What is Epilepsy in children?
Epilepsy is a disease with repeated epileptic seizures (more than two) and psychopathological disorders. An epileptic seizure (attack) is a manifestation of an excessive and abnormal discharge of brain neurons, which provokes the appearance of sudden pathological phenomena, manifested by motor, autonomic, mental disorders and changes in consciousness. Currently, epilepsy is one of the most pressing problems of pediatric neurology. The incidence in the pediatric population is up to 0.5-0.75%. Debut epilepsy can occur at any age, depending on the form of the disease. Epilepsy in childhood is characterized by a large number of seizures resistant to treatment and clinical symptomatology.
Causes of Epilepsy in Children
The role of the trigger (trigger) factor in the development of such an imbalance can play infections, injuries and other causes. In recent years, the assumption about the autoimmune nature of epilepsy and epileptic syndromes has been more and more reasonably expressed. Its validity is confirmed by the presence of autoantibodies to neuroantigens in the blood of patients with epilepsy. Neuroimmune processes arise, as a rule, secondarily and are one of the pathogenetic mechanisms of disease progression.
Pathogenesis during epilepsy in children
In the pathogenesis of epilepsy in children, the leading role is played by disorders in the formation and maturation of the brain during the prenatal period, the characteristics of biochemical and autoimmune processes that may be genetically accurate. In patients with epilepsy and their immediate relatives, deviations in water-electrolyte balance, acid-base state, carbohydrate, fat, mediator metabolism, as part of protein fractions, etc. are found. The role of mediators (GABA, serotonin, kinurenin, etc.) is of particular importance, the state of the membranes of neurons, their permeability. There is a theory of the presence in the body of a system of endogenous convulsives and anticonvulsants, the imbalance of which can lead to the development of the disease.
Epileptic seizures are divided into 2 types: partial and generalized. In turn, partial and generalized seizures are divided into simple and complex.
The development of a simple partial seizure depends on the location of the epileptic focus (focus) in the brain. During the attack, the child is conscious, can independently describe their feelings. Simple partial seizures are accompanied by motor disorders (convulsions in the face, legs, hands); specific sensory symptoms, for example, hallucinations in any form; somatosensory impairment (in the arms and legs or on half of the face); vegetative disorders (sweating, pallor or redness of the skin, dilated pupils, etc.); mental disorders.
When complex partial seizures observed changes in consciousness. Seizures begin with simple partial seizures with further impairment of consciousness. Complicated partial seizures are often accompanied by aura — various short-term sensations in the form of discomfort in the stomach and nausea, general weakness, headache and dizziness, speech disorders, numbness of the hands, lips, and tongue, with constriction in the throat, chest pain, lack of air, drowsiness, auditory and olfactory hallucinations, automated movements.
In patients with secondary-generalized tonic-clonic, tonic or clonic epileptic seizures that begin after a simple or complex partial seizure. Most often, they begin suddenly with an aura that lasts a few seconds, then the patient loses consciousness, after which convulsions appear – the body, arms and legs are stretched and in tension, with the head thrown back or turned to the side, breathing is delayed, the jaws are clenched. Tonic seizure lasts 15-20 s. Then there are clonic convulsions. They are manifested by contraction of the muscles of the arms and legs, torso, neck. Breathing is hoarse, noisy, foam is released from the mouth, often it is mixed with blood, because during an attack the child bites his tongue or cheeks. At the end of the attack comes general muscle relaxation. In this state, the patient does not respond to external stimuli, his pupils are dilated, there is no reaction to light, there are no tendon and protective reflexes, involuntary urination is observed. The clonic phase of epilepsy lasts 2-3 minutes.
Generalized seizures are accompanied by absansy, for which the characters are sudden short off of consciousness with minimal motor manifestations or their absence at all. Attacks begin suddenly, patients become inactive, immobile with a missing look, hypomimic face. During an attack, the patient may have partial memories of the events or their complete absence in the memory. During an attack, patients may respond to harsh sounds or pain stimuli. The most typical disorder is a disorder of consciousness followed by its rapid recovery. Aura and post-attack confusion are not typical; their presence usually indicates the occurrence of complex partial seizures (“pseudoabsances”). Patients and parents of children do not always feel short absences, the duration of which varies from 2-3 to 30 s.
Absansy divided into simple and complex. Simple absences are characterized by all of the above symptoms. Complicated absences differ in the strong manifestation of the symptoms of seizures. They are characterized by: sudden short-term violent twitching of various muscle groups, the patient is conscious. Parents note that their children drop or involuntarily drop objects. Patients describe the pain in the form of a sudden blow under the knees, after which they involuntarily crouch, sometimes even fall on their knees or buttocks, and may be or lose consciousness. When falling, patients may have seizures, an institution of the eyeballs, dilated pupils, muscle tension, a tremor, which turns into clonic muscle twitching. The duration of a convulsive attack ranges from 30 seconds to 10 minutes. In most patients, the duration does not exceed 5 minutes.
Symptoms of Epilepsy in Children
Considering the localization of the epileptic process, as well as the background against which seizures occurred, the disease has a large number of forms depending on the location, age, symptoms, symptoms of the syndromes:
- Frontal epilepsy
- Occipital epilepsy
- Temporal epilepsy
- Parietal epilepsy
Rolandic epilepsy is one of the forms of epilepsy, which manifests itself at any age of a child, ranging from 2 to 14 years old, is usually accompanied by short night facial seizures. The disease has a favorable prognosis.
In the clinical symptomatology of the attacks, simple partial (motor, sensory, less often vegetative), complex partial (motor and secondary-generalized) seizures are distinguished. Often during sleep, patients can make peculiar sounds such as “gurgling”, “grunting” or “gargling”. Minimal manifestation of motor and sensory paroxysms (short-term disorders), so parents may not pay attention to them.
Rolandic epilepsy begins with a seizure with a somatosensory aura: a feeling of tingling, numbness, “electric tingling” in the area of the pharynx, tongue, and gums. After this attack may end or go into a partial motor attack. Attacks may occur while the child is sleeping. The duration of attacks is short: from a few seconds to 2-3 minutes. A small number of severe long-lasting attacks ending in transient post-attack paresis (Todd paralysis) have been reported. The frequency of attacks on average 2-4 times a year. When a child is 1-2 years old, seizures may occur more frequently, but over time they will occur less and less. In young children during the first year from the start of diagnosis, the frequency of attacks can be high — weekly and even daily. Typical are considered night attacks, mainly when falling asleep and awakening. The course of this form of epilepsy is favorable and has a good prognosis with spontaneous remission in almost all cases.
Idiopathic partial epilepsy with occipital paroxysms (IZE) – a form of this childhood illness with simple partial seizures with visual disorders – hallucinations, photogyesia (flashes of light), visual illusions (macro, micropsia, metamorpho-psia), migraine-like symptoms – headache, diffuse or hemicranium type, nausea, vomiting, dizziness, as well as motor and convulsive disorders. At present, 2 variants of the IZE are identified – with early and late debut. The disease begins in the age range of 2-12 years with two debut peaks – at 3-5 (early form) and 9 (late form) years; it manifests itself as simple (motor and sensory), complex (motor and psychomotor) partial and secondary-generalized convulsive seizures. The classic version of IZE is occipital epilepsy with late debut (Gastaux epilepsy).
Vegetative paroxysms include epigastric sensations, nausea, vomiting, headache, dizziness. The duration of attacks varies from a few minutes to several hours; the frequency is usually small. There is a variety of IZE with an early debut of seizures – at the age of about 4 years (Panayotopoulos epilepsy). Characterized by severe attacks, starting with vomiting, headache, followed by tonic abduction of the eyes and head. Attacks usually end with unilateral or generalized tonic-clonic seizures. There is a very long loss of consciousness – from tens of minutes to several hours. Typical seizures during sleep, especially before awakening patients. The prognosis for IZE is favorable. Complete remission occurs in 95% of cases.
Primary epilepsy during reading is a form of epilepsy with a presumptive localization of the lesion in the temporo-parietal region, the main clinical sign is the provocation of epileptic seizures during reading. The age of patients varies from 12 to 29 years. Attacks occur after reading the first words of the text. In some cases, attacks can provoke a game of chess, cards and other board games, mental arithmetic, writing. For clinical manifestations, simple partial motor and somatosensory paroxysms are characteristic. A typical feeling of numbness, stiffness, twitching or twitching in the muscles involved in the act of reading aloud: the muscles of the lower jaw, tongue, pharynx, lips and facial muscles. Clonic jerking in the muscles of the mandible is the most common clinical symptom. It is important to note that motor and sensory manifestations during seizures are usually bilateral and symmetrical, and are only occasionally marked on one side. In isolated cases, symptoms such as visual hallucinations (simple and complex), paroxysmal dyslexia, epileptic nystagmus are described. Simple partial paroxysms can occur both in isolation and with subsequent generalization to tonic-clonic seizures.
Benign idiopathic neonatal family convulsions are a rare form of epilepsy. A family history of patients with idiopathic neonatal family convulsions (HCC) is aggravated by the presence of similar attacks in the neonatal period in the immediate family. An autosomal dominant mode of inheritance has been established. In most cases, the disease makes its debut from the 2nd or 3rd day of the postnatal life of a child, in isolated cases during the first month of life.
Clinically, idiopathic NSS manifests mainly generalized multifocal or focal clonic seizures with short periods of apnea, stereotypical motor and oculomotor phenomena in the form of tonic tension of the axial muscles, deviation of the eyes, tonic reflexes, pedaling phenomena, stereotypic postotonic reactions. In addition, there may be vegetative-visceral disturbances in the form of abundant drooling, reddening of the face and neck, changes in respiratory rate and heart rate. EEG abnormality in the interictal period, as a rule, is absent or alternating zero activity is noted. During an attack, changes observed in non-family idiopathic neonatal seizures are recorded.
Benign idiopathic neonatal nonfamily seizures (NNS) occur in newborns against the background of relative well-being on the 3-7th day of postnatal life (usually on the 5th day). They manifest themselves in the form of the epileptic status of generalized multifocal or focal clonic seizures, the duration of which does not exceed 24 hours. Generalized multifocal clonic seizures are asynchronous clonic contractions of muscles of individual parts of the body, face and limbs. Their distinctive feature is a migratory character, in which the clonic contraction spreads extremely quickly from one part of the body to another spontaneously and chaotically, involving in turn the mimic muscles of the face, the muscles of the abdomen, and the extremities. Consciousness of the child is usually not disturbed. Characterized by serial seizures.
Benign myoclonic epilepsy of infancy (DMEM) is one of the rare forms of epilepsy with short generalized myoclonic seizures without deactivating consciousness. Myoclonic seizures predominate in the muscles of the neck and upper extremities. Usually, the muscles of the shoulder girdle are involved with instant lifting of the shoulders, dilution of the elbows to the sides, easy adduction and flexion of the arms at the elbow joints. When a child begins to walk, myoclonic attacks in the muscles of the legs are noted: instantaneous flexion of the lower limbs with a slight squat or a possible fall on the buttocks. Falls (myoclonic astatic seizures) with this syndrome are rarely observed, but if this happens, the child immediately rises and continues to be active. As a rule, short-term (several seconds) and non-intensive attacks, the consciousness and memory of the attacks are usually preserved. Attacks can occur at any time during the day, in a state of drowsiness, during wakefulness. The disease makes its debut in the age range from 4 months to 3 years. The average age of the child at the beginning of the attacks is the 21st month.
Child abscess epilepsy (AED) is a form of epilepsy, manifested by the main type of seizures – absans with a debut in children from 1 to 9 years old. Clinically, absences are characterized by a sudden short shutdown (or a significant decrease in the level) of consciousness with minimal motor phenomena or their absence. The onset of unexpected epilepsy attacks, the patients interrupt or slow down their activity, become immobile with a blank empty fixed look, a hypomimous face (simple absans). Typically deep disturbance of consciousness, followed by its immediate restoration. Very short absans are not always felt sick and may be imperceptible to parents for a long time, becoming apparent only with the use of special tests. The duration of absences varies from 2-3 to 30 s. A characteristic feature of absensov – their high frequency, reaching tens and hundreds of attacks per day. Often, patients for the entire period of the disease there are only 1-2 convulsive seizures. Complete therapeutic remission is achieved in 70-80% of cases.
Juvenile absence epilepsy (UAE) is a type of epilepsy with the main type of seizures – absences making their debut in the teenage period with a high probability of joining generalized convulsive seizures. Age in the debut of the absences varies from 9 to 21 years. The debut of absences after 17 years is celebrated only in isolated cases. Absansy manifested by a short shutdown of consciousness with congelation and hypomimia. A characteristic feature of SAA is the predominance of patients with simple absences, i.e. seizures without any motor component. The duration of attacks ranges from 3 to 30 s.
Juvenile myoclonic epilepsy (UME) is a form of adolescent epilepsy with an established genetic defect, with convulsive seizures, mostly in the hands after awakening the sick. The onset of the disease varies from 2 to 22 years.
During attacks, unexpected, short, violent twitching of various muscle groups occurs with a sound mind. Attacks always involve the muscles of the arms and shoulder girdle, as a result of which patients involuntarily throw objects to the side. During attacks, they can inflict involuntary blows to those around them. Attacks are usually pronounced, but the intensity of twitching may be minimal, and only patients themselves are able to feel them.
When an attack occurs in the legs, the patients feel as if a sudden blow under the knees and slightly squat involuntarily. With massive paroxysms, it is possible to fall “as if knocked down” on your knees or buttocks. The frequency of the attack varies from several times a day to once a month. Its duration is a fraction of a second. Characterized by attacks immediately after awakening patients. In most patients, seizures occur only in the morning, within 30-60 minutes after awakening. The growth of paroxysms can be observed when falling asleep or during a sudden night awakening, in rare cases they can be observed throughout the day.
Epilepsy with isolated generalized convulsive seizures (epilepsy with arousal episodes). This form of epilepsy is defined as a syndrome that manifests itself exclusively with generalized convulsions in the absence of a clear focus on EEG, structural brain damage and the presence of any disease that may be the cause of epilepsy. The debut of generalized convulsive seizures (GSP) varies in a wide age range: from 1 year to 30 years with a maximum in puberty.
Clinically, SHGs manifest by sudden (without aura) shutdown of consciousness with the fall of the sick, convulsions, the establishment of eyeballs, and dilated pupils. First comes the short tonic phase of the attack with the predominant tension of the axial muscles, which ends with a tremor with a transition to clonic muscle twitching. The duration of the attack ranges from 30 seconds to 10 minutes. Rare seizures are typical. A distinct distribution of seizures by time of day is characteristic, paroxysms predominate during the period of awakening, falling asleep, and in sleep.
West syndrome – age-dependent epileptic syndrome with a special type of epileptic seizures (infantile spasms) – massive contractions of the musculature, a specific variant of changes on the EEG – gypsarhythmia and psychomotor retardation. Very often, infantile spasms occur in series of 10-15 spasms, following practically without interruption, one after the other.
Lennox-Gastao syndrome refers to generalized forms of epilepsy with various types of seizures, including seizures, atypical absences and episodes of tonic seizures or absences, with severe mental and motor developmental delay. Lennox-Gastaut syndrome occurs in children aged 1 to 8 years, most often from 3 to 5 years, often occurs after other epileptic syndromes, most often after West syndrome. The clinical picture of the syndrome is characterized by multiple daily attacks and a decrease in cognitive functions. The most common types of seizures are atypical tonic absences, but there may be other seizures. A typical combination of more than two types of seizures. The frequency of seizures is high, epileptic status occurs. Seizures are characterized by flexion movements of the head and torso, usually with impaired consciousness. There may be seizures with abduction and raising hands and falling. In addition, seizures with a slow extension of the extremities and abduction of the eyeballs with vegetative symptoms and slowing of breathing are noted.
Seizures in the form of atypical absences are characterized by sudden onset and termination, they can be moderately expressed and difficult to determine clinically. Loss of consciousness may be incomplete. The degree of impairment of consciousness is incomplete, characterized by serial tonic convulsions, a longer duration of convulsive seizures (several days, weeks), with a tendency to re-develop.
The delay of psychomotor development is observed in 90% of children, the rest maintains normal intelligence even after a long illness. Most children are lagging behind in development before the onset of seizures. The earlier the seizures begin, the more pronounced the decrease in intelligence. The incidence of epileptic seizures and episodes, as well as polytherapy, can affect the level of development. Autistic character traits, attention deficit, hyperactivity, and aggressiveness are also often noted, disrupting social adaptation and reducing school performance.
Epilepsy with myoclonias-astatic seizures (Duse syndrome) is one of the forms of generalized epilepsy, seizures begin at preschool age. Clinical manifestations of the disease include various types of seizures: myoclonic, myoclonic-astatic, typical absences, generalized tonic-clonic seizures with the possible addition of partial paroxysms. The main manifestations of myoclonic-astigic epilepsy are myoclonic and myoclonic-astatic seizures: short, lightning-fast twitches of small amplitude in the legs and arms, “nods” with a light propulsion of the body; the feeling of “beats under the knees.” Consciousness during these attacks remains intact (in the absence of absences), patients instantly rise after a fall. The frequency of myoclonic attacks is high. Generalized convulsive seizures, as well as absences, are observed in almost all patients. Characterized by short simple partial motor attacks, the frequency of which does not exceed 1 time per week.
Early myoclonic encephalopathy is a rare age-dependent epileptic syndrome. In most cases, the disease begins at an age not exceeding 3 months. The main type of seizures are myoclonias, mainly in the form of a fragmentary myoclonus. In addition, there may be frequent sudden partial seizures and tonic spasms. A typical sign should be considered frequent fragmentary myoclonias, which are not only the most frequent type of seizures, but are also considered to be the debut, early symptom of the disease. Over the course of the disease, fragmentary myoclonias gradually give way to a leading clinical role of frequent partial seizures. Myoclonias occur not only in the waking state, but also during sleep. In severity, they can vary from a slight twitching of the distal phalanges of the fingers to myoclonia of the hands, forearms, eyelids and the angle of the mouth. Their frequency is from several per day to several tens per minute.
The characteristic outcome of the disease is the death of patients in the first 5 years of life; survivors suffer from severe psychomotor disorders.
Early epileptic encephalopathy (Otahara syndrome) is a form of encephalopathy, the earliest age-dependent epileptic syndrome in its debut. Attacks make their debut in the first 2 or 3 months. life, but especially often in the 1st month. The main type of seizures are serial or isolated tonic spasms. Attacks are repeated not only in the waking state, but also at night. In addition to tonic spasms, in almost half of cases motor partial seizures may occur, sometimes according to hemitipu. Myoclonic seizures are uncharacteristic, although in some cases may occur. The duration of tonic spasm is approximately 10 seconds; in one series can be observed from 10 to 40 spasms. The total daily number of spasms is large enough and can reach 300-400.
Electric epileptic status during slow sleep (ESES syndrome) manifested during slow sleep is an electroencephalographic diagnosis and in some cases may not be accompanied by clinical manifestations. Occurs at the age of 8 months. – 11.5 years, more often – in 4-14 years. After 15 years, the syndrome usually does not occur. Often, seizures occur at night, can be both generalized and partial: motor seizures (myoclonic absences, generalized clonic seizures, orofacial paroxysms). The frequency of attacks is variable – from rare to daily. In some cases, with ESES syndrome, there are attacks with speech disorders.
Landau – Kleffner syndrome occurs at the age of 3-7 years. Characterized by a triad of symptoms: aphasia, epileptic seizures, behavioral disorders. Early symptoms are progressive speech impairment and verbal agnosia. Speech disorders are characterized by speech perseveration, paraphasia. In most cases, pre-disease speech disorders are absent. Further, the child has epileptic paroxysms. Attacks, as a rule, simple partial motor. Less common are generalized tonic-clonic, hemiclonic or complex partial seizures and absences. Atonic and tonic paroxysms are extremely rare. One of the features of epileptic paroxysms in Landau-Kleffner syndrome is their nocturnal nature. The attacks are usually short. Disorders of behavior are expressed by aggression, hyperactivity, autism.
Febrile seizures are disorders of a convulsive nature in children aged 6 months and older. up to 5 years with fever. Febrile seizures are divided into typical (simple) and atypical (complex).
Simple febrile seizures have the following symptoms:
- non-burdened family heredity for epileptic disorders (with the exception of febrile seizures themselves);
- the duration of the attack from 1 to 5 minutes, a maximum of 10 minutes;
- the absence of focal neurological disorders both before and after the attack;
- the presence of hyperthermia (body temperature during an attack of 38.5 ° C or more);
- generalized tonic or clonic-tonic character;
- short-term stupidity or drowsiness after an attack is possible.
Difficult febrile seizures:
- the age of the patient at the time of the first paroxysm is more than 5 years;
- the presence of neurological pathology, deviations in psychomotor development before or after the attack;
- burdened familial hereditary epilepsy;
- long, more than 10 min. attack;
- lateralized or focal nature of the seizure, as well as its repetition in the next 24 hours;
- presence of focal or epileptic activity on EEG.
Epileptic status is defined as a condition in which each subsequent seizure occurs earlier than the patient has completely left the previous attack, i.e. he still has pronounced disorders of consciousness, hemodynamics, respiration, or homeostasis.
The main causes of status epilepticus with an established diagnosis of epilepsy are: violations of the regimen; a break in taking antiepileptic drugs; the abolition of antiepileptic drugs is too fast; somatic and infectious diseases; teenage pregnancy; a relative decrease in the dose of antiepileptic drugs due to a significant increase in body weight (for example, as children grow). Status epilepticus can last from 1 minute to over 60 minutes.
Diagnosis of Epilepsy in children
For the diagnosis used laboratory and instrumental studies. Electroencephalography is one of the leading places in the diagnosis of epilepsy. It is necessary to take into account that approximately 50% of patients with epilepsy in the interictal period have a normal EEG, and functional tests (hyperventilation, photostimulation and sleep deprivation) in 90% of patients can determine the changes in the EEG. In the absence of EEG changes after functional loads, re-examination or monitoring of EEG is performed.
Neuroimaging is also one of the main diagnostic links. It is aimed at identifying organic brain damage, setting syndromic and etiological diagnosis, determining the prognosis, treatment tactics. The methods of neuroimaging include CT, MRI. Magnetic resonance imaging is performed with seizures with partial onset at any age; in the presence of focal neurological symptoms; treatment-resistant forms of epilepsy; resumption of seizures. According to the testimony of the health of patients with epilepsy, laboratory tests are conducted: blood, urine, biochemical (electrolytes, albumin, immunoglobulins, calcium, transaminases, alkaline phosphatase, thyroid hormones, phosphates, magnesium, bilirubin, urea, glucose, creatinine, amylase, iron, ceruloplasmin, lactates, prolactin, porphyrins), serological. If necessary, the survey plan includes: Doppler ultrasound of the brachiocephalic vessels, ECG monitoring, CSF analysis.
Treatment of Epilepsy in children
The basic principle of the treatment of epilepsy: the maximum therapeutic efficacy with a minimum of undesirable manifestations of drugs. Antiepileptic therapy is prescribed after the presence of repeated attacks and with a combination of characteristic symptoms, as well as after conducting research.
Treatment of epilepsy can begin after an accurate diagnosis. Treatment begins with the use of a single drug. The advantages of monotherapy compared with polytherapy are:
- High clinical efficacy (completely stop or minimize seizures succeed in 70-80% of patients).
- The ability to assess the suitability of this drug for the treatment of a particular patient, to choose the most effective dose and mode of administration. The doctor avoids the use of chemical compounds that are useless for the patient.
- Less chance of adverse reactions during treatment. In addition, it is always clear which drug is responsible for the undesirable effect; measures to eliminate it are facilitated (dose reduction or cancellation of this drug).
- Lack of mutual antagonism with the simultaneous use of several antiepileptic drugs.
For adequate antiepileptic therapy, the nature of the seizure in a patient is determined, taking into account the peculiarities of the epileptic syndrome (the patient’s age in the opening, the frequency of attacks, the presence of neurological symptoms, intelligence), the toxicity of the drug and the possibility of side effects. The choice of antiepileptic drug is determined mainly by the nature of the attacks and, to a much lesser extent, by the form of epilepsy.
Treatment begins with a standard average age dose. It is prescribed not immediately in full, but gradually, in the absence or insufficient effect, it is transferred to the use of the entire age dose (in 1-3% of patients, seizures can be eliminated with a dose of the drug less than the standard, average age). The dose of the drug is selected individually for each patient.
Tablets with a slow release of the active substance have an important advantage over conventional drugs (valvroic acid derivatives – depakinchrono, conculex retard; carbamazepine derivatives – tegretolretard, timonilretard). Their use reduces the risk of undesirable effects and ensures the stability of the therapeutic effect.
If the maximum tolerated dose of the drug is reached, but the seizures do not stop within a month, the drug of the second and then the third row is gradually injected, and the previous one is gradually canceled.
Replacement of antiepileptic drugs is carried out gradually over 1-2 weeks. and longer. Special attention due to the presence of pronounced withdrawal syndrome should be paid to barbiturates and benzodiazepines.
If consecutive monotherapy with various antiepileptic drugs does not stop the attacks, then the patient has drug resistance, which most often occurs during early debut of epilepsy, serial epileptic paroxysms, complex partial seizures, the patient has frequent (more than 4 per month) seizures or several types of paroxysms , reduced intelligence, brain dysgenesis.
The presence of drug resistance is an indication for polytherapy (usually no more than 2 drugs). It should be emphasized that antiepileptic drugs are combined with different pharmacodynamics and in accordance with the spectrum of their action with drugs that minimize the frequency of seizures during monotherapy. When a good therapeutic effect of pharmacotherapy is achieved, the drugs are canceled, taking into account the absence of short-term disorders. In this case, the normalization of the EEG is not decisive.
In many symptomatic forms of epilepsy (epilepsy with myoclonic absences, myoclonic-astatic epilepsy, Lennox-Gastaut syndrome, symptomatic partial epilepsy, etc.), an imperfect period should not be less than 4 years.
In the majority of idiopathic (benign) forms of epilepsy (rolandic, pediatric absans, juvenile absans, etc.), antiepileptic therapy can be canceled 2 years after the cessation of seizures.
Premature discontinuation of treatment can lead to relapse of epilepsy. In many cases, patients are forced to take antiepileptic drugs for life. Cancel therapy should be gradually (in order to avoid the development of seizures up to epileptic status) within 3-6 months. under the control of EEG, slowly reducing the dose of drugs.
A pronounced therapeutic effect is achieved in 80-85% of patients with epilepsy. Modern antiepileptic drugs either suppress the pathological activity of neurons in the epileptic focus (for example, diphenin, ethosuximide, etc.), or disrupt the spread of excitation from it, the involvement of other neurons, and thus prevent seizures (for example, phenobarbital, etc.).
It is almost impossible to correlate between the form of epilepsy (and, therefore, to a certain extent, the localization of the focus as a population of neurons, the first to give rise to an epileptic discharge) and the mechanism of action, the place of application of well-defined antiepileptic drugs.
Sodium valproate and calcium valproate are administered intravenously and administered orally during meals. Drugs under the influence of the acidic environment of the stomach are converted into valproic acid, which is absorbed from the gastrointestinal tract. Valproaty prolonged action (depakinchrono, concouleksretard) prescribed 1 time per day.
Carbamazepine is slowly absorbed from the gastrointestinal tract when administered during a meal. The multiplicity of appointments 2-4 times a day. Retardirovanny forms of carbamazepine administered 1 time per day.
Oxcarbazepine (trileptal) when administered orally is inactivated by gastric juice, so it is prescribed 1-1.5 hours before a meal.
According to its clinical and pharmacological characteristics, clobazam is similar to clonazepam. The main metabolite of clobazam is N-desmethylklobazam, which by 25% provides the anti-epileptic effect of the drug.
Lamotrigine (Lamictal) is administered intravenously or administered orally. After taking the drug before a meal, it is completely and rapidly absorbed. With monotherapy, lamotrigine is prescribed 1 time per day. When combined therapy with drugs (carbamazepine, difenin, phenobarbital), accelerating the conversion of lamotrigine in the liver, it is prescribed 2 times a day.
Topiramate (Topamax) is a structurally new anticonvulsant drug from the group of sucrose sulfamates. Topiramate GABA-positive effect, blocks potential-dependent sodium channels, has an antagonistic effect on one of the types of glutamate receptors. The multiplicity of appointments 2-3 times a day.
Phenobarbital is good, but slowly absorbed when taken in the small intestine. The maximum concentration in the blood occurs after 2-8 (sometimes 12) hours, in newborns (until the 15th day of life) – even later.
Barbiturates. The multiplicity of prescription drugs with a preventive purpose 1 time per day.
Difenin is very well absorbed in the small intestine. There are drugs difenina for parenteral administration. After intramuscular injection, the drug is absorbed very slowly.
Ethosuximide is administered orally during meals, rapidly absorbed. The multiplicity of appointments 2-3 times a day.
Inhibition of biotransformation of antiepileptic drugs occurs when they are coadministered with isoniazid, sulfonamides (especially those containing trimethoprim), diacarb, coumarins (neodicoumarin, etc.), fluconazole, cimetidine, amiodarone, neuroleptics (derivatives of a number of lymphocylins, cimetidine)
Difenin, phenobarbital, hexamidine and carbamazepine are stimulators of hepatic enzymes, they increase the biotransformation of other antiepileptic drugs. This, however, has little clinical significance, since the decrease in the antiepileptic effect of this drug is offset by the effect of adding another drug. More practically significant is the increase in biotransformation of drugs from other pharmacological groups, such as theophylline, indirect anticoagulants, quinidine, vitamins D, K, B6, B12, digitoxin, lidocaine, levomycetin, doxycycline, minocycline, rifampicin, cyclosporine, aminazine, aminocyte, doxycycline, aminocycine, rifampicin, cyclosporine, aminocetin, amycin, amylamine, amitazin, amitazine, amitazin, amitazin, amitazin, amitazin, amitazin, amitazin, amitazin, amitazin, amycinumine, doxycycline, minocycline, rifampicin, cyclosporine, aminoxin, lidocaine, levomycetin , glucocorticoids, nonsteroidal anti-inflammatory drugs (paracetamol, butadione, etc.).
Undesirable effects of antiepiptic drugs:
- Drowsiness, drowsiness, headache, impaired memory and cognitive functions, ataxia, tremor, nystagmus, diplopia, mental disorders, depression, psychosis, decreased libido, motor disinhibition, provocation of epileptic seizures, weight gain.
- Osteopathy, hemorrhage, megaloblastic anemia, disorders of sexual development (the result of increased activity of liver enzymes).
- Diarrheal disorders (anorexia, nausea, vomiting, diarrhea).
- Hyperplasia of the gums (difenin).
- Hematotoxicity (leukopenia, thrombocytopenia, hypoplastic anemia, agranulocytosis).
- Hepato and nephrotoxicity.
- Dysfunction of the pancreas (valproate).
- Violation of porphyrin metabolism (barbiturates in patients with hereditary metabolic disorders).
- Allergic reactions (often rash).
- Muscular dystrophy, cardiomyopathy, respiratory distress syndrome in newborns born to mothers who took valproate.
- Edema (carbamazepine, due to increased secretion of antidiuretic hormone).
Prevention of Epilepsy in children
The main preventive measure is the timely detection of epilepsy and early treatment. Prevention of head injuries, proper perinatal care also apply to preventive measures. Since epileptic seizures are consequences of pathologies of the brain, stabilization of the condition and control of the frequency of seizures are the main tasks not only during treatment, but also during the period of rehabilitation and prevention. To stabilize the condition of patients, special antiepileptic drugs can be used.
All preventive measures are aimed at ensuring that the patient can lead a normal life without any restrictions, but at the same time he needs to adhere to the daily routine, maintain a healthy and full sleep, not drink alcohol, avoid stressful situations, and physical exertion should be light and only after the recommendations of the doctor.