Epilepsy

Overview

Epilepsy is a disorder that causes seizures or convulsions due to abnormal activity of brain cells, called neurons. The disorder may be caused by head injury, trauma, brain tumors or infections, such as meningitis or encephalitis. Conditions at birth or before birth also may lead to epilepsy, including an insufficient supply of oxygen to the brain, bleeding in the brain or abnormal blood vessels. But in many cases, the cause is unknown.

Some types of epilepsy run in families and have been tied to specific genes. Epilepsy may occur at any age, but it typically develops in early childhood.

The Epilepsy Center at UCSF Benioff Children's Hospital is dedicated to the comprehensive diagnosis and treatment of infants, children and adolescents with epilepsy. Our neurologists and neurosurgeons are among the nation's leading epilepsy experts and will work closely with you to identify the specific type of seizure affecting your child and develop the best possible treatment plan.

Signs & symptoms

Most children with epilepsy experience more than one type of seizure. The two types of seizures are generalized or partial, depending on the part of the brain where a seizure is triggered.

Generalized Seizures

Generalized seizures result from electrical impulses arising from the entire brain. They typically occur without warning. There are six types of generalized seizures.

• Tonic-clonic ("grand-mal" seizure) — Your child will lose consciousness and may also collapse. The child's body becomes stiff and begins jerking. Finally, your child will fall into a deep sleep. During grand-mal seizures, injuries such as tongue-biting can occur, as well as a loss of bladder control.
• Absence seizure ("petit mal" seizure) — Your child will lose awareness and stare blankly for a few seconds. Usually, there are no other symptoms. These seizures may occur several times a day.
• Myoclonic seizure — Your child's body may jerk, as if being shocked by electricity. The jerks can range from a single muscle to the entire body jerking.
• Clonic seizure — Both sides of your child's body jerk rhythmically at the same time.
• Tonic seizure — Your child's muscles suddenly become very stiff.
• Atonic or akinetic seizure — During this kind of seizure, the muscles will relax, particularly in the arms and legs, which can cause children to suddenly fall and often times, injure themselves.

Partial Seizures

Partial seizures, also known as local or focal seizures, originate from activity in a smaller part of the brain. They are divided into simple and complex seizures, as well as those that evolve from partial-onset seizures into generalized tonic-clonic seizures. The difference between simple and complex seizures is that during simple partial seizures, your child will retain awareness. During complex partial seizures, your child will lose awareness.

• Simple partial seizure — Your child may experience movements such as jerking or stiffening, various sensations, peculiar memories such as a feeling of "deja-vu" or various emotions. Full consciousness is retained.
• Complex partial seizure — Same as a simple partial seizure except that your child's awareness is impaired and they may appear to be "out of touch" or "spaced out." They also may involuntarily chew, walk, fidget, or perform other repetitive movements or simple actions.
• Secondarily generalized seizure — If a partial seizure evolves into a tonic-clonic ("grand mal") seizure, it's known as a secondarily generalized seizure.

Diagnosis

In the United States, about 2 million people have epilepsy, including 300,000 children under the age of 14.

To determine if your child has the condition, a team of doctors and other medical professionals at the UCSF Epilepsy Center will assess your child's medical condition and determine the type of seizures your child is having. This information is essential in determining the best treatment for your child.

The first step is documenting your child's medical history as well as your immediate family's medical history. We will ask many questions about what occurs when your child has a seizure. Some of the questions will include:

• How old was your child when the seizures began?
• Describe what happened when your child had his or her first seizure.
• Does anything in particular seem to trigger your child's seizures?
• What does your child experience during seizures?
• What do observers notice during the seizures?
• How long do the seizures last?
• How frequently do they occur?
• What treatments have been administered for seizures and what were the results?

If your child's primary care doctor has sent your child's medical records, we will review this information. Be sure to tell the neurologist about any medications your child is currently taking, including over-the-counter medications, vitamins, nutritional supplements or herbal remedies.

Neurological Exam

Your child will also have a complete neurological examination. This may include scheduling for certain tests, such as:

• Blood or urine tests
• Electrocardiogram (ECG), which measures heart activity
• Electroencephalogram (EEG), which measures electrical activity in the brain
• Imaging tests such as X-rays, magnetic resonance imaging (MRI), or computed tomography (CT) scans
• Other procedures, such as positron emission tomography. Also called PET imagining or PET scan, positron emission tomography is a non-invasive diagnostic test that combines the technologies of computed tomography (CT) and nuclear medicine

Treatment

Your child's team of doctors and health professionals will design a treatment plan for your child's specific needs, a plan that may include more than one kind of treatment. Your child also may be referred to additional doctors or other medical professionals.

Most medical treatments involve some risks or complications. We will explain possible risks or complications related to your child's treatments. Feel free to ask questions about your child's treatment.

Medications

In many cases, seizures can be successfully prevented with medications. There are more than 20 medications used to treat seizures in children. Many of these are not formally approved for children but are very commonly used in the pediatric population.

The type of medication your child will receive depends on many factors and every child is different. Your child's neurologist will explain how to take the medication and the side effects that may occur. Over time, your child's medication regimen may be changed. It is very important that your child take the medication exactly as directed. Call your neurologist if you have any questions about the medications or if your child is experiencing unexpected side effects.

If the first medication chosen is not effective, your doctor will discuss the next medication option. The goal is for your child to have no seizures and no side effects, and the treatment plan may change at any time depending on how your child responds. Some children require two to three medications to control their seizures; monitoring for side effects while on these combinations is very important.

Some patients do not respond to medications and continue having seizures. In these cases, other testing and treatments may be recommended.

Surgery

Surgery is often considered if medications fail to control seizures. There are many different types of surgical procedures used to prevent seizures.

If surgery is an option, your child will undergo additional tests to pinpoint the location of the seizures. These tests include inpatient video EEG monitoring, high-resolution MRI, magenetoencephalography (MEG), brain PET scans or SPECT scanning. Once the presurgical evaluation is complete, your doctor will discuss what type of surgical procedure is the best option for your child.

Procedures used to control seizures include:

• Focal resections are the most common surgical approach for treating epilepsy and provide the best chance for patients to gain complete seizure control. These procedures involve removing a small area of the brain where seizures originate. New brain monitoring techniques allow doctors to better pinpoint brain tissue causing seizures. Types of resections include:

  • Temporal lobectomy, in which a portion of the temporal lobe is removed to control seizures.

  • Lobar resection, in which a portion of a seizure-producing lobe — frontal, parietal or occipital lobe — is removed, if it can be done without damaging vital functions.

  • Hemispherectomy, in which one sphere of the brain is removed or disabled. The remaining half of the brain takes over many of the functions of the half that was removed. This procedure is used to treat severe conditions that have not responded to other treatments.

• Disconnection procedures, which disrupt abnormal electrical activity that occurs in the brain and triggers epileptic seizures. Two types of disconnection operations are:
  • Gamma Knife radiosurgery delivers a finely focused, high dose of radiation to remove tissue without damaging surrounding tissue. Some types of seizures such as gelastic seizures, which are accompanied by brief, sudden bursts of emotion, may be treated with this technology because they come from an area of the brain that is difficult to access in other ways.
  • Vagus nerve stimulation involves minor surgery to implant an electrical stimulator under the skin on the right side of the chest. The stimulator sends regular electrical pulses through the vagus nerve to the brain to reduce the onset or frequency of seizures. If a seizure occurs between doses of current, you or your child can pass a magnet over the device to trigger an additional dose.

Vagus nerve stimulation helps prevent or lessen the severity of seizures in children when open brain surgery is not an option. Children with a vagus nerve stimulator continue to take medication, but can sometimes reduce the amount or number of medications.

• Laser ablation
• Implant device: responsive neurostimulator

Ketogenic Diet

This special high-fat, low-protein, no-carbohydrate diet has been recommended for many years for some children with epilepsy that do not respond to medications. The diet mimics certain effects of starvation, which helps to prevent seizures.

Our pediatric dietitian has specialized training in starting and managing the ketogenic diet. This treatment involves an initial clinic visit, followed by a three- to four-day hospital stay when a team of doctors will follow your child closely and train the caregivers on how to make each meal.

This can be a very effective treatment, with approximately 25 percent of children becoming seizure-free and another 50 percent having more than a 50 percent reduction in seizures. While these are excellent outcomes, the diet is often difficult on the child and the rest of the family. With the appropriate guidance, however, it can often be successful.

Prevention and Follow-Up

To help cope with epilepsy and reduce your child’s chance of injury from seizures, we recommend these guidelines:

• Have your child carry identification, such as a bracelet, card or necklace that indicates that your child has epilepsy. In an emergency, this information can ensure that your child receives the right care.
• Explain to family, friends, teachers and sports coaches how to care for your child if he or she has a seizure.
• If your child has regular or even occasional seizures, make sure your child avoids dangerous situations at school and during leisure activities. Your child should be careful when playing sports and should not swim unattended.
• Your child should never stop taking seizure medication or change the amount taken without discussing it with a doctor first.
• Talk to your child's doctor or pharmacist before taking other medications in addition to seizure drugs.