– Epilepsy

Epilepsy is categorized as being symptomatic or idiopathic:

If the underlying cause of someone’s epilepsy is known, then it is called symptomatic. Some of the many possible causes of symptomatic epilepsy include structural brain abnormalities, brain trauma, stroke, tumors, and drug intoxication or withdrawal, including alcohol.

A majority of cases of epilepsy are idiopathic, with no known underlying cause. Idiopathic epilepsy can run in families.

Seizures can be subdivided into partial and generalized seizures. Partial seizures are localized to one area of the brain and are either simple or complex. Simple partial seizures have no alteration of consciousness, while complex partial seizures are accompanied by altered consciousness.

A partial seizure may become secondarily generalized, meaning that it may spread to other parts of the brain and appear to an observer to be a generalized seizure.

Generalized seizures involve both hemispheres (sides) of the brain and possibly the entire brain. Types of generalized seizures include tonic-clonic seizures, absence seizures, myoclonic seizures, atonic seizures, tonic seizures, and clonic seizures.

Some seizures may be preceded by an abnormal perception called an aura, which might be visual (such as flashing lights), auditory, motor, emotional, or others.

Partial seizures may present in a variety of ways, depending upon the part of the brain that is involved. For example, a partial seizure may present with focal motor activity, such as movement of a part of the body, or a sensory symptom, such as a change in vision.

Generalized seizures are often associated with impaired consciousness. With tonic-clonic seizures, which used to be called grand mal seizures, there is loss of consciousness and muscle stiffening followed by contractions. Someone experiencing an absence seizure, which is also known as a petit mal seizure, will have impaired consciousness and may appear to be staring off into space. During the postictal period, which is the time after a seizure ends, confusion, drowsiness, and headache may be observed.

Status epilepticus, a medical emergency in which there is a prolonged continuous seizure or multiple seizures without full recovery of consciousness in between, is associated with a high mortality rate that can be up to 20 percent or higher per episode.

Evaluation and treatment:

Electroencephalography, also known as EEG, and imaging of the brain are useful tools in the evaluation of seizures. An EEG measures the electrical activity of the brain and can help to confirm that epilepsy is present and may help to classify the type of epilepsy. However, an EEG may be normal in someone with epilepsy and can be abnormal even in the absence of epilepsy and so caution needs to be taken in interpreting the results.

MRI or CT scanning of the brain can help detect lesions (structural brain abnormalities) that may underlie epilepsy. The goal of epilepsy treatment is freedom from seizures with minimal side effects from therapy. Treatment compliance is important, since some epileptics may seize even after missing one dose of medication. There are more than 20 medications available for the treatment of epilepsy. While most epileptics will achieve adequate seizure control with medications, up to about one third will not. Failure of the initial medication to achieve seizure control decreases the chance that a subsequent medication will be successful.

There is no generally accepted antiepileptic medication of choice and which medication to prescribe needs to be decided by the doctors on an individualized basis taking several issues into account, including the type of epilepsy, possible side effects, potential interaction with other medications that the patient may be taking, age, gender, and other medical impairments.

Some nonpharmacologic options that may be available when epilepsy is resistant to medications include surgery to resect the part of the brain that is felt to be causing the seizures and implantation of a device that electronically stimulates the vagus nerve. While vagus nerve stimulation rarely eliminates seizures entirely, on average seizure frequency is reduced by about 50 percent. Deep brain stimulation is an experimental treatment for epilepsy in which electrodes are placed deep into the brain.

Epileptics have an increased risk of psychiatric disorders, such as depression and anxiety, and epilepsy is associated with an increased suicide risk. Epilepsy is associated with an increased mortality risk, and the risk is higher if the epilepsy is not well controlled, in younger epileptics, and in cases where there is a documented cause for the seizures (symptomatic epilepsy).

Some epileptics die suddenly from a cause that cannot be identified, and this is referred to as sudden unexpected death in epilepsy, or SUDEP. Although the cause of SUDEP is unclear, cardiac arrhythmia, respiratory impairment, and neurologic dysfunction may contribute. SUDEP tends to occur in young people during sleep following tonicclonic seizures. Some risk factors for SUDEP include frequent tonicclonic seizures, long duration of epilepsy, male gender, and being on multiple seizure medications.

Case Studies

Applicant 1 is a 40 year old applicant with a history of idiopathic generalized tonic-clonic seizures since childhood who has been well followed, is compliant with the antiepileptic medication, and has not had a seizure in six years. This applicant can be Standard Plus.

Applicant 2 is a 50 year old applicant with a history of symptomatic epilepsy caused by a vascular malformation in the brain. Five seizures have occurred in the last two months, the applicant is not compliant with antiepileptic medications, and the last three neurologist appointments have been missed. This applicant would be declined.

Applicant 3 is a 30 year old applicant with a history of idiopathic generalized tonic-clonic seizures who is well followed and last had a seizure three years ago. This applicant would be Table Two. Applicant 4 is a 50 year old applicant with a history of idiopathic generalized epilepsy diagnosed in childhood who has been seizure free off medications for over five years. The applicant is well followed and otherwise healthy. This applicant can be Preferred.

 

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