Epilepsy. Symptoms, treatment.

dr.thomas
MEDICAL SPECIALIST Dr. Thomas Pitts

This content has been written and checked for quality and accuracy. Content Administrator Updated on: 17/10/2023. Next review: 17/04/2024

General Information

Epilepsy is a condition characterized by recurrent (more than two) epileptic seizures not provoked by any immediately definable cause. An epileptic seizure is a clinical manifestation of an abnormal and excessive discharge of brain neurons, causing sudden transient pathological phenomena (sensory, motor, mental, vegetative symptoms, changes in consciousness). It should be remembered that several epileptic seizures provoked or caused by any distinct causes (brain tumor, CMT) do not indicate that the patient has epilepsy.

Classification

According to the international classification of epileptic seizures are partial (local, focal) forms and generalized epilepsy. Seizures of focal epilepsy are divided into: simple (without impairment of consciousness) – with motor, somatosensory, autonomic and mental symptoms and complex – accompanied by impairment of consciousness. Primary generalized seizures occur with 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 that do not fit any of the above types of seizures, as well as some neonatal seizures (chewing movements, rhythmic eye movements). There are also recurrent epileptic seizures (provoked, cyclic, occasional) and prolonged seizures (status epilepticus).

Symptoms of epilepsy

In the clinical picture of epilepsy there are three periods: ictal (seizure period), postictal (postictal) and interictal (interictal). In the postictal period, there may be a complete absence of neurological symptoms (except symptoms of the disease that causes epilepsy – craniocerebral trauma, hemorrhagic or ischemic stroke, etc.).

There are several main types of aura, preceding a complex partial attack of epilepsy – vegetative, motor, mental, speech and sensory. The most common symptoms of epilepsy include nausea, weakness, dizziness, throat tightness, tongue and lip numbness, chest pain, drowsiness, ringing and/or noise in the ears, olfactory paroxysms, lumpy feeling in the throat, etc. In addition, complex partial seizures are in most cases accompanied by automatized movements that seem inadequate. In such cases, contact with the patient is difficult or impossible.

A secondary generalized seizure usually begins suddenly. After a few seconds of aura (the course of the aura is unique for each patient), the patient loses consciousness and falls down. The fall is accompanied by a peculiar cry, which is due to the spasm of the vocal slit and convulsive contraction of the muscles of the chest.

Then comes the tonic phase of the epilepsy attack, so named for the type of convulsions. Tonic convulsions – the torso and limbs stretch out in a state of extreme tension, the head tilts and/or turns to the side contralateral to the lesion, breathing is delayed, the veins in the neck swell, the face becomes pale with slowly increasing cyanosis, the jaw is tightly clenched. The tonic phase of the attack lasts 15 to 20 seconds.

Then comes the clonic phase of an epilepsy attack, accompanied by clonic convulsions (noisy, hoarse breathing, foaming from the mouth). The clonic phase lasts 2 to 3 minutes. The frequency of convulsions gradually decreases, followed by complete muscle relaxation, when the patient does not react to stimuli, pupils are dilated, their reaction to light is absent, protective and tendon reflexes are not evoked.

The most common types of primary generalized seizures, distinguished by involvement of both hemispheres of the brain in the pathological process, are 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) interruption of the child’s activity (playing, talking), the child freezes, does not react to a call, and in a few seconds continues the interrupted activity. Patients do not realize or remember the seizures. The frequency of absences can reach several dozen per day.

Diagnosis

Diagnosis of epilepsy should be based on the history, 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, and to differentiate between epileptic and other seizures; determine the type of epileptic seizures and form of epilepsy; familiarize the patient with the recommendations of the regime, assess the need for medication therapy, its nature and the possibility 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 the responsibility of neurologists and epileptologists. The main method of examination of patients with the diagnosis of “epilepsy” is EEG, which has no contraindications. EEG is performed on all patients, without exception, to detect epileptic activity. The most frequently observed types of epileptic activity are sharp waves, spikes (peaks), “peak – slow wave”, “sharp wave – slow wave” complexes. Modern methods of computer analysis of the EEG make it possible to determine the localization of the source of pathological bioelectrical activity. When EEG is performed during a seizure, epileptic activity is registered in most cases, in the interictal period EEG is normal in 50% of patients.

EEG in combination with functional tests (photostimulation, hyperventilation) reveals changes in most cases. It should be emphasized that the absence of epileptic activity on the EEG (with or without the use of functional tests) does not rule out the presence of epilepsy. In such cases, repeat examination or video monitoring of the EEG is performed.

In the diagnosis of epilepsy the most valuable among the neuroimaging methods of research is brain MRI, which is shown to all patients with local onset of epileptic seizures. MRI allows identifying the diseases that influenced the provoked character of seizures (aneurysm, tumor) or etiological factors of epilepsy (mesial temporal sclerosis). Patients diagnosed with pharmacoresistant epilepsy in connection with subsequent referral for surgical treatment also undergo MRI to determine the localization of the CNS lesion. In some cases (elderly patients) additional studies are necessary: biochemical blood tests, fundus examination, ECG.

Epilepsy attacks must be differentiated from other paroxysmal states of non-epileptic nature (syncope, psychogenic seizures, vegetative crises).

Conservative therapy

All epilepsy treatment methods are aimed at stopping seizures, improving quality of life and stopping medications (in remission). In 70% of cases, adequate and timely treatment leads to the cessation of epilepsy seizures. Before prescribing antiepileptic drugs, a detailed clinical examination and analysis of MRI and EEG results should be performed. The patient and his family must be informed not only about the rules of medication, but also about possible side effects. Indications for hospitalization are: first-ever epileptic seizure, epileptic status and the need for surgical treatment of epilepsy.

One of the principles of drug treatment of epilepsy is monotherapy. The drug is prescribed in the minimum dose, and then increase it until the seizures are stopped. If the dose is insufficient, it is necessary to check the regularity of the drug and find out whether the maximum tolerated dose has been reached. The use of most antiepileptic drugs requires continuous monitoring of their blood concentrations. Treatment with pregabalin (Lyrica), levetiracetam, valproic acid starts 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 newest antiepileptic drugs (topiramate, oxcarbazepine, levetiracetam), registered for use in monotherapy. When choosing between traditional and newer drugs, the individual characteristics of the patient (age, gender, concomitant pathology) must be taken into account. Valproic acid is used to treat unidentified epileptic seizures.

When prescribing a particular antiepileptic drug, the lowest possible frequency of administration (up to 2 times/day) should be aimed for. Due to the stable plasma concentration, prolonged-acting drugs are more effective. The drug dose prescribed to an elderly patient creates a higher blood concentration than the same drug dose prescribed to a younger patient, so it is necessary to start treatment with small doses followed by titration. Withdrawal of the drug is carried out gradually, taking into account the form of epilepsy, its prognosis and the possibility of recurrence of seizures.

Surgical treatment

Pharmacoresistant epilepsies (ongoing seizures, ineffectiveness of adequate antiepileptic treatment) require additional examination of the patient to decide on surgical treatment. Preoperative examination should include video-EEG recording of seizures, obtaining reliable data on the localization, anatomical features and the nature of epileptogenic zone distribution (MRI).

Based on the results of the above studies, the nature of surgical intervention is determined: surgical removal of epileptogenic brain tissue (cortical topectomy, lobectomy, hemispherectomy, multilobectomy); selective surgery (amigdalo-hippocampectomy for temporal lobe epilepsy); callosotomy and functional stereotactic intervention; vagus stimulation.

There are strict indications for each of the above surgical interventions. They can be performed only in specialized neurosurgical clinics with the appropriate techniques and with the participation of highly qualified specialists (neurosurgeons, neuroradiologists, neuropsychologists, neurophysiologists, etc.).

Prognosis and prevention

The prognosis for work capacity in epilepsy depends on seizure frequency. In the remission stage, when seizures occur less frequently and at night, the patient’s ability to work is preserved (if night-shift work and business trips are excluded). Daytime epileptic seizures accompanied by loss of consciousness limit the patient’s ability to work.

Epilepsy affects all aspects of a patient’s life, so it is a significant medical and social problem. One facet 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 that accompany epilepsy are often unfounded. The vast majority of patients who receive proper treatment lead normal lives without seizures.

Prevention of epilepsy includes possible prevention of CHM, intoxication and infectious diseases, prevention of possible marriages between patients with epilepsy, adequate temperature reduction in children to prevent fever, a consequence of which may be epilepsy.

Articles about lyrica

Antiepileptic agent; binds to the additional subunit (a2-delta protein) of the potential-dependent Ca2 + -channels in the CNS, which promotes the manifestation of analgesic and anticonvulsant action. Reduction in the frequency of seizures begins within the first week.

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