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Absence: modern methods of diagnostics and treatment
Absence: modern methods
Actuality. Absences are states with sudden short loss of consciousness. Patients stop and stay in the pose that they were when the absence caused and when the absence is finished they continue doing action. During such attack patients may turn pale (seldom they may flush), roll their eyes and throw their heads. Attacks are springing up in groups several times in the day, mainly after sleeping in the morning. Such a difficult problem requires further research of modern methods of diagnostics and treatment to improve patient's life. It is one of the most widespread types of children and teenagers epilepsy attacks. There are 6,13 cases of new diagnosed absence attacks in the year among 100 000 children under 16 years [1; 2; 11]. Absences make 50% through all generalized seizures [3]. Girls preponderate in 1,5-2 times. First appearance of children absence epilepsy (CAE) takes place in the age of1 to 9 years, averages 5,3 ± 0,31 years [1]. Effectiveness of treatment of epilepsy depends on accurate diagnostics of every form of epilepsy or epileptic syndrome. Epilepsy form influences as prognosis of disease's tendency (intellect saving, sensitivity to anticonvulsants) as treatment tactics. That's exactly diagnosis determines when the anticonvulsant therapy should be started, what medicine should be given, what dose of anticonvulsant a patient requires and how long should the treatment last [12].
The objective of research. To analyses modern methods of diagnostics and treatment of absence with the aid of literature information.
Results. During an absence (a small fit), the patient interrupts the conversation or some action, his gaze stops or wanders, and after a few seconds he continues the interrupted conversation or action. In some cases, the deactivation of consciousness is accompanied by a change in the tone of individual muscle groups (more often the muscles of the face, neck, upper limbs), bilateral light muscle twitching or vegetative disorders. Diagnostics of absences in many cases is difficult. Outside the attack, most often there are no signs of neurologic pathology. There may be a gap in mental development. The main method of diagnosing epilepsy is the EEG, at which typical specific absences reveal a specific generalized pattern-peak — a slow wave at a frequency of 3 Hz. For the detection of absences, a standard clinical record and an EEG background record are required, in which the bioelectric activity of the brain during the interstitial period can be quite normal, but discharges of generalized bilateral synchronous complexes of 3 Hz peak-wave can be recorded for various periods on background of normal basal rhythms [2]. Moreover, functional tests can be used: eye opening has a blocking effect on epileptiform activity; rhythmic photostimulation provokes the appearance of peak-wave activity in a small number of patients with CAE (not more than 10% of cases); hyperventilation — the main provoking factor for the
DOI: http://dx.doi.org/10.20534/ESR-17-3.4-55-56
Sanina Alexandra, Sechina Yulia, Shevhenko Petr, Karpov Sergey, Vyshlova Irina, Stavropol State Medical University, Russia Department of neurology, neurosurgery and medical genetics
E-mail: Karpov25@rumbler.ru
of diagnostics and treatment
appearance of absences [1; 5; 3]. If necessary, they use EEG-video monitoring, positron emission tomography (PET), as well as a number of biochemical, immunological and other special methods of investigation.
In the treatment of epilepsy with typical absences, the base drug is sodium valproate, as was shown in many studies. The advantage is given to monotherapy. For example, in one of the studies, clinical systematization was carried out and the principles of therapy for the absence of children epilepsy were developed. At the same time, all variants of absence seizures were isolated into separate epileptic syndromes: child's absence-epilepsy (CAE); Juvenile absences-epilepsy (UAE); Juvenile myoclonic epilepsy (UME); Epilepsy with myoclonic absences (OMA). The main criteria for differential diagnosis were the age of the debut of absences, their nature, the presence of concomitant seizures, EEG data and response to therapy. The drugs of choice in the treatment of all forms of absense epilepsy were the derivatives of valproic acid. The initial treatment was carried out with monotherapy with depakin in the initial dose of 15 g/kg/day with a gradual increase to 30-50 mg/kg/day and higher to obtain a pronounced therapeutic effect. When the monotherapy was ineffective, a combination of valproate + lamotrigine (lamictal) or valproate + succinimide (suxilep) was used. The starting dose of lamic-tal was 0.2 mg/kg/day in one dose, with a gradual increase to 25 mg/kg/day in 2 divided doses. In comparison, lamictal was more effective than suxylep in cupping absences and had significantly better tolerability. The therapeutic prognosis varied significantly depending on the form of absence epilepsy. The best prognosis was observed in CAE and JME with achievement of complete remission in 70% and 71% of cases, respectively. In the case of JAE, the prognosis was significantly dependent on the adherence of generalized convulsive seizures, and remission was noted in 56% of patients. With EMA, remission was achieved in 33% of cases, solely with polytherapy (combination of depakin and lamiktal). The study shows the need to identify different forms of absent epilepsy due to different prognosis and therapeutic approaches [4; 9; 10].
Initial treatment of absences is carried out with monotherapy with valproic acid derivatives. If it is inefficient, there is optimal the combination of valproate with lamotrigine. The prognosis ofvarious forms of epilepsy with atypical absences is much worse and requires, as a rule, the use of polytherapy with antiepileptic drugs (AEP). In this case, the combination ofvalproates with suc-cinimides is optimal. In addition, the psychotherapeutic methods used at different stages of the disease acquire special significance. Their effectiveness depends on a complex of factors, including qualitative characteristics of the pathological process, as well
Section 5. Medical science
as individual personality characteristics, the level of its compensatory capabilities. General and special psychotherapeutic measures contribute to a higher level of rehabilitation of patients, which is reflected in more orderly behavior, fixes the achieved reduction of convulsive disorders, and in some cases, causes a transfer to a stable decrease in the doses of anticonvulsants [5; 6; 7; 8]. Resistance to AED, the presence of neurological and cognitive impairment in patients with absence forms of epilepsy require careful examination (including high-resolution neuroimaging and modern methods of molecular genetic diagnosis) to exclude the symptomatic genesis of epilepsy [3]
Conclusion. All types of small seizures occur mainly in childhood, but, disappearing in adolescence, can be transformed into polymorphic convulsive and large epileptic seizures. In connection with this, the treatment of small forms of epilepsy must be combined with the use of anticonvulsants to prevent large seizures. The leading method of diagnosis at present with small forms of epilepsy is the EEG using provocative samples, especially hyperventilation; the leading method of therapy is still the use of valproic acid and etho-suximide. Therefore, the diagnosis and treatment of small forms of epilepsy are one of the most difficult problems in medicine, which requires further study.
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