WHAT IS A GRAND MAL SEIZURE?

     An elderly patient was recently being seen to adjust medications.  The visit was nearly over and he asked, “Doc, what is a grand mal seizure?”  It seems his grandson living in another state was diagnosed with epilepsy after the child had several grand mal seizures.  My patient wondered what lay in store for his grandson because of this diagnosis.  Could the child go to school?  Could the child drive a car?  Was this going to kill the child? Can the seizures be stopped?  I finally had to slow him down and answer one question at a time.

     Personal stories often make the best examples.  My story is at a friend’s house with an end of school swimming party around the first of June.  The swimming pool was a modest 60 feet long.  A group of the students started swimming the length of the pool under water and then somebody said they could swim the length and back again.  As you might expect, soon there was someone bragging that they could swim the length of the pool, back again, and then do a third trip down the pool underwater without ever coming up for a breath.  The bets were made and my friend fully expected to win a case of beer for his efforts.

     So, he sat on the edge of the pool and took a lot of real deep breaths pretty fast.  He envisioned storing up enough oxygen to let him win the bet.  He dove off the edge of the pool and made the first length with ease, swam back the second length still going strong.  He turned and started the third lap.  He got half way down the pool and came to the surface for an instant.  He then sank like a rock.  Fortunately, there was a lifeguard who recognized what had happened.  The lifeguard dove in and fished him out to the side of pool.  My friend then proceeded to have a grand mal seizure due to the lack of oxygen getting to his brain.

     As the seizure started, my friend was quite blue and his left arm began to twitch uncontrollably.  Soon the left shoulder was involved and his head pulled strongly toward the left side.  Over the next 10 to 15 seconds (seemed like years), the right arm began to twitch in addition and then he arched his back in a tense spasm turning to his side involuntarily.  Finally both legs began to twitch.  During the seizure, several bystanders became very distressed and tried to hold his arms and legs so that he wouldn’t hurt himself thrashing about on the concrete next to the pool.  As his arm twitched back and forth, there was no way that they could hold him still.  The trashing was very violent and very strong.  He bit his tongue and bled from his mouth.  He lost his urine.  Finally, the twitching stopped and he lay unconscious as he had been since he was removed from the swimming pool perhaps less than two minutes before.  The lifeguard started artificial respiration pushing on his chest but no water came out of his mouth.  Certainly in no less then 30 seconds (again seemed like 30 years) he took a deep gasp of air, choked violently and began to breath.  In a few minutes his color returned.  Within several minutes, his consciousness returned and he sat up wondering if he had won his beer.  We gave it to him just for the effort even though he hadn’t completed the three cycles underwater.  We took him to the emergency room for evaluation where the doctor said that my friend needed to have further evaluations of the head.  My friend was still a little confused and slow at this point asking if it was because of the seizure.  The doctor joked at that point and said the examination was really needed to figure out why supposedly smart medical students do such stupid things.

     I told this story to my patient whose grandson had grand mal seizures.  I added that after a grand mal seizure the person frequently is very fatigued and sometimes will have very sore muscles from all the work of pulling one muscle against the other in an uncontrolled way.  When elderly people have a grand mal seizure, they will sometimes break their bones if osteoporosis is a problem.

     The story continues about my college friend with him getting an electroencephalogram evaluation, multiple blood tests, and various x-rays of the head.  They all returned within normal limits.  It was not felt that my medical student friend needed a medication to prevent the next seizure. He simply needed not to put himself in harms way as he had.

     My grandfather patient who asked what a grand mal seizure was noted that his grandson with epilepsy had multiple grand mal seizures over several months time and had been advised to take medication. The grandson really wasn’t interested in taking medications and had tried stopping them several times with resultant recurrent seizures.  One of these seizures had resulted in a fall with severe bruising to the side of the head.  The grandson finally had decided to take medications on schedule to prevent further seizures.

     Other questions that the grandfather asked had to do with whether the seizures could be stopped with medications. The answer is most of the time one or more medications in combination can be used to stop seizures.  Unfortunately, for those individuals who have epilepsy with recurrent seizures, taking a medication on a long term basis is required.  Like my medical student friend who had only the one seizure at a time when he had no oxygen to his brain, children may have a single seizure in response to a very high fever and not require medications long term.  But true epilepsy in which the seizures recur frequently unless treated does require long term medication use.  My grandfather patient then asked if his grandson could go to college and obtain a degree and get a job.  The answer to all of those questions is yes.  People with epilepsy do function very normally if they take their medications.  If they neglect the medications, recurrent seizures are a predictable likelihood.

     The last question my grandfather patient asked was whether the seizure would kill the grandson.  The answer is no.  Unless the seizures are secondary to another condition that is fatal, the seizures by themselves are not fatal. They only cause harm depending upon what activity the person might be involved with when a seizure occurs.  If the seizure occurs while a person is driving a car, severe consequences can occur.  Thus if a person with epilepsy is going to lead a “normal” life, medication constancy is very important.

     One of the most powerful people in our history was Julius Caesar.  He ruled Rome at its height.  He had grand mal epilepsy at a time when there was no medication to help and somehow was still able to rule the entire Roman Empire.  Thus, epilepsy by itself does not preclude high accomplishment.

     Next week’s column will discuss the medications available to treat grand mal epilepsy, their side effects and their expected benefits.  A discussion of the cause of epilepsy will be very short.  We haven’t got a clue as to why these things occur.  We fortunately do have very effective treatments.