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Epilepsy is a clinical syndrome or disease. It is characterized by recurrent, abnormal discharges of nerve cells in the brain resulting in brain dysfunction. It manifests as disorders of movement, sensation, consciousness, mental and vegetative nerves.
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According to domestic statistics, the incidence of epilepsy is 7.6/100,000-40/100,000 per year, and foreign reports are 17/100,000-70/100,000. Most are in the range of 20/100,000-500/100,000. Its prevalence is 3.5‰-4.8‰. The incidence of epilepsy varies by age, with the highest incidence at 1-10 years of age, especially within 1 year of age, slightly lower at 10-19 years of age, and lower thereafter, but increases after 60 years of age, which is associated with some diseases that increase with age.
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The classification of seizures is complicated, here is a brief introduction of the common domestic classification method.
(1) Partial seizures
① Simple partial seizures, motor, sensory and autonomic seizures without impairment of consciousness.
②Complex partial seizures with impaired consciousness, including impaired consciousness only, psychiatric symptoms, and automatism.
③Partial seizures extended to generalized seizures.
(2) Generalized seizures
①Generalized tonic-clonic seizures (grand mal seizures)
②Absorption seizures (petit mal seizures)
③Other: myoclonic seizures, clonic seizures, tonic seizures, atonic seizures.
(3) Seizures that cannot be classified
Seizures that cannot be classified into the above categories due to insufficient information or
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Primary epilepsy: including idiopathic and cryptogenic epilepsy. These patients do not have structural changes or metabolic abnormalities in the brain that can cause symptoms. Seizure types are limited to grand mal, classic petit mal, or large myoclonic seizures. Seizures are more susceptible to physical and environmental influences. A small number of patients have a significant family history.
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Secondary epilepsy is caused by a variety of organic brain diseases or metabolic disorders, also known as symptomatic epilepsy. Common etiologies include.
(1) Congenital disorders: such as congenital malformations of brain development and fetal infections.
(2) Cranio-cerebral trauma: including birth injuries.
(3) Infections: such as various brain infections or systemic infections with cases of toxic encephalopathy, may lead to epilepsy. It is more common in children.
(4) Tumors: Intracranial tumors are a common cause in cases of seizures starting in adults, especially those close to the cerebral cortex.
(5) Vascular diseases: such as cerebrovascular malformations, cerebral hemorrhage, cerebral infarction, etc.
(6) Degenerative diseases: such as multiple sclerosis and brain atrophy caused by degenerative diseases can lead to seizures.
(7) Metabolic disorders: such as hypoglycemia, hypocalcemia, phenylketonuria, uremia, etc.
(8) Brain parasitic diseases: such as cerebral cysticercosis, cerebral schistosomiasis, etc.
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There are physiological and environmental factors, including infection, poisoning, fatigue, alcoholism, lack of sleep, allergic reactions, fever, mood swings, etc., which may promote seizures. Gonadal function also has an effect. In women with PMS, various types of seizures are often more frequent than usual, and some patients have seizures only in the premenstrual period or during menstruation (menstrual epilepsy). Many patients have seizures related to the sleep-wake cycle, with some having seizures only or mostly during the daytime and some at night. In addition, sudden discontinuation or change of antiepileptic drugs or even increase in dosage is a common trigger for increased seizures.
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If you suspect that you or a family member has epilepsy, you should take the initiative to seek medical advice about diagnosis and treatment and actively treat it. Because of the complexity and intractability of epilepsy, a significant number of patients take detours in the consultation process, blindly believing in biased and secret prescriptions, listening to lobbying doctors, and increasing and decreasing antiepileptic drugs on their own; these will inevitably delay the diagnosis and miss the time for effective diagnosis and treatment.
This is not only a waste of time but also a financial burden, even some fake drugs make the patient’s family in debt, while the patient has serious toxic side effects. Therefore, it is important to go to the epilepsy specialist or neurology department of a regular hospital according to your specific condition, and those who are suitable for surgery should be treated with surgery as soon as possible.
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When diagnosing epilepsy clinically, in addition to detailed medical history and seizure performance, the first thing that should be done is EEG, which is an extremely valuable diagnostic aid. Even in the interictal period, about 80% of patients generally have positive EEG abnormalities. If the examination is repeated and appropriate evoked tests are used, the positive rate can be increased to about 90%-95%.
However, a minority of patients have only EEG abnormalities and no clinical seizures, and these patients are not yet diagnosed as having epilepsy. In the case of 5-20% of epileptic patients with normal EEG, if there are typical clinical seizures, and if antiepileptic drugs are effective and other diseases can be excluded, the diagnosis of epilepsy cannot be arbitrarily denied. The diagnosis can be clarified by rechecking or performing long-range EEG monitoring to capture seizures.
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Nowadays, high-quality video EEG can be monitored for 24 hours or even days, and the patient’s video recording and EEG data are displayed and stored on the same screen. The video data of seizures can be repeatedly played back and analyzed, providing an objective basis for diagnosis, classification, and comparison of efficacy of epilepsy, and also helping in differential diagnosis of non-epileptic seizures. Especially for various types of intractable and occult epilepsy, long-range video EEG plays a decisive role. The abnormal performance of EEG helps to classify epilepsy, localize and characterize epileptogenic foci, and provide a reliable basis for surgical removal of epileptogenic foci.
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The current accepted view is that; CT and MRI are of great value in clarifying the cause of most secondary epilepsies. Both are imaging examinations that can detect organic or structural lesions such as brain tumors, vascular malformations, brain cysts, abnormal calcifications, and developmental malformations of the brain, and combined with EEG can diagnose epilepsy and localize the epileptogenic focus.
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Positron emission tomography, abbreviated as PET, is known as the latest technique for studying physiological processes in the human body. Unlike CT and MRI, PET is not only a structural image, but more importantly, a functional image. It is able to reflect the physiological and biochemical changes in brain tissue. Many patients with epilepsy do not have organic brain changes or structural abnormalities, but only brain dysfunction, and PET is the best tool to study their dysfunction.
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Epilepsy, whether primary or secondary, can cause neuronal damage, mental retardation, trauma, and even sudden and unexpected death. The most important goal of treatment is to control seizures and maintain normal neuropsychiatric function, and the main means of seizure control is pharmacotherapy. With the regular application of available antiepileptic drugs, about 70%-80% of epileptic patients can be controlled, and many patients can be cured for life. Patients with definite lesions, those for whom drug therapy is ineffective, or those who develop intolerable toxicities need to be considered for surgical treatment.
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Phenytoin sodium (dalantin), carbamazepine, sodium valproate, paroxetine, ethosuximide, clonidine, phenobarbital, etc. are commonly used as first-line drugs.
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Toltea, lamotrigine, gabapentin, anacetin, oxcarbazepine, and fexamate should be used according to medical advice.
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The diagnosis should be established without doubt before drug treatment. It is clear that the treatment of epilepsy is a rather long process, and it is important to understand the toxic effects of drugs and the precautions in life. The purpose of treatment is to let the patient live like a healthy person, so it is important to respect the patient’s personality while strictly following the medical advice.
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The basic principles of epilepsy medication are.
(1) Choose the most appropriate medication to control this type of seizure.
(2) Start with a small dose and gradually increase until seizures are controlled or significant drug toxicities occur. Timely testing of blood levels facilitates medication adjustment.
(3) If one drug does not control the seizure satisfactorily, add a second drug under the guidance of the doctor and try to gradually reduce the dosage of the first drug after the seizure is controlled.
(4) Apply monotherapy as much as possible.
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The effect of drug therapy may be unsatisfactory in the following cases.
(1) There is significant structural brain damage.
(2) Seizures begin in infancy.
(3) Suffering from multiple types of seizures.
(4) Have underdeveloped intelligence.
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(1) Blood concentration is below the therapeutic range.
(2) The drug selection is not reasonable.
(3) The medication is not taken as prescribed.
(4) Incomplete response of the patient and family.
(5) Development of drug resistance.
(6) Complicated progressive neurological disease.
(7) Single medication may be inferior to combined medication.
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The relationship between serum concentrations of active drugs and efficacy and side effects in epileptic patients is closer than that between dose and effect, so it is important to monitor serum drug concentrations.
(1) Each drug has a range of optimal therapeutic concentrations in the serum. Within this range, most patients show the best therapeutic effect and the least toxic side effects.
(2) Many antiepileptic drugs have a narrow therapeutic range, with a small safety margin between efficacy and toxic serum levels.
(3) Serum drug levels obtained with drugs administered per kilogram of body weight may vary markedly from patient to patient.
(4) The efficacy of the same drug varies from patient to patient, even if the seizure type is the same. When the drug is not effective, it should first be clear that the serum concentration of the drug has reached the optimal therapeutic level.
(5) When multiple drugs are used in combination, it is likely to cause drug-drug interactions, which may affect the metabolism and therapeutic effect of the drug.
(6) When combining drugs or reducing or stopping drugs, drug concentration check is also necessary.
(7) Other diseases may also affect the absorption and excretion of antiepileptic drugs and change the serum drug levels.
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(1) When starting medication, adjusting the dose or adding other drugs, 2-3 weeks after the start of treatment, when the drug concentration is estimated to reach steady state.
(2) When treatment fails and toxic side effects are apparent. (3) When the patient is combined with other diseases that interfere with drug use.
(4) During pregnancy, in order to control the attack and reduce the toxic side effects of the drug to the pregnant woman and the fetus.
(5) When there is a change in clinical symptoms.
All of the above should be tested for serum drug concentration. And we must know the patient’s age, weight, gender, liver and kidney function, and medication consumption, etc. Specimen collection is best done in the morning before the first dose.
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(1) Patients with seizure free for at least 2 years can gradually reduce the dosage to discontinue the drug according to the EEG.
(2) If the EEG has a tendency to progress, the drug cannot be discontinued.
(3) The drug should also not be discontinued if the brain disease is still active.
(4) Prepubertal patients should take medication until after puberty.
(5) Do not discontinue medication if you have experienced recurrent seizures or if you are considering a recurrence that is difficult to manage.
(6) If the epileptogenic focus is satisfactorily removed by surgery, the drug can be reduced or discontinued early if the EEG is free of epileptiform seizure waves after 1 year of medication.
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The number of epileptic patients in China is more than 5 million, and there are about 300,000 new patients each year, which is not only extremely painful for the patients themselves, but also a heavy burden to the society and families. Although new anti-epileptic drugs are constantly appearing and their efficacy is improving, most patients need to take medication for life and are troubled by the side effects of medication. At least half of these patients can be cured surgically or controlled with antiepileptic drugs.
Approximately 25,000-30,000 epilepsy patients require surgery each year in China, but only a minority undergo surgery each year, and the vast majority are treated at low levels, or even incorrectly. Therefore, it is necessary to provide an objective understanding of epilepsy surgery along with medical treatment of epilepsy to avoid stepping into misconceptions.
Complete control or remission of seizures. Complete control means complete cessation of seizures without antiepileptic drugs, which means that the seizure-producing tissues are completely removed surgically; while remission means that the seizure-producing tissues are not completely removed, but only the conduction pathways of epilepsy or the amplified structures of epileptic discharges are destroyed.
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In the past, formal drug therapy was not effective, the duration of the disease was more than 4 years, and at least 4 episodes per month were used as the measurement criteria. It is no longer used, but whether seizures affect the patient’s quality of life as the criteria. The general selection criteria for surgical patients are.
(1) Limited seizures;
(2) Failure of regular drug therapy with no trend of remission for more than 2 years;
(3) Seizures seriously affect the patient’s quality of life;
(4) The patient’s physical and mental status can cooperate with the completion of preoperative evaluation and postoperative rehabilitation;
(5) The epileptogenic lesions are not in the important functional areas of the brain, and the surgery will not cause significant disability to the patient. (6) Those with clear lesions in the brain found by CT, magnetic resonance imaging (MRI), etc., and those whose epileptogenic foci can be localized by EEG and can be removed by surgery. On the basis of strict control of the indications for surgery, different surgical methods are selected according to the different conditions of the patients.
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If there are obvious occupying lesions in the brain, such as tumor, brain abscess, inflammatory lesions, vascular malformation, brain cyst, etc., the epileptogenic foci and lesions can be removed by EEG monitoring, and about 60%-90% of epilepsy can be cured after surgery.
(2) Anterior temporal lobectomy: the most used surgical method at present, if the positioning is accurate more than 80% of the patients can have their seizures completely stopped. And it rarely causes functional impairment.
(3) Selective amygdala and hippocampus resection: selective removal of the amygdala and hippocampus to avoid damage to the temporal cortex. The rate of complete control of epilepsy is 42.85%, and the effective rate is 85.71%.
(4) Hemispherectomy: For patients with intractable epilepsy, with epileptogenic foci involving most or all of one hemisphere, with functional compensation on the contralateral side, and with Wada confirmed speech center in the healthy hemisphere. The seizure control and efficiency is nearly 100%.
The corpus callosum is the nerve tissue that connects the left and right hemispheres, and is the connecting fiber for the transmission of epileptic discharges to the contralateral side. There is also an increase in seizures.
(6) Multiple submembranous transverse fiber resection: The transverse fibers of neurons are cut under multiple soft meninges to block the spread of synchronous discharges of neurons in the epileptic foci. It is mainly applicable to refractory epilepsy in major functional areas.
(7) Stereotactic surgery; the advantage of this procedure is that it does not require craniotomy and less damage to brain tissue, but requires higher accuracy of localization. The aim of this procedure is to destroy the epileptogenic nuclei and block the spread of epileptic discharges through body orientation.
(8) Chronic cerebellar stimulation and vagus nerve stimulation: This procedure involves placing special deep brain stimulation electrodes in the anterior or posterior lobes of the bilateral cerebellar cortex and stimulating the cerebellum through the radio receivers buried under the skin to reduce the number of seizures. Vagus nerve stimulation is performed by implanting a miniature stimulator in the subcutaneous tissue under the left clavicle and introducing electrodes through a subcutaneous tunnel into the lower part of the neck and wrapping them around the vagus nerve. Seizures are suppressed by stimulation. The effectiveness rate varies from 50-75%.
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Epilepsy has been a class of intractable disorders that has plagued neurologists, seriously threatening the health of patients and affecting social and family life. Currently, there are various surgical procedures such as anterior temporal lobectomy, selective amygdala hippocampal resection, cortical resection of epileptogenic foci, brain stereotactic surgery, cerebral commissurotomy, submural transverse fiber cut, hemispherectomy and chronic cerebellar stimulation. The cure rate, efficiency rate, disability rate and mortality rate vary among different surgical procedures, with an overall cure rate of 60%-80%, efficiency rate of 71%-95%, disability rate of 5%-17% and mortality rate of 0-4%. The key to successful surgery is the precise location of the epileptogenic focus, complete resection, and the effective and rational application of antiepileptic drugs. Due to the individual differences of each patient and the severity of the disease, the specific efficacy may vary.
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Most patients with epilepsy require general anesthesia and craniotomy, which is a complex and lengthy procedure that may result in complications and even disability or death. The procedure may vary from patient to patient and will be explained to you in detail by your supervising physician. Patients with poor general health, those who cannot cooperate with the surgery and those with chronic diseases such as hypertension, heart disease and diabetes are at increased risk of surgery.
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Because seizures can cause injury to the patient and may accidentally injure others, repeated seizures can cause serious physical and psychological damage to the patient and make it more difficult to control the epilepsy. Therefore, it is necessary for the patient and family members to strictly follow the doctor’s instructions and to take the antiepileptic drugs on time and in accordance with the dosage after discharge. Do not discontinue or reduce your medication on your own. Seek medical consultation for special conditions. To ensure a smooth recovery and future treatment, please follow the medical protocol and visit the hospital for review at 3 months, 6 months, 1 year, 2 years and 3 years after surgery without any special circumstances.
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Patients who appear to have low intelligence and mental abnormalities should not be ridiculed, teased or even scolded. Reasonable requests made by patients should be met, and unreasonable ones should be patiently explained, but they should never be unprincipledly accommodated, perfunctory or deceptive, not to mention conflict. Patients who cannot take care of themselves should be bathed and have their hair cut regularly, and their clothes should be increased or decreased in time when the climate changes. For those patients who are depressed and suspicious, they should be encouraged and led to carry out cultural and sports activities or participate in simple physical labor, which can help stabilize their emotions. In addition, a reasonable work and rest schedule should be arranged, sleep should be sufficient, and not lying in bed all day. Those who have a habit of smoking and drinking should try to quit.
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Seizures often occur suddenly, so you should not drive a car, and you should strictly follow the traffic rules when riding a bicycle. Crosswalks should be used as much as possible when walking. Parents educate and manage children to play away from water, roads and railroads. Adopt more normal habits.
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Studies have shown that antiepileptic drugs can cause deficiencies of vitamin K, folic acid, vitamin D, and calcium and magnesium. Vitamin K is related to blood clotting and can cause bleeding when deficient. Fresh vegetables, soybean oil, and egg yolk contain large amounts of vitamin K. Vitamin D, calcium, and magnesium are related to the growth of bones and teeth, and calcium deficiency can aggravate seizures. Therefore, sufficient vitamin D, calcium, and magnesium should be supplied during childhood. Fish, liver, soy products, eggs, and milk are rich in calcium and vitamin D. Folic acid deficiency is also associated with increased seizures. Animal kidneys, beef, and green vegetables contain folic acid, but cooking time should not be too long to avoid excessive destruction. Vitamin B6 is associated with the production of γ-aminobutyric acid. Rice, wheat bran, beef liver, and fish contain large amounts of vitamin B6.
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Recent studies have shown that after taking a large amount of sweets at a time, the body is stimulated to secrete too much insulin (a hormone that lowers blood glucose concentration) due to the large amount of sugar entering the bloodstream, thus causing blood glucose to drop quickly and low blood glucose leading to a lack of energy for the brain and promoting seizures. Likewise, starvation can make seizures easier. It should be prevented in life.
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There is no clear evidence whether nicotine and some carcinogenic substances in cigarettes can induce epilepsy, but some doctors have found a clear relationship between seizures and smoking in some patients. Nicotine has a significant effect with the diastole of cerebral blood vessels, thus it seems that epileptic patients should not smoke. There is a clear relationship between alcohol and seizures, and prolonged heavy drinking can directly produce alcoholic moderate line epilepsy. Many patients have experienced seizures triggered by alcohol consumption. A person who is sensitive to alcohol may overdose on one glass of beer. Drinking alcohol for people with epilepsy can do more harm than good.
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There is no risk of seizures when tea, coffee, cola, etc. are consumed properly, but large amounts or too much tea and coffee can also trigger seizures. This is because these beverages contain more or less central excitatory substances that reduce the anticonvulsant ability and induce seizures. Therefore, it is important to note that stimulating drinks should be lighter and in moderation.
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Epileptic patients should not choose jobs such as aircraft, motor vehicle driving, work at height, near water, around heavy machinery work, electrician, firefighting work, direct contact with strong acids, strong alkalis, highly toxic substances and other dangerous work. In particular, it is not advisable to choose occupations that may endanger the health of others when seizures occur, such as surgeons, firefighters, police officers and ambulance personnel of sea and road agencies. All types of military service are strictly prohibited for people with epilepsy to enlist.
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The following points are for reference.
(1) From a eugenic point of view, patients with primary epilepsy should be prohibited from having children.
(2) Close relatives who both have primary epilepsy should also be prohibited from having children.
(3) A family history of epilepsy on both sides should prohibit childbirth.
(4) If one party is epileptic and the other party has only EEG abnormalities, childbirth should also be prohibited.
(5) If one partner has a family history of epilepsy and has already had a child with epilepsy, the second child should not be born.
(6) Women with epilepsy who have a clear family history of epilepsy should be prohibited from having children if they are married.
(7) Patients with generalized seizures with extensive EEG abnormalities and siblings with similarly manifested EEGs should be prohibited from having children.
(8) Patients with epilepsy with no family history and abnormal EEG in their family line may have children after 1 year of cure of epilepsy (including return of normal EEG) during the reproductive age.
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Deaths in patients with epilepsy are due to.
(1) Directly related to seizures, such as persistent status epilepticus or seizures resulting in accidents ;
(2) Other diseases not related to seizures, drug side effects, vital organ diseases. Statistically, deaths caused by status epilepticus are: 23% to 30%.