Seizures are the manifestation of uncontrolled electrical activity in the brain. Affected individuals show clinical symptoms of seizures with twitching or jerking of one side or their entire body. With this they can make gasping noises, turn blue in the face, bite their tongue or lose control of their bladder. These symptoms are charateristic of a grand mal seizure. During an epileptic attacks, the person is not responsive or aware of what is going on around them. Fortunately there is excellent treatment available to control seizures and in many cases, keep patients seizure free.

It is estimated that there are 2-3 million individuals in the United States who suffer from recurrent seizures (epilepsy.) Many of these people are neurologically intact with the cause of their seizures being unknown. It is estimated that up to 10 percent of the population will suffer a single seizure in their life time. This does not mean that they will go on to have recurrent seizures or epilepsy. The average lifetime risk of having recurrent seizures is 3 percent.

Risk of developing seizures include prior head injuries, alcohol or drug abuse, stroke, meningitis or other brain infections. Brain damage from trauma, surgery or tumors can also predispose to seizures. For anyone who has even a single seizure, they should see a neurologist for a complete evaluation. A minimum of screening lab work, an EEG (electroencephalogram) and MRI brain scan should be done. Of course a complete history and physical (neurological) exam is also required. One important point to remember is that a normal EEG does not exclude the possibility that a patient suffers from seizures. In fact, approximately 70 percent of patients with recurrent seizures will have a normal EEG at all times other than during the time when they are having a seizure.

Fortunately there are several excellent seizure preventing medications (anticonvulsants) available. For decades, Dilantin, Tegretol and Depakote were the mainstay in seizure treatment. In the 1990s, several new anticonvulsants received FDA approval. These included Felbatol, Topamax, Lamictal, Neurontin, Keppra and Zonegran. In 2005, the FDA approved Lyrica for treatment of seizures. Although highly effective in controlling and stopping seizures, the newer anticonvulsants are overall no more effective than the older agents. One benefit of the newer agents is that they do not require as much lab monitoring as the older agents. Some anticonvulsants, such as Lamictal, Neurontin and Lyrica require no lab monitoring.

In summary, patient with recurrent seizures (epilepsy) or for those that have had a single seizure but are at high risk for further seizures, there are a number of therapeutic options available to control their seizures and improve their quality of life. Many patients can have complete control of their seizures, meaning seizure free, with appropriate evaluation and treatment. Most neurologically intact individuals can lead normal lives with specific seizure care by a neurologist. This fact has been shown through many studies on seizures and is the foundation of evidence based medicine for seizure control. It is critical that they see a neurologist as soon as possible, after their first attack, so that proper evaluation and treatment can be started.

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Myasthenia gravis is a rare disorder of muscle weakness, affecting approximately 70,000 individuals in the United States. Many confuse this with multiple sclerosis. Multiple sclerosis is a central nervous system disorder affecting the insulation (myelin) on nerve cells in the brain and spinal cord. In contrast myasthenia gravis is a muscle disease where transmission of electrical impulses to the muscle fail. This results in the muscle not contracting fully, resulting in weakness. This condition can selectively affect the eye muscles, muscles of the head and neck or be generalized affecting all muscle, including the diaphragm. If the diaphragm is involved, patients can have varying degrees of breathing problems, including respiratory failure.

Myasthenia gravis (MG) is the standard model of a neurological autoimmune disorder. It is the the best understood of all autoimmune diseases. In autoimmune diseases, the body’s immune system fails to recognize a particular body system as being part of “itself.” In MG, the immune system does not recognize the transmitter receptors for acetylcholine (the muscle communication transmitter) as being part of the body’s own system. The immune system for antibodies against the receptors and attacks them. With fewer receptors on the muscle membrane, the muscle does not get the full chemical message to contract. This causes affected individuals to have weakness in the muscles affected by MG. These antibodies can be detected by a blood test for acetylcholine receptor antibodies. It is important to note, however, that not all patients with myasthenia will have a positive antibody test, known as a false negative (as high as 25%.) Particularly patients with ocular myasthenia frequently have negative tests. This does not mean that they do not have the condition.

Diagnosis of myasthenia is based on a careful medical history and detailed neurological exam. All patients with MG have some degree of visual symptoms including double vision or eyelid drooping. The presence of variable eyelid drooping, particularly if it shifts from side to side, is virtually diagnostic of myasthenia gravis. Confirmatory tests can include EMG testing and a chemical test known as the Tensilon test. Tensilon (edrophonium) is a chemical that temporarily blocks the enzyme that stops the action of acetylcholine. This has the effect of making the acetylcholine receptors that are “on” stay on longer, thereby combating weakness. Patient’s with suspected myasthenia can be given Tensilon. This short acting drug will temporarily reverse the weakness that myasthenic patients have. Other lab work should be performed to exclude other muscle diseases, thyroid problems or other metabolic problems that could cause muscle weakness.

Once the diagnosis is made, patients can be treated with Mestinon ( pyridostigmine.) Mestinon is a long acting version of Tensilon and works by inhibiting cholinesterase, the chemical that breaks down acetylcholine. If we did not have this enzyme, we could not relax our muscles. When acetylcholine is removed from the muscle receptor the muscle no longer contracts. Mestinon works well for symptomatic relief of the muscle weakness and associated symptoms of MG. Other symptoms associated with weakness can include chewing and swallowing difficulties, weakness of breathing with shortness of breath and generalized weakness. Double vision and drooping eyelids, conditions made worse by being in bright sun light, are frequent complaints.

For patients that have persistent symptoms, despite Mestinon therapy, clinicians will frequently employ the use of immunosuppressant therapy that will dampen the response of the immune system. This has the effect of limiting the destruction of the acetylcholine receptors on the muscle membrane surface. The most commonly used drug for this is Prednisone, a steroid drug, frequently used to treat autoimmune disorders. Although Prednisone works very well, it has its downside. Prednisone side effects can include weight gain, elevated blood sugar, cataracts, accelerated osteoporosis and other serious medical problems. Other immunosuppressants have been used with success. These include Imuran (azathioprine), cyclosporine, Cytoxan (cyclophosphamide) and CellCept (mycophenolate.) While being helpful in treating MG, these powerful immunosuppresants have their own lists of potential side effects. The purpose of immunosuppressant therapy is to cause myasthenia to go into remission. This is not always successful.

For patient’s with a severe worsening of their myasthenia symptoms, hospitalization may be necessary. Higher dosage, intravenous steroids can be given in combination with a blood filtering technique, known as plasmaphersis. The latter is used to filter out the acetylcholine receptor antibodies. A surgical technique, thymectomy, can be used to remove the thymus gland in the chest. This gland is responsible for making the cells that make the acetylcholine receptor antibodies.

Myasthenia gravis is a serious neurological condition and autoimmune disease characterized by muscle weakness that can affect vision, swallowing, breathing and general activities. Serious complications, including respiratory failure, can develop for untreated patients. Affected individuals should seek out care from a board certified neurologist, preferably one specializing in movement disorders or neuromuscular disease.

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