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THE DIAGNOSIS OF EPILEPSY
There are numerous tests that can be used to try and diagnose epilepsy. This chapter outlines some of the investigations that your doctor may suggest to you as being worthwhile.
Clinical history
The most important aspect in making a diagnosis of epilepsy is obtaining a good description of the seizures, either from the patient, parent or other people who may have witnessed the fit. An eye witness account is of great value. In the history, it is important for the doctor to obtain information about the patient’s birth, subsequent illnesses and whether or not there is a family history of epilepsy. It is also of value to obtain information on any events that may have led up to the seizure.
Physical examination
All patients with epilepsy should have a full physical examination the first time they present to their doctor. In primary (idiopathic) epilepsy, physical examination is usually normal. In secondary epilepsy, there may be abnormalities of the nervous system which can be detected. Clinical and laboratory tests
There are a number of investigations which may be necessary in an attempt to make a diagnosis of epilepsy.
Laboratory tests
Your doctor may suggest tests which include measuring the blood sugar concentration, blood calcium, magnesium and, rarely, amino acids. It may also, in certain situations, be desirable to look at the child’s chromosome pattern. A lumbar puncture, which means obtaining a sample of spinal fluid, is needed in some cases, but is not a routine investigation in epilepsy.
Skull X-ray
In a limited number of patients a skull X-ray may be of some help. It is rarely of any value in idiopathic epilepsy.
Electroencephalography
The electroencephalograph (EEG) measures differences in electrical activity between different parts of the head, arising from the spontaneous activity of the underlying brain cells.
Routine EEG: when your doctor requests an EEG for you, or your child, this entails going to an EEG laboratory where electrodes will be placed on the scalp and connected to an electrical recorder. Routine recordings may be made sitting or lying down. While the recording takes place, it is important that the subject be relatively still, as any muscular movement may be recorded on the EEG tracing and will make it difficult to interpret. Keeping still can be difficult for children and to get a satisfactory recording from a young child may take well over an hour.
The EEG is regarded by many, parents included, as the mainstay of the diagnosis of epilepsy. While this may be true, it is important to bear in mind that the EEG has some very real limitations. These include the fact that from a technical point of view it may be difficult to obtain an adequate recording in a young child. Perhaps more important is the fact that often patterns obtained on an EEG are non-specific. In other words, they suggest that something might be wrong, but do not provide precise information as to what the problem is. Furthermore, it is important to remember that an EEG is recorded over a short period of time, perhaps 20 minutes, so that for the person who has occasional fits, the EEG may be quite normal at the time that it is done. About 40% of patients with epilepsy have a normal EEG and about 25% of non-epileptic persons have an abnormal EEG. Thus the EEG does not necessarily give the whole answer.
The advantages of the EEG are that it is a relatively short test, painless and inexpensive. In some cases it may allow a precise diagnosis to be made. It also provides a permanent record which can be used as a progress report when required. It may be carried out when the patient is awake or asleep as these two different states affect the EEG and may be diagnostically helpful.
The EEG in childhood is more difficult to interpret than it is in adults. This is because of brain growth and maturation in childhood. It is important that an EEG performed on a young child be interpreted by someone experienced in looking at such EEGs.
Special EEG studies: occasionally it may be necessary to do a more sophisticated EEG in patients where there is diagnostic difficulty. Telemetry implies the use of long-term EEG recording techniques, with or without video observation, to allow better definition of complex or ill-explained fits. This is done by obtaining an EEG recording during the actual fit. It is of value in people with complicated epileptic problems.
Computerized tomography (CT scanning)
This is an X-ray procedure in which the patient lies with the head held still in an X-ray machine. A rapid sequence of X-rays of the skull and brain within it are taken and then an injection of dye is given and the sequences repeated. It is a painless procedure, although young children may be a bit scared by all the machinery. As it is imperative to lie still to get adequate pictures, it may be necessary to give a light general anaesthetic in the very young child.
In primary (idiopathic) epilepsy, the CT scan is often of little help. In less than 10% of persons is any useful information obtained. On the other hand, in secondary epilepsy the CT scan is a lot more useful as the brain damage can actually be seen. It will not detect very small lesions.
PET scanning and MRI
These two techniques, positron emission tomography (PET) and magnetic resonance imaging (MRI), both have the potential to assist in the diagnosis of epilepsy, especially PET scanning. They are very expensive techniques and so are not widely available. This is quite appropriate as these techniques will not be applicable to the majority of people with epilepsy. They will, however, be of use to epileptics with particular problems.
How many investigations any one person may need will depend upon the amount of information obtained after getting a history and examining the patient. It will also be related to the type of epilepsy and its severity. As stated in 1979 by Niall O’Donohue, a noted paediatric neurologist: “At all times, the physician should resist the mania for modern investigation. This is always expensive and time-consuming and frequently in the worst interests of the patient. There are no ‘routine’ investigations; there are only those that are indicated by the specific diagnostic problems presented by the patient.”
I am reminded of the 24-year-old patient I saw some years ago after he had had three grand mal fits over a period of 20 months. Each fit was embellished by an EEG and a CT scan. Both were normal on each occasion! How fortunate for him (and his doctor) that he was fully insured. Patients, and in the case of children, their parents, have the right to know what the tests are being done for, their relative risk and worth. Obtain this information from your doctor. If the explanation is unclear to you, get a second opinion. You are quite entitled to consult a second doctor if you so wish.
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