Overview
Chronic brain disease that occurs in adults and is characterized by abnormal neuronal discharges in the brain.
Sudden loss of consciousness, convulsions, clenching of teeth, foaming at the mouth, and rigidity of the limbs are common.
Some of the causes are unknown, and some of them originate from brain injuries and systemic metabolic diseases.
Combination of surgery and neuromodulation based on antiepileptic drug therapy.
Definition
Epilepsy is a chronic disorder of brain dysfunction caused by abnormal discharges of neurons in the brain, and is one of the most common neurological disorders.
Epilepsy can occur at any age, but there are differences in the causes and probability of its onset in different populations.
Adult epilepsy can begin both in infancy and childhood and continue into adulthood. The most typical form of epilepsy is idiopathic epilepsy, which is genetically linked and whose treatment and management often continue from earlier programs, as described in the term “idiopathic epilepsy”.
It also includes first-onset epilepsy in adulthood, which is often associated with central nervous system lesions and systemic diseases. The most typical is secondary epilepsy following cerebrovascular disease, the treatment and management of which differs considerably from that of idiopathic epilepsy and is the focus of this entry.
Classification
Classification according to etiology
Symptomatic epilepsy: epilepsy with a definite cause, also known as secondary epilepsy.
Idiopathic epilepsy: epilepsy with an unknown cause, also known as primary epilepsy, which may be closely related to genetic factors.
Cryptogenic epilepsy: the most common type of epilepsy that manifests as symptomatic epilepsy, but the cause has not been clarified.
Classification according to the range of epileptic sources
Focal seizures are characterized by abnormal electrical signals originating from no more than one cerebral hemisphere, such as temporal lobe epilepsy and frontal lobe epilepsy.
In generalized seizures, the abnormal electrical signals originate from both sides of the brain, including cortical and subcortical structures.
Morbidity
There are about 9 million people with epilepsy in China, with about 5 to 7 per 1000 people suffering from the disease.
Epilepsy is common in children and the elderly.
There is no authoritative data on the incidence of epilepsy in adults.
Causes
Causes
Idiopathic epilepsy: the cause is unknown and may be genetically related.
Cerebrovascular disease: e.g. cerebral infarction, cerebral hemorrhage, cerebral venous thrombosis, etc.
Head trauma: the more severe the brain injury, the higher the probability of epilepsy.
Medical operations on the brain: e.g. after craniotomy.
Central nervous system infections, such as meningitis or encephalitis.
Neurodegenerative diseases: such as Alzheimer’s disease and vascular dementia.
Brain tumors: e.g. glioma, brain metastases.
Metabolic disorders: e.g. renal failure, hypoglycemia, hyponatremia, hypernatremia, hypercalcemia, and hypocalcemia.
Other diseases: eclampsia, carbon monoxide toxic encephalopathy, systemic lupus erythematosus encephalopathy.
Drug causes: e.g., phenothiazines (e.g., chlorpromazine, phenazine), isoniazid, tricyclic antidepressants (e.g., doxepin, amitriptyline) overdose; benzodiazepines (e.g., diazepam, clonazepam) and other drug withdrawal reactions.
Alcohol abuse: e.g. alcohol intoxication, alcohol withdrawal reactions.
Substance abuse: e.g. use of banned substances such as heroin, cocaine, methadone, amphetamines, ecstasy.
Influencing factors
Age
The common causes of epilepsy vary by age:
In adulthood, it is mostly encephalitis, craniocerebral trauma, brain tumors and metabolic disorders.
In old age, it is mostly cerebrovascular disease, brain tumor and Alzheimer’s disease.
Heredity.
The prevalence of close relatives of patients with symptomatic epilepsy is 15 per thousand, which is higher than that of the general population.
Sleep
Sleep deprivation can increase the risk of seizures.
Seizures are closely related to the sleep-wake cycle, e.g., generalized tonic-clonic seizures often occur after morning awakening.
Internal environmental changes
Excessive fatigue, alcohol consumption, endocrine disorders, electrolyte disorders and metabolic abnormalities can lead to seizures.
A few patients have seizures only during menstruation or pregnancy.
Pathogenesis
Nerve cells in the brain transmit information through electrical signals and control various sensory, motor and physiological activities of the human body.
When the nerve cells are abnormally excited for various reasons, they repeatedly erupt with disorganized electrical signals that spread rapidly to other brain regions, resulting in abnormal nerve function.
At this point, the patient may manifest a series of disorders of consciousness, behavior, cognition, emotion, motor function or sensation, known as epileptic seizures.
It is important to note that “epilepsy” and “seizure” have different meanings. An “epileptic seizure” is a symptom and usually refers to the full duration of a seizure. On the other hand, “epilepsy” is a disorder that is repetitive and requires at least one or more seizures before a diagnosis of epilepsy can be made.
Symptoms
Seizure Characteristics
The different types of epileptic seizures take different forms, but all have the following common features:
Episodic, with symptoms occurring suddenly and lasting for a period of time followed by a rapid return with normal intervals.
Short-lived, with seizures usually lasting a few seconds or minutes, with the exception of status epilepticus.
Repetitive, the seizure occurs more than once, usually with a second or more seizures.
Stereotypical, the clinical presentation of each seizure is almost identical.
Seizure Manifestations
Generalized seizures
Generalized tonic-clonic seizures
It is one of the most obvious forms of seizure presentation and used to be called grand mal seizure.
During the seizure, the patient may experience loss of consciousness, dilated pupils, apnea, cyanosis, foaming at the mouth, and tonic clonic seizures of both limbs, which usually last for 1 to 5 minutes. It takes 5-15 minutes from the onset of the seizure to recovery of consciousness. Upon awakening, headache, generalized muscle pain, fatigue, no memory of the seizure.
Loss of consciousness seizure
Most commonly seen in children and rarely last into adulthood or occur in adulthood.
It is typically characterized by a sudden onset and cessation of loss of consciousness, which appears to be a “freeze” and often lasts for 5 to 20 seconds.
During the seizure, the patient may suddenly stop the original activity, drop the object in his hand, not be able to respond to the call, and stare forward without falling to the ground.
The patient is awake immediately afterward and has no memory of the seizure.
Clonic seizure
Rhythmic twitching of bilateral limbs, lasting several minutes.
Tonic seizure
Continuous contraction of the muscles of both limbs or the whole body, muscle rigidity, fixed in a certain position.
No clonus occurs.
Myoclonic seizure
Sudden, brief, rapid, electric shock-like twitching of the muscles.
May be limited to a single muscle or group of muscles in the face, trunk, limbs, or throughout the body.
Dystonic seizures
Sudden relaxation of the muscles of the head, trunk, or limbs.
In mild cases, the seizure may be characterized by a “nodding head”, while in severe cases, the seizure may be a sudden fall, lasting about 1 to 2 seconds or longer.
Focal Seizures
Focal seizures with clear consciousness
Repeated twitching of one side of the mouth, eyelids, fingers or toes, the whole face, or one limb.
Abduction of one upper limb, semi-flexion of the elbow, and gaze toward the hand on that side.
Involuntary repetition of single sounds or words, or inability to speak.
Pins and needles, numbness, and electric shock in one or both limbs.
Hallucinations, hallucinations, smells, tastes, and episodes of vertigo.
Epigastric pain, belching or bloating, vomiting, excessive sweating, pale or flushed face, raised sweat, dilated pupils, urinary incontinence.
A sense of déjà vu, rapid recollection of past events, and a trance like a dream.
Focal seizures with impaired consciousness
Typically called automatisms, the patient appears to be awake and completing a series of behaviors, but is not actually conscious.
Constant chewing and pouting.
Involuntary movements of the limbs occur, such as repeatedly fastening buttons, getting up, opening doors, and so on.
The above behaviors are repeated and the episodes are prolonged, but they are less likely to develop into symptoms such as generalized convulsions.
Complications
Anxiety and depression
Related to repeated seizures causing life and social disorders, abnormal discharges affecting the neural circuits responsible for emotional processing, and long-term use of antiepileptic drugs.
It is characterized by irritability, low mood, depression and lack of interest in anything.
Trauma, accidents
Epileptic seizures cause falls, resulting in craniocerebral trauma, bone fractures, and tongue bites.
Manifestations include headache, nausea and vomiting, limb weakness, difficulty in movement, bleeding inside the mouth, etc.
Lung infection
Related to high secretion in the mouth during seizures, leading to aspiration.
Manifested as fever, cough, sputum, etc.
Cognitive impairment
Associated with hypoxia as well as edema of brain cells due to persistent or frequent seizures, emotional depression, and long-term use of antiepileptic drugs.
Memory loss is the most common symptom, followed by distraction, slow thinking, unfavorable speech and reduced life skills.
Medical Treatment
Department of Medicine
Neurology
When there are abnormalities such as twitching of limbs, confusion, incontinence, etc., it is recommended to consult a doctor promptly.
Neurosurgery
When antiepileptic drug treatment is ineffective and surgical treatment is desired, neurosurgery is recommended.
Emergency Department
In the following cases, it is recommended to go to the emergency department as soon as possible or call the 120 emergency number.
Symptoms such as limb twitching and involuntary movements are not relieved for more than 5 minutes.
The patient has apnea and loss of consciousness after the seizure stops.
Seizures in pregnant women.
Fever accompanied by convulsions.
Seizure stops, followed by a second seizure.
Preparation for medical treatment
Preparing for your visit: registering, preparing your documents, FAQs
Tips for your visit to the doctor
The clinical symptoms of epilepsy are complex. You should try to keep a record of the symptoms, duration and frequency of seizures so that you can give your doctor more information.
If the patient’s whole body is convulsing, you should remove dangerous objects around you, and do not forcefully pry open the mouth or stuff towels or chopsticks in the patient’s mouth.
Special Note: Family members are recommended to accompany the patient to the doctor in case the patient falls or has an accident.
Preparation List
Symptom list
Particular attention should be paid to the time of onset of symptoms, special manifestations, etc.
What were the symptoms at the time of the attack? How old was the first attack?
Are the symptoms the same for each attack? How long was the interval between attacks?
Was the person awake during the attack?
Were the seizures related to exertion, emotions, or other causes?
Medical History Checklist
Is there a past history of craniocerebral trauma, intracranial tumors, cerebral hemorrhage, cerebral infarction, intracranial infection, etc.?
Is there a family history of epileptic patients or people with similar symptom onset?
Is there a history of chronic alcohol or drug use, such as chlorpromazine, phenazopyridine, isoniazid, doxepin, amitriptyline, diazepam, etc.?
Checklist
Test results in the last six months, which can be brought to the doctor’s office
Laboratory tests: blood glucose, liver function, kidney function, blood routine, urine routine, etc.
Electrophysiologic examination: electroencephalogram.
Imaging examination: cranial CT, cranial MRI, etc.
Medication list
Medication used in the last 3 months, if there is a box or package of medication, you can bring it to the doctor’s office
Antiepileptic drugs: carbamazepine, phenytoin sodium, sodium valproate, etc.
Drugs that tend to cause seizures: chlorpromazine, phenazopyridine, isoniazid, doxepin, amitriptyline, diazepam, clonazepam.
Diagnosis
Diagnosis is based on
Medical history
The patient may have developed the disease in infancy or childhood.
There is a history of craniocerebral trauma, intracranial tumors, cerebral hemorrhage, cerebral infarction, and intracranial infections.
There is a family history of epileptic patients or people with similar symptom onset.
There is a history of long-term alcohol consumption or drug use, such as chlorpromazine, phenazopyridine, isoniazid, doxepin, amitriptyline, diazepam, and so on.
Clinical manifestations
Symptoms
There are symptoms such as limb convulsions, eye rolling, foaming at the mouth, loss of consciousness, incontinence, falling, and sensory abnormalities.
Seizure symptoms are characterized by suddenness, transience, repetition and consistency.
Physical signs
The doctor will focus on the patient’s state of consciousness, mental state, limb strength, various reflexes and pathological signs.
The doctor will also observe the shape and size of the patient’s head, appearance, and physical deformities to screen for certain neurocutaneous syndromes.
Laboratory Tests
Routine tests
Purpose: To find and identify the cause of symptoms and to monitor the adverse effects of medications.
Main items: blood routine, blood sugar, electrolytes, liver and kidney function, blood gas.
Note: Some items need to be checked on an empty stomach.
Antiepileptic Drug Blood Concentration
Purpose of examination: to clarify whether the dosage of epilepsy drugs is reasonable, and to assist in determining the effect of drugs.
Precautions: Fasting is required for the examination, do not take medication before blood collection, and take additional medication according to the doctor’s requirement after blood collection.
Electroencephalography
Purpose of examination: To confirm the diagnosis of epileptic seizure and the type of seizure.
Results: Waveforms characteristic of seizures such as spikes, sharp waves, spikes and slow waves, sharp and slow waves, etc. may appear.
Precautions
Wash your hair carefully the day before the test and do not use any hair care products, such as conditioner or gel.
Stay quiet and relaxed during the examination and do not carry electronic products such as cell phones.
Follow the doctor’s instructions to perform movements such as opening and closing the eyes and speeding up the breathing rate.
Imaging
Cranial CT / Cranial MRI (Magnetic Resonance Imaging)
Purpose of the examination: To determine the presence of structural lesions in the brain.
Significance of the examination: idiopathic epilepsy usually has no abnormality; other types may reveal brain tissue malformations, hemorrhages, infections, tumors, and other lesions.
Precautions
CT examination has some radiation and should not be used by pregnant women.
The MRI requires the removal of metal objects from the body, and those who have metal implants or pacemakers in their bodies need to consult a physician to confirm whether the test can be performed.
Functional Magnetic Resonance Imaging (fMRI)
Purpose of examination: to assist in localizing epileptic foci.
Significance: Localized hypermetabolic manifestations may be epileptic foci.
Precautions: It is necessary to cooperate with the doctor’s command to complete the task during the examination, and the rest is the same as ordinary cranial MRI.
Positron Emission Tomography (PET)
Purpose of examination: To detect epileptic foci without obvious structural abnormalities.
Significance of the examination: Epileptic foci are hypermetabolic during the seizure period and hypometabolic during the seizure.
Precautions
Fasting is usually required for 6 hours before the examination.
Drink as much water as possible after the examination to promote the elimination of contrast agent metabolism.
Genetic testing
Purpose: If epilepsy is considered to be caused by heredity, genetic testing needs to be perfected.
Significance: To clarify the hereditary characteristics, to guide the use of medication according to the type of mutation, to assess the prognosis, and to assess the possibility of passing the mutation to the offspring, and to guide eugenic sterilization.
Caveat: Not used as a routine etiologic screening tool, usually performed when there is a high degree of suspicion for a particular disorder.
Neuropsychological Evaluation
Purpose of the examination: to assess cognitive and mental status; to hypothesize about damaged brain areas; to assess the possible effects of surgery on cognitive function.
Content of assessment: Intelligence, language, cognition, mood, behavior, quality of life and social functioning.
Other tests
Electrocardiography: to detect arrhythmias, cardiogenic diseases, and to help identify epilepsy and syncopal seizures.
Lumbar puncture: to assist in determining the presence of intracranial infection, intracranial hemorrhage, etc.
Differential Diagnosis
Syncope
Similarity: both have episodic loss of consciousness.
Differences
Syncope has clear triggers, such as nervousness, emotional excitement, standing for a long time, coughing, laughing, urination, defecation, etc. It is often manifested by pale face, sweating, and a lack of consciousness.
It can often be manifested as pallor, sweating, sometimes irregular pulse, occasionally accompanied by twitching and urinary incontinence.
Loss of consciousness caused by reflex syncope rarely exceeds 15 seconds and is characterized by a rapid return of consciousness and full wakefulness, without postictal blurring of consciousness.
The electroencephalogram is usually unremarkable during the interictal period, and cardiac problems such as arrhythmias may be detected on electrocardiography.
Hysteria
Similarities: both may be characterized by falling and twitching of limbs.
Differences
Dysthymic disorder often occurs after mental stimulation or in the presence of other people.
Seizures can take various forms, with non-stop shouting and twitching of limbs, intense self-expression, exaggerated movements, often with eyes closed tightly, pale/red face, no tongue biting or urinary incontinence, and no fall injuries.
There are no corresponding abnormal brain waves on the EEG during the seizure.
Transient ischemic attack (TIA)
Similarities: both may present with limb weakness and fall episodes.
Differences
Transient ischemic attack is most common in the elderly, often with a history of arteriosclerosis, coronary heart disease, hypertension, diabetes mellitus, and so on.
There are no corresponding abnormal brain waves on the EEG during an attack.
Hypoglycemic attack
Similarity: both may have limb twitching or tetany, accompanied by loss of consciousness.
Differences
Hypoglycemia may be associated with a history of diabetes mellitus, pancreatic B-cell tumors, overdose of hypoglycemic medication, or failure to eat in a timely manner after taking medication.
Seizures tend to be partial seizures, with blood glucose levels significantly lower than normal or the patient’s general state at the time of the seizure.
Treatment
Aim of treatment: to reduce the number of seizures and improve the quality of life.
Treatment principle: Patients with a clear cause should be treated for the cause. Most of the patients with no clear cause or incurable cause should be treated with medication.
First aid treatment
If there is a persistent seizure that cannot be stopped or repeated for a period of time (status epilepticus), first aid treatment is required.
Have the patient lie down in a safe and stable place.
Uncollar the patient to keep the airway open, and quickly clear the mouth of any foreign objects to prevent choking.
Do not put anything into the patient’s mouth and do not force-feed food or medicine.
If the patient’s limbs are convulsing violently, do not forcefully pull or press the limbs, or it is likely to cause fractures.
If the seizure lasts for more than 5 minutes or is frequent, call “120” in time to get help from medical personnel as quickly as possible.
Medication
Antiepileptic drugs
Principles of use
For the first seizure, if no lesions are found in the brain, no medication can be used for a while, but we should be alert to the possibility of a second seizure, and review the EEG in about 3 months.
If the seizure recurs within six months, medication should be considered.
Different types of epilepsy will have corresponding first-line therapeutic drugs. One of these drugs is usually chosen first in full dosage and duration.
If the first drug does not work well, another drug from the first line may be chosen for use alone or in combination.
Other medications may be added when the first-line medication is not effective or is not tolerated.
Commonly used drugs
Table 1. Commonly used drugs in adult epilepsy
Seizure type drugs
Adult partial seizures Grade A: carbamazepine, phenytoin sodium Grade B: sodium valproate Grade C: gabapentin, lamotrigine, oxcarbazepine, phenobarbital, topiramate, aminocaproic acid
Adult partial seizures
Grade A: carbamazepine, phenytoin sodium Grade B: sodium valproate Grade C: gabapentin, lamotrigine, oxcarbazepine, phenobarbital, topiramate, aminocaproic acid
Partial seizures in the elderly Grade A: Gabapentin, Lamotrigine Grade B: None Grade C: Carbamazepine
Partial seizures in the elderly
Grade A: Gabapentin, Lamotrigine Grade B: None Grade C: Carbamazepine
Adult generalized tonic-clonic seizures Grade A: None Grade B: None Grade C: Carbamazepine, Lamotrigine, Oxcarbazepine, Phenobarbital, Phenytoin Sodium, Topiramate, Sodium Valproate
Adult generalized tonic-clonic seizures
Grade A: None Grade B: None Grade C: Carbamazepine, Lamotrigine, Oxcarbazepine, Phenobarbital, Phenytoin sodium, Topiramate, Sodium valproate
(Note: Initial monotherapy for specific types is clinically considered first for grades A and B, then for grade C)
Precautions
Adverse reactions such as cardiac arrhythmias, atrioventricular block, bone marrow suppression, hepatic and renal impairment, hyponatremia, and rash may occur.
It needs to be taken for a long period of time. During the medication period, it is necessary to strictly follow the doctor’s requirements to take the medication on time, according to the dosage and regularly, and it is forbidden to stop, reduce or change the medication without authorization.
Some antiepileptic drugs have teratogenic effects, women need to adjust the antiepileptic drugs under the guidance of a professional doctor before or during pregnancy, and mothers need to suspend breastfeeding when using drugs during lactation.
Other drugs
For intracranial infections, tumors, autoimmune diseases, neurodegenerative diseases and other conditions, treatment is also needed to address the cause.
Surgery
For those who do not respond well to regular antiepileptic drug therapy, appropriate surgical treatment may be considered to alleviate the patient’s seizures.
Common methods: resection of epileptic foci, corpus callosotomy, temporal lobectomy, hippocampectomy of amygdala, implantation of cerebral pacemaker and vagus nerve electrical stimulation.
Surgical treatments such as tumor resection and lesion removal are also required for diseases such as brain tumors and intracerebral parasites.
Ketogenic Diet
Ketogenic diet is to induce the production of ketone bodies in the body by increasing the proportion of fat energy in food to suppress seizures. It can be used for patients who have difficulty controlling their condition with medication, and the common pattern is as follows:
A very small amount of carbohydrates (e.g., staple foods such as rice and pasta), a moderate amount of protein (e.g., milk, lean meat) and a large amount of fat (e.g., butter, cream, etc.).
The fat to protein + carbohydrate mass ratio is (3 to 4):1, with about 90% of energy coming from fat.
The ketogenic diet must be followed strictly under the guidance of a doctor and dietitian, and should not be used without authorization to avoid serious adverse effects.
Prognosis
Cure
Most patients have good seizure control with standardized antiepileptic drug therapy, and most do not have life expectancy.
The prognosis of adult epilepsy is closely related to the cause of the disease.
Most patients have good seizure control with standardized antiepileptic drug therapy.
Most types of epilepsy do not affect life expectancy, but malignant tumors and severe systemic diseases can affect survival time.
Harmful
Repeated seizures can affect normal life and work, and can lead to low self-esteem, anxiety and depression.
Seizures are prone to accidents such as falls, car accidents and burns, leading to fractures and traumatic brain injury.
Sudden death may occur if there is a persistent epileptic condition that is not terminated in time.
Daily
Dietary management
In addition to the ketogenic diet, the following principles are recommended for daily diet.
Daily diet should be light, avoiding oversatiety, overfatting, overheating, overcooling, avoiding smoking and alcohol, as well as spicy and stimulating foods.
Increase the daily intake of vegetables and fruits to ensure the supply of dietary fiber, calcium, potassium and vitamins.
Long-term use of antiepileptic drugs may affect the metabolism and absorption of folic acid and vitamin B12, and even lead to megaloblastic anemia. In addition to vegetables and fruits, it is also necessary to supplement animal offal, eggs, beans, yeast and nuts.
Avoid beverages that affect nerve excitability such as alcohol, cola, strong tea and strong coffee.
Life Management
Life should be regular, ensure sleep time, and avoid excessive tension, exertion, and staying up late.
Family members of those with frequent seizures need to take better care and accompany them.
Avoid placing unstable, fragile and sharp objects in the living environment to avoid accidental injury.
It is not advisable to do dangerous sports or occupations, such as swimming, hiking, aerial work and driving.
Psychological support
Patients should keep a positive and optimistic mindset and communicate with relatives and doctors more often.
Relatives should give patients enough support, encouragement and comfort.
Disease monitoring
The form, frequency and duration of seizures can be recorded by means of taking videos, keeping diaries or journals, etc., so as to assist the doctor in understanding the condition and treatment effect, and formulating and adjusting the treatment plan.
Follow-up review
Follow the doctor’s instructions for review, usually every month for the first 3 months of taking the medication; after 3 months of taking the medication, every 3 to 6 months for regular review.
Tests to be done during the review: electroencephalogram, head CT, head MRI, etc.
Prevention
Preventing the disease
Some types of epilepsy are genetically related. Genetic counseling and prenatal diagnosis are recommended for those who are planning to have children.
Pregnant women need to adjust the medication in advance under the guidance of the doctor to avoid the teratogenic effect of drugs.
Seizure prevention