Features of the development and treatment of partial epilepsy. Partial epilepsy Complex partial seizures

There are simple convulsive manifestations without loss of consciousness and complex ones, accompanied by stupefaction. Their general feature– availability characteristic features, allowing to determine the area of ​​​​brain damage. Against the background of the spread of excitation of motor neurons, simple seizures can transform into complex ones, and then into secondarily generalized ones.

Simple seizures

The code for partial seizures of this type is G40.1 according to ICD-10. Previously, the complex of symptoms preceding a seizure of secondary generalization was designated by neurologists as “aura.” Based on short-term convulsive manifestations, the localization of the source of excitation can be determined. Aura happens:

• Motor or rotatory, when the affected area of ​​brain cells is in the anterior central gyrus. Externally, this type is manifested by the patient running or rotating around its axis.
• Auditory, accompanied by noise, ringing in the ears. It occurs against the background of irritation of Heschl’s temporal gyrus, the primary hearing zone.
• Visual is the result of excitation of the occipital lobe, namely the primary visual center. Symptoms are described as "sparks, flashes in the eyes."
• Olfactory in the form of a sensation of an unpleasant odor, epileptic activity is noted in the hippocampus.

The listed types of aura represent a separate partial convulsive attack or precede secondary ones with subsequent generalization. They last no more than a few seconds while maintaining consciousness. That is, the patient remembers this condition, but due to its short duration, he cannot prevent the consequences (injuries during seizures, falling). Motor partial seizures are also called Jacksonian seizures, after the name of the doctor who first described them. Symptoms develop in the following order: twitching of the corner of the mouth, spasms of facial muscles. Jackson also established the relationship of these PP with the anterior middle gyrus.

Types of visceral attacks

For diagnosis and timely treatment, it is important for the doctor to be able to identify partial vegetovisceral convulsive manifestations. These paroxysms are often mistakenly attributed to symptoms of vegetative-vascular or neurocirculatory dystonia. However, despite their isolation, they can transform into complex or secondary generalized seizures. There are two types of vegetative visceral attacks.

Vegetative with characteristic symptoms: facial redness, sweating, increased blood pressure, heart pain, fever to subfebrile levels, disorders heart rate, thirst, chills. The second form - visceral - is characterized by either unpleasant sensations in the epigastrium or sexual paroxysms. These include erection, orgasm, and irresistible sexual desire. The types of partial seizures with corresponding symptoms are discussed in more detail below.

Aphasic

They first appear in childhood, starting at the age of 3, and are characterized by the gradual development of aphasia - the loss of already acquired speech skills. At first, this sensorimotor disorder looks like a lack of reaction on the part of the child when addressed to him. Then, over the course of several months, the pathological signs increase: the answers become monosyllabic, then speech disappears completely.

At this stage, aphasia is joined by a disorder of auditory perception - agnosia, which contributes to the formulation of diagnoses such as autism or hearing loss. After a few weeks, epileptic seizures themselves appear, most often generalized with a tonic-clonic type of seizures (alternating prolonged spasms and twitchings).

In parallel, in most cases there is an increase in aggressiveness, irritability, and hyperactivity.

Dysmnestic

Partial attacks of this type include the so-called “déjà vu” states. During paroxysm, the patient has a persistent feeling that what is being experienced or observed now has already happened before. The definition applies not only to visual images, but also to auditory, olfactory, and tactile ones. Moreover, situations, pictures or conversations seem extremely familiar, to the point of photographic precision in the reproduction of details.

The repetition of experiences and impressions is refracted through the prism of the patient’s personality, and does not exist separately. That is, your own emotions and mood seem familiar. Conversations transferred in consciousness from the past to the present are those conversations in which the patient took part, and not abstract speech or songs. At the same time, the confidence that what is being experienced now has already taken place makes one constantly remember specific dates of events. Since this is impossible, most patients are inclined to believe that the images and sounds were previously seen or heard in dreams.

The attacks are characterized by a paroxysmal nature: the patient freezes in immobility, concentrating on what he saw or heard. The gaze is usually fixed on one point; there is almost no reaction to external stimuli. The condition after a dysmnestic seizure is similar to that after a classic generalized one - weakness, absent-mindedness, temporary loss of ability to work. The focus of neuronal damage is localized in the hippocampus, mainly on the right side.

Ideatorial

Ideation attacks are a consequence of excitation of the deep parts of the temporal or frontal lobes brain. The disorders that arise in this case are close to schizophrenic in their manifestations and require differential diagnosis.

The most common complaints are disturbances in the thought process in the form of the presence of alien, violent ideas. The patient constantly concentrates on these thoughts, noting their duality, foreignness, and the most common topics for pathological thoughts - death, eternity.

Emotional-affective

This type of convulsive state is characterized by paroxysms of fear or positive emotions. The first ones are more common and are usually associated with a premonition of death, the apocalypse, and accusing oneself of any wrongdoing. The patient's condition at these moments, in terms of vegetative manifestations, resembles a panic attack, which often forces him to hide or run away.

Excitement is the cause individual structures limbic system. A rush of opposite sensations is less common. With heightened perception, emotions such as delight, euphoria, happiness, close to an orgasmic state are experienced.

Illusory

Despite the name, delusional seizures are related to perceptual disturbances rather than illusions. If psychosensory synthesis is disrupted, the following types of this disorder can be observed:

• Metamorphopsia is a distortion of the perception of the environment. The patient “sees” how objects change their shape, color and size, and move in space. Objects can come closer or further away, spin around, or disappear. This vestibular disorder is called an “optical storm” and allows one to identify a lesion at the junction of several lobes of the brain - parietal, occipital and temporal.
• Somatopsychic depersonalization is also manifested by distorted perception, but in this case the object is one’s own body. It seems to the patient that it or individual parts are enlarged, curved, the limbs fill the entire surrounding space or are separated from the body.
• Autopsychic depersonalization is the result of right-sided irritation of the temporoparietal lobe. It is expressed in the form of a feeling of unreality of one’s own personality, fenced off from the surrounding world. The reflection in the mirror is perceived as alien; in especially severe cases, the syndrome of autometamorphosis or transformation into another person is diagnosed.
• Derealization is characterized by the seeming unreality of the situation, objects are perceived as unreal, their colors and shapes can be blurred, depersonalized, and lacking volume. In this case, external information hardly reaches the patient’s consciousness and is poorly perceived. The cause of this condition is damage to the posterior part of the temporal gyrus.

All of the listed paroxysms are united under the term “special states of consciousness,” that is, its change.

This type of partial seizures is divided according to clinical phenomenology into four subtypes: motor, sensory, autonomic-visceral, and with impaired mental functions.

1. Simple motor partial seizures. They are characterized by localized spasms in certain muscle groups against the background of clear consciousness of the patient. Based on clinical manifestations, the following types of partial seizures are distinguished.

A. Focal motor seizures without marching. This type of seizure is manifested by repeated local convulsive twitching (clonic convulsions), tonic movements (tonic convulsions), and tonic-clonic convulsions. They are characterized by limited distribution and lack of distribution. The epileptic focus is localized in the motor zone of the cortex, corresponding to the somatotopic representation in the motor homunculus.

b. Focal motor partial seizures with marching (Jacksonian). After the focal appearance of convulsions, they spread quite quickly (within 30-60 s) along the hemitype from one muscle group to another, according to their sequence of representation in the motor homunculus (ascending or descending “march”). The epileptic focus is located in the motor cortex. This type of seizure was first described by the English neurologist John Jackson in 1869.

V. Adverse partial seizures. They are characterized by a tonic (tonic-clonic) rotation of the eyeballs, head and (not in all cases) torso in the direction opposite to the hemispheric localization of the epileptic focus. It is usually located in the frontal lobe (anterior adversive field), although cases of these seizures developing when the EO is localized in the parietal lobe (posterior adversive field) have been described.

d. Postural partial seizures. With this type of seizure, adversion of the head and eyes is purely tonic in nature and is usually accompanied by raising with abduction of the arm bent at the elbow with a clenched fist (Magnus-Klein phenomenon). The localization of the epileptic focus usually corresponds to the anterior adversive field.

d. Phonatory partial seizures. The main clinical symptom of these seizures is vocalization - rhythmic pronunciation or (less often) shouting of the same vowels or individual syllables. Less commonly observed is a sudden stop of speech of a non-aphasic type (not associated with damage to Broca's or Wernicke's centers). The occurrence of these seizures is associated with the localization of the epileptic focus in the lower part of the premotor zone or in the supplementary motor zone of the cortex.

Simple motor partial seizures are much more often observed with actual focal cerebral pathology than with epilepsy. Against the background of these seizures, a general convulsive seizure may develop; in these cases, partial seizures are referred to as “motor aura” (from the Greek aura - breath, breeze).

2. Simple sensory partial seizures. These seizures are characterized by elementary sensory sensations that occur paroxysmally without a corresponding stimulus. The sensations can be positive (paresthesia, noise, flashes, etc.) or negative (numbness, hypacusia, scotomas, etc.). Based on clinical manifestations, the following types of simple sensory partial seizures are distinguished.

A. Somatosensory seizures (without marching and with marching). The main clinical manifestation of these seizures is paresthesia ■ - sensations of crawling, electric current, tingling, burning, etc. Seizures can be limited to the area of ​​occurrence or spread upward or downward in a hemi-type similar to a motor march; in this case they are usually referred to as somatosensory Jacksonian seizures. The epileptic focus is localized in the region of the posterior central gyrus, corresponding to the zones of somatotopic sensory representation.

b. Visual, auditory, olfactory, gustatory, vestibular seizures. Their clinical phenomenology: visual - sparks, flashes, stars (focus in the cuneus or gyrus lingualis of the occipital lobe); auditory - noise, crackling, ringing (focus in the area of ​​Heschl's convolutions in the temporal lobe); olfactory - vague or unpleasant odor (focus in the anterior superior part of the uncus of the hippocampus); gustatory - taste of bitter, sour, unpleasant taste in the mouth (focus in the insular or peri-insular area); vestibular - paroxysms of non-systemic or systemic vertigo (focus in the temporal lobe).

Simple sensory partial seizures are much more often observed with actual focal cerebral pathology than with epilepsy. Against the background of these seizures, a general convulsive seizure may develop; generalized tonic-clonic convulsions in these cases are often preceded by a sensory aura (somatosensory, visual, auditory, olfactory, gustatory).

3. Simple autonomic-visceral partial seizures (simple seizures with autonomous symptoms).

These seizures are characterized by two groups of symptoms: digestive and/or vegetative. Digestive phenomena manifest themselves as vague and unpleasant sensations in the epigastric region - a feeling of emptiness, tightness, heat, “weightlessness”. Most often, these sensations “roll up to the throat” and “hit you in the gut.”

fishing,” accompanied by hypersalivation. With vegetative partial seizures, the following manifestations are characteristic: hyperemia of the face, eyes, cheeks; cold extremities; hyperthermia with chills; thirst and polyuria with discharge of light-colored urine; tachycardia with palpitations; increased blood pressure.

Vegetative-visceral seizures are one of the most common types of seizures in epilepsy with localization of the epileptic focus in the visceral region. full-time share They are characterized by a combination with other “temporal seizures” (partial seizures with impaired mental functions, automatisms) and/or transformation into a general convulsive seizure; a generalized tonic-clonic seizure in these cases is preceded by a vegetative or visceral (digestive) aura.

4. Simple partial seizures with mental dysfunction.

This is a fairly large group of seizures, characterized by a variety of clinical phenomena in memory, thinking, mood, and various types of sensitivity. The following types are distinguished.

A. Aphasic. This type of seizure is manifested by speech disorders of the aphasic type in the form of paroxysms of motor or sensory aphasia. The epileptic focus is determined in Broca's or Wernicke's center of the dominant hemisphere.

b. Dysmnestic. Finding yourself in some unfamiliar environment or seeing (hearing) something for the first time, the patient experiences a feeling of “already seen,” “already heard,” “already experienced” (deja vu, deja etendu, deja vecu). Sometimes such illusions are of the exact opposite nature with a feeling of alienation or complete misrecognition of a previously known situation, faces, voices - “never seen”, “never heard”, “never experienced” (jamais vu, jamais etendu, jamais vecu). Dysmnestic seizures can also occur in the form of transient global amnesia and dreamy states; with the latter, the situation seems “unreal”, “different”,

“special”, and the surroundings may seem dull, unclear, unusual. The epileptic focus is localized in the mediobasal regions of the temporal lobe (usually in the right hemisphere).

V. Partial seizures with impaired thinking (ideational). At the beginning of the attack, a thought appears (for example, about death or eternity, something read, events experienced before, etc.), which the patient is unable to get rid of (violent thinking). The localization of the epileptic focus most often corresponds to the deep parts of the frontal or temporal lobe.

d. Emotional-affective. In most cases, the patient suddenly develops an unmotivated feeling of fear (“panic attack”), which is accompanied by corresponding facial reactions, and often forces the patient to hide or run. Pleasant emotional sensations of joy, pleasure, happiness, bliss, etc. are much less common; in literature they are referred to as “Dostoyevsky’s epilepsy” (similar seizures were described by the writer both in himself and in the characters of his literary works). The epileptic focus is usually found in the mediobasal regions of the temporal lobe and (less commonly) in the frontal lobe.

d. Illusory and hallucinatory. Illusory partial seizures are characterized by a distorted perception of a sensory stimulus: visual (dys-metamorphopsia), olfactory, gustatory. The epileptic focus is located in these seizures in the temporal lobe, and in illusory visual ones - in the area of ​​​​the junction of the occipital and temporal lobes.

Illusory seizures also include somesthetic seizures. They are characterized by a violation of the perception of the size or position of parts of their own body and limbs in space: autotopognosia - an arm or leg seems larger, smaller, or special in shape; kinesthetic illusions - sensations of movement in a motionless arm and/or leg, impossibility of movement in a limb, incorrect postures; gender had ya -

feeling of having an extra arm or leg. The focus is localized during somesthetic seizures in the right parietal lobe.

Hallucinatory seizures can be represented by hallucinations of varying degrees of detail. Simple hallucinatory seizures are characterized by the preservation of consciousness; during the seizure or after it, the patient maintains contact with others and can talk about his feelings. During hallucinatory seizures, the epileptic focus is located in the deep parts of the temporal lobe.

Partial seizures with mental dysfunction (especially dysmnestic and emotional-affective) are a common type of seizure in epilepsy with localization of the focus in the temporal lobe. They are characterized by a combination with other “temporal” seizures (vegetative-visceral automatisms) and the possibility of transformation into a general convulsive seizure (generalized tonic-clonic seizures may be preceded by a “psychic” aura - aphasic, dysmnestic, etc.).

1.B. Complex (complex) partial seizures.

Consciousness during these seizures is lost with further amnesia for the events at the time of the seizure. Clinically, they can proceed similarly to the simple partial seizures described above, but with loss of consciousness from the very beginning of the seizure or as it develops. Special types of complex seizures, which always occur with loss of consciousness, are temporal pseudo-absences and automatisms.

A. Temporal pseudoabsences. They occur suddenly and are clinically characterized only by loss of consciousness lasting 1-2 minutes. The lesion is found in the mediobasal regions of the temporal lobe.

b. Automatisms (psychomotor seizures). This type of seizure represents actions of varying degrees of complexity that the patient performs against the background of lost or twilightly narrowed consciousness. Subsequently, the patient becomes amnesiac about the actions at the time of the attack, or only fragments of memories are retained about them.

The duration of simple automatisms usually does not exceed 5 minutes. These can be oral automatisms (swallowing, chewing, licking, sucking movements, sticking out the tongue), gestures (rubbing hands or face, rearranging things), facial (expressing fear, anger, joy, laughter), speech (pronouncing individual letters, syllables, words, individual phrases), procurative (a short-term episode of walking in which the patient “bumps” into objects or people). Simple automatisms occur in most cases with loss of consciousness, and they themselves subsequently become completely amnesic.

Outpatient automatisms are more complex and lasting. They occur in a state of twilightly narrowed consciousness, so the patient gives the impression of a thoughtful or not quite awakened person - he comes into contact only after repeated contact, answers questions in monosyllables or not to the point, and at times “withdraws into himself.” Automatism itself can be manifested by such oriented and correct actions as walking while avoiding obstacles, crossing the street at a traffic light, traveling in public transport, etc. However, there is no goal in such actions, and they themselves are performed unconsciously. At the end of outpatient automatism, the patient cannot explain how and why he found himself in an unfamiliar environment, what he did during the attack, who he met, etc. In some cases, the duration of automatism reaches several hours and even days (epileptic trances). With them, patients make long journeys, wander, “lead a second life” (Bekhterev V.M., 1923). A type of ambulatory automatism such as somnambulism can also have an epileptic nature (A.I. Boldyrev, 1990). (sleepwalker, dream-like state).

Automatisms are a fairly common type of seizures in epilepsy with localization of the epileptic focus in the temporal or frontal lobe. They are combined in most patients with epilepsy with other temporal partial seizures (vegetative-visceral-

severe, with impaired mental functions) and secondary generalized convulsive seizures.

Epilepsy is a disorder of the conduction of nerve impulses in the brain, which occurs with epileptic seizures of varying severity and symptoms. The pathogenesis of this disease is a disruption of neural communication in the brain. Unlike the generalized form of this disease, which affects both hemispheres, partial epilepsy is associated with damage to individual areas of the brain.

Classification of partial epilepsy

Medical classification of this type of disease is based on the area of ​​the brain where increased activity is detected during an epileptic seizure. By the way, the localization of the focus of pathological nervous excitability determines the clinical picture of the seizure:

• Temporal lobe epilepsy is the most common form of partial epilepsy. It accounts for up to half of the cases of this disease.
• Frontal epilepsy ranks second in prevalence. It is diagnosed in 24–27% of patients with partial epilepsy.
• Occipital partial epilepsy affects approximately 10% of patients.
• The parietal is the least common (1% of cases).

The location of the lesion in the brain can be determined by performing an electroencephalogram (EEG). The examination is done at rest, during sleep (polysomnography). But the most important thing for diagnosing partial epilepsy is taking EEG readings during an attack. Since it is almost impossible to “catch” it, special medications are administered to the patient during the examination to stimulate a seizure.

Reasons for the development of the disease

Many doctors agree that partial epilepsy is in most cases a multifactorial disease. Moreover, its main cause is genetic predisposition. It is believed that this is due to the fact that partial epilepsy often manifests in childhood or adolescence.

The following pathological conditions can provoke the onset of the development of the disease and increase the frequency of attacks, as well as become an independent cause:

• Benign or malignant neoplasms brain.
• Cysts, hematomas, abscesses.
• Aneurysms, vascular malformations.
• Ischemia, strokes and other pathologies that cause persistent circulatory disorders in the brain.
• Neuroinfections (meningitis, encephalitis, syphilis, etc.).
• Congenital pathologies of the development of the nervous system.
• Head injuries.

Under the influence of such factors, a set of neurons in a certain lobe of the brain begin to generate signals of pathological intensity. Gradually, this process affects nearby cells - an epileptic seizure develops.

Symptoms. Types of partial seizures.

The clinical picture of epileptic seizures in all patients is purely individual. However, there are several types of seizures. Simple partial seizures occur with complete or partial preservation of consciousness. This condition can manifest itself in the following form:

• Low-intensity muscle contractions of the facial muscles, muscles of the arms and legs, a feeling of tingling, numbness, “goosebumps” on the skin.
• Turning of the eyes with simultaneous turning of the head and sometimes the body to the same side.
• Chewing movements, grimaces, drooling.
• Stopping speech.
• Epigastric pain, feeling of heaviness in the abdomen, heartburn, increased peristalsis with symptoms of flatulence.
• Visual, olfactory, taste hallucinations.

Complex partial seizures are observed in approximately 35–45% of patients. They are accompanied by loss of consciousness. The person understands what is happening to him, but is unable to answer questions addressed to him or speak. At the end of the attack, amnesia is observed, when the patient does not remember what happened.

Epilepsy: Partial motor epileptic seizure

Epilepsy: Secondary generalized seizure

Epilepsy. Questions and answers

Often the onset of focal pathological activity covers both hemispheres of the brain. In this case, a secondary generalized seizure develops, which most often manifests itself in the form of convulsions. Complex partial seizures of epilepsy are characterized by the following symptoms:

• The appearance of negative emotions in the form of fear of death, inexplicable severe anxiety.
• Experiencing or concentrating on events or words that have already happened.
• Being in a familiar environment, a person perceives it as unfamiliar or, conversely, experiences a feeling of “déjà vu.”
• A feeling of unreality of what is happening, the patient observes himself from the outside, can identify with the characters of books he has read or films he has watched.
• The appearance of automatisms - certain movements, the nature of which is determined by the area of ​​​​brain damage.

In the interictal period in the initial stages of partial epilepsy, a person may feel normal. However, over time, symptoms of the underlying disease or brain hypoxia progress. This is accompanied by symptoms of sclerosis, headaches, personality changes, and dementia.

Treatment

Partial epilepsy is an incurable disease. Main goal drug therapy– achieve a reduction in the number of attacks, that is, remission of the disease. For these purposes the following are most often prescribed:

• Carbamazepine. This drug is considered the “gold standard” in the treatment of all forms of epilepsy. Start taking it with a minimum dose (for an adult it is 20 mg/kg), and then, if necessary, increase the dosage.
• Depakine.
• Lamotrigine or Lamictal.
• Topiramate.

Sometimes combinations of two antiepileptic drugs are used to achieve a better effect. However, recently, such treatment tactics are rarely used due to the high risk of side effects.

In approximately a third of patients drug therapy"doesn't work" In this case, neurosurgery is recommended.

Partial epilepsy is a neurological diagnosis indicating a brain disease that occurs in a chronic form.

People knew this disease back in ancient times. The very first authors to write works on epilepsy were Greek scientists. Today, 40 million people are susceptible to all forms of epilepsy known to medicine.

For centuries, people believed that it was impossible to get rid of epilepsy, but today experts have refuted such a judgment. This disease can be overcome: about 60% of those affected can lead a normal life, and in 20% the occurrence of attacks can be prevented.

Manifestation of partial epilepsy

Epilepsy is usually called a disease that occurs against the background of spontaneous excitation of neurons located in one or several areas of the cerebral cortex; as a result of this excitation, an epileptogenic focus is formed. Along with the attack, disturbances appear in:

• Activities of the musculoskeletal system.
• Speech functions.
• Reactions to the world around us.
• Presence of spasms.
• Cramps.
• Numbness of the body.

Precursors of an attack characteristic of this pathology are:

1. Increased body temperature.
2. Dizziness.
3. Feeling anxious.
4. Absent-mindedness.

Such sensations are usually called an aura; they are associated with the affected area of ​​the cerebral cortex. A person describes similar sensations to the doctor, and a specialist, in the shortest possible time, uses them to diagnose the disease and establish its clinical picture.

An attack occurring in mild form, may go unnoticed by the people around the patient; more severe forms are already an obstacle to normal life. An epileptic needs to completely limit himself from playing sports, consuming alcohol and tobacco products, experiencing an emotional background, and driving a car.


A patient suffering from partial epilepsy can instantly become an outcast from society, since due to an unexpected loss of control over his own body, he can frighten other people.

Characteristics of partial epileptic seizures

The area of ​​brain damage caused by partial seizures is localized in certain areas. They are in turn divided into simple and complex. When observing a simple attack, human consciousness remains intact; during a complex attack, the opposite picture occurs.

Simple attacks are accompanied by clonic convulsions of some parts of the body, severe salivation, blueness of the skin, foam at the mouth, rhythmic muscle contractions, and impaired respiratory function. Duration of the attack - 5 minutes.

If a patient begins to have a tonic attack, then he has to take a certain position; this is a necessary measure due to tension in the muscles of the body. In this case, the head is thrown back, the epileptic falls to the floor, he stops breathing, because of this the patient’s skin turns blue. Duration of attack - 1 minute.

In a severe partial attack, consciousness is impaired. The lesion affects the areas responsible for attention and touch. The main symptom of such an attack is stupor. The patient freezes in place, his gaze is directed to one point, he begins to perform the same actions, loses connection with the world around him for a minute or more. Having regained consciousness, the epileptic does not remember what happened to him.

Types of partial seizures

Sensory partial seizure accompanied by hallucinations:

• Flavoring.
• Visual.
• Auditory.

The type of hallucination depends on the locality of the lesion in a certain place. A person may experience numbness in some parts of the body.

Autonomic partial seizure is the result of damage to the temporal lobe. It is characterized by the following symptoms:

• Profuse sweating.
• Drowsiness.
• Depressive state.
• Frequent heartbeat.

When partial epilepsy transitions to generalized, both hemispheres are affected simultaneously. Such attacks are typical for 40% of patients. In this case, experts call absence seizure a type of epilepsy. This disease occurs in children and adolescents.

The disease is more typical for girls. In appearance, the attack looks like fainting, turning into a state of stupor. The number of absence seizures can reach up to 100 cases per day. This condition can be activated by factors such as:

• Bad dream.
• Flashes of bright light.
• Phase of the menstrual cycle.
• Passive state.

First aid

First aid for an epileptic is carried out as follows:

1. Determine that the patient is actually having an attack.
2. The patient's head should be turned to the side to avoid tongue sinking and suffocation.
3. If an epileptic has a vomiting problem, he should be turned on his side so that he does not choke.
4. The patient must be placed on a completely flat surface and his head supported.
5. Under no circumstances should a person be transported, restrain convulsions, or do artificial respiration, and also unclench your teeth.
6. From the moment the attack ends, the patient must be given the opportunity to recover.

Treatment

A neurologist may prescribe for people suffering from epileptic seizures drug treatment in the form of antiepileptic drugs: valproic acid, phenobarbital, midazolam, diazepam and so on.

If drug therapy does not bring any effect, then experts recommend surgery, as a result of which part of the brain is removed - the source of partial epilepsy.

Epileptic seizures can be partial (focal, local), arising as a result of focal neural discharges from a localized area of ​​one hemisphere. They occur without impairment of consciousness (simple) or with impairment of consciousness (complex). As the discharge spreads, simple partial seizures can develop into complex seizures, and simple and complex seizures can transform into secondary generalized seizures. Partial seizures predominate in 60% of patients with epilepsy.

A. Simple partial seizures

In previous classifications, to designate similar precursors of secondary generalized seizure the concept of “aura” (Pelonos term) was used, which means “a whiff, a light breeze.” Neurosurgeons and neurologists call the aura a “signal symptom”, since its character is one of the main clinical criteria to determine the primary epileptic focus. With a motor aura (when the patient begins to run), or rotatory (spinning around its axis) - the epileptic focus is located in the anterior central gyrus, with a visual aura (“sparks, flashes, stars in the eyes”) - the epileptic focus is localized in the primary cortical center of vision occipital lobe, with an auditory aura (noise, crackling, ringing in the ears) - the focus is located in the primary center of hearing (Heschl's gyrus) in the posterior parts of the superior temporal gyrus, with an olfactory aura (sensation of an unpleasant odor) - the focus of epileptic activity is usually located in the cortical center sense of smell (anterior upper part hippocampus), etc.

Thus, the “aura” can be a simple partial seizure without loss of consciousness (“isolated aura”), or it can be a stage of a secondary generalized seizure. In this case, the sensations that the patient experiences during the aura are the last thing he remembers before losing consciousness (usually there is no amnesia for the “aura”). The duration of the aura is several seconds (sometimes a fraction of a second), so the patient does not have time to take precautions to protect himself from bruises and burns when falling.

As for simple partial motor seizures (I, A, 1), they are usually called Jacksonian, as they were described by Jackson in 1869, who was the first to establish that their occurrence is associated with a focal lesion of the anterior central gyrus (usually begins with twitching of the corner of the mouth , then other facial muscles, tongue, and then the “march” moves to the arms, torso, legs of the same side).

Timely diagnosis of simple partial vegetative-visceral seizures is of great importance for the practitioner (I, A, 3). These seizures occur as isolated paroxysms, but can transform into complex partial seizures or are an aura of secondarily generalized convulsive seizures. It is customary to distinguish between 2 clinical variants of these seizures:

• visceral seizures - unpleasant sensations in the epigastric region that “roll up to the throat”, “hit the head” (epigastric aura), paroxysmal sexual phenomena in the form of irresistible sexual desire, erection, orgasm (“orgastic seizures”),
• vegetative seizures - characterized by pronounced vasomotor phenomena - facial hyperemia, impaired thermoregulation with an increase in body temperature to subfebrile with a feeling of chills, thirst, polyuria, tachycardia, sweating, bulimia or anorexia, increased blood pressure, algic symptoms (cardialgia, abdominal algia, etc.) .

Often isolated visceral-vegetative paroxysms (or psycho-vegetative crises, as they are now called) are considered as a manifestation of “vegetative-vascular dystonia”, “neurocirculatory dystonia”, “ autonomic neurosis", etc., which leads to diagnostic errors and inadequacy of therapy.

There are criteria characteristic of epileptic vegetative seizures. These include:

• weak expression or absence of provoking factors for their occurrence, including psychogenic ones;
• short duration (does not exceed 510 minutes);
• convulsive twitching during an attack;
• tendency to have serial attacks;
• post-paroxysmal stupor and disorientation in the environment;
• combination with other epileptic seizures;
• photographic identity of vegetative-visceral paroxysms, in which each subsequent attack is an exact copy of the previous one;
• changes in the EEG characteristic of epilepsy in the interictal period in the form of hypersynchronous discharges;
• bilateral bursts of high-amplitude activity;
• peak wave complexes - slow wave and other specific epileptic changes in brain biopotentials.

Previously, many researchers considered autonomic-visceral disorders as a result of damage to the interstitial brain (diencephalon) under the terms “diencephalic syndrome”, “diencephalosis”, “diencephalic crises”, “hypothalamic autonomic syndrome”, “diencephalic epilepsy”.

It has now been established that the localization of the epileptic focus during vegetative-visceral seizures can be not only in the diencephalic region, but also in other brain structures:

• amygdala-hippocampal region;
• hypothalamus;
• opercular region;
• orbitofrontal region;
• parietal;
• temporal lobe of the brain.

In this regard, autonomic-visceral seizures are studied in the section of “symptomatic locally caused epilepsy” (International Classification of Epilepsy, New Daily, 1989).

“Simple partial seizures with mental impairment” (“mental seizures”) are presented in section I.A.4. “Mental seizures” include a variety of psychopathological phenomena that occur in patients with epilepsy, both in the form of isolated attacks and in the form of secondarily generalized convulsive seizures. This group includes the following seizures.

1.A.4.a. Aphasic seizures were first described in 1957 by W. Landau and F. Kleffner under the name “acquired epileptic aphasia.” Most often they appear at the age of 37 years. Aphasia is the first symptom and is of a mixed sensorimotor nature. Speech disturbances occur over several months. At first, children do not respond to addressed speech, then they begin to use simple phrases, individual words, and finally stop speaking altogether. Sensorimotor aphasia is accompanied by auditory verbal agnosia, and therefore patients are diagnosed with early childhood autism and hearing loss. Epileptic seizures (generalized tonic-clonic, atonic, partial), as a rule, occur within several weeks after the development of aphasia. As the disease progresses, most patients experience behavioral disorders in the form of hyperactivity, increased irritability, and aggressiveness. The EEG reveals typical changes in the form of high-amplitude multifocal spikes or peak wave complexes in the centrotemporal and centrofrontal sections of both the dominant and subdominant hemispheres. During sleep, epileptic activity is activated, the peaks and complex spread to both hemispheres.

I.A.4.6. Dysmnestic seizures. These include paroxysms of “already seen”, “already heard”, “already experienced” (dejavu, deja etendu, deja vecu). As a rule, the phenomenon of “deja vu” is expressed in a feeling of familiarity, identity, and repeatability of impressions that arise in the process of perception. In this case, there is a kind of photographic repetition of an already former situation; it seems that the entire situation is being repeated in detail, as if it had been photographed in the past and transferred to the present. The objects of reduplicated experiences are a wide variety of phenomena related to both perceived reality and the mental activity of the patient (visual and auditory impressions, smells, thoughts, memories, actions, deeds). The reduplication of experiences is closely intertwined with the patient’s personality, refracted through it - not the events themselves are repeated, but their own mood, in tune with some kind of past. It is not some abstract words of the song that seem to be heard, but precisely those conversations and conversations in which the patient himself took part: “I already thought so, worried, experienced similar feelings in relation to this situation.” When attacks of “deja vu” appear, patients painfully try to remember when they could see this or that state of affairs, situation, trying to concentrate their attention on this memory. Subsequently, when these conditions are repeated, patients, not finding the identity of the experienced sensations in their own real life, are gradually inclined to the conclusion that all this is familiar to them from dreams, although they never manage to localize these dreams in a certain time interval. The essential features of “deja vu” epileptic disorders are their paroxysmal nature, stereotypy and photographic repeatability, in which each subsequent attack is an exact copy of the previous one. During an attack, patients feel as if they are in another dimension, freeze in place, hear words addressed to them, but their meaning is difficult to understand. The gaze becomes motionless, focuses on one point, and involuntary swallowing movements are observed. At these moments, they are completely focused on the “deja vu” experience, unable to take their eyes off the object. This feeling is compared to reading interesting book when no force can force you to break away from it. After the end of the attack, they feel weakness, fatigue, drowsiness, and sometimes loss of performance, that is, a condition close to that which occurs after generalized tonic-clonic seizures.

The occurrence of “deja vu” attacks is associated with the amygdalohippocampal localization of the epileptic focus, and with a right-sided focus, “already seen” occurs 39 times more often than with a left-sided one.

I.A.4.B. Ideatorial seizures are characterized by the appearance of alien, violent thoughts, while the patient seems to be “stuck” on one thought that he is unable to get rid of, for example, about death, eternity, or something he has read. Patients describe such conditions as “an alien thought”, “double thought”, “thought cessation”, “speech arrest”, “speech paralysis”, experience the experience of “splitting of thinking from speech”, “a feeling of emptiness in the head”, “thoughts run with incredible speed” - that is, all these disorders are close to schizophrenic (“sperrung”, “mentism”) and require differential diagnosis with schizophrenia.

The localization of the epileptic focus in patients with ideation seizures corresponds to the deep parts of the frontal or temporal lobe.

1.A.4.G. Emotionally affective seizures. Patients develop unmotivated, paroxysmal fear with ideas of self-accusation, premonition of death, “the end of the world,” reminiscent of psychovegetative crises with a predominance of anxiety disorders (“ panic attacks"), which causes patients to run away or hide.

Attacks with positive emotions (“happiness”, “delight”, “bliss”, with brightness, volume, relief of the perception of the environment), as well as with experiences close to orgasm, are much less common.

F. M. Dostoevsky described his condition before the development of a secondarily generalized convulsive seizure:

"All of you, healthy people, and you have no idea what happiness is, the happiness that we, epileptics, experience a second before a seizure... I don’t know whether this bliss lasts seconds or hours, or eternity, but believe the word, all the joys that life can give , I wouldn’t take it for him.”

F. M. Dostoevsky describes the emotionally affective aura of the hero of the novel “The Idiot”, Prince Myshkin, even more figuratively and vividly:

“...suddenly, in the midst of sadness, spiritual darkness, pressure, his brain seemed to ignite for moments, and with an extraordinary impulse his mind and all his vital forces tensed. The feeling of life and self-awareness almost increased tenfold in these moments, which lasted like lightning. The mind and heart were illuminated with extraordinary light; all his worries, all his doubts, all his worries seemed to be pacified at once, resolved into some kind of supreme calm, full of clear, harmonious joy and hope...”

The epileptic focus in patients with emotional-affective seizures is most often found in the structures of the limbic system.

1.A.4.D. Illusory seizures. Phenomenologically, this group of seizures does not belong to illusions, but to psychosensory disorders. Among them, the following types of psychosensory synthesis disorders are distinguished.

1. Attacks of metamorphopsia are characterized by sudden experiences that surrounding objects begin to change their shape, stretch out, twist, change their locations, are in constant motion, it seems that everything around is spinning, a closet, a ceiling is falling, the room is narrowing, there is a feeling that the surroundings float away somewhere, objects rise up, begin to move, move towards the patient or move away. This phenomenon is described in the literature under the name “optical storm” and is associated with a violation of the constancy of perception, as a result of which the objective world turns into kaleidoscopic chaos - flickering colors, shapes, sizes. The vestibular component is the leading one in the structure of attacks of metamorphopsia - “ When we detect vestibular disorders, we pull out the whole gamut of psychosensory phenomena as if by a thread"[Gurevich M. O., 1936].

The epileptic focus in patients with metamorphopsia is often localized at the junction of the temporal, parietal, and occipital lobes.

2. Attacks of “body schema” disorders (somatopsychic depersonalization), in which patients experience sensations of enlargement of body parts, sensations of rotation of the body around its axis, experiencing lengthening, shortening, and curvature of limbs.

In some cases, disorders of the “body diagram” are massive, fantastic, and absurd (“arms and legs are torn off, separated from the body, the head grows to the size of a room,” etc.). Here is an observation.

Example. Patient Sh., 14 years old, 2 months after a severe flu with symptoms of meningoencephalitis, before falling asleep with her eyes closed, began to feel that her hands were bulging and, turning into balls, were flying around the room. At first it was very interesting and funny, but these states began to be observed every evening, each time becoming more complex and acquiring new details. I felt that the bones were diverging, being separated from the muscles, the muscles were twisting around objects, and the body was crumbling into bones, spinning before my eyes. The patient felt that her head was enlarged, spinning around her neck, then flying to the side and running after her. I felt that my hands were changing shape and size: sometimes they were thick and short, sometimes long and airy, like a wolf from cartoons. She was convinced that convulsive seizures were a blessing compared to the experiences described above, “it is so painful and difficult to feel that your own body is disintegrating into bones spinning in the air.”

3. Paroxysms of autopsychic depersonalization are characterized by experiences of the unreality of one’s “I”, a feeling of a barrier, a shell between oneself and the outside world. Patients cannot integrate all objects and phenomena into one; they experience fear of the unusualness and unknowability of their surroundings. Their own face seems alien, dead, distant to them. In some cases, the alienation of the perception of one’s own personality can reach the severity of autometamorphosis syndrome with the experience of transformation into another person.

The epileptic focus in this group of patients is often localized in the right parietotemporal lobe.
4. Derealization paroxysms are characterized by:

• a feeling of unreality, unnaturalness, unusual perception of the environment;
• lack of three-dimensionality of perception (objects seem flat, as in a photograph);
• dullness, pallor of the surrounding world, loss of sharpness and clarity of its perception;
• changes in the perception of color and coloring of the environment;
• alienation of objects, persons (“dehumanization” of the environment);
• a feeling of the unknown, the unknowability of the real world;
• loss of meaning of the internal meaning of the environment;
• worthlessness, uselessness of the surrounding, emptiness of the external world;
• experiences of the “immateriality” of the environment, the inability to perceive the world around us as reality.

In this state, objects are perceived as if they are not real, the situation seems unnatural, unreal, and it is difficult for consciousness to comprehend the meaning of what is happening around. Here is an observation.

Example. Patient Yu., 16 years old. 5 years after the first convulsive seizure, a feeling began to appear that the speech of others suddenly lost its usual meaning. At the same time, words, phrases, letters suddenly acquired some kind of special meaning, understandable only to him. At that moment, it seemed to him that he somehow understood the inner meaning of phrases in a very cool, original way - a person’s voice was heard, but something special, something else was guessed, only by the movements of the head, lips, hands of those around him did he know that the person was saying or asking for something. The duration of this state lasted several seconds, while consciousness did not turn off, the ability to react to the environment did not disappear, but he was so absorbed in experiences that other thoughts and reasoning did not appear. In this state he could not utter a word, although he emphasized that if he could concentrate very much, he could answer any question in monosyllables.

The epileptic focus in these patients is usually located in the posterior parts of the superior temporal gyrus.

Thus, the entire group of simple partial seizures with impaired mental functions is characterized by a state of altered consciousness, known as “special states of consciousness.”

The first use of the term “special states” (Ausnahmezustande) belongs to N. Gruhle (1922), which he understood as mild twilight states with a disturbance of affect, hallucinatory delusional experiences, but without subsequent amnesia, that is, consciousness changes, but is not darkened, as in twilight states " According to this position, the difference between special and twilight states is only quantitative, that is, in special states a lesser degree of disturbance of consciousness occurs, and therefore amnesia does not develop.

The same disorders, but under a different name (dreamy states), were studied by I. Jackson (1884), analyzing patients with epilepsy with an “intellectual aura.” He described “dream states” as “the sudden appearance in the mind of images that are not related to the real situation, strangeness, unreality, a feeling of altered perception of the environment, the absence of amnesia after the end of the attack, as well as the presence of illusions, taste and olfactory hallucinations, and violent memories.”

However, the modern understanding of “special states of consciousness” is associated with the concept of M. O. Gurevich (1936), who identified the “lacunar nature of disturbances of consciousness” as the main feature of “special states,” in contrast to the generalized nature of twilight states. Lacunarity is expressed not only in the absence of amnesia, but also in the fact that after the end of the attack, patients are critical of what they experienced during special conditions and, as a rule, do not come to a delusional interpretation.

M. O. Gurevich considered the main symptoms of “special states of consciousness” to be psychosensory disorders, which included depersonalization, derealization, the phenomenon of “deja vu”, disturbance of the body diagram, metamorphopsia, spatial disorders in the form of a symptom of turning the environment by 90° and 180°, optic-vestibular violations. At the same time, M. O. Gurevich did not recognize the possibility of combining psychosensory disorders with visual, auditory, olfactory hallucinations, and even more so with delusional ideas. However, in later works, other authors included in the group of psychosensory disorders verbal true and pseudohallucinations, visual hallucinations and phenomena of mental automatism, olfactory and gustatory hallucinations, violent memories, and perceptual deceptions of orientation.

1. A.4.e. Hallucinatory seizures.

1. Olfactory hallucinations (paroxysmal sensations of odors that do not exist at the moment). As a rule, patients feel one strictly defined, sharply unpleasant odor of gasoline, paint, and feces. However, the smell may be undifferentiated and difficult to describe.
2. Gustatory hallucinations are manifested by unpleasant sensations of taste in the mouth (metal, bitterness, burnt rubber).
3. Auditory hallucinations are divided into elementary (acoasms - noise, crackling, whistling) and verbal ("voices" of a threatening, commentary imperative nature).
4. Visual hallucinations can also be elementary (flashes of light, dots, circles, lightning) and complex with panoramic images of people, animals and their movement. Often patients observe a change in pictures, the dynamics of the plot, like in a movie. Particularly characteristic are ecmnestic hallucinations (memory hallucinations), manifested in the appearance of images and scenes that actually took place in the patients’ lives many years ago. Sometimes they reach such brightness and imagery that patients seem to be watching a film in which they see themselves from the outside (autoscopy).

B. Complex partial seizures

Most often, complex partial seizures with automatisms are observed (1.B.2.6) - the former name is “psychomotor seizures,” which are variants of twilight stupefaction.

Their main clinical manifestation is the patient’s involuntary motor activity with the performance of actions of varying complexity against the background of twilight stupefaction. The duration of the attacks is 35 minutes, after their completion complete amnesia occurs.

Based on the nature of the dominant automatism, the following varieties are distinguished:

1. Attacks of oral automatism (oralimentary seizures) - manifest themselves in the form of swallowing, chewing, sucking, licking, tongue protruding and other opercular symptoms.
2. Automaticity of gestures - characterized by rubbing hands, unbuttoning and buttoning clothes, sorting through objects in a purse, rearranging pieces of furniture.
3. Speech automatisms - pronouncing meaningless words and phrases (connected or incoherent).
4. Sexual automatisms - manifested by masturbation, depraved acts, exhibitionism (more common in men).
5. Outpatient automatisms are characterized by the movement of patients in a state of twilight stupefaction (they strive to run somewhere, push away others, knock down objects standing in their way).
6. Somnambulism (sleepwalking) - during daytime or night sleep, patients perform automated, sometimes life-threatening actions.