Even as experts around the world come together to improve their understanding of complex diseases, the challenges presented by some can be confounding. In untangling the complications binding these ailments, healthcare professionals have accepted that there will always be something left to be discovered about them.
Epilepsy is one such condition. While there are effective treatments for certain cases, given its type, causes and other associated variables, proper diagnosis and management can be challenging. Using our Practo Connect platform as a powerful opportunity to not only raise awareness about the disease, but also evaluate current approaches in its treatment, we conducted a webinar on March 21 with two of India’s most respected neurologists, Dr (Lt Gen) CS Narayanan and Dr PN Renjen.
“With March 26 observed as Epilepsy Awareness Day, this is an opportune time for healthcare professionals like us to exchange notes on how we can manage diagnosis and treatment of epilepsy better,” says Dr (Lt Gen) CS Narayanan, HOD – Neurology, Manipal Hospitals, Dwarka, New Delhi.
Adding to that, Dr PN Renjen, Senior Consultant, Neurology, Indraprastha Apollo Hospitals, New Delhi, says, “Currently affecting more than 5.5 million people, epilepsy is a serious problem in India. In fact, many of these patients are children and young adults. This necessitates that we pay closer attention to this neurological condition to cast away common misconceptions.”
Epilepsy: symptoms, causes, and more
Epilepsy is a common neurological condition characterized by spontaneous recurrence of unprovoked seizures that varies depending on the cause and type of the epilepsy.
“The brain is full of cells communicating with electrical discharges,” says Dr Narayanan. “Here, a seizure is abnormal, excessive and synchronous electrical discharges to the brain, and if it lasts for more than 5 minutes, we call it status epilepticus. On the other hand, epilepsy is defined as two or more unprovoked seizures separated by at least 24 hours. This means that if there is a cluster of these convulsions happening in a single day, it is not classified as epilepsy,” he adds.
Why does this happen?
“The balance between the excitatory and inhibitory neurotransmitters determines if a person is going to have a seizure or not,” says Dr Narayanan, adding, “However, 40% of the time we don’t know the exact cause. These cases are presumed genetic, but we do not label them as such until the gene is identified.”
According to him, the lifetime likelihood of experiencing at least 1 epileptic seizure or receiving a diagnosis of epilepsy is about 9% and 3% respectively, which is quite high. On the other hand, the prevalence of active epilepsy is about 0.8%.
Treatment of epilepsy: clinical challenges in diagnosis and management
Arriving at the correct diagnosis is the first step to managing this neurological condition. A reliable approach is to first narrow down the type of epilepsy based on symptoms exhibited. An electroencephalogram (EEG) test will help identify the type of epilepsy (generalized or focal) to help with the final diagnosis. However, it is not a confirmatory test, but only an adjunct one.
“Although EEG can greatly support the diagnosis of epilepsy, what’s critical is to spend time with the patient to identify the type.If possible, patients should video record their symptoms to help with the correct diagnosis,” says Dr Renjen.
Adding to that, Dr Narayanan says, “We must not rely on EEG alone for the diagnosis of epilepsy because a negative EEG does not exclude epilepsy in a patient.”
For cases where a patient is experiencing symptoms for the first time, the number one step is to rule out other symptoms through some routine investigations like blood count, serum electrolytes, liver and kidney function tests, etc. After that, the patient’s brain is studied for structural abnormalities with the help of certain tests, including EEG and MRI. If no abnormalities are recorded or observed, patients should not be treated with anti-epileptic drugs.
“In persons presenting with first unprovoked seizure, the risk of recurrence is about 50%,” says Dr Narayanan. “It’ll be as low as 15% if all investigations are normal. But patients should be advised to still avoid certain conditions which can precipitate seizures, including alcohol consumption and sleep deprivation,” he adds.
In cases when patients are already diagnosed with epilepsy, care should be taken to assess the adequation of therapy, and if required, change doses or start a new medication. Even a ketogenic diet is known to play a crucial role in managing epilepsy for some patients.
According to both Dr Narayanan and Dr Renjen, most people who are diagnosed with epilepsy can manage their symptoms on one or several drugs known to treat the condition. For others, especially those with refractory epilepsy, a surgery may help control their seizures. However, even in these cases, a thorough examination must be made to identify why these patients are not responding to medication before resorting to surgery.
Impact of COVID-19 on patients with epilepsy
Various effects of COVID-19 on epilepsy patients – including worsening of seizures – have been studied in recent months. Patients with epilepsy, as with the general population, should be treated for COVID-19. However, healthcare professionals need to be aware of the potential for interactions between anti-epileptic drugs (AEDs) and COVID-19 therapies.
“Caution should be exercised as interactions between the two can either diminish or enhance the effectiveness of drugs, or cause side effects,” says Dr Renjen. “In fact, some combinations of AEDs and COVID-19 therapies can cause potentially fatal arrhythmias. Hence, as clinicians, we need to give special attention to this when treating patients with epilepsy,” he adds.
Given the complex nature of this neurological condition, management and treatment of epilepsy remains a major challenge. While effective treatment options are continuously being explored, the first step is to diagnose a patient correctly.
These challenges have been compounded by the onset of the COVID-19 pandemic. With many patients with epilepsy reporting worsening of seizures when found to be carrying Coronavirus, interactions between anti-epileptic drugs (AEDs) and COVID-19 therapies need to be carefully evaluated.
Join us every month as we partner with leading industry and doctor associations for our educational webinar series, Practo Connect. Hosted exclusively for the doctors, by the doctors, it is intended to help doctors navigate these uncertain times better.
Watch this, as well as previous webinars, here.