Epilepsy

Epilepsy is a chronic brain disease characterized by recurrent seizures resulting from excessive electrical activity of a group of neurons in the brain. Etiology

- Idiopathic (primary, essential, cryptogenic) epilepsy is observed in 75% of patients.
- Symptomatic (secondary) epilepsy
- Metabolic disorders
- hypoglycemia
- Hypoparathyroidism
- Phenylketonuria.
- Vascular disease and stroke
- cerebral infarction
- Vascular malformation
- Vasculitis
- Intracerebral hemorrhage.
- Volumetric processes in the brain
- Neoplasms
- intracranial hemorrhage
- Hematomas.
- Congenital brain damage.
- brain injury
- skull fracture
- Birth injury.
- Hypoxia of the brain
- Adams-Stokes Syndrome
- anesthesia
- Carbon monoxide poisoning
- Retention of breath.
- CNS infection
- Meningitis
- HIV infection
- brain abscess
- Encephalitis
- Neurosyphilis
- Rabies
- Tetanus
- malignant malaria
- Toxoplasmosis
- Cysticercosis of the brain.
- drugs and toxic agents
- Camphor
- Hingamin
- Corazol
- Strychnine
- Picrotoxin
- Lead
- Alcohol
- Cocaine.
- Anaphylactic reaction.
- Withdrawal syndrome later
- Anticonvulsant Therapy
- Taking tranquilizers Long-term use of alcohol.
- cerebral edema
- Hypertensive encephalopathy
- Eclampsia.
- Hyperpyrexia
- Acute infections
- Heatstroke. Genetic aspects – see Appendix 2. Hereditary diseases: mapped phenotypes.

Classification.

- Partial (focal, local) seizures
- Simple partial seizures (consciousness preserved) VC movement disorders (including Jacksonian epilepsy) -tr With somatosensory and specific sensory symptoms (hallucinosis)
- With vegetative traits
- With mental symptoms (dysphasic, dysmnesic, cognitive and affective symptoms).
- Complex partial seizures
- Simple partial seizures followed by disturbances of consciousness
- Just a disturbance of consciousness.
- Generalized seizures (consciousness impaired)
- Absences (petit mal – small epileptic seizure)
- Only with impaired consciousness
- with clonic component
- With an atonic component
- With tonic
- With automatisms
- With a vegetative component.
- Myoclonic seizures.
- clonic seizures.
- Tonic seizures.
- Tonic-clonic seizures (grand mal – a large convulsive seizure).
- Atonic seizures.
- Febrile seizures (convulsions) – Generalized convulsions that occur between the ages of 3 months and 5 years against the background of an increase in body temperature and are not due to any other reasons.
- epileptic status.
- Unclassified seizures.

Clinical picture

- General symptoms
- Seizures are often caused by an infectious disease,

clinically manifested fever.

- Focal neurological symptoms are characteristic of brain tumors or any other localized lesion.
- Edema of the optic disc indicates an increase in ICP.
- Foci of hemorrhages in the fundus are characteristic of arterial hypertension.
- Meningeal syndrome is the result of irritation of the membranes of the brain (including meningitis).
- Headache.
- A generalized seizure is always accompanied by impaired consciousness. There are primary generalized (bilateral involvement of the cerebral cortex) and secondary generalized (local involvement of the cortex with subsequent bilateral spread) seizures.
- Absences (petit mat) – primary generalized non-convulsive seizures in the form of a short-term loss of consciousness lasting from 10 to 30 seconds with minimal physical activity (blinking, myoclonic twitches with a frequency of 3 Hz)
- The patient suddenly stops his activity for the duration of the attack and resumes it immediately after the attack.
- Absences may occur several times a day, often while the patient is sitting quietly. Rarely seizures occur during exercise
- Absences are genetically determined, they are observed mainly in babies, they never begin after 20 years
- In the intervals between seizures, patients are completely normal.
- Clonicotonic seizures (grand mat, large convulsive seizures) – classic epileptic convulsions
- Convulsions may begin with an aura (discomfort in the epigastric region, involuntary head movements, visual and auditory hallucinations, etc.), followed by a cry, loss of consciousness and the patient’s fall
- A short phase of tonic contractions is followed by a phase of clonic convulsions, covering the muscles of the limbs, trunk and head.
- Involuntary urination and defecation may occur
- EEG: generalized epiactivity or spikes and slow waves
- Seizure duration – 2-5 minutes
- Seizure may be preceded by prodromal mood changes
- The post-seizure state is infrequently manifested by confusion, deep sleep, headache and muscle pain.
- Seizures can occur at any age.
- Myoclonic seizures are accompanied by sudden twitching of the muscles of the limbs or trunk; as a rule, they are observed with metabolic disorders, degenerative diseases, encephalitis.
- Atonic and akinetic epileptic seizures are primary generalized short-term seizures observed in babies and are characterized by a sharp loss of consciousness and muscle tone, as a result of which the child falls. A sudden fall does not often lead to injury.
- Sshshamov’s seizures (nodding convulsions, convulsions of greeting) – primary generalized seizures, manifested in a sharp bending of the arms, torso and extension of the legs
- Seizures last a few seconds but may recur several times a day
- Observed in the first 3 years of life, after which they are often replaced by other forms of seizures
- Brain damage has traditionally been clearly identified as the cause of seizures.
- partial seizure
- Simple partial seizures begin with specific focal motor, sensory, or psychomotor events without impairment of consciousness.
- Present with isolated tonic or clonic activity or transient sensory disturbances
- Epileptic activity may subsequently involve areas of the body – Jackson’s seizure (for example, starting on the face, involving the arm, then the leg) or have constant local manifestations, and then generalize (Kozhevnikov epilepsy)
- Often preceded by complex or generalized seizures
- EEG: focal epiactivity – spikes associated with slow waves during a seizure, and sometimes in the interictal period.
- Complex partial (psychomotor) seizures can occur at any age and are traditionally associated with organic changes.
- The seizure is often preceded by an aura, followed by disturbance of consciousness. The aura includes hallucinations (olfactory, gustatory, auditory, visual) or complex illusions (such as deja vu – already seen, jamais vu – never seen). It is not often that a seizure occurs without an aura.
- At the beginning of the seizure, the patient may stagger, make automatic useless movements, make inarticulate sounds; he does not understand speech and sometimes actively resists the assistance provided.
- The patient loses contact with others for 1-2 minutes
- Nausea or vomiting, local sensory or motor manifestations traditionally accompany complex seizures
- Confusion usually lasts 1–2 minutes after the seizure has ended.
- Some patients develop psychomotor status epilepticus – the patient is in a state of confused or inhibited consciousness for hours or days
- EEG: epiactivity in the temporal or frontotemporal regions.
- Febrile convulsion
- Appears between the ages of 3 months and 5 years
- Seizures appear on the background of fever
- Up to 4% of babies suffer, a genetic predisposition has been determined
- Benign (simple) seizures – brief, single, generalized; complicated – or focal, lasting more than 15 minutes, or occurring 2 or more times within 24 hours
- 2% of babies later develop epilepsy, the likelihood of epilepsy is higher in babies with complicated febrile seizures.
- Status epilepticus (continuous epileptic with
- padok)
- Motor, sensory and mental seizures follow each other, consciousness in the intervals between seizures is not fully restored
- Clonic-tonic status epilepticus can last for hours or days, often ending in death. Occurs spontaneously or as a result of too rapid withdrawal of anticonvulsant products
- Prolonged partial epilepsy is a form of rare focal (usually in the hands or face) motor seizures that recur at intervals of seconds or minutes, lasting days or weeks.
- Epileptic psychoses
- May occur acutely following one or a series of seizures, or gradually if not associated with seizures
- In the clinical picture, the whole spectrum of psychotic disorders is observed: hallucinatory-paranoid, affective-paranoid, catatonic and other syndromes
- Emotional saturation of experiences, rage, ecstasy are characteristic
- Delirium, as a rule, is grandiose in content (patients consider themselves great missionaries, masters of the cosmos, or, conversely, great sinners)
- Episodes of pronounced psychomotor agitation with aggression and destructive actions are often observed.
- Often the clinical picture resembles an attack of schizophrenia
- The duration varies from a few weeks to several years.
- Chronic personality changes in epilepsy
- The more pronounced the earlier the disease began
- Characterized by excessive sentimentality, obsequious attitude towards persons on whom the sick depend, suspicion, vindictiveness, excessive pedantry and the desire for order, in severe cases – vindictiveness, cruelty, outbursts of anger on minor occasions.
- Speech is slow, stereotypical, detailed, patients have difficulty switching from one topic of conversation to another
- In the malignant course of epilepsy, dementia develops: a decrease in intelligence, a limitation of the range of interests to one’s health and needs, selective memory loss (they only remember well what concerns their personality), in severe cases – lack of criticism, absurd behavior, disinhibition of instincts, cruelty, aggressiveness.

Laboratory research

- Peripheral blood test
- Changes characteristic of an acute infectious process
- Signs of metabolic disorders – changes in the content of glucose, sodium, potassium, calcium, phosphorus, magnesium, urea, etc.
- Determination of the content of drugs in the blood plasma (including anticonvulsant products) and toxic substances (usually alcohol). Special Studies
- EEG – susceptibility, specificity and scope of studies depend on the factors underlying the diseases and the anatomical localization of the focus of the seizure
- The 24-hour EEG is used for continuous monitoring of cortical activity.
- MRI and CT of the brain can determine the presence of focal changes in the substance of the brain. With the localization of the focus in the frontal and temporal lobes, generalized convulsions often appear.
- Drugs affecting results
- Anticonvulsant therapy may alter EEG results
- The blood concentration of anticonvulsants can change as a result of taking products such as erythromycin, sulfonamides, warfarin, cimetidine, and also when drinking alcohol. Differential diagnosis involves finding out the cause of an epileptic seizure (see Etiology) and other diseases similar in clinical manifestations
- Narcolepsy
- Migraine
- Fainting
- Simulation of an epileptic seizure
- Trigeminal neuralgia and other neuralgic syndromes
- Schizophrenia (with epileptic psychoses)
- Dementia.

Treatment:

Outpatient mode, except for epileptic

status.

Tactics of conducting

- Relief of an epileptic seizure with a combination of anticonvulsant products. During an attack, it will be necessary to monitor the patency of the respiratory tract, take measures to prevent biting and retraction of the tongue and protect the sick person from injury.
- Preventive treatment
- Correction of reversible disorders (metabolic disorders, arterial hypertension, fever, withdrawal symptoms)
- The choice of anticonvulsant depends on the type of seizure and side effects.
- The smallest number of drugs should be assigned in the most simplified reception scheme
- Prophylactic anticonvulsants are also taken in stressful situations.
- The content of the anticonvulsant product in the blood is determined by:
- at the initial appointment (after 2 weeks)
- when prescribing drugs that enter into drug interactions
- with treatment failure
- when symptoms of intoxication appear.
- If necessary, surgical treatment is indicated.
- Febrile seizures
- Decrease in body temperature
- With frequent febrile seizures, prophylactic administration of diazepam is likely – 0.33 mg / kg after 8 hours immediately after an increase in body temperature, the intake should be continued for 24 hours after normalization of body temperature. Surgery. Resection of the temporal lobe, excision of the cortical epileptic focus, and dissection of the corpus callosum can reduce the frequency and severity of seizures in some patients. Drugs of choice
- Generalized seizures.
- Clonic-tonic seizures (grand mat)
- Phenytoin (difenin) 200-400 mg/day in 1-3 doses (therapeutic concentration in the blood – 10-20 mcg/ml)
- Phenobarbital 100-200 mg/day in 1-2 doses (10-30 mcg/ml)
- Carbamazepine 600-1,200 mg/day in 2-4 doses (4-12 mcg/ml) a Valproic acid 750-1,000 mg/day in 1-3 doses; start with 15 mg / kg / day, increase the dose during the week by 5-10 mg / kg / day to 60 mg / kg / day (50-150 mcg / ml).
- Absences
- Ethosuximide 500–1,500 mg/day in 1–2 divided doses (therapeutic blood concentration 40–100 mcg/ml)
- Valproic acid
- Clonazepam nbsp; 0.01-0.03 mg / kg / day with a gradual increase to 0.1-0.2 mg / kg / day (up to 20 mg / day) in 2-3 doses (20-80 ng / ml )
- Oxazolidinediones (trimethadione [trimethine]) are prescribed only when other products are ineffective or contraindicated.
- Myoclonic seizures
- Valproic acid
- Clonazepam
- Withdrawal seizures (barbiturate or alcohol withdrawal syndrome)
- Phenytoin (difenin) for the relief of an acute attack
- Magnesium preparations for the prevention of seizures in alcohol withdrawal.
- Partial seizures
- Phenytoin
- Carbamazepine
- In psychosis (depending on the leading clinical syndrome) – antipsychotics, antidepressants, lithium products, tranquilizers.
- For status epilepticus
- Vitamin B, 100mg IV
- Glucose 25-50 g IV bolus (children 1 g/kg)
- Diazepam 10-20 mg IV or 10 mg IV every 15 minutes for 1 hour (children up to 0.3 mg/kg IV)
- To prevent recurrent attacks, diphenin is administered 500 mg IV at a rate of 50 mg / min, then 500 mg at 100 mg for 30 minutes (children – 10 mg / kg IV twice every 30 minutes)
- If diphenine is ineffective – phenobarbital 90-120 mg / e, can be repeated after 10-15 minutes up to 1000 mg (children -10 mg / kg, again – up to 25 mg / kg) or thiopental 2-4 mg / kg IV, then continuous infusion at a rate of 2–8 mg/kg/h
- Diazepam, barbiturates are administered with the likelihood of tracheal intubation.
- Precautions
- If you are taking anticonvulsant products, you will need regular blood tests.
- Cancellation of products is made within a few weeks
- Trimetin and valproic acid are absolutely contraindicated during pregnancy.
- Difenin
- Nystagmus when looking to the side is a sign that the patient is taking the product
- Walking ataxia and drowsiness are common clinical manifestations of toxic effects.
- If a measles rash occurs, another product is recommended
- Side effects: hirsutism, gingival hypertrophy, megaloblastic anemia, osteomalacia, lymphadenopathy, lupus-like syndrome
- Carbamazepine
- Side effects: leukopenia, liver dysfunction, rash
- Valproic acid
- Side effects: gastrointestinal disorders, sedation (especially with a rapid dose increase), ataxia, liver dysfunction, thrombocytopenia.
- drug interaction
- Difenin
- Warfarin isoniazid enhance the action of difenin
- With long-term use of barbiturates, the concentration of diphenine in the blood decreases.
- Valproic acid
- Increases the concentration of phenobarbital and changes the concentration of difenin in the blood.

Course and forecast

- Idiopathic epilepsy – the prognosis is relatively favorable, the frequency of seizures decreases with age. Seizures respond relatively easily to anticonvulsant therapy.
- Symptomatic epilepsy – the prognosis is less favorable. Seizures are much more difficult to treat. With complex partial seizures in the interictal period, mental disorders often appear that do not depend on the frequency of seizures.
- With status epilepticus, mortality is 6-18% (3-6% in infants) of cases. The prognosis worsens with the lengthening of seizures. The mortality rate for seizures lasting more than 12 hours is 80%.
- In the absence of seizures for more than 2 years, you can gradually stop taking anticonvulsant products. The resumption of seizures after 3 years after the withdrawal of products is noted in 33% of patients. Observation
- Regular monitoring of blood levels of anticonvulsants (see Management Tactics)
- Observation of the probable side effects of drugs and their prevention. Pregnancy
- The risk of congenital anomalies increases by 2 times when a pregnant woman takes anticonvulsant products, therefore, for the entire period of pregnancy, and especially in the first trimester, it is recommended to reduce their dose
- If an attack, a particularly grand mal seizure, occurs when the dose of anticonvulsants is lowered, the dose will need to be increased immediately.
- Folic acid is recommended to reduce the risk of congenital anomalies during anticonvulsant therapy.
- Breastfeeding while the mother is taking anticonvulsants is not contraindicated, but the concentration of the product in the mother’s blood will need to be monitored. Age features
- Idiopathic epilepsy traditionally begins between 2 and 14 years of age.
- Seizures before the age of 2 years are traditionally associated with developmental defects, birth trauma, or metabolic disorders.
- At the age after 25 years, symptomatic epilepsy traditionally occurs due to trauma, tumor or other organic pathology of the brain.

ICD

G40 Epilepsy
G41 Status epilepticus The term samshma seizures comes from the Arabic salam – an oriental ceremonial greeting in the form of a low bow.