epilepsy

Quick Overview

• Description: Epilepsy is characterized by epileptic seizures. These are short-term dysfunctions of the brain in which nerve cells are discharged electrically in extreme form.
• To shape: There are several types of seizures and forms of epilepsy, such as generalized seizures (such as absences or grand mal), partial seizures, Rolando epilepsy, Lennox-Gastaut syndrome, West syndrome, etc.
• Causes: partly unknown, partly due to another illness (brain damage or inflammation of the skin, concussion, stroke, diabetes etc.). Very often, only the combination of genetic predisposition and another disease leads to the development of epilepsy, experts believe.
• Treatment: usually with medication (antiepileptic drugs). If these are not effective enough, surgery or electrical stimulation of the nervous system (such as vagus nerve stimulation) can sometimes be considered a treatment.

What is epilepsy?

Epilepsy (“epilepsy”) is one of the most common transient brain dysfunctions. It is characterized by epileptic seizures: Nerve cells (neurons) in the brain suddenly fire synchronized and uncontrolled pulses for a short time.

Such a seizure can be pronounced to different degrees. Accordingly, the effects are variable. For example, some patients experience only a slight twitching or tingling of individual muscles. Others are briefly “as if stepping away” (absent). In the worst case, it leads to an uncontrolled seizure of the whole body and to a short unconsciousness.

Epilepsy: definition

According to the International League Against Epilepsy (ILAE), epilepsy is diagnosed in the following cases:

• There are at least two epileptic seizures more than 24 hours apart. Most of these seizures come “from nowhere” (unprovoked seizures). On the other hand, triggers for seizures can be detected in more rare forms of epilepsy, such as light stimuli, sounds or warm water (reflex attacks).
• Although there is only a single unprovoked attack or reflex attack, the probability of further seizures over the next ten years is at least 60 percent. It is just as big as the general risk of relapse after two unrequested seizures.
• There is a so-called epilepsy syndrome, for example, the Lennox-Gastaut syndrome (LGS). Epilepsy syndromes are diagnosed on the basis of specific findings, such as type of seizure, electrical brain activity (EEG), the result of imaging examinations, and the age of onset.

From this “real” epilepsy you have to call so-called opportunity seizures differ. These are single epileptic seizures that can occur in the course of various diseases. As soon as the acute illness subsides, these occasional cramps also disappear. An example of this are febrile convulsions: These epileptic seizures occur in connection with fever, especially in young children. There are no indications of an infection of the brain or any other specific cause.

In addition, occasional cramps, for example, in severe circulatory disorders, poisoning (with drugs, heavy metals), inflammation (such as meningitis = meningitis), concussion or metabolic disorders occur.

Epilepsy: frequency

In industrialized countries such as Germany, between five and nine out of every 1,000 people are affected by epilepsy. Every year, about 40 to 70 out of every 100,000 people become ill. The highest risk of disease is in childhood and beyond the 50th to 60th year of life. However, epilepsy can basically occur at any age.

In general, the risk of developing epilepsy over the course of life is currently around three to four percent – and rising as the proportion of older people in the population increases.

Epilepsy forms

There are many different forms and manifestations of epilepsy. The divisions in the literature, however, vary. A commonly used (rough) classification looks like this:

• generalized epilepsy and epilepsy syndromes: Here the seizures capture the entire brain. Depending on the nature of the seizure, generalized seizures are further subdivided, for example into tonic seizure (cramping and stiffening limbs), clonic seizure (slow twitching of large muscle groups) or tonic-clonic seizure (“grand mal”).
• focal epilepsy and epilepsy syndromes: Here the seizures are limited to a limited brain area. Its function depends on the symptoms of the seizure. Possible, for example, twitching of the arm (motor attack) or visual changes (visual attack). In addition, epilepsy can begin focal, but then spread to the entire brain. This results in a generalized seizure.

In addition to these two major groups of epilepsies, there are also attacks with unclear onset and unclassifiable epileptic seizures. Read more about the different types of epilepsy seizures in the article Epileptic seizure.

Epileptical attack

In an epileptic seizure, either the whole brain (generalized seizure) or a limited brain area (focal seizure) is suddenly overly active. The whole often takes only a few seconds, sometimes a little longer. As a rule, an epileptic seizure is over after two minutes at the latest.

An epileptic seizure is often followed by an after-phase: although the brain cells no longer discharge electrically morbidly, abnormalities can still appear for up to several hours. These include, for example, a disturbance of attention, speech disorders, memory disorders or aggressive states.

Sometimes, after an epileptic seizure, people are fully restored after just a few minutes.

Read more about the course and characteristics of epileptic seizures in the article Epileptic seizure.

First aid

An epileptic seizure can be disturbing for outsiders. In most cases, however, it is not dangerous and ends on its own within a few minutes. If you are experiencing an epileptic seizure, you should follow these rules to help the patient:

• Keep Calm!
• Do not leave the patient alone, calm him down!
• Protect the patient from injury!
• Do not hold the patient!

For more information on first aid for an epileptic seizure, read the text “Epileptic Seizure: First Aid”.

Epilepsy in children

Epilepsy often occurs in childhood or adolescence. It is one of the most common diseases of the central nervous system in this age group. In Germany and other industrialized countries, about 50 out of every 100,000 children develop new epilepsy each year.

With the regular intake of medication can usually prevent further epileptic seizures in the young patients. Also important is a healthy lifestyle: If the epileptic seizures are “triggered” by certain triggers (such as lack of sleep, flickering light, certain sounds, etc.), these should be avoided as far as possible.

Overall, epilepsy in children is treatable in many cases. And the concern of many parents that epilepsy could affect the development of their child is usually unfounded.

You can read all important information in the article Epilepsy in children.

Epilepsy: symptoms

The exact symptoms of epilepsy depend on the form of the disease and the severity of epileptic seizures. For example, the mildest variant of a generalized seizure exists only in a brief mental “absence” (absence): the patient has “stepped away” for a short time.

At the other end of the scale, for example, there is the “big bang” (grand mal): First, the whole body becomes tense and stiffened (tonic phase). Then he begins to twitch uncontrollably (clonic phase). During such a tonic-clonic seizure, the patients are unconscious.

Another severe form of epilepsy is the so-called “Status epilepticus”: This is an epileptic seizure that lasts more than five minutes. Sometimes there is a series of seizures in quick succession without the patient regaining full consciousness in between. Such situations are emergencies that need to be treated as soon as possible by the ambulance!

Read more about the different symptoms and manifestations of epilepsy in the article Epileptic seizure.

Epilepsy: cause and risk factors

The onset of epilepsy is diverse and complex. Often, the exact disease development remains in the dark. Thus, in some cases, despite modern investigation methods, no specific cause for epileptic seizures can be identified, even though there is clear evidence of a cause in the brain. Then one speaks of unexplained (cryptogenic) epilepsy.

Sometimes one can not even explain why a patient experiences epileptic seizures. There are no indications of the cause, such as pathological changes in the brain or metabolic disorders. That’s what doctors call one idiopathic epilepsy.

Recently, however, this term (at least partially) by “genetic epilepsyFor many sufferers, genetic alterations, such as neurotransmitters, presumably or demonstrably exist, such genetic alterations can, according to experts, contribute to the onset of epilepsy, which is why it is usually not hereditary usually only the susceptibility to seizures continues to their children.The disease occurs only when external factors are added (such as sleep deprivation or hormonal changes).

Finally, there are another group of epilepsies in terms of the causes: for example, structural changes in the brain or underlying diseases can be identified as the cause of epileptic seizures in many patients. That’s what medical professionals call symptomatic epilepsy or, according to recent proposals, as structural / metabolic epilepsy, These include, for example, epileptic seizures based on congenital malformations of the brain or brain damage acquired at birth. Also craniocerebral trauma, brain tumors, stroke, inflammation of the brain (encephalitis) or the meninges (meningitis) as well as metabolic disorders (diabetes, thyroid diseases, etc.) defective here are among the possible causes of epilepsy.

Sometimes epilepsy is genetically as well as structurally / metabolically conditioned. For example, in some people with a genetic susceptibility to epileptic seizures, epileptic seizures are triggered by stroke, meningitis, intoxication, or other specific disease.

Epilepsy: examinations and diagnosis

Anyone who first experiences an epileptic seizure should be examined by a doctor. He can tell if it really is epilepsy or if the seizure has other reasons. The first contact person is usually the family doctor. If necessary, he will refer the patient to a specialist in neuropathic diseases.

first meeting

The first step on the way to diagnosing “epilepsy” is the Survey of the medical history (Anamnesis): To do this, the doctor talks in detail with the patient (if old enough) and accompanying persons (such as parents, partners). He describes the epileptic seizure in detail. Here it is advantageous if people are in the conversation, who have observed the seizure. The affected person often can not remember it well. Based on the descriptions, the doctor can assess the seizure picture (seizure history).

Sometimes there are photos or video recordings of the epileptic seizure. They can be very helpful to the doctor, especially when focusing on the patient’s face. The eyes are important seizure symptoms and help to distinguish an epileptic seizure from other seizures.

As part of the conversation, the doctor also asks about possible triggers of the attack (such as flickering light), possible underlying diseases and known cases of epilepsy in the relationship.

investigations

After the conversation follows one physical examination, Also the Condition of the nervous system is examined by various tests and examinations (neurological examination). This includes one Measurement of brain waves (Electroencephalography, EEG): Sometimes epilepsy can be detected by means of typical curve changes in the EEG. However, the epilepsy EEG can also be inconspicuous.

Very important in the clarification of an epileptic seizure is the magnetic Resonance Imaging (MRI or magnetic resonance imaging). This creates detailed cross-sectional images of the brain. The doctor can then detect any damage or malformations of the brain as a possible cause of the seizure.

In addition to the MRI is sometimes also a Computed tomogram of the skull (CCT). Especially in the acute phase (shortly after the seizure), computed tomography can help, for example, to detect cerebral hemorrhage as a trigger of the seizure.

In suspected encephalitis (encephalitis) or another underlying disease as the cause of epileptic seizure can laboratory tests Bring clarity. Thus, a blood test can give indications of inflammation or metabolic changes. If the doctor suspects drug use as the trigger of the seizure, appropriate blood tests are made.

In addition, the doctor can use a fine hollow needle from the spinal canal to take a sample of the cerebrospinal fluid (CSF or lumbar puncture). The analysis in the laboratory helps, for example, to detect or exclude brain or meningitis (encephalitis, meningitis) or a brain tumor.

In individual cases, further investigations may be necessary, for example to rule out other types of seizures or to clarify the suspicion of certain underlying diseases.

Epilepsy: treatment

The long-term treatment of epilepsy patients usually takes over a resident neurologist or pediatric neurologist. Sometimes it may be wise to contact an outpatient clinic or clinic specializing in epilepsy treatment (Epilepsy, Epilepsy Outpatient Clinic, Epilepsy Center). For example, if the diagnosis is unclear, epileptic seizures occur despite treatment, or there are specific problems associated with epilepsy.

Epilepsy: Therapy not always necessary

Did anyone (so far) just an epileptic seizure, can often be waited with the treatment. In some cases, it is sufficient for patients to avoid known triggers (such as loud music, flickering lights, computer games) and adopt a healthy lifestyle. These include, among other things, regular living, well-regulated and adequate sleep, and abstinence from alcohol.

In addition, patients should be extra cautious in situations where a sudden onset can have dire consequences. This applies, for example, to extreme sports, scaffolding work and handling heavy machinery. If possible, epileptics should avoid such situations.

At a structural / metabolic epilepsy The doctor initially treats the underlying disease (meningitis, diabetes, liver disease, etc.). Again, patients should avoid all possible factors that can trigger an epileptic seizure.

Sometimes, even after a single attack, treatment with epilepsy drugs is advisable. That may be the case, for example, when the patient enters high risk of further seizures Has. Even with certain types of epilepsy (such as Lennox-Gastaut syndrome, temporal lobe epilepsy, etc.), the drug therapy should begin immediately.

In general, medics advise at the latest after the second attack to an epilepsy treatment.

In general, it always depends on the Situations of the individual patient on when and how epilepsy is treated. For example, some patients only have an epileptic seizure every few years. Others have more frequent seizures, but they feel that they are less stressful (for example, only short “dropouts” = absences). Then the doctor will weigh the benefits and risks of epilepsy treatment very carefully. He also takes into account the patient’s willingness to follow medical advice (adherence = adherence). Prescribing medication does not make much sense if the patient does not take it (regularly).

Medication

For most epilepsy patients, drug treatment helps to lead an attack-free life. Are used so-called antiepileptics, They inhibit the excessive activity of nerve cells in the brain. This can reduce the risk of seizures. That is why we speak of anticonvulsants (= anticonvulsants). But the drugs can not do anything about the cause of epilepsy. This means that anti-epileptic drugs only have a symptomatic effect but can not cure epilepsy.

As antiepileptic drugs, various drugs are used, for example levetiracetam or valproic acid. The doctor will choose an active substance for each patient, which probably works best in this case. The type of seizure or the form of epilepsy plays an important role here. In addition, the doctor takes into account when choosing the antiepileptic drug and its dosage possible side effects. The goal is that the treatment prevents (or at least reduces) the number of seizures. At the same time, the drug should cause no or only tolerable side effects.

As a rule, the doctor prescribes in epilepsy just a single antiepileptic (Monotherapy). If this medication does not produce the desired effect or causes severe side effects, the doctor may attempt to switch the patient to another drug. Sometimes several preparations have to be tried out until the individually “best” antiepileptic drug is found.

In some patients, epilepsy can not be adequately controlled with monotherapy. Then the doctor can two (or more) antiepileptics prescribe. Such a combination therapy is carefully planned and monitored. In general, the more different medicines someone uses, the more likely it can be unwanted interactions. The risk of side effects may also increase.

The epilepsy drugs will be often as a tablet, capsule or juice ingested. Some can also as Syringe, infusion or suppository be administered.

Antiepileptic drugs can only help if used regularly. So it’s very important to follow the doctor’s instructions exactly!

How long does it take to use antiepileptic drugs?

Be anti-epileptic drugs usually over several years ingested. If, thanks to treatment, epileptic seizures no longer occur for a long time, patients may in some cases in consultation with the doctor try that To discontinue medication, But that should not happen abruptly. Instead, the dosage should be gradually reduced as recommended by the physician.

In some patients, the epileptic seizures then return (sometimes even months or years later). Then the epilepsy drugs must be taken again. Other patients remain permanently seizure-free even after stopping the antiepileptic drugs. This can happen, for example, when the cause of the seizures (like meningitis = meningitis) has healed in the meantime.

This can not be predicted in individual cases. The attending physician can only estimate how high the seizure risk is without medication based on the individual situation of the patient. In some cases, epileptics must be prepared from the start to be comfortable with the medication lifelong need – for example, if a permanent brain damage is the epilepsy cause.

Never stop using your epilepsy medications on your own – it can be life threatening!

Surgery (epilepsy surgery)

In some patients, epilepsy is not sufficiently treatable with medication. If the seizures always start from a limited brain area (partial seizures), this may be the case Part of the brain surgically removed be (resection, resective operation). This can in many cases prevent future epileptic seizures.

Resective surgery is only possible under certain conditions. Thus, cutting out the relevant brain region must be relatively safe. In addition, it must not entail any unacceptable disadvantages for the patient, such as serious impairment of certain brain functions.

Resective brain surgery is mainly used in patients who develop epileptic seizures in the temporal lobes of the brain.

Rarely, other surgical procedures are performed in severe epilepsy. This can be the case, for example, in patients who often experience severe falls – epileptic seizures that can cause them to fall in a flash and possibly injure themselves severely. Here can be a so-called Barred section (callosotomy) The surgeon cuts all or part of the so-called bar (corpus callosum) in the brain. This is the connector between the right and left hemispheres. This procedure can significantly reduce the number of falls. As a side effect but threaten cognitive impairment. Therefore, the benefits and risks of Kallosotomy must be weighed very carefully.

stimulation methods

In addition to surgery, so-called stimulation methods come into question when drugs in epilepsy do not work sufficiently. Certain structures in the brain or those leading to it (vagus nerve) are stimulated with low current intensity. This can help against epileptic seizures.

For use in epilepsy come various procedures. The most widespread is the Vagus nerve stimulation (VNS): The patient is implanted with a small, battery-powered device under the skin below the left collarbone. It is a type of pacemaker that is connected to the left vagus nerve at the neck via a cable that also runs under the skin. At intervals (for example, every five minutes for 30 seconds) there are light surges to the nerve. This can significantly reduce the frequency of epileptic seizures. However, some patients may take a few months to get this effect.

During the current impulses, some patients experience hoarseness, coughing or discomfort (“buzzing” in the body).

Vagus nerve stimulation can also positively influence co-existing depression.

Another stimulation method is the Deep brain stimulation: The patient is implanted small electrodes at specific locations in the brain. They stimulate the nerve tissue with electrical impulses. As a result, the number of seizures in many patients drops. Possible side effects include depression and memory problems. The deep brain stimulation should only be done in specialized centers. In Germany, it is not yet widely used as a method of epilepsy treatment. Much more often, the procedure is used in Parkinson’s patients.

Treatment in status epilepticus

When someone suffers from status epilepticus, bystanders should Call the emergency doctor immediately (Tel. 112) – there is danger to life! The patient first gets a sedative (benzodiazepine). It may also be administered by lay people when the epileptic carries the emergency medicine: it is either placed in a cheek (buccal tablet) or introduced as a cream through a small tube into the patient’s anus. The arrived ambulance can also administer the tranquilizer as a syringe into a vein. Then he brings the patient quickly to a hospital. There the treatment is continued.

If the status epilepticus still can not be stopped after 30 to 60 minutes, many patients will be anesthetized and artificially ventilated.

Epilepsy: history and prognosis

The course and prognosis of epilepsy depend on the type of seizure and the form of epilepsy. There are also differences from patient to patient. In general, about half of the patients remain in a single epileptic seizure. The other half sooner or later has another seizure. Thereafter, the seizure risk continues to increase: About seven out of ten patients who have had two attacks, get another epileptic seizure within a year.

Particularly at risk are people in whom epilepsy is caused by an underlying disease such as a brain disease: The risk of further seizures is about twice as high as in patients whose epilepsy is based on a genetic predisposition or has no known cause.

Avoid seizures

With the correct and consistent treatment In most cases, further epileptic seizures can be avoided. Patients can do even more to prevent seizures. So many sufferers of adequate sleep with regular sleep times (Sleep hygiene).

Sometimes epileptic seizures are caused by certain trigger provoked. Then patients should avoid them as much as possible. But that works only if you know the trigger. A seizure calendar can help: The patient records the day, time and type of each seizure together with the current medication. In addition, accompanying circumstances and possible triggers are recorded, such as computer work, loud music, alcohol consumption, sleep deprivation, emotional stress or the sight of certain optical patterns (such as checkerboard patterns). This helps physician and patient to identify the trigger factors.

Living with epilepsy

If epilepsy is well controlled by treatment, you can lead a largely normal life as a patient. But you should have some Precautions heed in order to avoid dangerous situations:

• Do not use electric knives or cutting machines.
• Do without bathing and shower rather. Never go swimming unaccompanied. In epileptics death by drowning is about 20 times more common than in the normal population!
• Always ride only with a helmet bike and prefer low-traffic routes.
• Choose a low bed (danger of falling).
• Secure sharp edges in the apartment.
• Keep a safe distance to roads and waters.
• Do not lock up. Instead, use a “busy” sign on the toilet.
• Do not smoke in bed!

Whether you as the epilepsy patient the driver’s license make or keep, depends on whether you are fit to drive. Ask your neurologist for advice. He is best at assessing the risk of seizure.

Epilepsy patients who sit behind the wheel even though they are unfit to drive endanger themselves and others! In addition, they risk their insurance coverage.

Most Professions and sports are generally also possible for epileptics – especially when epileptic seizures no longer occur due to therapy. In individual cases, the attending physician can best estimate whether the patient should do without a specific activity or sport better. He may also recommend special precautions.

Epilepsy: Contraception & Infertility

Some epilepsy drugs weaken the effect of birth control pills from. Conversely, the pill may affect the effectiveness of some antiepileptic drugs. Girls and women with epilepsy should discuss such interactions with the attending physician. He may recommend another contraceptive.

If women with epilepsy want to have offspring, they should discuss this with their neurologist – best, even before they get pregnant. Maybe in pregnancy the adapted drug epilepsy treatment become. In fact, anticonvulsants may interfere with the development of the child or cause birth defects at higher doses (up to the 12th week of pregnancy). This risk is also higher in a combination therapy (several antiepileptic drugs) than in a monotherapy (treatment with a single antiepileptic drug). This will be considered by the doctor in the treatment planning.

A special feature also applies to Folic acid supplementsrecommended to all women in pregnancy: Some antiepileptic drugs lower folic acid levels in the body. Therefore, epileptics may take the folic acid in higher doses.

If there is an epileptic seizure in pregnancy, there is usually no particular cause for concern: The unborn child generally does not suffer from the seizure – unless it is a long-lasting, generalized seizure, or the expectant mother injured severely. But that happens only very rarely. Ever are Seizures during pregnancy are not very commonAbout two-thirds of all epileptic women remain seizure-free for the entire nine months. Besides, most women bring with them epilepsy healthy children to the world.

Additional information

Books

• Epilepsy. 100 questions that you never dared to ask (Günter Krämer and Anja Daniel-Zeipelt, 2012, Hippocampus)
• Epilepsie: Die Krankheit erkennen, verstehen und gut damit leben (Günter Krämer, 2013, Trias)
• Mein schönes Leben mit Epilepsie: Ein Ratgeber für Betroffene und Angehörige (Silke Meinhardt, 2016, ersa Verlag)

guidelines

• Leitlinie “Erster epileptischer Anfall und Epilepsien im Erwachsenenalter” der Kommission Leitlinien der Deutschen Gesellschaft für Neurologie (Stand: 2017)

Selbsthilfe

• Deutsche Epilepsievereinigung
• Epilespie Bundes-Elternverband