Epilepsy is a condition characterized by repeated (more than two) epileptic seizures, not provoked by any immediately identifiable causes. Epileptic seizure is a clinical manifestation of abnormal and excessive discharge of neurons of the brain, causing sudden transient pathological phenomena (sensitive, motor, mental, vegetative symptoms, changes in consciousness). It should be remembered that several epileptic seizures provoked or caused by any distinct causes (brain tumor, TBI) do not indicate the presence of epilepsy in the patient.
ICD 10
G40 Epilepsy
General information
Epilepsy is a condition characterized by repeated (more than two) epileptic seizures, not provoked by any immediately identifiable causes. Epileptic seizure is a clinical manifestation of abnormal and excessive discharge of neurons of the brain, causing sudden transient pathological phenomena (sensitive, motor, mental, vegetative symptoms, changes in consciousness). It should be remembered that several epileptic seizures provoked or caused by any distinct causes (brain tumor, TBI) do not indicate the presence of epilepsy in the patient.
Classification
According to the international classification of epileptic seizures, partial (local, focal) forms and generalized epilepsy are distinguished. Focal epilepsy attacks are divided into: simple (without disorders of consciousness) — with motor, somatosensory, vegetative and mental symptoms and complex — accompanied by a violation of consciousness. Primary generalized seizures occur with the involvement of both hemispheres of the brain in the pathological process. Types of generalized seizures: myoclonic, clonic, absences, atypical absences, tonic, tonic-clonic, atonic.
There are unclassified epileptic seizures — not suitable for any of the above types of seizures, as well as some neonatal seizures (chewing movements, rhythmic eye movements). There are also repeated epileptic seizures (provoked, cyclical, accidental) and prolonged seizures (epileptic status).
Symptoms
There are three periods in the clinical picture of epilepsy: ictal (period of attack), postictal (post-attack) and interictal (inter-attack). In the postictal period, there may be a complete absence of neurological symptoms (except for the symptoms of the disease causing epilepsy — traumatic brain injury, hemorrhagic or ischemic stroke, etc.).
There are several main types of aura that precedes a complex partial attack of epilepsy — vegetative, motor, mental, speech and sensory. The most common symptoms of epilepsy include: nausea, weakness, dizziness, a feeling of compression in the throat, a feeling of numbness of the tongue and lips, chest pain, drowsiness, ringing and / or tinnitus, olfactory paroxysms, a feeling of a lump in the throat, etc. In addition, complex partial seizures in most cases are accompanied by automated movements that seem inadequate. In such cases, contact with the patient is difficult or impossible.
A secondary generalized attack begins, as a rule, suddenly. After a few seconds that the aura lasts (each patient has a unique aura flow), the patient loses consciousness and falls. The fall is accompanied by a peculiar cry, which is caused by a spasm of the glottis and a convulsive contraction of the chest muscles.
Then comes the tonic phase of an epilepsy attack, so named after the type of seizures. Tonic convulsions — the trunk and limbs are stretched out in a state of extreme tension, the head is thrown back and / or turns to the side, the contralateral lesion, breathing is delayed, veins in the neck swell, the face becomes pale with slowly increasing cyanosis, the jaws are tightly compressed. The duration of the tonic phase of the attack is from 15 to 20 seconds.
Then comes the clonic phase of an epilepsy attack, accompanied by clonic convulsions (noisy, hoarse breathing, foam from the mouth). The clonic phase lasts from 2 to 3 minutes. The frequency of convulsions gradually decreases, after which complete muscle relaxation occurs, when the patient does not react to stimuli, the pupils are dilated, their reaction to light is absent, protective and tendon reflexes are not called.
The most common types of primary generalized seizures, characterized by involvement in the pathological process of both hemispheres of the brain – tonic—clonic seizures and absences. The latter are more often observed in children and are characterized by a sudden short-term (up to 10 seconds) stop of the child’s activity (games, conversation), the child freezes, does not respond to the call, and after a few seconds continues the interrupted activity. Patients do not realize and do not remember seizures. The frequency of absences can reach several dozen per day.
Diagnostics
Diagnosis of epilepsy should be based on anamnesis data, physical examination of the patient, EEG and neuroimaging data (MRI and CT of the brain). It is necessary to determine the presence or absence of epileptic seizures according to the anamnesis, clinical examination of the patient, the results of laboratory and instrumental studies, as well as differentiate epileptic and other seizures; determine the type of epileptic seizures and the form of epilepsy; familiarize the patient with the recommendations for the regimen, assess the need for drug therapy, its nature and the likelihood of surgical treatment. Despite the fact that the diagnosis of epilepsy is based primarily on clinical data, it should be remembered that in the absence of clinical signs of epilepsy, this diagnosis cannot be made even in the presence of epileptiform activity detected on the EEG.
Diagnosis of epilepsy is performed by neurologists and epileptologists. The main method of examination of patients diagnosed with epilepsy is EEG, which has no contraindications. EEG is performed in all patients without exception in order to detect epileptic activity. More often than others, such variants of epileptic activity are observed as acute waves, spikes (peaks), complexes “peak — slow wave”, “acute wave — slow wave”. Modern methods of computer analysis of EEG allow us to determine the localization of the source of pathological bioelectric activity. When EEG is performed during an attack, epileptic activity is recorded in most cases, in the interictal period, EEG is normal in 50% of patients.
On EEG in combination with functional tests (photostimulation, hyperventilation), changes are detected in most cases. It should be emphasized that the absence of epileptic activity on the EEG (with or without functional tests) does not exclude the presence of epilepsy. In such cases, a second examination or video monitoring of the EEG performed is carried out.
In the diagnosis of epilepsy, the most valuable among neuroimaging research methods is brain MRI, which is shown to all patients with a local onset of an epileptic seizure. MRI allows you to identify diseases that have affected the provoked nature of seizures (aneurysm, tumor) or etiological factors of epilepsy (mesial temporal sclerosis). Patients with a diagnosis of “pharmacoresistant epilepsy” in connection with subsequent referral for surgical treatment also undergo MRI to determine the localization of CNS lesion. In some cases (elderly patients), additional studies are necessary: biochemical blood analysis, fundus examination, ECG.
Seizures of epilepsy should be differentiated from other paroxysmal states of non-epileptic nature (fainting, psychogenic seizures, vegetative crises).
Treatment
Conservative therapy
All methods of treatment of epilepsy are aimed at stopping seizures, improving the quality of life and stopping taking medications (at the stage of remission). In 70% of cases, adequate and timely treatment leads to the cessation of epilepsy attacks. Before prescribing antiepileptic drugs, it is necessary to conduct a detailed clinical examination, analyze the results of MRI and EEG. The patient and his family should be informed not only about the rules of taking medications, but also about possible side effects. Indications for hospitalization are: for the first time in life, an epileptic seizure has developed, an epileptic status and the need for surgical treatment of epilepsy.
One of the principles of medical treatment of epilepsy is monotherapy. The drug is prescribed at a minimum dose, followed by its increase until the seizures stop. In case of insufficient dose, it is necessary to check the regularity of taking the drug and find out whether the maximum tolerated dose has been achieved. The use of most antiepileptic drugs requires constant monitoring of their concentration in the blood. Treatment with pregabalin, levetiracetam, valproic acid begins with a clinically effective dose, when prescribing lamotrigine, topiramate, carbamazepine, slow titration of the dose is necessary.
Treatment of newly diagnosed epilepsy begins with both traditional (carbamazepine and valproic acid) and the latest antiepileptic drugs (topiramate, oxcarbazepine, levetiracetam) registered for use in monotherapy. When choosing between traditional and the latest drugs, it is necessary to take into account the individual characteristics of the patient (age, gender, concomitant pathology). Valproic acid is used to treat unidentified epilepsy attacks.
When prescribing an antiepileptic drug, one should strive for the lowest possible frequency of its administration (up to 2 times / day). Due to the stable concentration in plasma, prolonged-acting drugs are more effective. The dose of the drug prescribed to an elderly patient creates a higher concentration in the blood than a similar dose of the drug prescribed to a young patient, therefore it is necessary to start treatment with small doses followed by their titration. Withdrawal of the drug is carried out gradually, taking into account the form of epilepsy, its prognosis and the possibility of resumption of seizures.
Surgical treatment
Pharmacoresistant epilepsies (ongoing seizures, ineffectiveness of adequate antiepileptic treatment) require additional examination of the patient to resolve the issue of surgical treatment. Preoperative examination should include video EEG recording of seizures, obtaining reliable data on localization, anatomical features and the nature of the spread of the epileptogenic zone (MRI).
Based on the results of the above studies, the nature of the surgical intervention is determined: surgical removal of epileptogenic brain tissue (cortical topectomy, lobectomy, hemispherectomy, multilobectomy); selective surgery (amygdalo-hippocampectomy for temporal epilepsy); callosotomy and functional stereotactic intervention; vagus stimulation.
There are strict indications for each of the above surgical interventions. They can be carried out only in specialized neurosurgical clinics with appropriate equipment, and with the participation of highly qualified specialists (neurosurgeons, neuroradiologists, neuropsychologists, neurophysiologists, etc.).
Prognosis and prevention
The prognosis for working capacity in epilepsy depends on the frequency of seizures. At the stage of remission, when seizures occur less and less frequently and at night, the patient’s ability to work remains (in conditions of exclusion of night shift work and business trips). Daytime seizures of epilepsy, accompanied by loss of consciousness, limit the patient’s ability to work.
Epilepsy affects all aspects of the patient’s life, therefore it is a significant medical and social problem. One of the facets of this problem is the paucity of knowledge about epilepsy and the associated stigmatization of patients whose judgments about the frequency and severity of mental disorders accompanying epilepsy are often unfounded. The vast majority of patients receiving proper treatment lead a normal lifestyle without seizures.
Prevention of epilepsy provides for the possible prevention of TBI, intoxication and infectious diseases, prevention of possible marriages between patients with epilepsy, adequate reduction of temperature in children in order to prevent fever, the consequence of which may be epilepsy.