Seizures: Types, Manifestations and Treatment

Introduction

Epilepsy is the malformation of the neurological character that may cause unprovoked seizures and changes in the behavior, cognitive perception and motor functions of people of all ages. It is the neurological disease from which people worldwide suffer because of epilepsy being a chronic disorder that anyone may have. It has many clinical features and may obtain heritable forms. Thus, it is imperative to be able to identify manifestations of types of seizures when they occur to assist the neurologist in proper treatment of these children.

Speaking about unprovoked seizures, one should remember that special treatment is required for children and adults – with the seizures causing motor dysfunctions, it is highly probable that a person having a seizure may physically hurt him- or herself. The consideration of this fact is highly relevant for children because of their incomplete understanding of the nature of the disorder, thus being at risk of corporal damage.

It is also notable that epilepsy and unprovoked seizures resulting from it may be caused by a set of conditions that do not necessarily include hereditary predisposition or preliminary having the disease. The seizures may be provoked by stress, by infection and other circumstances that are not directly connected with the genetic or biological predisposition, which puts a much larger category of people at risk of obtaining the disease. However, the precise information on the varied manifestations of seizures, their treatment modalities and classification may become essential not only for the correct treatment of children having this type of a disease but may also essentially assist in preventing the seizures and efficient treatment thereof. For this reason the study issue for the present paper is the multifaceted nature of seizures, their typology, manifestations and treatment means that may help in stipulating the type of a seizure the child is currently having in order to arrange medical care properly and create a guidance for those interested in obtaining as much information about the nature of epilepsy and seizures as possible.

Definition of Seizures

Seizures in their essence are the revelation of certain chronic or occasional disorders in the neurological system of a person caused by a set of factors. According to the definition of Adel K. Afifi and Ronald Arly Bergman (2005), Epilepsy is a common clinical condition characterized by recurrent paroxysmal attacks of motor, sensory, autonomic, or psychic symptoms and signs depending on the area of the brain involved. Epileptic seizures are triggered by synchronized discharges of a group of neurons in the cerebral cortex as a result of developmental abnormality, infection, trauma, tumor, metabolic derangement, or stroke.

Looking at seizures with children more precisely it becomes relevant to enumerate diseases that may arouse such manifestations. It is known that seizures may be sometimes caused by a virus, so it is important to investigate the cases in which seizures have the bacteriological, infectious origin. For example, such a pediatric infectious disease as congenital varicella syndrome causes a huge damage for the CNS with microcephaly, cortical atrophy, intrauterine encephalitis and seizures. One more grave disease is human herpes viruses (HHV) 6 and 7 that can infect almost all people in early childhood and arouse such consequences as undifferentiated febrile illness and roseola infantum. Thus, febrile seizures are stated to play a significant role in the formation of this disease (Barton et al., 2008).

Roseola has been associated with classic febrile seizures in infants and young children. Seizures typically occur in the pre-eruptive phase of illness. In one large, prospective study, HHV-6 accounted for 31% of first-time febrile seizures in children up to 2 years old, whereas 13% of children with HHV-6 primary infection developed seizures (Barton et al., 2008).

Acute post-infectious encephalitis is an unpredictable illness that can result in a full recovery without complications or otherwise can bring to the emergency of seizures and finally coma. Convulsions happen during seizures which may then become recurrent in the course of the disease (Barton et al., 2008).

Nipah and Hendra viruses that can be transferred to people from fruit bats of the pteropid bat species, dogs, cats, horses or pigs have also been proven to be instigators of seizures. There was only one case of recurrent seizures recorded for Hendra virus, but nipah virus is known to affect the CNS first of all and to cause multiple neurological complications. Seizures were registered for about a quarter of patients in cases of this virus infection (Barton et al., 2008).

Influenza A and B has proven to be a companion of seizures as well, having them as one of the common consequences accompanying the flow of the disease:

Febrile seizures have been observed in 19.5% of hospitalized patients with influenza A infection, with equal prevalence in male and female patients. In comparison with adenovirus or PIV, patients hospitalized with influenza A seem to be both at greater risk for febrile seizures… as well as for recurrent seizures during the same admission (Barton et al., 2008).

Other diseases that may cause seizures or that have seizures as a complication accompanying the course of the disease are: paralytic poliomyelitis, aseptic meningitis, West Nile Neuroinvasive Syndromes (that are statistically more often met with children), LAC encephalitis (children seem to be the most vulnerable group for having seizures – the statistics shows from 42% to 62% of cases: generalized, focal, partial, complex or status epilepticus) (Barton et al., 2008).

However, proceeding from the infectious nature of seizures to other existing causes it is necessary to remember that seizures are first of all manifestations of a certain neurological disorder or malformation. Seizures have been stated to be the direct symptom and manifestation of epilepsy. As it goes about children in the present work, it is notable that children are a risk group; this neurological disorder (epilepsy) is recorded with about 1% of the pediatric age, thus increasing the risk enormously (Sarnat et al., 2007). The majority of cases of epilepsy and seizures in childhood, if treated correctly, have a positive progress for recovery for the future; nevertheless, there is still a group of children with incurable seizures that may produce a wide range of grave consequences for their health:

Intractable epilepsy places the child at risk of physical injury, learning and cognitive disability, social embarrassment, inability to drive, and will have a major impact on family life and the development of personal relationships (Sarnat et al., 2007).

There is much information about the probable causes of seizures, as they are the consequences of different diseases and states of health. However, the study of seizures and their manifestations with children is highly important because of the statistics putting children at the highest risk of their development. According to the information provided by the studies of seizures and their probable epidemiology in the acute care unit it was found out that elderly people are very probable to develop seizures, thus getting in the risk group, but children “in the first year of life have the highest incidence of SE of any age group studied” (Hall et al., 2005). Consequently, adequate attention should be paid to that fact in the course of studying seizures, as accumulated information about seizures with children may help parents and medical professionals define the problem in a timely manner and provide children with more efficient clinical care.

Types of Seizures

Generally, a seizure is accompanied by “abnormal cortical neuronal discharge, which may lead to altered consciousness” (Yarnell et al., 2007). The risk is increased with people who have a low seizure threshold. The first known type is isolated seizure – it does not necessarily presuppose the disease because of a single occurrence. In order to define epilepsy only recurrent seizures may become relevant. The diagnosis of epilepsy requires at least two unprovoked seizures, thus showing the spontaneous and recurrent tendency (Yarnell et al, 2007).

Classification and typology of seizures was conducted by the International League Against Epilepsy and as a result two main types of seizures were worked out. The first type is the primary or generalized seizure that involves the malfunction of both cerebral hemispheres and gives the result of loss of consciousness, motor and sensory symptoms and partial, focal effect on only one part of the brain. Sometimes the primary seizure does not involve problems with consciousness (Yarnell et al., 2007).

Secondary generalized seizures are partial, but then they spread and become generalized. Electroencephalograph (EEG) is usually used to indicate the measure of seizures’ effect and the type of a seizure because they introduce changes in the person’s EEG indicators (Yarnell et al., 2007).

Shorvon et al. (2004) provide a more detailed classification of seizures including partial seizures (simple partial seizures, complex partial seizures, partial seizures evolving to secondary generalized seizures: tonic-clonic, tonic and clonic), generalized seizures (absence seizures, atypical absences, myoclonic seizures, clonic, tonic and atonic seizures), and unclassified epileptic seizures (Shorvon et al., 2004).

Examining the mentioned types of seizures the authors have formulated the following characteristics thereof. Partial seizures may occur with motor signs including focal motor without march, focal motor with march (jacksonian), versive, postural and phonatory motor signs (vocalization or arrest of speech). Simple partial seizures can also be with somatosensory or special-sensory symptoms (simple hallucinations) including somatosensory, visual, auditory, olfactory, gustatory and vertiginous symptoms. There can also be witnessed autonomic symptoms or signs (including epigastric sensation, pallor, sweating, piloerection and papillary dilatation) and psychic symptoms (disturbance of higher cerebral function). The authors mention that these symptoms rarely occur without impairment of consciousness and are more common during complex partial seizures. They include dysphasic, dysmnesic, cognitive, affective symptoms, illusions and structures hallucinations (Shorvon et al., 2004).

The next type to be investigated is complex partial seizures. They are accompanied with the simple partial onset followed by impairment of consciousness (with simple partial features followed by impaired consciousness and with automatisms) and with impairment of consciousness at onset (with impairment of consciousness only and with automatisms). Partial seizures evolving to secondary generalized seizures are divided into simple partial seizures (evolving to generalized seizures), complex partial seizures (evolving to generalized seizures) and simple partial seizures evolving to complex partial seizures and further evolving to generalized seizures (Shorvon et al., 2004).

Proceeding to generalized seizures, the first type (absence seizures) has the following accompanying symptoms: impairment of consciousness only, with mild clonic components, with atomic components, with tonic components, with automatisms, with autonomic components. Atypical absence is characterized by changes in tone that are more pronounced than in absence seizures and the onset and/or cessation that is not abrupt. Myoclonic may be single or multiple (Shorvon et al., 2004).

It is also relevant to include another scale of classification of seizures outlined by Shorvon et al. (2004) – it is the international classification of epilepsies and epileptic syndromes:

1. Localization-related (focal, local, partial epilepsies and syndromes).

1.1. Idiopathic (with age-related onset)

• benign childhood epilepsy with centrotemporal spike
• childhood epilepsy with occipital paroxysms
• primary reading epilepsy

1.2. Symptomatic epilepsy

• chronic epilepsia partialis continua of childhood (Kojewnikow’s syndrome)
• syndromes characterized by seizures with specific modes of precipitation

1.3. Cryptogenic

2. Generalized epilepsies and syndromes

2.1. Idiopathic (with age-related onset – listed in order of age)

• benign neonatal familial convulsions
• benign neonatal convulsions
• benign myoclonic epilepsy in infancy
• childhood absence epilepsy (pyknolepsy)
• juvenile myoclonic epilepsy (impulsive petit mal)
• epilepsy with grand mal (GTCS) seizures on awakening
• other generalized idiopathic epilepsies not defined above
• epilepsies with seizures precipitated by specific models of activation

2.2.Cryptogenic or symptomatic (in order of age)

• West syndrome (infantile spasms, Blitz-Nick-Salaam-Kraempfe)
• Lennox-Gastaut syndrome
• epilepsy with myoclonic-astatic seizures
• epilepsy with myoclonic absences

2.3. Symptomatic

2.3.1. Non-specific aetiology

• early myoclonic encephalopathy
• early infantile epileptic encephalopathy with suppression-burst
• other symptomatic generalized epilepsies not defined above

2.3.2. Specific syndromes

• epileptic seizure may complicate many disease states

3. Epilepsies and syndromes undetermined whether focal or generalized

3.1. With both generalized an focal seizures

• neonatal seizures
• severe myoclonic epilepsy in infancy
• epilepsy with continuous spike-waves during slow-wave sleep
• acquired epileptic aphasia (Landau-Kleffner)
• other undetermined epilepsies not defined above

3.2. Without unequivocal generalized or focal features. All cases with generalized tonic-clonic seizures in which clinical and EEG findings do not permit classification as clearly generalized or localization-related such as in many cases of sleep-grand mal (GTCS) are considered not to have unequivocal generalized or focal features.

4. Special syndromes.

4.1. Situation-related seizures (Gelegenheitsanfalle)

• febrile convulsions
• isolated seizures or isolated status epilepticus
• seizures occurring only when there is an acute metabolic or toxic event due to factors such as alcohol, drugs, eclampsia, non-ketotic hyperglycaemia.

Note: from Shorvon et al. (2004). The Treatment of Epilepsy.

Manifestations of Seizures

The most important issue in the explanation of manifestations of seizures is to understand the initial reason causing them. It is stated that the main trigger of a seizure is a number of abnormal neurons that perform the malfunction and result in the neurological dysfunction of the brain:

Epileptiform discharge in a large group of neurons can be triggered by a small group of abnormal cells that generate bursting behavior. The most dramatic examples of abnormal neurons in cortical dysplasia are the ‘balloon cell’, characteristic of tuberous sclerosis, which stains positively for markers of both neurons and glia, and has multiple ‘dendritic trees’ that show little orientation specificity, and the ‘giant cell’, which is often found together with balloon cells in Taylor-type focal dysplasia (Sarnat et al., 2007).

The result of cortical dysplasia is the cortical circuitry dysfunction and consequently – the hyper-innervation of certain cortical zones, added to the decreased number of inhibitory neurons in and around dysplastic lesions, generally contributing to the overall hyperexcitability (Sarnat et al., 2007).

Winner et al. (2008) have compared the manifestations of migraine and epilepsy to indicate their interrelations and connection. Certain findings of their research may be highly relevant for the present paper. The scientists state that one of major manifestations of epilepsy is headache, which occurs before or after the seizure but which is often neglected because of a much more serious effect of other seizure manifestations. They have also found out certain manifestations typical solely for the epileptic seizures:

Several epilepsy syndromes may have features of either autonomic or sensorimotor phenomenon similar to migraine. Abdominal epilepsy, or epilepsy from insular regions, may be associated with significant gastrointestinal convulsions. Panayiotopoulos syndrome, specifically, is associated with events of vomiting and eye deviation without convulsions in a child typically aged 5. children with benign rolandic epilepsy (i.e. benign epilepsy with centrotemporal spikes) may have a postictal weakness of one arm in a manner similar to that of hemiplegic migraine (Winner et al., 2008).

Simon D. Shorvon also investigated a set of characteristics of seizures related to the age of patients and found out that the difference in manifestations was evident. Neonatal seizures are more relevant for the present paper, they are outlined as follows:

Clinical signs are necessarily confined to motor features and are usually focal or multifocal, reflecting the immature synaptic connections in the neonatal brain. The EEG changes are variable and non-specific. Seizures can take a form of tonic attacks, clonic seizures unilateral focal seizures, electrographic seizures without overt clinical changes and so-called subtle seizures. The seizures can have mild or atypical features such as grimacing, staring, eye movements, posturing or pedaling movements (Shorvon, 2005).

Treatment Modalities

The treatment of seizures is conducted with the help of various anti-epilepsy medicines (AEM), so it is necessary to carefully guide the treatment of a patient who already takes these medicines but continues having seizures. Medications are really specialized and may be non-adjustable to the individual health characteristics of the person; over-dosage is also an undesirable and even dangerous for health perspective. Thus, it is necessary to conduct treatment carefully and consider all relevant circumstances.

Treatment of epilepsy is highly specific and has a number of aims. As outlined by Simon D. Shorvon (2005), they are the following:

• seizure control (the usage of drugs controlling the seizures has been proved to be extremely efficient, showing a much higher rate of remissions and the improvement of the state of health of patients with epilepsy; however, it is very important to design the treatment according to the type of seizures the patient has and to the extent of severity of the disease to fit the treatment scheme to the individual situation – otherwise the treatment may cause undesired complications or side effects or, what is worse, not achieve its primary aim);
• avoidance of side-effects (they may be of different types: immunologically determined idiosyncratic reactions that are rare but can be at times severe and life-threatening; dose-related reversible side-effects depending on the individual profile of the patient that are usually short-term and mild; long-term irreversible side-effects that may occur in case of intensive long-term treatment with the usage of high doses of medications; and teratogenicity);
• avoidance of social consequences of epilepsy and secondary handicap (the assistance of the doctor in the choice of medication and considerations of a broader sense than only hospitalization treatment should also take an important place in the process of treatment, since the patient also needs to accommodate to the normal social life again, hence there is a strong need to plan treatment and other issues jointly by the doctor and the patient);
• suppression of subclinical epileptic activity (the essence of this activity is in the necessity to suppress not only seizures by the medication but also the EEG changes, which may require other types of treatment which nevertheless should be still tailored according to the patient’s individual profile);
• reduction of mortality and morbidity;
• prevention of epileptogenesis (the point concerns the considerations over the period of time for which the treatment should be taken because of the proven statistics of prophylactic treatment being not efficient and the ability to suppress seizures being only contextual);
• improving quality of life (the overall aim of the treatment should be suppressing seizures thus helping the individual function normally in the social system, to work and to perform routine activities etc., thus the treatment should suit the needs of the patient as much as possible) (Shorvon, 2005).

Thus, it becomes clear that treatment of epilepsy bears not only the medical or, to be more precise, clinical character, but it is a broader notion with a much broader set of aims. The person who has epilepsy is becoming an inadequate member of society; this happens either because of the bias of common public concerning the abnormal behavior noticed in the course of seizures, or simply because of the person ill with epilepsy being unable to perform his or her ordinary tasks and live a normal life in the society. Anyway, no matter what reasons for the acquired abnormality are, still the person who has epilepsy needs rehabilitation if he or she managed to get cured of the disease successfully. Or, in another sense, if the person still remains with the illness through his or her life, he or she has to learn to function with the abnormalities and continue living among other people not having the disease, which is very hard, taking into consideration the unexpectedness of seizures and their flow. For this reason treatment has to include an individual factor – the doctor together with the managing personnel, with the family and personal consultants have to work hard on the removal of shock and discontent, maybe even shame from the life of the patient in order to help him or her to adjust to the life complicated with the obtained illness.

Defining the treatment aims, it is necessary to find out what kinds of medicines are generally used to treat seizures. According to the information listed by Devinsky et al. (2005), the modern spectrum of drugs used to treat epilepsy is as follows:

acetazolamide, barbiturates, benzodiazepines [clonazepam, clobazam (not FDA-approved), clorazepate, lorazepam, valium] carbamazepine, ethosuximide, felbamate (serious risks limit its use), gabapentin, leveticetam, lamotrigine, methsuximide, oxcarbazepine, phenotyn, primidone, tiagabine, topiramate, vigabartin (not FDA_approved; retinal toxicity limits its use), and zonisamide.

The authors also indicate that there are certain kinds of treatment designed for those who are not susceptible to medical treatment and they are vagus nerve stimulation and epilepsy surgery (Devinsky et al., 2005). However, medications used in treatment of epilepsy may be at times inefficient and result in continuation of epileptic seizures. If such a situation takes place, the disease is called intractable epilepsy.

Intractable epilepsy can be defined as seizures which have not been completely controlled with AEMs one year after onset, despite accurate diagnosis and carefully monitored treatment. Once intractable, there is a low probability of remission. Predictors of intractability include the presence of partial seizures, structural abnormalities on imaging studies, and abnormalities on the neurological examination. If a person continues to have seizures in spite of adequate treatment with AEMs, surgical or other options should be considered (Burnham et al., 2001).

Conclusion

Seizures are a manifestation of other illnesses that may be of different nature, both infectious and hereditary – they represent unprovoked motor and neurological malfunctions of the body sometimes accompanied with loss of consciousness, hallucinations and motor impairment. The manifestations of seizures are highly varied; there are a huge number of classifications of seizures depending on which part of the brain is affected: one or both. The long-lasting research in the sphere of neurological function of the human brain shows that the initial reason instigating the seizure of any type is the existence of abnormal neurons that damage the normal cortical circuitry and bring about the whole set of accompanying symptoms. The nature of action of these neurons is still not completely researched; however, much has been understood in the result of this discovery.

There has been much done to establish efficient treatment methods for epilepsy and all kinds of seizures known in the contemporary medicine. The interrelation of the level of risk to obtain epilepsy and the age of patients has also been established – it is known now that the highest risk groups are elderly people and infants. The fact that this disease is mostly inheritable adds many people to the risk group even if the initial signs and symptoms of epilepsy, as well as the seizures in the most vulnerable age, have not been observed. This is why separate attention is now being paid to the risk groups, and much research is being held with the purpose of finding out the initial launchers of the disease as well as working out the most varied set of ways to prevent the illness from evolving.

Despite the existing wide range of treatment modalities the usage of many drugs is restricted and dangerous; besides there are patients on whom the medical treatment does not produce any effect. Besides, it is notable that a number of people are not susceptible to treatment because of some individual predisposition, as well as many people experience continuous seizures and other manifestations of the disease in a variety of implications despite any kind of taken treatment. This fact puts into question the existing set of treatment facilities and methods; nevertheless, it is clear that the positive effect produced on a comparatively larger group of patients still manifests the efficiency of the existing way of treatment of the disease.

As a result of these findings, a set of alternative measures to control seizures and to assist patients with seizures has been created and is being successfully implemented nowadays. However, it is essential to keep in mind all possible effects from the drugs prescribed in the course of epilepsy treatment so that to tailor the treatment scheme to the individual needs of the patient.

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