Overview.
A group of epileptic syndromes originating in the frontal lobe
Seizures are complex and varied, short in duration, and commonly occur at night, such as involuntary twitching of the head, face, and limbs, large-scale dancing of the limbs, accompanied by strange noises.
The onset of epilepsy is related to heredity, cortical dysplasia, traumatic brain injury, cerebrovascular disease, intracranial tumors, and infections.
Comprehensive treatment with drugs, surgery, etc.
Definition
Frontal lobe epilepsy refers to a group of epilepsy syndromes in which the lesion originates in the frontal lobe, which is a type of focal epilepsy.
The frontal lobe is a high-level part of the developing brain, and its function is related to somatic movement, verbal expression, attention, emotion, and mental activity.
Frontal lobe epilepsy is commonly seen in children, and because of its diverse clinical features and low EEG detection rate, it poses great difficulty in confirming clinical diagnosis.
Classification
According to the etiology, it can be divided into primary and secondary.
Primary frontal lobe epilepsy: genetically related.
Secondary frontal lobe epilepsy: generally caused by acquired infection, trauma, lesions and other factors.
Incidence
There are about 9 million or more epilepsy patients in China, and about 5 to 7 out of every 1,000 people suffer from epilepsy.
Frontal lobe epilepsy is the second most common type of focal epilepsy, accounting for about 25% of all focal epilepsies.
Primary frontal lobe epilepsy is common in children.
Etiology
Causes
Primary frontal lobe epilepsy
Genetic factors
Autosomal dominant nocturnal frontal lobe epilepsy, also known as sleep-related hyperkinetic epilepsy.
It is a genetically related disorder that begins in childhood or adolescence.
Cerebral cortical dysplasia
Some congenital disorders of brain development that involve the frontal lobe can cause frontal lobe epilepsy, which may be accompanied by mental retardation and behavioral abnormalities in some patients.
For example, focal cortical dysplasia, hemispheric megalencephaly, etc.
Secondary frontal lobe epilepsy
Including traumatic brain injury, cerebrovascular disease, intracranial infection, intracranial tumor and other diseases.
Frontal lobe epilepsy may also be caused if the site of injury or lesion involves the frontal lobe.
Commonly, such as cerebral contusion, cerebral hemorrhage, encephalitis, glioma and so on.
Who is at risk?
People with the following conditions are prone to frontal lobe epilepsy.
Have congenital or born with structural brain abnormalities, brain injuries.
Have seizures in infancy or early childhood.
Have motor or intellectual developmental disorders.
Have epilepsy in the family.
Have a history of brain injury, cerebrovascular disease, intracranial infections and tumors.
Symptoms
Main Symptoms
The presentation of frontal lobe seizures depends on the site of frontal lobe involvement.
Seizures are usually focal and come in a variety of forms.
Recurrent, sudden, brief (<30 seconds), nocturnal seizures are the main features.
Aura
Dizziness, nervousness, abnormal thinking, and fear may occur.
Speech disorders, limb tightness, etc.
Focal clonic seizure
Involuntary rapid twitching of one side of head and face muscles and limbs.
No consciousness disorder.
Postural tonus
Uplifting of both upper limbs, which may or may not be symmetrical, and tonic extension of the lower limbs may occur.
Obstruction of consciousness may not be obvious.
Excessive movement
Frenzied movements of the limbs of large amplitude, with sudden onset and abrupt discontinuation, accompanied by abnormal vocalizations and shouting.
Consciousness is not clear during the seizure, but can be restored more quickly after the seizure.
Deflective Ankylosis
It is characterized by deflection of both eyes or head to one side, or both of them at the same time.
In severe cases, it is accompanied by rotation of the body to one side.
Loss-of-consciousness seizure
Sudden onset of staring, speech and movement stop.
If it occurs during sleep, it is characterized by a sudden eye-opening gaze that lasts for a short time before falling asleep.
Vocal and speech disorders
Crying and moaning sounds may occur.
Difficulty in speech, suspension of speech, etc.
Complications
Falls and injuries
Falls and injuries are often caused by sudden convulsions of the limbs and impaired consciousness.
Traumatic brain injury, limb fracture, mouth and tongue bite may occur.
Anxiety and depression
Repeated seizures cause obstacles to life and socialization.
It is characterized by irritability, low mood, depression and lack of interest in anything.
Persistent status epilepticus
Seizures lasting for more than 5 minutes uninterruptedly or briefly interrupted to reoccur with no return of consciousness during the seizure.
It is characterized by persistent generalized convulsions, violent clonus, and apnea, which can lead to sudden death in severe cases.
Cognitive impairment
It is related to factors such as hypoxia of brain cells, cerebral edema, dysfunction of brain network, and emotional depression caused by persistent or frequent seizures.
Children show learning difficulties and poor intellectual and linguistic development, and adults often show memory loss, slow thinking, unfavorable speech and reduced life skills.
Consultation
Department of Medicine
Neurology
Patients with symptoms such as staring at the eyes, involuntary twitching of the head, face and limbs, stopping of speech, exaggerated movements, and strange voices during seizures should consult a doctor promptly after the seizure stops.
Emergency Medicine
If the patient’s symptoms such as stiffness and twitching of limbs, involuntary movements, etc. cannot be relieved for more than 5 minutes, please call 120 and consult the Emergency Department promptly.
Preparation for medical treatment
Preparing for medical treatment: registration, preparation of documents, and common problems.
Tips for medical treatment
If you have a record of the time, symptoms, state of consciousness, and medications you take during a seizure, please bring it with you and inform the doctor.
Family members are recommended to accompany the patient to help describe the medical history, and avoid driving or riding to the clinic on your own.
Preparation Checklist
Symptom list
Particular attention should be paid to the time of onset of symptoms, special manifestations, etc.
Are there any symptoms such as seizure premonition, eye gaze, limb twitching, exaggerated movements, loss of consciousness, etc.?
Are there any symptoms such as abnormal sensations in the limbs, speech difficulties, emotional instability, etc.?
Are there any symptoms such as strange movements and sounds?
Are there any symptoms such as swallowing, salivation, chewing, panic attacks, etc.?
Do the above symptoms occur frequently?
Do the above symptoms occur briefly and then disappear, or are they persistent?
Medical History Checklist
Is there a family history of people with epilepsy or similar symptoms?
Are there any congenital or hereditary disorders such as neonatal ischemic-hypoxic encephalopathy, hemizygous megalencephaly, or inherited metabolic disorders?
Is there a history of craniocerebral trauma, intracranial tumors, cerebral hemorrhage, cerebral infarction, intracranial infection?
Checklist
Test results in the last six months, which can be brought to the doctor’s office
Laboratory tests: liver function, kidney function, blood routine, blood drug concentration, blood sugar, urine routine, etc.
Electrophysiologic examination: electroencephalogram
Imaging examination: cranial MRI, cranial CT, 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: phenobarbital, phenytoin sodium, carbamazepine, valproic acid, oxcarbazepine, levetiracetam, lamotrigine, etc.
Diagnosis
Diagnosis is based on
Medical history
There is a family history of epilepsy.
There are congenital or hereditary disorders such as neonatal ischemic-hypoxic encephalopathy, hemimegalencephaly, and focal cortical dysplasia.
History of craniocerebral trauma, intracranial tumor, cerebral hemorrhage, cerebral infarction, and intracranial infection.
Clinical features
There are symptoms such as binocular gaze, involuntary convulsions of the head, face and limbs, speech suspension, exaggerated movements, strange voice, and twitching of the limbs.
Seizure symptoms are characterized by suddenness, transient, repetitive and stereotyped.
Examination
Laboratory tests
Objective: To find and identify the causes of seizures and to monitor the adverse effects of drugs.
Common items: blood routine, liver and kidney function, blood glucose, electrolytes, blood drug concentration.
Precautions
Fasting is required.
Do not take medication before blood collection for blood concentration test, and take additional medication as required by the doctor after blood collection.
Cranial CT / Magnetic Resonance Imaging (MRI)
Purpose of examination: To detect structural abnormalities in the brain, which is conducive to clarifying the cause of epilepsy and localization of the lesions.
Examination results: It can find cerebral cortical dysplasia, intracerebral hemorrhage, ischemic foci, intracranial occupations and other lesions.
Precautions
CT examination has certain radiation, and is not suitable for infants, children and pregnant women.
Metal objects should be removed from the body before the MRI examination, and those who have metal implants or pacemakers in their bodies should consult their physicians to confirm whether the examination can be performed.
Functional Magnetic Resonance Imaging
Purpose of the examination: to assist in locating important functional areas, especially for patients whose epileptic foci are close to important functional areas such as speech and movement, and to guide surgery.
Results of the examination: Interpretation by a doctor is required.
Precautions: During the examination, it is necessary to cooperate with the doctor’s command to complete the task, and the rest is the same as ordinary cranial MRI.
Conventional EEG/Video EEG
Purpose: To confirm the diagnosis of epileptic seizures and the type of seizures.
Results: Episodic or paroxysmal epileptic waves (spikes, sharp waves, spikes and slow waves, sharp and slow waves, etc.) can be detected in the frontal lobe and other brain regions.
Precautions
Video EEG is of higher value than conventional EEG.
Discontinue medications, such as sedatives, anti-epileptic drugs, etc., according to the doctor’s request before the examination.
Clean your head before the examination, avoid using hair gel, head oil, etc.
Avoid wearing clothes made of nylon, so as not to cause static electricity to interfere with the examination.
Intracranial EEG
Purpose: It is the gold standard for localizing epileptic foci by surgically placing electrodes inside the skull.
Applicable people: Epileptic foci cannot be detected by conventional means, or important functional areas exist near the epileptic foci.
Cautions
It is an invasive test and carries certain risks.
It may lead to subdural and intracerebral hemorrhage, epileptic persistence, cerebral edema, etc.
Genetic testing
Purpose: If the onset of the disease is considered to be related to genetic factors, genetic testing needs to be improved, if there is a family history of autosomal nocturnal frontal lobe epilepsy.
Significance: Define the hereditary characteristics, and based on the type of mutation can guide the use of medication, assess the prognosis, and assess the possibility of passing the mutation to the offspring, guiding eugenics.
Caveat: Not used as a routine etiologic screen; usually performed when there is a high degree of suspicion for a disease.
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.
Commonly used methods: Montreal Cognitive Assessment Scale (MoCA), Brief Mental Status Examination (MMSE).
Assessment content: intelligence, language, cognition, emotion, behavior, quality of life and social functioning.
Differential Diagnosis
Syncope
Similarity: Both may have sudden and short-lived loss of consciousness, which can be recovered on its own.
Differences
Syncope often occurs under stressful situations and has obvious aura, such as dizziness, pallor, and lowered blood pressure, etc. The electroencephalogram (EEG) is usually not abnormal during the attack.
Electroencephalogram (EEG) is usually not abnormal during the attack, and EKG examination may reveal cardiac problems such as arrhythmia.
Sleep disorders
Similarities: Both have symptoms such as movement and consciousness disorders occurring during sleep.
Differences
Sleep disorders may include sleepwalking, nightmares, moaning, and violent rolling. Nightmares are often accompanied by pallor, sweating, dilated pupils, and panic, and episodes usually last from 0.5 to 30 minutes.
Cranial MRI is usually free of structural abnormalities.
Pediatric night terrors
Similarity: both have symptoms such as sudden onset of convulsions, crying and shrieking at night.
Differences
Pediatric night terrors are often characterized by restless sleep, easy awakening, crying, accompanied by excessive sweating and occipital baldness.
There is no structural abnormality in cranial MRI and no typical abnormal brain waves in EEG.
Tourette syndrome
Similarities: both may have facial and limb tics.
Differences
Tourette’s syndrome is common in male children. Involuntary tics of the head, face, and limbs occur with clear consciousness, and may produce explosive sounds and obscene language (profanity), which can be controlled or alleviated by distracting the child.
There are no corresponding abnormal brain waves on the electroencephalogram (EEG) during an attack.
Treatment
Aim of treatment: to control seizures, reduce recurrence rate, prevent complications and improve quality of life.
Treatment principle: Drug treatment is the mainstay, and some patients with refractory epilepsy can undergo surgical treatment.
Emergency treatment for seizures
Frontal lobe epilepsy can develop into generalized seizure and epileptic status quo.
First of all, immediately let the patient lie down in a safe and stable site to avoid falling and hurting.
Unbutton the collar and coat, tilt the head to one side, and keep the airway open.
Quickly clear foreign objects from the mouth to prevent choking.
Do not stuff anything into the patient’s mouth and do not force-feed food or drugs.
If the patient’s limbs are convulsing violently, do not press or move them to avoid fractures and sprains.
Do not rush to move the patient after convulsions, and let him/her rest appropriately until he/she recovers consciousness.
Antiepileptic drugs
Antiepileptic drugs can reduce neuronal excitability and control seizures.
Drug selection
The type of drug can be chosen according to the patient’s age and seizure type.
Seizure type Class A drug Class B drug Class C drug
Adult partial seizures Carbamazepine, phenytoin sodium valproate gabapentin, lamotrigine, oxcarbazepine, phenobarbital, topiramate, aminocaproic acid
Adult partial seizures
Carbamazepine, phenytoin sodium
Sodium valproate
Gabapentin, lamotrigine, oxcarbazepine, phenobarbital, topiramate, aminocaproic acid
Partial seizures in children Oxcarbazepine/carbamazepine, phenobarbital, phenytoin sodium, topiramate, sodium valproate
Partial seizures in children
Oxcarbazepine
/
Carbamazepine, phenobarbital, phenytoin sodium, topiramate, sodium valproate
Geriatric partial seizures Gabapentin, Lamotrigine / Carbamazepine
Partial seizures in the elderly
Gabapentin, Lamotrigine
/
Carbamazepine
Adult generalized tonic-clonic seizures // Carbamazepine, Lamotrigine, Oxcarbazepine, Phenobarbital, Phenytoin Sodium, Topiramate, Sodium Valproate
Adult generalized tonic-clonic seizures
/
/
Carbamazepine, Lamotrigine, Oxcarbazepine, Phenobarbital, Phenytoin Sodium, Topiramate, Sodium Valproate
Generalized tonic-clonic seizures in children // Carbamazepine, phenobarbital, phenytoin sodium, topiramate, sodium valproate
Generalized tonic-clonic seizures in children
/
/
Carbamazepine, phenobarbital, phenytoin sodium, topiramate, sodium valproate
Childhood apoplectic seizures // ethosuximide, lamotrigine, sodium valproate
Childhood apoplectic seizures
/ /
/
Ethosuximide, Lamotrigine, Sodium valproate
Principles of drug use
Different types of epilepsy will have corresponding first-line therapeutic drugs.
Usually, one of the drugs (preferred class A) is chosen first and used in full dosage and for a full course of treatment.
If the first drug is not effective, another drug from the first-line drugs can be used alone or in combination.
When the first-line drug is not effective or is not tolerated, other drugs may be added.
Precautions.
Adverse reactions such as cardiac arrhythmia, AV block, bone marrow suppression, hepatic or renal impairment, hyponatremia, and rash may occur during administration.
During the use of the drug should strictly follow the doctor’s requirements, on time, according to the amount of regular take, not unauthorized stop, reduce or change the drug.
Some antiepileptic drugs have teratogenic effect, women need to adjust the antiepileptic drugs under the guidance of the doctor before or during pregnancy.
Surgery
Indications: unresponsive to medication, clear seizure type.
Surgery: resective surgery, blocking surgery, destructive surgery, neuromodulation surgery.
Focal resective surgery: resection of epileptic foci or related cerebral cortex.
Obstructive surgery: blocking the propagation path of epileptic abnormal discharges, thus reducing the frequency of seizures, e.g. corpus callosotomy, multiple subchondral transection, etc.
Destructive surgery: precise destruction of epileptic foci that are deeper in location or located in functional areas through stereotactic.
Neuromodulation surgery: common vagus nerve stimulation, deep brain electrical stimulation, through minimally invasive techniques to regulate the functional state of the brain, improve the abnormal discharges of neurons in the brain, and reduce seizures.
Cautions: intracranial hemorrhage, infection, local neurological deficits may occur after surgery.
Dietary treatment
Ketogenic diet is to induce the production of ketone bodies in the body and inhibit seizures by increasing the proportion of fat energy in food. It can be used for patients who have difficulty controlling their condition with medication, especially for pediatric patients, and the common patterns are as follows:
A very small amount of carbohydrates (e.g., staple foods such as rice, noodles, etc.), 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 strictly followed by doctors and dietitians, and should not be used without authorization to avoid serious adverse reactions.
Cutting-edge treatment
In the future, we will look for molecular targets for epileptogenesis for precise treatment, starting from the causative gene mutation of epilepsy, autoimmunity, neuroinflammatory cascade activation, and brain-gut-microbe axis regulation.
Pyngabine, which has been approved to enter clinical research, is expected to be the first new anti-epileptic drug with independent property rights in China.
Everolimus, has been approved for use in focal epilepsy associated with tuberous sclerosis.
Prognosis
Cure
Most of them have good prognosis after reasonable standardized antiepileptic drug treatment.
A subset of patients treated with rational drug combinations continue to have frequent seizures and eventually become medically refractory to treatment.
Surgical treatment has a favorable prognosis in about 50% of patients.
Prognostic factors
Patients with the following conditions may have a poor prognosis
Long duration of the disease.
Frequent and severe seizures.
Structural abnormalities in functional areas of the brain on cranial magnetic resonance imaging (MRI).
Young age at first seizure.
Hazardous
Sudden appearance of limb twitching, consciousness disorder, dizziness and other symptoms, prone to accidental injuries, such as falls, burns, traffic accidents and so on.
Repeated and frequent seizures seriously affect daily life and work, and bring heavy burden to society and family.
Long-term recurrent seizures are prone to depression, anxiety and even suicidal tendencies.
Daily
Daily Management
Diet management
In addition to the ketogenic diet, daily diet is recommended to follow the following principles.
Daily diet should be light, avoid overfilling and overstuffing, overcooling and overheating, avoiding tobacco, alcohol, strong tea, strong coffee as well as spicy and stimulating food.
Increase the daily intake of vegetables and fruits to ensure the supply of dietary fiber, calcium, potassium and vitamins.