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Childhood epilepsy

26 March 2020


What are seizures?

Seizures are caused by a change in the neurological state, arising from an abnormal electrical and chemical discharge in the brain, so depending on where this abnormal electrical discharge is generated, the symptoms will be different and will affect a motor area that will have a movement crisis in the area of the brain responsible for consciousness. There could be loss of consciousness, but there could also be visual and sensory manifestations, among others. These seizures are the change that a child or an adult suffers as a result of such abnormal electrical activity.

It is very important to mention that not all seizures will develop in the context of epilepsy, for example, in a child between 6 months and 5 years old whose temperature rises and convulses, we are facing a fever fit usually caused by an infection which causes the temperature to rise and thus the seizures. To establish an epilepsy diagnosis, we must have recurrent and unprovoked seizures, that is, we must have more than two seizures that occur in the absence of these fever or infectious processes, which is not the response derived by the consumption of drugs or other medicines or a blow to the head, etc. When we confirm that the person is having isolated and unprovoked seizures, then we diagnose epilepsy. And again, the seizures will depend on the location of the cerebral cortex where these electrical and chemical discharges are being generated, which can be expressed in different ways.

Now that we have understood the difference between a seizure and the clinical context of epilepsy, we also need to talk about the cause of these seizures. They can be the product of metabolic problems, for example, in little children with deficiency of some enzymes or the accumulation of certain substances, they can also be due to the lack of oxygenation and blood supply to the brain, as in the case of hypoxia and ischemia, or they can also be the product of brain tumors and vascular or cerebral cortex malformations, etc. Seizures and discharges can be the product of a structural deviation in the brain, particularly in the cerebral cortex, however, almost half of the cases do not have a cause that we can identify with imaging studies, tomography, or MRI, that is, epilepsy can be lesional, non-lesional, where there is usually a genetic background that explains why the cerebral cortex is producing more electrochemical activity and generating this type of seizures. The treatment for lesional epilepsy is a little different from non-lesional treatment. We can understand it because if we think that we have temporal lobe seizures, which are more frequent in lesional epilepsies, and when we perform an imaging study or an MRI we find that there is a scar, a very interesting possibility opens up to seek surgical treatment to dry out the lesion that is causing the discharges that, in turn, cause the seizures, we could offer a definitive cure for epilepsy, in cases of being able to find a lesion in these brain areas.

Does it have a cure?

Fortunately, the vast majority of epilepsies can be controlled, even though it is devastating and extremely frequent. Most patients with epilepsy, both children and adults, can be controlled with medication. The first line of treatment for epilepsy is pharmacological treatment. We have about 20 antiepileptic drugs in our country and with them we can control more or less 7 out of 10 patients, regardless of their type of epilepsy. We must also remember that they can be generalized seizures, they involve the whole brain, and focal seizures, they start in one specific part of the brain, so different antiepileptic drugs will respond differently. That is why it is very important to approach a specialist when we suspect either kind of seizures, starting with a general practitioner or pediatrician and then with a neurologist or neuro pediatrician to define the diagnosis. Fortunately, the vast majority of patients will respond satisfactorily when we have already started pharmacological treatment, that is, we will have none or very few seizures, very few or no adverse effects of the drugs, and, most importantly, the density of children or adults with epilepsy is as close to what epilepsy would be, that is, children can return to school, do sports, family, and social activities; and adults have a completely normal life. What we are looking for with epilepsy treatment is to reintegrate those people who suffer from it, return them to a completely normal life, being careful of medications that have to be used since all the drugs that act in the central nervous system have some adverse effects. Fortunately, the vast majority of patients will have a great quality of life despite their epilepsy, but it is very important to precisely define the type of epilepsy to implement the best treatment and therapeutic strategy to help them.

Is it the same treatment for all epilepsies and is it the same for children as it is for adults?

No. Currently, a medicine that exists to deal with generalized seizures, that is, an epilepsy that does not have a brain lesion, and that appears at 10 or 12 years of age and has a very particular epileptic syndrome, is called generalized idiopathic epilepsy, which is one of the most common types of epilepsy in young people and adolescents. In this case, we are going to prescribe a drug with 4 treatments that are highly effective in controlling it. We are talking about medications such as balcoic acid, or ebesintafetafre or motricita, which are medications that usually control more than 90% of seizures in patients. However, if we make a mistake when selecting the treatment, interpret these seizures as a total onset, and start treatment from another family of drugs, it is very common for seizures to get out of control. The most important thing is to establish a diagnosis and implement the best treatment for each patient.

From what age can we know if our children have epilepsy?

Epilepsy can occur from premature babies, there are even reported cases of epileptic seizures in the womb; neonatal seizures are frequent and are the product of some metabolic diseases and nanosystems. From that moment on, epilepsy will continue to occur in all age groups, which will change the compulsive seizures of epilepsy in very young babies, which is usually different from that of young people, young adults, older adults, and the elderly. For example, a common cause of seizures without epilepsy is the sequelae of head trauma, such as a severe blow to the head that causes a bruise and then a scar. These structural sessions can eventually lead to seizures and head trauma, which is a frequent pathology in young adults. A little later comes brain or metastatic tumors that can also cause it but it is very rare to have epilepsy due to brain tumors in the first two years of life and vice versa, a cortical dysplasia, which is a cerebral cortex malformation, frequently causes seizures in children within the first years of life, but it would be very rare for a cortical dysplasia to cause seizures in an older adult. So we have to try to individualize the diagnosis in each of our patients and the age group to which they belong.

In the case of newborns, what could be the consequences if the parents do not know that they are having epileptic seizures?

There are two main reasons for wanting to make an early diagnosis. The first is that during seizures there may be injuries, traumas, even cardiorespiratory complications. The person suffering from an epileptic crisis can get hurt and that is the first reason why we should try to avoid them. The second reason is that seizures, particularly in very young children, will progressively compromise neurodevelopment, this means that the cause and origin of the seizures will compromise the acquisition of cognitive areas and language functions. So the earlier, the more effective we can be with diagnosing seizures. It may be the particular subject of very young children because they are going to have much more complete neurodevelopment.

Could we do an MRI or one of the first tests in children to know that they do not have this type of problem?

No. The majority of children, neonates, or newborns will not have epilepsy, and performing imaging studies and electroencephalography will not allow us to select children with a higher risk of having seizures. This applies differently to a child who had perinatal complications. A child who had a resuscitation procedure and we suspect that it had a serious respiratory problem can cause a neonatal proxia issue, then this would be a potential cause of epilepsy. So, if we had these risk factors for a traumatic delivery and a prolonged delivery, a child who begins with jerks, for example, with abnormal movements, these would definitely be the case that should be consulted with the neuro pediatrician to find out if there is a risk of first crisis, since in these cases treatment must be started as early as possible.

How expensive can epilepsy treatment be?

There is no single treatment for all types of epilepsy. Usually what we seek is to control our patients in therapy mode, using antiepileptic drugs in low but effective doses. But when we do not control the crises with a few drugs, then we have to think about post-therapy, that is, using more than one drug very carefully and protecting the adverse effects and interactions of one drug with another, and this, of course, can raise treatment costs. That is why it is very difficult to establish what the general cost is for all patients because it is a very wide range of those who respond very well with low-dose drugs and relatively cheap drugs and those who need second or third-generation treatment and not only two or three, but 5 or 6 medications.

Is epilepsy hereditary?

Most epilepsies are acquired, but there are some conditions where it is hereditary. Some epilepsies are genetically determined, although fortunately they are not the majority and the fact of having a father or a mother, even a brother with epilepsy, does not significantly inherit the risk of epilepsy in the rest of the relatives.

It is very important to insist that in the face of epilepsy, families with this neurological condition must approach their pediatricians and their family doctors. Epilepsy in the vast majority of cases allows the family affected by this disease to have a normal life, but this depends on having an accurate and timely diagnosis. Even when we do not have good control with more than two drugs, we call this type of epilepsy drug-resistant or difficult-to-control epilepsies and in these cases, there are surgical procedures where we can disconnect some structures or the cerebral cortex. When multiple medications fail, a neurosurgical procedure that is usually very safe and effective may be considered for some patients.

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