EPILEPSY

EPILEPSY

I.INTRODUCTION – DEFINITIONS

There are two distinct concepts in epilepsy:

• Epileptic seizure
• Epilepsy disease 

Epileptic seizure:

• Corresponds to an excessive paroxysmal hypersynchronous and self-sustained discharge of a +/- extended neuronal population. 
• It constitutes a symptom of variable significance, unique or not, isolated or not.

Epilepsy disease

Corresponds to a chronic condition of various etiologies characterized by the repetition of epileptic seizures resulting from excessive discharge of cerebral neurons regardless of the clinical and paraclinical symptoms that may be associated.

II.EPIDEMIOLOGY

• Epilepsy is the most common disabling neurological condition. 
• The incidence is on average 50/100,000 inhabitants per year. 
• The prevalence varies from 0.5 to 2%, it is similar to that of diabetes or chronic rheumatism.
•  Incidence and prevalence rates are higher at the extremes of life (before 10 years and beyond 60 years). 
• About 50% of epileptics begin before the age of 10. 

III.CLASSIFICATION

The international classification of epilepsy combines two parameters: symptomatology and etiology. 

a- Classification according to symptomatology:

1- Generalized epilepsy: 

• They include crises whose clinical characteristics do not include any element that could relate to an anatomical or functional structure located in a hemisphere. 
• Critical and intercritical EEG abnormalities are bilateral, symmetrical and synchronous in both hemispheres. 

2- Partial epilepsies:  

Crises have a focal starting point, we describe: 

• Simple partial seizures: these occur without any alteration of consciousness. 
•  Complex partial seizures: they involve, either immediately or secondarily, an alteration of consciousness.
•  Partially simple or complex secondarily generalized seizures.

b- classification according to etiology:

1- Idiopathic epilepsies 

• These are epileptic syndromes occurring in normal subjects, without brain lesions, without neurological or intellectual deficit, without significant history apart from family history.
• there is a genetic character that can sometimes be demonstrated. 

2- Symptomatic epilepsies 

• They are the consequence of various brain lesions, these lesions can be old, scarring or progressive.
• The type of seizure will depend on the functional specialization of the affected brain structure (e.g. temporal, frontal, parietal epilepsy, etc.). 

3- Cryptogenic epilepsies The cause of these epilepsies is hidden and eludes current means of investigation.

VI. Semiology of crises

A – Generalized crises 

1- Generalized tonic-clonic seizures (grand mal)

 Sudden onset with loss of consciousness often leading to a traumatic fall, then follows .

 – Tonic phase (10 to 20 seconds), the body stiffens, there is blocking of breathing with cyanosis .

 – Clonic phase (30s to 2 minutes) there are symmetrical generalized rhythmic muscle jerks (clonies) with sometimes a bite of the long. 

• Comatose phase of muscular relaxation with often loss of urine, deep and noisy breathing then post-critical sleep lasting from a few minutes to 2 or 3 hours .
•  Upon awakening, there is amnesia of the epileptic seizure. 

2- Tonic crises 

• They mainly concern the child and often occur during sleep. 
• They are characterized by a muscle contraction with sudden or gradual onset and end, it can be global or affect a muscle group. 

3- Clonic seizures: 

• They are mainly found in children. 
• They manifest as generalized, often asymmetrical clonia associated with loss of consciousness.

4- Atonic crises 

• It is a very brief sudden loss of postural tone with altered consciousness. 
• The crisis can affect a part of the body (e.g. the head falling suddenly) or the entire body with the patient falling. 

5- Myoclonic seizures: 

• These are isolated bilateral shocks, often localized to the upper limbs and sometimes to the lower limbs, leading to a fall. 
• These crises are often morning crises, encouraged by sleep deprivation, and not accompanied by altered consciousness. 

6- Absences: 

– It is a brief and brutal suspension of consciousness without falling, the child stops the current activity, remains frozen, with a fixed and vague gaze, lasts 5 to 10 seconds then the child resumes his activity as if nothing had happened. 

B- Partial seizures

 1- Simple partial seizures Simple partial seizures are characterized by the absence of alteration of consciousness. 

a- Motor crises:

1- Somato-motor crises: these are sudden or tonic-clonic contractions of fixed location e.g.: hemiface, limb, origin: primary motor cortex. 

2- Bravais-Jacksonian seizures: they reflect the progressive diffusion of the discharge to the entire motor cortex. The seizure begins in the face, hand or foot then extends to the root of the limb and then to the entire half of the body.

3- Versive seizures: these are the most frequent partial motor seizures. They result in a combined deviation of the eyes and the head and sometimes the trunk, the origin is variable.

4- Aphasic crises : this is a critical disturbance of language in its expression or development. 

b – Sensitive and sensory crises: 

1- Somato-sensory crises: they are most often of the paresthesia type, either limited or having a Jacksonian gait. Origin: primary parietal cortex. 

2- Visual crises: elementary visual hallucinations: phosphenes, scotomas or amputation of the visual field. 

3_ Hearing crises: tinnitus, deafness  

2. Complex partial seizures: 

• They are very diverse, related to a discharge of the associative cortex, especially temporal, sometimes frontal. 
• These seizures are accompanied by a loss of consciousness and may become generalized secondarily. 
• The manifestations are: . A loss of consciousness without falling, associated with various automatisms (gestural, verbal, vegetative, oro-alimentary, etc.): “temporal absence”.
•  Affective or intellectual symptoms (fear, anxiety, memory disorders, dream state, etc.). 
• Psycho-sensory crises: a type of visual, auditory or bodily illusions or hallucinations. 
• Psychomotor crises: onset with vegetative disorders (epigastric discomfort, fear, tachycardia, etc.) associated with automatisms. 
•  

V. POSITIVE DIAGNOSIS

• It is based on questioning (patient, family, possible witnesses); the elements to be taken into consideration are: the paroxysmal and stereotyped nature of the crises, traumatic fall, post-critical amnesia, the notion of myalgia on waking, etc. 
• EEG: This is the recording of cerebral electrical activity, it includes a recording of activity at rest, a hyperpnea test and intermittent light stimulation.
• The EEG is useful when it shows paroxysmal elements such as spikes, spike-waves, polyspikes, generalized or focused waves consistent with the clinical presentation of the seizures.
•  It should be emphasized that epilepsy may be accompanied by a normal EEG. Paroxysmal EEG abnormalities may be seen outside of any context of epileptic seizure. 
• Brain computed tomography and nuclear magnetic resonance imaging are requested for etiological research. 

VI. ETIOLOGICAL FORMS

• Birth accidents Neonatal anoxia and obstetric trauma (epilepsy may occur late)
•  Tumors Mainly observed in adults, they manifest as late epilepsy, especially partial, all types of tumors can be seen (meningiomas, glioblastomas, etc.) 
• Infections – brain abscesses, tuberculoma – viral encephalitis (herpes) – purulent or tuberculous meningitis – syphilitic meningoencephalitis 
• Post-traumatic epilepsy Epilepsy can occur more or less late after the trauma, the risk is significant if there is a coma, a skull fracture or an associated brain injury. 
• Vascular causes – AVCI – Cerebral hemorrhage – Arteriovenous malformation, hematoma – Cerebral thrombophlebitis
•  Epilepsy without known cause This is the most common setting, we speak of: – idiopathic epilepsy (genetic predisposition) – cryptogenetic epilepsy (hidden cause not detectable by current means of investigation) The characteristics of these epilepsies are: onset in childhood or adolescence, a normal neurological and psychological examination, a normal CT or MRI examination and the EEG which shows a normal background rhythm with generalized or focused paroxysmal discharges. 
• Other causes Epileptic seizures can be a symptom during: – ionic disorders: hypoglycemia, hypercalcemia – alcoholism – drug intoxication – general conditions (eg lupus) – neurological conditions (eg Alzheimer’s) 

VII. SYNDROMIC FORMS

1- Flexion spasm disease (West syndrome) This is a generalized epilepsy appearing in infants between 3 and 9 months, it includes: – flexion spasms rarely in extension occurring in bursts – a characteristic EEG trace (permanent disorganized paroxysmal activity) – arrest of psychomotor development

 2- Lennox Gastaut syndrome This is a generalized epilepsy beginning between 2 and 7 years of age, it includes: – various seizures with mainly atonic daytime seizures and tonic nighttime seizures – the EEG shows slow diffuse spikes and waves – psychomotor retardation 

3-Absence epilepsy in children This is an idiopathic generalized epilepsy, the onset occurs between 3 and 12 years, the absences are very frequent (up to 50/day), the EEG shows generalized spikes and waves at 3 c/s. 

4- Epilepsy with grand mal seizures The onset occurs in childhood or adolescence, grand mal seizures can be nocturnal, upon waking, or random, the EEG shows a normal background rhythm and generalized paroxysmal discharges 

5- Centro-temporal partial epilepsy This is a benign partial epilepsy that heals in adolescence, the seizures are often nocturnal: partial orofacial motor seizures. The EEG shows large amplitude diphasic spikes in the temporal regions 

6- Benign juvenile myoclonic epilepsy Onset 13 and 19 years, there is myoclonus especially in the morning, associated with grand mal seizures. There is a relapse when treatment is stopped. 

VIII. TREATMENT

1. rules of processing 

– treatment must be regular, daily and continuous 

– use of monotherapy, we use a single anti-epileptic drug adapted to the seizures, in case of failure we substitute another. 

– Monitoring: it is based on the frequency of attacks, the side effects of medication and socio-professional integration 

– Hygiene and daily life, it is necessary to have sufficient sleep, avoid alcoholic beverages and lead a normal life with limited restrictions.

2.  Medicines 

1) classic anti-epileptics – carbamazepine (Tegretol): partial epilepsy (CPC), grand mal seizures – Na+ valproate (Depakine): generalized E (absences, grand mal), partial E – phenytoin (Dihydan): partial E – phenobarbital (Gardenal): grand mal seizures – benzodiazepines (Valium – Rivotril): status epilepticus 

2) new anti-epileptics They are used in combination with classic anti-epileptics in drug-resistant epilepsy: – Lamotrigine (Lamictal), Vigabatrin (Neurontin), Levopiracetam (Képpra). 

EPILEPSY

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EPILEPSY