Epilepsy in children – new opportunities for diagnosis and treatment
Epilepsy is one of the most common diseases. It is known that about 1% of people from the general population had at least one epileptic seizure in their life. In childhood, epilepsy is even more common – in 4-5% of the total child population. Its manifestation, course, prognosis and treatment approaches in childhood are significantly different. Only in children there are both benign (can go away on their own, even without treatment), and malignant (when any treatment is ineffective, the disease continues to progress) forms of the disease. Manifestations of seizures in childhood have significant differences: they often occur atypically, have an erased appearance, and changes in an electroencephalographic study do not correspond to the clinical picture.
Fortunately, in childhood, thanks to the achievements of modern science, the treatment of epilepsy has become effective in 70-80% of cases.
The breakthrough in research in the field of epileptology is characteristic of the last decade. For many epileptic syndromes, a genetic nature has been established, new forms of the disease have been described, diagnostic methods have improved, many antiepileptic drugs have been synthesized and their mechanisms of action established, and the efficacy for individual forms of the disease has been investigated.
What is meant by epilepsy?
Epilepsy is a disease characterized by repeated, unprovoked seizures, which are based on a hypersynchronous electrical discharge of brain neurons (cells).
There are many forms of epileptic seizures. Features of the course of the seizure depend on which parts of the brain are in a state of excitement and are involved in its implementation.
Most people with epilepsy mean convulsive or tonic-clonic seizures, which begin with a sudden loss of consciousness, stiffness of the entire skeletal muscle, respiratory arrest is also observed, the eyes are usually drawn up, the pupils are dilated. This phase, which lasts 20-30 seconds, is followed by a typical convulsive stage. It manifests itself in the rhythmic twitching of the arms, legs, head, neck, in severe sweating, salivation. Due to respiratory arrest, the face often acquires a bluish color. Sometimes involuntary urination occurs, biting the tongue. In addition to such attacks, about 40 different types of epileptic seizures are distinguished in children, which differ in clinical symptoms, approaches to therapy, and prognosis. However, basically, the whole variety of epileptic seizures is divided into generalized (when both hemispheres of the brain are involved at the same time), focal (the seizure starts from a certain part of the brain) and undifferentiated, when using all available diagnostic methods, an epileptic seizure cannot be attributed to generalized or focal . Some patients have several types of seizures, then they talk about polymorphic seizures.
The need for a correct diagnosis The
treatment efficiency and prognosis of the further course of the disease depend on the accurate diagnosis of the form of epilepsy. In recent years, the range of diagnostic capabilities in Ukraine has expanded significantly.
To confirm the epileptic nature of the seizure, an electroencephalographic (EEG) study of the brain is carried out, which fixes the epileptic discharges, the presence of an epileptic focus – the part of the brain where they arise. In addition to the usual EEG, various loads are performed to clarify the diagnosis – photostimulation, hyperventilation, sleep deprivation. Sometimes, for proper diagnosis, repeated studies are necessary. Significantly improved the diagnosis of epilepsy, the use of EEG-video monitoring, when simultaneously with the recording of EEG video surveillance of the patient is conducted, EEG-examination during night sleep. Neuroradiological studies (computed tomography, magnetic resonance imaging, positron emission tomography) have been widely used to clarify the diagnosis and highlight symptomatic epilepsies.
Achievements in the treatment of epilepsy
The main goal in the treatment of epilepsy is drug remission, followed by drug withdrawal, achieving complete remission with a high quality of life.
The main stages in the treatment of epilepsy can be formulated as follows: identifying and eliminating the causes of seizures, eliminating possible provoking factors, making an accurate diagnosis with establishing the type of epileptic seizure, choosing the right treatment, developing tactics regarding getting an education, choosing a profession, and solving social issues. The key to this process remains the correct selection of medication and long-term, regular intake of antiepileptic drugs (AEDs).
In the treatment of epilepsy, leading experts in the world and in our country profess the principles of monotherapy and reasonable polytherapy. In other words, treatment almost always begins with one antiepileptic drug, and in case of its insufficient effectiveness or intolerable side effects, replace it with another or resort to the combined use of two AEDs. This tactic allows the use of modern AEDs to achieve a significant reduction in the frequency of seizures in a large percentage of patients – a complete cessation of epileptic seizures,
and also reduces the likelihood of adverse side effects.
The main factors affecting the choice of antiepileptic drug are the type of seizure, epilepsy syndrome, concomitant diseases in each individual patient. Smaller, but also of great importance are the social and economic situation, gender and age of the patient.
The same patient may experience several types of seizures, depending on the epilepsy syndrome that the patient suffers from, for example, absences and generalized tonic-clonic seizures in patients with juvenile abscess epilepsy. In patients with focal seizures, secondary generalized seizures may join over time – the so-called generalization of epilepsy occurs. In a number of patients, making an accurate diagnosis is difficult due to the difficulty of collecting an anamnesis, the inaccuracy of information about the pattern of seizures, the inability to conduct a complete instrumental examination, the complexity of the diagnostic picture, the presence of several types of seizures. According to some estimates, the number of such patients can reach 30-37% of the total number of patients with epilepsy. Given the above, it is preferable to use in the first row of the choice of drugs with a wide spectrum of action, which make it possible to carry out monotherapy with several types of seizures in one patient and avoid errors with an unknown type of seizures or limited diagnostic capabilities.
In the last decade, significant successes have been achieved in the treatment of epilepsy: standards for medical and social rehabilitation of patients have been developed, new antiepileptic drugs (AEDs) have been synthesized and introduced into clinical practice. Vigabatrin, oxcarbazepine, lamotrigine, gabapentin, felbamate, tiagabine, topiramate, levetiracetam began to be used to treat epilepsy.
Of the new synthesized preparations, lamotrigine, topiramate, felbamate, gabapentin are registered and widely used in Ukraine.
Thus, 3 generations of drugs are distinguished:
– phenobarbital, phenytoin, suxinimide, primidone, diphenin, ethosuximide;
– salts of valproic acid, carbamazepine;
– vigabatrin, oxcarbazepine, levetiracytes, felbamate, lamotrigine, topiramate, gabapentin.
In recent years, second-generation drugs: valproic acid salts and carbamazepines are most often used to treat epilepsy. These drugs, unlike the first-generation drugs, rarely cause side effects, are highly effective for various types of seizures, and, unlike the third-generation drugs, are well studied.
Moreover, second-generation drugs work well on certain types of seizures. Valproic acid preparations are a wide range of drugs. Valproates are highly effective in both generalized and partial seizures (with or without secondary generalization), and also rarely cause a paradoxical aggravation of seizures. Valproates are recommended as first-line treatment for the treatment of the entire spectrum of generalized seizures and focal seizures with secondary generalization. An important advantage of valproate is that these drugs maintain and even improve the child’s cognitive (cognitive) functions without causing sedation, giving him the opportunity to learn and live a full life.
Carbamazepines are indicated and are first-line drugs for focal and secondary-generalized seizures. The current requirements for anticonvulsants are efficacy and safety during long-term therapy with medium therapeutic doses.
In the near future, preference will be given to drugs with a wide spectrum of effectiveness (effective in all forms of epilepsy), but without side effects and complications, unlike barbiturates, which were widely used in the 60s.
Epilepsy therapy issues to be resolved
Ineffective diagnosis of epilepsy, especially in non-specialized medical institutions when it is not possible to identify the type of seizure.
The appointment of antiepileptic drugs without taking into account their features and side effects, the general condition of the patient and the presence of somatic pathology.
The high cost of modern antiepileptic drugs, which limits their use.
Insufficient awareness of patients, their parents and relatives about epilepsy, its course, the need to apply certain restrictions, long-term treatment, and therefore frequent breakdowns of drug remissions occur.
The presence of side effects from the use of antiepileptic drugs that worsen the quality of life.
Lack of standards for the diagnosis and treatment of epilepsy.
Lack of national programs for medical and social rehabilitation of patients with epilepsy.
Only the solution to these problems will improve the diagnosis, treatment, quality of life of patients suffering from epilepsy. This is especially true for children, since the lack of effect of treatment leads to the continuation of the disease in adulthood, often to disability, and causes social and economic problems for the patient,
his relatives, and the whole society.