Epilepsy in adults: diagnosis and treatment

Epilepsy in adults is a chronic disease of the nervous system, consisting in repeated specific attacks (epipripeds). Species of epipriplets described more than 40, all of them are accompanied by pathological electrical activity of the brain. To establish a reliable diagnosis, additional research methods are required, sometimes carried out repeatedly (to "catch" the wrong electrical discharges). The selection of an effective antiepileptic drug for the prevention of epileptic attacks is a complex task. This requires a comprehensive account of all components of the disease: a clinical type (type) of seizure, frequency of seizures, concomitant diseases, occupational characteristics, age of the patient and many another. We will talk about diagnosis and treatment in this article.

Diagnostics

Talking to the patient and finding out the history of the disease is an important stage of the diagnostic process.

In the diagnosis of epilepsy, the classification of epilepsy and epilepsy, developed back in 1989 by the International Antiepileptic League, is used. The division is based on the cause of the occurrence of epi-seizures. From this point of view, all types of epilepsy and episindromes (both local and generalized) are divided into:

• idiopathic - this group includes all episindromes with hereditary predisposition. Relatives of the patient can identify such clinical symptoms. In this case, a complete clinical examination, the use of additional research methods do not reveal signs of primary lesions of the brain (ie, at the onset of the disease in the brain, they do not find anything that could provoke epitopes. Despite this, epipriphes do appear);
• symptomatic - these include those situations where the appearance of epileptic attacks is due to brain damage or the presence of some kind of disease in the body as a whole. For example, previous severe cerebral trauma or neuroinfections, metabolic disorders;
• cryptogenic - this group includes those episindromes that are probably symptomatic, but it was not possible to detect their cause with the help of modern diagnostic methods. Cryptogenic epilepsy is a diagnosis that leads to a further search for the cause of the disease.

Why is the reason so important? Because the therapeutic tactics depends crucially on it. If the cause of epilepsy is known, then, if possible, it should be eliminated. Sometimes, only the elimination of the factor that caused the episyndrome can reduce the frequency of seizures or even bring them to naught. When the cause remains unknown, when prescribing treatment, they rely on the type of epileptic fit (local or generalized) that has arisen in the patient.

To determine the type of epileptics, the doctor must carefully collect the anamnesis of the disease. Even the smallest details are important. Did the patient feel a fit? What sensations did he experience during and after the seizure? What, in the opinion of the patient, provoked an attack? How often do these conditions occur? And much more should be known to the doctor. Since for most of the seizures the patient can not remember his feelings, the information can be provided by relatives, colleagues, who were present during the development of epiprust.

After finding out the complaints and the history of the disease, a neurological examination is performed. In this case, for epilepsy is characterized by an interesting feature: in most cases at the beginning of the disease neurologist does not find any gross neurologic changes. This, strangely enough, serves as a small proof in favor of the diagnosis of epilepsy.

For an accurate determination of the nature of the seizure, the exclusion of other diseases reminiscent of epicas (for example, fainting, hysterical seizures), and the choice of a drug for treatment of the patient is carried out by additional methods research.

Additional research methods

Electroencephalography helps the physician to identify specific epileptic activity of the brain.

The most informative and necessary method of research in epilepsy iselectroencephalography (EEG). This is a method of recording the electrical activity of the brain, completely harmless and painless. It is used to answer the question: is there epileptic activity in the brain? The method is as follows: the patient is wearing a kind of cap-net (helmet) containing electrodes. For at least 20 minutes, electric impulses are recorded from the surface of the scalp. At the same time, various samples are used during the recording: with opening and closing the eyes, with visual, sound stimulation, a sample with deep and frequent breathing. Samples help to provoke pathological electrical activity of the brain in the presence of epilepsy. With insufficient information content of the usual EEG technique, it is performed after sleep deprivation (after sleep deprivation during the day), EEG in sleep, EEG video monitoring is used. The last two types of EEG are carried out in a hospital.

In epilepsy, an electroencephalogram records specific epileptic activity in certain areas of the brain in the form of peaks (spikes), acute waves, peak-wave complexes, polypic. For each type of seizures, generalized and partial, their specific changes are characteristic. Those. EEG allows us to clarify the type of epicas, the place of their occurrence.

In 50% of cases in patients with epilepsy, a normal electroencephalogram is recorded. The absence of pathological changes after a single EEG is not yet indicative of the absence of an episyndrome in the patient. Sometimes epiaktivity can be registered only during the recording of the EEG during the day (EEG video monitoring is used for this purpose).

It should be noted that the detection of epileptic signs on an electroencephalogram in the absence of clinical manifestations of epipriplets does not indicate the presence of epilepsy in a person. The diagnosis of epilepsy requires mandatory clinical symptoms. If they do not exist, there can not be a diagnosis either.

In order to distinguish epipripeds from other conditions that are accompanied by a disturbance of consciousness, falls (fainting, problems with blood supply to the brain, violation of the rhythm of cardiac activity, etc.), use ultrasound transcranial doplerography (UZDG), ECG monitoring.These methods are also painless and do not require any preliminary preparation. UZDG provides information on the state of blood vessels and blood flow in the carotid and vertebrobasilar basins of the brain. It is carried out in the conditions of a polyclinic, and in a hospital. ECG monitoring (Holter monitoring) is an ECG recording during the day using a special small sensor. The patient at the same time leads a normal lifestyle with the recording of his actions on paper (for example, he dined at 14-00, from 14-30 to 15-00 he walked on foot at the usual pace, etc.).

Computed tomography or magnetic resonance imaging of the brainare also used in the diagnosis of predominantly symptomatic types of epilepsy. They can detect tumors, scarring and adhesions, signs of acute disorders of cerebral circulation, i.e. structural disorders in the brain.

A patient with suspected epilepsy should perform a series of laboratory tests: a general blood test, a general urine test, coagulogram, biochemical blood test (electrolytes, protein, urea, creatinine, transaminases, bilirubin, glucose, amylase, alkaline phosphatase). If the infection process is suspected, serological methods are used. The list of necessary analyzes is specified in each specific case.

The whole spectrum of surveys usually allows you to answer the questions: is the seizure epileptic, what type is it, does it have a morphological reason? All this information is needed to determine the tactics of treatment.

How to treat epilepsy in adults?

To begin treatment it is necessary only in that case when there is a confidence, that attacks are epileptic (and do not have other nature - fainting, mental diseases, etc.).

Medication

To begin with, it is necessary to resolve the question of the use of antiepileptic drugs in general (anticonvulsants).

If the patient had only one epileptic fit, then in some cases antiepileptic drugs are not prescribed. These are situations when the seizure was provoked by something (for example, acute violation of cerebral circulation), when there is a pregnancy, when the seizure occurred after prolonged sleep deprivation. The diagnosis of true epilepsy is very important, so that anticonvulsants are not prescribed to a healthy person.

Mandatory antiepileptic drugs are prescribed if the disease began with epistatus, if it is already a repeated proven epileptic seizure, if it is a case of hereditary epilepsy.

It is advisable the appointment of anticonvulsants in such cases (in the presence of an epiprip):

• when detecting epiactivity on EEG;
• if a person had a birth injury;
• if epipriposition is severe and their re-development threatens the life of the patient;
• mental symptoms in the patient.

Which anticonvulsant will be prescribed to the patient depends on a number of factors: from the type of seizure (generalized or partial), the type of epilepsy (idiopathic, symptomatic or cryptogenic), age and sex of the patient, the presence of concomitant diseases, possible side effects, material opportunities.

To date, there is a large number of antiepileptic drugs. For each of them, one or another degree of effectiveness is established experimentally for different types of seizures, a therapeutically effective dose. Preparations for the generalized and partial seizures are isolated preparations of the first and second lines, i.e. those with which to begin treatment in the first place and those that stand in the reserve. The cases of resistance, i.e. the uselessness of taking any drug for a particular type of seizures. The doctor takes all this into account when selecting an anticonvulsant on an individual basis.

After taking into account all the above factors, the doctor chooses one of the anticonvulsants of the first line. It should be taken to the patient within three months after reaching a therapeutically effective dose (some drugs start taking with a small dose, gradually increasing it to the required dose). Three months later, the situation is assessed: whether the seizures decreased (stopped), how is the drug transferred? If everything is good, then this drug is taken for a long time in the appropriate dose for 3-5 years.

If the seizures continue or if there are side effects that significantly worsen the quality of life, then the choice of the drug is reviewed. Assign a new medicine, but the previous drug is not canceled yet (as a sharp break in therapy can trigger more seizures and even an epistatus). When the dose of the new drug will match the therapeutically effective, then the first one can be gradually canceled. Again, evaluate the effect of the drug at the end of three months of continuous intake.

If the result is not again achieved, then combinations of two anticonvulsants are selected (considering their mechanisms of action and possible side effects, as well as their interaction with each other in organism). If two drugs do not help together, then try combinations of the three. Simultaneous intake of more than three antiepileptic drugs is considered ineffective. Unfortunately, only such an "experienced" way can be chosen the right treatment, which will reduce the attacks to naught. Of course, such searches are possible only with the precise diagnosis of epilepsy, since almost all anticonvulsants are not completely harmless, and their long-term administration inevitably has a side effect on the body.

The main anticonvulsants used at present are:

• Valproate (Depakin, Convulsofin, Convoolex, Enkorat), the therapeutically effective dose is 15-20 mg / kg / day;
• Carbamazepine (Finlepsin, Tegretol), 10-20 mg / kg / day;
• Phenobarbital (Benzonal, Hexamidine), 200-600 mg / day;
• Diphenin (Phenytoin), 5 mg / kg / day;
• Lamotrigine (Lamycatal, Convulsant, Lamolep), 1-4 mg / kg / day;
• Topiramate (Topamax, Topsaver, Toreal), 200-400 mg / day;
• Clonazepam 5 mg / kg / day;
• Felbamate, 400-800 mg / day;
• Ethosuximide (Suxilep, Petunidan), 15-20 mg / kg / day;
• Gabapentin (Neurontin, Gabagamma, Tebantin), 10-30 mg / kg / day;
• Pregabalin (Lyrical), 10-15 mg / kg / day.

Since epilepsy is a chronic disease requiring long-term continuous therapy and constant monitoring, the patient should be examined by the attending physician at least once every three months. It is obligatory to conduct an EEG once every 6 months, consultations of related specialists, if necessary, conducting laboratory research methods to control side effects from antiepileptic preparations.

If the background of a three-year reception of an anticonvulsant did not show any epiprime, according to EEG results normal electrical activity of the brain, the attending physician may consider the gradual withdrawal of the drug (within -2 years). If, against a background of a reduction in the dose, or when withdrawal is returned epiaktivnost, and again there are seizures, the patient should return to taking anticonvulsants.

Diet for epilepsy in adults

First of all it should be said that patients with epilepsy are categorically contraindicated in alcohol! In any form! Any, even low-alcohol drinks, can provoke epiphary, lead to an epistatus. Refusal of alcohol is a prerequisite for effective treatment.

Eating sick epilepsy should be rational, meet the basic requirements of proper nutrition for healthy people.

It is undesirable to consume a large amount of legumes, salted and spicy food, smoked meat, very fatty meat, carbonated drinks. A fluid restriction is recommended.

Since the treatment of epilepsy consists in the continuous admission of anticonvulsants, and some of them lead to deficiency of certain substances in the body, small changes in the diet are sometimes simple are needed. With a deficiency of folic acid and vitamin B12, you need to eat more leafy green vegetables, citrus, pumpkin, carrots, veal and beef liver, sea fish (herring, sardines) and seafood (mussels, oysters, crabs). In some forms of epilepsy, foods rich in vitamin B6 are useful: milk, egg yolks, nuts, wheat germ, beef liver, greens. It is advisable to limit the intake of simple sugars (baking pastry, cookies, sweets) a little, and increase the fiber content of fruits and vegetables.

There is evidence of some effectiveness of a diet with a high fat content (up to 70% of energy needs of the body) against the background of a decrease in the total amount of carbohydrates.

Some anticonvulsants have a side effect in the form of weight gain (valproate). In this case, you need to adhere to a low-calorie diet.

Since many antiepileptic drugs have a toxic effect on the liver, patients with epilepsy should follow the principles of the therapeutic diet number 5 (diet for patients with diseases liver).

Surgery

When treatment with anticonvulsants does not bring the expected effect, it is impossible to achieve control over epiprust, or when initially cause of seizures is some kind of education in the brain (for example, a tumor), then a decision is made to perform a surgical treatment.

All surgical procedures for epilepsy can be divided into two groups: resection methods (removal) and functional (when surgical procedures are performed without removing any parts brain). The first group includes resection of the epileptic focus, resection of the temporal lobe, hemisferectomy (removal of the hemisphere of the brain); to the second - komisurotomiyu (dissection of neural connections between the left and right hemispheres), stimulation of the vagus nerve, multiple subpial incisions (superficial incisions of the cortex of the head brain). Of the new surgical methods currently undergoing research, it is worth mentioning the gamma knife and the implantation of a neurostimulator that suppresses epi-activity in the brain. The issues of surgical treatment in many respects are controversial due to the large traumatic operations. And not always holding them gives a 100% result. That is why now, such minimally invasive methods as gamma-knife and neurostimulator are being developed.

Epilepsy is a dangerous and serious illness that can cause a sharp restriction of life. However, timely diagnosed, it can be controlled by constant medication. Effective treatment allows you to stop the development of epicas, improve the quality of life, reduce the limitations in opportunities, return interest to the world. Epilepsy is not a sentence yet! It is worth remembering to anyone who has encountered such a diagnosis.

Channel "Russia 1 the program "On the most important" about epilepsy.