An approach to epilepsy

Abstract

The key to understanding and managing epilepsy is to decide whether seizures are genetic/idiopathic or caused by focal brain pathology. The classification of seizures was modified in 2010 after many variations of the original 1981 system and inconclusive debate. Major changes included abandoning many entrenched words and complete rejection of the Focal subsystem. While most of the reasoning is rational, the focal system is described in a long list of terms; general clinicians are therefore faced with a more challenging task than that required for understanding the old classification system. Some of the difficulties include using common words with non-intuitive neurological definitions, ambiguous words and the tendency to merge seizure categorisation with epilepsy. This article highlights some of the fundamental principles in trying to categorise seizures and offers a simplified way of using descriptive words to structure the organisation of Focal seizures. Focal seizures are broken down to A, B and C – an easy-to-remember schema for general clinicians, patients and carers. Words such as ‘Aura’ and ‘Blank stare’ are strategically used to represent old seizure types and how they may be linked in the same patient. Awareness or the lack thereof is explained and how the same patient may have different seizure types and combinations of these. There is less change in the Generalised seizures category, but these are often confused with Focal seizures. Absences are confused with blank stares, while Generalised Tonic-Clonic seizures (GTCSs) are confused with ‘Focal-onset evolving rapidly to GTCSs’. Diagrams to illustrate the concepts of Generalised and Focal are included, as well as tables to demonstrate the differences between seizures that appear similar and points to consider in separating them. Focal seizures may mimic almost any human behaviour. Sorting and grouping the symptoms of Focal seizures with awareness (auras) is covered, along with sorting both the former and those without awareness seizures (As and Bs) by brain lobes. Distinguishing between Generalised and Focal seizures is not merely an academic exercise. It assists in determining the aetiology and has a material impact on the choice of management. Appropriate management of seizures starts with identifying the various seizure types. Time will tell whether or not this new descriptive approach to organisation of seizures makes the task easier and more effective.