Epileptic seizures: how to recognise them and what to do

By Cristiano Antonino On Jul 28, 2022

What is epilepsy and epileptic seizures: epileptic seizures are clinical manifestations that appear in an incidental manner

The onset may be at any age and in most cases the repetition over time is unpredictable: seizures may even be a sporadic or unique clinical manifestation.

The disease that causes them is variable and controlling it may lead to their disappearance.

If by epileptic seizure we mean the single episode, the term epilepsy refers to the proven risk that seizures will recur over time.

In many patients, seizures have a chronic course, independent of the course of the cause of the seizure, and may require long-term treatment, usually with drug therapy.

The epileptic seizure must therefore be considered a symptom, while epilepsy is understood to be a chronic disease.

It is estimated that there are about 60 cases per 100,000 inhabitants in Italy (Fiest 2017) and the number of new cases of epilepsy expected each year is about 6,200.

Symptoms of an epileptic seizure

The International League Against Epilepsy (ILAE) uses as its definition of an epileptic seizure: ‘A transient onset of signs and/or symptoms due to abnormal, excessive or synchronous neuronal activity in the brain’ (Fisher 2017).

In other words, seizures are the clinical manifestation of an excessive and pathological discharge of brain neurons.

There are seizures with:

convulsive manifestations, i.e. involuntary movements, spread throughout the body;
various neurological disorders, if the pathological discharge affects only part of the brain.

In seizures without widespread convulsive manifestations, a distinction is made between episodes with impaired consciousness and episodes in which the patient maintains an adequate relationship with the surrounding environment.

What to do in the event of a first epileptic seizure

In the presence of a patient with a first epileptic seizure, the clinical problem is to establish whether this is the first evidence of a chronic condition characterised by the repetition of seizures or whether it was a one-off event that will not be repeated in his or her future life.

In the latter case, the indication for chronic prophylactic treatment is essentially useless.

Usually the epileptic seizure lasts only a few minutes, but on some occasions called epileptic states, seizures last for a very long time without interruption: in this case the brain may be damaged.

This is why status epilepticus requires urgent treatment, unlike single seizures of normal duration.

The first epileptic seizure in a person’s life requires hospitalisation, which is indispensable in order to identify the cause and ensure appropriate treatment.

To this end, haematological, neuroradiological and electroencephalographic investigations are indispensable.

On the other hand, if the seizures were already present in the patient’s clinical history, instrumental investigations are generally minor and can be performed even only on an outpatient basis, without the need for hospitalisation.

In the case of an episode that repeats events that have already occurred in the past, hospitalisation should only be indicated in the case of traumatic lesions during the course of the seizure or, as indicated above, in the case of seizures that last too long.

Causes of an epileptic seizure

For patients with new-onset seizures, the aetiological diagnosis is crucial.

Almost all pathologies with focal or diffuse lesions of the central nervous system, such as strokes, tumours and malformations, can give rise to an epileptic manifestation either singly or expressed as an epileptic state.

It is important to bear in mind that systemic metabolic disorders, such as, for example, severe reductions in blood sugar, can also cause epileptic manifestations.

Then there are:

factors triggering seizures, as in the case of specific stimuli for some patients: for example, intermittent light stimuli;
factors favouring seizures, such as sleep deprivation or high temperature. One of the main favourable factors is failure to take therapy.

Therapy

Therapy is generally pharmacological and is indicated in patients in whom a risk of seizure recurrence is demonstrated.

It is based on the use of drugs that can control the seizures or at least reduce their number or intensity.

These drugs do not definitively cure the problem: the eventual disappearance of the crises, which occurs in 30-40% of cases, is in fact an event linked to the spontaneous evolution of the disease.

As written above, only status epilepticus has an indication for drug therapy in an emergency, whereas for ‘normal’ seizures the optimal strategy is generally that of a modification of the usual treatment schedule.

In patients with seizures that do not respond to therapy (drug-resistant), there may be an indication for neurosurgical evaluation for a different treatment strategy.

There are currently about 14 different drugs that can control or reduce epileptic seizures.

Their regular intake is the basic criterion for a correct assessment of efficacy.

The doses, and not only the types of drugs, may differ in individual patients, but the basic criterion remains that a good drug must control seizures and not give any side effects.

Modalities for introduction, continuation of therapy and possible discontinuation vary from patient to patient; these aspects often require specific medical expertise.

What to do and what not to do in the event of a seizure

It must be remembered that in the event of an epileptic seizure, specific intervention by witnesses is rarely required.

Firstly:

opening the mouth or swallowing liquids should not be attempted;
confine oneself to trying to avoid traumatic falls;
have the patient assume a lying position on their side until they regain consciousness. This almost always occurs spontaneously without the need for stimulation by those present.

European Resuscitation Council (ERC), The 2021 Guidelines: BLS – Basic Life Support

Pre-Hospital Seizure Management In Paediatric Patients: Guidelines Using GRADE Methodology / PDF

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