepsy. Epilepsy can be caused by different aetiologies, which can vary depending on the age of onset [2]:

Age of onset	Common causes
Infants	Perinatal hypoxiaMetabolic disordersBrain injuries/bleedingGenetic disordersDevelopmental disorders
Children	Perinatal anoxiaBrain injuriesInfections Genetic disordersVascular, metabolic, developmental disorders
Adolescents and adults	Traumatic brain injuries Infections Genetic disordersBrain tumoursStroke
Elderly	Stroke Dementia Brain tumoursInfectionsBrain injuries

Who is at risk of epilepsy?

As epilepsy can be caused by a variety of contributing factors, anyone can develop epilepsy. However, epilepsy was observed to be more common in individuals with the following factors:

• Age – Epilepsy is commonly seen in young children and the elderly, largely due to genetics or developmental disorders and dementia or stroke respectively.
  
• Family history – Genetics can play a role in the likelihood someone develops epilepsy. If a family member has a history of epilepsy, you may be at higher risk of developing epilepsy as well.
  
• Infections – Infections that lead to central nervous system inflammation, such as meningitis or encephalitis, can increase the risk of epilepsy. Young children and elderly people are also more at risk of these infections due to their weak immune systems.
  
• Traumatic brain injuries – Trauma to the head can lead to damage on parts of the brain, these damages can consequently lead to epileptic symptoms.
  
• Dementia – Having dementia is associated with epilepsy in elderly people.
  
• Stroke – Stroke or other vascular diseases can lead to brain damage in parts of the brain affected by the event. This can consequently lead to an increased risk of epilepsy.

What are the complications of epilepsy?

Epilepsy can cause seizures to occur at unexpected times. This can potentially cause danger to you or those around you. Common complications of epilepsy include:

• Falling – Losing control of your muscles, or losing consciousness can cause you to suffer from falls, which may injure you or cause bone fractures.
  
• Drowning – Risks of drowning are increased in people with epilepsy, especially if they have a seizure while in the water, such as while swimming or sitting in a bath.
  
• Getting into vehicle accidents – Vehicular accidents can occur when you have a seizure while driving or riding a motorbike. For this reason, the Singapore Road Traffic Act states that persons with epilepsy are not allowed to drive.
  
• Mood disorders – Epilepsy can lead to mood disorders such as depression or anxiety due to a poor quality of life. Visiting a counsellor or psychologist can be beneficial for those affected with mood disorders due to their epilepsy.
  
• Status epilepticus – Status epilepticus is a life-threatening condition where someone is in a constant state of seizure for 5 minutes. Medical treatment should be given as soon as the 5-minute mark is reached. At 30 minutes of constant seizure, neuronal damage is likely to occur and the risk of death greatly increases.
  
• Sudden unexpected death in epilepsy – Sudden unexpected death in epilepsy occurs in 1 in every 4000 adult patients and in 1 in every 4500 children patients [2]. Although the exact cause is not clear, it is speculated that heart and lung conditions are involved in the cause of sudden unexpected death in epilepsy.

How is epilepsy diagnosed?

Epilepsy is one of the most common neurological disorders, diagnostic methods for epilepsy include [2]:

• Physical examination – The initial physical examination by your neurologist can include taking your medical history and family history of epilepsy. Your doctor will ask you questions regarding your symptoms, the frequency of seizure episodes, and possible triggers. Your doctor will also perform some tests to evaluate cognitive function.
  
• Electroencephalogram (EEG) – An EEG measures electrical activity of your brain and is an important tool for the diagnosis of epilepsy. EEGs can help identify whether the seizure has a focal or generalised onset by detecting the parts of the brain with overactive neuronal activity.
  
• Brain imaging – Imaging modalities such as magnetic resonance imaging (MRI) scans, computed tomography (CT) scans, positron emission tomography (PET) scans, and single photon emission computed tomography (SPECT) scans, allow your doctor to visualise the structure and shape of the brain, and to identify possible causes to a seizure, such as the presence of tumours, strokes, or developmental abnormalities [3].
  
• Blood tests – Blood tests can be done to rule out other causes of seizures such as infections or metabolic disorders.
  
• Genetic tests – Genetic tests can be helpful to identify possible genetic conditions that contribute to epilepsy. These tests also allow your doctor to administer a suitable treatment for your condition.

How is epilepsy treated?

Treatment of epilepsy are commonly done using the following:

• Medications – Medicating patients with anti-epileptic drugs (AEDs) is the most common method for the treatment of epilepsy. There is no shortage of AEDs available, however selection of AEDs used for epilepsy treatment has to be done carefully. The selection of AEDs is specific to the type of epilepsy, as some AEDs may worsen or exacerbate certain types of epilepsy. Furthermore, the patient’s age, sex, comorbidities, and presence of other concomitant treatments need to be taken into consideration to minimise side effects or prevent drug-drug interactions [4]. Examples of common AEDs used for epilepsy treatment are as below [5]:

Type of epilepsy	AEDs
Focal	Gabapentin, lamotrigine, levetiracetam, oxcarbazepine, topiramate, carbamazepine, valproate, lacosamide, pregabalin, zonisamide, clobazam
Generalised	Lamotrigine, topiramate, valproate, clobazam, levetiracetam

Medicating using AEDs requires careful and thorough diagnosis and assessment by your doctor to administer the most suitable AED for the patient. In some cases, combinations of AEDs may be used for better management of seizures.

• Diet therapy – The ketogenic diet, a diet high in fat and low in carbohydrates, is known to reduce seizures. However, following the diet can be challenging and increases the risk of dehydration, constipation, and malnutrition. A more well-tolerated alternative can be a low-glycemic index diet. However, it is still important to only follow these diet therapies under the supervision of a doctor or healthcare professional.
  
• Surgery – In cases where medications are no longer effective, or in cases of drug-resistant epilepsy, surgical intervention may be considered [2]. Common types of surgery for epilepsy include [3]:

Surgery	Description
Focal resection	Focal resections can be done to treat focal epilepsy by removing the non-critical parts of the brain that are causing seizures. A common example is temporal lobectomy for treatment of temporal lobe epilepsy.
Cortical excision	Cortical excision involves removal of the outer layer of the brain, the cortex, which causes epilepsy.
MRI-guided laser ablation	This is a minimally invasive option for removing the epileptogenic parts of the brain, similar to focal resection. The surgery requires drilling a burr hole instead of a craniotomy, where a portion of the skull is removed for surgery.
Corpus callosotomy	Corpus callosotomy involves severing the connection between the brain hemispheres to prevent the spread of generalised seizures from one side to the other. This treatment is often reserved for severe generalised epilepsy, and is not a curative surgery but reduces the severity of seizures.
Vagus nerve stimulation (VNS)	VNS involves implanting a pacemaker-like device which is connected to the vagus nerve on the neck. The device will send signals to the nerve, which are then sent to the brain to stop or reduce seizures. The procedure is also indicated for patients who may not be suitable candidates for other types of brain surgery.
Deep brain stimulation (DBS)	DBS also involves the use of a pacemaker-like implant, which is connected to small electrodes in the brain. The device will send signals to these electrodes to stimulate the corresponding parts of the brain, hence reducing seizures.
Multiple subpial transections	Multiple subpial transections involve making small cuts on the parts of the brain that cause seizures, preventing the spread of the signals that cause the seizures. It is often done when the parts of the brain responsible for the seizures are vital and cannot be removed (unlike in focal resection).

Summary

Epilepsy is one of the most common neurological disorders, affecting millions of individuals worldwide. The hallmark of epilepsy is recurrent, unprovoked seizures, which can occur without warning and vary in severity. While there is currently no cure, there are effective treatment options available to help manage the condition and significantly improve a patient’s quality of life.

If you or a loved one is living with epilepsy or another seizure disorder, schedule a consultation with us today for a detailed diagnosis and personalised treatment plan. 

Frequently Asked Questions

How long can I live with epilepsy?

A study showed that life expectancy is reduced by 10 - 11 years in patients with epilepsy compared to the general population [5]. Epilepsy can reduce your lifespan, likely due to premature deaths associated with epilepsy, such as sudden unexpected death in epilepsy, accidents, and cardiovascular disorders. Treatment to reduce seizures can prevent deaths due to seizures in life-threatening situations.

Do I have to take medications for epilepsy for the rest of my life?

Some patients can stop taking AEDs if their seizures have stopped for at least 1 to 2 years in children, or 2 to 5 years in adults [6]. However, the risk of relapses are still present and stopping medication should be done after comprehensive consultation with your doctor.

What happens if I do not treat my epilepsy?

Untreated epilepsy can lead to a poor quality of life and potential premature death. Having recurrent seizures significantly affects your ability to perform daily tasks and function normally. Furthermore, the risks of life-threatening conditions such as status epilepticus or sudden unexpected death in epilepsy are increased if your seizures are not managed or controlled.

Can you die from an epileptic seizure?

Although it is relatively rare, you can die from an epileptic seizure. The most serious risks include status epilepticus, which refers to a seizure that lasts longer than 5 minutes, or seizures that occur without recovery in between. This requires immediate attention as it can lead to brain damage or death. Another risk is Sudden Unexpected Death in Epilepsy (SUDEP), which is a seizure that occurs during sleep. 

References

1. Falco-Walter J. Epilepsy-Definition, Classification, Pathophysiology, and Epidemiology. Semin Neurol. 2020 Dec;40(6):617-623. doi: 10.1055/s-0040-1718719. Epub 2020 Nov 5. PMID: 33155183.
2. Milligan TA. Epilepsy: A Clinical Overview. Am J Med. 2021 Jul;134(7):840-847. doi: 10.1016/j.amjmed.2021.01.038. Epub 2021 Mar 26. PMID: 33775643.
3. Anwar H, Khan QU, Nadeem N, Pervaiz I, Ali M, Cheema FF. Epileptic seizures. Discoveries (Craiova). 2020 Jun 12;8(2):e110. doi: 10.15190/d.2020.7. PMID: 32577498; PMCID: PMC7305811.
4. Tomson T, Zelano J, Dang YL, Perucca P. The pharmacological treatment of epilepsy in adults. Epileptic Disord. 2023 Oct;25(5):649-669. doi: 10.1002/epd2.20093. Epub 2023 Jul 8. PMID: 37386690.
5. Dreier JW, Laursen TM, Tomson T, Plana-Ripoll O, Christensen J. Cause-specific mortality and life years lost in people with epilepsy: a Danish cohort study. Brain. 2023 Jan 5;146(1):124-134. doi: 10.1093/brain/awac042. PMID: 35234848.
6. Hixson JD. Stopping antiepileptic drugs: when and why? Curr Treat Options Neurol. 2010 Sep;12(5):434-42. doi: 10.1007/s11940-010-0083-8. Epub 2010 Jun 26. PMID: 20730110; PMCID: PMC2918788.