Diagnosis and treatment of epilepsy

Epilepsy is a chronic brain disease characterized by uncontrolled seizures. They arise as a result of a pathologically enhanced impulse in the cerebral cortex. The disease is characterized by an undulating course – after an attack, a period of remission begins. Clinical manifestations of the disease depend on the localization of the focus, the severity and type of seizures.

Causes

One of the main causes of epilepsy is hereditary predisposition: if the parents have a history of convulsive symptoms, then the child is more likely to develop them. Epilepsy also develops under the influence of the following reasons:

• Traumatic brain injury;
• Violations of cerebral circulation;
• Dysplasia of cerebral vessels;
• Volumetric formations in the cerebral cortex;
• Neurosurgical intervention;
• Infectious diseases of the central nervous system;
• Postponed ischemic or hemorrhagic stroke.

The occurrence of epileptic seizures is due to the presence in the cerebral cortex of a stable focus with epileptic activity. Convulsive activity from the primary focus can spread through commissural fibers, cortical neuronal complexes, and the centrencephalic system of the brain. In the presence of increased convulsive activity for a long time, secondary foci occur.

Epilepsy can develop under the influence of the following provoking factors:

• Hormonal failures;
• Alcoholism and drug addiction;
• chronic stress;
• Excessive emotional stress;
• Chronic fatigue.

Secondary seizures of epilepsy occur in patients suffering from brain tumors, cerebral vascular pathology, after hemorrhage in the head, due to poisoning with toxic substances.

The frequency of epileptic seizures

The frequency of attacks can vary from one in 2-3 months to daily single or multiple. A seizure can be provoked by sleep disturbance, stress, excessive alcohol consumption, a long stay in a stuffy room, sharp flashes of light, etc. At the moment, a specific factor affecting the increase in the frequency of epileptic seizures is not yet known .

Harbingers of epileptic seizures

The first harbinger of epileptic convulsions is the aura. It is individual for each patient. Due to the constancy of the precursors, patients can warn others about the onset of an attack or move to a safe place on their own.

There are the following types of aura preceding the onset of an epileptic attack:

• hallucinations;
• A sharp contraction of the muscles of the upper or lower extremities;
• Repetition of the same movements;
• Feeling of burning, crawling or tingling in various parts of the body;
• A sharp deterioration in mood.

The duration of the aura is a few seconds. During this time, patients do not lose consciousness.

Diagnostics

Diagnosis of the disease occurs through the collection of anamnesis. The specialist listens to complaints, on the basis of which a preliminary diagnosis can be made.

After that, the patient is sent for laboratory and hardware examinations, which makes it possible to differentiate epileptic seizures from other pathologies, allows you to find out the cause, nature of the changes, determine the form and prescribe treatment.

The diagnosis is made by neurologists and epileptologists, who find out the causes of epilepsy in adults using indications obtained from a comprehensive detailed examination.

Instrumental diagnostic methods

The safest hardware diagnostics is an EEG. It has no contraindications, it can be used to fix areas of paroxysmal activity. It can be sharp waves, spikes, slow waves. Modern EEG makes it possible to identify the exact localization of the pathological focus.

The most informative neuroimaging method is MRI of the brain. The study allows you to identify the initial cause of the deviation, to determine the localization of the lesion in the central nervous system.

Laboratory diagnostic methods

Epilepsy occurs under the influence of various reasons, in order to identify the presence of an infection, an inflammatory process, hormonal disruptions, genetic defects, the patient needs to take a general, biochemical, molecular genetic blood test, and check the oncomarker .

First aid for seizures

Properly provided assistance with an epileptic seizure reduces the risk of complications and injuries. The person who happened to be next to the patient should pick him up and prevent him from falling. You also need to do the following:

• Put a blanket, pillow or roll of clothes under your head;
• Release the neck and chest from squeezing objects and clothing (tie, shirt, scarf);
• Gently turn the patient’s head on its side to minimize the risk of inhalation or passive casting of vomit, own saliva;
• Open your mouth and put a cloth or handkerchief into it to prevent the patient from biting his tongue;
• Do not forcefully open your mouth;
• If breathing stops for a long time, perform artificial ventilation of the lungs from the mouth to the nose or mouth.

During an attack, the patient may experience involuntary urination or defecation. This manifestation of epilepsy should not cause fear in others. After an attack, patients usually experience drowsiness, severe weakness.

What does an EEG look like in epilepsy?

To obtain accurate EEG readings for epilepsy, it is necessary to prepare the patient for the procedure. You need to wash your hair thoroughly to keep your hair clean. Fixing devices are not allowed. This will allow you to get closer contact with the scalp. Before the procedure, it is not recommended to eat food for two hours, but also not to feel hungry. You must also remove all jewelry before the procedure.

EEG signs of epilepsy

EEG in epilepsy helps to identify foci of neuronal activity. EEG parameters determine the form of pathology. Also, with their help, you can track the dynamics, determine the dosage of medications. The greatest value of this method is that painful changes can be detected in the intervals between attacks.

There are the following types of EEG:

• routine electroencephalography. Diagnosis, in which the recording and registration of brain biopotentials is carried out to determine epilepsy;
• using additional electrodes;
• during night sleep. EEG indicators are recorded during nocturnal sleep;
• long-term EEG in epilepsy. Recording indicators during the day;
• EEG with standard activation procedures. Hyperventilation, photostimulation and the use of other types of stimulation, such as reading, watching movies, music;
• video monitoring;
• sleep deprivation procedure.

Quite often, changes in the EEG occur when the eyes move, changes in the rhythm of breathing, pulsation of blood vessels or motor reflexes. Therefore, it is very important to correctly interpret the signs of epilepsy in the EEG.

MRI of the brain in epilepsy

Magnetic resonance therapy for epilepsy shows the affected areas of the brain and is carried out in almost all cases of the disease. This is a great way to determine the degree of spread of the disease to healthy cells and the rate of its development.

According to the deep conviction of international anti- epileptic organizations, the process of undergoing an MRI or CT scan is mandatory and should be carried out at the request of a doctor.

Many modern clinics with the latest equipment provide the opportunity to diagnose this disease, so the procedure is mandatory. Successful testing requires:

1. Referral for research with a competent statement of a possible diagnosis and the need for diagnostics. The referral should indicate possible suspicions of pathology and any of its manifestations. Based on previous examinations, including EEG, the neurologist can assume the possible location and nature of the pathological process.
2. Modern MRI scanner with optimal power and amplitude. Such devices conduct research even with minimal cuts.
3. A radiotherapy specialist with in-depth knowledge of neurology, who has a good understanding of the specifics of the nervous system. The doctor needs to know when additional methods of data collection can be used that are not covered by the medical protocol.

Whether an MRI shows epilepsy depends largely on physicians and consultants, as well as MRI specialists, who are often unable to constructively analyze the collected data in order to establish a treatment strategy and confirm the final diagnosis.

Can an MRI detect epilepsy?

Epilepsy as a disease has been known for more than 7 thousand years, but instrumental diagnostics began only in 1929. Magnetic resonance imaging in this case is a reliable instrumental method for diagnosing such a pathology, therefore, complex procedures are practiced all over the world to determine the spread and development of the disease to the last minute detail. Thanks to this, it is possible to establish the causes of the pathology, of which there are many:

• defect and anomaly of the brain of a different nature;
• sclerotic changes;
• oncology and benign tumors;
• changes as a result of blows and experienced traumas;
• infectious lesions;
• vascular pathologies;
• degenerative changes;
• metabolic disorders.

In other words, diagnostics using modern equipment allows us to examine the pathology from the inside and determine the sources and factors that provoked its development. This method undoubtedly affects the level of therapeutic measures, since the final conclusions about the patient’s diagnosis are based on the indications of MRI or CT.

Who prescribes an MRI for epilepsy

Any disease requires the attention of a narrow specialist, and epilepsy is no exception. Especially when you consider the fact that the most important human organ is affected. After a detailed history, the therapist refers the patient to a neurologist, who records the client on an EEG if his suspicions allow for the possibility of damage to tissue cells. This conclusion is required by the radiologist in order to:

• clarify the areas where epileptic activity was detected;
• if necessary, introduce a number of additional programs during the procedure;
• compare the indicators that were obtained by EEG and MRI, and determine structural changes in tissues.

The use of tomography has several goals that the neurologist pursues.
Only those who have had a seizure identified and described during anamnesis are sent to MRI to clarify suspicions and collected data, since the program allows you to study in detail possible structural disorders of the areas that are most active during seizures. In addition, the procedure is recommended for patients with an already confirmed established diagnosis who cannot get rid of seizures with medication.

CT or MRI – which is better?

Quite a lot depends on the choice of equipment, so an arbitrary visit to such diagnostic centers is unacceptable. For more detailed diagnostics, the MRI unit is equipped with programs that were created to obtain additional information about the state of the affected tissues. The absolute coverage of such tissues by the information field of the tomograph greatly simplifies the process of determining therapy and the level of risks for individual cases.

Computed tomography is performed to obtain a detailed cross-sectional picture of the brain. Specialized equipment ensures the safety of the procedure and efficiency, and also guarantees the quality of the results. This is a painless version of the examination, the only contraindication to which is pregnancy. Both options for tomography have their advantages, but the need to use one or another device is determined by the attending physician.

How is an MRI done for epilepsy?

The main obstacle for many is the fact that during the tomography the patient must be immobile for up to 50 minutes, which is extremely difficult for people with increased irritability or constant anxiety.

The specialist conducting the procedure is in another room behind glass and keeps in touch with the patient via a microphone. There must be no foreign objects in the examination area that could interfere with the operation of the unit. The patient should carefully listen to the doctor and follow his instructions, while maintaining maximum immobility. A lengthy but non-traumatic process extracts all the necessary information about the state of the cells and the extent of the disease.

MRI with contrast for epilepsy

It is known that epilepsy is a disease that has several factors that provoke characteristic seizures. This greatly expands the range of searches for affected tissue areas, so different research methods are used.

The procedure itself consists of injecting a substance intravenously, it quickly spreads through the vessels and veins, eventually reaching the brain. The contrast itself contains the allowable rate of iodine and other compounds, which, when released into the blood and under the influence of rays, display their own color. This is how the easily recognizable grid of the venous system appears.

Contraindications

There is no need to carry out any special measures before the diagnosis itself. The patient can continue drug treatment, adhere to the diet and all the requirements of the doctor. Usually the patient leads a full life, without restrictions and precautions.

Despite all the harmlessness, the procedure still has a number of limitations. This is the presence of any metal implants in the body, implants of the inner and middle ear, as well as pacemakers. In addition, it is not recommended to undergo an examination for people whose weight exceeds 130 kg. The first months of pregnancy in women are also contraindications.

MRI for epilepsy in children

Unfortunately, one of the causes of the disease is a congenital pathology of fetal development. Children of all ages often become patients of neurologists and epileptologists. MRI for epilepsy in babies is performed in order to exclude the most dangerous causes that require surgical intervention:

• tumor;
• consequences of injury;
• congenital developmental anomalies;
• cortical dysplasia;
• manifestations of genetic diseases.

It is worth remembering that this examination requires a stationary state (in the case of examining children) for about 20-30 minutes, so this often becomes a problem. Children are afraid of noise, the absence of adults nearby and unfamiliar sensations.

Deciphering MRI for epilepsy

The interpretation of MRI images of the brain is carried out exclusively by a qualified radiologist. Often this is a specialist who personally carried out the diagnosis and works closely with the patient’s doctor. Correctly interpreting and explaining the resulting images requires professional medical education and significant practical experience.

Basic information is transmitted electronically to the attending physician. Specialists conduct a thorough study of scans , after which they report the results. Pictures are used to prescribe additional diagnostic measures if the disease causes controversial statements. None of the doctors with a narrow specialization in other areas has the right to interpret the results in an arbitrary order.

To achieve an optimal result in treatment, patients are prescribed drugs for epilepsy of the following properties:

• anticonvulsants – help to relax the muscles, they are prescribed for both adults and children;
• tranquilizers – allow you to remove or reduce the excitability of nerve fibers, the funds have shown a high degree of effectiveness in the fight against small attacks;
• sedatives – help relieve nervous tension and prevent the development of severe depressive disorders;
• injections – used in twilight conditions and affective disorders.

Idiopathic focal epilepsy is benign. It requires symptomatic treatment. In focal forms with seizures that appear in series 2-3 times a month and are accompanied by an increase in mental disorders, neurosurgeons perform an operation.

Surgical treatment of epilepsy

Surgical interventions for such pathologies have been practiced for over 100 years. Thanks to the developed branch of neurosurgery and innovative developments in the field of medicine, their effectiveness is 80%.

People who have undergone surgery can completely get rid of chronic seizures and return to a full life. Modern technologies make it possible to create a detailed map of the areas of the brain that are responsible for the vital functions of the body – speech, movement, memory and coordination.

Indications for surgical treatment

It is known that this disease is as diverse as the factors that provoke it. Therefore, in each individual case, therapy is selected solely on the basis of the patient’s history and the results of tests, diagnostics on CT or MRI, as well as EEG.

The possibility of surgical treatment is discussed when a number of conditions are met:

1. The disease has a focal (focal) character. The epileptogenic region of the brain is precisely determined , the removal of which will save the patient from seizures.
2. Weighing the risks. Any operational activity should not lead to a deterioration in the quality of human life due to neurological or neuropsychological deficits.
3. The form must be exclusively pharmacoresistant , that is, at least two drugs do not affect the affected areas.

Since the operation is prescribed in special cases, the preparation and preliminary procedures before the intervention also require attention. Due to competent diagnosis and examination, a complete picture of the appearance and development of the disease in a patient is often restored.

Examination and tests before surgery

The high efficiency of such a radical treatment can only be achieved with strict adherence to all standards of preparatory examinations carried out before the day of surgery. They include:

• MRI according to the program of epileptic scanning;
• EEG video recording, which is mandatory for any form of pathology;
• a detailed description or video of seizures that were recorded at home;
• study of the neuropsychological profile of the patient to confirm the existing deficit of mental functions;
• analysis of possible risk factors and complications that may occur during and after surgery;
• epileptologist consultation.

Operational manipulations are carried out only in specialized centers, specialized clinics with the mandatory availability of resuscitation equipment.

Intracranial EEG recording

EEG (electroencephalogram) is a diagnostic measure that is mandatory for patients with any damage or pathologies of the brain. This method makes it possible to ascertain normal electrical activity and to reveal the pathological potential of the brain and disturbances in its structure. EEG is widely used for:

• epilepsy;
• differential diagnosis of epileptic seizures;
• non-epileptic paroxysmal states.

It is impossible to evaluate the EEG as the main source of diagnosis. By its nature, most of the evidence is passive. Registration of EEG data in the absence of significant stimuli does not allow determining the reactivity of certain normal rhythms and obtaining a detailed picture with reliable information about pathological activity.

Types of surgical treatment

Surgical treatment in Russia is based on several techniques that are widely used throughout the world and in practice have excellent results. However, it is worth noting that 100% efficiency is provided not by the method of surgical intervention, but by other factors that determine the period of the disease, the degree of brain damage, the stage of development, and the individual physical and neurological data of the patient. Therefore, it is almost impossible to single out the most effective method. Main types of interventions:

• resection of the temporal lobe;
• lesionectomy ;
• callosotomy of the corpus callosum;
• functional hemispherectomy ;
• vagus nerve stimulation;
• multiple sublial incisions;
• implantation of the RNS neurostimulator.

The choice of a certain type of operation depends entirely on the doctor, who, based on the already available data on the patient’s condition and his test results, approves the method that is most effective in a particular example.

Ketogenic diet for epilepsy

The ketogenic diet is a diet that aims to produce an increased amount of ketone bodies in the body, which in turn is a cure for epilepsy, since when released into the brain, ketone bodies have an anticonvulsant effect.

A ketogenic diet with strict adherence to it has a positive result in 70% of cases. This type of nutrition is especially effective for children, despite the fact that it is most difficult for a child to adhere to this diet.

Menu on the ketogenic diet for adults

The main principle of the ketogenic diet is the ratio of proteins and carbohydrates relative to fats – the balance should correspond to a value of 1 to 4, while the amount of protein consumed should be several times higher than the amount of carbohydrates. A healthy person receives energy from carbohydrates – due to their oxidation, ATP (adenosine triphosphate) is released, which in turn is a fuel for our body.

During the diet, the regimen can be adjusted based on personal indicators or the wishes of the patient. The basis of such a diet should be an abundance of healthy fats, which are recommended to be obtained from the following products:

• fatty sea fish;
• beef, lamb, pork;
• salo;
• butter and cream;
• vegetable oils – olive, coconut, linseed, sea buckthorn and sesame;
• seeds, nuts;
• avocado.

Dangerous foods for epilepsy

It is important for people with epilepsy to avoid overeating and to limit their intake of simple sugars. The diet for epilepsy is aimed at reducing the load on the human body and preventing the development of seizures. You should limit the use as much as possible:
 

• refined sugar, honey;
• flour products (bread, rolls, cookies, pasta);
• various cereals;
• vegetables and fruits containing a large amount of starch (mainly root crops);
• alcohol;
• various sauces with a high percentage of carbohydrate content.

Refusal of harmful products allows not only to reduce the likelihood of repeated epileptic seizures, but also to improve the general condition of the patient. It should be understood that even rare minimal violations of the rules of nutrition threaten poor performance of the entire diet. It is important to turn such a diet into a lifestyle.

Menu for a ketogenic diet for adults

As a rule, the ketogenic diet is not prescribed for all patients, but only for those who do not have a positive reaction to the use of antiepileptic drugs. This diet is most effective in childhood. However, despite the high efficiency of this diet, it has a number of contraindications:

• cerebrovascular pathologies;
• encephalopathy;
• kidney and liver diseases;
• diseases of the endocrine system (or predisposition to them);
• mitochondrial pathologies;
• diseases of the cardiovascular system.

A sample menu on a ketogenic diet is as follows:
 

• the first meal (breakfast) – scrambled eggs with ham or bacon, a salad of non-starchy vegetables, seasoned with olive oil;
• the second meal (lunch) – stewed or fried pork or beef, steamed vegetables;
• the third meal (dinner) – fatty sea fish (salmon, mackerel, herring), fresh vegetables and hard cheese.

The duration of this diet is regulated by the doctor. It takes at least 3-4 weeks to get results. If the diet has given a positive result, it is recommended to adhere to this diet for life.

Ketogenic diet for children

For children, the ketogenic diet is indicated only after one year to avoid developmental delays and serious complications of internal biorhythms.
For normal development, children must eat all the trace elements and vitamins in sufficient quantities.

The diet of a ketogenic diet in children will roughly coincide with the diet in adults. However, children are also prescribed special fatty milk drinks that “teach” the child’s body to consume large amounts of fat. Milk drink can be consumed in the form of a cocktail or ice cream.

The choice of treatment tactics

Based on the collected data, the doctor makes a decision on the medical or surgical treatment of a certain type of disease. Recall that there is a pathology that cannot be treated with medication, so it refers to indications for surgical intervention.

Often, for a detailed acquaintance with the nature of the disease, doctors interview the relatives of the patient and demand to describe the features of the attacks, sometimes they are asked to make a home video in order to familiarize themselves with them. After analyzing all the indicators obtained, the doctor decides on individual therapy using drugs that stop seizures.

Vagus nerve stimulation in epilepsy

Vagus nerve stimulation is a minimally invasive operation in which a miniature device is placed under the skin. The epilepsy stimulator is located by specialists in the collarbone area, it is used to generate impulses, which then enter the vagus nerve using special electrodes. So, the device can be programmed to generate pulses lasting 30 seconds every 5 minutes. Flexible settings allow you to choose the optimal mode for each patient.

An epilepsy stimulant can cause complications, which experts warn the patient about. So, during the operation, neck vessels and nerves can be damaged. In addition, the patient may experience an allergic reaction to anesthesia or bleeding. Experienced specialists preliminarily study possible risks and take measures to minimize them.

Indications for the procedure

Impulses in the brain are transmitted from neuron to neuron in an orderly manner. With epilepsy, foci of pathological pulsation occur, and the order of impulses is violated. Drug therapy for epilepsy can effectively control seizures.

Vagus nerve stimulation in epilepsy is indicated in the following cases:

• with the ineffectiveness of drug therapy;
• conservative treatment gives a positive effect, but when using drugs, side effects occur;
• other surgical treatments for epilepsy failed to control seizures;
• the patient has frequent and prolonged depression due to epilepsy.

Neurologists at the Yusupov Hospital in the treatment of epilepsy prefer the safest methods and minimally invasive procedures. Each therapeutic measure assigned to a patient with epilepsy is reasonable and rational.