Doctor epileptologist

An epileptologist is a doctor who specializes in the diagnosis and treatment of epilepsy. However, he is also engaged in the diagnosis of other neurological diseases, for example, episodes of loss of consciousness of various origins, sleep disorders.

In most cases, the practitioner is an epileptologist neurologist with in-depth knowledge of paroxysmal disorders (diseases of the nervous system that are accompanied by seizures), electrophysiology, neuroimaging , pharmacology of antiepileptic drugs and genetics, as well as social rehabilitation of patients. 

Additional knowledge in these areas is necessary for differential diagnosis, determination of the exact diagnosis and form of epilepsy, referral for examination in order to correct therapy and treatment of patients with severe rare forms (a neurologist, as a generalist specialist, is far from always able to effectively solve these problems).

A pediatric epileptologist deals with the diagnosis, treatment and prevention of the development of epileptic conditions in children.

What does an epileptologist treat

An epileptologist treats epilepsy, which is understood as a set of neurological chronic diseases, combined into one group according to the mode of occurrence (seizures are defined as sudden transient excessive excitations of neurons in the cerebral cortex).

An epileptologist treats primary generalized forms of the disease, in which seizures are characterized by bilateral symmetrical manifestation. Such forms include absences (minor seizures, in which there is a sudden short-term blackout) and tonic-clonic seizures.

Partial (focal) seizures are the result of damage to nerve cells in a specific area of ​​the right or left hemisphere of the brain. Consciousness can be preserved (simple form), it can be disturbed or changed (complex form). The development of a secondary generalized form is possible, in which the onset looks like a convulsive or non-convulsive focal seizure or absence , after which motor convulsive activity spreads to all muscle groups (it is bilateral).

Patients with:

Idiopathic forms of the disease that appear at a certain age (age-dependent debut). These forms include benign childhood epilepsy ( Rolandic epilepsy), benign occipital epilepsy, primary reading epilepsy, autosomal dominant frontal epilepsy with nocturnal paroxysms, familial temporal lobe epilepsy, etc. prone to spontaneous remission, normal main activity on the EEG and the presence of unilateral or multifocal peak-wave complexes, which are most pronounced in sleep. These diseases are considered genetically determined because the frequency of familial cases is high. The neurological status is not impaired, there are no structural changes in the brain, the prognosis is favorable.

Symptomatic forms of the disease, which include epilepsy:

• Frontal (the focus is localized in the frontal lobe);
• Temporal (the focus is localized in the temporal lobe);
• Occipital (the focus is located in the occipital lobe).
• Parietal (the focus is located in the parietal lobe);
• Cryptogenic forms (occur for an unknown reason).

An epileptologist also treats:

• familial neonatal benign seizures;
• neonatal idiopathic benign seizures;
• benign myoclonic epilepsy of early childhood;
• childhood and juvenile absence epilepsy;
• myoclonic juvenile epilepsy;
• epilepsy, accompanied by generalized convulsive seizures on awakening;
• epilepsy Kozhevnikov;
• West syndrome (infantile spasms), etc.

In addition, the epileptologist deals with the treatment of febrile seizures and seizures caused by an acute metabolic disorder, isolated seizures and episyndromes (which are a consequence of a disease that resembles epilepsy in clinical signs). The reason episindroma can be:

• traumatic brain injury;
• an abscess or brain tumor;
• fainting conditions that cause heart rhythm and conduction disorders;
• sclerosis of the hippocampus;
• encephalitis;
• perinatal trauma, hypoxia, etc.

When is it necessary to contact an epileptologist

An epileptologist’s consultation is necessary for persons who have had sudden onset:

• attacks of loss of consciousness, accompanied by convulsive twitching;
• seizures in which loss of consciousness is not accompanied by convulsions;
• occasional “disconnections” from the surrounding reality;
• paroxysmal states of unknown origin, which are accompanied by compulsive automatic movements.

An epileptologist is also necessary for patients who:

• revealed previously untreated epilepsy or epilepsy that did not respond to therapy prescribed by a neurologist;
• there are epileptic syndromes arising for various reasons (seizures that recur periodically and resemble an epileptic seizure, but are not epilepsy).

The classic sign of epilepsy is a prolonged convulsive seizure, preceded by an “aura” (a short-term condition, which is accompanied by specific, sometimes difficult to describe, the patient’s sensations). At the moment of the aura, the patient can hear noise, smell some kind of smell, etc. Since during a convulsive attack there is a spasm of the glottis, a cry occurs, after which there is a loss of consciousness and the involvement of all the muscles of the body in the convulsive process. The attack is accompanied by noisy breathing, blue face. Since saliva is not swallowed in this state, foam appears on the lips. The seizure usually ends in deep sleep.

A pediatric neurologist-epileptologist consults children who have:

• loss of consciousness for an unclear reason;
• “Disconnections” for a few seconds from the surrounding reality, during which the child does not come into contact and interrupts the started activity;
• attacks with tonic tension of the limbs or facial muscles, or with convulsive twitching;
• attacks that are characterized by unusual sensations (flashes of light, a feeling of heat, etc.);
• sudden jerking or lightning-fast twitching (more often observed in the morning);
• states that are accompanied by difficulty speaking, unmotivated aggression and other unusual behavior;
• Delayed mental development and regression of speech functions also require the consultation of a pediatric neurologist-epileptologist.

Stages of consultation

An appointment with an epileptologist includes:

Study of the anamnesis. The epileptologist should clarify the frequency and nature of seizures, the absence or presence of an aura, its nature, the duration of the disease, the presence or absence of such seizures in relatives, past illnesses and injuries, with which the first attack was associated, etc.

Conducting a general and neurological examination to identify or exclude neurological symptoms and suggest other causes of seizures. The presence of neurological symptoms is a sign of organic pathology of the brain, which provokes epileptic seizures.

Referral to the necessary examinations to clarify the diagnosis.

After the examinations, the epileptologist offers possible treatment options and gives recommendations on how the patient should behave when he feels the approach of an attack, and what he needs to do after the attack (in the case of a child, recommendations are given to his relatives).

Diagnostics

The main studies that an epileptologist prescribes for suspected epilepsy are:

• Video-EEG monitoring (electroencephalography with synchronous recording of video and audio streams, long-term, with sleep enabled); 
• MRI of the brain, allowing to exclude the organic cause of seizures (tumor, cyst, etc.);
• If necessary, MRI angiography of the cerebral vessels, functional MRI is performed.

Since the sensitivity of the EEG between seizures is not absolute (in a small number of patients with epilepsy, epileptiform discharges are not recorded at all), a normal EEG does not allow to exclude a clinical diagnosis in the presence of epileptic seizures. In addition, reported epileptiform disorders can occur in people without epilepsy. Epileptiform EEG phenomena are sharp wave discharges of spikes , complexes Spike -wave or polyspike -wave (pointed potentials can occur in healthy people during sleep, etc.).

The likelihood of detecting epileptiform discharges between seizures depends on the form and type of seizures, the age of the last seizure, etc. For example, with temporal lobe epilepsy, this probability is higher than with localization of the focus in the basal cortex. Epileptiform discharges are more common in children than in adults.

To identify some forms of epilepsy during examination, a standard activation procedure is used: hyperventilation (deep breathing test) and rhythmic photostimulation (RFS). Also, with the consent of the patient during the EEG, provocations of various kinds are used (if there is a suspicion of musicogenic epilepsy, reading epilepsy, etc.). The likelihood of registering epileptiform discharges is also increased by sleep deprivation (deprivation, lack).

When an attack occurs for the first time, hospitalization is often carried out, since a single examination does not accurately determine the cause of the attack. In these cases, standard studies can be carried out:

• neurological examination;
• general blood analysis;
• blood test for electrolytes and osmolarity ;
• analysis of the activity of ALT , ASAT and other liver enzymes;
• plasma glucose analysis;
• toxicological research;
• blood chemistry.

If an infection is suspected, a lumbar puncture is done and cerebrospinal fluid is examined.

Treatment

People with epilepsy rarely need emergency medical attention with repeated seizures, as seizures usually resolve on their own within a few minutes.

The use of active anticonvulsant therapy can cause an overdose of anticonvulsants, which is more harmful to the patient than the attack itself. An urgent cessation of an epileptic seizure is required only in case of status epilepticus, which is characterized by epileptic seizures following each other for more than 30 minutes, between which the patient does not regain consciousness.

When treating an epileptologist:

• corrects disorders that can provoke seizures (hyponatremia, arterial hypertension, withdrawal symptoms, etc.);
• selects anticonvulsants, in accordance with the type of seizures;
• minimizes the number of antiepileptic drugs taken at the same time;
• extremely simplifies the medication regimen;
• controls the level of the drug in the blood plasma during treatment.

Measurement of the drug level in blood plasma is carried out:

• 2 weeks after the last dose adjustment;
• when prescribing drugs interacting with each other;
• with the ineffectiveness of therapy;
• with symptoms indicating intoxication.

For febrile seizures of an uncomplicated nature, anticonvulsant therapy is not required; for recurrent seizures, diazepam is used for prophylactic purposes.