Disorders To Be Distinguished From Epilepsy

Before treatment with anticonvulsants begun, diagnosis of epilepsy must be as certain as possible. When treatment with anticonvulsants has started, and no improvement occurs at all, then the diagnosis of epilepsy should be considered.

The conditions that people often mistaken epileptic seizures for are; fainting attack and psychogenic (pseudo epileptic)
 A detailed medical history and clear witnessed account of the attacks are a must for differentiating these conditions.
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SYNCOPE (FAINTING)
 Syncope is much more common than epilepsy, and the main differences from epileptic seizures are shown in table 17.There is loss of consciousness due to a sudden decrease in the cerebral blood flow. Syncope may be divided further in three groups:

Reflex syncope (vasovagal syncope)

This is the most common type and includes simple fainting. Precipitating factors are anxiety, hunger,
or any unpleasant experience causing vagal nerve stimulation and reduced venous return. Standing at parades in warm weather (when venous pooling occurs in legs) is a common cause of fainting.

The onset is often gradual, with a feeling of faintness, nausea or dizziness. Blurring r blacking out of vision is often present before the patient slumps to the floor.
Loss of consciousness is short, and often there are some uncoordinated clonic jerks (
Causing the confusion with epileptic seizures).there is pallor and sweating and the pulse is slow.

Recovery is quick without confusion. Treatment is to increase the blood flow to the head by putting the head between the knees, or to lie down.

Cardiac syncope
This is caused by heart disease, disturbance of the heart’s rhythm or reduces cardiac output. The attacks can occur in any situation; in children it is often seen after exertion.
A prolonged ECG maybe necessary to make the correct diagnosi

Postural syncope
This occurs within seconds or minutes of assuming an upright position in patients, whose postral reflexes are impaired.
(Elderly people, diabetic patients or due to medication or alcohol)

Breath holding spells
These occur in infants and children between who cannot restrain their emotions. There is a sudden arrest
Of the respiration followed by cyanosis, unconsiousness and sometimes twitching lasting a few seconds.
The attack stops spontaneously and never results in brain damage.

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Drug Therapy

Living with epilepsy is never easy. Parents with Epileptic children need not give up medication as it is the only chance their loved ones to have a life almost normal to other kids. Stigmatization and diminished self-worth are few of the issues affecting Epilepsy victims and so, much love and care is paramount to ensure they too have a life, and a less complicated one too.
More than one seisure should have occured, and other causes for the convulsions excluded before regular treatment with anti Epileptic drugs (AEDs) is  begun.
The aim is to try and prevent furher seizures,either completely or to reduce their frequency and severity as much as possible with least possible side effects.

The medication should be given daily for many years, sometimes lifelong, sometimes  less. After a sesure free period with medication for atleast two years in idiopathic, and atleast three years in symptomatic epilepsy, the dosagemight be reduced gradually over many months, and if no relapse has occurred, dicontinued.

In cases where the epilepsy was very severe before treatment was started, or where there is a known brain lesion, it is better to continue the treatment for much longer, as the chance of relapse is then much greater.

Sudden Miscontinuation Effects.
A sudden discontinuation may lead to a dangerous status epilepticus. The treatment should be started with one drug only.Ideally, the choice of the drug depends on the type  of epilepsy and the seisure type.

In practice, however, it also depends on the availability and affordability of the drug.





As it is often difficult to know in the beginning which type of epilepsy there is, treatment is usually started according to the presenting seizure type. The most common are the generalised tonic clonic seizures(GTCS).

The main four AEDs are;

1. Phenobarbitone
2. Phenytoin
3. Carbamazepine
4. Valproate

If we are able to differenciate between primary and secondary tonic clonic seizures, then phenobarbitone is the drug of choice for the primary GTCS and phenytoin for the secondary GTCS, but all fournare effective and can be tried separately if necessary.

Guide To AEDs Administration

Inorder to start anticonvulsant drugs treatment in previously untreated patients, there are guiding principals one should observe:

• carefully establish diagnosis.
• start drug treatmment with one drug.
• start treatment with small dose.
• gradually increase dosage until complete seizure control.
• the aim of tratment is to achieve the lowest maintenance dose which results in complete seisure control
• a gradual introduction of an anticonvulsant can produce theraputic effects just as fast as a rapid initiation with large doses,but with fewer side effects.
• rapid increases of large doses may not improve seizure controll and may increase the risk of side effects.
• severe `intoxication` side effects appearing at the beginning of the treatment can indicated too rapid or too large dosage increases.
• if the initial drug treatment is not well tolerated, e.g. if side effects occur of if the maximum tolerated dose does not produce seizure controll,substitute the initial drug with another first line anticonvulsant.
• a second anticonvulsant  should be  added gradually at first, then slowly withdrawn.
• Incase of acute withdrawaal symptoms, e.g. reccurence of seizures, use DIAZEPAM as a control drug.
• Regular compliance is the key to successful seizure control, and counselling the patient is the most critical factor in compliance.

Side effects of AEDs

Phenobarbitone
Drowsiness especially during the first week of treatment, slowly disappearing, and only recurring when the dosage becomes high.
In some children ther might be a reduction in scholastic performance or changes in the behaviour, such as hyperactivity and sometimes aggressiveness.

Phenytoin

• drowsiness
• Gum hypertrophy
• Hirsutism
• ataxia
• Nystagmus

Besides these reversable cerebellar signs at  high dosage, it has  been suggested recently that a permanent cerebellar syndrom may also result from chronic therapy. If toxicity has appeared, the dosage should be ommitted for one day and then restarted on a lower level.
If at all possible, a change-over to another anticonvulsant could be made to prevent further misharps.

                                                   

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