Physical Examination.
Routine internal medicine and neurological examinations
Laboratory tests.
Look for causes of seizures, including: blood, urine, cerebrospinal fluid tests
Electroencephalography.
1. Clinical applications.
① For diagnosis and typing of epilepsy, to find spike, spike wave, spike slow, spike slow complex wave, seizure rhythm wave and other epileptiform discharges.
②To find the cause of sudden cognitive regression in patients with epilepsy.
(③Assess whether the patient has indications for surgical treatment.
④Assess the likelihood of reoccurrence of seizures after the first seizure.
⑤ Evaluate the risk of recurrence with discontinuation of antiepileptic drugs.
2. EEG diagnosis and typing of epilepsy.
①Tonic clonic seizures: synchronous and symmetrical discharges in bilateral cerebral hemispheres, starting with spike-wave rhythms, followed by alternating spikes and slow waves.
② Typical anhedonic seizures: bilateral symmetrical and synchronous 3HZ spike-slow complex wave rhythm bursts.
③Tonic seizures: bilateral low amplitude fast wave or spike-wave rhythm bursts.
④Clonic seizure: fast wave activity or spike-slow/multiple spike-slow complex wave bursts.
⑤ Myoclonic seizures: widespread multi-spine slow-composite wave bursts.
⑥Atensive seizures: generalized bursts of multi-spike slow complex waves, low amplitude electrical activity or electrical suppression.
(vii) Simple partial seizure: focal abnormal discharge.
(viii) Complex partial seizures: unilateral or bilateral temporal or frontotemporal region epileptiform discharges.
3. The positive rate of conventional EEG-epileptiform discharges is 30-40%. The positive rate of long-range video EEG (including multiple evoked tests, sleep evoked, pterionic electrodes, etc.) increases to about 80%. Some patients with epilepsy can have a normal EEG, and a normal EEG does not exclude epilepsy, when the EEG monitoring time is appropriately extended.
Ancillary tests.
1, magnetic resonance imaging (MRI): has high diagnostic value for the diagnosis of causes of epilepsy. Such as cerebral white matter lesions, vascular malformations, cortical dysplasia, cerebral softening foci, occupancy, cerebrovascular disease, hydrocephalus, other abnormalities of brain tissue, etc.
2.CT–Quick and convenient, suitable for application when MRI is not possible, in addition, it has absolute advantage for intracerebral calcified foci.
3, Magnetoencephalography: used for localization of epileptogenic foci and functional area localization in refractory epilepsy, this test is expensive and not a routine test.
4. In addition, there are SPECT and PET examinations, which are used for preoperative localization of epileptic foci.
Classification of seizures: There are two main categories: generalized seizures and partial (focal) seizures. Diagnosis is made based on seizure performance, EEG, and brain MRI.
Classification of epileptic syndromes: a specific epileptic phenomenon consisting of a group of symptoms and signs. Common epileptic syndromes include: benign familial neonatal convulsions, infantile spasms (WEST), Lennox-Gastaut syndrome, aphasic epilepsy, benign childhood epilepsy with central temporal area spikes, benign occipital lobe epilepsy in children, juvenile myoclonic epilepsy, frontal lobe epilepsy, temporal lobe epilepsy, and occipital lobe epilepsy.
Diagnosis of epilepsy: The diagnosis and typing of epilepsy is made based on seizure symptoms, EEG findings, and cranial MRI. To obtain a correct and accurate diagnosis, there are three important steps.
Step 1 – Is the seizure event a seizure?
Step 2 – What type of seizure is it?
Step 3 – What is causing the seizure?
The new diagnostic protocol is divided into 5 cores, which are intended to facilitate clinical diagnosis and facilitate diagnostic studies and treatment decisions for patients.
Core 1: Seizure phase symptomatology
Core 2: Types of seizures
Core 3: Epilepsy syndrome
Core 4: Etiology
Core 5: Functional impairment: presence of cognitive, developmental, and motor problems
Drug therapy.
1, treatment goals: control seizures as much as possible; adverse drug reactions do small; improve the quality of life, psychological status, work and learning ability, etc.
2. Indications for medication.
①Patients with first seizures should start antiepileptic treatment if: there is a high risk of seizures again; the patient has typical clinical manifestations and EEG changes consistent with the diagnosis of epilepsy syndrome; the patient cannot tolerate the risk of another seizure.
(②Two or more unprovoked seizures within 1 year should be started on medication.
Epilepsy health promotion.
1. Emphasize the importance of following medical prescriptions for timely and long-term medication.
2. Inform about the possible adverse reactions caused by medication.
3. When traveling for a long time, bring enough medication and avoid sudden discontinuation of medication.
4.Try to avoid triggering factors: heavy alcohol consumption, lack of sleep, strong flashing lights, overeating, etc.
5, make a good record of seizures: record in detail the performance and duration of each seizure, the severity and performance after remission.
6, epileptic patients should not engage in driving, high altitude or water, electricians and other high-risk work.
General treatment of tonic-clonic seizures.
1, if there are seizure aura, first help the patient to bed or homeopathic lying flat or on the side to prevent accidental falls and bruises.
2.Turn the patient’s head to the side to facilitate the flow of secretions from the mouth to avoid accidental aspiration or suffocation.
3.Unlock the collar and trouser belt to keep the airway open.
4. Do not press the patient’s limbs hard during convulsions to avoid fractures and sprains.
5.Most of the seizures resolve on their own within a few minutes and no special treatment measures are necessary.
6.If breathing is not restored after the convulsions stop, artificial respiration should be given immediately, and if necessary, take to hospital immediately.
Follow-up visit.
Follow-up time.
1. Determine the follow-up interval according to the specific conditions of the patient.
2. The follow-up interval should be shortened if the condition is serious or unstable.
3. If the seizures are completely controlled or significantly reduced, the follow-up interval is usually once every 3-6 months.
4. Postoperative patients should be followed up once every 3 months, 6 months and 12 months after surgery. After stabilization, the patient should be followed up once every six months or once a year.
Contents of follow-up visit
1.Patients’ general condition and compliance with medication.
2. Frequency, form, and severity of seizures.
3. Any adverse drug reactions.
4, laboratory tests: some drugs need to monitor blood routine, liver and kidney function, etc.
5.Electroencephalogram must be checked to understand the abnormal wave changes of EEG.
6.Patient’s psychosocial condition.
7.Children’s growth and development.
8.Female patients’ contraception and pregnancy.
9.Older patients combined with other diseases and medication.
Gradual reduction and discontinuation of medication.
1.It should be decided according to the type of seizures, previous seizures, the presence of persistent intracranial lesions and EEG abnormalities, and the possibility of re-seizures.
2. Generally, primary epilepsy patients with complete control for 2-5 years and normal EEG before considering discontinuation of medication.
3.After no seizure, EEG still has abnormalities, multiple seizure forms, obvious neuroimaging abnormalities and neurological deficits, the recurrence rate is significantly higher after discontinuation of medication, and the duration of medication should be extended.
4.Discontinuation of medication should be gradually reduced, mostly within a few months, and some patients need more than 1 year.
If the seizures recur during the drug reduction process, stop withdrawing the drug and restore the drug dose to the pre-dose reduction level.
6. For some epilepsies, some patients have difficulty stopping the medication and may need to take it for life.
Epilepsy surgical treatment: To be evaluated and operated at a professional, qualified epilepsy surgery
Surgical indications.
1. Drug-refractory epilepsy.
2.Surgically treatable secondary epilepsy, such as intracranial occupying lesions.
3. Certain special types of epilepsy syndromes, such as hippocampal sclerosis and medial temporal lobe epilepsy.
4. The epileptogenic focus is clearly localized and does not overlap with important functional areas in the brain.
Surgical modalities: mainly include: radical resection and palliative surgery.