Epilepsy in old age: causes and manifestations

Epilepsy is a common neurological disease that is diagnosed at least as often as stroke in older people. The course of this pathology among older people is especially dangerous, since the body is more susceptible to influence, and attacks occur much more often. It is almost impossible to predict epileptic seizures.

Diagnostic tests and studies for epilepsy among older patients are lacking. Diagnosing this diagnosis among people of this age category is not easy. It will take many years of experience to determine the etiology of the disease, the stage and form of epilepsy, and possible risks. Only a qualified epileptologist can select the correct treatment method for the disease.

Despite the fact that the number of patients with epilepsy increases every year, little attention is paid to the study of this problem. One American research center examined the topic of this pathology among the elderly. Cerebrovascular and neurodegenerative disorders considered to be etiological causes of epilepsy have been studied. The researchers also paid attention to diagnostic methods in this age group and treatment methods.

Epidemiology

The incidence of epilepsy has a number of factors that could trigger its development. According to epileptologists, the disease is distinguished by its bimodal nature. Most often, this diagnosis is made to newborns and young children, as well as elderly people over 60 years of age. According to medical statistics, epilepsy is diagnosed most often among older people. This group of patients exhibits seizures that were unprovoked. Sometimes pathology is associated with acute processes occurring in the body.

According to the data obtained, the first seizure among elderly people was recorded in 136 cases among 100 thousand subjects. Active epilepsy among older people occurs in 1.5%. Among patients who are in a nursing home, the active form is observed in 5%. The prevalence of this pathology is growing every year.

Diagnosing epilepsy in old age is extremely difficult. To establish an accurate diagnosis, the attending physician completely studies the patient’s medical history, analyzes the frequency and nature of complaints. Eyewitness accounts who may have been present during epileptic seizures are also taken into account. Most often, attacks begin when the disease progresses. It is likely that the prevalence rates of epilepsy among people over 60 years of age are lower than those reported. However, the prevalence of the disease among this population group is much higher than among young people. The figure is twice as high.

Alpha Rhythm

UDC 616.832-004.2:616-08-039.71 Kirillovskikh O.N., Myakotnykh V.S., Borovkova T.A., Myakotnykh K.V. Ural State Medical Academy, Ekaterinburg

Summary.

Based on the observation of 29 patients, the article comprehensively examines the problem of epilepsy that arose after an ischemic stroke in old age. Risk factors for the development of post-stroke epilepsy were identified: cortical and cortical-subcortical localization of small and medium-sized ischemic foci in the frontal and temporal regions of the brain. The period of manifestation of epileptic seizures was determined to be between 6 months and 2 years after a stroke. The predominant clinical variants of seizures have been identified - complex partial seizures, often accompanied by postictal motor deficit. The main pathological changes in the bioelectrical activity of the brain are presented - lateralized epileptiform discharges, regional slowdowns against the background of a high-amplitude EEG variant in the presence of pronounced interhemispheric asymmetry. Partial sleep deprivation and EEG sleep monitoring are recommended to detect latent epileptiform activity in diagnostically difficult cases. The possibility of effective pharmacotherapy with anticonvulsants with neuroprotective properties and linear pharmacokinetics, acting primarily on partial seizures, has been demonstrated.

Key words: post-stroke epilepsy, risk factors, bioelectrical activity of the brain, antiepileptic treatment.

Relevance of the problem.

In recent years, the problem of epilepsy in the elderly and senile, the differential diagnosis of epileptic seizures and non-epileptic paroxysmal conditions of other origins, as well as the possibilities of treating epilepsy in the elderly suffering from multiple pathologies has received increasing attention [1,2,3,19]. Among the entire population of patients with epilepsy over the age of 60 years, epilepsy in an elderly patient, which exists for many years - “aging epilepsy”, and epilepsy with the onset of the disease in old age - “late epilepsy” or “epilepsia tarda” are distinguished. The main etiological factor for the development of late epilepsy is cerebrovascular pathology, in particular a previous ischemic stroke [3,12,13]. The incidence of post-stroke epilepsy in the population, according to various authors, ranges from 2.5% to 9% [3,15]. Is it possible to predict the development of this complication, what factors contribute to the clinical manifestation of post-stroke epilepsy, variants of the clinical course, neurophysiological features, principles of pharmacotherapy - these and other questions, despite the interest of domestic and foreign researchers in them, remain not fully clarified.

Purpose of the study

Determination of risk factors, clinical and neurophysiological features of epilepsy and the possibilities of its treatment in elderly and senile people who have suffered an ischemic stroke.

Material and research methods.

Over the course of 5 years, a comprehensive prospective study was carried out on 29 patients over the age of 60 years (m = 75.5 ± 6.87 years) who had suffered an acute cerebrovascular accident, after which epileptic seizures . The diagnosis of epilepsy was established based on the observation of at least two unprovoked seizures that occurred no earlier than 2 weeks after the stroke. The comparison group consisted of 30 patients with an average age of 75±5.66 years with a history of stroke of 3-5 years, but who did not suffer from epilepsy. The selection of patients into the comparison group was carried out by random sampling among patients admitted for inpatient treatment, with the selection criteria being age 60 years and older and a history of acute cerebrovascular accident.

The study included an analysis of clinical data, including comorbidities, assessment of the degree of cognitive impairment using the Mini-Mental State Examination (MMSE) scale and the clock drawing test, a wide range of laboratory tests, ECG, and consultations with specialists. The study of the state of cerebral hemodynamics was carried out using transcranial ultrasound Dopplerography (TCUSDG) using the Companion III device (Siemens, Germany) and using duplex scanning of the brachiocephalic arteries using the Acuson Asper device (Siemens, Germany). Magnetic resonance imaging (MRI) was carried out using an “Obraz 2” device (Russia) with a magnetic field strength of 0.14 Tesla and a magnetic induction value of 0.5 Tesla in the sagittal, frontal and axial planes with a slice thickness of 5 mm. Electroencephalography (EEG) was carried out using a computer electroencephalograph "Encephalan-131-01" (Russia, Taganrog) with visual assessment and calculation of indices for standard frequency ranges and the amplitude of the main rhythms. If there was no epileptiform activity on a routine EEG or if the results were questionable, patients underwent additional studies - EEG with sleep deprivation, daytime ambulatory EEG monitoring , EEG sleep monitoring using the Nicolet-one device. When conducting EEG with sleep deprivation, the patient was woken up on the day of the study at 4 a.m., and the EEG was recorded at 9 a.m. Partial sleep deprivation, in our opinion [8], is no less informative than complete sleep deprivation, but is easier to tolerate in elderly patients. When assessing changes in the EEG, the Classification of the American Neurophysiological Association was used [9].

Results and its discussion.

In all patients of the main study group, according to the classification, epileptic seizures were classified as late, the so-called “scarring epilepsy” [12]. During the first year after the stroke, an epileptic attack was noted in 17 (58.6%) patients, during the second year - in 11 (37.9%) and in one patient the first attack occurred in the 3rd year after the stroke. In total, in 2 (6.9%) patients, the first epileptic seizures manifested up to 6 months after the stroke.

Since epilepsy in ischemic cerebral disease is symptomatic, locally caused, and its clinical manifestations are associated with pathological processes in a certain structure of the brain, we conducted a comprehensive analysis of the localization and size of postinsulin ischemic foci identified during MRI (Table 1) .

Table 1. Neuroimaging results in patients with post-stroke epilepsy.

From the data presented, it is obvious that among patients with post-stroke epilepsy, significantly more often (p

Rice. 1. Localization of the focus of ischemic softening in patients with post-stroke epilepsy (n=29)

Among patients suffering from post-stroke epilepsy, cystic-gliotic changes in the cortical-subcortical localization predominated, mainly in the frontal and temporal regions of the brain (n = 25; 86.2%). At the same time, the localization of the ischemic focus influenced the clinical picture of epileptic seizures and to some extent determined the prognosis of the course of epilepsy. Post-stroke changes in the temporal regions of the brain correlated with the manifestation of epilepsy with complex partial seizures (n=9; 31%), in a third of patients (n=3; 33.3%) these seizures occurred with secondary generalization. When post-stroke cystic-glial changes were localized in the frontal lobe with involvement of the sensorimotor cortex, epilepsy debuted with simple partial seizures (n=8; 27.6%)), of which 3 (37.5%) had secondary generalization. In 5 (17.2%) cases, extensive foci of ischemic softening measuring more than 35 mm in diameter involved two and three lobes of the cerebral cortex in the pathological process, which also affected the clinical characteristics of the first epileptic seizures. In general, in the patients we observed, complex partial epileptic seizures predominated; the second place in frequency of occurrence was occupied by simple partial seizures, which occur mainly when the ischemic focus is localized in the cortical parts of the brain. When post-stroke cystic-glial changes were localized in the area of ​​the motor areas of the cerebral cortex (n=2; 6.9%), the first seizures had a Jacksonian character.

When studying cerebral blood flow using TC ultrasound (Table 2), no significant differences were revealed in the average linear blood flow velocity (Vm) and the peripheral vascular resistance index (Pi) in the middle cerebral artery, although the pattern of stenosis was slightly more often detected in patients in the comparison group ( p>0.05). The degree of atherosclerotic damage to extracerebral vessels, determined by duplex scanning by the thickness of the intima-media complex at the level of the common carotid artery, was comparable in both compared groups. The average value of median stenosis, expressed as a percentage, in the group of patients with post-stroke epilepsy was 48.5% (40.25-54.25%), in the comparison group - 51.1% (42.8-56.7%); p>0.05.

Table 2. Results of cerebral blood flow studies.

Note: * - median and interquartile range

Thus, the degree of occlusive atherosclerotic lesions of extra- and intracerebral vessels was comparable in both study groups and, therefore, could not be a risk factor for the development of post-stroke epilepsy.

An EEG study revealed some common features that distinguish the bioelectrical activity of the brain of patients with post-stroke epilepsy from that of people of the same age who have suffered a stroke but do not suffer from epileptic seizures (Table 3). This is, first of all, a higher amplitude level of the main EEG rhythms: if in the comparison group the EEG amplitude, as a rule, did not exceed 60 μV, then in patients with epilepsy the average amplitude level was twice as high - 116 ± 4.8 μV. Patients with epilepsy were also characterized by a noticeable tendency to synchronize the main bioelectrical activity due to dysfunction of the mid-stem structures of the brain. Thus, in a study of routine EEG, in 12 (41.4%) patients suffering from post-stroke epilepsy, a high-amplitude EEG variant was observed for a given age with a tendency to synchronize the main cortical rhythms; in the comparison group the same figure was 2 (6.7%); R

Table 3. Comparative characteristics of EEG results

Distinctly less often (P

Much more often (alpha rhythm by approximately 1 Hz for every 10 years lived [14,18]. However, a slowdown in the main activity of the II-III degree in elderly patients is most often a marker of severe cortical atrophy of the brain [9,17].

A characteristic feature of the EEG of patients suffering from post-stroke epilepsy with sufficiently large foci of softening of the brain was pronounced interhemispheric asymmetry - a relatively intact EEG over the undamaged hemisphere and pronounced slow-wave activity with epileptiform elements such as “sharp-slow wave”, “spike-slow wave” in the projection focus of post-stroke softening (Fig. 2, 3).

Rice. 2. EEG of patient K., 69 years old. The focus of regional epileptiform activity “sharp-slow wave”, “spike-slow wave” in the projection of the focus of post-stroke softening in the right temporal region.

Fig 3. EEG of patient V., 72 years old, Regional epileptiform activity “acute-slow wave” in the right temporoparietal region against the background of pronounced interhemispheric asymmetry and relative preservation of the background EEG in the intact left hemisphere. Recording against the background of sleep deprivation.

In patients in the comparison group, interhemispheric asymmetry was observed half as often as among patients suffering from post-stroke epilepsy (Table 3). At the same time, representatives of the comparison group on the side of the ischemic focus more often observed low-amplitude slow-wave activity in the theta range without a spike and/or sharp-wave component.

In general, the informative value of routine EEG in patients with post-stroke epilepsy turned out to be quite high: in 12 (41.4%) the waking EEG revealed focal and lateralized epileptiform activity “sharp-slow wave”, “spike-slow wave”; conditioned epileptiform activity in the form of regional periodic slowing and bursts of high-amplitude pointed theta-delta waves was recorded in 20 (69.0%) patients. However, in 9 (31.0%) patients, no focus of epileptiform and/or conditional epileptiform activity was detected on routine EEG; These were mainly patients with small, less than 15 mm in diameter, softening lesions identified during MRI. In 11 (37.9%) patients of the main observation group, no clear interhemispheric asymmetry was revealed. To clarify the diagnosis, EEG was recorded against the background of partial sleep deprivation and in a state of physiological sleep. In 5 (17.2%) patients, against the background of sleep deprivation, a routine EEG recorded regional conditioned epileptiform activity in the form of high-amplitude sharp waves in the theta range, polymorphic sharp waves in shape and amplitude, and polymorphic epileptiform “sharp-slow wave” complexes ( Fig 4).

Fig 4. EEG of patient P., 85 years old. Diagnosis: consequences of an ischemic stroke in the basin of the left anterior cerebral artery with a softening focus in the left frontal region, 13 mm in diameter; symptomatic epilepsy, complex partial epileptic seizures with secondary generalization. After sleep deprivation, epileptiform activity is recorded in the form of “spike-slow wave” complexes in the left frontotemporal region with a tendency to spread to the same areas of the contralateral hemisphere.

Taking into account the common occurrence of insomnia in the elderly and senile, it was possible to obtain a complete EEG recording during sleep in only 5 (17.2%) patients with post-stroke epilepsy. The EEG picture of slow-wave sleep is characterized by disorganization: the first phase of slow-wave sleep is prolonged, shallow sleep with frequent awakenings for 8-12 seconds and movement artifacts, specific sleep patterns - K-complexes, vertex potentials and sleep spindles - were not clearly expressed, delta sleep shortened, the amplitude of delta activity is reduced. In 3 (60%) of 5 patients, it was not possible to achieve the delta sleep stage at all, probably due to insufficiently comfortable registration conditions. also, not a single patient had a stage of “rapid eye movement” sleep. However, against a generally disorganized background, in all 5 examined patients, mainly in the second stage of slow-wave sleep, focal epileptiform activity of the “sharp-slow wave” type was recorded, localized mainly in the frontotemporal leads, on the side of the post-stroke focus of softening (Fig. 5).

Rice. 5. EEG of patient A., 74 years old. Diagnosis: consequences of ischemic stroke in the left internal carotid artery; symptomatic epilepsy, simple partial seizures with secondary generalization. In stages I - II of slow-wave sleep, epileptiform complexes of the “acute-slow wave” type are recorded in the left frontotemporal region.

Pharmacotherapy of post-stroke epilepsy using individually selected antiepileptic drugs in the vast majority (n=26; 89.7%) of cases made it possible to achieve complete remission of seizures for a year or more against the background of monotherapy; in 3 (10.3%) patients, the frequency of seizures decreased by more than 50%. Taking into account the fact that post-stroke epilepsy is locally caused, symptomatic with a distinct partial component of seizures, preference was given to carbamazepiu and/or oxcarbazepiu (Trileptal) as the first choice drug [16,20]. Typically, a prolonged form of carbamazepine (finlepsin retard) was used at a daily dose of 5-10 mg/kg. The main disadvantage of the drug is the induction of microsomal liver enzymes (increased transaminases) and a distinct sedative effect, accompanied by drowsiness and dizziness. Since these symptoms are quite common in elderly patients even without the prescription of anticonvulsants, preference was often given to a more modern drug - oxcarbazepine, which, while not inferior to carbamazepine in effectiveness, has better tolerability. However, both carbamazepine and oxcarbazepine were not used in cases where the phenomenon of secondary bilateral synchronization was detected on the EEG due to the risk of seizure aggravation [11]. In our study, 12 (41.4%) patients received finlepsin retard, 16 (55.1%) patients received trileptal. Only 2 (6.9%) patients had to be prescribed valproate (Depakine-Chrono).

Conclusions.

1. The main risk factors for the development of post-stroke epilepsy in elderly and senile people are the cortical and cortical-subcortical localization of foci of post-stroke scar changes of small and medium size, localized mainly in the frontal and temporal regions of the brain, in the presence of high-amplitude synchronization of the main cortical rhythms on the EEG.
2. The vast majority of cases of post-stroke epilepsy in the elderly and senile age debut between 6 months and 2 years after an ischemic stroke.
3. The clinical picture of post-stroke epilepsy is dominated by complex partial seizures, often accompanied by post-ictal motor deficits simulating a recurrent stroke, which creates certain diagnostic difficulties.
4. The presence of pronounced disturbances of cerebral blood flow at the macrocirculatory level with the formation of hemodynamically significant stenoses does not directly affect the clinical variants and frequency of epileptic seizures in post-stroke epilepsy in the elderly.
5. The main pathological changes in the bioelectrical activity of the brain in elderly patients with post-stroke epilepsy are periodic lateralized epileptiform discharges and/or periodic regional slowing, recorded in the same hemisphere as the focus of post-stroke scar changes, against the background of a high-amplitude EEG variant for elderly people in the presence of pronounced interhemispheric asymmetry
6. In diagnostically difficult cases, partial sleep deprivation and EEG sleep monitoring in elderly and senile patients allows us to identify latent epileptiform activity and confirm the epileptic genesis of paroxysms.
7. Pharmacotherapy of post-stroke epilepsy in the elderly and senile age in most cases allows achieving complete remission of epileptic seizures when using anticonvulsants with neuroprotective properties and linear pharmacokinetics, acting predominantly on partial seizures, such as carbamazepine and oxcarbazepine (Trileptal), as monotherapy.

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Cerebrovascular pathologies

According to medical data, the development of epilepsy is often triggered by a stroke. It is this diagnosis that becomes the main cause in 50-70% of cases. Post-stroke epilepsy develops within several months after a stroke. In the first year after the incident, the risk of developing attacks increases 20 times. An epileptic seizure can occur many years later.

In 80% of cases, epilepsy occurs precisely after a hemorrhagic stroke. After an ischemic form of neurological pathology, seizures occur only in 5% of cases approximately one and a half to two weeks after the incident. When diagnosing the body of an elderly person after an attack, factors that could influence the appearance of the symptom are assessed. A comprehensive assessment of cerebrovascular factors is carried out.

Neurodegenerative disorders

The risk of developing epilepsy increases if the patient suffers from neurodegenerative pathologies, including Alzheimer's disease and others. Such disorders and other dementias occur in up to 20% of cases among older adults. According to studies, it has been proven that Alzheimer's disease has the greatest impact on the body. The risk of epilepsy increases if the disease was suffered at a young age. With this diagnosis, various types of seizures are possible, including myoclonic seizures.

The article presents the results of a study of 418 patients suffering from acute and chronic cerebral ischemia with the development of epileptic seizures. The clinical, functional and neuroimaging characteristics of these patients are characterized. The issues of treatment of patients with “vascular” epilepsy are considered.

Epilepsy in acute and chronic cerebral circulatory disorders and its drug treatment

The results of the survey of 418 patients suffering from acute and chronic cerebral ischemia with the development of seizures are presented in the article. The characteristic of clinical, functional and neuroimaging peculiarities of these patients are given. The issues of treatment of patients with “vascular” epilepsy are considered.

Epilepsy is one of the most common diseases of the nervous system. It is currently believed to be the third most common neurological problem in older people after dementia and strokes [1, 2]. Newly diagnosed epilepsy in adults is often symptomatic, which requires clarification of risk factors for its development [3, 4, 5]. The results of recent studies have shown that one of the main risk factors for the development of epilepsy in patients of the older age group is cerebral circulatory disorders [1, 6, 7, 8]. It is believed that about 30% of newly diagnosed epileptic seizures in patients over 60 years of age occur as a result of a stroke [9, 10]. The incidence of epileptic seizures in patients who have suffered a stroke, according to various authors, varies widely – from 3% to more than 60% [8, 11, 12, 13, 14, 15]. Such significant fluctuations in the indicator can be explained by the different designs of the studies, the lack of clarity of definitions, the heterogeneity of the studied cohorts of patients, as well as different durations of observation of patients after a stroke.

In order to clarify the risk factors for epilepsy that developed in adults, we conducted a comprehensive examination of 203 patients aged 18 to 81 years (96 men and 107 women) with various types of epileptic seizures that first developed in adulthood [16]. As a result of this study, it was revealed that the largest group consisted of patients with cerebrovascular pathology (28.1%). Among patients in this group, 20.2% of people suffered from chronic cerebral ischemia without the manifestation of acute cerebrovascular accidents; 5.9% of patients suffered an ischemic stroke, among them 25% were observed with a diagnosis of “early recovery period of ischemic stroke”; 33.3% of the patients were in the late recovery period of ischemic stroke. Residual effects of ischemic stroke were present in 41.7% of patients. At the same time, 91.6% of patients (of the number of patients with stroke) suffered an ischemic stroke in the carotid system, 8.3% in the vertebrobasilar region. In 2.6% of patients there was a late recovery period of hemorrhagic stroke in the territory of the right middle cerebral artery and in 5.6% of patients there were residual effects of subarachnoid hemorrhage. Nonspecific vasculitis was diagnosed in 4.5% of patients. Thus, the vascular factor plays an important role in the development of epilepsy in older age groups.

Despite a significant amount of research devoted to the problems of “vascular” epilepsy (primarily post-stroke epilepsy), many aspects of this problem remain unexplored. It should be noted that epileptic seizures against the background of acute cerebrovascular accidents are often ignored and not taken into account during therapy. Modern instrumental diagnostic methods have created the basis for obtaining accurate information about structural changes in the central nervous system, the functional state of the brain, and hemodynamics of the brain in patients with epileptic seizures.

We also comprehensively examined 418 patients (242 men and 176 women) aged from 48 to 89 years, suffering from ischemic brain damage with various types of epileptic seizures. Among them, 57.9% were patients who had suffered an ischemic stroke, 42.1% were patients suffering from chronic cerebral ischemia without the manifestation of a stroke. The control groups included 203 patients with ischemic stroke and 130 patients with chronic cerebral ischemia, but without the development of epileptic seizures. They were comparable to the main groups in terms of age, clinical characteristics and representation of pathogenetic subtypes of stroke.

The examination was carried out in a hospital setting at the Interregional Clinical Diagnostic Center (Kazan). Instrumental studies were performed in the interictal period. Neurological examination was carried out according to the generally accepted method and assessed according to the NIHSS scale (National Institutes of Health Stroke Scale). Visualization of brain structures was carried out using magnetic resonance imaging (MRI) on a device with a voltage of 1.5 Tesla in T1, T2, FLAIR, DWI modes with an assessment of the measured diffusion coefficient (ADC - apparent diffusion coefficient), using MR angiography. Cerebral perfusion was studied using X-ray computed tomography (XCT) in perfusion mode. The functional state of the cerebral hemispheres was assessed using electroencephalograms (EEG). Transcranial Dopplerography examined the arteries of the carotid and vertebrobasilar territories (VBB) with determination of the average linear blood flow velocity (ALBV), reactivity during dilator (Cr+) and constrictor (Cr-) responses. In addition, a duplex estracranial and transcranial study of cerebral vessels was performed to assess the level and degree of stenosis and cerebrovascular reactivity (CVR) with photostimulation and hypercapnic tests.

Digital material was subjected to mathematical processing using Microsoft Excel and Statistica (v 6.0). Pairwise comparison of frequencies in the control and main groups was carried out using the χ2 test. To assess the significance of differences in quantitative characteristics whose distribution is different from normal, the Kruskal-Wallis test was used. The normality of distribution of quantitative indicators was checked using the Kolmogorov-Smirnov test. The significance of the differences was assessed at the 5% significance level.

By type of seizure, focal seizures predominated (91.9%, p <0.001), and only 8.1% of patients were diagnosed with primary generalized epileptic seizures. 1.3% of patients with ischemic stroke developed status epilepticus at its onset or in the first 7 days. At the same time, in patients with ischemic stroke, it was revealed that among early post-stroke attacks, simple partial seizures were more often diagnosed (45.6%, p <0.01). Similar results were obtained by other researchers. In the works of CF Bladin et al., C. Lamy et al., C. J. Kilpatrick et al., M. Giroud et al. [13, 17, 18, 19], 50-90% of early post-stroke epileptic seizures were simple partial seizures. A.B. Gekht, A.V. Lebedeva et al [20] noted the predominance of partial seizures with secondary generalization among patients with early seizures. At the same time, A. Arboix et al., Siddiqi SA et al. [21, 22] observed a higher incidence (50% and 74%, respectively) of the development of primary generalized tonic-clonic seizures in the early period of stroke.

Various types of epileptic seizures were equally represented in patients with different pathogenetic subtypes of ischemic stroke. Partial attacks developed equally often in strokes in different vascular territories. Generalized (57.1%) and secondary generalized (55.8%) seizures were significantly more often observed in patients with left carotid territory (p<0.05). In all patients with status epilepticus, the stroke was in the left carotid system.

Epileptic seizures can develop in different periods of a stroke and depending on the time of their development; in relation to a stroke, precursor seizures, early seizures and late seizures are distinguished. Currently, there is no generally accepted opinion on the timing of the onset of these attacks, and they vary from study to study. When conducting our own research, we, like many neurologists dealing with the problem of post-stroke epilepsy, adhere to the classification proposed in 1962 by G. Barolin et al. [23], according to which:

1) precursor seizures precede the development of stroke (among the patients we studied who had suffered an ischemic stroke and suffered from epileptic seizures, precursor seizures were observed in 12% of cases);

2) early seizures develop in the first 7 days after acute cerebrovascular accident - stroke (according to the results of our study, 45% of patients had early seizures);

3) late seizures appear after 7 days of stroke (according to our data, late seizures were observed in 43% of patients).

According to our observations, early attacks were more often observed in patients with ischemic stroke in the left carotid system (49.5%, p <0.05) compared to patients with stroke in the right carotid region (36.9%) and vertebrobasilar region (13.6%), while patients with late seizures were represented almost equally among patients with stroke in the left (43.9%) and right (46.7%) carotid territories. Late seizures during strokes in the vertebrobasilar region developed in 9.4% of cases.

A tendency towards increased frequency of seizures was found in the group of patients with polymorphic partial seizures, both among patients who had a stroke (44.1%) and among patients with chronic cerebral ischemia without acute vascular events (55.9%) (p<0.05 ). In addition, there was a tendency to increase the development of generalized seizures in patients over 70 years of age, both in the group of patients who had a stroke (42.9%) and those suffering from chronic cerebral ischemia without stroke (57.9%).

Pathogenetic subtypes of stroke were presented in the study group as follows: atherothrombotic stroke subtype was diagnosed in 55.8% of patients, cardioembolic in 26.4%, lacunar stroke in 12.8% of patients, and in 5% of cases the stroke subtype was difficult to verify . It was noted that precursor seizures developed significantly more often in patients with the lacunar subtype of stroke (29%) compared to other subtypes (p<0.01) (Fig. 1). Early seizures appeared more often in the cardioembolic subtype of stroke (53.2%, p<0.05), and seizures developed especially often in the onset of cardioembolic stroke (39.1%) (Fig. 1, 2). Late seizures were equally common in all stroke subtypes.

Figure 1. The ratio of epileptic seizures depending on the time of their development in different subtypes of ischemic stroke

Figure 2. The ratio of epileptic seizures that developed at the onset of different pathogenetic subtypes of stroke.

When analyzing the clinical picture, it was noticed that patients with the development of early epileptic seizures in the first days of a stroke exhibit a more severe neurological deficit on the NIHSS scale compared to patients without seizures (probably associated with neurotransmitter blocks in the conditions of the appearance of epileptic activity). However, the regression of neurological deficit by the time of discharge from the hospital is more pronounced in patients with seizures (Fig. 3).

Figure 3. Comparison of the magnitude of change in neurological deficit during hospitalization in patients with ischemic stroke with the development of epileptic seizures and without seizures

In patients suffering from epileptic seizures, focal pathological activity on electroencephalograms was recorded in 39.5% of cases with a predominance in the temporal region (87.3%, p <0.001) compared to all other registered localizations. The left-sided localization of focal activity predominated (59.6% compared to 40.4% in the right hemisphere), both in patients with ischemic stroke (57.7%) and in patients with chronic cerebral ischemia without clinical manifestation of stroke (63 .6%).

It should be emphasized the importance of conducting an electroencephalographic study in patients with cerebral ischemia with the development of clinical paroxysmal states, as well as in patients with stroke with impaired consciousness, even without clinical symptoms of convulsive syndrome, for the purpose of early diagnosis of non-convulsive status epilepticus and timely correction of therapy.

When analyzing magnetic resonance imaging of patients in the main and control groups, it was revealed that in patients suffering from epileptic seizures, the cortical localization of ischemia was more often visualized (72%) compared to patients in the control group (33.1%, p <0.001) (Fig. 4 , 5).

Figure 4. The focus of the infarction in the basin of the left in the left hemisphere of the MCA

Figure 5. Postischemic brain cyst

This pattern was noted both in patients with ischemic stroke with the development of attacks (81.3% compared to 43% in the control group) and in patients with chronic cerebral ischemia without stroke (59.1% compared to 19.4% in control group). The association of the cortical localization of the infarction with the development of epileptic seizures has been described in many studies [8, 17, 23]. In addition, it has been noted that the spread of ischemia to the cerebral cortex can serve as a predictor of both early and late epileptic seizures. At the same time, there are studies in which this connection is not observed, however, in them neuroimaging was performed only on a small number of patients [24, 25].

Noteworthy are the results of assessing the measured diffusion coefficient (ADC - apparent diffusion coefficient), calculated on diffusion maps in the area of ​​interest of patients with acute cerebrovascular accident and which is an indicator of the “depth” of changes in brain tissue during ischemia. In patients with early epileptic seizures, the median ADC in the lesion was 0.00058 mm2/sec (interquartile range 0.0005-0.0006 mm2/sec), while in patients in the control group this figure was lower - 0.00048 mm2/sec (interquartile range 0.00045-0.00054 mm2/sec) (p=0.029) (Fig. 6a, 6b, 6c).

Figure 6a. ADC card of a patient with an epileptic seizure

Figure 6b. Seizure-Free Patient ADC Card

Figure 6c. ADC in the ischemic focus in patients with ischemic stroke with the development of early epileptic seizures and without seizures

Similar results were also revealed according to the data of perfusion maps obtained when performing RCT of the brain in perfusion mode. In patients with ischemic stroke with the development of early epileptic seizures, less severe hypoperfusion characteristics were recorded compared to patients in the control group without the development of seizures. It can be assumed that this heterogeneity of ischemic damage in the hypoperfusion zone may serve as the basis for the development of epileptogenic foci.

In the main group, in 76.8% of cases, a steno-occlusive process of the main arteries of the brain was detected (in patients with ischemic stroke, stenoses were detected in 82.2% of cases, among patients with chronic cerebral ischemia without stroke - in 69.3%). At the same time, the study of cerebral vessels did not reveal a significantly significant difference in the frequency of occurrence of the stenotic process in the main and control (67.3%) groups. It was revealed that in patients with cerebral ischemia, suffering from epileptic seizures, in the presence of occlusion of the great vessels of the brain, secondary generalization of seizures developed significantly more often (30.4%, p<0.01). Status epilepticus developed in patients with stenoses of the great vessels of more than 50%.

Consequently, patients with cerebral ischemia more often develop focal seizures, and in the first 7 days of a stroke simple partial seizures predominate. Early epileptic seizures are more often observed with the cardioembolic subtype of stroke and with damage to the left carotid system. The prevalence of cortical localization of ischemic foci was revealed, and in patients with early epileptic seizures against the background of ischemic stroke, polymorphic heterogeneity of the structure of the ischemic foci was noted. A tendency towards generalization of epileptic seizures in older age groups was discovered, with the development of a stroke in the left carotid system, as well as in conditions of critical stenosis and occlusion of the main vessels of the brain.

An important aspect is the features of the treatment of epilepsy that develops against the background of cerebral ischemia. Anticonvulsant therapy should be prescribed not only taking into account the form of epilepsy, the type of seizures, but also taking into account possible drug interactions, since patients with cerebral ischemia, as a rule, are representatives of older age groups, have several concomitant diseases, for which they take several medicines.

Currently, the drugs of choice are often carbamazepines and valproic acid drugs. However, given the similarity of the pathogenetic mechanisms of development of ischemia and epilepsy, antiepileptic drugs with neuroprotective properties (such as lamotrigine, topiramate, levetiracetam) are of interest when choosing anticonvulsants for the treatment of epilepsy that has developed against the background of ischemic brain damage.

Despite the mixed results of different studies, the prevailing opinion today is that early seizures do not require immediate antiepileptic therapy [15, 25]. Dynamic monitoring of the patient is necessary. Anticonvulsants should be prescribed when the patient develops repeated unprovoked seizures. The issue of prophylactic administration of antiepileptic drugs to patients who have suffered a stroke is debatable. According to the recommendations of the American Stroke Association, their prophylactic use is indicated in the acute period for patients with lobar hemorrhage and subarachnoid hemorrhage [26, 27]. At the same time, prophylactic administration of antiepileptic drugs to patients who have suffered an ischemic stroke is not recommended [28, 29].

Thus, the study of “vascular” epilepsy is very relevant for understanding the pathogenetic basis of the formation of epileptic activity, identifying risk factors in order to develop a diagnostic algorithm for predicting the development of epileptic seizures, as well as improving the treatment and prevention of epilepsy in patients with cerebrovascular pathology.

T.V. Danilova

Kazan State Medical University

Interregional Clinical Diagnostic Center, Kazan

Danilova Tatyana Valerievna - Candidate of Medical Sciences, assistant at the Department of Neurology and Neurosurgery, Faculty of Advanced Training and Teaching Staff, neurologist of the Department of Neurology

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Injury

Old age is the main risk factor for the development of post-traumatic epilepsy. In 20% of cases, neurological pathology occurs among older people after head injury. We are talking about a fall from a height that caused damage.

An increased risk of developing post-traumatic epilepsy appears in the following cases:

• loss of consciousness;
• amnesia for more than a day;
• skull fracture;
• brain contusion;
• subdural hematoma;

Head injuries in old age are more dangerous than in younger people. The risk of subdural bleeding increases, especially if treatment with platelet aggregation inhibitors or anticoagulant treatment is carried out.

Tumors

Convulsive seizures can become a symptom that indicates the presence of a neoplasm among any age group. Seizures are typical for the formation of poorly differentiated primary tumors, and not for highly differentiated ones. Old people often suffer from meningiomas, gliomas and metastatic tumors, which can cause seizures.

Often, seizures indicate the development of metastasis. According to data obtained after the study, it became known that in 43% of cases, metastases were found in patients, the cause of which was the attacks. In general, malignancy is not detected until the onset of epileptic seizures.

Mental illness

People suffering from epilepsy often have a history of mental pathologies. Neurological disease can be provoked by constant stress, depression, and emotional stress. Epileptologists often wonder whether mental disorders are predisposing factors for the development of epilepsy or are independent risk factors.

In 2009, a special study was conducted in which veterans of the control group and veterans with epilepsy, which was diagnosed for the first time, took part. As a result, researchers have proven that anxiety, depression, and alcohol abuse are common among newly diagnosed patients.

After this, scientists looked at risk factors such as head injury and stroke, dementia, brain tumors and proved that only psychosis is associated with epilepsy. There is no 100% guarantee that the tests are diagnostically accurate. Among elderly patients, there is a relationship between mental disorders and epilepsy, but they do not always become the main factors that provoke the development of the disease.

It is also known that the group of veterans did not include a representative population of elderly people. In the future, researchers will conduct studies that will prove or disprove a possible connection between mental disorders and epilepsy.

Post-stroke epilepsy

ON THE. Schneider, A.V. Chatskaya, D.V. Dmitrenko, O.I. Shevchenko, Department of Medical Genetics and Clinical Neurophysiology of the Institute of Postgraduate Education of the State Educational Institution of Higher Professional Education "Krasnoyarsk State Medical Academy of the Federal Agency for Health and Social Development"; S.V. Prokopenko, Department of Nervous Diseases, Krasnoyarsk State Medical Academy of the Federal Agency for Health and Social Development, Russia

Summary

This review examines current epidemiological and clinical data on post-stroke epilepsy.

Keywords

post-stroke epilepsy, prevalence.

In recent years, all developed countries have seen a significant increase in epilepsy in adults (late-onset epilepsy). It has been shown that in elderly patients the primary incidence of epilepsy is 2.5–3 times higher than in other age groups, including children and young adults [18].

Elderly patients have a large number of risk factors for epileptic seizures compared to other age groups due to concomitant cerebral and somatic pathology. Among the most significant identifiable risk factors for late-onset epilepsy, cerebrovascular pathology is detected in 40% of cases. In this regard, it is recommended that all elderly patients with newly diagnosed epilepsy undergo screening to identify risk factors for vascular pathology and select therapy to reduce it [9]. The second important identifiable cause of late-onset epilepsy is dementia, accounting for 11 to 16% of cases [18].

The third leading cause of epilepsy in the elderly is neurosurgical pathology, including brain tumors (4%) and traumatic brain injuries (1 to 3%). Most authors emphasize that the cause of late-onset epilepsy can be the neurosurgical interventions themselves for hematomas, tumors, and intracerebral hemorrhages [13]. C. Kellinghaus et al. (2004) note the difficulties of diagnosing late-onset epilepsy, since focal components (auras), automatisms, atypical absences and unilateral seizures predominate with the development of post-ictal Todd's palsy. All this can be regarded by practitioners as conditions of non-epileptic origin, for example psychomotor agitation, cortical and hemispheric infarctions [13].

On the other hand, A. Zaidi et al. (2000) showed that cardiovascular events can mimic seizure-like conditions. In this case, patients are prescribed anticonvulsants, and doctors mistakenly make a conclusion about the pharmacoresistance of seizures against the background of antiepileptic therapy. Among conditions of vascular origin resembling epileptic seizures, the authors noted bradycardia, hypotension, vasovagal syncope, vasovagal reactions during intravenous injections, heart rate blockade during palpation of the carotid arteries and irritation of the carotid sinus [29]. Therefore, in elderly patients, when diagnosing newly diagnosed post-stroke epilepsy (PSE), a comprehensive cardiac examination is recommended. It was also noted that in elderly patients, post-ictal confusion lasts significantly longer than in young patients and children. In addition, diagnostic difficulties are associated with the difficulty of interpreting interictal interictal EEG. In connection with the above, the problem of late-onset epilepsy is becoming relevant in most developed and developing countries, including Russia, due to the presence of demographic problems and the aging of the population [1].

It is believed that 30–40% of cases of late-onset epilepsy in people over 60 years of age are associated with a stroke [6, 11, 19, 28].

Currently, most countries in the world use the classification of G. Barolin and E. Scherzer (1962), who proposed the division of epileptic seizures in cerebrovascular pathology depending on their onset in relation to the development of stroke [5]. Heralding seizures develop before a stroke in the presence of cerebrovascular disease (CVD) and are a common manifestation of transient cerebrovascular accident (TCI) or a manifestation of the so-called “silent” stroke, which is not accompanied by a pronounced neurological deficit and is subsequently diagnosed retrospectively according to CT data . Early epileptic seizures (early) appear during the first 7 days of stroke development. Late seizures (late), or LSE, imply the development of epileptic seizures 7 days or more after the onset of stroke [1, 4, 8, 15, 16, 25].

Studies conducted in Norway have shown that severe strokes are statistically significant independent predictors (risk factors) of PIE. Currently, using the example of the American population, it has been shown that more than 20 thousand new cases of epilepsy develop in Americans every year. These studies were published in 2005 in the journal Epilepsy [19]. One long-term prospective study involving more than 500 patients showed that the prevalence of PIE was 3.5% in patients with moderate stroke. This study showed that severe strokes increase the risk of developing PIE by 5 times compared with moderate strokes. However, treatment in specialized stroke units, age at onset of primary stroke, and geographic features did not statistically significantly affect the risk of developing epilepsy in this study. At the same time, it was noted that thrombolysis in the acute period of stroke, along with the use of modern neuroprotective drugs, can play an important role in the prevention of PIE. In this regard, assessing the effect of stroke treatment in the most acute and acute stages on the risk of developing PIE is of interest to researchers in many countries [19].

A Norwegian study found that stroke increases the risk of developing epileptic seizures. Moderate to severe stroke was a statistically significant predictor of epilepsy in a Norwegian population. Researchers noted the importance of studying the risk and causes of PIE after stroke, as well as knowledge of therapy to prevent PIE for general practitioners and subspecialties [19]. A study conducted at the Norwegian National Epilepsy Center found that 484 patients with late-onset epilepsy had a history of stroke. Researchers have found that 2.5% of stroke patients develop PIE within one year after the stroke. In 3.1% of patients, post-stroke epilepsy developed within 7–8 years from the moment of stroke and/or cerebral infarction. In this case, the diagnosis of PIE was established in the study sample in the presence of two or more unprovoked epileptic seizures that developed within one week after the stroke or later. Analysis of associated potential risk factors that play a role in the development of PIE showed the significance of a score on the Scandinavian Stroke Scale of less than 30 points. These factors are most often detected in severe strokes and increase the risk of developing PIE [5].

Thus, stroke (hemorrhagic or ischemic) is a significant cause of the development of epilepsy in old age. This is very important, since PIE is one of the reasons for frequent visits to therapists [19].

M. Lossius et al. (2005) examined the prevalence of PIE, which was defined as 2 or more epileptic seizures that first developed no earlier than 4 weeks after the stroke. The study was based on a review of the available world literature covering the prevalence, risk factors, pathophysiology and prognosis of PIE. A large variability in the incidence of PIE development was shown - from 2.3 to 43% (according to different authors). Moreover, the average incidence of PIE was 2.5% during the first year after stroke, increasing to 4.4% over the next 5 years. Severe strokes were more predictive risk factors for the development of PIE than mild strokes. The authors explained the high variability in the frequency of PIE by the peculiarities of the course of stroke in different populations, different definitions of the diagnosis of PIE, and different designs of studies. On the other hand, severe strokes were characterized by high mortality, and patients with minor strokes, as a rule, did not have PIE. The authors showed that the risk of developing PIE doubles from the first to the fifth year after stroke [19].

Of great interest is a review of the literature on the possibility of developing epileptic seizures (both convulsive and non-convulsive) in patients who have suffered an ischemic stroke, published by O. Camilo, LB Goldstein (2004). The authors showed a very large variability in the incidence of PIE - from 2 to 33% in the early post-stroke period and from 3 to 67% in the late post-stroke period. However, the average incidence of PIE (according to data obtained through mathematical processing) was 2.4% and was higher in cases where epileptic seizures developed late after the stroke. The authors noted that to better understand the social aspects of PIE and its prevention and adequate treatment, many national studies are needed [7]. This can be explained by the peculiarity of long-term epileptogenesis in patients in the older age group.

On the other hand, the available medical literature, based on a study conducted in the UK, shows that patients with late onset epilepsy (after 60 years of age) have an increased risk of developing stroke. Based on an analysis of the National Center for General Practitioner Statistics database, R. Tallis et al. (Department of Geriatric Medicine at the University of Manchester) analyzed 4,709 clinical cases of PIE in England and Wales and 4,709 age-matched controls (over 60 years) without a history of epilepsy. This population-based study included individuals who had no history of cerebrovascular pathology, brain injury, brain tumors, alcohol or drug addiction, dementia, or no indication of taking antiepileptic drugs for any other reason. The average year of birth in this sample was 1920. Both groups (control and matched) included 2044 men and 2645 women. It was shown that stroke developed in 10% of patients with epilepsy compared to 4.4% of individuals in the control group. The absolute difference was 5.6%. The average risk of stroke in the matched group was 2.89%, compared with 1.4% in patients with high HDL cholesterol concentrations. The authors noted that patients who developed epileptic seizures in old age have an increased risk of stroke [12].

The first largest study to study the problem of PIE in Russia was carried out by E.S. Prokhorova (1982). The result showed that the incidence of PIE after hemorrhagic stroke (intracerebral hemorrhage) was 8.69% of cases, after ischemic stroke - 4.12% of cases. Interestingly, the frequency of epileptic seizures in PNMC was quite high and amounted to 8.8% of cases, which was comparable to the data of O. Daniele (1989) - 9% of cases [3, 10].

According to A.B. Hecht et al. (2003), in the Russian population the incidence of PIE is about 9.6%, while in 6% of patients epileptic seizures developed within the first week from the onset of stroke and were classified as early epileptic seizures. PIE later than the first week from the onset of stroke was registered in 5.4% of patients; in 60% of patients, PIE developed between the 3rd and 12th months of the recovery period. The average incidence of PIE was 4.2% of cases, which is comparable to the results of studies conducted in Norway and the UK. The cumulative risk of PIE by the end of the first year after stroke was 3.27%, and by the end of the second year of follow-up - 5.7%. The authors noted that the development of early epileptic seizures had a negative impact on the course of the recovery period of stroke, predisposing to continued severity of neurological deficits, low survival rates and the risk of developing a recurrent stroke within two years after the initial stroke. The most significant risk factors for the development of PIE were: old age (50–59 years), atrial fibrillation, stroke severity, as well as smoking and alcohol abuse. At the same time, the authors showed that PIE developed more often in strokes of moderate severity and minor strokes, with cerebral infarction foci measuring 10–30 mm, predominantly in the frontal and temporal localization (according to MRI data) [1, 2].

M. E. Lancman et al. (1993), analyzing MRI data in patients with PIE, showed the greatest risk of developing seizures after hemorrhagic strokes, cortical infarctions, as well as strokes with extensive brain damage (within more than one lobe) [17]. A significant risk factor for the development of PIE is the development of status epilepticus in the acute and acute periods of stroke [25].

Treatment of PIE is much more complex compared to the treatment of epilepsy in young patients [14, 23]. This is associated with an increased risk of drug-drug interactions, age-dependent hepatic and renal dysfunction, requiring increased intervals for taking antiepileptic drugs compared with young and middle-aged patients, cognitive impairment in the elderly associated with concomitant Alzheimer's disease, Parkinson's disease, hypertensive multi-infarct encephalopathy, exogenous toxic (alcoholic) encephalopathy, etc., which potentiate increased sensitivity and increased side effects of antiepileptic drugs [18]. Dose-related side effects of antiepileptic drugs, such as dizziness or balance disorders, as well as drug-specific side effects, such as hyponatremia or tremor, may be due to higher serum concentrations of antiepileptic drugs compared to younger patients [23]. The increase in side effects of anticonvulsants may be due to the elderly age of patients; for example, the risk of AED-associated osteoporosis and osteomalacia while taking phenobarbital, phenytoin, and permidon significantly increases [20]. At the same time, the risk of developing osteopenia and osteoporosis increases significantly with polytherapy compared to monotherapy. On the other hand, information on studies of new anticonvulsants in the elderly is limited [18]. Thus, in 2004 in the United States, 21,435 war veterans (patients with epilepsy over 65 years of age) were treated with phenobarbital and phenytoin in more than 80% of cases [21], although both of these drugs have a significant sedative effect and cause the development of cognitive impairment, as well as potentiate drug-drug interactions [26]. Phenytoin causes dosing difficulties in older patients because it has non-linear side effects.

Elderly patients receive many medications for both epilepsy and somatic diseases. Antiepileptic drugs may enter into drug-drug interactions with other drugs. A minimal drug-drug interaction profile has been described only for new antiepileptic drugs (gabapentin, levetiracetam) [27]. Both drugs are effective in focal epilepsy and are excreted primarily unchanged through the kidneys, but their dosage depends on the impairment of renal function. Somnolence may mimic the use of these drugs [18]. According to recent studies, only 25% of patients with late-onset epilepsy have generalized tonic-clonic seizures, 43% have only complex focal seizures, 32% have focal seizures, which are extremely difficult to diagnose in older age groups because they are underestimated by both patients and his relatives and neurologists.

Traditional antiepileptic drugs - carbamazepine, phenytoin, valproate are metabolized in the liver. Thus, carbamazepine and phenytoin, by inducing hepatic metabolism, can reduce the effects of many drugs, including chemotherapy, glucocorticosteroids or warfarin. Valproate and lamotrigine inhibit hepatic metabolism and increase the risk of developing liver failure, especially against the background of existing hepatoduodenal insufficiency. Carbamazepine significantly increases the risk of hyponatremia, which should be taken into account when treating patients with PIE receiving treatment for arterial hypertension using thiazide diuretics (hypothiazide, indapamide, arifon). At the same time, the frequency of dizziness, lethargy, and somnolence associated with hyponatremia increases significantly [24]. In this regard, it is important to conduct clinical pharmacomonitoring of the concentrations of carbamazepine (finlepsin, tegretol, etc.) and oxcarbazepine (trileptal), as well as the concentration of sodium in the blood serum.

Among the side effects of antiepileptic drugs in the older age group, the most common are: weight gain - 55.3%, sedation - 44.3%, gastrointestinal complications - 29.5%; memory and thinking disorders - 29.1%, dizziness - 28.7%, weight loss - 27.6%, cognitive impairment - 27.2%, hyponatremia - 7.1% [22].

AED-induced side effects in patients with post-stroke epilepsy can be minimized by stepwise dosage selection, starting with minimal doses followed by titration to an effective dose [23].

Among the diagnostic tests for post-stroke epilepsy, the most significant are: magnetic resonance imaging of the brain and magnetic resonance angiography (if indicated), electroencephalography with mandatory daytime, nighttime, and if possible, 24-hour EEG monitoring, laboratory studies of the electrolyte balance of the blood serum, a study of the concentration of anticonvulsants in the blood ( clinical pharmacomonitoring of antiepileptic drugs), examination of the cardiovascular system, including consultation with a cardiologist, ECG, echocardiography, Holter monitoring (if indicated), testing of cognitive functions.

Literature 1. Burd G.S., Gekht A.B., Lebedeva A.V. et al. Epilepsy in patients with ischemic cerebral disease // Journal. neurol. and psychiatry. - 1998. - No. 2. - P. 4-8. 2. Gekht A.B., Lebedeva A.V., Poletaev A.B. et al. Post-stroke epilepsy // Stroke. - 2003. - No. 9. - P. 195. 3. Prokhorova E.S. Epileptic seizures in cerebrovascular accidents in patients with ischemic disease and atherosclerosis: Abstract of thesis. Dis... Dr. med. Sci. - M., 1981. - P. 42. 4. Arboix A., Garcia-Eroles L., Massons JB et al. Predictive factors of early seizures after acute cerebrovascular disease // Stroke. - 1997. - Vol. 28, No. 8. - R. 1590-1594. 5. Barolin GS, Sherzer E. Epileptische Anfalle bei Apoplektikern // Wein Nervenh. - 1962. - Vol. 20. - P. 35-47. 6. Berges S., Moulin T., Berger E. et al. Seizures and epilepsy following strokes: recurrence factors // Eur. Neurol. - 2000. - Vol. 43, No. 1. - R. 3-8. 7. Camilo O., Golgstein LB Seizures and epilepsy after ischemic stroke // Stroke. - 2004. - Vol. 35, No. 7. - P. 1769-1775. 8. Cheung CM, Tsoi TH, Au-Yeung M, Tang AS. Epileptic seizures after stroke in Chinese patients // J. Neurol. - 2003. - Vol. 250, No. 7. - R. 839-843. 9. Cleary P., Shorvon S., Tallis R. Late-onset seizures as a predictor of subsequent stroke // Lancet. - 2004. - Vol. 363. - P. 1184-1186. 10. Daniele O., Mattaliano A., Tassianari CF, Natale E. Epileptic seizures and cerebrovascular disease // Acta Neurol. Scand. - 1989. - Vol. 80. - P. 17-22. 11. Hauser WA, Ramirez-Lassepas M., Rosenstein R. Risk for seizures and epilepsy following cerebrovascular insults // Epilepsia. - 1984. - Vol. 25. - P. 666. 12. Hendry J. Seizure onset after age 60 years associated with increased risk of stroke // Lancet. - 2004. - Vol. 363. - R. 1184-1186. 13. Kellinghaus C., Loddenkemper T., Dinner DS et al. Seizure semiology in the elderly: a video analysis // Epilepsia. - 2004. - Vol. 45. - P. 263-267. 14. Kilpatrick CJ, Davis SM, Tress BM et al. Epileptic seizures in acute stroke // Arch. Neurol. - 1991. - Vol. 48, No. 1. - P. 9-18. 15. Kilpatrick CJ, Davis SM, Tress BM et al. Epieptic seizures in acute stroke // Arch. Neurol. - 1990. - Vol. 47, No. 2. - R. 157-160. 16. Lamy C., Domigo V., Semah F. et al. Early and late seizures after cryptogenic ischemic stroke in young adults // Neurology. - 2003. - Vol. 60, No. 3. - R. 365-366. 17. Lancman ME, Golimstoc A., Norscini J., Granillo R. Risk factors for developing seizures after a stroke // Epilepsia. - 1993. - Vol. 34, No. 1. - R. 141-143. 18. LaRoche SM, Helmers SL Epilepsy in the elderly // Neurologist. - 2003. - Vol. 9. - P. 241-249. 19. Lossius MI, Ronning OM, Slapo GD et al. Poststroke epilepsy: occurrence and predictors-a long-term prospective controlled study Akershus Stroke Study // Epilepssia. - 2005. - Vol. 46, No. 8. - R. 1246-1251. 20. Pack AM, Morrell MJ Epilepsy and bone health in adults // Epilepsy Behav. - 2004. - Vol. 5. - P. 24-29. 21. Pugh MJV, Cramer J, Knoefel J et al. Potentially inappropriate antiepileptic drugs for elderly patients with epilepsy // J. Am. Geriatr. Soc. - 2004. - Vol. 52. - P. 417-422. 22. Ramsay RE, Rowan AJ, Pryor FM Treatment of seizures in the elderly: final analysis from DVA cooperative study # 428 // Epilepsia. - 2003. - Vol. 44, No. I9. - R. 170. 23. Ramsay RE, Rowan AJ, Pryor FM Special considerations in treating the elderly patient with epilepsy // Neurology. - 2004. - Vol. 62. - P. 24-29. 24. Ranta A., Wooten GF Hyponatremia due to an additive effect of carbamazepine and thiazide diuretics // Epilepsia. - 2004. - Vol. 45. - R. 879. 25. Rumbach L., Sablot D., Berger E. et al. Status Epilepticus in stroke: report on a hospital-based stroke cohort // Neurology. - 2000. - Vol. 54, No. 2. - R. 350-354. 26. Shorvon SD Handbook of epilepsy treatment. - Oxford (United Kingdom): Blackwell Science, 2000. 27. Sirven JI The current treatment of epilepsy: a challenge of choices // Curr. Neurol. Neurosci. Rep. - 2003. - Vol. 3. - R. 349-356. 28. So EL, Annegers JF, Hauser WA et al. Population-based study of seizure disorders after cerebral infarction // Neurogy. - 1996. - Vol. 46, No. 2. - R. 350-355. 29. Zaidi A., Clough P., Cooper P. et al. Misdiagnosis of epilepsy: many seizure-like attacks have a cardiovascular cause // J. Am. Cool. Cardiol. - 2000. - Vol. 36, No. 1. - P. 181-184.

Other reasons

Among elderly patients, epileptic seizures can be provoked. Seizures are acutely symptomatic, and it is impossible to interpret the causes of their development. The following possible causes of the disease are identified:

• electrolyte and metabolic disorders (hypocalcemia, hypomagnesemia, hyponatremia);
• alcohol withdrawal;
• infectious pathologies of the nervous system;

Some medications taken by patients in this age group can significantly lower the seizure threshold. Such medications include Tramadol and others. Elderly people are sensitive to the epileptogenic effects of the following drugs:

• antipsychotics;
• antidepressants, including tricyclics;
• antibiotics;
• thiazide diuretics;

Even herbal medicines lower the seizure threshold. These include ginkgo biloba.

Epilepsy in questions and answers

23.Sep.2020

Epilepsy is one of the most common neurological diseases globally. We learned from a neurologist at the OKB what precedes epilepsy and whether it can be treated.

What are the first signs of epilepsy?

The first signs of the disease usually appear between the ages of 5 and 15 years. The most characteristic symptom is a seizure, which occurs suddenly. Sometimes, a few days before a seizure, it is possible to determine its approach by the appearance of precursors - headache, sleep disturbances, loss of appetite, increased irritability. The patient loses consciousness and falls. Tonic convulsions occur, the person is tense, the limbs are stretched, the head is thrown back, and the breath is held. This phase lasts 15-20 seconds, after which clonic convulsions appear. The latter are twitching muscles of the neck, limbs and torso. Characterized by hoarse, loud breathing, bluish skin, recessed tongue, and foamy discharge from the mouth. The phase lasts several minutes, after which the muscles relax and the condition stabilizes. In addition to grand mal seizures, patients have convulsive attacks, during which they lose consciousness for a few seconds, but do not fall.

Who is predisposed to epileptic seizures in children and adults?

• People with brain diseases: tumors, injuries, abscesses. • People with traumatic brain injuries. • People who have suffered inflammatory diseases of the brain and membranes. • People after a stroke. • Abuse of alcohol and other toxic substances. • People whose immediate family members suffer from epilepsy.

What are the causes of epilepsy?

According to statistics, more than 50% of people with epilepsy have an idiopathic form of the disease, i.e. with an unknown reason. Epilepsy whose cause is known is called secondary or symptomatic epilepsy. Causes of secondary epilepsy: • Traumatic brain lesions • Brain tumors • Abscesses • Meningitis and encephalitis • Subarachnoid and intracerebral hemorrhages • Intoxication with alcohol, mercury, carbon dioxide, lead, etc. • Genetic factors.

What to do if you have an epileptic attack?

If you find yourself nearby, the best help will be your calmness and adherence to the rules:

• During an attack, the patient should not be carried, except in cases where he may be in danger, for example, on the roadway, near a fire, on stairs or in water.
• In case of increased salivation and vomiting, the patient should be placed on his side or his head should be turned to the side. This should be done gently, without using force.
• Do not try to restrict the person's movements.
• Do not try to open a person’s mouth, even if the tongue is biting: this can lead to injury to the teeth, oral mucosa, upper and lower jaws, and the tongue itself. It is important to understand that tongue biting occurs at the very beginning of an attack. If the patient bites his tongue or cheek, then the injury has already occurred. Further attempts to open the mouth are useless and can lead to injury to the oral mucosa.
• You need to wait for the attack to end, being close to the patient and carefully observing his condition in order to correctly and completely describe the manifestations of the attack to the doctor.
• It is very important to note the time when the attack began, since the duration of an attack or series of attacks approaching 30 minutes means that the patient enters a life-threatening state - status epilepticus. In this situation, it is necessary to call an ambulance.
• After an attack, as a rule, the patient feels weak, exhausted, or falls asleep. In this case, there is no need to disturb him in order to give the nerve cells a chance to recover. It is necessary to make sure that the attack is over and the patient has entered post-attack sleep. The patient is unconscious, does not react to others, “does not awaken”; After an attack, the patient reacts as if someone is being “disturbed from sleeping.” It is necessary to remain close to the patient and wait until the period of confusion ends and consciousness is fully restored.

What can trigger an epileptic attack?

Seizures usually occur without antecedent factors (randomly) and are completely unpredictable. Some patients notice certain conditions that may trigger attacks. After identifying provoking factors, measures can be taken to avoid them, which will help reduce the frequency of epileptic seizures in the future. Examples of factors that trigger attacks in some patients include flashing lights, sleep restriction, stressful situations, and the use of alcohol or certain medications. Women with epilepsy often report an increase in the frequency of seizures during menstruation, which is likely due to hormonal changes and fluid retention.

The question is often asked about what treatment for epilepsy can be considered successful. How to treat epilepsy?

Thanks to the successes of modern pharmacotherapy, complete control of attacks is possible in 70-75% of cases. Thus, most epilepsies are treatable and curable diseases. However, it must be remembered that different forms of epilepsy have different courses and prognosis. There are intractable (difficult to treat) forms of epilepsy, which are characterized by early onset of the disease (the first 3 years of life), high frequency of attacks, psychomotor retardation, and resistance of attacks to anticonvulsant therapy. The doctor and relatives must understand that the goals of treating favorable and catastrophic forms of epilepsy are different. Treatment of epilepsy should be comprehensive and continuous. The most important thing in the treatment of epilepsy is taking anticonvulsant drugs, which reduce the frequency of seizures or completely eliminate them.

Can you give morbidity statistics for the district and our hospital as well? Is there a special record of patients?

Today, 1–2% of people suffer from epilepsy; in Russia this figure ranges from 1.5 to 3 million people. It is quite difficult to establish the exact number of patients, because most often epilepsy is confused with hysteria, which has a similar form - seizures. Cramps can also be caused by metabolic problems. Hence the incompleteness of patient records. There were about 500 registered patients (diagnosed for the first time in their lives) in 2005-2006. But then the treatment methods were not so common. And since the beginning of 2021, emergency medical teams have visited patients with epileptic seizures 1,350 times. At the moment, there are 3,000 people in the register of patients living in the district and suffering from epilepsy. Colleagues at the Surgut District Epileptology Center have registered 1,800 adult patients.

Clinical manifestations

Epileptic seizures are more easily tolerated in older people than in younger people. Epilepsy is not so acute. Most often, complex partial seizures are observed, which complicate the diagnosis at the initial stage. In patients of this age category, an extratemporal epileptic focus is diagnosed. The typical olfactory foci of an epileptic seizure, which are mainly characteristic of young people, are rarely detected.

If symptoms are observed that are called so-called “harbingers” of an epileptic attack, then they include constant dizziness. There are also short-term loss of consciousness, impaired perception, memory loss, problems with coordination and attentiveness. Both young and old people exhibit signs such as tongue biting, fractures and dislocations. The post-ictal period lasts from one to several days.

Epilepsy in acute and chronic cerebrovascular accidents and its drug treatment

The article presents the results of a study of 418 patients suffering from acute and chronic cerebral ischemia with the development of epileptic seizures. The clinical, functional and neuroimaging characteristics of these patients are characterized. The issues of treatment of patients with “vascular” epilepsy are considered.

Epilepsy in acute and chronic cerebral circulatory disorders and its drug treatment

The results of the survey of 418 patients suffering from acute and chronic cerebral ischemia with the development of seizures are presented in the article. The characteristic of clinical, functional and neuroimaging peculiarities of these patients are given. The issues of treatment of patients with “vascular” epilepsy are considered.

Epilepsy is one of the most common diseases of the nervous system. It is currently believed to be the third most common neurological problem in older people after dementia and strokes [1, 2]. Newly diagnosed epilepsy in adults is often symptomatic, which requires clarification of risk factors for its development [3, 4, 5]. The results of recent studies have shown that one of the main risk factors for the development of epilepsy in patients of the older age group is cerebral circulatory disorders [1, 6, 7, 8]. It is believed that about 30% of newly diagnosed epileptic seizures in patients over 60 years of age occur as a result of a stroke [9, 10]. The incidence of epileptic seizures in patients who have suffered a stroke, according to various authors, varies widely – from 3% to more than 60% [8, 11, 12, 13, 14, 15]. Such significant fluctuations in the indicator can be explained by the different designs of the studies, the lack of clarity of definitions, the heterogeneity of the studied cohorts of patients, as well as different durations of observation of patients after a stroke.

In order to clarify the risk factors for epilepsy that developed in adults, we conducted a comprehensive examination of 203 patients aged 18 to 81 years (96 men and 107 women) with various types of epileptic seizures that first developed in adulthood [16]. As a result of this study, it was revealed that the largest group consisted of patients with cerebrovascular pathology (28.1%). Among patients in this group, 20.2% of people suffered from chronic cerebral ischemia without the manifestation of acute cerebrovascular accidents; 5.9% of patients suffered an ischemic stroke, among them 25% were observed with a diagnosis of “early recovery period of ischemic stroke”; 33.3% of the patients were in the late recovery period of ischemic stroke. Residual effects of ischemic stroke were present in 41.7% of patients. At the same time, 91.6% of patients (of the number of patients with stroke) suffered an ischemic stroke in the carotid system, 8.3% in the vertebrobasilar region. In 2.6% of patients there was a late recovery period of hemorrhagic stroke in the territory of the right middle cerebral artery and in 5.6% of patients there were residual effects of subarachnoid hemorrhage. Nonspecific vasculitis was diagnosed in 4.5% of patients. Thus, the vascular factor plays an important role in the development of epilepsy in older age groups.

Despite a significant amount of research devoted to the problems of “vascular” epilepsy (primarily post-stroke epilepsy), many aspects of this problem remain unexplored. It should be noted that epileptic seizures against the background of acute cerebrovascular accidents are often ignored and not taken into account during therapy. Modern instrumental diagnostic methods have created the basis for obtaining accurate information about structural changes in the central nervous system, the functional state of the brain, and hemodynamics of the brain in patients with epileptic seizures.

We also comprehensively examined 418 patients (242 men and 176 women) aged from 48 to 89 years, suffering from ischemic brain damage with various types of epileptic seizures. Among them, 57.9% were patients who had suffered an ischemic stroke, 42.1% were patients suffering from chronic cerebral ischemia without the manifestation of a stroke. The control groups included 203 patients with ischemic stroke and 130 patients with chronic cerebral ischemia, but without the development of epileptic seizures. They were comparable to the main groups in terms of age, clinical characteristics and representation of pathogenetic subtypes of stroke.

The examination was carried out in a hospital setting at the Interregional Clinical Diagnostic Center (Kazan). Instrumental studies were performed in the interictal period. Neurological examination was carried out according to the generally accepted method and assessed according to the NIHSS scale (National Institutes of Health Stroke Scale). Visualization of brain structures was carried out using magnetic resonance imaging (MRI) on a device with a voltage of 1.5 Tesla in T1, T2, FLAIR, DWI modes with an assessment of the measured diffusion coefficient (ADC - apparent diffusion coefficient), using MR angiography. Cerebral perfusion was studied using X-ray computed tomography (XCT) in perfusion mode. The functional state of the cerebral hemispheres was assessed using electroencephalograms (EEG). Transcranial Dopplerography examined the arteries of the carotid and vertebrobasilar territories (VBB) with determination of the average linear blood flow velocity (ALBV), reactivity during dilator (Cr+) and constrictor (Cr-) responses. In addition, a duplex estracranial and transcranial study of cerebral vessels was performed to assess the level and degree of stenosis and cerebrovascular reactivity (CVR) with photostimulation and hypercapnic tests.

Digital material was subjected to mathematical processing using Microsoft Excel and Statistica (v 6.0). Pairwise comparison of frequencies in the control and main groups was carried out using the χ2 test. To assess the significance of differences in quantitative characteristics whose distribution is different from normal, the Kruskal-Wallis test was used. The normality of distribution of quantitative indicators was checked using the Kolmogorov-Smirnov test. The significance of the differences was assessed at the 5% significance level.

By type of seizure, focal seizures predominated (91.9%, p <0.001), and only 8.1% of patients were diagnosed with primary generalized epileptic seizures. 1.3% of patients with ischemic stroke developed status epilepticus at its onset or in the first 7 days. At the same time, in patients with ischemic stroke, it was revealed that among early post-stroke attacks, simple partial seizures were more often diagnosed (45.6%, p <0.01). Similar results were obtained by other researchers. In the works of CF Bladin et al., C. Lamy et al., C. J. Kilpatrick et al., M. Giroud et al. [13, 17, 18, 19], 50-90% of early post-stroke epileptic seizures were simple partial seizures. A.B. Gekht, A.V. Lebedeva et al [20] noted the predominance of partial seizures with secondary generalization among patients with early seizures. At the same time, A. Arboix et al., Siddiqi SA et al. [21, 22] observed a higher incidence (50% and 74%, respectively) of the development of primary generalized tonic-clonic seizures in the early period of stroke.

Various types of epileptic seizures were equally represented in patients with different pathogenetic subtypes of ischemic stroke. Partial attacks developed equally often in strokes in different vascular territories. Generalized (57.1%) and secondary generalized (55.8%) seizures were significantly more often observed in patients with left carotid territory (p<0.05). In all patients with status epilepticus, the stroke was in the left carotid system.

Epileptic seizures can develop in different periods of a stroke and depending on the time of their development; in relation to a stroke, precursor seizures, early seizures and late seizures are distinguished. Currently, there is no generally accepted opinion on the timing of the onset of these attacks, and they vary from study to study. When conducting our own research, we, like many neurologists dealing with the problem of post-stroke epilepsy, adhere to the classification proposed in 1962 by G. Barolin et al. [23], according to which:

1) precursor seizures precede the development of stroke (among the patients we studied who had suffered an ischemic stroke and suffered from epileptic seizures, precursor seizures were observed in 12% of cases);

2) early seizures develop in the first 7 days after acute cerebrovascular accident - stroke (according to the results of our study, 45% of patients had early seizures);

3) late seizures appear after 7 days of stroke (according to our data, late seizures were observed in 43% of patients).

According to our observations, early attacks were more often observed in patients with ischemic stroke in the left carotid system (49.5%, p <0.05) compared to patients with stroke in the right carotid region (36.9%) and vertebrobasilar region (13.6%), while patients with late seizures were represented almost equally among patients with stroke in the left (43.9%) and right (46.7%) carotid territories. Late seizures during strokes in the vertebrobasilar region developed in 9.4% of cases.

A tendency towards increased frequency of seizures was found in the group of patients with polymorphic partial seizures, both among patients who had a stroke (44.1%) and among patients with chronic cerebral ischemia without acute vascular events (55.9%) (p<0.05 ). In addition, there was a tendency to increase the development of generalized seizures in patients over 70 years of age, both in the group of patients who had a stroke (42.9%) and those suffering from chronic cerebral ischemia without stroke (57.9%).

Pathogenetic subtypes of stroke were presented in the study group as follows: atherothrombotic stroke subtype was diagnosed in 55.8% of patients, cardioembolic in 26.4%, lacunar stroke in 12.8% of patients, and in 5% of cases the stroke subtype was difficult to verify . It was noted that precursor seizures developed significantly more often in patients with the lacunar subtype of stroke (29%) compared to other subtypes (p<0.01) (Fig. 1). Early seizures appeared more often in the cardioembolic subtype of stroke (53.2%, p<0.05), and seizures developed especially often in the onset of cardioembolic stroke (39.1%) (Fig. 1, 2). Late seizures were equally common in all stroke subtypes.

Figure 1. The ratio of epileptic seizures depending on the time of their development in different subtypes of ischemic stroke

Figure 2. The ratio of epileptic seizures that developed at the onset of different pathogenetic subtypes of stroke.

When analyzing the clinical picture, it was noticed that patients with the development of early epileptic seizures in the first days of a stroke exhibit a more severe neurological deficit on the NIHSS scale compared to patients without seizures (probably associated with neurotransmitter blocks in the conditions of the appearance of epileptic activity). However, the regression of neurological deficit by the time of discharge from the hospital is more pronounced in patients with seizures (Fig. 3).

Figure 3. Comparison of the magnitude of change in neurological deficit during hospitalization in patients with ischemic stroke with the development of epileptic seizures and without seizures

In patients suffering from epileptic seizures, focal pathological activity on electroencephalograms was recorded in 39.5% of cases with a predominance in the temporal region (87.3%, p <0.001) compared to all other registered localizations. The left-sided localization of focal activity predominated (59.6% compared to 40.4% in the right hemisphere), both in patients with ischemic stroke (57.7%) and in patients with chronic cerebral ischemia without clinical manifestation of stroke (63 .6%).

It should be emphasized the importance of conducting an electroencephalographic study in patients with cerebral ischemia with the development of clinical paroxysmal states, as well as in patients with stroke with impaired consciousness, even without clinical symptoms of convulsive syndrome, for the purpose of early diagnosis of non-convulsive status epilepticus and timely correction of therapy.

When analyzing magnetic resonance imaging of patients in the main and control groups, it was revealed that in patients suffering from epileptic seizures, the cortical localization of ischemia was more often visualized (72%) compared to patients in the control group (33.1%, p <0.001) (Fig. 4 , 5).

Figure 4. The focus of the infarction in the basin of the left in the left hemisphere of the MCA

Figure 5. Postischemic brain cyst

This pattern was noted both in patients with ischemic stroke with the development of attacks (81.3% compared to 43% in the control group) and in patients with chronic cerebral ischemia without stroke (59.1% compared to 19.4% in control group). The association of the cortical localization of the infarction with the development of epileptic seizures has been described in many studies [8, 17, 23]. In addition, it has been noted that the spread of ischemia to the cerebral cortex can serve as a predictor of both early and late epileptic seizures. At the same time, there are studies in which this connection is not observed, however, in them neuroimaging was performed only on a small number of patients [24, 25].

Noteworthy are the results of assessing the measured diffusion coefficient (ADC - apparent diffusion coefficient), calculated on diffusion maps in the area of ​​interest of patients with acute cerebrovascular accident and which is an indicator of the “depth” of changes in brain tissue during ischemia. In patients with early epileptic seizures, the median ADC in the lesion was 0.00058 mm2/sec (interquartile range 0.0005-0.0006 mm2/sec), while in patients in the control group this figure was lower - 0.00048 mm2/sec (interquartile range 0.00045-0.00054 mm2/sec) (p=0.029) (Fig. 6a, 6b, 6c).

Figure 6a. ADC card of a patient with an epileptic seizure

Figure 6b. Seizure-Free Patient ADC Card

Figure 6c. ADC in the ischemic focus in patients with ischemic stroke with the development of early epileptic seizures and without seizures

Similar results were also revealed according to the data of perfusion maps obtained when performing RCT of the brain in perfusion mode. In patients with ischemic stroke with the development of early epileptic seizures, less severe hypoperfusion characteristics were recorded compared to patients in the control group without the development of seizures. It can be assumed that this heterogeneity of ischemic damage in the hypoperfusion zone may serve as the basis for the development of epileptogenic foci.

In the main group, in 76.8% of cases, a steno-occlusive process of the main arteries of the brain was detected (in patients with ischemic stroke, stenoses were detected in 82.2% of cases, among patients with chronic cerebral ischemia without stroke - in 69.3%). At the same time, the study of cerebral vessels did not reveal a significantly significant difference in the frequency of occurrence of the stenotic process in the main and control (67.3%) groups. It was revealed that in patients with cerebral ischemia, suffering from epileptic seizures, in the presence of occlusion of the great vessels of the brain, secondary generalization of seizures developed significantly more often (30.4%, p<0.01). Status epilepticus developed in patients with stenoses of the great vessels of more than 50%.

Consequently, patients with cerebral ischemia more often develop focal seizures, and in the first 7 days of a stroke simple partial seizures predominate. Early epileptic seizures are more often observed with the cardioembolic subtype of stroke and with damage to the left carotid system. The prevalence of cortical localization of ischemic foci was revealed, and in patients with early epileptic seizures against the background of ischemic stroke, polymorphic heterogeneity of the structure of the ischemic foci was noted. A tendency towards generalization of epileptic seizures in older age groups was discovered, with the development of a stroke in the left carotid system, as well as in conditions of critical stenosis and occlusion of the main vessels of the brain.

An important aspect is the features of the treatment of epilepsy that develops against the background of cerebral ischemia. Anticonvulsant therapy should be prescribed not only taking into account the form of epilepsy, the type of seizures, but also taking into account possible drug interactions, since patients with cerebral ischemia, as a rule, are representatives of older age groups, have several concomitant diseases, for which they take several medicines.

Currently, the drugs of choice are often carbamazepines and valproic acid drugs. However, given the similarity of the pathogenetic mechanisms of development of ischemia and epilepsy, antiepileptic drugs with neuroprotective properties (such as lamotrigine, topiramate, levetiracetam) are of interest when choosing anticonvulsants for the treatment of epilepsy that has developed against the background of ischemic brain damage.

Despite the mixed results of different studies, the prevailing opinion today is that early seizures do not require immediate antiepileptic therapy [15, 25]. Dynamic monitoring of the patient is necessary. Anticonvulsants should be prescribed when the patient develops repeated unprovoked seizures. The issue of prophylactic administration of antiepileptic drugs to patients who have suffered a stroke is debatable. According to the recommendations of the American Stroke Association, their prophylactic use is indicated in the acute period for patients with lobar hemorrhage and subarachnoid hemorrhage [26, 27]. At the same time, prophylactic administration of antiepileptic drugs to patients who have suffered an ischemic stroke is not recommended [28, 29].

Thus, the study of “vascular” epilepsy is very relevant for understanding the pathogenetic basis of the formation of epileptic activity, identifying risk factors in order to develop a diagnostic algorithm for predicting the development of epileptic seizures, as well as improving the treatment and prevention of epilepsy in patients with cerebrovascular pathology.

T.V. Danilova

Kazan State Medical University

Interregional Clinical Diagnostic Center, Kazan

Danilova Tatyana Valerievna - Candidate of Medical Sciences, assistant at the Department of Neurology and Neurosurgery, Faculty of Advanced Training and Teaching Staff, neurologist of the Department of Neurology

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Epileptiform conditions

Diagnosing epilepsy in old age will require a lot of effort and attention from doctors and is often considered incorrect. Very often, epilepsy is confused with other diagnoses that have similar symptoms. The attending physician is obliged to study the patient's medical history, conduct a full diagnostic examination and pay attention to concomitant pathologies.

Some signs and clinical situations at this age mask epilepsy. For example, when falling or fainting, a person has no idea about the development of epilepsy. We are also talking about signs such as cardiac syncope, arrhythmia, disturbed sleep and memory loss.

Material and methods

136 patients aged 0-15 years with diagnosed IS were examined, regardless of the blood supply involved.

The criteria for including patients in the study were: childhood age (0-15 years); diagnosis of IS (I63.0-I63.9 according to ICD-10), confirmed by clinical data, results of CT and/or MRI of the brain; informed consent of parents or their legal representatives for examination of children. The observation period was 18 months - 12 years.

A retrospective assessment of the type of seizures and EEG results in the acute period of IS was given in two groups. The group with PIE included 22 patients whose diagnosis was made according to the recommendations of the International League Against Epilepsy [26] based on verification of seizures that persisted or developed after the end of the acute period of IS, confirmed by electroencephalography and neuroimaging data and requiring the administration of prolonged antiepileptic therapy. The control group included 114 patients who did not suffer from epilepsy at the end of the recovery period of IS and throughout the entire observation period, regardless of the presence or absence of convulsive syndrome in the acute period of IS.

Statistical processing was performed using standard methods of descriptive and analytical statistics and the software package for applied statistical analysis Statistica for Windows, version 7.0 “Stat Soft, Inc.”, USA and Microsoft Excel. The accepted level of confidence in rejecting the “null” hypothesis was no less than 95%. Differences were considered statistically significant when the p

<0.05 or less for all types of analysis.

Heart rhythm disturbances

Cardiac arrhythmia is a common complaint in old age, which poses a threat not only to the health, but also to the life of the patient. Manifested by sudden loss of consciousness and other signs of the cardiovascular system. Arrhythmia can be short-term or long-term. This pathology is not always associated with chronic fatigue. Often arrhythmia occurs for no apparent reason. The increased risk of cardiac arrhythmia increases in the case of ventricular tachycardia and coronary artery disease. In such cases, the functioning of the heart is disrupted.