Epilepsy: main steps in testing and diagnosis

We are indeed living very exciting times. In no other period in history have epilepsy specialists and researchers been equipped as well to tackle the problem of Epilepsy. With the advent of new technologies such as Magnetic Resonance Imaging (MRI), video EEG monitoring, Positron Emission Tomography (PET), and Magnetoencephalography (MEG) to mention a few, specialists can better solve the so-called inverse problem.

So what is the inverse problem? To answer this question we must first understand what is epilepsy, and to understand what Epilepsy is we must know what a seizure is. A seizure is a brief change in behavior associated with abnormal electrical activity in the brain. Epilepsy is simply a predisposition to have seizures and its consequences, be it depression, loss of wages, etc. To be an epileptic by definition one must have more than one unprovoked seizure (not caused by alcohol, low blood sugar, or other external factors), the exception being status epilepticus, which we will discuss at some other point.

You are probably asking yourself now, so what brings on seizures? Well, it depends on the age of onset and other factors. What we know from epidemiological studies is that people in the extremes of life are most vulnerable. In infants, for example, we commonly see developmental anomalies, infections, and trauma as frequent causes of seizures, while neurodegenerative processes (i.e. Alzheimer’s disease), stroke, and brain tumors are the most frequent culprits in the elderly.

The doctor’s prognosis is somehow one of the most stressful events a patient undergoes right after being diagnosed with a life-threatening medical condition. While prognoses are not 100% accurate, the timeframe provided is carefully studied based on your condition and the symptoms you are showing. As for epilepsy, it is not a chronic ailment. Despite affecting the brain, people with epilepsy do not undergo degenerative conditions similar to what people with HIV/AIDS or cancer undergo. Prognosis of epilepsy is actually dependent on the consistency of medication, how often therapies are conducted, and if there are people who look after an epileptic to perform first aid during seizure attacks.

Well-known figures are said to have had epilepsy, like Socrates, Dostoevsky, Napoleon, and Joan of Arc. More recently, there is Prince and Neil Young. When asked about his epilepsy, Young said it was, “… just part of the landscape.”

The notion of epilepsy didn’t pop up until 18 years ago. This is because most of us have this equation in our heads: epilepsy = seizure = convulsions. The fact is many seizures are non-convulsive.

Do I have an epileptic condition?

During an EEG, they lay you down and cover your head with electrodes to measure brain wave activity. You relax, even sleep for about thirty minutes with ongoing interruptions for tests.

The results of the test may indicate there was something askew in the brain activity putting the symptoms patient described in a clearer light and allowing the “probable” to be removed.

This may give you some idea of the vagueness surrounding an individual’s epilepsy, at least as far as identifying it goes. We can know a lot about the condition; it gets dodgy when trying to understand or even recognize it in a particular circumstance. It also makes it possible to determine which type of epilepsy you have.

Not all seizures are created equal!

Seizures can be focal or generalized depending on whether they arise from a specific area in the brain that is affected, such as the Temporal lobe in the former, or from bilateral structures in the center of the brain called the Thalami in the latter. Clinically, a key feature that helps us distinguish focal from generalized seizures is the presence of a warning or aura in the former.

Therefore, people who experience focal seizures may present with varied symptoms that range from an overwhelming sensation of fear to flashing lights depending on the area of the brain that is affected. On the other hand, generalized seizures are thought to arise from the thalami and spread equally to both hemispheres leading to absences or staring spells, and generalized tonic-clonic seizures otherwise known as grand mal seizures, among others.

Does a person walk in a circle, consider non-existent objects, pronounce a text in an unknown language? These may be signs of a focal attack, the causes epilepsy of which may be completely unexpected events and phenomena. This type of seizure is difficult to diagnose without taking into account the full medical history.

Another way in which we can corroborate whether someone is having focal or generalized seizures is through an electroencephalogram (EEG). An EEG is a study that helps us evaluate brain wave activity for the presence of seizures. Electrodes are placed on the scalp these, in turn, are connected through wires to amplifiers that magnify the tiny electrical currents recorded from the brain. People with focal seizures have electrical discharges called sharp waves or spikes coming from a focal area in the brain, which like the ripples in a pond after throwing a stone leave their mark for us to see. With generalized epilepsy, we see what we call generalized spike and wave discharges, which unlike the epicenter of the ripples look more like a tsunami.

What should I remember during a visit to an epileptologist?

If you or your loved one has had a seizure, a correct diagnosis is essential. Excellent communication is key to successful diagnosis and future epilepsy treatment. Being an active participant in your office appointment helps you get the most accurate diagnosis possible.

1) List all your epilepsy symptoms in detail.

2) Be thorough when you discuss your condition and epilepsy treatment.

3) Let your neurologist/epileptologist know you want to be a partner in your healthcare.

4) When discussing your expectations, don’t be timid.

5) Listen carefully to what your neurologist/epileptologist says.

6) If you don’t understand your epilepsy diagnosis or treatment, ask questions.

Your neurologist/epileptologist will also review your medical history. Questions your neurologist/epileptologist may ask during your first visit are:

1) Did you have any complications at birth?

2) Have you ever had any head injuries?

3) Did you ever have any seizures with a high fever when you were a child?

4) Does anyone else in your family have seizures?

These are the most important questions for making the correct diagnosis and prescribing the optimal epilepsy cure. If you do not know the answers to any questions, try to find this information in your clinic or ask your close relatives.

Dr. Ali Elahi

This article is written by Dr. Ali Elahi, a specialist in neuromuscular disorders, certified by the American Board of Psychiatry and Neurology (ABPN). His expertise includes evaluation and treatment of patients with epilepsy, stroke, headache, neuromuscular disease, and cerebral palsy.He also manages neurological emergencies in the Intensive Care Units.

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