Classification of epileptic seizures and choice of drugs - Causes, symptoms and treatment. MF.
INTERNATIONAL CLASSIFICATION EPILETICAL PARTICLES ( ILAE, 1981)
I. Partial( focal, local) epileptic seizures of
A. Simple partial seizures( consciousness not broken)
1. With motor symptoms
a) focal motor with march;B) focal motor without a march( Jacksonian);C) version of the
;D) postural;
f) flashlight( vocalization or speech stop).
2. With somatosensory or specific sensory symptoms
a) somatosensory;B) visual;
c) auditory;D) olfactory;E) flavoring;F) fits of dizziness.
3. With autonomic symptoms of ( sensations in epigastrium, pallor, sweating, reddening of face, dilated pupils).
4. With the mental symptoms of ( disorders of higher cortical functions):
a) dysphasic;
( b) Dyspnestic( for example, deja vu);C) cognitive( dream states, impaired sense of time);D) affective( fear, anger, etc.);E) illusions( eg, macropsia);
f) structural hallucinations( for example, music, scenes).B. Complex partial attacks( consciousness violated).
1. Beginning as simple partial with subsequent loss of consciousness:
a) with signs of simple partial seizures( A.1-A.4) and subsequent impairment of consciousness;B) with automatisms.
2. Beginning with impaired consciousness:
a) only with a violation of consciousness;B) with automatisms.
C. Partial seizures with secondary generalization.
Simple partial seizures( A) with secondary generalization.
2. Complex partial seizures( B) with secondary generalization.
3. Simple partial seizures, passing into complex partial ones with subsequent secondary generalization.
II. Generalized epileptic seizures.
A. Absenses:
a) only a violation of consciousness;B) with the clonic component;C) with the atonic component;D) with tonic component;E) with automatisms;F) with autonomic symptoms.
B. Myoclonic seizures.
C. Clonic seizures.
D. Tonic seizures.
E. Tonic-clonic seizures.
F. Atonic( astatic) attacks.
THE BASIC PRINCIPLES OF EPILEPSE CLASSIFICATION AND OF EPIDEPTIC
SYNDROME 1. The principle of etiology:
Idiopathic:
- there is no evidence of CNS evidence;
is a known or possible genetic predisposition.
Symptomatic:
is a known etiology and verified morphological disorder.
Cryptogenic.
- the cause is unknown, hidden;
- syndromes do not meet the criteria of idiopathic forms;
- no evidence of a symptomatic nature.
2. Localization principle:
- localization-conditioned( focal, local, partial);
- generalized forms;
- forms that have features of both partial and generalized.
3. Age at which the attack occurred:
- forms of newborns;
- infant;
- children's;
- Youth.
4. The main type of seizures that determine the picture of the syndrome:
- absence;
- myoclonic absence;
- infantile spasms, etc.
5. Flow characteristics and predictions:
- benign;
- severe( malignant).
INTERNATIONAL CLASSIFICATION OF EPILEPSIS AND OF EPILEPTIC SYNDROME ( recommended in 1989 by the International League against Epilepsy).
1. LOCALIZATION-DEFERRED( FOCAL, PARCIAL) EPILEPSIES AND SYNDROME.
1.1.Idiopathic forms( the onset of seizures is associated with age):
- benign epilepsy of childhood with central-temporal adhesions;
- epilepsy of children with occipital paroxysms on EEG;
is the primary epilepsy of reading.
1.2 Symptomatic forms:
- chronic progredient partial epilepsy of children( Kozhevnikov's syndrome);
- syndromes with specific causes of provocation of attacks( reflex epilepsy);
- fronto-, temporo-, parietal-, occipital-lobe epilepsy.
1.3.Cryptogenic forms( undefined forms).
2. EPILEPSIA AND SYNDROME WITH GENERALIZED ACCIDENTS.
2.1.Idiopathic( the onset of seizures is associated with age):
- benign neonatal family seizures;
- benign idiopathic neonatal seizures;
- benign infantile myoclonic epilepsy;
- epilepsy with pycnoleptic absences( picnoleptic, absense-epilepsy in children);
- children's absence epilepsy;
- juvenile myoclonic epilepsy;
- epilepsy with generalized tonic-clonic seizures upon awakening;
- other forms of generalized idiopathic epilepsy;
- epilepsy with specific provoking factors( reflex and start-epilepsy).
2.2. Cryptogenic or symptomatic forms( associated with the age of onset of seizures):
- Vesta syndrome( infantile spasms);
- Lennox-Gastaut syndrome;
- epilepsy with myoclonic-astatic seizures;
- epilepsy with myoclonic absences.
2.3 Symptomatic forms:
2.3.1.Nonspecific etiology:
- early myoclonic encephalopathy;
- infantile encephalopathy with areas of the isoelectric EEG;
- other symptomatic generalized forms of epilepsy;
2.3.2 Specific syndromes of
3. EPILEPSIA AND SYNDROME UNMARKED AS THAT ARE FOCAL OR GENERALIZED
3.1.Together, generalized and focal seizures:
- attacks of newborns;
- severe myoclonic epilepsy of early childhood;
- epilepsy with prolonged peak-waves on the EEG during a slow phase of sleep;
- aphasia-epilepsy syndrome( Landau-Kleffner);
- other vague forms of epilepsy.
3.2.Without certain generalized and focal signs of ( many cases of generalized tonic-clonic seizures, which according to the data of the EEG clinic can not be attributed to other forms of epilepsy of this classification, as well as many cases of large seizures during sleep).
4. SPECIAL SYNDROME
4.1.Situational( casual) seizures:
- Febrile convulsions.
- Seizures associated with the acute effects of metabolic or toxic factors, as well as deprivation( sleep deprivation), alcohol, drugs, eclampsia, etc.
4.2.Isolated seizures or isolated epileptic status
CLASSIFICATION OF EPILEPSIS AND EPILEPTICAL SYNDROME IN ICD # 10
G40 Epilepsy.
Excluded:
- Landau-Kleffner syndrome( F80.3x);
- convulsive fit of the BDU( R56.8);
- epileptic status( G41.-);
- Todd's palsy( G83.8)
G40.0 Localized( partial) idiopathic epilepsy and epileptic syndromes with convulsive seizures with focal origin
Included:
- benign pediatric epilepsy with peaks on the EEG in the central temporal region;
- child epilepsy, with paroxysmal activity on the EEG in the occipital region.
G40.1 .Localized( focal)( partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures
Includes:
- seizures without altering consciousness;
- simple partial seizures, which turn into secondary generalized seizures.
G40.2 Localized( partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures
Includes:
- seizures with a change of consciousness, often with epileptic automatism;
- complex partial seizures, which turn into secondary generalized seizures.
G40.3 Generalized idiopathic epilepsy and epileptic syndromes
Included:
- benign myoclonic epilepsy of early childhood;
- benign minor convulsions( familial);
- children's epileptic absences( picnolepsy);
- epilepsy with large convulsive seizures( grand mal) upon awakening;
- juvenile absences-epilepsy;
- juvenile myoclonic epilepsy( juvenile small fits, grand mal);
- nonspecific epileptic seizures atonic;
- nonspecific epileptic seizures are clonic;
- nonspecific epileptic seizures myoclonic;
- nonspecific epileptic seizures are tonic;
- nonspecific epileptic seizures are tonic-clonic.
G40.4 Other types of generalized epilepsy and epileptic syndromes
Includes:
- epilepsy with myoclonic absences;
- epilepsy with myoclonic-astatic absences;
- children's spasms;
- Lennox-Gastaut syndrome;
- salaamov tick;
- symptomatic early myoclonic encephalopathy;
is West's syndrome.
G40.5 Special epileptic syndromes
Included:
- epilepsy partial continuous( Kozhevnikova);
- epileptic seizures related to alcohol use;
- epileptic seizures associated with the use of medicines;
- epileptic seizures associated with hormonal changes;
- epileptic seizures associated with sleep deprivation;
- epileptic seizures associated with exposure to stress factors.
G40.6 Grand mal seizures, unspecified( with or without small seizures( petit mal))
G40.7 Small seizures( petit mal), unspecified grand mal
G40.8 Other specified forms of epilepsy
Included:
- epilepsy and epileptic syndromes, not defined as focal or generalized.
G40.9 Epilepsy, unspecified
Included:
- epileptic convulsions of the BDU;
- - epileptic seizures of the BDU;
- - epileptic seizures of the BDU.
G41.1 Epileptic status
G41.0 Epileptic status of grand mal
Includes :
- tonic-clonic epileptic status.
Excluded:
- partial partial epilepsy( Kozhevnikova)( G40.5).
G41.1 Epileptic status of reit mal( small seizures)
Included:
- status epilepticus of absences.
G41.2 Complicated partial epileptic status
G41.8 Other specified status status
G41.9 Epileptic status, unspecified
Treatment of epilepsy
Treatment of epilepsy is aimed at normalizing brain electrical activity and stopping seizures. Antiepileptic drugs stabilize the membrane of the nerve cells of the brain and thus increase the threshold of convulsive readiness and reduce electrical excitability. As a result of such exposure to drugs, the risk of a new epileptic attack is significantly reduced. A valproate and lakmictal are able to reduce the interictal excitability of the brain, which allows to further stabilize the condition and prevent the development of epileptic encephalopathy.
Use:
- Antiepileptic drugs - carbamazepine( finlepsin), valproate( depakin chrono), lamitcal, topamax, gabapentin, clonazepam, etc. - the drug and its doses are selected by the physician individually
- In case of secondary epilepsy, additional treatment for the underlying disease
- is provided. Symptomatic treatment -for example, drugs that improve memory or reduce depression
Patients with epilepsy are forced to take antiepileptic drugs for their own protection for a long time. Unfortunately, such drugs can cause side effects( decreased cognitive activity, lethargy, hair loss, decreased immunity).In order to detect unwanted effects in time, a survey of interested organs is conducted every six months( general and biochemical analysis of blood, ultrasound of the liver and kidneys).
Despite all the difficulties encountered on the way to curb epilepsy, the spent forces and time are rewarded with a hundredfold: 2.5-3 years after the last attack, once again a comprehensive examination( video EEG monitoring, MRI of the brain) and a gradual decreasedose of an antiepileptic drug, resulting in its complete cancellation! The patient continues to lead the old way of life, using the same small precautions as before, but he is no longer tied to the constant intake of tablets. And this cure was made possible in 75% of cases!
General principles for the treatment of epilepsy:
- Treatment of epilepsy should be started after a second attempt.
- Principle of monotherapy.
- Antiepileptic drugs( AEP) are prescribed strictly in accordance with the form of epilepsy and the nature of the seizures.
- Treatment of epilepsy should start with small doses of the drug and gradually increase dosages until complete control of seizures. The therapy should be individual, continuous.
- In case of ineffectiveness of one drug, it must be gradually replaced by another AED effective in this form of epilepsy. If one AEP is ineffective, you can not immediately add to it a second drug, that is, switch to polytherapy, without using all the reserves of monotherapy.
- Gradual withdrawal of drugs when control over seizures( 2-4 years of absence of seizures).
- If necessary, the complexity of therapy( etiopathogenetic approach).
- Continuity of therapy.
- Improving the quality of life.
Necessary measures before initiation of anticonvulsant therapy:
- Evaluation and documentation of the patient's status before the start of therapy: physical examination, laboratory tests, EEG( including EEG sleep), neuroradiologic examination( if necessary), assessment of cognitive functions.
- Discussion of therapy, prognosis and social consequences( school, exercise, elimination of provoking factors, cost of treatment) with parents.
- Coordination with the parents of the goals of therapy.
- The choice of an adequate anticonvulsant( including epileptic syndrome, type of seizures, possible side effects of the drug).
- Explains the potential risk to parents when using the selected drug and situations where they need to see a doctor.
The main indications for use:
anticoulsants :
1. Treatment of patients with a definite diagnosis of "epilepsy"( the presence of repeated non-provoked attacks, exclusion of attacks of non-epileptic genesis)
2. Treatment of patients with one paroxysm( the presumed diagnosis of "epilepsy") withthe following characteristics:
· The patient has a history of febrile convulsions;
· Presence of family burden on epilepsy;
· Mental retardation;
· Focal neurological symptoms;
· When detecting "epileptiform" EEG patterns.
3. Treatment of patients with one or more provoked seizures due to an acute illness or condition( encephalitis, withdrawal syndrome, use of convulsants) - while continuing treatment of the underlying disease
4. Prophylactic treatment of patients with diseases or conditions with a high likelihood of seizures or epilepsy(craniocerebral trauma, neurosurgical intervention, stroke, encephalitis) - anticonvulsant therapy should be started only if epileptic paroxysis occurs
The choice of antiepileptic drugs depending on the types of seizures
possible worsening or aggravation of seizure frequency with the use of a number of antiepileptic drugs( pERUCCA ET AL., 1998)
| Preparation |
| Syndrome Seizures that are worsening |
| Carbamazepine | Absence epilepsy Juvenile myoclonic epilepsy Progressive myoclonic epilepsy Rolandic epilepsy | Absenses, myoclonia Myoclonic seizures Myoclonia Complexes peak-wave during slow-wave sleep, negative myoclonus |
| Phenytoin | absence epilepsy progressive myoclonic epilepsy | Absences Cerebellar symptoms |
| Phenobarbital | absence epilepsy | Absences - in the presence of high doses of |
| Benzodiazepines | Syndrome Lennox-Gastaut | tonic seizures |
| Lamotrigine | Severe myoclonic epilepsy Juvenile myoclonic epilepsy | When prescribing high doses of Myoclonic seizureand |
| Vigabatrin | Absence epilepsy Epilepsy with myoclonia | Abscesses Myoclonia |
| Gabapentin | Absence epilepsy Epilepsy with myoclonia | Abscesses Myoclonia |