INTRODUCTION:

A seizure is any clinical event caused by an abnormal electrical discharge in the brain and epilepsy is the tendency to have recurrent seizure.Major seizure cause loss of consciousness ,with patient falling to the ground and presenting with a history of ‘blackouts’.Minor seizure causing alteration of consciousness,without the patient falling to the ground ,may also be described by the patient as ‘blackouts’.¹

^{pathoPHYSIOLOGY AND CLASSIFICATION:}

‘Epileptic’ cerebral cortex exhibits hypersynchronus repetitive discharge involving large group of neurons,which in normal brain is inhibited by inhibitory neurotransmitter like GABA.Trans membrane potential in the neurons is decreased and it is postulated that both under activity of the inhibitory neurotransmitter and over activity of the excitatory one is responsible for that due to which the neurons are prone to repetitive and synchronous fire.If the seizure activity is restricted to a particular area of a single hemisphere it is called partial seizure and if it involves both the hemisphere simultaneously and synchronously, it is called generalized seizure.In absence seizure the conscious is lost but the patient remains standing or sitting.²

^{CLINICAL ASSESSMENT:}

In generalized tonic clonic seizure the patient becomes unconscious and fall down heavily if standing and often sustaining injury.Respiration is arrested and central cyanosis may be witnessed.This tonic phase is followed by a clonic jerks or just be replaced by a flaccid state of deep coma.urinary incontinence and tongue bite may occur during the attack.A period of post-ictal confusion or headache and a period of subsequent malaise and/or confusion are usually seen.Many trigger factors are identified for initiation of the seizure activity like sleep deprivation, alcohol withdrawal,recreational drug misuse,physical and mental exhaustion,flickering light including TV/computer screens,inter current infection and metabolic disturbance,loud noise music etc.¹

^{CAUSES AND DIAGNOSIS:}

The cause of the epilepsy may be idiopathic or many other pathological cause like genetic ,developmental,tumours ,trauma,vascular,infections,inflammation,metabolic ,drugs,alcohols,toxins or degenerative conditions.To establish the diagnosis of epilepsy ambulatory EEG and videotelemetry are useful and to define its type standard EEG ,sleep EEG and EEG with special electrode are useful.To find out structural lesion in the brain CT and MRI are useful and if metabolic cause is suspected urea,electrolytes,blood glucose,LFTS,serum calcium/ magnicium etc should be done.If inflammatory or infective nature of the disease is suspected full blood count,ESR,CRP,CXR,serology for syphillis,HIV,collagen disease and CSF examination should be done.¹

^{IMMEDIATE MANAGEMENT:}

First aid of the patient who has an episode of seizure includes moving away of the person away from danger like fire water,machinery ,furniture etc.After convulsion ceases, the patient should be turned to semi prone position and a clear airway should be ensured.Nothing should be inserted into the mouth and if the convulsion persists for more than 5 minute or recur without person regaining consciousness,urgent medical attention should be summoned.The person may be drowsy and confused for some 30-60 minutes and should not be left alone until fully recovered.The immediate medical attention includes ensuring the patient airway and giving oxygen to offset cerebral hypoxia.Intravenous anticonvulsant like diazepam 10 mg should be given only if the convulsion are continuous or repeated.if the patient is a known case of epilepsy blood should be taken for anticonvulsant level.The cause should be investigated.¹

^{LONG TERM MANAGEMENT:}

Epilepsy is a chronic condition requiring careful long-term management. The treatment is complex, involving classification and diagnosis, selection and monitoring of the appropriate antiepileptic agent, and evaluation of the chosen drug’s side effects and drug interactions. Because these side effects increase when drugs are combined, mono therapy is recommended. Long-term management issues and optimal drug selection differ from patient to patient. If seizures are not controlled by medication, the patient may have been misdiagnosed or misclassified. Noncompliance, a major cause of apparent unresponsiveness to treatment, should also be ruled out.  The long term management includes the treatment of the patient with anticonvulsant drugs, of which the patient treatment should be started with the first line drug,which should be started with low dose and gradually the dose should be increased to effective control of seizure or until side effects.compliance should be checked and if the first line therapy fails treatment with the second-line drug should be started gradually withdrawing the first one.Three agents should be tried singly before trying combination therapy.More than two drugs in combination at one time should not be considered.If all the above majors fails occult structural or metabolic lesion should be considered or whether the seizure are truly epileptic.For GTCS first line therapy is carbamazepine and the second line are lamotrigine,sodium valporate,topiramate etc. For many patients, a therapy that brings the seizures under control is initiated soon after diagnosis. For these patients, long-term management consists of monitoring for the long-term adverse effects of medication; providing psychological, career, and social assistance, if necessary; and, ultimately, determining whether medication should be discontinued.

For a second group of patients, medication substantially reduces seizure frequency, but seizures will not be completely eliminated. For this group, long-term management consists of determining the risk–benefit ratio of changing to new therapies, making sure that each therapy is used to its maximum benefit, and keeping side effects to a minimum.

Finally, a group of patients exists who do not respond to any standard therapy. The first step in managing these patients is to determine whether continued seizures are actually due to treatment failure or whether there is another explanation, such as misclassification, noncompliance with medication regimen, or the presence of no epileptic (pseudo epileptic, psychogenic) seizures. If failure is due to seizure intractability, long-term management for these, the most difficult patients, consists of a rational approach to choosing successive drug regimens. If conventional medications fail, the next step is to consider alternative medications or surgical intervention. These patients also need substantial emotional, psychological, and vocational support. ⁴

SOCIAL ASPECT:

Since the treatment has a long course ,it cause a lot of the financial burden to the patient as well as some side effect are inevitable.To moniter the compliance and the side-effect profile the plasma level of some of the drugs has to be measured occasionally like of cabamazepine and phenoytin⁵.Another problem with the epilepsy is that the patient has to restrict himself from some of the activities which are dangerous for them like for a vehicle driver.If a person has been in such type of job then it is mandatory that he refrain from such job, and involve himself in a less risky jobs at least for two year after the effective control of disease.Patient education and education of the caretaker of the patient is of prime importance.They should be told about the nature of the disease,the risk of the complications, treatment modalities, outcome of the treatment,side effect of the drugs and the prognosis of the patient.If the patient is getting married ,the other party should also be told of the disease and that he can have normal marital and sexual life and can have normal children.³

Resource:

1. Principle and practice of medicine by Davidson;20th edition,page no.1167
2. Essentials of medical pharmacology by KD Tripathi;5th edition,page no. 369
3. MURTAGH’S general practice 4th edition,page no.1292
4. The long term management of Epilepsy byjacqualine french;march 1,1994 vol 120,on internet
5. www.wickipedia.com-from internet.