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ЗмістModule 2. special (nosology) psychiatry
4. Intersubject integration
Contents of theme.
Etiology and Pathogenesis
Classification of epileptic seizures
The “Epileptic Personality”
Safety and side effects
Principles of anticonvulsant use and management
Responsive Neurostimulator System (RNS)
Treating prolonged seizures.
Ministry of Health of Ukraine
Bukovynian State Medical University
on the methodical meeting
of the Department of neurology, psychiatry
and medical psychology nm. S.M.Savenko
“____” ___________ 2009 (Report № __).
Chief of the Department
Professor V.M. Pashkovsky
for 4-th year students of medical faculty №2
(the speciality “medical affair”)
for independent work during preparing to practical class
Theme 27: Epilepsy, basic symptoms. Clinical description of paroxysm. Classification of epilepsy. Epileptic psychoses. Treatment of patients with epilepsy. The first aid at epileptic status.
Topical module 6. Polyetiological mental disorders.
1. Actuality of theme:
Epilepsy (from the Greek ??????ί? /epili΄psia/ ) is a common chronic neurological disorder characterized by recurrent unprovoked seizures. These seizures are transient signs and/or symptoms of abnormal, excessive or synchronous neuronal activity in the brain. About 50 million people worldwide have epilepsy, with almost 90% of these people being in developing countries. Epilepsy is more likely to occur in young children, or people over the age of 65 years, however it can occur at any time. Epilepsy is usually controlled, but not cured, with medication, although surgery may be considered in difficult cases. However, over 30% of people with epilepsy do not have seizure control even with the best available medications. Not all epilepsy syndromes are lifelong – some forms are confined to particular stages of childhood. Epilepsy should not be understood as a single disorder, but rather as a group of syndromes with vastly divergent symptoms but all involving episodic abnormal electrical activity in the brain.
2. Duration of practical classes - 2 hours.
3.1. To know:
2.To give first aid about epileptic fits.
3.To conduct differential diagnosis.
4.To conduct measures of prophylactic of epilepsy
3.3. To capture practical skills:
1.To collect anamnesis in patients with epilepsy.
2. To give first aid about major spasmodic seizure.
3. To give first aid about epileptic status.
4. To give first aid about epileptic twilight state.
^ (base level of preparation).
5. Advices to students.
Definition. Epilepsy is a chronic psychoneurological disorder caused by impaired brain function, which manifests in recurrent. periodic, paroxysmal states (seizures), and in some cases causes concomitant chronic alterations of personality and/or cognitive processes.
It is a polyetiological disorder, which can be caused by different pathogenic factors. The so called genuine (idiopathic) epilepsy or the epileptic disease is an illness with hereditary predisposition and belongs to the group of endogenous mental disorders. Organic (symptomatic) epilepsy may develop as the consequence of a brain injury (traumatic epilepsy), encephalitis, meningitis, cerebrovascular haemorrhage or thrombosis or any other organic brain damage, in which an epileptogenic focus is formed. It is a group of cells which have high excitation potential and periodically produce high amplitude synchronic impulses. An epileptic seizure develops if, owing to metabolic or some other reason the brain has high convulsion readiness.
Epilepsy as a specific disorder is diagnosed if seizures in a patient occur with certain frequency, regularly. A separate (single) paroxysm is a symptom of brain dysfunction, either localized or general. The occurrence of a fit signals that the neural, humoral, metabolic, and vascular regulatory systems of the brain are not in balance. Hypoglycaemia, pyridoxine deficiency, eclampsia, uraemia, anoxia, hyponatremia, water intoxication, and fever are all states that may lead to convulsions. In the same class should be mentioned seizures after the withdrawal, usually abrupt, of a wide class of pharmacological agents. Whether the pathology be neoplasm, vascular disease, vascular malformation, abscess, acute or chronic infection. or degenerative disease, fits may be an early symptom.
Aura. The earliest symptoms in a seizure, particularly the aura, have an important localising value in cases of focal epilepsy. The aura is perhaps of equal importance to the epileptic himself, for it warns him of the onset of a seizure and allows him a little time to find a safe place. The aura is often present, even in the primary grand mal epileptic, although not in the petit mal. The acute phenomenon is frequently described as diffusely visceral. This feeling may last for a few seconds or several minutes before the overt seizure. A period of several hours or days of increasing irritability, restlessness, and mild depressive symptoms may precede a major seizure. These symptoms usually disappear abruptly after the seizure itself.
Grand Mal Seizures. These may have a brief aura and are often initiated by a cry, presumably due to forced expiration of air. The cry is followed by or is simultaneous with the loss of consciousness, which is followed by falling to the floor., often with physical injury, and the advent of extreme tonic spasm, the extensor muscles dominating the flexors. This is usually followed by a clonic phase in which there is alternating flexion and extension of the body musculature, which may lead to biting of the tongue or mouth or further injury to the head. Cyanosis is often marked until the seizure terminates, with deep noisy breathing and often with profuse sweating and salivation. There may be relaxation of the sphincters, with loss of urine or feces during the seizure, and in the male the ejaculation of semen, usually with erection, may occur. The EEG during this period is dominated by high voltage and fast activity in all leads and often terminates with an isoelectric period during which little or no spontaneous electrical activity is visible. The patient may waken into a confused state described as the post-seizure twilight state; he may become perfectly alert and oriented although somewhat slowed down and dull, or he may lapse into apparently normal sleep for some minutes or an hour or two. On recovery he usually complains of muscular aches and often of a severe headache. A marked bulimia may occur after the fit, leading the patient to ingest copious volumes of food or liquid. With complete recovery, there may well be feelings of depression and despair, often in reaction to the reality aspects of the seizure and social embarrassment.
Petit Mal Seizures. These seizures are extremely rare in adults. The classic triad of petit mal seizures includes the classic absence, myoclonic seizures or lightning jerks (including salaam seizures), and atonic seizures. The attack is accompanied by a bilaterally synchronous EEG wave and spike formations at about 3 per second and is often easily brought on by hyperventilation. A characteristic attack is quite brief — 10 to 30 seconds — and may pass unnoticed by the patient or by an unskilled observer. It is accompanied by total unconsciousness but of such a brief duration as to make only a transient lapse in conversation and with so little retrograde amnesia that it can easily be concealed. Such seizures can be a problem if there are large numbers of them in sequence or during the course of the day.
The myoclonic seizures may or may not include unconsciousness. They are characterized by a very short jerky movement of the body, either a sudden flexion movement of the trunk muscles with raising of the arms giving rise to the salaam or, particularly in older patients, an abrupt extension movement, notably of the shoulders, arms, and hands.
Atonic seizures are characterized by momentary losses of muscle tone, usually with unconsciousness, causing the patient to slump to the ground but recover promptly.
These seizures have clinical or EEG evidence of a specific, usually cortical, site of origin. They are more likely to be due to identifiable pathology, such as a scar, vascular lesion, tumour, or brain atrophy, than are the generalized seizures described above. However, the majority of patients with focal seizures also have grand, mal seizures. Of particular importance in diagnosing and localizing the focal seizure are the events just preceding or initiating the attack.
Jacksonian seizures. These seizures, first described by Hugh-lings Jackson, have a focus around the central sulcus and so are introduced by contralateral focal motor or sensory phenomena. Characteristically the thumb or corner of the mouth is first involved; the involvement then spreads by contiguity. If primarily motor, the manifestation is muscle twitching; if primarily sensory, the description is usually one of numbness, paresthesia, and tingling. As long as the symptoms remain unilateral, the patient does not lose consciousness, but the motor phenomena may become bilateral, consciousness may be lost, and the patient may show a characteristic generalized seizure. Jacksonian seizures are often post-traumatic in origin, although other pathology should be investigated.
Anterior temporal focus seizures. An anterior temporal lobe abnormality is the commonest of the focal phenomena by EEG finding. Most characteristic is the spike or a train of spikes, although slow waves may also be seen in this region. The anterior temporal lobe abnormality is accompanied most commonly by psychomotor seizures, but it may manifest grand mal seizures. The clinical picture is often characterized by lapses of consciousness, which are sometimes confused by the unwary with petit ma) attacks and which often begin with head-turning, orienting movements of the eyes, lip-smacking, swallowing, and salivation.
Other focal seizures. Foci in the frontal, midtemporal, and occipital regions of the brain are quite rare. The EEG is usually characterized by focal spikes that may spread to involve other brain regions. Frontal seizures are often initiated with adversive eye movements or occasionally head movements and may involve phenomena of forced thought. Midtemporal foci are more common than the others and show an unusual propensity for the disappearance of both the EEG abnormality and the seizures in late adolescence or adulthood. The clinical phenomena usually include grand mal seizures, and there may be focal facial movements at the onset. Occipital seizures are probably the rarest of the group, usually manifesting themselves primarily with the grand mal seizure, although there may be an initial visual aura or flashing lights and diplopia. Strabismus is common in these cases.
Psychic seizures (mental equivalents of seizures) seem to be primarily of temporal lobe origin and may either precede a generalized convulsion or, more commonly, occur without loss of consciousness. Sometimes they are called psychic equivalents of seizures.
Perceptual Changes. The most common phenomena are changes in visual perception described as changes in the size of an object as if it were receding or approaching. Everything may look very small and distant or quite large. With auditory, phenomena, the voices in a room become very distant or very loud and confused as if everyone were shouting. One patient described the floor and walls as wavy.
Changes of Self-Awareness. Feelings of depersonalisation and derealisation may last for a matter of seconds or a few minutes and then abruptly disappear or be followed by some further elaboration of the seizure sequence. Related to these feelings perhaps are the sudden feelings of intense familiarity, the phenomenon of deja vu. The reciprocal experience of jamais vu is also seen in which the subject, although in a familiar situation, feels that it is entirely new and strange. In both these situations there is usually an awareness that the feeling is not reasonable.
Changes of thought. Particularly striking is the phenomenon of forced thought, in which a thought, a word, or a sentence may obtrude itself on consciousness and seem to occupy the whole centre of awareness. On occasion it may be an obscenity, but it may equally well be an apparent nonsense phrase or a melody. The thought may be clearly remembered after the attack or only dimly remembered or forgotten. Disorganisation of thought may be another such phenomenon, with the patient complaining that there is a brief period during which he seems to know what he wants to think about but cannot put the ideas together.
Changes of Mood and Affect. Paroxysmal attacks of fear ranging from anxiety to terror are frequent accompaniments of this kind of psychic seizure. These attacks are described as different from the apprehension that many epileptics feel at the onset of the seizure. Acute feelings of despair and depression also occur. Feelings of pleasure, elation, and serenity seem to be rare. Disphoric mood attacks with feelings of anger combined with anguish are also characteristic of epilepsy.
Complex Hallucinatory Experiences. These rare experiences are most often auditory hallucinations, but they may also be olfactory. The patient usually has a clear insight into the hallucinatory nature of the phenomenon, feels it as alien to himself, and may be quite anxious concerning its reflections on his sanity.
Complex Stereotyped Automatisms. Complex acts may appear to be purposeful but are inappropriate to the situation and in general arc stereotyped: that is, repeated almost identically in the same form on each occasion. In a few patients, a seizure can be precipitated by asking them to carry out their characteristic automatism. In others, carrying out the act under hypnosis gives rise to a rich associative flow, reinforcing the impression that the act has symbolic significance.
Postictal twilight state. This state usually follows one or several seizures. At the close of the grand mal seizure or perhaps after a period of sleep, the patient may be apparently awake but in a confused state, mumbling incoherently and fumbling with his clothing or other objects. Periods of excitement sometimes appear, lasting from minutes to (rarely) several days. This excitement may include extreme agitation, paranoid ideation, hallucinations, and delusions that may lead to aggressive outbursts. Consciousness is markedly disturbed, although the patient shows neither motor nor speech impairment, and there is usually complete amnesia for these periods. Such states usually clear completely and with surprising abruptness. Throughout this period of confusion, the EEG shows diffuse symmetrical slow activity, not the paroxysmal activity of the seizure state.
Ictal twilight state. This state may begin with the disturbance of consciousness and no other warning or, more often, it may be preceded by symptoms of focal disturbance, usually of the temporal lobe. The most common early symptoms are searching movements of the head and eyes, lip-smacking, masticatory movements, and swallowing. During the state itself, the patient becomes disoriented and is only partially aware of his surroundings. He may wander around aimlessly, fumble with his clothing, mumble unintelligibly, or say phrases of intelligible words that are inappropriate in context. He may respond to external stimuli but does so inappropriately. The period may last for 5 or 10 minutes. If the state is prolonged, there may be more overt agitation, expressions of fear, anxiety, incoherent talk, and aggressive acts, particularly if attempts are made to restrain the patient. Some patients present apparently purposeful and well coordinated movements with no recall or only dim memories of the period, which may last hours to days.
Petit mal status. The twilight states ated with petit mal status are relatively uncommon. The EEG in these cases is characterized by continuous or nearly continuous bilaterally synchronous spike and wave patterns, and the clinical picture is apparently dominated by confusion but frequently with fairly complex confused behaviour, as described for the postictal twilight state. An attenuated form of this same phenomenon may appear in patients who complain of mental dullness, which may last for several days, characterized by difficulty in concentration and general slowing of the thought processes without the confusional picture just described. These protracted periods of mental slowing may terminate abruptly.
^ . The recurrence without interruption of grand mal seizures in an epileptic. Seizures repeat approximately every 10 minutes, and the patient remains unconscious between them.
Status epilepticus is a most common cause of death in epileptics. It occurs more frequently in symptomatic than in idiopathic epilepsy, and it often appears to be precipitated by withdrawal or change of anticonvulsant medication, or by intercurrent infection (where high temperature may produce a state of internal withdrawal from medication). Other cases include occlusive cerebrovascular disease, hypertensive and metabolic encephalopathies, neoplasm, head trauma, degenerative diseases of the brain, and, sometimes, collagen disorders and similar systemic diseases.
The complications caused by this state are various and dangerous: brain or lung oedema, inhibition of the breathing centre in the brain, heart failure, etc. Thus, status epilepticus demands urgent treatment measures, and sometimes resuscitation. All the drugs are injected by parenteral way, most of them intravenously. Anticonvulsant medicines include solutions of magnesium sulfate (25 % — 20.0), which also has a dehydrotising effect; some anxiolytic drugs, in particular benzodiazepines, in intraveneous injections also have anticonvulsant action, (chlordiazepoxide, etc.). If seizures prevail in spite of medication, it is sometimes necessary to narcotize the patient. Besides the termination of seizures, the patient must receive symptomatic treatment to prevent complications (diuretics, drugs to support heart activity, breathing analeptics).
Those who insist on a set of common personality traits identify the following: slowness of reactions, perseveration, rigid emotional attitudes, kind of “black-and-white” assessment of people and events (either very good or very bad), fixed opinions, particularly concerning religious issues, excessive accurateness, preciseness and punctuality, strict adherence to social norms and rules, unresponsiveness to external factors, sometimes — self-centeredness and hypochondriasis. Some of these patients have a tendency to hobbies which demand great patience and persistence, like collecting things (stamps, coins, etc.) or making models. The emotional sphere in epileptic patients has certain specific features: on one hand, tendency to long-lasting emotional states (emotional rigidity) and on the other — explosion readiness.
Most western authors, however, agree that, in non-institutionalized epileptics as a group, these are not characteristic features and that personality types and abnormalities show the general broad range noted in the rest of the population. It may well be that many of the described specific traits reflect the underlying cerebral dysfunction and organic brain damage.
The mainstay of treatment of epilepsy is anticonvulsant medications. Often, anticonvulsant medication treatment will be lifelong and can have major effects on quality of life. The choice among anticonvulsants and their effectiveness differs by epilepsy syndrome. Mechanisms, effectiveness for particular epilepsy syndromes, and side effects, of course, differ among the individual anticonvulsant medications. Some general findings about the use of anticonvulsants are outlined below.
History and Availability. The first anticonvulsant was bromide, suggested in 1857 by Charles Locock who used it to treat women with "hysterical epilepsy" (probably catamenial epilepsy). Potassium bromide was also noted to cause impotence in men. Authorities concluded that potassium bromide would dampen sexual excitement thought to cause the seizures. In fact, bromides were effective against epilepsy, and also caused impotence; it is now known that impotence is a side effect of bromide treatment, which is not related to its anti-epileptic effects. It also suffered from the way it affected behaviour, introducing the idea of the 'epileptic personality' which was actually a result of the medication. Phenobarbital was first used in 1912 for both its sedative and antiepileptic properties. By the 1930s, the development of animal models in epilepsy research lead to the development of phenytoin by Tracy Putnam and H. Houston Merritt, which had the distinct advantage of treating epileptic seizures with less sedation. By the 1970s, an National Institutes of Health initiative, the Anticonvulsant Screening Program, headed by J. Kiffin Penry, served as a mechanism for drawing the interest and abilities of pharmaceutical companies in the development of new anticonvulsant medications.
Currently there are 20 medications approved by the Food and Drug Administration for the use of treatment of epileptic seizures in the US: carbamazepine (common US brand name Tegretol), clorazepate (Tranxene), clonazepam (Klonopin), ethosuximide (Zarontin), felbamate (Felbatol), fosphenytoin (Cerebyx), gabapentin (Neurontin), lacosamide (Vimpat), lamotrigine (Lamictal), levetiracetam (Keppra), oxcarbazepine (Trileptal), phenobarbital (Luminal), phenytoin (Dilantin), pregabalin (Lyrica), primidone (Mysoline), tiagabine (Gabitril), topiramate (Topamax), valproate semisodium (Depakote), valproic acid (Depakene), and zonisamide (Zonegran). Medications commonly available outside the US but still labelled as "investigational" within the US are clobazam (Frisium) and vigabatrin (Sabril). Medications currently under clinical trial under the supervision of the FDA include retigabine, brivaracetam, and seletracetam. Other drugs are commonly used to abort an active seizure or interrupt a seizure flurry; these include diazepam (Valium, Diastat) and lorazepam (Ativan). Drugs used only in the treatment of refractory status epilepticus include paraldehyde (Paral), midazolam (Versed), and pentobarbital (Nembutal).
Some anticonvulsant medications do not have primary FDA-approved uses in epilepsy but are used in limited trials, remain in rare use in difficult cases, have limited "grandfather" status, are bound to particular severe epilepsies, or are under current investigation. These include acetazolamide (Diamox), progesterone, adrenocorticotropic hormone (ACTH, Acthar), various corticotropic steroid hormones (prednisone), or bromide.
Effectiveness - The definition of "effective" varies. FDA-approval usually requires that 50% of the patient treatment group had at least a 50% improvement in the rate of epileptic seizures. About 20% of patients with epilepsy continue to have breakthrough epileptic seizures despite best anticonvulsant treatment.
^ - 88% of patients with epilepsy, in a European survey, reported at least one anticonvulsant related side effect. Most side effects are mild and “dose-related” and can often be avoided or minimized by the use of the smallest effective amount. Some examples include mood changes, sleepiness, or unsteadiness in gait. Some anticonvulsant medications have "idiosyncratic" side-effects that can not be predicted by dose. Some examples include drug rashes, liver toxicity (hepatitis), or aplastic anemia. Safety includes the consideration of teratogenicity (the effects of medications on fetal development) when women with epilepsy become pregnant.
^ - The goal for individual patients is, of course, no seizures and no side effects, and the job of the physician is to aid the patient to find the best balance between the two during the prescribing of anticonvulsants. Most patients can achieve this balance best with monotherapy, the use of a single anticonvulsant medication. Some patients, however, require polypharmacy; the use of two or more anticonvulsants.
Serum levels of AEDs can be checked to determine medication compliance, to assess the effects of new drug-drug interactions upon previous stable medication levels, or to help establish if particular symptoms such as instability or sleepiness can be considered a drug side-effect or are due to different causes. Children or impaired adults who may not be able to communicate side effects may benefit from routine screening of drug levels. Beyond baseline screening, however, trials of recurrent, routine blood or urine monitoring show no proven benefits and may lead to unnecessary medication adjustments in most older children and adults using routine anticonvulsants.
If a person’s epilepsy cannot be brought under control after adequate trials of two or three (experts vary here) different drugs, that person's epilepsy is generally said to be medically refractory. A study of patients with previously untreated epilepsy demonstrated that 47% achieved control of seizures with the use of their first single drug. 14% became seizure free during treatment with a second or third drug. An additional 3% became seizure-free with the use of two drugs simultaneously. Other treatments, in addition to or instead of, anticonvulsant medications may be considered by those people with continuing seizures.
Epilepsy surgery is an option for patients whose seizures remain resistant to treatment with anticonvulsant medications who also have symptomatic localization-related epilepsy; a focal abnormality that can be located and therefore removed. The goal for these procedures is total control of epileptic seizures, although anticonvulsant medications may still be required.
The evaluation for epilepsy surgery is designed to locate the “epileptic focus” (the location of the epileptic abnormality) and to determine if resective surgery will affect normal brain function. Physicians will also confirm the diagnosis of epilepsy to make sure that spells arise from epilepsy (as opposed to non-epileptic seizures). The evaluation typically includes neurological examination, routine EEG, Long-term video-EEG monitoring, neuropsychological evaluation, and neuroimaging such as MRI, Single photon emission computed tomography (SPECT), positron emission tomography (PET). Some epilepsy centers use intracarotid sodium amobarbital test, functional MRI or Magnetoencephalography (MEG) as supplementary tests.
Certain lesions require Long-term video-EEG monitoring with the use of intracranial electrodes if noninvasive testing was inadequate to identify the epileptic focus or distinguish the surgical target from normal brain tissue and function. Brain mapping by the technique of cortical electrical stimulation or Electrocorticography are other procedures used in the process of invasive testing in some patients.
The most common surgeries are the resection of lesions like tumors or arteriovenous malformations which, in the process of treating the underlying lesion, often result in control of epileptic seizures caused by these lesions.
Other lesions are more subtle and feature epilepsy as the main or sole symptom. The most common form of intractable epilepsy in these disorders in adults is temporal lobe epilepsy with hippocampal sclerosis, and the most common type of epilepsy surgery is the anterior temporal lobectomy, or the removal of the front portion of the temporal lobe including the amygdala and hippocampus. Some neurosurgeons recommend selective amygdalahippocampectomy because of possible benefits in postoperative memory or language function. Surgery for temporal lobe epilepsy is effective, durable, and results in decreased health care costs. Despite the efficacy of epilepsy surgery, some patients decide not to undergo surgery owing to fear or the uncertainty of having a brain operation.
Palliative surgery for epilepsy is intended to reduce the frequency or severity of seizures. Examples are callosotomy or commissurotomy to prevent seizures from generalizing (spreading to involve the entire brain), which results in a loss of consciousness. This procedure can therefore prevent injury due to the person falling to the ground after losing consciousness. It is performed only when the seizures cannot be controlled by other means. Multiple subpial transection can also be used to decrease the spread of seizures across the cortex especially when the epileptic focus is located near important functional areas of the cortex. Resective surgery can be considered palliative if it is undertaken with the expectation that it will reduce but not eliminate seizures.
Hemispherectomy involves removal or a functional disconnection of most or all of one half of the cerebrum. It is reserved for people suffering from the most catastrophic epilepsies, such as those due to Rasmussen syndrome. If the surgery is performed on very young patients (2–5 years old), the remaining hemisphere may acquire some rudimentary motor control of the ipsilateral body; in older patients, paralysis results on the side of the body opposite to the part of the brain that was removed. Because of these and other side effects it is usually reserved for patients who have exhausted other treatment options.
Ketogenic diet- a high fat, low carbohydrate diet developed in the 1920s, largely forgotten with the advent of effective anticonvulsants, and resurrected in the 1990s. The mechanism of action is unknown. It is used mainly in the treatment of children with severe, medically-intractable epilepsies.
^ - methods of anticonvulsant treatment with both currently approved and investigational uses. A currently approved device is vagus nerve stimulation (VNS). Investigational devices include the responsive neurostimulation system and deep brain stimulation.
Vagus nerve stimulation (VNS)- The VNS (US manufacturer = Cyberonics) consists of a computerized electrical device similar in size, shape and implant location to a heart pacemaker that connects to the vagus nerve in the neck. The device stimulates the vagus nerve at pre-set intervals and intensities of current. Efficacy has been tested in patients with localization-related epilepsies demonstrating that 50% of patients experience a 50% improvement in seizure rate. Case series have demonstrated similar efficacies in certain generalized epilepsies such as Lennox-Gastaut syndrome. Although success rates are not usually equal to that of epilepsy surgery, it is a reasonable alternative when the patient is reluctant to proceed with any required invasive monitoring, when appropriate presurgical evaluation fails to uncover the location of epileptic foci, or when there are multiple epileptic foci.
^ (US manufacturer Neuropace) consists of an computerized electrical device implanted in the skull with electrodes implanted in presumed epileptic foci within the brain. The brain electrodes send EEG signal to the device which contains seizure-detection software. When certain EEG seizure criteria are met, the device delivers a small electrical charge to other electrodes near the epileptic focus and disrupt the seizure. The efficacy of the RNS is under current investigation with the goal of FDA approval.
Deep brain stimulation (DBS) (US manufacturer Medtronics) consists of computerized electrical device implanted in the chest in a manner similar to the VNS, but electrical stimulation is delivered to deep brain structures through depth electrodes implanted through the skull. In epilepsy, the electrode target is the anterior nucleus of the thalamus. The efficacy of the DBS in localization-related epilepsies is currently under investigation.
^ . The use of the Gamma Knife or other devices used in radiosurgery are currently being investigated as alternatives to traditional open surgery in patients who would otherwise qualify for anterior temporal lobectomy.
Avoidance therapy. Avoidance therapy consists of minimizing or eliminating triggers in patients whose seizures are particularly susceptible to seizure precipitants (see above). For example, sunglasses that counter exposure to particular light wavelengths can improve seizure control in certain photosensitive epilepsies
Warning systems. A seizure response dog is a form of service dog that is trained to summon help or ensure personal safety when a seizure occurs. These are not suitable for everybody and not all dogs can be so trained. Rarely, a dog may develop the ability to sense a seizure before it occurs. Development of electronic forms of seizure detection systems are currently under investigation.
Psychotherapy. Since the epileptic patient has a condition that may well persist for life and around which his future must be organized, it is well for him to have a psychotherapeutic relationship with his physician. The physician may have to intervene in some situations, particularly in those school systems that exclude epileptic children of normal intelligence from classroom activities.
Alternative or complementary medicine. A number of systematic reviews by the Cochrane Collaboration into treatments for epilepsy looked at acupuncture, psychological interventions, vitamins and yoga and found there is no reliable evidence to support the use of these as treatments for epilepsy.
^ Status epilepticus is a prolonged seizure or cluster of seizures that requires emergency treatment. It can happen in people who don’t have a history of epilepsy and in those who do.
A seizure or cluster of seizures that goes on for more than 20 to 30 minutes during which you or the person seizing does not wake up may cause brain damage. Emergency treatment should be started as soon as possible in these cases.
Medicine used to stop the seizure is given in a vein (intravenously, or IV) so that it takes effect more quickly. If IV medicine is not available, medicine may be given rectally or as a shot in the muscle.
Vital signs, such as blood pressure and pulse rate, will be checked. A physical exam and various lab tests are done to rule out or identify any life-threatening medical conditions (such as meningitis, stroke, or failure of the heart, liver, or kidneys) that may have caused the prolonged seizure.
Prevention of epilepsy. Proceeding from the fact that epilepsy is a polyetiological disorder, measures that can be taicen for its prevention vary. Some authors consider that approximately half the epilepsy cases are preventable in the sense that they are the caused by trauma, infections, and birth injury with damage to the brain. These secondary cases are increased when there is poor prenatal and perinatal care, malnutrition, neglect, and violence.
The idiopathic epilepsy is an illness with hereditary predisposition. The twin-pair data indicate a strong inheritable predilection for epilepsy. These investigators find about 85 per cent concordance for epilepsy in monozygotic twins, versus 5 per cent for dizygotic twins. Among monozygotic twins with symptomatic epilepsy they find about 14 percent concordance, versus 0 percent for dizygotic twins.
1. To collect anamnesis, clinical psychopathological examination of patients with epilepsy.
2. To diagnose different types of epileptic seizures.
3. Make up plan of examination and treatment of patients with epilepsy.
4. Urgent help at epileptic status.
5. The interpretation of results electroencephalography and echoencephalography of patients with epilepsy.
6. To solve the tasks and tests.
5.4. Material for self-contrrol.
A. Questions of self-controls:
1.Determine emotional disorder, which very often is present in patients with epilepsy and has next signs: anxiety, depression and horror; attacks with feelings of anger combined with anguish; aggression.
E. Pathological effect
2. Patient K, 23 old years, sufferings on epilepsy during 10 years. Objectively: he has repeated spasm fits every 2-3minits – clonic and tonic contraction of hands and legs; pupils are dilated; pupilliary, corneal and tendon reflex absent; cyanosis of integuments; red foam exudes from mouth; tachycardia (150 per minute); involuntary miction. Duration fit – 60 sec. Determine syndrome of disturbance of consciousness.
E.Clouded mental state
3. Patient L, 32 old years, sufferings on epilepsy. He becomes excited suddenly without reason. Psychical status: patient has disorientation in own personality and surroundings, optic and acoustic hallucination, delusions of relation and persecution. His face expresses fear, angry. Patient’s behaviour is aggressive. Determine psychopathological syndrome.
A. Delirium syndrome
B. Maniac syndrome
C. Heboid syndrome
D. Twilight syndrome
E. Paranoid syndrome
4. Patient C, 38 old years, sufferings on epilepsy. He used anticonvulsive drugs irregulary. He has status epileptic. Urgent help we shall begin from:
A.Prophylactic of traumas of head
D.Restoring of permeability of airway
5. Women A, 29 old years, sufferings on epilepsy from 9 old years. He used anticonvulsive drugs irregulary. She has status epileptic. Your tactic:
A.Hospitalization in neurology department
B. Hospitalization in mental department
C. Hospitalization in reanimation department
D. Hospitalization in neurosurgery department
E. Call of psychiatrist or neurologist
6. Patient G, 40 old years, prisoner. He accused in homicide. He had serious trauma of head in 35 old years, after it he sufferings on grand mal seizures with loss of consciousness. Objectively: he is irritable, dissatisfied in all, has stiffness of thinking; criticism absent. Your tactic:
A.Discharge the prisoner at home
B.Put in prison
C.To treatment in out-patients clinic
D.To treatment in specialised clinic of closed type
E. To treatment in mental clinic
7. Patient O, 42 old years. Objectively: he has spasm fits very often during day, consciousness is lost inter fits; pupils are dilated; pupilliary, corneal and tendon reflex absent; cyanosis of integuments; blood pressure – 80/65 mm hg, temperature of body 39,9. Determine psychopathological state.
B. Catatonic stupor
8. Patient P, 20 old years, sufferings on epilepsy. He has status epileptic. Urgent help we shall begin from next medicines:
9. Women A, 30 old years, sufferings on epilepsy in long time. In time status epileptic next complications appear: breaking breathing, dampness of cardiac tones, extrasystoles, blood pressure – 90/60 mm hg. What medicine is forbidden in this case:
10. Patient M, 18 old years, sufferings on epilepsy in long time. He has dysphoria without reason. He becomes irritable, angry, aggressive to surrounding persons, dissatisfied in all. What medicine you will use with purpose prophylactic this state?
D.Valproic acid (Depakene)
1. After a head injury that the patient had 5 years ago he developed affective disturbances: suddenly and for no serious reason he feels anger. His mood during these periods is characterized by tension, depression combined with anger or even rage, high irritability with a tendency to aggressive actions.
Determine psychopathological syndrome.
2. A patient, while making repairs at home, suddenly stood quite still with the painting brush in his hand, then dropped it. This state lasted for a few seconds. After that the patent was rather confused, for some moments he couldn't understand what was happening. He totally forgot the state he was in and the events around him, occurring while he was in that state.
Determine psychopathological syndrome.
3. Ambulance was called to a 48 years old man. According to the relatives he has had three episodes of lost consciousness and attacks during the day. Patient is unconscious, fell on the floor, tonic and then clonic convulsions of trunk and extremities happened. The attack lasted for 4 minutes, ended by involuntary urination. What type of attack was observed?
4. Patient T., female, 35 years old, suffers from epileptic fits since she was 15 years old. She has seizures during which she loses consciousness, falls down and has tonic and clonic convulsions. The fits occur once a week. What are the main principles of treatment in epilepsy?
5. Patient S., 25 years old, worker. Hi suffers from epileptic fits since he was 10 years old. He visited a doctor and disappeared. He returned at home in 3 days without coat. He is staying in mental hospital in this moment. Psychical state: his behaviour is wonderful, he does not speak, doesn’t answer on questions, looks on ceiling. He began to speak on next day. Your state improves gradually. He told how went to a doctor but did not remember incidents of last three days. Familiars told that they saw patient on bank of river over 30km from town. He looked wonderfully. He was thoughtful, had not answers on questions. Determine psychopathological syndrome and disease.
Prepared by assistant S.D.Savka
|Ministry of Health of Ukraine Bukovynian State Medical University||Ministry of Health of Ukraine Bukovynian State Medical University|
|Ministry of Health of Ukraine Bukovynian State Medical University||Ministry of Health of Ukraine Bukovynian State Medical University|
|Ministry of Health of Ukraine Bukovynian State Medical University||Ministry of Health of Ukraine Bukovynian State Medical University|
|Ministry of Health of Ukraine Bukovynian State Medical University||Ministry of health of ukraine bukovynian state medical university|
|Ministry of health of ukraine bukovynian state medical university||Ministry of Health of Ukraine Bukovynian State Medical University|