0 Epilepsy is more common in the first years of life and after the age of 60.
0 May be caused by an imbalance between the excitatory neurotransmitter (glutamate aspartate) and the inhibitory neurotransmitter (GABA). Another mechanism is ion channel transport disorders such as K, Ca, Na, which will disrupt the resting potential of the cell membrane.
0 In the classification, first of all, it is checked whether the seizure is partial or generalized.
0 If loss of consciousness is added in partial seizures, it is said as a complex partial seizure. There are many types of generalized seizures.
0 Autonomic symptoms accompanying seizures may include sweating, flushing, pupillary dilation, vomiting, and incontinence.
0 Psychic symptoms are related to fear, anxiety.
0 In simple partial seizures, although consciousness is clear, the seizure may become generalized (secondary generalization) due to spread to other parts of the brain.
Epilepsy Classification
A- Partial (focal, local) Seizure
1. Simple Partial Seizures (state of consciousness not impaired)
a. with motor symptoms
b. with special sensory symptoms
c- With autonomic symptoms
2. Complex Partial Seizure (going with unconsciousness)
3. Secondary Generalized Seizure
B- Generalized Seizure
1. Absence Seizure
2. Myoclonic Seizure
3. Tonic Seizure
4. Tonic - Clonic Seizure
5- Atonic Seizure
Partial Seizures
Seizures of Frontal Lobe Origin
• Automatisms can be seen; they can be in a weird, semi-purpose, a manual way. Postictal Todd's palsy is common.
• Todd's palsy: It is a temporary loss of strength on the side of the convulsion lasting 24-36 hours after partial seizures. It can occur after any partial seizure.
Seizures of Temporal Lobe Origin
• It constitutes more than 50% of partial seizures. Odor, auditory illusions and hallucinations may be encountered.
• Automatisms oro bucco lingual movements are seen in 75% of the patients, and facial and neck movements are seen in 50% of the patients.
Seizures of Parietal Lobe Origin
• Elementary paresthesias are the most common somatosensory seizure symptoms. It may be in the Jacksonian style.
• The seizure that starts in one extremity can also spread to the other extremities (Jacksonian type seizure).
Seizures of Occipital Lobe Origin
• It can cause seizures, usually with visual symptoms, and can be confused with migraine aura.
• Carbamazepine and Oxcarbazepine are the first treatment options in partial epilepsy. Lamotrigine and Levetiracetam can also be used.
Generalized Seizures
absence epilepsy
• It begins in childhood (3-9 years) and rarely continues in adolescence. It is slightly more common in girls.
• Sudden cessation of mental activity without loss of postural tone and resumed seconds later.
• 3 Hz (2.5-4) spike wave discharges occur in EEG as a diagnostic.
• Blinks and mild dizziness are common during an attack.
• There may be more than 100 attacks per day.
• This reduces the child's school success and reduces social communication.
• For this reason, these children may receive mental retardation wrong diagnosis
• Attacks can typically be induced by hyperventilation.
• Valproate is preferred after the first ethosuximide in treatment.
Myoclonic seizures
• Sudden, short-term seizures that occur in muscle groups or extremities in the style of jumping and shaking.
• Benign myoclonies are temporary, can be seen in infants and adults, there is no EEG finding.
• Complex myoclonies indicate serious underlying disease (lafora body disease, mitochondrial encephalomyopathy, sialidosis, etc.).
• The typical finding in EEG is 3-6 Hz generalized multiple spike-wave discharges.
• Valproic acid is used as drug therapy.
• Carbamazepine and Phenytoin are not used in these patient groups because they increase absence and myoclonies.
General tonic-clonic epilepsy (Grand-mal)
• It usually starts between the ages of 10-20.
• It may progress with prodromal findings such as abdominal pain, a strange feeling in the epigastrium, flushing of the face, constipation and diarrhea.
• A sound is produced during "expiration" due to contraction in the larynx muscles. Epileptic cry---vocalization is called.
• Post-ictal confusion and headache are present during the recovery period.
• Valproic Acid is the first choice in generalized epilepsy, Lamotrigine, Levetiracetam, Topiramate, Zonisamide can also be used.
Cryptogenic Or Symptomatic Generalized Epilepsy Syndromes
West syndrome
• The three main symptoms are:
• Infantile spasms, mental retardation, multifocal foci called hypsarrhythmia in EEG, chaotic picture with diffuse and focal slow activity.
• It starts at 3-12 months, it is more common in males.
• Perinatal asphyxia, tuberous sclerosis, CNS infections play a role in the etiology.
• Symmetrical massive myoclonias occurring in the neck, trunk and extremities.
• Seizures can be flexor, extensor, tonic, myoclonic.
• ACTH, vigabatrin are used in treatment. It is often resistant to treatment.
Lennox-Gastaut syndrome
• It can be considered as an extension of West syndrome.
• More than one seizure type (tonic, clonic, etc.) can be seen together. Tonic-atonic seizures are the most common.
• Slow spike (1-2.5 Hz) appearance on EEG is typical.
• It is a severe form of disease with mental motor retardation and persistent convulsions.
• Status epilepticus is common.
• An anterior callosotomy may be attempted.
|
Medicine |
Indications |
|
carbamazepine |
1st option in partial epilepsy |
|
Na-Valproate |
Generalized epi.de 1st option+
partial ep. |
|
phenytoin |
Partial epi. + status epilepticus |
|
phenobarbital |
Partial + Generalized epi + status
epi. (2.) |
|
clonazepam |
Generalized epi (myoclonus) + status
epilepticus |
|
ethosuximide |
Specific for absence seizures |
|
Levetiracetam |
can be preferred as an alternative to
Na Valporoate |
Status epilepticus and its treatment:
• More than 5-10 minutes or more than one seizure during this time.
• Since it is a fatal picture, the steps to be followed in treatment
• Airway, respiration, circulation are checked first.
• Rapid blood biochemistry is checked.
• I.v. benzodiazepine is given for a short time; lorazepam is the first choice. (Clonazepam or Diazepam can also be preferred instead of Lorazepam since they are not available in our country.)
• If the seizure does not stop, the second treatment is switched to IV phenytoin. It can cause cardiac arrhythmia and hypotension. If the patient has idiopathic generalized epilepsy (absence or myoclonus) is not given.
• Valproate is used in the second treatment in absence and myoclonus.
• If the seizures do not stop, the patient is taken to the intensive care unit.
• Midazolam and propofol anesthesia is started.
• If there are no intensive care conditions, phenobarbital is started to the patient during transport.
Imaging methods that should be requested for the patient with epilepsy
• MR is the imaging method of first choice in epileptic patients. CT is superior to MRI in showing calcifications. Functionally, SPECT can be used; It is useful in terms of focal localization with hyperperfusion. PET can also be used as a guide in mapping cerebral blood flow.
Surgical treatment of Epilepsy
• If seizures cannot be controlled with medication, if they are focal, if there will be no major neurological deficits, and surgery is performed.
• Temporal lobectomy In seizures of temporal origin
• Hemispherectomy, callosotomy (which keeps generalized seizures focal) can be applied in surgical treatment.
• Surgery is not performed in idiopathic and primary generalized seizures.
Epilepsy in Pregnancy
• Treatment should not be interrupted in a pregnant patient.
• All anticonvulsants are teratogenic.
• The most common teratogenic effect is cleft lip and palate.
• Neural tube defects, heart anomalies can also be seen.
• The risk of neural tube defects is most common with valproate use.
• A single and low dose drug should be chosen as much as possible in pregnant women. (monotherapy)
• Daily 5 mg folic acid treatment should be given.