Aetiology and pathogeny....... 292
Pathological anatomy..... 293
Clinical picture....... 295
Children have 303 Features of epilepsy...303
Epilepsy (epilepsia; Greek epilepsia skhvatyvaniye, epilepsy; synonym: morbus sacer, morbus divinus, epilepsy) — the chronic, polyetiological disease which is characterized by repeated convulsive and (or) psychopathological paroxysms and is frequent change of the personality.
For a long time E. divided on idiopathic (genuinical) and symptomatic. It was meant that at idiopathic E. explicit organic lesion of a brain is absent; the concept «symptomatic epilepsy» provided developing of epileptic seizures at various organic diseases of c. N of page. However in connection with further studying E. as separate nozol. forms, and also implementation of new perfect diagnostic methods number of forms E. the obscure nature gradually decreased, and need for the terms «genuinical epilepsy», «idiopathic epilepsy», «symptomatic epilepsy» practically disappeared. S. N. Davidenkov in 1960 suggested to refuse these concepts as deprived of any sense. Besides the concept «idiopathic epilepsy» distracts attention of doctors from careful search of etiologies that interferes with timely purpose pathogenetic of reasonable treatment. In the terminological dictionary on epilepsy (1975) such concepts as «idiopathic epilepsy» and «genuinical epilepsy», admit outdated and unsuitable for the use. As for the concept «symptomatic epilepsy», without instruction nozol. forms, I will accompany given epileptic seizures, it does not make any sense. Nek-ry researchers in case of epileptic attacks of the obscure etiology suggest to use the term «epileptic syndrome».
History. AA. it was known for many centuries B.C. In Hippocrates's compositions it under the name «sacred disease» was considered as the disease of a brain caused by various reasons. Ibn-Xing in detail described a wedge, a picture and treatment of epilepsy. V17i18vv. AA. it was described in works to G. Burkhava and S. A. Tissot. Modern studying E. began with a research of L. F. Bravais who described her focal (localization) forms in 1827. J. Jackson believed that unilateral spasms at E. are caused by irritation of certain crinkles of a cerebral cortex (see Hyperkinesias). Generalized
attacks a number of researchers, e.g. Kussmaul and Tenner (A. Kussmaul,
A. Tenner, 1859), explained with irritation of «the convulsive center» of a myelencephalon. A. Ya. Kozhevnikov in 1894 described a special form E., called around the world kozhevni-kovsky epilepsy (see). Big contribution to studying E. brought experimental and clinical works
of B. M. Bekhtereva. Studying in experimental conditions a metabolism at epilepsy, I. P. Pavlov and M. V. Nentsky connected developing of epileptic seizures with accumulation in an organism carbamic to - you. In the USSR a big contribution to studying E. also N. I. Gra-shchenkov, M. Ya. Sereysky, P. M. Sa-radzhishvili, A. D. Speransky, etc. brought.
Statistics. Epilepsy — the widespread disease which is observed worldwide. According to the data provided by A.S. Efros (1936) in Germany number of patients E. equally 2,9%0, in Italy — 1,15%0, in England — from 0,3 to 6,49%0, in Sweden — 5%0. According to JI. A. Prozorova (1936), incidence E. in Moscow made 3 — 4%0. V. V. Braylovsky and A. I. Volfov-sky defined that number of patients E. in one of the districts of Ukraine makes 1,9%0 with fluctuations for various places from 0,3 to 6,2%0. In the Georgian SSR among isolates (e.g., in the Estonian village) E. makes 1,39%0, and sick men twice more, than sick women. According to S. N. Davidenkov, frequency E. among parents and children of patients makes 4,9%. According to Lennox (W. G. Lennox), transfer E. to children takes place in 2,5% of cases. In psychiatric-tsakh patients E. make 8,7 — 10%.
Much more often E. meets at children's and youthful age (patients at this age make about 47 — 68% of total number of patients E.).
Etiology and pathogeny. Most of researchers consider what is inherited itself E., and only certain degree of convulsive readiness, predisposition, edge can lead to developing of epileptic seizures under the influence of various external and internal factors. Results of kli-niko-electrophysiologic, radiographic and tomographic researches showed that for development E. as diseases with a progreduated current existence of the stable center of epileptic activity caused by organic lesion of a brain is necessary.
The reasons of cerebral pathology at E. there can be inborn malformations, diseases of mother during pregnancy causing a hypoxia of a fruit (toxicosis of pregnant women, inf. diseases, hron. a heart disease and lungs), a Rhesus factor-konf-liktnaya pregnancy (see the Rhesus factor), birth trauma, asphyxia in labor, post-natal neuroinfections, neurotoxicoses.
Among numerous patol. the processes causing development
E., it is necessary to allocate the processes proceeding with formation of a hem between a brain and its covers. AA. it can be observed also at disturbances of cerebral circulation, vascular displaziya, primary and metastatic tumors of a brain, craniocereberal injuries, effects of neurosurgical operations. The tumors which are followed by development E. (most often gliomas), are localized preferential in the field of a lateral (silviyevy) furrow of a brain, in the central crinkles, back departments of frontal lobes, is more rare in parietal areas - and sites of occipital shares, adjacent to them, is even more rare in a brain trunk.
A certain role in studying of mechanisms of convulsive attacks at E. played their modeling — so-called experimental epilepsy. So, in 1870 Gittsig and Frich (E. Hitzig, G. Th. Fritsch) in an experiment, irritating a cerebral cortex with a galvanic current, received convulsive reduction of muscles. Ferrier (N. Ferrier, 1873) for this purpose used faradic current. Batelli (M. of Batelli, 1903) tested a method of the electroshock caused by transcranial stimulation for animals to-ry in the subsequent Cherletti and Bini (U. Seg-letti, L. Bini, 1938) used for treatment mentally sick (see. Electroconvulsive therapy). J. And the mante in 1913 was developed by essentially new method experimental E. — so-called reflex epilepsy. Irritating with strychnine nek-ry motor zones of a cerebral cortex and at the same time stimulating the respective reflex areas of leather of an animal, it caused the clonic reductions passing sometimes into generalized. Clementia (A. Clementi, 1929) was offered by a method of irritation of various sense bodys with preliminary administration of strychnine in the corresponding zones of bark. D. Da-niyelopolu (1933), having applied the principle of Amantea, showed that after application of strychnine on a motive zone of bark, the irritation it can cause an epileptic seizure. Openkhovski (Th. Openchowski, 1883) and A. D. Speransky (1935) observed developing of epileptic seizures during the freezing of the limited site of a cerebral cortex. Convulsive attacks in an experiment cause also by an injection of the substances causing spasms (e.g., Corazolum, strychnine). Morgan (S. T. of Morgan, 1939) described so-called audiogene E. with toniko-clonic spasms and the subsequent coma, provoked by sounds of high frequency.
Goddard (G. Goddard, 1967) showed that repeated stimulation of various formations of limbic system (see) and especially amygdaloid complex, leads to progressive reduction of the threshold of spasms. Electric irritations cause electrographic and behavioural sdvyg in the beginning, then there are also spasms in process of repetition of irritation passing into generalized convulsive attacks. This phenomenon received the name «swing».
Since I. P. Pavlov's works the mechanism of a convulsive attack is connected with excitement of a subcortex against the background of braking of cortical structures. A considerable stage in studying of a pathogeny E. U. Penfild and G.'s concept of Jasper (1954) about «tsentrentsefalichesky system» of a brain as to the initial structure causing emergence and spread of generalized and small convulsive attacks, and also nek-ry avtomatizm was. The concept was not accepted by all researchers. In 1965 Mr. of J. Bancaud with sotr. established that in development of generalized attacks bark of a frontal lobe is important. In Ottino's researches (Page A. Ottino) with sotr. (1971) formation of the bilateral cortical centers of convulsive activity in sigmoid crinkles was carried out.
Various researchers E. in the presence of primary epileptic center allocate three ways of distribution of convulsive activity: on cortical neural complexes; through systems of a corpus collosum and other komissuralny fibers, and also through a reticular formation of the brain trunk connected with cerebellar system; through tsentrentsefalichesky system of a brain. And the leading role in distribution of convulsive activity is assigned to preferential retikulokortikalny reciprocal ways.
At long existence of convulsive activity in primary epileptic center in one or several sites of a brain there can be secondary centers of convulsive activity, sometimes in the beginning — in the symmetric site of bark of other hemisphere — the so-called mirror center. Formation of the secondary center takes place a stage of the dependent projective center, to-ry further can pass into a stage of the independent center, activity of the last does not fade even at the termination of convulsive activity of primary center. At the person formation of such secondary center occurs in several years after developing of a disease. Formation of secondary, tertiary and other centers of convulsive activity speaks about progreduated disease. Due to implementation of neurosurgical methods of treatment
E., and also with development of modern methods of a research there was an opportunity to specify localization of the damages of a brain causing emergence of these or those displays of an epileptic seizure, including and mental disorders. So, U. Penfilda and G. Dzhasper managed to be called during neurosurgical interventions in patients hallucinatory or illusory states by irritation of various points with temporal and partially parietal lobe.
The mechanism of the termination of convulsive categories (self-stopping) can be presented in several options. Also. Dyusser de Barenn with sotr. (1941) revealed brake properties of the cortical field 4S, a cut carries out braking through a kernel having a tail. A phenomenon of suppression of activity of cortical structures also nek-ry areas of bark, the located kpered from the central crinkle, in nek-ry points of parietal and occipital areas, forefront of an island and pole of a temporal share, and also amygdaloid yyr have. J. Moruzzi (1950) in experimental conditions proved an inhibitory role of the wedge-shaped kernel which is under the influence of a peripheral impulsation of a carotid sine. Brake properties of caudal structures of a va-roliyev of the bridge are shown. V. M. Okudzhava in in 1969 with the help morfofiziol. researches specified localization of these brake structures in a caudal reticular kernel of the bridge. Fiziol. mechanisms of the termination of epileptic activity were in detail investigated in experiments with intracellular and extracellular recording of bioelectric activity of cortical neurons. At the same time it was shown that one of the main mechanisms of the termination of convulsive activity is long hyperpolarization of neurons of a cerebral cortex.
In a crust, time in emergence E. the role of such endogenous substances as amino acids (asparaginic and glutaminic, glycine, taurine, etc.), polypeptides (substance P), monoamines (adrenaline, a hole a drain of a lean, dopamine, serotonin), acetylcholine, etc., carrying out mediator functions of various character is established. So, glycine and taurine perform brake function, and acetylcholine and glutaminic to - that is exciting. By pilot studies it is established that in the epileptic center balance upset between the exciting and braking mediators is observed. The same imbalance of mediators is found in cerebrospinal liquid, in blood and urine. In the interepileptic period at one patients decrease in excretion of adrenaline, noradrenaline, DOFA, dopamine and
5-oxyindolacetum to - you, at others — increase in their excretion is noted. At a number of patients considerable decrease in content of serotonin in blood and cerebrospinal liquid is observed. During an attack of such changes it is not revealed. Upon termination of a convulsive attack the content of monoamines in blood and urine increases in nek-ry cases. Perhaps, these shifts reflect the mechanism of the active termination of a convulsive attack.
A pathogeny of overwhelming number of psychopathological frustration at E. it is unknown. There are separate facts testimonial
of the fact that in genesis of initially arising crazy psychoses a part is played also by a genetic factor.
Pathological anatomy. Patol. the changes of a brain and other bodies and systems developing at E., are quite various. In the analysis of each case E. it is necessary to differentiate first of all morfol. the changes of a brain which caused development E., what is not always possible, and the changes caused most E. In the analysis of cases E., development a cut is caused by organic changes of a brain, it is necessary to consider that it is long proceeding E. also leads to sharply expressed changes of a brain and other bodies therefore it is not always possible to define what changes were the reason of development E. and what are its effects.
The main morfol. the changes developing in a brain at
E., are caused by convulsive attacks. During spasms neurons as much as possible spend energy that leads to strengthening of oxidizing processes in cells of a brain. As a result of it the relative hypoxia of a brain which is unevenly expressed in its different departments develops. The hypoxia of a brain amplifies in process of development of attacks also because the reduced muscles strenuously consume oxygen. The wet brain (see Hypostasis and swelling of a brain) arising at the proceeding generalized spasms increases that is promoted by the increasing pressure in veins of a chest cavity, a cut is transferred to intracranial veins. Owing to hypostasis there is a vklineniye of certain departments of a brain, first of all hooks of crinkles of a hippocampus, in cutting is mashed a cerebellum. Disturbance of vasomotor reactions leads to weakening of a blood-groove in vessels of a microcirculator bed that is registered on the increasing vascular resistance and arterialization of a venous blood. Functional overstrain of neurons, disturbances of microcirculation and hypostasis of various degree of manifestation in different departments of a brain and even within its same anatomic education lead to acute changes of neurons, small vessels and cells of a neuroglia. Its ischemic damage representing a coagulative necrosis of a cell is considered the main change of neuron which is a direct consequence of a hypoxia. Through a nek-swarm time after a convulsive attack there are single or multiple damages of neurons (depending on their sensitivity to a hypoxia and some other factors) at safety of other structural elements of a brain (cells of a neuroglia, vessels, etc.), the necrosis of certain sites of a brain develops incomplete, or elective, (see below). Along with incomplete necroses there are also small heart attacks (the centers of a full necrosis), wet brain of various degree of manifestation, small hemorrhages. At single convulsive attacks of hemorrhage come to light seldom. Further the cytolysis of a не-кротизированных of neurons develops (see the Cytolysis), a neyronofagiya (see), the satellitosis, a hypertrophy and proliferation of astrocytes, appear rod forms of a microglia. On site separate nekrotizirovanny neurons there are glial small knots, in the field of sites of an incomplete necrosis the isomorphic or anizomorfny gliosis develops. As a result of the organization of the centers of a full necrosis small gliomezoder-malny hems with cysts of various form or without them form, on site hemorrhages there are macrophages containing hemosiderin. All these morfol. changes gradually, after numerous attacks, lead to reduction of volume of certain (predilektsionny) areas of a brain (see below) and to their consolidation. After repeatedly repeating spasms and death of a large number of neurons so expressed gliosis (see) develops that the superficial boundary glial membrane of convolutions of the brain is considerably thickened, the surface of crinkles becomes similar to pebble-leather. Consolidation and wrinkling of crinkles of temporal area — a so-called ulegiriya is especially sharply expressed (Greek ule a hem + lat. gyrus crinkle). Also sharp thickening of perichorioid and vokrugzheludochkovy boundary glial membranes is observed. It is supposed that these changes are connected not only with death of neurons, but also with mechanical factors — frequent paroxysmal changes of volume of a brain, at to-rykh glial membranes are exposed to temporary stretching. Also proliferation of cells of outside and average covers of int-tratserebralny vessels and, more rare, their endotheliocytes is explained by influence of the same factors that, apparently, is caused also by influence of a hypoxia. Also web and soft covers of a brain, especially around vessels are exposed to a thickening. In nek-ry cases shvartoobrazny thickenings and unions of an arachnoid membrane from soft form; the subarachnoid space increases, forming kistoobrazny cavities. It is necessary to consider that these changes can result postponed a pia-arachnitis (see Meningitis) and a cherepnomozgovy injury as before development
E., and during it. Reduction of the weight (weight) of a brain, expansion of a subarachnoid space and ventricles is characteristic for E., proceeding with numerous convulsive attacks, however in most cases at E. the weight of a brain is reduced slightly or happens within norm. In cases E., proceeding without convulsive attacks or with their small number, the weight of a brain can be increased.
The most expressed changes caused by convulsive attacks develop in an ammonovy horn, is preferential in Zommer's sector — the site of bark, shaped the arch turned by a convex part towards the lower horn of a side ventricle. Sharply expressed isomorphic gliosis of crinkles of a hippocampus developing at E. and being an essential element patoarkhitektonik of epilepsy (see Patoarkhitektonik), gave a reason for wrong judgment
of it as about the reason of development E earlier. Ischemic changes of neurons with the subsequent their loss and a gliosis are observed also in bark of other departments of parencephalons, preferential near vessels; in a gear kernel and bark of a cerebellum, in a cut first of all pear-shaped neurons (Purkinye's cell), and then neurocytes grains, star-shaped and spindle-shaped neurocytes (Golgi's cells) perish; in lateral and dorsomedial departments of a thalamus; in a striate body, most often in a head of a kernel having a tail and in a shell of a lenticular kernel near a front leg of the internal capsule; in average departments of the lower olive kernel of a myelencephalon. The listed departments of a brain are pre-dilecture for E. zones, i.e. zones, in to-rykh most often and first of all changes, characteristic of this disease, develop. The same changes can be observed also in other formations of a brain. Their localization in each separate case depends also on weight E., from diseases and patol. the states which caused it from a combination E. with other diseases and some other factors, to-rye it is necessary to analyze in each case taking into account a wedge, data. The death toll of neurons and expressiveness of the subsequent gliosis, and also other changes of a brain does not correlate with quantity and the nature of convulsive attacks though judgment of weight E. quite often is based on these morfol. symptoms of the postponed attacks.
By means of a submicroscopy it is established that the most common form of pathology of neurons of temporal area of a brain of the person, in a cut localized the epileptogenic centers, the so-called dark neurons characteristic of a hypoxia are. In them strengthening of an osmiofiliya of kernels and cytoplasm, expansion of the perinuclear tank decide on its invagination in a kernel, disturbance of an integrity of a perinuclear membrane, and also sharp expansion of a cytoplasmic reticulum, vacuolation, consolidation of mitochondrions, reduction of number of ribosomes and lysosomes, phagocytosis of these changed neurons cells of a neuroglia. Along with «dark» neurons neurons with the central and peripheral chromatolysis are found (see. A nervous cell), the accumulations of hollow mitochondrions, osmiofilny and osmiofobny inclusions which are, apparently, derivatives of mitochondrions, the reduced quantity trailer, branchings of dendrites and spinules. In synapses increase and deformation of synoptic bubbles, deep invagination of the contacting membranes in cytoplasm of dendrites are observed. In cells of a neuroglia in the epileptogenic centers glikogenovy granules, «dark» lizosomalny bodies and phagocytal vacuoles collect. In capillaries the hypertrophy of organellas and increase in quantity of pi-notsitozny bubbles in cytoplasm of endotheliocytes, a thickening of a basal membrane is observed. With the help immu-nogistol. methods it is established that at convulsive attacks permeability of a blood-brain barrier is broken (see). In crinkles of a hippocampus with characteristic for E. the gliosis found changes of a basal membrane of capillaries, a thickening of a basal membrane of endotheliocytes, in to-rykh the quantity of mitochondrions decreases and the number of dense contacts between endotheliocytes increases. Apparently, reduction of quantity of mitochondrions leads to disturbance of operation of «ionic pump» of endotheliocytes and reduction of potassium ions in sinapso-catfishes.
In a brain of animals, at to-rykh convulsive attacks caused introduction of a bikukullin, L-allilglitsina, kainovy to - you, drawing on a cerebral cortex of aluminum hydroxide, compounds of cobalt, «dark» neurons, expansion of a cytoplasmic reticulum, vacuolation, the hypostasis of neurons extending on dendrites and astrocytes, reduction of number of synapses, a necrosis of neurons and cells of a neuroglia, demyelination of nerve fibrils, a gliosis, hemorrhages, deposits of calcium in mitochondrions of bodies and dendrites of neurons, and also in membranes of lysosomes and cytoplasm of astrocytes are also found.
Nek-ry researchers allocate a special condition of neurons — their «epileptization» defining «convulsive readiness» of a brain. To characteristic morfol. to signs of «epileptization» they refer activation of a large number of aksodend-ritichesky (exciting) synapses. In the centers of convulsive activity changes of internal and outside membranes of mitochondrions, fragmentation and disintegration of cristas, expansion of tanks of a cytoplasmic reticulum and uneven distribution to their surfaces of ribosomal granules are found. At spasms considerable reduction of the synoptic bubbles containing a mediator is noted. In dynamics morfol. changes of a brain at E. nek-ry scientists allocate four phases. In the first phase under the influence of various factors (a birth trauma, malformations of a brain, etc.) forms primary patol. the center, in the area to-rogo the necrosis and dystrophic changes of neurons, a hypertrophy and a hyperplasia of cells of a neuroglia and other processes are observed. In the second phase, in a cut epileptic seizures have preferential focal character, primary epileptic center with characteristic of it Epi-leptizatsiyey of neurons is formed. In the third phase in a brain «epileptic systems» with involvement in patol form. process of a hippocampus (see), an amygdaloid kernel (see area Amigdaloidnaya) and a reticular formation (see) that promotes developing of generalized attacks. In this phase changes of aksodendritichesky synapses not only in primary center, but also in subcrustal and trunk structures of a gomolateralny and contralateral parencephalon are observed. The fourth phase is the phase «epileptization» of a brain. The frequent attacks which are observed in this phase bring to sharply expressed and extended morfol. to the changes of a brain characteristic of E.
Smert of patients E. quite often comes during the epileptic status. During the opening are found a hyperemia of vessels of a brain with cyanosis of its bark, wet brain with strangulyatsionny furrows on a lower surface of hemispheres of a cerebellum and hooks of crinkles of a hippocampus — signs of a vklineniye (see Hypostasis and swelling of a brain), a cut can be followed by development of small or massive secondary hemorrhages in varoliyev the bridge and a mesencephalon. Hemorrhages under covers of a brain and in its substance are possible. Hemorrhages, as a rule, small; at localization in the field of kernels of cranial nerves of a myelencephalon they can be a cause of death of patients. Nek-ry researchers connect disturbances of breath and tongue biting during convulsive attacks with disturbances of a hemodynamics in the field of kernels of hypoglossal and vagus nerves. At the epileptic status death can be caused and by exhaustion of functions of neurons. Single epileptic seizures can cause paralysis of the centers of breath and blood circulation in connection with the heavy epileptic category. At epileptic excitement perhaps acute development of heart failure, a coma, hyperthermia. Heart failure can arise during spasms and as a result of a necrosis in papillary muscles of a myocardium and in front department of an interventricular partition of heart. At the sudden death of patients E. it is necessary to consider that death can be promoted by a hyperostosis of a calvaria. According to nek-ry researchers, the thickness of bones of a calvaria on a cut measured not less than in two places and making 8 mm and more is a sign of a hyperostosis. At the same time owing to the small volume of reserve spaces discrepancy between the volume of a neurocranium and a brain is observed that leads to a vklineniye of its trunk even at small hypostasis or a plethora of vessels. Quite often at the died adult patients E. find a persistent thymus (see), signs hron. insufficiency of bark of adrenal glands. Also the combination of a hyperostosis of a calvaria to a persistent thymus is observed. Death can be promoted also various chronically proceeding patol. the processes in covers of a brain connected with injuries, recurrent wet brain, and also others patol. the processes caused most E. or acquired in its current. These so-called pe-rientsefalny processes strengthen characteristic for E. lability of vegetative functions. On opening quite often find not only multiple small focal necroses of a myocardium, but also hems in it, and also dystrophic changes of a liver, kidneys, ruptures of muscles, injuries of bones of extremities, trunks and skulls, traces of a prelum of peripheral nerves, most often beam, injuries of soft tissues of the head, traces of bites of language, burns. At injuries of the head find contusional injuries of a brain, the majority to-rykh results from antiblow. Are most typical for E. the fresh and organized centers of damage of orbital parts of the lower frontal crinkles and basal sites of temporal shares near their poles arising during the falling on a nape.
Clinical picture. Classification E. it is not developed. In a wedge, practice use the classification of epileptic seizures offered H. Gastaut in 1969, on a cut allocates three groups of epileptic seizures. The first group is presented by primary and generalized and secondary and generalized attacks. Primary and generalized attack call an attack, in a wedge, to a picture to-rogo and according to EEG the focal symptomatology does not come to light. If it is available, then the attack is qualified as secondary and generalized. However considering the fact that the epileptic seizure always has the local center of excitement, nek-ry researchers, e.g. P. M. Saradzhishvili, dispute such division of generalized attacks. The second group is made by focal (partial) attacks. The so-called not classified epileptic seizures enter into the third group. In 1981 WHO offered the following classification of epileptic seizures:
A. The generalized attacks
revealed clinically and electrophysiologically. I. Convulsive generalized: toniko-clonic, tonic, clonic, myoclonic, infantile spasms, epileptic status. II. Small attacks — absentias epileptica; simple absentias epileptica; difficult absentias epileptica: atonic,
akinetic, hyperkinetic, with a clonic component (a myoclonic absentia epileptica), with elementary short-term automatism, vegetative and visceral (enuresis, vasculomotor). III. Polymorphic attacks.
B. Focal (partial) attacks. I. Motive: jacksonian, adversivny, tonic postural, speech (vocalization, stop of the speech), aphotic, myoclonic (kozhevnikovsky) epilepsy. II. Touch attacks: somatosensory, visual, acoustical, olfactory, flavoring (sometimes in combination with the chewing movements), attacks of dizziness.
III. Vegetative and visceral attacks: preferential visceral and general vegetative attacks (so-called diencephalic epilepsy).
IV. Attacks with mental disorders: twilight dull
ny consciousnesses, or twilight consciousness; avtomatizm (psychomotor attacks); attacks of disturbance of perception — elementary illusory attacks, difficult illusory attacks — already seen, already slyshanny, endured or never seen, never slyshanny and never endured; hallucinatory; ideatorny attacks; dysphoric, polymorphic attacks. V. Secondary and generalized attacks.
B. Gemikonvulsivny attacks.
G. Not classified epileptic seizures.
Epilepsy develops in children's more often, is frequent at infantile age. Directly, and long before it spasmophilic, hypoglycemic, or febrile paroxysms (short-term generalized toniko-clonic spasms can sometimes precede its beginning at high temperature at children to 3-year age), nightmares, lunacy; visceral crises (the gripes in a navel which sometimes are followed by abdominal murmur, nausea and defecation at confusion of consciousness, unpleasant feelings in epigastric area).
Data on epileptogenic value of a dream are of interest. The factor provoking the epileptic seizure revealed clinically and elektroentsefalografichesk is the slow phase of a dream while in a bystry phase of a dream convulsive activity usually is suppressed. Depending on a confinedness of attacks to a cycle a dream — wakefulness allocate E. a dream, wakefulnesses and mixed (diffusion).
The generalized convulsive attack of the patient has quite often a presentiment in several hours or even days. At the same time it has a headache, irritability, instability of mood, etc. The general convulsive toniko-clonic attacks with a loss of consciousness quite often begin with a characteristic harbinger, or aura (see). Usually the attack arises from emergence of the tonic spasm (more or less long reduction of muscles) passing into clonic. At the same time the face of the patient is distorted, turned blue, quite often he bites tongue. Sharply expressed vegetative symptoms are noted (tachycardia, increase of breath, a mydriasis, etc.), there is no pupillary test on light. Then there occurs the general relaxation of muscles, but consciousness remains broken, then there comes the dream of different duration. The attack proceeds of several minutes before half an hour, with the subsequent amnesia. At children the attack can be limited to tonic, clonic or myoclonic spasms (see Spasms).
Approximately in 2 — 3% of cases E. the epileptic status is noted, to-ry develops suddenly and is characterized by emergence of a series of attacks (their frequency can be more than 5 — 6 in an hour), in intervals between to-rymi consciousness completely is not recovered. They quite often are followed by a hyperthermia (in nek-rykh cases temperature increases to 40 ° above). In hard cases the convulsive attack is characterized by quickly occurring myoclonic reduction; at the same time tendinous and periosteal reflexes are suppressed.
Carry also small attacks, or the absentias epileptica which are characterized short-term to generalized attacks (within several seconds) a loss of consciousness. These attacks can sometimes repeat with a frequency of 100 and more once a day. At typical simple absentias epileptica of the patient interrupts the begun speech or any action; at the same time it is pale, the look which stiffened, eyeballs are taken quite often away up, there are several scarcely noticeable blink movements. Quite often during a simple absentia epileptica patients continue the same actions, as to it (automatically take several steps if they went before an attack, or mark time). During simple absentias epileptica the vegetative and visceral frustration which are shown easing or a short apnoea, sharp bradycardia can be also observed it is frequent expansion of pupils, etc. The termination of an attack comes also suddenly, as well as began it, without being followed by an indisposition or devocalization.
Difficult absentias epileptica include various forms of attacks: an atony
chesky (sharp decrease in a muscle tone), akinetic (an obezdvizhennost without atony), hyperkinetic (the involuntary excessive movements, twitchings), myoclonic (short-term reduction of one or several muscles more often causing the movements), etc.
Both simple, and difficult absentias epileptica are considered typical if they are characterized at an elektroen-tsefalografichesky research by emergence of a complex of categories (the 3rd peak wave in 1 sec.). At changes on EEG in the form of acute and slow waves, multiple peak waves absentias epileptica are considered as atypical. Option of an absentia epileptica is the syndrome of Lennox — of Gasto, at Krom at mentally retarded children on EEG are noted two peak wave in 1 sec.
In some cases there can be polymorphic attacks — a simultaneous or consecutive combination of different types of attacks.
At a careful nevrol. a research at patients E. sometimes it is possible to find a wedge, signs of organic lesion: anizoreflek
this, Babinsky's symptom, Rossoli-mo, etc. Nek-ry researchers note the comparative frequency of phenomena of oral automatism, a palmar and mental symptom, a hobotkovy reflex, etc.
Focal (partial) attacks share on motive, touch, vegetative and visceral, and also attacks with mental disorders and secondary and generalized. Carry to motive attacks jacksonian (see. Jacksonian epilepsy), adversiv-ny (an attack in form of motion of eyes, the heads and trunks aside), tonic postural (with increase in a tone of postural — the anti-gravitational muscles supporting normal position of a body and its parts in space), speech (vocalization, i.e. an izdavaniye of any sound or unusual sound combinations, a stop of the speech), aphotic (an attack in the form of motor or touch aphasia) and myoclonic.
Touch attacks in typical cases begin with various paresthesias (somatosensory attacks), sometimes arise on a gemitipa and pass into motive spasms. Visual attacks are characterized by false perceptions; paroxysmal emergence of scotoma is sometimes noted (see). Less often acoustical attacks meet feeling of various sounds, noise, etc. Olfactory attacks are characterized by uncertain, is more often unpleasant, feelings. Much less often attacks of flavoring feelings and attacks of dizziness meet. These touch elementary attacks are quite often observed in the form of aura of a motive attack.
Vegetative and visceral attacks happen preferential visceral, to-rye are characterized by various unpleasant feelings in internals, and the general vegetative (so-called diencephalic E.), at to-rykh pristupoobrazny fervescence, the ABP is observed, and also sweating amplifies, the heart rhythm etc. changes.
Attacks happen to mental disorders several types. Attacks with twilight consciousness are characterized by fugues (the sudden and short-term motive excitement in the form of elementary movements or actions which is followed by twilight stupefaction). They come often after generalized convulsive attacks and can last from several minutes to several days. On EEG, especially at a research of a night dream, the unilateral or bilateral centers in temporal or frontotemporal areas come to light. Avtomatizma, or psychomotor attacks, arise sometimes as aura of convulsive attacks or as poslepripadoch-ny twilight consciousness. They are shown by various gesticulations, the pantomimic movements, verbal and out-patient
(unmotivated circulations) avtomatizm, proceed from several seconds to several days. Disturbances of perception happen illusory and hallucinatory character and belong to temporal paroxysms. At elementary illusory attacks consciousness at patients is in most cases changed. Visual illusory attacks are observed often, in some cases acoustical attacks in the form of a mikroakuziya (perception of the weakened sound), macro-akuzii (perception of the strengthened sound), teleakuziya (false perception of removal of a source of a sound), and also disturbances of perception of position of own body or an extremity are noted. At visual illusions are involved in process occipital area, at acoustical illusions and feelings of dizziness — an upper temporal crinkle; at olfactory and flavoring illusions categories arise in medial department of a temporal share. Difficult illusory attacks in the form of paroxysms already seen, already slyshanny, already endured are observed less often. Hallucinatory attacks are followed by visual hallucinations (the motionless objects moving or painted in different colors, people) more often. These attacks are observed more often during the involvement in process of zadnevisochny areas of a brain; auditory and olfactory hallucinations — at localization patol. the center in an anteriointernal part of a temporal share, flavoring hallucinations — during the involvement in process of parainsulyarny area. Ideatorny attacks are characterized by conditions of violent thoughts, actions, painful for the patient; they proceed of several minutes till several o'clock. Paroxysmal dysphorias are expressed by attacks of change of mood.
Temporal epilepsy belongs to focal attacks. Often use the term «temporal epilepsy» in scientific literature and a wedge, practice; he points to existence of the epileptic center in structures of a temporal share of a brain (including a gippokampomindalevidny complex). At temporal E. attacks as with elementary touch (acoustical, olfactory or flavoring) or motor (adversivny or afatiche-sky) symptoms, and attacks with mental disorders are observed. Besides, generalized toniko-clonic convulsive attacks and attacks of an atypical absentia epileptica can meet.
In a wedge, a picture secondary and generalized attacks are more often observed, at to-rykh continuous generalization of spasms after any focal a symptom signal is noted; e.g., after short-term chewing and deglutitory movements generalized toniko-clonic spasms develop.
Gemikonvulsivny attacks are characterized by myoclonic spasms on one side of a body, at the following attack they arise on other party, consciousness at the same time is lost. Such attacks are more often observed at early children's age.
Carry nek-ry forms of attacks of reflex character when the attack comes under the influence of any external irritant to not classified epileptic seizures. Most often the so-called photogene attacks caused by any visual irritant meet. So-called audiogene attacks are described, as the reason to-rykh serve certain acoustical irritants; their version is the muzykogenny attack.
The epilepsy which developed after a craniocereberal injury, JI. JI. Rokhlin (1948) defined as traumatic epilepsy and considered as an organic disease of a brain, in emergence to-rogo an injury plays a role of a causal and pathogenetic factor, and a wedge, the picture is presented by steady and constant epileptic seizures. By data
A. I. Boldyreva (1971), at adult patients E. the post-natal cherepnomozgovy injury is etiol. a factor in 14,7% of cases. Vinken and Bryan (R. of J. Vinken, G. W. Bru-yn, 1974) provide the following statistical data: a slight cherepnomozgovy injury without considerable nevrol. symptoms, with a short-term loss of consciousness is complicated by epileptic seizures in 7% of cases; the craniocereberal injury which is followed by a long loss of consciousness, unstable bilateral nevrol. symptomatology — in 10% of cases; the expressed contusion of a brain — in 38% of cases; a craniocereberal injury with the destruction of substance of a brain complicated by a hemorrhage and an infection — in 57% of cases. Specific weight E. at injuries in wartime considerably increases. According to a number of researchers, it is caused by the general background of psychological tension. On terms of emergence allocate early traumatic E. (in the first
3 months after an injury) and late. According to various researchers, traumatic E. arises most often in the first 3 — 6 months after an injury.
Wedge, picture traumatic E. it is characterized by polymorphism. Most often there are focal attacks (more often motor, are slightly more rare touch attacks) with secondary generalization. Psychomotor attacks meet in 15 — 20% of cases. Most of researchers deny possibility at traumatic E. small attacks even at children under 5 years.
One of characteristic signs traumatic E. — variability of a current. JI. JI. Rokhlin (1948) allocates the following types of a current traumatic E.: residual (with a tendency to the termination of attacks); stationary (stabilization of attacks on the frequency and expressiveness); progreduated, or malignant (systematic repetition of attacks and complication of symptomatology).
Mental disorders at epilepsy. Disturbances of mental activity at E. are shown by changes of the identity of the patient, and also various psikhopatol. frustration.
Degree of a progrediyentnost of changes of the personality at E. depends on age, in Krom the disease, frequencies and features of attacks, and also from the carried-out treatment began. Than earlier the disease began, the more often there are attacks and the less patient is exposed to treatment, rather there occur changes of the personality, in particular weak-mindedness (see). From the accessory factors strengthening psikhopatol. disturbances at E. (characterologic and psychopathological), alcoholism, craniocereberal injuries and vascular diseases of a brain have the greatest value.
Changes of the personality at E. are shown by explosive lines — irritability, discontent, impatience, cantankerousness, sensitivity, petty fault-finding with tendency to roughness, the quarrels, fits of anger and even rage which are followed by quite often aggressive actions. Along with it at E. opposite properties meet: shyness, timidity, tendency to self-abasement, the exaggerated courtesy reaching flattery and servility, the exaggerated respect and tenderness in the address, the aspiration to emphasize the consent with the interlocutor and to please it — a so-called defenzivnost. The listed polar disturbances of efficiency can occur at the same patient as in pure form, and in various combinations.
Mood of patients E. it is usually expressed very much definitely and podver-
the wife to frequent fluctuations — from the gloomy irritation lowered with feeling, hostility and hopelessness to povyshenno-careless or just a little excited. Mood swings at E. arise as it is spontaneous, and under the influence of ordinary events and impressions. All changes of efficiency at E. have feature: time having arisen, they long time do not change, despite change of circumstances (viscosity of affect). It is peculiar not only to such affects as irritability, hostility, offense, etc., but also opposite (joy, sympathy, an arrangement). Mental abilities of patients E. are also changeable: they
complain of block of thoughts, difficulty or impossibility to concentrate attention, decrease in working capacity, on the contrary, become excessively active, talkative, capable to perform that work, edges seemed to them invincible until recently. Such peremezhayemost of mood and mental capacities represents one of the major lines in character of patients with epilepsy.
Thinking of patients E. has a number of the peculiar features which are shown in features of the speech. Are most characteristic jamming on details, impossibility to allocate the main thing, difficulty of transition from one representations to others in this connection patients with great difficulty can introduce the main idea. They are not able to give the short answer. Speech of patients E. it is poor in words (oligophasia), constantly is followed by returns to already told. It dazzles with the florid banal expressions, diminutive words, definitions containing value affective judgment — «good, fine, bad, disgusting», and at frequent at patients E. religiousness words occur in statements, to-rymi believers (the so-called divine nomenclature) use. The speech can be melodious, be followed by pathetic intonations. In statements of the patient E. own «I» and his disease win first place, then there are relatives and acquaintances, to-rykh it assesses always positively, and also daily household questions. About all this to the interlocutor it is reported in the trustworthy tone. Quite often the patient takes the doctor aside and with an air of mystery tells it some trifle. Patients E. highly appreciate all that belongs to the concept «justice», napr, pravdolyuby, legality, fidelity to the word, conscientiousness, and emphasize existence of these qualities at themselves. They are always advocates of an order, especially in trifles. Understanding of other people, in particular their interests, at patients E. it is reduced. In their opinion, all shall feel in relation to something the same feelings (e.g., a grief, joy), as at them. At one patients childishness and immaturity of judgments, at others — judiciousness, tendency to admonitions, aspiration to reconcile, i.e. the qualities inherent to the persons who much were seeing and who worried are expressed. Such patients already in youth make an impression of «little old men». Relation of patients E. to the disease (as, however, and to all other) is defined by mood of this moment. However most often they are absorbed by the disease state and in general any small illnesses. Patients consider departures of an organism extremely important and endlessly speak about them with the purpose to cause sympathy, with the purpose to brag as to them it is good. Patients E. are usually diligently treated and, despite different assessment of the state, in general believe in positive success of treatment and in recovery (epileptic optimism). In no small measure the fact that patients willingly undertake affairs and obligations is explained by epileptic optimism, to-rykh they is not able to execute.
Patient E. quickly tires the interlocutor with thoroughness, importunity, digging in trifles. The listed properties of the personality allowed to formulate the main quality of mentality of patients E. — viscosity («the epileptic the Georgian» — always emphasized at diagnosis of epilepsy P. B. Gannushkin).
The clear manifestation of changes of the personality which is followed by changes of memory, various on depth, demonstrates existence of epileptic weak-mindedness. Rate of increase of changes of the personality, and also changes of memory depends on age, in Krom the disease, its duration, the nature of attacks, their frequency, existence of additional vrednost (e.g., craniocereberal injuries, alcoholism), the carried-out treatment began.
Against the background of the described changes of the personality in one cases in connection with attacks (before their approach or after them), in others — without the visible external reason arise various psikhopatol. frustration. In the majority of them combine on a number of the general signs: as a rule, on the sudden beginning and the termination; uniformity a wedge, pictures at the same patient (as «cliche»); short duration or a tran-zitornost (from several seconds to several days, more long terms are more rare).
At E. the following psikhopatol is observed. frustration: disfo
riya, or frustration of mood, twilight stupefaction; postconvulsive stupor, epileptic special states; so-called epileptic dreams, epileptic crazy psychoses. Dysphorias meet in each case E., and the fact that they appear without any occasion is characteristic. At one patients are noted the melancholy which is followed by pain in a breast, alarm or the baseless scare which is combined with malignancy, suspiciousness, tension and readiness for destructive actions. Patients in such state complain of painful thoughts, from to-rykh cannot get off; most often it is thoughts of suicide or murder of relatives (homocidal thoughts). In less serious condition the blind irritation is observed, patients are captious, are dissatisfied with everything. Other patients periodically become silent, sad, slow-moving. Complain that it is difficult for them to concentrate. Cannot comprehend the questions turned to them, occurring around.
Much less often conditions of the increased mood which is combined with irritability meet. Are characteristic enthusiasm, up to ecstasy, theatrical behavior, the pathetic speech. In some cases the increased affect carries a moriopodobny (foolish) shade, and behavior of the patient — character of a clownery. Hypomaniacal and maniacal states at E. are not followed by a noticeable gallop of the ideas and an otvlekayemost (see. Maniacal syndromes). Both speech, and motive frustration have a shade of sluggishness and unproductiveness. Frustration of mood prie. can be followed by a condition of stupefaction with confusion (see) and amnesia of various depth (see Amnesia), the crazy ideas, impulsive inclinations in the form of vagrancy, theft, hard drinking, sexual excesses (see. Impulsive inclinations, Sexual perversions). Frustration of mood at E. several hours or proceed days.
There is a considerable number of patients E., at to-rykh during life only single attacks, napr, small attacks, and psikhopatol were noted. frustration were exhausted by monopolar or bipolar changes of mood, i.e. the phenomena of a tsirkulyarnost (see. Ma-niakaljno-depressive psychosis). However changes of the personality at such patients have typical epileptic lines.
The most frequent form of pathology of consciousness at E. twilight stupefaction is (see). The simple form of twilight stupefaction and its version (out-patient automatism, fugues — trances, noctambulation — a lunacy) and twilight stupefaction meet productive frustration (the nonsense changed by affect, hallucinations).
The crazy ideas and hallucinations (see) usually have frightening character. The crazy ideas of religious and mystical and erotic contents prevail; less often the ideas of prosecution and greatness meet. From hallucinatory frustration prevail visual and olfactory. Visual hallucinations are more often than a stsenopodobna, differ in big emotional brightness and are quite often painted in red, yellow, white color, is more rare in others, or shine and sparkle. The visions coming to the patient or restricting it (certain people, the whole crowd, monsters, the rising water, the running train flying on the patient the airplane) are characteristic. Visual hallucinations with vision of blood, the fires, the sun, red or pink clouds, red flags are frequent. Scenes of religious contents, and also such where historical events with participation of great people are developed are frequent. Sometimes similar fantastic pictures are combined with events of ordinary contents. So, the patient, being in the sky and meeting Christ, easily eats with it Russian cabbage soup from one bowl and at the same time reports to him about the everyday affairs, asking to give advice; according to Zamt (P. Samt, 1875), «the epileptic is good luck familiar».
Olfactory hallucinations are expressed in emergence of off-flavor, napr, a smell of smoke, a burned feather or hair, burned, a smell of dampness, poisonous gases, urine.
At twilight stupefaction frustration of mood are noted, to-rye are extremely intensive and can be very changeable. Most often it is the fear reaching in some cases degree of horror, rage, rage, ecstasy replacing each other throughout a short span.
The simple form of twilight stupefaction is followed by full amnesia of an episode (see Amnesia). It arises at E., proceeding with generalized convulsive attacks. Twilight stupefaction with productive psikhopatol. frustration can be followed by incomplete, including retardirovanny amnesia of an episode. Such twilight stupefaction arises usually in the presence of polymorphic attacks.
When in a wedge, a picture of a condition of stupefaction at E. stsenopodobny visual hallucinations and fear prevail, tell about epileptic deliriums and when stupefaction is followed by nonsense and hallucinations of fantastic contents — about epileptic oneiroid (see. Oneiric syndrome). In both cases partial amnesia of an episode is more often observed.
In many cases of the twilight stupefaction which is not followed by amnesia, and also an epileptic delirium and oneiroid after their disappearance there is a residual nonsense (see).
Postconvulsive stupor (see. Struporous states) most often develops during twilight stupefaction and epileptic oneiroid; at heavy dysphorias, and also after the generalized attacks which are especially arising series substuporoz-ny states develop. There is a spontaneous development of a stupor much less often. Motive block at the same time has various depth — from states with an insignificant obezdvizhennost with elements of a mutism (failure from the speech), from to-rykh the patient it is possible to remove by the verbal address (substupor), to states with a full obezdvizhennost with an absolute mutism, negativism, a symptom of the airbag and wax flexibility for some time (a state, at to - rum of a part of a body of the patient keep the situation given them); can be observed an echolalia (repetition of the heard words) and perseveration (dominance of one any thought, representation). Usually motive block does not reach extreme degrees, in particular there is no stupor with catalepsy and the stupor which is followed by a pose of an embryo. Conditions of an obezdvizhennost can suddenly be replaced by a condition of excitement with destructive actions. After an attack and at a simple form of twilight stupefaction the stupor is shown first of all or exclusively motive disturbances (an empty stupor). At twilight stupefaction and at epileptic oneiroid the stupor is always followed psikhopatol. frustration (the nonsense changed by the affect, hallucinations) inherent to that psychosis, against the background of to-rogo it arose (a receptor stupor). Duration of a postconvulsive stupor — several minutes or days, more rare longer. Amnesia at the same time can be full or partial.
M. O. Gurevich (1946) allocated epileptic special states — group psikhopatol. the frustration combined by such signs as short duration (of several seconds and minutes till several o'clock), frequent emergence of easy degree of stupefaction with confusion, an allopsikhichesky disorientation (consciousness of the «I» remain not changed), absence of full amnesia of an episode. At epileptic special states affective frustration — fear, alarm, depression or povyshenno-ecstatic mood, and also disorders of perception of time (time hangs unusually heavy or rushes instantly) are always noted, there are disturbances of space perception, vestibular disturbances. Carry also snopodobny states paroksizmalno arising depersonalizatsionno-derealizatsion-nye frustration to epileptic special states (see Depersonalization), states already seen, slyshanny, endured (or opposite frustration by it), kataplektopodobny states (see the Cataplexy), various, first of all mental, auras which are not followed by the subsequent development of an attack. Distinguish hallucinatory from mental auras — in the form of visual, in particular panoramiche-sky, acoustical, usually verbal and olfactory hallucinations; the idea-even auras which are shown disturbances of thinking (breaks of thoughts, their accelerated current, emergence of involuntarily arising thoughts, including in the form of memoirs); auras with a condition of the changed consciousness, most often snovidny (oneiric); auras with dominance of frustration of a body scheme (see), metamorphopsias (distortion of size or a form of the perceived objects and space), macropsias and micropsias (see Metamorphopsias).
To psikhopatol. to frustration at E. it is necessary to carry also nek-ry dreams, special on the subject — so-called epileptic dreams. They are defined by the sensual brightness, usually burdensome or frightening contents, an okrashennost in red color or colors, close to it, emergence of depressive affect — up to sharp fear and, more rare, the increased affect. In some cases such dream is replaced by a convulsive attack that allows to refer epileptic dreams to auras.
Epileptic crazy psychoses proceed sharply (acute psychoses) and chronically (long psychoses). Acute epileptic crazy psychoses are followed more often by the ideas of prosecution, poisoning, causing physical harm in this connection they are called epileptic paranoids (see. Paranoid syndrome). At them also the hypochiondrial nonsense can be observed. The prevailing affect — a depression with alarm, fear, frequent rage. Much less often crazy psychoses meet an expansive delirium, first of all religi-ozno-megalomaniac contents. At the same time povyshenno-ecstatic affect prevails. More often acute psychoses arise against the background of the expressed dysphorias, is much more rare — spontaneously. Psikhopato of l. frustration disappear completely or are replaced by residual nonsense (see Nonsense). Psychosis happens single, but the recurrent current is more often observed. Duration of attacks from several days to several months. The psychoses arising against the background of dysphorias are usually short-term.
Long crazy epileptic psychoses can develop as residual nonsense — paranoiac, paranoid, paraphrenic (see. A paranoid syndrome, the Paranoiac syndrome, the Paraphrenic syndrome) after epileptic oneiroid, an epileptic delirium and twilight stupefactions with psikhopatol. frustration, not followed by full amnesia in the period of twilight stupefaction. The wedge, a picture of such residual nonsense remains stationary throughout a long time. The nonsense in these cases tends to a regrediyentnost. Its complication is observed only at the repeated psychoses which are followed by twilight stupefactions. At a number of patients hron. crazy psychoses arise after acute epileptic paranoids at their recurrent current. In rare instances at E. hron. crazy psychoses arise initially. Their wedge, a picture can be limited to one syndrome, napr, paranoiac, but can gradually become complicated with development of paranoid and paraphrenic states. Paranoiac psychoses are defined by the systematized nonsense of damage, prosecution, hypochiondrial or religious nonsense.
At paranoid psychoses the crazy ideas are followed by verbal hallucinations (see Hallucinations) and (or) various manifestations of a syndrome of Kandinsky — Klerambo (see Kandinsky —
Klerambo a syndrome). At paraphrenic states along with the ideas of greatness the reli-giozno-mystical crazy ideas are usually expressed. Paranoiac and paranoid psychoses are followed by ponizhenno-spiteful affect more often. At paraphrenic modification a wedge, pictures affect happens raised or povyshenno-ecstatic, however the ponizhenno-spiteful mood is often observed.
Psikhopatol. frustration at E. (heavy dysphorias, twilight stupefactions, many forms of epileptic special states, a postconvulsive stupor and especially epileptic crazy psychoses) usually appear at the remote stages E. At the same time the urezheniye of attacks (is, as a rule, noted up to their total disappearance, napr, at crazy psychoses).
Emergence psikhopatol. frustration and a simultaneous urezheniye (up to total disappearance) attacks at E. sometimes is followed by easier subsequent disease — changes of the personality and symptoms of weak-mindedness accrue more slowly. At the same time progreduated current E. it is observed also in the presence of one only psikhopatol. frustration. When psikhopatol. frustration join attacks through a short time term, especially at an early onset of the illness, their emergence involves bystry increase of changes of the personality and emergence of weak-mindedness. According to psychiatrists, psikhopatol. frustration as if replace attacks; therefore they are often called epileptic equivalents.
There are exceptional cases E., to-rye are exhausted by one psikhopatol. frustration, i.e. epileptic equivalents — so-called mental (hidden, masked, larvirovanny) epilepsy. The term «epilepsia larvata» entered B. Morel in 1860. At mental epilepsy the same changes of the personality are observed, as at E. in general.
Gasto (1975) considers the term «epileptic equivalent» unsuccessful since definition «epileptic» is often used in cases of symptomatic epilepsy or epilepsy with an unspecified etiology. Since mental E. it is shown in the form of equivalents, according to Gasto, this expression shall be considered as also incorrect. At psychiatrists, for to-rykh the nosological diagnosis in general and at E. in particular is defined first of all by features of changes of the personality, but not a hypothetical etiology, the terms «epileptic equivalent» and «mental epilepsy» keep the initial value.
The diagnosis is established on the basis of the anamnesis, by a wedge, pictures, an electroencephalography and a method of registration of evoked potentials of a brain (see Elektroentsefalografiya). Carefully and purposefully collected anamnesis has crucial importance in establishment of nature of an attack (in practice the doctor seldom should observe an attack at a certain patient therefore it is forced to be based on stories of the relatives observing an attack). One attack cannot be the basis for statement of a dianoz of epilepsy. He shall send the doctor to search for the possible reasons of his emergence. In the presence of repeated attacks it is necessary to resolve two main diagnostic issues: whether attacks in character are epileptic; if attacks have epileptic character, then it is necessary to find out whether they are a sign E. or a manifest symptom of other diseases of a nervous system with organic lesion of a brain. In typical cases establishment of nature of an attack comes easy.
In atypical cases the epileptic seizure (especially diencephalic) is differentiated, first of all, with a hysterics, at Krom are absent the expressed clonic and tonic stage, the expression, theatricality of movements and poses, strengthening of convulsive movements in the presence of people are noted (see Hysteria). The epileptic seizure should be distinguished from a faint (see), at Krom of the patient faints more often not at once, and gradually (in the beginning darkens before eyes, there is dizziness, the general weakness, nausea, the person turns pale, pulse weakens, myoclonias can sometimes be observed). Besides, epileptic seizures need to be differentiated with other diseases, at to-rykh there can be various paroxysmal states (attacks of drowsiness, an obezdvizhennost, various types of spasms, etc.), napr, with a narcolepsy (see), a katalepsy (see), a spasmophilia (see), Menyer's disease (see Men-er a disease), migraine (see), an inten-tsionny spasm of Ryulf — sudden emergence of tonic convulsive movements in muscles of extremities at the unexpected movements, napr, at a sudden rising, consciousness at the same time is not changed (see Ryulf an intentsionny spasm).
At children's age considerable difficulties arise at an otgranicheniya of attacks E. from episodes of enuresis, nightmare, lunacy. At the same time it is necessary to remember that without other characteristic signs E. these paroxysms are display of pathology of mechanisms of a night dream and have with E nothing in common. Attacks E. can be one of displays of a tumor, abscess and vascular diseases of a brain, an arachnoiditis (see), multiple sclerosis (see), a tuberous sclerosis (see), a syndrome of Sterdzha — Weber — Krabbe (see the Entsefalotri-geminaljny angiomatosis), eclampsias (see), tetanies (see), a lupus erythematosus (see), various comas (a hypoglycemic, diabetic, uremic, hepatic coma, a coma at exogenous intoxications).
The electroencephalography is the most widespread and quite effective diagnostic method of E. V the interepileptic period various types of paroxysmal categories can be found: acute and slow waves, peaks, various complexes (e.g., peak wave), bystry waves, rhythmic categories of various frequency, etc. the Elektroentsefalografichesky signs typical for any one type of attacks, as a rule, do not exist. The exception represents an absentia epileptica, at Krom both in the mezhpristupny period, and during an attack complexes
peak waves with a frequency of 3 in 1 sec. can be registered.
Generalized toniko-drive-chesky a convulsive attack on EEG begins with sharp falling of amplitude of electric activity with the subsequent emergence of frequent fluctuations (20 — 40 in 1 sec.). This period proceeds several seconds and corresponds to a tonic phase of an attack, then on EEG appear the rhythmic activity consisting of 10 fluctuations in 1 sec. with gradual increase of amplitude of fluctuations. In 10 sec. after the beginning of an attack the frequency of waves begins to decrease gradually and perekho-goes in a theta - or delta activity. After the last clonic spasm on EEG within several seconds there is a falling of amplitude of fluctuations.
Since introduction to a wedge, practice of a method of registration of evoked potentials attempts of use it in the diagnostic purposes become at E. Odnako the received results have contradictory character. According to one researchers, at E. evoked potentials of various modality (visual, acoustical, somatosensory) a little in what differ from norm. Other researchers note shortening of stage of latency, in one case early, and in another — late components of evoked potentials, and also increase in amplitude of all components. According to a number of researchers, at nek-ry patients E. even amplitude of evoked potentials decreases. Changes of the evoked potentials found at E., are identical to all types of epileptic seizures. The exception makes photogene E., at a cut early emergence of occipital components of visual evoked potentials and significant increase in their amplitude is observed. Therefore the technique of evoked potentials with success is used at diagnosis photogene E.
For the purpose of diagnosis resort to methods of artificial calling of an attack. Among them the most effective method is the hyperventilation (any deep and overbreathing with a frequency of 20 — 30 times of 1 min. within
3 — 5 min.); water loading (within 1 hour to the patient allow to drink up to 2 l of water and at the same time to inhale a nose 0,05 g of Adiurecrinum); a deprivation of a dream (during 24 — 48 hours), etc.
Essential help in establishment E. can render a computer tomography (see the Tomography computer), a nuclear magnetic resonance nondestructive testing (see Nuclear magnetic resonance), an emission computer tomography (see). The computer tomography finds the epileptic center approximately in 10% of patients with primary and generalized convulsive attacks, and in half of cases — at Lennox's syndrome — Gasto.
Diagnosis E. it is possible to establish on the basis of characteristic for E. changes of the personality; the elektroentsefa-lografichesky research at the same time has the important, but subordinated value. Differential diagnosis of epileptic oneiroid, a postconvulsive stupor, epileptic acute crazy psychoses is carried out with the schizophrenia (see) proceeding attacks; hron. crazy psychoses at E. delimit from continuously proceeding crazy schizophrenia.
The epileptic oneiroid, twilight stupefactions, epileptic special states expressed to a dysphoria at E. it is necessary to differentiate with the similar states arising in the remote period after a cherepnomozgovy injury (see), especially when in the remote period attacks were observed.
Arising at E. monopolars-nye or bipolar disorders of mood it is necessary to differentiate with maniac-depressive psychosis and a cyclotymia (see. Maniac-depressive psychosis); the expressed epileptic changes of the personality which are followed by dysphorias — with an epileptoidny psychopathy and a psychopathy of a circle excitable (see Psychopathies).
Treatment can be medicamentous and operational. At drug treatment follows is-, to go from the following principles: selection of adequate antiepileptic means (see. Antiepileptic means), the choice to-rogo depends hl. obr. from a type of an epileptic seizure; regularity and duration of treatment. Га^ hundred (H. Gastaut) with sotr. (1965) divides antiepileptic funds for the funds applied at all forms of generalized and focal convulsive and not convulsive attacks and for the means applied at generalized not convulsive forms like absentias epileptica. The most widespread anticonvulsants (see) the first type are barbiturates — phenobarbital (see), a hexamidine (see), benzonal (see); gidantoinata — di Pheninum (see), etc. Phenobarbital is ratio of mixture of Sereysky. Treat drugs of the second type Trimethinum (see), suktsinimida (an Ethosuximidum, Suxilepum, Pyknolepsinum, Puphemidium), valproyevy to - that. Also such antiepileptic means as carbamazepine (Finlepsinum), Tegretolum, benzodiazepines — diazepam (see), clonazepam, Phenazepamum were widely adopted (see) etc.
At generalized toniko-clonic convulsive attacks phenobarbital, a hexamidine, dipheninum, clonazepam are shown; myoclonic attacks will respond to treatment a hexamidine and valproyevy to more - that; at focal convulsive attacks the favorable effect renders benzonal. At typical (simple) absentias epileptica it is reasonable to appoint Trimethinum, suktsinimida (including Puphemidium), valp-royevy to - that. Atypical absentias epileptica will respond to treatment carbamazepine and valproyevy to - that. At temporal
E., in particular at psychomotor attacks, the satisfactory therapeutic effect renders carbamazepine, clonazepam and valproyevy to - that.
At psikhopatol. frustration apply neuroleptics (see); at domination, e.g., of hallucinatory-dilision symptomatology the combination of aminazine (see) with Triphtazinum is recommended (see). Twilight and other forms of deep stupefaction, and also condition of psychomotor excitement stop by means of enemas from Chlorali hydras (cm:) or intramuscular administration of hexenal (see). In the subsequent aminazine can be used, to-ry if necessary enter intramusculary, or a haloperidol (see). The same drugs treat patients with acute and chronic crazy psychoses. At dysphorias apply neyleptit, in some cases in combination with amitriptyline (see).
Data on the principles of the choice of antiepileptic means are provided in the table.
At purpose of antiepileptic treatment it is necessary to adhere to the principle of monotherapy (to appoint one antiepileptic means), at its insufficient efficiency or existence of polymorphic attacks recommend the second means and consider pharmacokinetic interaction of different antiepileptic means.
The greatest efficiency of antiepileptic means is reached by creation of constant optimum therapeutic concentration of this drug in blood serum of the patient. It allows to prevent the phenomena of medicinal intoxication in many cases and, besides, as appropriate to select doses, especially when patients have to give at the same time several antiepileptic means.
At timely begun treatment, after the first attack, practically always there comes complete cessation of attacks if there is no serious organic illness of a brain (e.g., tumors). Having achieved the termination of attacks, treatment is continued within 5 — 6 years then at normalization of EEG it is possible to stop treatment gradually. Having rummaged in treatment it is inadmissible because of danger of approach of the epileptic status. At impossibility of definition of concentration of antiepileptic means in blood of the patient the maximum doses of pharmaceuticals shall be dated by the time of developing of attacks. So, at an absentia epileptica of a dose shall be identical throughout the day, and at attacks during sleep the maximum dose needs to be given before approach of a night dream; at patients with day attacks stimulators, napr, Sydnophenum are useful. To pregnant women, patients E., it is not necessary to stop medicinal treatment; nek-ry researchers recommend to reduce a dose a little.
Treatment in sanatoria of patients E. with rare attacks, having at the same time associated diseases demanding a dignity. - hens. treatments, quite often favorably affects a current most E. Patients E. do not need in special to lay down. food. however it is necessary to limit amount of fats, sweets, mineral salts, liquids, alcohol intake is prohibited. The dream shall be regular and full.
The single epileptic seizure, as a rule, does not demand urgent therapeutic interventions, it comes to an end in itself. However at a generalized convulsive attack apply nek-ry precautionary measures: it is necessary to hold the head of the patient, protecting from blows; to avoid development of aspiration asphyxia (see) and retractions of language, the head it is necessary to turn on one side; between teeth since the bite of language is possible, insert the spoon, a stick or the pallet wrapped in a soft tissue.
At the epileptic status it is necessary to remove spasms, to normalize breath and activity of cardiovascular system and to liquidate metabolic frustration. Pre-hospital therapy is directed to the prevention of asphyxia. In the ambulance car enter an air duct into an oral cavity of the patient, delete the emetic masses and slime from upper respiratory tracts, enter the probe into a stomach, at the same time intravenously struyno enter 10 mg of Seduxenum into 20 ml of 40% of solution of glucose. If spasms proceed, then under control of breath and the ABP intravenously slowly enter 50 ml of 1% of solution of hexenal; intramusculary — 5 ml of 10% of solution of hexenal and 5 mg of Seduxenum. In the absence of anticonvulsant effect apply an inhalation anesthesia nitrous oxide with oxygen (in the ratio 2:1).
In a hospital at the proceeding spasms to the patient intravenously enter 40 — 50 mg of Seduxenum and 10 — 15 mg of Droperidolum (or instead of Droperidolum of 20 ml of 20% of solution of oksibu-tirata-sodium). In the absence of effect, dysfunction of external respiration after premedication (1 ml of 0,1% of solution of atropine, 2 ml of 1% of solution of Dimedrol, 1 ml of 2% of solution of Promedolum) begin a barbituric anesthesia — enter tubarin at the rate of 0,4 — 0,5 mg! kg, at the same time carry out an intubation of a trachea and artificial ventilation of the lungs (the minute volume of breath on average 8 — 10 l! mines at a respiration rate 16 — 18 in 1 min., a phase ratio of a breath and an exhalation — 1:2). Further enter the depolarizing muscle relaxants (lysthenonum, Dithylinum) in a half dose. The barbituric anesthesia is carried out by Thiopentalum-natrium or hexenal to the II—III grade of anesthesia (see). If spasms are not stopped, pass on ftorotano - protoxidic oxygen-ny an anesthesia (in the ratio 1:1:1 or 0,5: 1,5: 1) or protoxidic pussycats - lorodny an anesthesia (in the ratio 2:1). The anesthesia is carried out within
2 — 3 hour.
After stopping of an attack each 6 hours and
1 — 2% solution of hexenal at the rate of 200 mg each 6 hours (in intervals between injections of Seduxenum) intravenously appoint Seduxenum on 2 — 4 ml of 0,5% of solution intravenously. For improvement of microcirculation
2 — 3 times a day or intravenously a cap of l ý-but 2 ml of Cavintonum enter 10 ml of 2,4% of solution of an Euphyllinum into 150 ml of 5% of solution of glucose 2 times a day, 5 ml of trental in the same cultivation 2 times a day intravenously; apply glyukozonovokai-new mix. For improvement of fabric exchange enter intravenously struyno vitamins of group B and ascorbic to - that into 10 ml of 40% of solution of glucose; 5 — 10 ml of nootropil — after an injection of Seduxenum. As cardiotonic means apply korglyukon and strophanthin, during the falling of the ABP appoint a dopamine (Intropinum). At stagnation in a stomach it is washed out by 2 — 3 times a day to pure water and enter after washing 200 — 300 ml of 5% of solution of glucose. For the purpose of prevention of bronchopulmonary complications recommend a daily sanatsionny fibrobronkho-skopiya solution of soda with Kanamycinum. At a hyperthermia on area of the main vessels impose bubbles with ice, apply water -
jet system to an artificial pryamokishechny hypothermia, numerous gastric lavages a cold water. Treatment is carried out under control of EEG, hemodynamic indicators, acid-base equilibrium, carry out correction of a water balance, metabolic disturbances, a diuresis, provide parenteral food with energy value to
2,5 — 3 thousand kcal.
Progress of treatment of patients at the epileptic status in many respects depends on use of a method of monitor control of functions of the brain which is widely implemented in a crust, time in a wedge, practice. Measures of urgent and emergency treatment should be undertaken at the epileptic status, a series of attacks, and also at acute psychotic states (e.g., at heavy dysphorias, twilight stupefaction).
Operational treatment of epilepsy. Indications to operational treatment are defined by existence focal E. with a frequency of convulsive attacks of 2 — 3 times and more in a month or with more rare attacks, but with tendency to their manifestation by series or to the epileptic status, and also AA., at a cut attacks are combined with heavy paroxysmal disorders of behavior with the accruing mental changes at inefficiency of systematic conservative therapy for 2 — 3 years. Operation can be performed also in earlier terms at a considerable progre-diyentnost of a disease.
Condition for the solution of a question of operational treatment E. careful comprehensive examination of the patient is, a cut allows to specify an etiology and a wedge,
a picture E., localization of the epileptic center that defines the choice of a specific way of operation.
In a crust, time use open operative measures, stereotaxic operations and the combined neurosurgical operations. Open operative measures with full or partial removal of the epileptic center include a lobectomy (see) — a lobby an occipital, subpialny resection of bark temporal, frontal less often in a zone of the epileptic center or removal of the shell moz-govogo a hem.
At a temporal lobectomy the pole of a temporal share is deleted with web and vascular covers throughout about 5 cm on the course of a silviyevy furrow in a dominant hemisphere and approximately on 7 cm — in not dominant. Change of konveksitalny bark of a temporal share, defeat of medial departments of a temporal share and its mediobazalny structures at temporal E. form the basis for a resection of front departments of a temporal share, an amygdaloid kernel and partially a hippocampus. At heavy multifocal E. apply operations on Forel's fields of N, a cerebral commissurotomy or a section of front departments of a corpus collosum.
Single-step destructions allow to perform stereotaxic operations; implantation of long-term intratserebralny electrodes for microdestruction of the deep epileptic centers or for carrying out to lay down. electrostimulations of brake epileptic systems (see. Stereotaxic neurosurgery). In some cases carry out combined neurosurgical vmeshthe atelstvo giving the chance after an osteoplastic craniotrypesis to make simultaneous record elektrokortikogram-we (EKOG) and a stereotaxic research of bioelectric activity of ipsilateralny deep educations, i.e. to define interrelations between cortical and the deep centers and to aim intervention at elimination of the dominant epileptic center. The combined neurosurgical operations include a resection of the epileptic center on the party of the most expressed morphological and elektroentsefalografichesky
changes and stereotaxic operation on the opposite side.
At multifocal E. with defeat of konveksitalny and subcrustal formations of one of hemispheres apply a technique of a single-step open operative measure with a stereotaxic research of function of underlying structures (kernels of a thalamus, an amygdaloid kernel, a hippocampus, etc.) for the purpose of possible stereotaxic destruction of the deep epileptic centers or destruction of bonds. patol. impulsation. In especially hard cases temporal E. (a bitemporal form) use the combined operations with destruction of several structures of a brain in various options, but to a thicket carry out a resection patholologically of the changed temporal share on the one hand and stereotaxic destruction of mediobazalny structures from the opposite side.
The choice of specific neurosurgical operation is made on the basis of data of comprehensive examination both against the background of reception of anticonvulsant drugs, and at their cancellation. At difficulties of identification dominant or the latent epileptic centers carry out special pharmakol. tests. One of the main objectives of operation — exact removal of the epileptic center therefore, whenever possible, operations are performed under control of EKOG.
The temporal lobectomy allows to achieve from most of patients of total disappearance or a considerable urezheniye of attacks and improvement of mental functions. D. G. Schaefer (1971) received favorable results at 74% of the operated patients, A. G. Zemskaya (1971) — at 75%; Rasmussen (Th. Rasmussen, 1979) on the basis of katamne-stichesky studying (within 35 years) the operated patients noted good result at 94% of patients, from them at 46% attacks stopped completely. Treatment of temporal epilepsy in the stereotaxic way also effectively, especially at use of a longitudinal gippo-kampotomiya (see). So, Nadvornik (P. Nadvornik, 1977) observed the termination of attacks and improvement of mental functions at 25% of the operated patients, an urezheniye of attacks — at 25%, a nek-swarm improvement — at 30% of patients.
Forecast. At timely treatment attacks completely stop. In some cases, despite the carried-out treatment, the disease accepts progreduated character with increase of attacks that leads to approach of weak-mindedness. Lethal outcomes are observed in some cases hard proceeding epileptic status.
Prevention generally comes down to the prevention of pathology of pregnancy, a birth trauma, heavy inf. diseases, especially at early children's age, and also craniocereberal injuries. Special attention should be paid on febrile attacks (see below), to-rye quite often become a debut E. If they repeat and remain aged after 3 years, then it is necessary to appoint antiepileptic treatment. Patient E. shall refuse a number of the professions dangerous both for it, and for people around (drivers of transport, roofers, etc.), and also nek-ry sports (swimming, mountaineering, riding, etc.).
An essential role in prevention E. can play the qualified medicogenetic consultation (see. Medicogenetic consultation). The risk to ache with E. considerably increases if both parents have hereditary burdeness on this disease.
Features of epilepsy at children.
Epilepsy — a disease of preferential children's age. According to Dodson (W. E. Dodson, 1984), about 75% of patients E. get sick in the childhood. Frequency of convulsive attacks at children aged up to 10 years is highest, and 2/3 of these attacks fall on the first three years of life. Frequency of convulsive attacks at newborns varies, according to a number of researchers, from 1,5 to 14%. Rather high frequency of epileptic attacks at children substantially is determined by comparison with adults by age not differentiation of a brain, physiological hyper synchronization of its activity and tendency to generalized reactions. The low threshold of convulsive readiness at children is caused also by instability of metabolism of «young» neuron and «young» neural populations (lability of axonal transport, transmembrane transfer of ions, molecular receptor and mediator systems of synoptic contacts). At the same time developing of epileptic seizures at children's age not always shall be regarded as manifestation E. According to T. Sh. Geladze
(1969), approximately at 1/3 clinically healthy school students in the first 3 years of life at least one epileptic seizure was observed. In this regard in a wedge, practice with extra care treat diagnosis «epilepsy» to children up to 3 years. The nature of epileptic manifestations at this age significantly differs from attacks at adults (see Spasms).
Epileptic attack — not chaos of chaotic muscular contractions, but strictly coordinate evolutionarily fixed motive stereotype, implementation to-rogo demands from a brain of a certain degree of a maturity of motive systems. It is characteristic that in ontogenesis (as well as in phylogenesis) originally there are tonic spasms and only at more perfect stages of development — clonic, myoclonic, and then vegetative attacks and epileptic equivalents. At newborns and children of chest age tonic or those-niko-clonic attacks prevail. In view of a variety of involuntary movements at newborns recognition of spasms at them can present great difficulties, a gene-ralizovannost of starts and hardenings in combination with a stop of a look, disturbance of acts of swallowing and breath allows to distinguish spasms from fiziol. movements. After the period of a neonatality there comes the besparoksizmalny period lasting 4 — 5 months when spasms are observed extremely seldom. In the second half of the year of life of a spasm gain more outlined tonic character, and dependence a wedge, manifestations of epileptic attacks from degree of a maturity of motive systems accurately is defined. At babies fleksorny tonic spasms, or «salaamova attacks», in the form of nods, bows with folding of hands on breasts, sometimes a short-term raskidyvaniye of hands, and then their crossing on a breast are more often observed. The motive systems of a brain which ripened by this time, preferential trunk, to a lesser extent — subcrustal participate in convulsive reaction. «Salaamova attacks» is practically not marked out at children is more senior than 3-year age. After 2 — 3 years and at adults tonic spasms proceed preferential in a look an extensor-nykh of spasms — extension of a trunk and legs, the zaprokidyvany heads back, assignment of hands in the parties or their pulling along a trunk. In classical expression the big toniko-clonic attack seldom demonstrates at children of preschool age, and at children of younger school age usually has abortal character, being followed by abdominal pains, sometimes vomiting, a hyperthermia, emotional reactions.
Only at children of early age so-called febrile and affective and respiratory attacks are observed. They can arise in life only once and then never repeat, however often are primary manifestation E., in this connection tactics of waiting, a delay with purpose of adequate anticonvulsant therapy are inadmissible.
Philosophy of treatment E. children have the same, as at adults, however specifically children's forms of epileptic attacks demand the differentiated approach: at «salaamovy attacks» diazepam and nitrazepam are most effective, at serial small attacks — purpose of anticonvulsants (Suxilepum, Pyknolepsinum, nitrazepam) against the background of dexamethasone. Considering that even in optimum dosages anticonvulsants render the braking effect on the developing brain, at E. at children the combination of this therapy to purpose of biogenic stimulators is especially important (lipocerebrinum, glutaminic to - you, nootropic means, in the conditions of a hospital — Encephabolum, tserebro a lysine). Anticonvulsant treatment E. at children has the features. At newborns at spasms very low elimination of anticonvulsants is observed, after the first week of life mechanisms of elimination in this connection significant increase in a dose quite often is required ripen. In general in the first 6 weeks of life of distinction between certain patients are so expressed that at purpose of anticonvulsants and calculation of a dose repeated definitions of concentration of drugs in blood are required. At babies aged from 2 up to 12 months note rather stable kinetics of drugs, but at the same time and their high clearance in this connection doses of drugs (on
1 kg of body weight) approximately in 3 — 5 times more the doses appointed by the adult patient. Further in process of growth of the child the relative dose of anticonvulsants gradually decreases. At the age of 10 — 15 years it reaches the dose recommended to the adult patient.
Treatment of the epileptic status at children is carried out in principle according to the same scheme, as at adults, however a dose of drugs, especially at a pre-hospital stage, shall be brought into accord with the body weight of the child and preference shall be given to intramuscular administration of drugs.
Table CHOICE of ANTIEPILEPTIC MEANS DEPENDING ON the TYPE of EPILEPTIC SEIZURES ON SKOLLO-LAVITsTsARI (G. Scollo-Lavizzari, 1981)
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