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The other thing that we'll want, and equally important as the MRI, if not more important, is the electroencephalogram or EEG. An EEG is a test where what we'll do is we'll hook up electrodes to your head and usually it's 21 electrodes through the head. They're on the skin, nothing inserted into the skin, and they glue them on. So it'll make your hair sort of messy for a couple of days or a day. And what you do is ideally you come in a little bit, sleep deprived. We tend to ask people to have a half nights sleep prior to the study. And the idea is we want you to come in, go into this nice dark room and take a nap. 20-30 minutes. And what we're doing is we're looking at all the brainwaves. And your brainwaves are incredibly small. You know, it's interesting the eyeball has a charge that's a hundred times more than the brainwaves that we see. So when you blink, we can actually see a huge change in the charge and the EEG. But what I'm looking for is what we call epileptiform discharges. What are epileptiform discharges? They are certain wave forms. They look like big spikes. And when I see those in someone who's had a seizure, I know that there's a high degree of likelihood they're going to have another seizure. And that's often something that we'll use to treat someone for epilepsy. I will point out that one of the issues we have is the EEG is so useful, but it's an insensitive test. It's about 50% sensitivity. What does that mean? So if I take someone I know who has epilepsy and I do an EEG on them, half the time the EEG is normal. And so an abnormal test is really valuable because it's so insensitive. When I see something abnormal, that's something I can really use and sort of help understand what's going on with you. But when it's normal, you have to take it with a grain of salt because you can still have epilepsy and have a normal EEG. You can also have a normal MRI and have epilepsy. So this is sort of where we get into this difficult position where if someone comes in with a seizure, they have a normal MRI and EEG, we have a sometimes a difficult decision to make or we just, we can't know for sure. And so we have to make our best judgment and sort of go from there.
The other thing that we'll want, and equally important as the MRI, if not more important, is the electroencephalogram or EEG. An EEG is a test where what we'll do is we'll hook up electrodes to your head and usually it's 21 electrodes through the head. They're on the skin, nothing inserted into the skin, and they glue them on. So it'll make your hair sort of messy for a couple of days or a day. And what you do is ideally you come in a little bit, sleep deprived. We tend to ask people to have a half nights sleep prior to the study. And the idea is we want you to come in, go into this nice dark room and take a nap. 20-30 minutes. And what we're doing is we're looking at all the brainwaves. And your brainwaves are incredibly small. You know, it's interesting the eyeball has a charge that's a hundred times more than the brainwaves that we see. So when you blink, we can actually see a huge change in the charge and the EEG. But what I'm looking for is what we call epileptiform discharges. What are epileptiform discharges? They are certain wave forms. They look like big spikes. And when I see those in someone who's had a seizure, I know that there's a high degree of likelihood they're going to have another seizure. And that's often something that we'll use to treat someone for epilepsy. I will point out that one of the issues we have is the EEG is so useful, but it's an insensitive test. It's about 50% sensitivity. What does that mean? So if I take someone I know who has epilepsy and I do an EEG on them, half the time the EEG is normal. And so an abnormal test is really valuable because it's so insensitive. When I see something abnormal, that's something I can really use and sort of help understand what's going on with you. But when it's normal, you have to take it with a grain of salt because you can still have epilepsy and have a normal EEG. You can also have a normal MRI and have epilepsy. So this is sort of where we get into this difficult position where if someone comes in with a seizure, they have a normal MRI and EEG, we have a sometimes a difficult decision to make or we just, we can't know for sure. And so we have to make our best judgment and sort of go from there.
So with respect to confirming the diagnosis, that is sometimes something that we need to try to do. And in the circumstances where that comes in most frequently is we take the information initially that we get and we decide we're going to do something, treat or not treat and sort of see what happens. And if someone doesn't do well, seizures continue and we're trying to figure out, well shoot are they seizures, is there something else going on? What's happening? There is a more definitive way to diagnose seizures and that's with something called the video EEG often done in an epilepsy monitoring unit like we have here at TMC. And with that, what happens is someone comes in to the hospital and actually is admitted for a week and we put an EEG on their head and under careful supervision we often will withdraw medications. And the idea is to capture a seizure with the EEG on your head. And the idea is that that really is the gold standard for detecting seizures because if it is indeed a seizure we'll see that electrical storm or those electrical discharges in the brain change as the seizure progressive.
And it helps to have the patient who may not even recognize what's going on. And one of the difficult things that we have in epilepsy is that the organ, your brain involved in recognizing what's going on and in the environment and recognizing something isn't right. It's the organ that's not working right. And so inherently there's a problem, they're often in recognition by the patient themselves as to what's going on. So, that being said, the history is probably the most important part of what I need. But I'll augment that with other studies. The next thing that I'll want is an MRI of the brain. A CT scan can work, but an MRI is much more sensitive and much better. I'll point out a CT scan is as an x-ray where they take slices through your head and we can image the skull really well, but the brain is a little bit harder to see with x rays. Where an is a giant magnet. And it doesn't show the bone very well, but the brain itself, we see with exquisite detail. And what I'm looking for. I can't see seizures with an MRI. But what I can see is structural abnormalities in the brain that I know would be associated with seizures, certain types of stroke. Again, I'll point out not all strokes can cause seizures, but some can. Brain tumors, scar tissue, and sometimes very subtle scar tissue, but we can pick it up. So an MRI would be really useful. I will point out that for a new seizure patient, we usually want to do these studies with contrast. Contrast is really important. This is where they give you an IV and they inject contrast into your veins. And the idea is that can be much more sensitive for picking up things like brain tumors that we wouldn't necessarily pick up with a normal scan.
The symptoms of epilepsy are recurrent unprovoked seizures. It's important to recognize that, you know, the generalized tonic clonic seizure, then big convulsive event, a grand mal seizure, which is a term that frankly we try not to use, but we do, that is actually not the most common type of seizure. And it's those partial onset seizures, those staring and confusion spells, which are much more common. And you know, I see this very frequently, which is people just don't always recognize recognize that that was a seizure. They see it happen and they blame it on, you know, something else, whether it's a TIA often, is what they'll sort of label it as. And they're actually seizures. So this is one of those, one of those types of diagnoses that the patients, the families and the physicians have to sort of be specifically thinking about. And again, it's recognition that it's not a disease of childhood only. It's a disease that we're seeing and people over the age of 50 and 60 and especially as our population gets older, we're going to have to be more and more vigilant about picking it up.
The next question I often get asked is sort of well when should I call 911 if someone has a seizure. And so I would point out that if it's a first time seizure or anything that you're uncomfortable with calling 911. Get them in the hospital. That being said, if someone has epilepsy, we have a known seizure disorder, well it's probably not particularly helpful to go into the hospital every time someone has a seizure. So when do you go in a couple of circumstances. One if the seizure is particularly prolonged, how long is a prolonged seizure? About five minutes if the seizures. Longer than five minutes call nine one one. And so one of the things that I recommend when someone's having a seizure, it's just try to look at the clock, try to get some idea of what the time is. It's hard to do when you're panicking when a loved one is having seizure, do your best. The next thing that I would sort of pay attention to is back to back seizures. So when someone has a seizure, doesn't come back to their baseline and has another seizure and bolt those circumstances back to back seizures and prolonged seizures, they probably need intravenous medication to help control their seizures. Calling 911 the paramedics in Tucson are fantastic. They're trained to recognize seizures and treat them in the field if they need it, and they'll get them to a hospital where they can get the treatment that they need. Lastly, if anyone gets hurt, if there is any injury that you think is something you can't handle, you're not sure about, get them into the hospital. Outside of that, patients don't always need to come into the hospital for seizure. Often a call to the neurologist alerting them that they had the seizure and asking for what to do next is enough.
Often during these periods, people sort of look spacey. They'll stare off and they might have what are called automatisms are automatic behaviors. And so the common sort of automatisms people have will be lip smacking, swallowing repeatedly, or people can have actually hand automatisms where they'll rub their fingers together, they might pick at things absentmindedly. A typical duration for a seizure like this can be 30 seconds to about three minutes and they can be subtle. So often people don't notice or don't recognize these seizures. As someone sitting by themselves, by themselves watching TV, if you're not watching them like a hawk, you'd never know that they were necessarily having a seizure. After the seizure is over the brain is exhausted, and the person is often I'm exhausted too. And that is that they're often confused afterwards and sleepy. And that's often a big distinguishing kind of character between the absence seizures and a complex partial seizure. Because both of those seizures, you're sort of staring off, you're not responsive. But with a complex partial seizure, there's an aura often about 50% of the time. And then afterwards there's a postictal period or this sort of after a seizure period where you're just not right, confused, or sleepy often. If the seizure were to get even bigger, well then the motor cortex gets involved and it can cross over the connection between the two hemispheres, which is called the Corpus callosum and involve the other side of the brain. And then you'll get what are called secondarily generalized seizure where the body stiffens up and shakes. Again, we call it secondarily generalized cause it started in one focal area and then spread out. Again, you know, these are typically a few minutes at most in duration. Four minutes would be a long seizure. And then afterwards people are exhausted, wiped out, not their normal selves for minutes to hours afterwards.
I often get asked questions about epilepsy first aid or what do you do when someone has a seizure? Someone you care about has a seizure. How do you approach it? And there are some important things to sort of be aware of. First when someone has a seizure, and in general the type of seizures that we're talking about for this type of issue is a convulsive seizure whereas clear cut, someone's having a big old convulsion and it's scary. They like they're dying, they stopped breathing, their lips turn purple, they have fun with the mouth, there might be blood. What do you do? So the first thing I would tell people to do is check out the environment and make sure that person's in a safe place. If they're not in a safe place, try to safely move them. If you can. Next, let them have their seizure. Don't hold them down and by, absolutely, there should be no reason that you stick anything in their mouth. And there's this common fallacy that someone having a seizure will choke on their tongue. That won't happen. But if you try to stick your finger in their mouth, they'll bite your finger off, and then they'll choke on that. So keep everything away from the mouth, let them have the seizure, time the seizure if you can. And then once the seizure is over, you want to turn them on their side. After the seizures over, they often will have a hard time protecting their airway. And sometimes people will get nauseated and vomit and they can actually choke on their own vomit. And so having them on their side protects their airway so that they can clear it.
So if someone's coming to the office with seizures, be prepared to have an MRI of the brain, and EEG and a thorough history taken from the physician, or care provider that's treating you. I often talk to my patients about the fact that it's difficult, and I liken the perfect test or I think about the perfect test. And to me the perfect test is a pregnancy test. It's negative or it's positive end of story. You got your answer. In epilepsy and seizures, often that isn't the case. And so we're stuck as physicians trying to make our best diagnosis with the information that's available, recognizing that the information is far from perfect. And so how do I try to make that determination? What do I need to make a diagnosis of epilepsy in a patient? So first and foremost, the history from the patient and it's really, really useful to have the patient, the person coming in and someone else, a friend, family member, preferably who knows them, who can help kind of augment the story. And the idea here is that someone comes, someone's referred to me for a first time seizure, for instance. I want to know, I'm going to be very careful about trying to go back and ask about anything in the past that sounds like a seizure. About 50% of people with a first time seizure who come in for a first time seizure have actually had a seizure in the past. And it's sort of, sometimes because people don't recognize these complex partial seizures, they don't recognize some of the seizures cause they're subtle. They're not obvious. It takes a little bit of fishing this sort of determine that.
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