The I.M.

Sechenov First Moscow State Medical University

Chair of nervous diseases

Paroxysmal disturbances:
epilepsy, syncope, panic attacks.
Definition of epilepsy

Epilepsy - a chronic brain disease from various etiologies,

manifested by repeated disorders of motor, sensory,
autonomic or mental function resulting from excessive
neuronal discharge.
Pathophysiology of epilepsy

Epileptic neurons

Epileptic foci

Inhibition deficit

Sensitization
Etiology of epilepsy

Idiopathic epilepsy - genetically determined defects not associated

with a significant structural abnormalities of the brain

Abnormal sensitivity of
neurons to depolarization

Abnormal quantity or quality

of transmitters and receptors

Hereditary metabolic defect

Etiology of epilepsy

Infection

Trauma

Tumor
Abnormalities of
cerebral cortex
Hypoxia

Hemorrhage Stroke

Vascular
malformation
Classification of seizures
Generalized (convulsive and non-convulsive)
Absences (small seizures)
Tonic-clonic (large seizures)
Clonic
Tonic
Myoclonic

Partial (focal)
Simple (consciousness not impaired)
with motor symptoms
with sensory symptoms
with autonomic symptoms
with psychiatric symptoms
Complex
Secondary generalized
Generalized tonic-clonic seizures
Tonic phase

Simultaneous bilateral
seizure activity

Clonic phase
Tonic-clonic phase
lasts in munuties

Postictal phase

Postictal phase
from minutes
to hours
EEG in tonic-clonic seizure

Tonic phase Clonic phase Postictal phase

Assistance in tonic-clonic seizure
Record the nature
and duration of
the seizure
Absences
Cortex

Thalamus

Suddenly start

2 - 15 sec.

Suddenly stop

EEG in absences
Simple partial seizures (partial motor seizures with Jacksonian march)

Motor cortex leg

trunk
shoulder
palm
face

EEG

Partial motor seizure on right side

After seizure the paresis may persist (Todd paralysis)

Simple partial seizures (partial motor and somatosensory seizures)
Supplementary motor cortex
Sensory cortex
leg
trunk
shoulder
palm
face

Numbness
and tingling

Simple partial seizures originating Sensory symptoms are distributed

in the supplementary motor cortex like the Jacksonian march
Simple partial seizures (sensory seizures)

Olfactory seizures
(hamate gyrus)

Simple audio Complex visual hallucinations

illusions or
hallucinations

Complex auditory
hallucinations
Simple visual hallucinations
Simple partial seizures (sensory taste, visceral and
autonomic seizures)

nausea
Sensory unusual or
taste seizures unpleasant taste
sweating

redness

repletion
Visceral Autonomic
Complex partial seizures (psychomotor automatisms)

Limbic brain structures involved

in most automatisms

chewing, smacking

patient unconsciously continues what the deal

clapping or
rubbing his hands

Repetitive, seemingly purposeful

activity (dressing and undressing) rolling pills
Generalization of epileptic activity in temporal lobe epilepsy

Simple partial Complex partial Secondary generalized

seizure seizure tonic-clonic seizure
Causes of personality changes in patients with epilepsy

organic brain damage

repetitive neuronal discharges, disorganize the function
of various areas of brain
patient's response to disease and its social
consequences
side effects of anticonvulsants
Investigation of patient with epilepsy

1. Detection of epileptic activity and location of the epileptic focus

Electroencephalography (EEG) 50%
EEG with provocative tests (hyperventilation rhythmic photostimulation) 70%
EEG after sleep deprivation 80%
EEG (printing) sleep 90%
EEG-video monitoring
Positron Emission Tomography (PET)
2. Identifying the cause of symptomatic epilepsy
MRI
CT-scan
EEG-video monitoring
General principles of treatment of epilepsy

Non-drug methods (rejection of the consumption of alcohol,

sufficient sleep)
Choice of antiepileptic drugs to the type of seizure, individual
selection of doses and combinations
Continuity
Duration
May be gradual (over 3-6 months) withdrawal of the drug in 2-5
years after remission
Medication for treatment of epilepsy
Generalized convulsive seizures:
valproate 900-1200 mg / day
carbamazepine 600-800 mg / day
lamotrigine 300-400 mg / day
phenobarbital 100-150 mg / day
phenytoin (phenytoin) 200-300 mg / day
Absences
valproate 900-1200 mg / day
ethosuximide 750 mg / day
clonazepam 6.4 mg / day
lamotrigine 300-400 mg / day
Partial seizures:
carbamazepine 600-800 mg / day
valproate 900-1200 mg / day
lamotrigine 300-400 mg / day
topiramate 200 mg / day
gabapentin 1200-1800 mg / day
levitiratsetam 1500 mg / day
Epileptic status

Prolonged epileptic condition arising from prolonged seizures or

seizures, repeated at short intervals, between which the patient
does not come in clear consciousness.
Causes of epileptic status

Poorly controlled epilepsy

Anticonvulsants cancel

Alcohol or drugs

Stroke

Trauma

Meningitis

Encephalitis
Treatment of epileptic status

Providing breathing, preventing asphyxia

i/v 10-20 mg of diazepam (Relanium) with 40% glucose, again (interval >
10 minutes) 40 mg
i/v Depakin 400-800 mg
Hospitalization in an intensive care unit
Narcosis
midazolam (Dormikum) i/v 0.2 mg / kg, then 0.1-1 mg / kg / h
hydroxybutyrate sodium 20% 1-2ml/min (10 ml)
sodium thiopental (Hexenal) 1g in 10 ml saline solution (1 ml per 10 kg)
i/v slowly for 1-2 minutes (max of 80 ml / day)
nitrous oxide and oxygen 1:2
Control of acid-base balance correction, electrolyte, glucose metabolism
and blood coagulation system
After the relief of cramps oral anticonvulsants (as required by tube)
Syncope - a condition that occurs due to transient
ischemia and hypoxia of the brain, manifested by a brief
breakdown of consciousness, accompanied by loss of
muscle tone, cardiovascular and respiratory disorders.
Types of syncope
Neurogenic
Vazodepressive (vasovagal)
Carotid sinus hypersensitivity
Orthostatic
Hyperventilation
Psychogenic
Somatogenic
Cardiogenic
In cerebrovascular disorders
In progressive autonomic failure (PAF)
Hypovolemic
Metabolic (hypoxia, hypoglycemia, intoxication)
Cough (bettolepsiya)
Iatrogenic
Investigation of patient with syncope
Anamnesis, clinical investigation
Orthostatic test
Carotid sinus massage
Clinical blood analysis
The blood level of glucose
Electrolytes (Na, K, Ca)
Cardiac fraction of CPC, troponin test
Electrocardiography
Holter ECG monitoring
ECG stress (bicycle ergometry)
Echocardiography
Electroencephalography
EEG-video monitoring
Duplex scanning of the main arteries of the head
CT and MRI
MR - angiography
Management of patient with syncope
Vazodepressive syncope
rational psychotherapy
sufficient amount of fluids and salts
avoid starvation, alcohol, stuffy room, intense exercise
in resistant cases:
minimal doses of beta-blockers
selective serotonin reuptake inhibitors
Carotid sinus syncope
Avoid sudden changes in the head, tight collars
Do not use an electric shaver
Orthostatic syncope, PAF
increased intake of fluid and salt
split meals
stockings
head of the bed elevated
mineralocorticoids (fludrokortizon)
alpha-agonists (midodrine)
Anxiety disturbances

5-10% of the population

Many patients treated in
different medical
specialties with wrong
diagnosis and receive
inadequate treatment
Frequent signs of anxiety disturbances

irritability and anxiety

fatigue and decreased performance capacity
anxiety attacks (panic attacks)
autonomic dysfunction
sleep disorders
Panic attack diagnostic criteria
Four of the following symptoms develop abruptly and reach a peak within 10 minutes
feeling lack of air, dyspnea
shortness of breath, choking sensation
feeling of heart beat
discomfort in the left side of the chest
dizziness, unstability
weakness, presyncope
chill, tremor
flushes of heat or cold
sweating
paresthesia
fear of death
fear of making uncontrolled action
derealization, depersonalization
Repeatability attacks: at least 4 episodes over 4 weeks
No communication with organic brain disease, intoxication, or physical illness
Treatment of patients with panic attack

Relief of a panic attack

psychotherapy
tranquilizers
sedatives
Prevention of recurrence of panic attacks
psychotherapy
antidepressants
TCA (amitriptyline, clomipramine)
SSRIs (fluoxetine, sertraline, paroxetine etc.)
atypical benzodiazepines (clonazepam, alprazolam)
Treatment of the underlying syndrome / illness - depression and anxiety disorders
psychotherapy
antidepressants
tranquilizers and sedatives
small neuroleptics
symptomatic therapy (beta-blockers, anti-asthenic drugs)