Seizures in Children:  More Severe Seizures

 

Transcript:

 

Guest:  Dr. Bernie Maria - Pediatrics

Host:  Dr. Linda Austin – Psychiatry

 

Dr. Linda Austin:  I’m Dr. Linda Austin.  I’m talking with Dr. Bernie Maria who is Professor of Pediatrics and Neurosciences.  Dr. Maria, we talked a couple minutes ago about febrile seizures.  Let’s talk, now, about the next most serious form of seizure.  What would that be?

 

Dr. Bernie Maria:  Well, when children are having seizures for no apparent reason, it’s what we call, unprovoked, and they’re having recurrent seizures, they’ve had two or more on a different day, that is technically what we call, epilepsy.  And when a child has had a single seizure that’s unprovoked, only half will have a second or develop epilepsy.  But if they have a second seizure within six months, they have an 80 percent or greater chance of having more.  So, it’s at that point in time that we want to intervene with medication to bring the seizures under control.  So, success is measured in terms of not having any further seizures and not changing the child, in terms of personality, sedation, and the like.

 

Dr. Linda Austin:  Now, most folks know that all seizures are not alike.  What are some of the different types of seizures that children commonly have?

 

Dr. Bernie Maria:  There are many different kinds of seizures that can arise in childhood.  Some are very bizarre, called infantile spasms, where children will have salaam-like jerking of the arms and legs, what we call myoclonic-type seizures.  That’s often associated with bad brain development, something that went wrong in utero when their brain was being put together. 

 

In older children, outside of infancy, seizures can basically arise from part of the brain, which we call partial seizures, or from the whole brain, as a whole, which we call generalized seizures.  And when seizures arise from part of the brain, they can spread to the whole brain.  So, the purpose of treatment is to keep focal or partial seizures in the brain from spreading and generalizing and causing the kind of shaking and stiffening that we see in the whole body, and to keep seizures that are arising from part of the brain that just move one arm or one hand unintentionally in a rhythmical fashion from spreading to the rest of the body.

 

Dr. Linda Austin:  So then, when you think about the criteria that would make you call a seizure severe, is it fair to say that it’s not necessarily how bad it looks but whether or not it can be controlled easily with medication?

 

Dr. Bernie Maria:  Yes.  I think on the spectrum of seizure severity, we go from children with mild or benign seizures, which are these febrile seizures that we talked about earlier, all the way to the more severe state, which is epilepsy, that is intractable or resistant to treatments like anti-epileptic medications.  Individual seizures can be very short, 95 percent of them lasting less than five minutes.  But in that five percent that seizures can last 20 minutes, 30 minutes, or longer, they’re more likely to damage the brain.  Although children can have seizures that last up to an hour, especially in the context of fever, that are completely benign, that do not in any way injure the brain, we worry as we get beyond five minutes for a given seizure.  We’re worried that it might cause some damage, so we call those more severe. 

 

Dr. Linda Austin:  How does it cause damage?

 

Dr. Bernie Maria:  When you’re having a seizure, you’re consuming a lot of energy in your brain.  You’re consuming oxygen and glucose, sugar, which brain cells, thinking cells, neurons like to use.  So, as you deplete those cells, because of the firing that goes on, the electrical storm, as we described it, of seizures, those cells lose those nutrients that are necessary to keep them alive.  They can, then, swell, die off, spill their contents, cause swelling in the brain that then damage other cells in the environment.  So, the worry about prolonged seizures is that they’re going to produce a scar, a permanent scar, by virtue of loss and death of brain cells in the areas of the brain where the seizures are occurring. 

 

Dr. Linda Austin:  And, then, will that scar tend to trigger further seizures?

 

Dr. Bernie Maria:  Right.  So, once you have a scar in the brain, the brain can learn to deal with that and circumvent that and wire itself around it, or it can hit a brick wall.  Those connections, those neuronal circuits, can be forever disrupted and then set up a stage where cells that are unhappy, by virtue of the fact that they’ve survived and have been damaged, can then recruit other cells in an environment where they’re happy and doing their job of making the brain work and corrupt them into an electrical storm that would then trigger more seizures. 

 

Dr. Linda Austin:  What are some of the common medications that you prescribe to control seizures?

 

Dr. Bernie Maria:  Well, there’s a long history of use of medications for the treatment of seizures and for the treatment of epilepsy.  They date back to the early 1910s and 1915s with Phenobarbital having been one of the first medications in use.  Then, Dilantin appeared in the 30s.  And in the last 25 years, no less than 25 different kinds of seizure medications have come to the market, each with their own strengths and weaknesses.

 

What we like to do in thinking about the developing brain and the fact that medications can alter a child’s ability to think clearly, pay attention and learn is to be very careful in selecting medications that have less of a chance of producing those kinds of side effects.  So, for example, we use medicines like leviteracetam, or Keppra.  We use medications like Trileptal, or oxcarbazepine.  We use medications like valproic acid or Depakote. 

 

So, depending on the type of epilepsy, on what the cause of that epilepsy is, on what the child’s unique circumstances are, for example, if this is a young teenager, a female, who has some issues with weight, well, the last thing we would want to do is select a medication like Depakote, for example, which might control seizures but might, really, cause a lot of issues with weight gain.  So, it’s a very individual, tailored, decision in terms of what medications to use.  And, if at all possible, we’d like to pick one medication, rather than combine them. 

 

Dr. Linda Austin:  Are there personality changes that go on in kids who have repeated seizures?

Dr. Bernie Maria:  Children with repeated seizures, or epilepsy, have a variety of neural behavioral problems, oftentimes, associated with their epilepsy, not that it is caused directly by the epilepsy.  But, by whatever made it so that the brain was wired in such a way to produce seizures in the first place, puts them at risk for different kinds of behaviors.  For example, we see a lot more issues with inattention, hyperactivity and impulsivity in patients with epilepsy, so it wouldn’t be at all unusual for them to have attention deficit disorder, requiring management in addition to their underlying epilepsy. 

 

Dr. Linda Austin:  Do you ever reach a point where medications are not enough?  If so, what do you do then?

 

Dr. Bernie Maria:  Because we have so many different kinds of medications now that are tailored to the particular kind of epilepsy that we’ve diagnosed, we’ll select two or three good medications, which should normally control the epilepsy, and if they are not controlling the epilepsy, we’ll then quickly move to other options.  So, if, for example, the brain MRI shows that there’s a scar or the area where the seizures are arising from did not develop normally, or is malformed, then, typically, within a reasonably short period of time, we consider correcting that with a surgical resection.  If one removes the damaged part of the brain triggering the epilepsy, there’s a very good chance that less medication will be needed and the patient will be seizure-free.

 

Dr. Linda Austin:  Do you ever reach a point with a patient where nothing seems to work?

 

Dr. Bernie Maria:  Unfortunately, yes.  There are some malformations in the brain that are so profound that in many cases they’re not compatible with life, where the fundamental wiring in the brain, all those trillions of connections between brain cells, was so abnormal to begin with, there’s really little that we can offer, other than the comfort of some seizure reduction.  Those are patients that have a shortened life expectancy and usually are not going to live into their second decade of life.

 

Dr. Linda Austin:  But it sounds as if that’s something you can’t really tell until you’ve started treating the child.

 

Dr. Bernie Maria:  Yes, Linda.  Children surprise us all the time.  If we look at the scan and we look at the EEG, brainwave test, and we look at the history and we examine the child, make our best judgment in predicting what will happen, I’m always surprised by how resilient children are and how responsive they are to medications when we wouldn’t have expected it otherwise.

 

Dr. Linda Austin:  I’m sure you get plenty of questions about dietary strategies.  Does anything work? 

 

Dr. Bernie Maria:  Yeah, there’s evidence that diets that are high in fat and low in sugar, what we call ketogenic diets, are anti-seizure and anti-epileptic.  And we’ve known since biblical times that fasting can help the brain control seizures.  So, this is a very structured diet that people really shouldn’t be doing on their own because it can be dangerous if not managed properly.  It can be a wonderful complement to seizure medication and sometimes can supplant medication.  The thing that I like most about the ketogenic diet is that it’s one of the few things that’s high in fat and good for you.

 

Dr. Linda Austin:  Dr. Maria, thank you so much.

 

Dr. Bernie Maria:  With pleasure.

 

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