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Epilepsy and convulsion syndromes

Epilepsy is a chronic disorder, which is characterized by the presence of:
• Epileptic focus.
• Recurrent attacks with various clinical signs. • Personality disorders between attacks.
• Some specific paraclinical signs.
Epilepsy as a disease should be differentiated from:
• Epileptic reaction;
↳ Epileptic reaction is the response of the brain to the strong external and internal damaging factors (such as electro shock,
insulin shock, brain hypoxia, severe alcohol intoxication and so on). The main clinical features of epileptic reaction are abortive
seizures or general tonic clonic seizures.
• Epileptic syndrome;
↳ Epileptic syndrome is characterized by recurrent epileptic attacks on the background of pathologic focus in brain. The attacks
are variable and depend on the localization of focus. Focal symptoms are obligatory in this case.
Risk factors:
1. Inheritance.
2. Organic brain diseases:
• Prenatal (infections cytomegalovirus, rubella, toxoplasmosis, toxicosis of pregnancy, diet disturbances);
• Perinatal (physical trauma, child birth anoxia, metabolic disorders, neonatal infection);
• Postnatal (infections, trauma, dehydration, toxins);
3. Disorders of brain function. Sleep disorders.
4. Paroxysmal states in childhood:
• Newborns seizures;
• Febrile seizures;
• Affective respiratory seizures.
Pathology:
Changes as
• results of organic diseases or • results of epileptic process.
Each epileptic attack causes hypoxic changes in brain and leads to the development of encephalopathy.

Pathophysiology:
1. There is a group of neurons with pathologic activity, which is called epileptic focus.
2. There is the ability to enforce and spread the activity.
3. Weakness of anti epileptic protection. (It is provided by caudal parts of the brain).

Neurochemistry of epilepsy:
1. Disorders of balance between glutamate (exciting neurotransmitter), GABA (inhibitory neurotransmitter) that leads to
desynchronization.
2. Disorders of K / Na pump. The antibodies themselves may be directly implicated in causing epilepsy.
(4-7). Increased prevalence of anticardiolipin antibodies (aCL) and
antinuclear antibodies (ANA) and changes in serum immunoglobulin
Immunology of epilepsy: concentrations
There is increasing content of antibrain antibodies. The primary attack causes disturbances of HEB. Immune system butts into strange to it
nervous system. The result is production of antibodies and CIC that are fixed in brain tissue and favour its damage in new places.

Classification of epileptic attacks Jacksonian march, also called Jacksonian seizure, is one kind of a simple partial
seizure. “Simple” in this context means patients do not lose awareness. Partial mea
I. Partial epileptic: that abnormal neuron firing only occurs in part of the brain, and, accordingly,
1. Simple: abnormal movement or sensation is limited to only part of the body.
a. Simple motor: • Focal motor without march; • Focal motor with march; • Adversive;• Postural;• Phonatory simple.
b. Simple sensory: • Somatosensory (with and without march); • Visual, acoustical, gustatory, smell);
c. Simple autonomic visceral.
d. Simple with psychiatric disorders: • Aphatic • Dysmnestic • thinking disturbances • Emotional affective • Hallucinatory.

because the tingling or twitching begins in a small area and then "marches" or spreads to a larger area of the body.
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2. Complex: personality disturbances, confusions, dazed
a. Temporal pseudoabsance; behaviour, motor activity appear as non flexed
actions, conciousness is lost or impaired
b. Automatisms.
3. Simple with generalization (secondary general).
II. General attacks: both hemispheres are involved,
1. Absance: • Typical; • Atypical.
2. Myoclonic.
3. Tonic clonic.
4. Tonic.
5. Clonic.
6. General atonic
III. Non classified
IV. Epileptic status

I. Clinical features; A.
I. General seizures.
Epileptic general tonic clonic attack (grandmal) usually begins with short initial stage that lasts several seconds. The last can manifest as:
• Bilateral general muscle jerks; • Loss of consciousness; • Autonomic changes; • Enlargement of pupils;

1. TONIC STAGE: 2. CLONIC STAGE:

• The tonic stage lasts about 10-20 seconds
• Seizures involve all the muscles
• Usually in the extensors but at the beginning flexors are more
involved
• Eyes are opened, looking upwards
• Mouth is opened
• Start from axial muscles and then involve extremities
• Shoulders are lifted and adducted
• Muscles of lower extremities are NOT involved
• Opistotonus and obstetrician arm are often observed
• Extension of great toe
• Epileptic shouting due to contraction of diaphragmatic muscle
• Then tonic stage is converted in clonic one
• Due to tonic muscles straining there is trembling of the muscles
• Between the muscles straining - relax pause
• Tongue biting, clonic vocalization
• This phase lasts 30-40 seconds
• Severe autonomic disorders apnoe, cyanosis, small skin
hemorrhages, pulsation of carotic arteries
• Pulsation is frequent, AP is increased
• Mydriasis
• Hyper- salivation that usually manifest as bloody foam.

3. NEXT STAGE CAN BE DIVIDED INTO EARLY AND LATE:

3.1 EARLY 3.2 LATE (RECOVERY)
• Lasts 1-5 min • Lasts 5-15 min
• Characterized by: New phase of tonic contraction
• Characterized by decreasing of mydriasis, normal
• Last stage is very similar to the one at the beginning
• But seizure dominates in the face, espc. chewing muscles superficial reflexes, decreased deep reflexes and Babinski
causing trismus sign (stimulation of the lateral plantar aspect of the foot
• Extremities aren't involved leads to extension of hallux)
• The eyes are looking upwards
• Mydriasis • Behavior of the patient is often automatic
• Ends with muscles atonia leading to involuntary urination • When patients are conscious they complain on headache,
• Corneal reflexes are absent
muscles pain and complete amnesia.
• Deep reflexes are increased
• Loss of consciousness
• Meaning patient is in coma

Different types of general tonic-clonic attack depending on age. In children tonic stage can last longer than clonic one. In newborn babies
there is often difference between right and left hemisphere seizures. Sometimes in children general tonic clonic attacks are associated with
vomiting and feces incontinence. Tonic attacks are seldom in grown ups. In children tonic attacks are often associated with atypical
absentia epileptica.
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There are three types of epileptic tonic attacks:
1. Axial body and facial muscles are involved in attack. There is spasm of respiratory muscles and breathing stop at expiration.
2. The same signs plus less involvement of extremities muscles.
3. Global means involvement of body and extremities muscles in the same way.

- These attacks are associated with loss of consciousness.

- There is mydriasis, tachycardia, increased AB and so on.
- General tonic clonic attacks are very dangerous for the patient.
- They can cause trauma, aggression and sudden death as a result of autonomic disorders and respiratory disturbances, acute suprarenal
insufficiency.

Clonic epileptic attacks

General typical clonic attacks are often observed in newborn babies. There is loss of consciousness, autonomic disorders, rhythmic clonic
seizures. Between the attacks of clonic muscles jerks there is muscle hypotonia.
If the attacks last 12 min the consciousness recovers quickly. But these attacks can last 45 min and even more. Then after the attack coma
can be developed.

Clinical features; B.
II. Without seizure attacks
Absentia epileptica are characterized by:
- sudden and short lasting (230 sec) loss of consciousness
- EEG peculiarities
EEG= electroencephalogram
- Absent gaze
- Interruption of patients activity
- Autonomic disorders (paleness or hyperemia of face, midriasis)
- The attack is finished suddenly. The patient doesnt remember anything about it.

If absentia is associated with any motor component it is called complex absentia. Complex absentia can be divided into
myoclonic, atonic, tonic and with automatisms.

Myoclonic absentia is characterized by loss of consciousness, rhythmic bilateral myoclonus in face and upper extremities. There are
jerks of eyelids, periorbital muscles, mouth edges, eye bulbs. The patient can loose some objects he is holding in his arms.
Atonic absentia is characterized by decreasing of postural tonus, hanging head and sudden drops.
Tonic absentia is associated with looking of eyes upwards. There is domination of either extensor or flexor component, symmetric or
asymmetric.
Absentia with automatism can be the sign of focal attack and absentia. The main condition for automatism is incomplete loss of
consciousness. Differential diagnosis in this case is very complicated. Thats why EEG should be made for such patients.
Typical absentia are associated with bilateral symmetric complexes top waves with frequency 3 per sec in frontal central lobe. They
are much more common in children and can be caused by hyperventilation or light. They are very refractory to the antiepileptic drugs.
Atypical absentia are associated with such EEG changes:
1. Bilateral symmetric complex of top wave which are rhythmically repeated with frequency 2 per sec.
2. Epileptic rhythm of gathering with frequency 10 per sec.
3. Epileptic rhythm of gathering with frequency 20 per sec.
4. Complex of multiple spikes waves with frequency 4 6 per sec.
Atypical absentia are resistant to hyperventilation and parox- ysmal light.
II.II. Focal
Focal Attacks
attacks
Focal attacks are those that clinically and on EEG manifest as the beginning of activation of neuron system of certain part of brain
hemisphere.
There are three groups of focal attacks:
1. Simple focal.
2. Complex focal.
3. Focal attacks with secondary generalization
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The main differential feature of complex focal attacks from simple ones is loss of consciousness.

Focal attacks are characterized by different symptoms motor, sensory, autonomic or psychiatric that depends on focus localization
and the peculiarities of morphofunctional organization of epileptic system.
Motor attacks are caused by discharges in certain part of motor cortex. Somatomotor or motor Jackson attacks are seizures in certain
muscle group according to the focus localization. They can be local or involve other group of muscles according to the topical localization
in the brain cortex.
In case of epileptic discharges in motor speech center speech disorders or involuntary vocalization involuntary repetition of words are
observed.
Sensory attacks manifest as simple or complex sensory disorders, such as somatosensory, visual, acoustical, olfactory, taste attacks
and epileptic attacks of dizziness.
Somatosensory Jackson attacks are associated with numbness, tingling in some part of the body. They can be localised or
involve other parts of the body. They are caused by epileptic discharges in Post Rollandic region. Very often the attack begins as
somatosensory and then converts into somatomotor.
Visual, acoustical, olphactory, taste attacks and epileptic attacks of dizziness they can manifest as simple disorders
or complex illusion or hallucinations.
Treatment
The main principals of epilepsy treatment should be emergency, accordance to stages, following.
On the way to hospital:
1. To release breathing air ways. 2. Digitalis drugs.
3. Sibazonum 0.01g.
In ambulance:
a) Tracheobronchial tree drain:
1. Sibazonum 30 ml in 150 ml of physiological solution, in 10 min we add the medication up to 100 120 mg;
2. Magnesiii sulfas 25% 10.0 in glucose 40 %;
3. Anesthesia with nitrous oxide;
4. Dosed anesthesia;
5. Aminazinum 25% 1-2 ml;
6. Atropinum 0.1% 1.0 s/c;
7. Cardiac, antihistamine, diuretics;
8. Natrii tiopentali 1g in 10 ml of physiological solution.
Epileptic status:
• To provide permeability of respiratory airways.
• To evaluate the function of heart vascular and respiratory systems. • To provide free way to veins.
• Lorazepam 4mg i/v or Diazepam 10 mg.
In the hospital:
• To take blood for analysis. • % of urea, electrolytes. • liver function. • % of glucose. • % of blood gas.
• etiology of attack: hypoglycemia 50% solution of glucose 50 mg at alcohol abuse Tiaminum
Next half an hour: to introduce the medication through the naso gastral probe. Fenitoin 18 mg per kg or Phenobarbitalum 15 mg per kg i/
v by drop 100 mg per kg.
In 30 minutes: General anesthesia. EEG.
Surgical methods of treatment:
1. Resections
• Anterior temporal lobectomy, Selective amygdalohypocampoectomia, Calosotomia, Hemisphereectomia.
2. Stereotaxic
• Destruction of deep temporal structures. This procedure on lateral part normally decreases seizures, on medial ones aggression.
3. Radio surgical with gamma knife
• Gamma waves from 201 sources are focused on certain aims. The effectiveness of this procedure is 70 80 %.
4. Electrostimulative stimulation of certain structures:
• Nucleus dentatus, the caput of nucleus caudatus (the price is 3.5 3 000 $)
• Stimulation of n. vagus this method is one of the newest one. It is indicated at partial seizures with secondary generalization.