Single epileptiform complexes. Focal epilepsy of childhood with structural changes in the brain and benign epileptiform patterns on the EEG (fedsim-depd) (preliminary results). Frontal lobe epilepsy

Zalevsky Timur Romanovich, 2 years 6 months (born August 30, 2014) AEDs accepted: does not receive. Video-EEG monitoring was carried out for 4 hours in a state of active and passive wakefulness, during nap and after waking up, with functional tests. Recording parameters: The study was conducted using the international “10-20” electrode placement pattern. Additional electrodes: ECG. Video-EEG monitoring system – Nihon Kohden, Japan. EEG in a state of wakefulness. The recording of wakefulness was carried out mainly with open eyes, the child is motorically active, and a large number of motor and myographic artifacts are noted. The main activity was assessed when looking closely at an object and at the moment of closing the eyes - rhythmic activity with a frequency of 6-7 Hz, an amplitude of up to 70 μV - the equivalent of the alpha rhythm - was fragmentarily recorded in the occipital regions of the hemispheres. In a state of active wakefulness, an arched sensorimotor rhythm with a frequency of 8 Hz and an amplitude of up to 50 μV is recorded in the fronto-central regions. Beta activity is represented maximally in the frontotemporal parts of the hemispheres, with variable lateralization, frequency 14-24 Hz, amplitude up to 20 μV, and is often difficult to differentiate against the background of myographic artifacts. Bioccipito-temporally, periodically with variable lateralization, irregular polyphasic potentials of the theta-delta range are recorded - occipital delta waves of children. Slow forms of activity are presented widely, diffusely in the form of low-amplitude waves, predominantly theta-, less often delta-range, insignificantly. During wakefulness, regional epileptiform activity in the left and right occipital regions is recorded independently in the form of single peaks and sharp waves, with an amplitude of up to 80 μV. . Functional tests. A test with opening and closing the eyes was not performed. The test with rhythmic photostimulation was carried out at frequencies of 3, 6, 9, 12, 15, 18, 21, 24, 27, 30, 33 Hz; photoparoxysmal forms of activity were not recorded. A clear reaction of rhythm assimilation was not detected. A hyperventilation test was not performed. Record while you sleep. As the patient fell asleep, there was a decrease in the index of basic activity, up to a reduction, and an increase in diffuse slow-wave activity in the theta range. Against this background, bilaterally synchronous flashes of slow waves of the delta range are recorded, with an amplitude of up to 220 μV, with an amplitude predominance bifrontally, periodically with a shift to the central regions - the phenomenon of hypnagogic hypersynchronization (a physiological phenomenon of the drowsiness stage). In the first and second stages of sleep, the appearance of vertex potentials in the central parts of the hemispheres is recorded, with an amplitude of up to 170 μV. Sharpened potentials similar to sharp-slow wave complexes in the frontal-central regions with amplitude predominance in the vertex leads were also recorded. Taking into account the morphological and localization features, these patterns can be considered within the framework of atypical physiological sleep transits - vertex potentials. The 2nd stage itself is represented by “sleep spindles” - fast rhythmic forms of activity in the fronto-central parts of the hemispheres, with a frequency of 12-14 Hz, amplitude up to 80 μV and K-complexes in the form of diffuse slow waves or polyphasic potentials, maximum amplitude in the central parts hemispheres, up to 260 µV. During sleep recording, arc-shaped, pointed waves with a frequency of 6-7 Hz, 14 Hz are periodically recorded in the temporal regions of the hemispheres, often with a tendency to diffuse distribution - physiological non-epileptic sleep transits of “6-14 Hz”. Delta sleep was accompanied during some recording epochs by an increase in the representation of diffuse high-amplitude slow-wave activity, first to 50% and then to 80% of the recording, with a simultaneous gradual reduction of physiological sleep patterns. During sleep, periodic regional theta-delta slowing is detected in the right temporal region, as well as in the left occipitotemporal region independently. Against this background, in the structure of regional slowing with a low index, regional epileptiform activity is recorded in the left and right occipital regions independently, less often in the right posterior temporal region (T6) with spread to the temporal parts of the ipsilateral hemisphere, as well as biocipitally in the form of single and grouped peaks and sharp waves , peak-slow wave complexes, sharp-slow wave, amplitude up to 160 μV. No clinical events were recorded during the study. Conclusion: ​ The basic rhythm corresponds to age. ​ Sleep is modulated by stage. Physiological sleep patterns are visualized.  During sleep, periodic regional theta-delta slowing was detected in the right temporal region, as well as in the left occipitotemporal region independently. ​ During wakefulness, regional epileptiform activity was recorded with an extremely low index in the left and right occipital regions independently in the form of single peaks and sharp waves. ​ During sleep, in the structure of regional slowing with a low index, regional epileptiform activity was recorded in the left and right occipital regions independently, less often in the right posterior temporal region (T6) with distribution to the temporal parts of the ipsilateral hemisphere, as well as bioccipitally in the form of single and grouped peaks and sharp waves, peak-slow wave complexes, sharp-slow wave. ​ No epileptic seizures were recorded. I am concerned about the delay in speech development (certain words from pictures, does not use in everyday life, speech is quiet, nasal), understands spoken speech, follows simple instructions, according to the speech pathologist, there are elements of autism. Hearing and vision are normal. Pregnancy and early development according to the age. We live in the Yaroslavl region, tell me if there is a need for an in-person consultation based on the EEG conclusion.

Thank you

The site provides reference information for informational purposes only. Diagnosis and treatment of diseases must be carried out under the supervision of a specialist. All drugs have contraindications. Consultation with a specialist is required!

The activity of the brain, the state of its anatomical structures, the presence of pathologies are studied and recorded using various methods - electroencephalography, rheoencephalography, computed tomography, etc. A huge role in identifying various abnormalities in the functioning of brain structures belongs to methods of studying its electrical activity, in particular electroencephalography.

Electroencephalogram of the brain - definition and essence of the method

The functional activity of the human brain depends on the activity of the median structures - reticular formation And forebrain, which determine the rhythm, general structure and dynamics of the electroencephalogram. A large number of connections of the reticular formation and forebrain with other structures and the cortex determine the symmetry of the EEG, and its relative “sameness” for the entire brain.

An EEG is taken to determine the activity of the brain in case of various lesions of the central nervous system, for example, with neuroinfections (poliomyelitis, etc.), meningitis, encephalitis, etc. Based on the EEG results, it is possible to assess the degree of brain damage due to various reasons, and clarify the specific location that was damaged.

The EEG is taken according to a standard protocol, which takes into account recordings in a state of wakefulness or sleep (infants), with special tests. Routine tests for EEG are:
1. Photostimulation (exposure to flashes of bright light on closed eyes).
2. Opening and closing eyes.
3. Hyperventilation (rare and deep breathing for 3 to 5 minutes).

These tests are performed on all adults and children when taking an EEG, regardless of age and pathology. In addition, additional tests may be used when taking an EEG, for example:

• clenching your fingers into a fist;
• sleep deprivation test;
• stay in the dark for 40 minutes;
• monitoring the entire period of night sleep;
• taking medications;
• performing psychological tests.

What does an electroencephalogram show?

Today, the electroencephalogram is widely used in the practice of neurologists, since this method allows for the diagnosis of epilepsy, vascular, inflammatory and degenerative brain lesions. In addition, EEG helps to determine the specific location of tumors, cysts and traumatic damage to brain structures.

An electroencephalogram with irritation of the patient by light or sound makes it possible to distinguish true visual and hearing impairments from hysterical ones, or their simulation. EEG is used in intensive care units for dynamic monitoring of the condition of patients in a coma. The disappearance of signs of electrical activity of the brain on the EEG is a sign of human death.

Where and how to do it?

Electroencephalograms for children under 14 years of age are taken only in specialized children's hospitals where pediatricians work. That is, you need to go to the children's hospital, find the neurology department and ask when the EEG is taken. Psychiatric clinics, as a rule, do not take EEGs for young children.

In addition, private medical centers, specializing in diagnostics and treatment of neurological pathology, also provide EEG services for both children and adults. You can contact a multidisciplinary private clinic, where there are neurologists who will take an EEG and decipher the recording.

An electroencephalogram should be taken only after a full night's rest, in the absence of stressful situations and psychomotor agitation. Two days before the EEG is taken, it is necessary to exclude alcoholic drinks, sleeping pills, sedatives And anticonvulsants, tranquilizers and caffeine.

Electroencephalogram for children: how the procedure is performed

To record an EEG, a cap is placed on the baby's head, under which the doctor places electrodes. The skin under the electrodes is wetted with water or gel. Two inactive electrodes are placed on the ears. Then, using alligator clips, the electrodes are connected to the wires connected to the device - the encephalograph. Because the electric currents are very small, then an amplifier is always necessary, otherwise brain activity will simply be impossible to register. It is the small current strength that is the key to the absolute safety and harmlessness of EEG, even for infants.

To begin the examination, the child's head should be placed flat. Anterior tilt should not be allowed as this may cause artifacts that will be misinterpreted. EEGs are taken for infants during sleep, which occurs after feeding. Wash your child's hair before taking the EEG. Do not feed the baby before leaving the house; this is done immediately before the test so that the baby eats and falls asleep - after all, it is at this time that the EEG is taken. To do this, prepare formula or express breast milk into a bottle that you use in the hospital. Up to 3 years of age, EEG is taken only in a state of sleep. Children over 3 years old can stay awake, but to keep your baby calm, take a toy, book, or anything else that will distract the child. The child should be calm during the EEG.

Typically, the EEG is recorded as a background curve, and tests with opening and closing the eyes, hyperventilation (slow and deep breathing), and photostimulation are also performed. These tests are part of the EEG protocol, and are performed on absolutely everyone - both adults and children. Sometimes they ask you to clench your fingers into a fist, listen to various sounds, etc. Opening the eyes allows us to assess the activity of inhibition processes, and closing them allows us to assess the activity of excitation. Hyperventilation can be carried out in children after 3 years of age in the form of a game - for example, asking the child to inflate a balloon. Such rare and deep inhalations and exhalations last for 2–3 minutes. This test allows you to diagnose latent epilepsy, inflammation of the structures and membranes of the brain, tumors, dysfunction, fatigue and stress. Photostimulation is carried out with the eyes closed and the light blinking. The test allows you to assess the degree of mental, physical, speech and mental development child, as well as the presence of foci of epileptic activity.

Electroencephalogram rhythms

The human EEG contains alpha, beta, delta and theta rhythms, which have various characteristics and reflect certain types of brain activity.

Alpha rhythm has a frequency of 8 – 14 Hz, reflects a state of rest and is recorded in a person who is awake, but with his eyes closed. This rhythm is normally regular, the maximum intensity is recorded in the area of ​​the back of the head and the crown. The alpha rhythm ceases to be detected when any motor stimuli appear.

Beta rhythm has a frequency of 13 – 30 Hz, but reflects the state of anxiety, restlessness, depression and the use of sedative medications. The beta rhythm is recorded with maximum intensity over the frontal lobes of the brain.

Theta rhythm has a frequency of 4–7 Hz and an amplitude of 25–35 μV, reflecting the state of natural sleep. This rhythm is a normal component of the adult EEG. And in children this type of rhythm on the EEG predominates.

Delta rhythm has a frequency of 0.5 - 3 Hz, it reflects the state of natural sleep. It can also be recorded in a limited amount during wakefulness, a maximum of 15% of all EEG rhythms. The amplitude of the delta rhythm is normally low - up to 40 μV. If there is an excess of amplitude above 40 μV, and this rhythm is recorded for more than 15% of the time, then it is classified as pathological. Such a pathological delta rhythm indicates a dysfunction of the brain, and it appears precisely over the area where pathological changes develop. The appearance of a delta rhythm in all parts of the brain indicates the development of damage to the structures of the central nervous system, which is caused by liver dysfunction, and is proportional to the severity of the disturbance of consciousness.

Electroencephalogram results

Such a conclusion must reflect the main characteristics of the EEG, and includes three mandatory parts:
1. Description of the activity and typical affiliation of EEG waves (for example: “The alpha rhythm is recorded over both hemispheres. The average amplitude is 57 μV on the left and 59 μV on the right. The dominant frequency is 8.7 Hz. The alpha rhythm dominates in the occipital leads.”).
2. Conclusion according to the description of the EEG and its interpretation (for example: “Signs of irritation of the cortex and midline structures of the brain. Asymmetry between the hemispheres of the brain and paroxysmal activity were not detected”).
3. Determination of Compliance clinical symptoms with EEG results (for example: “Objective changes in the functional activity of the brain were recorded, corresponding to manifestations of epilepsy”).

Decoding the electroencephalogram

Decoding the electroencephalogram involves interpreting the conclusion. Let's consider the basic concepts that the doctor reflects in the conclusion and their clinical significance (that is, what these or those parameters can indicate).

Alpha - rhythm

• constant registration of the alpha rhythm in the frontal parts of the brain;
• interhemispheric asymmetry above 30%;
• violation of sinusoidal waves;
• paroxysmal or arc-shaped rhythm;
• unstable frequency;
• amplitude less than 20 μV or more than 90 μV;
• rhythm index less than 50%.

High frequency and instability of the alpha rhythm indicate traumatic brain damage, for example, after a concussion or traumatic brain injury.

Disorganization of the alpha rhythm or its complete absence speaks of acquired dementia.

About delayed psycho-motor development in children they say:

• alpha rhythm disorganization;
• increased synchrony and amplitude;
• moving the focus of activity from the back of the head and crown;
• weak short activation reaction;
• excessive response to hyperventilation.

Excitable psychopathy is manifested by a slowdown in the frequency of the alpha rhythm against the background of normal synchrony.

Inhibitory psychopathy is manifested by EEG desynchronization, low frequency and alpha rhythm index.

Increased synchronization of the alpha rhythm in all parts of the brain, a short activation reaction - the first type of neuroses.

Weak expression of the alpha rhythm, weak activation reactions, paroxysmal activity - the third type of neuroses.

Beta rhythm

• paroxysmal discharges;
• low frequency, distributed over the convexital surface of the brain;
• asymmetry between hemispheres in amplitude (above 50%);
• sinusoidal type of beta rhythm;
• amplitude more than 7 μV.

Short spindles in the beta rhythm indicate encephalitis. The more severe the inflammation of the brain, the greater the frequency, duration and amplitude of such spindles. Observed in a third of patients with herpes encephalitis.

Beta waves with a frequency of 16–18 Hz and high amplitude (30–40 μV) in the anterior and central parts of the brain are signs of delayed psychomotor development of a child.

EEG desynchronization, in which the beta rhythm predominates in all parts of the brain, is the second type of neurosis.

Theta rhythm and delta rhythm

In children and young people under 21 years of age, the electroencephalogram may reveal diffuse theta and delta rhythms, paroxysmal discharges and epileptoid activity, which are a normal variant and do not indicate pathological changes in brain structures.

What do disturbances of theta and delta rhythms on the EEG indicate?
Delta waves with high amplitude indicate the presence of a tumor.

Synchronous theta rhythm, delta waves in all parts of the brain, bursts of bilateral synchronous theta waves with high amplitude, paroxysms in the central parts of the brain - indicate acquired dementia.

The predominance of theta and delta waves on the EEG with maximum activity in the occipital region, flashes of bilateral synchronous waves, the number of which increases with hyperventilation, indicates a delay in the psychomotor development of the child.

A high index of theta activity in the central parts of the brain, bilateral synchronous theta activity with a frequency of 5 to 7 Hz, localized in the frontal or temporal regions of the brain indicate psychopathy.

Theta rhythms in the anterior parts of the brain as the main ones are an excitable type of psychopathy.

Paroxysms of theta and delta waves are the third type of neuroses.

The appearance of high-frequency rhythms (for example, beta-1, beta-2 and gamma) indicates irritation (irritation) of brain structures. This may be due to various cerebrovascular accidents, intracranial pressure, migraines, etc.

Bioelectric activity of the brain (BEA)

What are they talking about various disorders bioelectric activity of the brain?
Relatively rhythmic bioelectrical activity with foci of paroxysmal activity in any area of ​​the brain indicates the presence of a certain area in its tissue where excitation processes exceed inhibition. This type of EEG may indicate the presence of migraines and headaches.

Diffuse changes in the bioelectrical activity of the brain may be normal if no other abnormalities are detected. Thus, if in the conclusion it is written only about diffuse or moderate changes in the bioelectrical activity of the brain, without paroxysms, foci of pathological activity, or without a decrease in the threshold of convulsive activity, then this is a variant of the norm. In this case, the neurologist will prescribe symptomatic treatment and put the patient under observation. However, in combination with paroxysms or foci of pathological activity, they speak of the presence of epilepsy or a tendency to seizures. Reduced bioelectrical activity of the brain can be detected in depression.

Other indicators

Interhemispheric asymmetry May be functional impairment, that is, not evidence of pathology. In this case, it is necessary to undergo examination by a neurologist and a course of symptomatic therapy.

Diffuse disorganization of the alpha rhythm, activation of diencephalic-stem structures of the brain against the background of tests (hyperventilation, closing-opening of eyes, photostimulation) is the norm, if the patient has no complaints.

Center of pathological activity indicates increased excitability of this area, which indicates a tendency to seizures or the presence of epilepsy.

Irritation of various brain structures (cortex, middle sections, etc.) is most often associated with impaired cerebral circulation due to various reasons (for example, atherosclerosis, trauma, increased intracranial pressure, etc.).

Paroxysms They talk about increased excitation and decreased inhibition, which is often accompanied by migraines and simple headaches. In addition, there may be a tendency to develop epilepsy or the presence of this pathology if a person has had seizures in the past.

Reducing the threshold for seizure activity indicates a predisposition to seizures.

The following signs indicate the presence of increased excitability and a tendency to convulsions:

• changes in electrical potentials of the brain according to the residual-irritative type;
• enhanced synchronization;
• pathological activity of the midline structures of the brain;
• paroxysmal activity.

Irritation of the cerebral cortex along the convexial surface of the brain, increased activity of the median structures at rest and during tests can be observed after traumatic brain injuries, with a predominance of excitation over inhibition, as well as with organic pathology of brain tissue (for example, tumors, cysts, scars, etc.).

Epileptiform activity indicates the development of epilepsy and an increased tendency to seizures.

Increased tone of synchronizing structures and moderate dysrhythmia are not pronounced disorders or pathologies of the brain. In this case, resort to symptomatic treatment.

Signs of neurophysiological immaturity may indicate a delay in the child’s psychomotor development.

Pronounced changes in residual organic type with increasing disorganization against the background of tests, paroxysms in all parts of the brain - these signs usually accompany severe headaches, increased intracranial pressure, attention deficit hyperactivity disorder in children.

Disturbance of brain wave activity (appearance of beta activity in all parts of the brain, dysfunction of midline structures, theta waves) occurs after traumatic injuries, and can manifest itself as dizziness, loss of consciousness, etc.

Organic changes in brain structures in children are a consequence infectious diseases, such as cytomegalovirus or toxoplasmosis, or hypoxic disorders that arose during childbirth. Necessary comprehensive examination and treatment.

Regulatory cerebral changes are registered in hypertension.

The presence of active discharges in any part of the brain , which intensify with exercise, means that in response to physical stress a reaction may develop in the form of loss of consciousness, visual impairment, hearing loss, etc. The specific reaction to physical activity depends on the location of the source of active discharges. In this case, physical activity should be limited to reasonable limits.

In case of brain tumors, the following are detected:

• the appearance of slow waves (theta and delta);
• bilateral synchronous disorders;
• epileptoid activity.

Desynchronization of rhythms, flattening of the EEG curve develops in cerebrovascular pathologies. A stroke is accompanied by the development of theta and delta rhythms. The degree of electroencephalogram abnormalities correlates with the severity of the pathology and the stage of its development.

Theta and delta waves in all parts of the brain; in some areas, beta rhythms are formed during injury (for example, with a concussion, loss of consciousness, bruise, hematoma). The appearance of epileptoid activity against the background of brain injury can lead to the development of epilepsy in the future.

Significant slowing of alpha rhythm may accompany parkinsonism. Fixation of theta and delta waves in the frontal and anterior temporal parts of the brain, which have different rhythms, low frequencies and high amplitudes, is possible in Alzheimer's disease

Epileptiform activity (EFA) is electrical oscillations of the brain in the form of sharp waves and peaks, significantly (more than 50%) different from background activity and, as a rule (but not necessarily), detected on the EEG in people suffering from epilepsy.

EFA is a heterogeneous group of brain potentials in the form of peaks, sharp waves, a combination of peaks and sharp waves with slow oscillations, which can differ from each other not only in period and shape, but also in amplitude, regularity, synchrony, distribution, reactivity, frequency and rhythm ([diagram of the main types of EFA].

H.O. Lüders and S. Noachtar (2000) proposed a detailed taxonomy of EFA, which reflects and especially emphasizes the heterogeneity of its various types: peaks (adhesions); sharp waves; benign epileptiform patterns of childhood (BEPD); peak-wave complexes; slow peak-slow wave complexes; peak-slow wave complexes 3 Hz; polyps; hypsarrhythmia; photoparoxysmal reaction; EEG of an epileptic seizure; EEG of status epilepticus.

EFA in the form of peaks and sharp waves in the interictal period is the summation of excitatory and inhibitory postsynaptic potentials associated with hypersynchronous neuronal discharge, paroxysmal depolarization shift and subsequent hyperpolarization. At the same time, the different manifestations of epileptiform activity on the EEG reflect the rapidity of neuronal synchronization and the path along which the discharge propagates in the cerebral cortex. Thus, EFA clearly demonstrates cortical excitability and hypersynchrony.

EFA is not a specific EEG phenomenon in patients with epilepsy. [!!! ] In this regard, doctors must still rely on clinical assessment in the diagnosis of epileptic seizures. Thus, when conducting a standard (routine) EEG in general group In adult patients with epilepsy, the detection rate of EFA varies from 29 to 55%. But repeated EEGs (up to 4 studies) with sleep deprivation increase the likelihood of detecting EFA in patients with epilepsy to 80%. Long-term EEG monitoring increases the detection of EFA on EEG in patients with epilepsy by 20%. Recording EEG during sleep increases the detection of EFA to 85 - 90%. During an epileptic attack, the representation of ictal (epileptic) EFA on the EEG already reaches 95%, however, with some focal epileptic seizures emanating from the deep parts of the cortex with a small projection to the surface, changes characteristic of an epileptic attack may not be recorded. You should also pay attention to the fact that EEG has a lower sensitivity for EFA in patients who have had a single epileptic attack or are already taking antiepileptic drugs (AEDs) - in these cases, the probability of detection is 12 - 50%.

Classic EFA EEG can be detected in populations without epilepsy, which is likely due to the genetic predisposition of these individuals, but they are not always susceptible to the development of epileptic seizures. In 2% of adults in a population without epileptic seizures, EEG recordings during sleep reveal EFA. More often, EFA is found in the population of children without epileptic seizures. According to several large population-based EEG studies in healthy children aged 6–13 years, the EEG revealed epileptiform changes (regional and generalized) in 1.85–5.0% of children. Only 5.3 - 8.0% of children who had epileptiform activity on the EEG subsequently developed epileptic seizures. There is a high frequency of detection of regional EFA in the form of benign epileptiform patterns of childhood (BEPD) on EEG in children with periventricular leukomalacia. EFA of the DEPD type can be detected in children with decreased school performance, manifestations of attention deficit hyperactivity disorder, stuttering, dyslexia, autistic disorders, etc.

Particularly interesting are the results of EEG studies in patients without epileptic seizures, but with various brain diseases - with large-scale brain lesions, such as abscesses and slowly growing tumors, after severe traumatic brain injury, stroke, congenital brain damage, etc. The frequency of detection of EFA on EEG in these patients reaches 10 - 30%. 14% of these patients subsequently develop epileptic seizures. EFA in the form of diffuse and multi-regional peaks, sharp waves can be detected in patients with metabolic encephalopathies without epileptic seizures - with dialysis dementia, hypocalcemia, uremic encephalopathy, eclampsia, thyrotoxicosis, Hashimoto's encephalopathy. (epileptic seizures may develop in some of these patients, but not always). Some drugs, such as chlorpromazine, lithium and clozapine, especially in high doses, can provoke the appearance of EFA. Withdrawal of barbiturates in patients without epilepsy can sometimes result in generalized epileptiform discharges and a photoparoxysmal EEG response.

more details about EFA in the article “Clinical significance of epileptiform activity on the electroencephalogram” by L.Yu. Glukhov LLC Institute of Child Neurology and Epilepsy named after. St. Luke"; Russia, Moscow (Russian Journal of Child Neurology, No. 4, 2016 [

Central paralysis and paresis occur when lesions are localized in the precentral gyrus. The somatic representation of motor functions roughly corresponds to that for cutaneous sensitivity in the postcentral gyrus. Due to the large extent of the precentral gyrus, focal pathological processes (vascular, tumor, traumatic, etc.) usually affect it not all, but partially. Localization of the pathological focus on the outer surface causes predominantly paresis upper limb, facial muscles and tongue (linguofacial brachial paresis), and on the medial surface of the gyrus - predominantly paresis of the foot (central monoparesis). Paresis of gaze in the opposite direction is associated with damage to the posterior part of the middle frontal gyrus (“the patient looks at the lesion”). Less commonly, with cortical lesions, gaze paresis in the vertical plane is noted.

Extrapyramidal disorders in lesions of the frontal lobes are very diverse. Hypokinesis as an element of parkinsonism is characterized by a decrease in motor initiative, aspontaneity (limited motivation for voluntary actions). Less commonly, when the frontal lobes are affected, hyperkinesis occurs, usually during voluntary movements. Muscle rigidity is also possible (more often with deep-seated lesions).

Other extrapyramidal symptoms are grasping phenomena - involuntary automatic grasping of objects placed on the palm (Yanishevsky-Bekhterev reflex), or (less commonly observed) an obsessive desire to grab an object that appears before the eyes. It is clear that in the first case, the reason for the involuntary motor act is the effect on skin and kinesthetic receptors, in the second - visual stimulation associated with the functions of the occipital lobes.

With lesions of the frontal lobes, reflexes of oral automatism are revived. You can evoke the proboscis and palmomental (Marinescu-Radovici), less often nasolabial (Astvatsaturova) and distant-oral (Karchikyan) reflexes. Sometimes the “bulldog” symptom (Yanishevsky’s symptom) occurs - in response to touching the lips or mucous membrane of the oral cavity with some object, the patient convulsively clenches his jaw.

With damage to the anterior parts of the frontal lobes with the absence of paresis of the limbs and facial muscles, one can notice an asymmetry in the innervation of the facial muscles during emotional reactions the patient has the so-called “facial paresis of the facial muscles,” which is explained by a disruption in the connections of the frontal lobe with the visual thalamus.

Another sign of frontal pathology is a symptom of resistance or resistance, which appears when the pathological process is localized in the extrapyramidal regions of the frontal lobes. During passive movements, involuntary tension of antagonist muscles occurs, which creates the impression of conscious resistance of the patient to the actions of the examiner. A particular example of this phenomenon is the symptom of eyelid closure (Kokhanovsky’s symptom) - involuntary tension of the orbicularis oculi muscle with closure of the eyelids when the examiner tries to passively lift upper eyelid sick. It is usually observed on the side of the pathological focus in the frontal lobe. The same involuntary contraction of the occipital muscles during passive tilting of the head or extension of the lower limb in knee joint may create a false impression that the patient has a meningeal symptom complex.

The connection of the frontal lobes with the cerebellar systems (fronto-pontocerebellar tract) explains the fact that when they are damaged, disorders of coordination of movements occur (frontal ataxia), which is manifested mainly by trunk ataxia, the inability to stand and walk (astasia-abasia) with deviation of the body in the opposite direction side of the lesion.

The frontal lobe cortex is an extensive field of the kinesthetic analyzer, so lesions of the frontal lobes, especially premotor areas, can cause frontal apraxia, which is characterized by incomplete actions. Frontal apraxia occurs due to a violation of the program of complex actions (their purposefulness is lost). Damage to the posterior part of the inferior frontal gyrus of the dominant hemisphere leads to motor aphasia, and to the posterior part of the middle frontal gyrus to “isolated” agraphia.

Changes in the sphere of behavior and psyche are very peculiar. They are referred to as the “frontal psyche.” In psychiatry, this syndrome is called apathetic-abulic: patients seem to be indifferent to their surroundings, their desire to carry out voluntary actions (motivation) decreases. At the same time, there is almost no criticism of their actions: patients are prone to shallow jokes (moria), and they are often complacent even in a serious condition (euphoria). These mental disorders can be combined with untidiness (a manifestation of frontal apraxia).

Symptoms of irritation of the frontal lobes are manifested by epileptic seizures. They are varied and depend on the location of the foci of irritation.

Jacksonian focal seizures occur as a result of irritation of certain areas of the precentral gyrus. They are limited to unilateral clonic and tonic-clonic seizures on opposite side in the muscles of the face, upper or lower limbs, but can further generalize and develop into a general convulsive seizure with loss of consciousness. When the tegmental part of the inferior frontal gyrus is irritated, attacks of rhythmic chewing movements, smacking, licking, swallowing, etc. occur (opercular epilepsy).

Adversive seizures are a sudden convulsive turn of the head, eyes and entire body in the direction opposite to the pathological focus. The attack may result in a general epileptic seizure. Adverse seizures indicate the localization of epileptic foci in the extrapyramidal parts of the frontal lobe (posterior parts of the middle frontal gyrus - fields 6, 8). It should be noted that turning the head and eyes to the side is a very common symptom. seizures and it indicates the presence of foci in the opposite hemisphere. When the cortex is destroyed in this zone, the head turns towards the location of the lesion.

General convulsive (epileptic) seizures without visible focal symptoms occur when the poles of the frontal lobes are affected; they are manifested by sudden loss of consciousness, muscle spasms on both sides of the body; tongue bite, foam at the mouth, and involuntary urination are often observed. In some cases, it is possible to determine the focal component of the lesion in the post-attack period, in particular temporary paresis of the limbs on the opposite side (Todd's palsy). An electroencephalographic study can reveal interhemispheric asymmetry.

Attacks of frontal automatism are complex paroxysmal mental disorders, behavioral disorders, in which patients unconsciously, unmotivated, automatically perform coordinated actions that can be dangerous to others (arson, murder).

Another type of paroxysmal disorder with lesions of the frontal lobes is petit epileptic seizures with a sudden loss of consciousness for a very short period of time. The patient's speech is interrupted, objects fall out of his hands, and less often, continuation of the started movement (for example, walking) or hyperkinesis (usually myoclonus) is observed. These short-term switches off consciousness are explained by the close connections of the frontal lobes with the midline structures of the brain (subcortical and brain stem).

When the base of the frontal lobe is damaged, homolateral anosmia (hyposmia), amblyopia, amaurosis, and Kennedy syndrome develop (atrophy of the optic nerve nipple on the side of the lesion, on the opposite side - congestion in the fundus).

The described symptoms show that when the frontal lobes are affected, movement and behavior disorders are observed mainly. There are also autonomic-visceral disorders (vasomotor, breathing, urination), especially with foci in the medial parts of the frontal lobes.

Syndromes of local damage to the frontal lobes

I. Precentral gyrus (motor area 4)

1. Facial area (unilateral damage - transient impairment, bilateral - permanent)
   • Dysarthria
   • Dysphagia
2. Hand area
   • Contralateral weakness, awkwardness, spasticity
3. Leg region (paracentral lobule)
   • Contralateral weakness
   • Apraxia of walking
   • Urinary incontinence (long-term with bilateral injuries)

II. Medial divisions (F1, cingulate gyrus)

1. Akinesia (bilateral akinetic mutism)
2. Perseverations
3. Grasp reflex in the hand and foot
4. Alien hand syndrome
5. Transcortical motor aphasia
6. Difficulty initiating movements of the contralateral arm (may require medical assistance)
7. Bilateral ideomotor apraxia

III. Lateral divisions, premotor area

1. Middle frontal gyrus (F2)
   • Deterioration of contralateral saccades
   • Pure agraphia (dominant hemisphere)
   • Contralateral weakness of the shoulder (mainly abduction and elevation of the arm) and hip muscles plus limb apraxia.
2. F2 of the dominant hemisphere. Motor aphasia

IV. Frontal pole, orbitofrontal region (prefrontal)

1. Apathy, indifference
2. Reduce criticism
3. Deterioration of goal-directed behavior
4. Impotence
5. Foolishness (moriah), disinhibition
6. Environment dependence syndrome
7. Apraxia of speech

V. Epileptic phenomena characteristic of the frontal localization of the epileptic focus.

VI. Damage to the corpus callosum (callosal syndromes)

1. Insufficiency of interhemispheric kinesthetic transfer
   • Inability to imitate the position of the contralateral hand
   • Apraxia of the left hand
   • Agraphia of the left hand
   • Constructive apraxia of the right hand
   • Intermanual conflict (alien hand syndrome)
2. Tendency to confabulation and unusual explanations for the behavior of one's left hand
3. Double hemianopsia.

Most general manifestation Frontal dysfunction is a defect in the ability to organize ongoing cognitive and behavioral acts. Motor functions can be impaired either in the direction of hyperkinesia (motor hyperactivity) with increased distractibility to external stimuli, or in the form of hypokinesia. Frontal hypokinesia is manifested by decreased spontaneity, loss of initiative, slowed reactions, apathy, and decreased facial expression. In extreme cases, akinetic mutism develops. It is caused by bilateral damage to the inferomedial frontal and anterior parts of the cingulate gyrus (interruption of connections between the frontal cortex and the diencephalon and the ascending activating reticular formation).

Characterized by problems in maintaining attention, the appearance of perseverations and stereotypies, compulsive-imitative behavior, mental torpidity, weakening of memory and attention. Unilateral inattention, affecting motor and sensory functions, most often observed with parietal damage, can also be observed after damage to the supplementary motor and cingulate areas. Global amnesia has been described in cases of massive damage to the medial frontal lobe.

An accentuation of premorbid personality characteristics is also characteristic, often the appearance of depressive disorders, especially after damage to the anterior sections on the left side. Typically decreased criticism, hyposexuality or, conversely, hypersexuality, exhibitionism, foolishness, puerile behavior, disinhibition, moria. Elevation of mood in the form of euphoria is more common with right-sided injuries than left-sided ones. Here Mori-like symptoms are accompanied high mood combined with motor agitation, carelessness, a tendency to flat, rude jokes and immoral acts. The patient's sloppiness and untidiness are typical (urinating on the floor in the room, in the bed).

Other manifestations include changes in appetite (especially bulimia) and polydipsia, gait disturbances in the form of apraxia of walking or a “marche a petite pas” type gait (walking in small short steps with shuffling).

Precentral gyrus (motor area 4)

Varying degrees of motor paresis in the hand can be observed with posterior frontal damage, as well as speech impairment with damage to these parts in the left hemisphere. Dysarthria and dysphagia with unilateral damage are often transient in nature, and with bilateral damage they are permanent. Impaired motor functions in the leg are characteristic of damage to the paracentral lobule (contralateral weakness or apraxia of walking). For the same localization, urinary incontinence is typical (long-term in case of bilateral injuries).

Medial divisions (F1, cingulate gyrus)

Damage to the medial parts of the frontal lobe is characterized by the so-called “anterior syndrome of akinetic mutism”, in contrast to the “posterior” (or mesencephalic) similar syndrome. In incomplete syndrome, “frontal akinesia” occurs. Damage to the medial sections is sometimes accompanied by impaired consciousness, oneiric states, and memory impairment. Motor perseverations may appear, as well as a grasping reflex in the hand and its analogue in the leg. “Bowing” seizures have been described, as well as such an unusual phenomenon as alien hand syndrome (a feeling of foreignness in the upper limb and involuntary physical activity in it.) The latter syndrome is also described in cases of damage to the corpus callosum (less often in other localizations). It is possible to develop transcortical motor aphasia (described only in frontal lesions), bilateral ideomotor apraxia.

Lateral divisions, premotor area

Damage to the posterior parts of the second frontal gyrus causes gaze paralysis in the direction opposite to the lesion (the patient “looks at the lesion”). With less severe lesions, deterioration of contralateral saccades is observed. In the left hemisphere, close to this zone, there is an area (upper premotor), damage to which causes isolated agraphia (“pure agraphia”, not associated with motor aphasia). A patient with agraphia is unable to write even individual letters; mild damage to this area can only manifest itself as an increase in the frequency of spelling errors. In general, agraphia can also develop with local lesions of the left temporal and left parietal lobes, especially near the Sylvian fissure, as well as with involvement of the basal ganglia on the left.

Damage to the posterior part of the third frontal gyrus in Broca's area causes motor aphasia. With incomplete motor aphasia, there is a decrease in speech initiative, paraphasia and agrammatism.

Frontal pole, orbitofrontal cortex

Damage to these departments is characterized by apathy, indifference, spontaneity, as well as mental disinhibition, decreased criticism, foolishness (moriah), disorders of goal-directed behavior, and syndrome of dependence on the immediate environment. Impotence may develop. Oral and manual apraxia is very typical for damage to the left anterior regions. When the orbital surface of the brain is involved (eg, meningioma), unilateral anosmia or unilateral optic atrophy may occur. Foster-Kennedy syndrome is sometimes observed (decreased sense of smell and vision on one side and congestive nipple on the opposite).

Damage to the corpus callosum, especially its anterior sections, separating the frontal lobes, is accompanied by peculiar syndromes of apraxia, agraphia (mainly in the left non-dominant hand), and other rarer syndromes (see the section “Damages to the corpus callosum” below),

The above neurological syndromes can be summarized as follows:

Any (right or left) frontal lobe.

1. Contralateral paresis or incoordination of an arm or leg.
2. Kinetic apraxia in the proximal parts of the contralateral hand (lesion of the premotor area).
3. Grasp reflex (contralateral supplementary motor area).
4. Decreased activity of facial muscles in voluntary and emotional movements.
5. Contralateral oculomotor neglect during voluntary gaze movements.
6. Hemi-inattention.
7. Perseverations and torpidity of the psyche.
8. Cognitive impairment.
9. Emotional disturbances (lack of spontaneity, decreased initiative, affective flattening, lability.
10. Deterioration of olfactory discrimination of odors.

Non-dominant (right) frontal lobe.

1. Instability of the motor sphere (motor program): what is referred to in foreign literature by the term “motor impersistence”, which does not have a generally accepted translation into Russian.
2. Inadequate perception (understanding) of humor.
3. Disturbances in the flow of thinking and speech.

Dominant (left) frontal lobe.

1. Motor aphasia, transcortical motor aphasia.
2. Oral apraxia, limb apraxia with preserved understanding of gestures.
3. Impaired fluency of speech and gestures.

Both frontal lobes (simultaneous damage to both frontal lobes).

1. Akinetic mutism.
2. Problems with bimanual coordination.
3. Aspontaneity.
4. Apraxia of walking.
5. Urinary incontinence.
6. Perseverations.
7. Cognitive impairment.
8. Memory impairment.
9. Emotional disturbances.

Epileptic phenomena characteristic of the frontal localization of the epileptic focus

Frontal lobe irritation syndromes depend on its location. For example, stimulation of Brodmann field 8 causes deviation of the eyes and head to the side.

Epileptic discharges in the prefrontal cortex tend to rapidly generalize into a grand mal seizure. If the epileptic discharge extends to field 8, then before secondary generalization a versive component of the seizure can be observed.

Many patients with complex partial seizures are of frontal rather than temporal origin. The latter are usually shorter (often 3-4 seconds) and more frequent (up to 40 per day); there is partial preservation of consciousness; patients recover from the seizure without a state of confusion; characteristic automatisms are typical: rubbing hands and hitting, snapping fingers, shuffling movements of legs or kicking them; head nodding; shrugs; sexual automatisms (manipulation of the genitals, thrusts of the pelvic area, etc.); vocalization. Vocal phenomena include swearing, screaming, laughing, and simpler unarticulated sounds. Breathing may be irregular or unusually deep. With seizures originating from the medial prefrontal region, there is a tendency to mildly develop status epilepticus.

Unusual ictal manifestations can cause erroneous overdiagnosis of pseudo-seizures (so-called epileptic “pseudo-pseudo-seizures”, “fireworks” seizures, etc.). Since most of these seizures originate from the medial (supplementary area) or orbital cortex, conventional scalp EEG often does not detect any epileptic activity. Frontal seizures occur more easily during sleep than other types of epileptic seizures.

The following specific epileptic phenomena of frontal origin have been described:

Primary motor area.

1. Focal clonic jerks (shudders), more often seen in the opposite arm than in the face or leg.
2. Stopping speech or simple vocalization (with or without salivation).
3. Jackson Motor March.
4. Somatosensory symptoms.
5. Secondary generalization (transition to a generalized tonic-clonic seizure).

Premotor area.

1. Simple tonic movements of the axial and adjacent muscles with versive movements of the head and eyes to one side
2. Secondary generalization is typical.

Accessory motor area.

1. Tonic lifting of the contralateral arm and shoulder with flexion at the elbow joint.
2. Turn your head and eyes towards the raised hand.
3. Stopping speech or simple vocalization.
4. Stopping current motor activity.

Cingulate gyrus.

1. Affective disorders.
2. Automatisms or sexual behavior.
3. Autonomic disorders.
4. Urinary incontinence.

Fronto-orbital region.

1. Automatisms.
2. Olfactory hallucinations or illusions.
3. Autonomic disorders.
4. Secondary generalization.

Prefrontal region.

1. Complex partial seizures: Frequent, brief seizures with vocalizations, bimanual activity, sexual automatisms, and minimal postictal confusion.
2. Frequent secondary generalization.
3. Forced thinking.
4. Adverse movements of the head and eyes or contraversive movements of the body.
5. Axial clonic jerks and patient falls.
6. Vegetative signs.

Damage to the corpus callosum (callosal syndromes)

Damage to the corpus callosum leads to disruption of the processes of interaction between the hemispheres, disintegration (disconnection) of their joint activity. Diseases such as trauma, cerebral infarction or tumor (less commonly - multiple sclerosis, leukodystrophies, radiation damage, ventricular shunting, aginesia of the corpus callosum) that affect the corpus callosum usually involve interhemispheric connections of the middle parts of the frontal lobes, parietal or occipital lobes. Disruption of interhemispheric connections in itself has almost no effect on everyday activities, but is detected when performing some tests. This reveals the inability of one hand to imitate the positions of the other (contralateral) due to the fact that kinesthetic information is not transferred from one hemisphere to the other. For the same reason, patients are unable to name an object that they feel with their left hand (tactile anomia); they have agraphia in the left hand; they can't copy right hand movements that are performed with the left (constructive apraxia in the right hand). Sometimes an “intermanual conflict” (“alien hand” syndrome) develops when uncontrolled movements in the left hand are initiated by voluntary movements of the right hand; the phenomenon of “double hemianopsia” and other disorders have also been described.

Perhaps of greatest clinical significance is the “alien hand” phenomenon, which can result from combined callosal and medial frontal damage. Less often this syndrome occurs with parietal injuries (usually in the picture of paroxysmal manifestations of an epileptic attack). This syndrome is characterized by a feeling of alienation or even hostility in one hand, involuntary motor activity in it, which is unlike any other known form of movement disorder. The affected hand seems to “live its own independent life”; involuntary motor activity is observed in it, similar to voluntary purposeful movements (palpating, grasping and even auto-aggressive actions), which constantly stresses these patients. A typical situation is also when, during involuntary movements, the healthy hand “holds” the sick one. The hand is sometimes personified with a hostile, uncontrollable alien “evil and disobedient” force.

“Alien hand” syndrome has been described in vascular infarctions, corticobasal degeneration, Creutzfeldt-Jakob disease, and some atrophic processes (Alzheimer’s disease).

A rare syndrome of damage to the central part of the anterior parts of the corpus callosum is Marchiafava-Benyami syndrome, which is related to alcoholic lesions of the nervous system. Patients suffering from severe alcoholism note in the anamnesis periodic syndrome alcohol withdrawal with tremors, epileptic seizures and delirium tremens. Some of them develop severe dementia. Characterized by dysarthria, pyramidal and extrapyramidal symptoms, apraxia, and aphasia. In the last stage, patients are in a deep coma. The diagnosis is made during life very rarely.

In 2009, 115 children with identified epileptiform changes on the EEG were sent to the paroxysmal conditions room of Children's City Clinical Hospital No. 9 for consultation. An EEG was done for headaches, hyperactivity, attention deficit, delayed speech development, cerebral palsy, and sleep disorders.

Some children underwent a repeated EEG study, and, if possible, video-EEG sleep monitoring, since in some cases only conclusions about epileptiform disorders on the EEG were presented, or the recording of the study was insufficiently informative or of insufficient quality.

During the study of EEG and repeated studies, epileptiform activity was confirmed in 54 patients. In other cases, myogram, ECG, rheogram artifacts, polyphasic complexes, paroxysmal activity, etc. were described as “epileptiform activity.”

In most cases, epileptiform activity was recorded in boys – 59% (32 children).

The age of children with identified disorders ranged from 5 to 14 years. Most often, epileptiform activity was recorded at the age of 5–8 years and was represented by DEND. Generalized peak-wave complexes were recorded in 3 patients.

In most cases (41), epileptiform activity in the form of DED had a low index of representation and was continuous in only 4 patients.

The structure of diagnoses of children with identified epileptiform activity was as follows: cerebroasthenic syndrome (30); syndrome autonomic dysfunction(6); attention deficit hyperactivity disorder (6); cerebral palsy (5); epileptiform cerebral disintegration (3); consequences of a neuroinfection (2); consequences of severe head injury (2). Some children were carried out additional examination(CT, MRI of the brain).

Neuroimaging revealed the following disorders in this group:

Congenital arachnoid cyst of the temporal lobe – 2

Periventricular leukomalacia – 3

Cerebral atrophy – 2

For some children, taking into account neuroimaging data and the presence of epileptiform activity on the EEG, anticonvulsant therapy is recommended for 3-6 months with subsequent EEG monitoring.

Valproic acid medications were prescribed to 6 children (20-25 mg/kg body weight) and 4 children were prescribed trileptal (25 mg/kg). Trileptal is prescribed to children with identified cerebral cysts of the temporal lobe and cerebral palsy (hemiparetic form).

During the year of observation of children in this group, no seizures were recorded. Further observation of these patients and monitoring of electroencephalographic disorders is necessary for the purpose of possible correction of non-epileptic disorders associated with epileptiform activity.
TACTICAL ALGORITHMS IN THE WORK OF THE EEG-VIDEO MONITORING OFFICE OF A SPECIALIZED NEUROLOGICAL DEPARTMENT
Perunova N.Yu., Safronova L.A., Rylova O.P., Volodkevich A.V.
Regional child Center epilepsy and paroxysmal conditions

CSTO No. 1, Ekaterinburg
Electroencephalographic video monitoring (EEG-VM), which allows synchronizing EEG and video information, visualizing epileptic seizures, making clinical-electroencephalographic comparisons and clarifying the form of the disease, is currently the most informative method for standard diagnosis of epilepsy and non-epileptic paroxysmal conditions

At the CSCH No. 1 in Yekaterinburg, the EEG-VM office was created in 2002. There are still no standards for conducting EEG-VM studies in Russia, so many technological approaches were developed independently by the office staff.

During the year in the EEG-VM room for the period 2002-2009, an approximately constant number of children and adolescents under the age of 18 were examined (1028-1162). Children staying in the hospital of CSCH No. 1 made up 58%, outpatients - 42%. Among all those examined, 14.6% were children of the first year of life.

As a result of EEG-VM, the diagnosis of epilepsy was excluded in 44% of those examined. The reasons for examination in this group of patients were: vegetative-vascular dystonia with syncopal paroxysms, hyperkinetic syndrome, paroxysmal sleep disorders, migraine, motor stereotypies, conversion disorders, infantile masturbation.

The diagnosis of epilepsy was established or confirmed in 56% of those examined. Epilepsy in this group was assessed as generalized in 61% of cases, and as partial in 39%.

Based on many years of experience in conducting EEG video monitoring studies in children and adolescents, we have proposed some special technological approaches or tactical algorithms.

Conducting the study while awake in most patients includes a standard set of functional tests (opening and closing the eyes, rhythmic photostimulation in various frequency ranges, phonostimulation, hyperventilation). A sensitization test for photosensitivity epilepsy is performing RFS immediately after waking up. Depending on the characteristics of the course of the disease, special methods of provocation can be used - playing, tactile provocation, watching television (for television epilepsy), exposure to a sharp sound (for startle epilepsy), reading complex text (for reading epilepsy). Patients with pseudoepileptic seizures may be exposed to provocative influences during conversation. Child monitoring early age in wakefulness and for patients with impaired consciousness, it is usually carried out without the use of functional tests (with the exception of RFS when indicated).

A study in the sleep state in most cases turns out to be quite informative when recording 1-2 cycles of daytime sleep after preparation by sleep deprivation. Studies in the state of night sleep (8 hours) are carried out with exclusively nocturnal nature of attacks, differential diagnosis of epileptic seizures and paroxysmal sleep disorders, behavioral disorders with the inability to sleep during the day. The office has the technical capabilities and experience in conducting long-term studies (24-48 hours), however, the need for such studies arises, in our opinion, only in special situations (for example, during clinical trials). Polygraphic research is technically possible using this diagnostic complex and is carried out if necessary - for example, when diagnosing epileptic breathing disorders.

We believe that the EEG-VM office should belong only to the clinical service and be located on the territory of a specialized department (to avoid untimely provision of assistance in the development of epileptic seizures, especially their series and statuses). Adequate interpretation of data can only be carried out by doctors with basic training in neurology - epileptology, who have also received training in neurophysiology (EEG). An individual approach to the doctor’s development of a program or tactical examination algorithm for each patient allows one to obtain the maximum amount of diagnostic information.

FOCAL EPILEPSY IN YOUNG CHILDREN:

EXPERIENCE OF TRILEPTHAL THERAPY
Perunova N.Yu., Volik N.V.
Regional Children's Clinical Hospital No. 1, Yekaterinburg
Focal epileptic seizures in infancy are difficult to identify due to the peculiarities of their clinical phenomenology; they are often detected only during EEG video monitoring. In this regard, one gets the erroneous impression that focal forms of epilepsy are rare in children of the first year of life. Meanwhile, if among epilepsies with onset in the first year of life, West syndrome accounts for 39-47%, then the share of symptomatic and cryptogenic focal epilepsies accounts for 23-36% (Caraballo et al., 1997; Okumura et al., 2001).

TO etiological factors Symptomatic focal epilepsies with onset in infancy include primarily cerebral dysgenesis (focal cortical dysplasia, pachygyria, polymicrogyria, schizencephaly, neuronal heterotopia, hemimegalencephaly), the neuroimaging diagnosis of which is hampered by the incompleteness of myelination processes in young children. The development of symptomatic focal epilepsies in infancy is also possible against the background of the consequences of perinatal hypoxic-ischemic brain damage with focal gliosis, mesial temporal sclerosis, Sturge-Weber syndrome, tuberous sclerosis, and brain tumors.

The semiology of partial seizures in infancy often includes motor phenomena (tonic or clonic, involving the face, 1 or 2 limbs, half the body), as well as versive manifestations (deviation of the eyes, head). Possible vegetative symptoms (pallor or redness of the face, mydriasis, tachypnea or apnea), nodding, different kinds automatisms (oroalimentary, facial, complex gestures).

Data from EEG video monitoring studies show combinations of epileptic seizures in accordance with the localization of the focus (Rather J.P. et al., 1998). The complex of frontal seizures in infants includes tonic postures, nodding, cessation of activity, eyelid myoclonus, gestural automatisms, and complex motor behavior. “Rolandic” seizures are manifested by unilateral or bilateral hypertonicity of the extremities, partial clones, and lateralized motor phenomena. Temporal lobe attacks include cessation of activity, staring, and oroalimentary automatisms. Finally, occipital seizures are characterized by deviation of the eyes, oculoclonus, myoclonus of the eyelids, sometimes “gazing” and late oral automatisms; prolonged epileptic blindness is possible.

Interictal changes in the EEG initially manifest themselves as rhythmic slowing, frequency-amplitude asymmetry, and sometimes regional slowing. Epileptiform activity may appear later than seizures and manifests itself in the form of spikes, sharp waves, as well as “sharp-slow wave” complexes that are polymorphic in shape and amplitude (unilateral, bilateral, multifocal).

Treatment of symptomatic and cryptogenic focal epilepsies of infancy requires maximum activity. Unfortunately, the range of anticonvulsants approved in Russia for use in young children and available (valproate, carbamazepine, barbiturates, benzodiazepines) is insufficient.

The use of the drug Trileptal®, the use of which is allowed for children from the age of 1 month, makes a significant contribution to the treatment of focal epilepsies of infancy. Recommended initial daily dose 8-10 mg/kg (divided into 2 doses), titration rate 10 mg/kg per week, maximum daily dose 55-60 mg/kg. Convenient for administration to young children is an oral suspension (60 mg/ml, 250 ml in a bottle).

We received our own positive clinical experience use of trileptal suspension in young children with focal epilepsy. During 2009 In the early childhood department of the CSCH No. 1, 73 children with epilepsy were treated. 15 children with partial epileptic seizures (20.5%) were prescribed Trileptal with dose adjustment, then therapy was recommended to take home. The children's ages ranged from 1 to 13 months.

In 1 observation, partial epilepsy was regarded as cryptogenic, and the child was prescribed Trileptal monotherapy.

14 patients had symptomatic forms of epilepsy. In 11 cases, these were symptomatic partial epilepsies against the background of severe or moderate perinatal brain damage, most often of hypoxic origin. The clinical picture included simple partial motor seizures, versive, oculomotor seizures, and tonic spasms. During EEG video monitoring, regional epileptiform activity was recorded.

In 3 patients, epileptic encephalopathies were detected against the background of cerebral dysgenesis (lissencephaly, agyria - 2 cases) and tuberous sclerosis (1 case). There was significant delay in motor and mental development. Epilepsy manifested itself as infantile spasms with a focal component - a version of the head, torso, freezing, and rolling eyes. During EEG-VM, multiregional or diffuse epileptiform activity was recorded.

All 14 patients received a combination of depakine and trileptal (suspension) 30-40 mg/kg. In all observations, a decrease in the frequency of attacks and good tolerability of therapy were noted.

**GBUZ SO "Sverdlovsk Regional cancer center", Ekaterinburg
Purpose of the work: to create an indicator of the state of processes of spatial synchronization of bioelectrical activity of the brain (BEA GM) based on the analysis of EEG spectra of bipolar leads and to study the possibility of its use to assess the risks of developing epileptization of brain tissue during the surgical treatment of epilepsy.

Group 1 consisted of 32 patients with frontal and frontotemporal forms of epilepsy after surgical treatment epilepsy (patients with positive (75% reduction in the frequency of attacks) and negative outcomes, and patients with right- and left-sided localization of the pathological focus were separately analyzed. Group 2 consisted of 24 healthy student volunteers. Based on the power spectra of bipolar EEG leads that do not have common points, the correlation coefficients between the spectra of their harmonics were calculated, which, by analogy with the coefficients of cross-correlation analysis, were called similarity coefficients (CS).The most pronounced and reliable variation in the average values ​​in the studied groups was observed for the CS calculated between leads F3-F7/C3- T3 and C3-T3/T5-P3 in the left hemisphere and F4-F8/C4-T4 and C4-T4/T6-P4 in the right hemisphere, respectively.CS between these leads were further considered as private characteristics (CS 1 and CS 2) state of spatial synchronization of the BEA GM, especially since we were talking about symmetrical leads of the left and right hemispheres. The use of two particular indicators of the state of spatial synchronization of the BEA GM for each hemisphere, having approximately the same information value, but not the same values, required a reasonable compromise between them - introduction generalized indicator. As such a generalized indicator of the state of spatial synchronization (SPS) of the BEA GM, the norm of the vector was calculated, the coordinates of which were partial indicators: SPS = (KS 1 2 + KS 2 2) 1/2, i.e. - square root of the sum of squares of partial indicators.

In group 2, all SPS values ​​for both hemispheres were less than 1 (average values ​​- 0.80 for the left hemisphere and 0.84 for the right), and after GW there was a predominant tendency towards their decrease (0.79 for the left hemisphere and 0.80 for right). In group 1, the average SPS indices, especially in the hemisphere of the lesion localization, were significantly increased - 1.03 in the left hemisphere with left-sided localization of the lesion and 0.97 in the right hemisphere with right-sided localization. After GV, the prevailing tendency was for their further increase - 1.09 in the left hemisphere with left-sided localization of the lesion and 1.06 in the right hemisphere with right-sided localization.

In the hemisphere contralateral to the lesion, along with increased values ​​of the SPS indicator after breastfeeding, there was a sufficient number of cases with normal values ​​of SPS (less than 1), characteristic of the control group with clearly normal functioning of the mechanisms regulating the spatial synchronization of the BEA GM. This made it possible to consider the value of the SPS indicator after GV in the hemisphere opposite to the localization of the focus of pathological activity as a criterion for the state of the regulatory mechanisms of spatial synchronization of BEA GM: exceeding 1 is a sign of a risk factor contributing to the development of further postoperative epileptization of brain tissue. Comparative probabilistic analysis showed that in the presence of this sign, the relative risk of lack of a positive effect from surgical intervention increases by 2.5 times.

Epileptic seizures or dystonic attacks, difficulties differential diagnosis
Rakhmanina O. A., Levitina E. V.

GOU VPO Tyumen State Medical Academy of Roszdrav

GLPU TO Regional Clinical Hospital No. 2

Tyumen
9 children (6 boys and 3 girls) with generalized symptomatic dystonia were examined. The distribution of children by age was as follows: 3 children under the age of 1 year, 3 children - from 1 to 2 years, 1 child - 3 and 4 years old, and 1 child 8 years old. Analysis of the causes of dystonia showed that 8 of these children had severe perinatal damage to the central nervous system with subsequent development of childhood cerebral palsy and 1 child was diagnosed with a chromosomal abnormality (deletion of the short arm of chromosome 5). All children had pathology of the antenatal period in the form of: gestosis (3), threat of miscarriage (4), intrauterine infection (3), polyhydramnios (1), chronic fetoplacental insufficiency (1), anemia (4) and frequent acute respiratory viral infections with increased temperature in mothers (1). All these factors led to the pathological course of the intrapartum period: acute asphyxia (5), prematurity (2), intracranial birth injury (1), intraventricular hemorrhage (2), with caesarean section childbirth was carried out only in 2 cases. All children had a severe course of the early neonatal period: in 5 - artificial ventilation (14.6±11.3 days), convulsive syndrome (3), meningoencephalitis (2), sepsis (1), anoxic cerebral edema (1) . During this period, 1 child suffered a severe traumatic brain injury, brain contusion with subarachnoid hemorrhage. CT/MRI of the brain revealed multiple structural defects: hydrocephalus (4 children, 2 of them with HPS); porencephalic cysts (3); periventricular leukomalacia (2); total subcortical leukomalacia – 1; cerebellar hypogenesis, Dandy-Walker anomaly (1), lobe atrophy (2), vascular malformation (1); cerebral dysgenesis (1). A child with a chromosomal abnormality had malformations of other organs (congenital heart disease, hydronephrosis, thymomegaly). A similar pattern of attacks allowed us to suspect dystonic attacks in all 9 children: “arching” sometimes with a torsion component, opening the mouth, sticking out the tongue. Consciousness is not lost, often a painful reaction in the form of a cry and provocation by a change in body position or touch during examination. Clinically, six of the 9 children had previously been diagnosed with epilepsy and had been unsuccessfully selected for antiepileptic treatment. When we conducted video-EEG monitoring at the time of the attack, these children did not reveal epileptiform activity. 3 children actually suffered from epilepsy in parallel: West syndrome (2), symptomatic focal epilepsy (1). At the same time, in 2 patients with remission of seizures within 1 year and at the time of the onset of the above-described conditions, the issue of recurrence of epileptic seizures or the appearance of dystonia was resolved. In 1 child, single flexor spasms persisted, which simplified the diagnosis of dystonia on the one hand; on the other hand, the question arose about the transformation of West syndrome into focal epilepsy. When conducting video-EEG monitoring at the time of dystonia, these 3 children also had no epileptiform activity. All 9 children were added to antidystonic therapy (Nacom, clonazepam, baclofen, Mydocalm) with a partial or significant positive effect. Thus, symptomatic dystonia in children was more common under the age of 4 years. With them, young children experience a combined effect of several pathological factors leading to severe damage to the central nervous system. Carrying out differential diagnosis of dystonia using video-EEG monitoring is necessary to ensure appropriate treatment for this category of patients.
ELECTROENCEPHALOGRAPHIC PATTERN OF BENIGN EPILEPTIFORM DISORDERS OF CHILDHOOD IN CHILDREN WITH SEVERE SPEECH DISORDERS
Sagutdinova E.Sh., Perunova N.Yu., Stepanenko D.G.
GUZ SO, DKBVL, “Scientific and Practical Center Bonum”, Yekaterinburg
Objective: To clarify the frequency of occurrence and main characteristics of the electroencephalographic pattern of benign epileptiform disorders of childhood (BED) in children with severe speech disorders without epileptic seizures.

Materials and methods: The study involved 63 children aged from 2 years 10 months to 4 years 6 months with severe impairments of expressive speech (OSD level 1), who had perinatal hypoxic-ischemic encephalopathy and did not currently have or have a history of epileptic seizures. Children with speech impairments due to severe neurological, mental, somatic diseases, genetic syndromes and hearing impairment were excluded from the study. All children underwent one-hour video EEG monitoring in a state of wakefulness and natural sleep on a Comet electroencephalograph (Grass-Telefactor, USA). Using visual assessment of EEG and video material, the presence and main characteristics of epileptiform activity were analyzed.

Results and discussion: The electroencephalographic pattern of benign epileptiform disorders of childhood was exclusively subclinical in nature and was recorded in 12 children (19%). Thus, the frequency of its occurrence among children with severe expressive speech disorders significantly exceeds the general population indicator, which, according to various authors, is 1.9-4%. During wakefulness and sleep, the DND pattern was recorded in 8 children (66.6%). An increase in the index of epileptiform activity during the transition from wakefulness to sleep was observed in only one child (8.3%). In 4 children (33.4%), this pattern was recorded only in the sleep state. Children with severe speech impairments were characterized by bilateral localization of the DND pattern (8 children, 66.6%), unilateral, predominantly left-sided localization was observed in only 4 patients (33.4%). The vast majority of children had a low or moderate index of epileptiform activity (11 children, 91.7%), and only one child (8.3%) had an index rated as high. The predominant localization of the DEND pattern was observed in the central-temporal regions of the brain (8 children, 66.6%), localization only in the central regions was observed in 2 children (16.7%) and with the same frequency this pattern was recorded in the temporo-parietal areas of the brain (2 children, 16.7%).

Conclusions: Thus, children with severe speech impairments are characterized by a higher frequency of occurrence of the subclinical electroencephalographic pattern DEND with a predominant bilateral localization in the central-temporal regions of the brain, with a low or medium index, than in the general population, without a significant increase in the sleep index. Considering the presence of a proven genetic predisposition, which manifests itself in the form of impaired maturation of neurons in the cerebral cortex, both in the formation of the DED pattern and in primary speech disorders in children, we can assume some commonality in the genetic mechanisms of these data pathological conditions. Further prospective studies are needed to evaluate the impact of the subclinical electroencephalographic pattern of DEND on the course and outcome of speech disorders, the risk of developing epilepsy and the need for antiepileptic therapy in children with severe speech disorders.

PRACTICAL ASPECTS OF THE WORK OF THE CHILDREN'S CITY EPILEPTOLOGICAL CENTER OF KAZAN
Sivkova S.N., Zaikova F.M.

Over the last decade, much attention has been paid to the creation of a specialized epileptological service for children and adolescents in different regions of Russia. The Republic of Tatarstan was no exception. In 2000, a room for the diagnosis and treatment of epilepsy and paroxysmal conditions was organized at the Children's City Hospital 8. The office has become the most important link in the organization of medical care for children suffering from epilepsy in Kazan.

Purpose of the work: to show the practical experience of the office in providing specialized advisory assistance to children with epilepsy.

Methods: Compare data from the practical work of the children's city epileptological service in the city of Kazan in 2000 and 2009.

Results obtained: In 2000, all patients registered in the office were divided into only two epilepsy groups, depending on the type of epileptic seizure: epilepsy with Grand mal seizures - 89.6% and epilepsy with Petit mal seizures - 10 ,4%. The group of patients with focal forms of epilepsy was not identified then. At that time, the leading position in treatment was occupied by phenobarbital - 51%; carbamazepine – 24%; valproic acid preparations – 18%. New generation drugs have not yet been used in therapy.

In 2009, the situation changed dramatically. 889 children with epilepsy, observed in the epileptology office, were divided into main groups according to forms of epilepsy, according to international classification epilepsies and paroxysmal conditions in 1989. The data is displayed as follows: idiopathic focal forms accounted for 8%; idiopathic generalized – 20%; symptomatic focal – 32%; symptomatic generalized – 8%; presumably symptomatic (cryptogenic) focal – 29%; undifferentiated – 3%. The range of antiepileptic drugs used has also changed in accordance with global trends in the field of epileptology. Currently, valproic acid preparations are used more often – 62%; carbamazepines 12%. The group of new antiepileptic drugs included: topiramate – 12%; lamotrigine – 3%; keppra – 5%; trileptal – 3%. The proportion of patients receiving phenobarbital therapy decreased significantly to 1.5%. The overwhelming number of patients are treated in monotherapy – 78%. 16% of patients receive 2 antiepileptic drugs. Clinical remission was achieved in 72% of children. Attacks continue despite regular treatment in 17% of cases. Most often, this group consists of patients with focal forms of epilepsy who are on combination therapy with several drugs. 3% of patients report irregular use of antiepileptic drugs.

Conclusions: monitoring patients in a specialized epilepsy center makes it possible to correctly diagnose a specific form of epilepsy in each specific case, prescribe adequate antiepileptic therapy in accordance with international standards for the treatment of epilepsy, increases the effectiveness of epilepsy treatment and, accordingly, improves the quality of life of patients and their families.

TREATMENT OF FOCAL FORMS OF EPILEPSY IN CHILDREN WITH ANTIEPILEPPTIC DRUGS

DIFFERENT GENERATIONS
Sivkova S.N., Zaikova F.M.
MUZ "Children's City Hospital 8", Kazan
Modern antiepileptic therapy can achieve an effect in the treatment of epilepsy in 70-80% of patients. However, 20-30% of children continue to have epileptic seizures. The use of drugs of different pharmacological groups and generations makes it possible to prescribe the most effective treatment both in monotherapy and in combination of several antiepileptic drugs.

The purpose of this work is to demonstrate the comparative effectiveness and tolerability of topiramate, lamotrigine and phenobarbital in the treatment of focal forms of epilepsy in children.

Materials and methods. The study included three groups of patients aged from 6 months to 17 years, with symptomatic focal forms of epilepsy - 79 people (82%) and presumably symptomatic (cryptogenic) focal forms of epilepsy - 17 people (18%). Patients received treatment with phenobarbital group drugs (34 patients) at a dose of 1.5 to 12 mg/kg/day; topiramate (31 patients) at a dose of 2.8 to 17 mg/kg/day and lamotrigine (31 patients) at a dose of 0.5 to 6 mg/kg/day.

Results. A positive effect in treatment (complete relief of attacks or a reduction in their frequency by 50% or more) was achieved in 27 (87%) receiving topiramate; in 22 (71%) patients receiving lamotrigine and in 13 (38%) patients receiving phenobarbital. Topiramate showed no significant difference when used at either low doses (78%) or high doses (83%). Lamotrigine was more effective at doses greater than 3 mg/kg/day (78%) versus lower doses (62%). Higher efficacy of phenobarbital was noted in doses less than 5 mg/kg/day (59%) compared with more high doses (42%).

Side effects were reported in 16 patients (52%) receiving topiramate. Of these, aggravation of attacks was noted in 1 case (3%). In this case, the drug was discontinued. Other undesirable effects included the appearance of salts in the urine, lethargy, drowsiness, and decreased appetite. In the group of patients receiving lamotrigine, adverse effects were noted in 10 patients (32%). Of these, in 2 cases (6%) an allergic reaction was observed in the form of pinpoint rash and angioedema, and in 2 cases (6%) an increase in attacks was recorded; Because of this, the drug was discontinued. In patients receiving phenobarbital therapy, side effects were observed in 16 patients (47%) and were more often associated with the effect of the drug on cognitive functions (aggression, irascibility, disinhibition, drowsiness, fatigue).

Conclusions. New generation antiepileptic drugs (topiramate and lamotrigine) have shown greater effectiveness and good tolerability in comparison with phenobarbital in the treatment of focal forms of epilepsy in children of different age ranges. Thus, rational antiepileptic therapy will reduce both the number of seizures in children with epilepsy and the level of side effects traditionally observed when prescribing outdated antiepileptic drugs.

USE OF TRILEPTAL IN PATIENTS WITH RESISTANT FOCAL EPILEPSY
Sorokova E.V.
Antiepileptic Center of Municipal Clinical Hospital No. 40, Ekaterinburg
The study group included 25 patients aged 18 to 38 years with resistant temporal lobe epilepsy, observed at the Antiepileptic Center of City Clinical Hospital No. 40 in Yekaterinburg. Of these, 13 patients were diagnosed with mesial temporal sclerosis, the rest were observed with cryptogenic forms. The frequency of attacks ranged from 8 per month to 10 per day; in the clinic, focal attacks predominated - in 14 patients, in the rest - in combination with secondary generalized ones.

It should be noted that all patients were diagnosed with a resistant form, since all received polytherapy with anticovulsants in high therapeutic dosages; 2 patients underwent surgical intervention.

15 patients were transferred to trileptal monotherapy in doses of 2400-2700 mg/day, the rest received a combination of trileptal with finlepsin or carbamazepine.

During EEG monitoring, regional epileptiform activity was recorded in 10 patients, and with secondary generalization in 8 patients.

Catamnesis averages 1.5 years. Remission occurred in 8 patients, 8 of whom took only Trileptal. Significant improvement (reduction of attacks by more than 75%) – in 11 patients. Trileptal was discontinued in 1 patient due to the appearance of a rash. In general, the drug was well tolerated, and 5 patients remained on the same therapy even in the absence of a significant reduction in the number of attacks. 10 patients noted a decrease in irritability, tearfulness, anxiety, and improved sleep and mood while taking trileptal. Blood tests showed a clinically insignificant decrease in hemoglobin in 2 patients. The absence of epileptiform changes in the dynamics of the EEG was noted in 7 patients, in 2 - positive dynamics in the form of a decrease in epileptiform activity. Thus, in case of resistant temporal lobe epilepsy, Trileptal has established itself as a highly effective anticonvulsant with good tolerability and a pronounced normothimic effect; combination with other carbamazepines is possible and also clinically successful.

ON THE ISSUE OF IMPROVING DISPENSARY OBSERVATION OF PATIENTS WITH EPILEPSY AND PAROXYSMAL CONDITIONS

A fairly widely accepted point of view is that younger age child by the time seizures appear, the more pronounced is the hereditary predisposition. The onset of the disease sometimes occurs unexpectedly for the patient and his environment at any age, even in the presence of factors affecting the central nervous system in fairly distant age periods.

When collecting anamnesis, the life characteristics of both the patient himself and his relatives are revealed, the so-called risk factors for the development of various pathologies. The study of epilepsy in children allows us to find out in more detail than in adults the course and type of seizure and the dynamics of the development of the disease. Among the identified conditions preceding the onset of epilepsy, special emphasis is placed on the presence of diseases of the “epileptic circle”: affective-respiratory attacks, fainting, stuttering, febrile seizures, sleepwalking, abdominal colic, etc. The very concept of “diseases of the epileptic circle” is ambiguously accepted by researchers in epileptology , but practitioners identify patients with these conditions from the general population as a risk group.

A number of works (V.T. Miridonov 1988,1989,1994) have identified two variants of the development of epilepsy in children. The first is characterized by the onset of the disease with the appearance of an epileptic seizure, the second option involves the onset of epileptic seizures to replace non-epileptic paroxysms. According to the authors’ observations, two thirds of observations correspond to the traditional variant and one third corresponds to the development of the disease according to the “second” type. Noting the role of hereditary factors in the occurrence of epileptic seizures, emphasis is constantly placed on the fact that when analyzing the health status of relatives in patients with various variants of the development of the disease, 1/3 revealed indications of paroxysmal conditions, both in the first and second groups.

Epilepsy lasts on average about 10 years, although for many the period of active seizures is significantly shorter (less than 2 years in more than 50%). A significant number (20-30%) of patients suffer from epilepsy throughout their lives. The nature of the attacks is usually determined by initial stage their occurrence, and this, along with other prognostic factors, makes it possible to ensure fairly high accuracy in predicting the outcome of the disease within several years after its onset. At the same time, transformation of seizures in children is acceptable as the brain “matures,” with a decrease in the process of growth in the tendency to generalize. This primarily affects generalized tonic-clonic seizures; their differentiation into primary and secondary generalized ones can be carried out after long-term observation of patients. In these clinical cases, neurophysiological and intrascopic research methods occupy a significant place.

Electroencephalography (EEG) occupies a leading place among neurophysiological methods. EEG allows not only to differentiate the form of a seizure, to establish the localization of the epileptic focus, but also to determine the effectiveness of drug therapy and routine measures. Implementation into everyday life medical practice“routine” EEG, not to mention EEG monitoring, allows one to evaluate the child’s brain response to the course of the disease over time.

Of the intrascopic diagnostic methods that allow intravital visualization of the brain, neurosonography, computed tomography and magnetic resonance imaging come to the fore.

Brain imaging is performed for the following purposes:

a) determining the etiology of the disease;
b) predetermination of the forecast;
c) providing patients with knowledge about their own illness;
d) determination of genetic recommendations;
e) providing assistance in planning the operation.

According to various authors, the introduction of neuroimaging methods has changed the ratio of symptomatic and idiopathic forms of epilepsy in favor of the former. All this suggests that a number of terms used in modern classifications will be dynamically revised, with the introduction of new diagnostic technologies into practice. Changes in approaches to the formulation of diagnosis and treatment tactics will change both the duration and principles of dispensary observation of patients with epilepsy at different age periods.

Introduction into practice of modern diagnostic technologies in combination with traditional methods allows for the identification of children at “risk” for the development of epilepsy. Excluding, in everyday life, situations that provoke the development of the disease: overheating, lack of sleep, intense exercise stress and by conducting dynamic monitoring of the results of neurophysiological research methods with minimal drug correction, will reduce the risk of developing the disease. This installation is most relevant in pediatric neurology, since emerging current issues of preventive vaccinations and visits to children's groups should have uniform approaches from doctors of various specialties.

In Yekaterinburg since 1996 a specialized appointment with a pediatric neurologist was organized for patients with epilepsy and paroxysmal conditions on the basis of the advisory clinic of the children's city clinical hospital No. 9. Over time, the diagnostic capabilities of the consultant expanded, but this also expanded the range of tasks assigned to this specialist. Solving medical, methodological, and expert issues by an epileptologist allows one to prolong the remission of the disease in patients. At the end of 2009 the dispensary group of patients with epilepsy (age up to 18 years) in Yekaterinburg amounted to 1200 people, the dispensary group “non-epileptic paroxysms” - 800. This differentiated approach to patients with paroxysmal conditions was introduced in 2005, this made it possible to have a clearer picture in the structure of the general morbidity, so and the number of disabled children. This greatly facilitated the solution to the issue of providing patients with antiepileptic drugs and made it possible to solve a wide range of social problems.

Clinical-electrophysiological and

neuropsychological characteristics of patients

with epileptic encephalopathies and

symptomatic focal epilepsy

from DEPD to EEG
Tomenko T.R. ,* Perunova N.Yu. **
*OGUZ SOKPB Children's Mental Health Center

**Regional Children's Center for Epilepsy and Paroxysmal Conditions

Regional Children's Clinical Hospital No. 1

Ekaterinburg
Goal of the work: to conduct a comparative analysis of clinical, electroencephalographic disorders and features of higher mental functions in children with epileptic encephalopathies and symptomatic focal epilepsy with benign epileptiform patterns of childhood (BEPD) on the EEG to determine the specificity and prognostic significance of this type of epileptiform activity.

Materials and methods: 29 patients with various forms epilepsy: 12 children with pseudolennox syndrome (PLS), 8 with epilepsy with electrical status epilepticus of slow-wave sleep (EESM) and 9 with symptomatic focal epilepsy (SFE).

The study included an assessment of clinical, genealogical, neurological, neurophysiological and neuroradiological data. Children aged 7 years and older underwent neuropsychological testing using a modified method of neuropsychological diagnosis and correction for developmental disorders of higher mental functions (Skvortsov I.A., Adashinskaya G.I., Nefedova I.V., 2000). The speech therapist assessed the patients' school skills (writing, reading and arithmetic). Patients with moderate to severe mental retardation were excluded from the neuropsychological examination. To determine the level of intelligence using D. Wexler's method (children's version), the children were tested by a psychologist. Patients with cognitive and behavioral disorders were examined by a psychiatrist.

To determine the index of epileptiform activity (EA), an algorithm for digitizing graphic elements was developed using Microsoft Excel. We took values ​​up to 29% as a low EA index, values ​​from 30-59% as average, and a high index of epileptiform activity corresponded to a value of more than 60%. The latter value, in our opinion, was characterized by the term “continued epileptiform activity”, since a high representation of DEPD was noted at all recording epochs, reaching up to 100% in some of them during slow-wave sleep.

Results: The study revealed that in symptomatic focal epilepsy with DEPD, the EEG showed exclusively motor focal and secondary generalized seizures associated with the sleep-wake cycle, of low and medium frequency (from several episodes per year to 1 time per week). Epileptiform activity during sleep was predominantly unilateral or bilateral independent (66%). The epiactivity index of wakefulness and sleep corresponded to low and average values ​​(up to 60%). The prognosis for the course of epilepsy in relation to seizures was favorable - remission or a reduction in the frequency of seizures by 75% was achieved in all patients on an average dose of monotherapy. However, these patients had a complicated obstetric history, severe cognitive deficits (88%) and delayed motor development (75%) (p

We made comparisons between the character, epiactivity index, neurological status, morphological changes in the brain and level of intelligence in patients with epileptic encephalopathies and symptomatic focal epilepsy. It turned out that in patients, bilateral bilateral synchronous epileptiform activity during wakefulness significantly more often took on a continued diffuse character during sleep (p

Patients with focal neurological symptoms were significantly more likely to have a high EA index (more than 60%) during sleep, compared to patients with diffuse neurological symptoms (p

Among patients with mental retardation, significantly more often (p

According to the data obtained, there was no relationship between the EA index and the level of intelligence. Thus, patients with a normal level of intelligence had an average value of the EA index in sleep (49.4±31.1%), with a borderline level - (49.6±31.7%), and children with low level– (52.2±33.9%).

According to CT and MRI data, 75% of patients in this group showed structural changes in the brain in the form of internal and external hydrocephalus, arachnoid cysts of the temporal and parietal lobes, asymmetric expansion of the lateral ventricles, cysts of the septum pellucidum and myeloradiculomeningocele. The presence of morphological changes in the brain in children with epileptic encephalopathies and symptomatic focal epilepsy contributed to the bilateral spread of epileptiform activity during sleep (p

During antiepileptic therapy, 14 (56%) patients showed positive dynamics in the form of remission or reduction in seizures by 75%. Of these, 5 patients with symptomatic focal epilepsy achieved remission with valproate monotherapy. However, despite the positive dynamics regarding seizures, a decrease in the EA index according to EEG video monitoring was observed in only 4 patients. All children continued to have cognitive and behavioral impairments.

Using neuropsychological techniques, 12 children were tested: with pseudolennox syndrome (6), epilepsy with electrical status epilepticus of slow-wave sleep (2) and symptomatic focal epilepsy (4) with an equal distribution by gender, aged 7 to 11 years. In half of the children examined, disorders of all higher mental functions were identified to varying degrees. The highest percentage of errors was observed in tests for kinesthetic (100%), spatial (100%), dynamic (92%) praxis, visual gnosis (100%), visual (92%) and auditory-speech memory (92%), and in subtest “drawing” (100%). Academic skills suffered significantly: reading in 80%, counting in 60%, writing in 80%.

According to the topical localization of higher mental functions, in patients with epileptic encephalopathies and symptomatic focal epilepsy, functional deficiency of the left hemisphere was observed to the greatest extent (p

Thus, the lateralization of the zone of functional neuropsychological defect and epiactivity coincided. No match in terms of topical localization was obtained.

According to the results of the D. Wexler test, 4 of the examined patients had normal intelligence, 4 had borderline intelligence, and 4 had mild mental retardation. Patients were divided by level of intelligence and compared by the number of incorrectly performed neuropsychological tests. Children with borderline intelligence and mental retardation made significantly more errors, compared with patients with a normal level of intelligence, in the following tests: visual gnosis (p

Thus, the factors influencing the neuropsychological profile of patients with pseudolennox syndrome, epilepsy with electrical status epilepticus of slow-wave sleep and symptomatic focal epilepsy are the level of intelligence, the presence of a history of delayed motor and speech development.

TACTICS OF SURGICAL TREATMENT OF PATIENTS WITH SYMPTOMATIC EPILEPSY WITH SERIAL AND STATUS COURSE OF SEIZURES

Shershever A.S.,* Lavrova S.A.,* Cherkasov G.V.,* Sorokova E.V.**

* City Clinical Hospital No. 40, Ekaterinburg
Any neurosurgical intervention, the main goal of which is to reduce epileptic seizures, can be regarded as surgical treatment of epilepsy.

Surgical operations (examples): excision of epileptogenic brain tissue, cortical topectomy, lobectomy, multilobectomy, hemispherectomy, and certain operations such as amygdala-hippocampectomy; callosotomy and functional stereotactic intervention; other functional procedures such as multiple dissection under the pia mater.

Based on our experience surgical treatment more than 1000 patients with epilepsy for the period 1964-2009. an algorithm for the intraoperative period was developed.

In the operating room, an EEG is recorded before the start of anesthesia.

Under general anesthesia, a scalp EEG is performed before the procedure begins. A compromise that suits the neurosurgeon, anesthesiologist and neurophysiologist is the III EEG stage of anesthesia according to Courtin.

EEG + ECoG is performed before the start of resection or stereotactic destruction of the conduction pathways of the epileptic system.

If the ECoG data coincides with the data on the localization of epileptogenic foci, a step-by-step ECoG is performed with resection of the foci, or multiple subpial transsection, or stereotactic destruction - stimulation of each target point through the inserted electrode with EEG recording.

If there is a threat of kindling development, it is necessary to deepen anesthesia to level IV - VI EEG stage of anesthesia according to Courtin.

The results were encouraging. The effectiveness of surgical treatment in combination with antiepileptic therapy was higher in patients with resistant epilepsy than in those receiving only conservative therapy.

Epidemiology and risk factors for paroxysmal conditions
Yakhina F.F.
Consultative and diagnostic office for epilepsy and paroxysmal conditions, Kazan
The two main causes of episodic loss of consciousness are syncope and epilepsy. In order to establish their prevalence and pathogenetic connection with various diseases, a clinical and epidemiological study of the unorganized population of Kazan was carried out. 1000 (men - 416, women - 584) people aged 15-89 years were examined. During the door-to-door examination, various studies were taken into account (general and biochemical blood and urine tests; ECG; Dopplerography of the vessels of the brain, heart and extremities; fundus of the eye; ECHO, EEG; MRI/CT, ​​etc.). To determine the vegetative status, a questionnaire with a score was used [Vein A.M., 1988].

The material was processed on an IBM PC 486 computer using the Paradox database and the statistical software package Statgraf (Statistical Graphics System).

It was found that epilepsy in adults in the general population of Kazan occurred in 0.5%. Tonic-clonic seizures occurred 1.5-2 years after severe traumatic brain injury in the parietal region in persons with a depressed fracture and plastic surgery. Moreover, all registered were men aged from 50 to 89 years. Presyncope and syncope were noted in 15.3% and occurred in a wide age range from 15 to 89 years. In this subgroup there were more women than men by 1.4 times.

Various diseases and borderline conditions in people with epilepsy did not differ from those in the general population (p>0.05). All patients had severe neurological deficits, and autonomic disorders occurred with the same frequency as in the general population (60% and 56.0%, respectively). In the comparison group, the likelihood of developing presyncope/syncope increases in the presence of cardiovascular, pulmonary and genitourinary diseases, neurological and endocrine pathology, and increased meteosensitivity. In epilepsy there is no such dependence.

It can be concluded that in the general population of Kazan, epilepsy in adults is registered in 0.5%, and fainting in 15.3%. Among patients with epilepsy, men predominate, and among those with syncope, women predominate. Epilepsy is more common in people over 50 years of age. Fainting can occur at any age, and the likelihood of their occurrence increases in the presence of somatic pathology.
APPLICATION
HISTORY OF STUDYING EPILEPSY AND DEVELOPMENT OF CARE FOR PATIENTS WITH EPILEPSY IN SVERDLOVSK-YEKATERINBURG
Shershever A.S., Perunova N.Yu.

The formation and development of neurosurgery in the Urals is directly related to the study of issues of surgical treatment of epilepsy. In the twenties, M.G. Polykovsky described the Kozhevnikovsky epilepsy syndrome for the first time in the Urals, and already in the thirties D.G. Schaeffer performed the first neurosurgical interventions for of this disease. At that time, the Gorsley operation was most widely performed, and if at first the area of ​​those parts of the motor cortex that were related to the limb covered by hyperkinesis was routinely removed, then later EcoG was used to localize the epileptic focus.

Further study of the pathogenesis and clinical picture of this disease showed that damage to the motor cortex is not always the leading factor determining the clinical picture of epilepsy. It was found that thalamocortical reverberant connections are essential for the implementation of hyperkinesis and epileptic seizures. This served as the basis for stereotactic interventions on the ventrolateral nucleus of the visual thalamus (L.N. Nesterov).

During the Great Patriotic War and in the immediate post-war period, the clinic team paid a lot of attention to the surgical treatment of traumatic epilepsy (D.G. Shefer, M.F. Malkin, G.I. Ivanovsky). During these same years, the clinic dealt with the issues of hypothalamic epilepsy (D.G. Shefer, O.V. Grinkevich), and the clinic of epileptic seizures in brain tumors was studied (Yu.I. Belyaev). All these works created the prerequisites for further expansion of research on the problem of epilepsy surgery.

Since 1963 at the Department of Nervous Diseases and Neurosurgery of the Sverdlovsk State medical institute Comprehensive work on the study of epilepsy began. At the Hospital of Veterans of the Patriotic War, where the department was then located, consultations were held, and research work was actively carried out.

In February 1977 By order of the Ministry of Health of the RSFSR No. 32m-2645-sh, an epileptological center was created in the neurosurgical clinic of City Clinical Hospital No. 40 (which has been the base of the Department of Nervous Diseases and Neurosurgery of the SSMI since 1974), later named the Sverdlovsk Regional Neurosurgical Antiepileptic Center (SONPEC).

With the opening of a permanent appointment with a neurologist-epileptologist in 1982. (Perunova N.Yu.) advisory assistance to patients with epilepsy became more accessible, 2.5-3 thousand consultations were carried out per year.

Since 1996 the organization of specialized epileptological receptions has begun - in the Children's multidisciplinary hospital No. 9 (1996, Panyukova I.V.), Regional Clinical Hospital No. 1 (1997, Shmeleva M.A., Tereshchuk M.A., Vagina M.A.), Regional Children's Clinical Hospital No. 1 (1999 , Rylova O.P., Zhukova T.A., Grechikhina A.I.), City Psychiatric Dispensary (2000, Danilova S.A., Baranova A.G.), Regional Center for Mental Health of Children and Adolescents psychiatric hospital(2006, Tomenko T.R.). At currently functioning receptions, 13-14 thousand qualified consultations can be carried out during the year for patients with epilepsy and paroxysmal conditions.

In 2002 in the neurological department of the CSCH No. 1, an EEG video monitoring room was organized, the first in the Ural region (Perunova N.Yu., Rylova O.P., Volodkevich A.V.). In 2004 On the same basis, the Regional Children's Center for Epilepsy and Paroxysmal Conditions was created (Safronova L.A., Perunova N.Yu.).

Carrying out EEG of daytime and night sleep and EEG video monitoring for children and adults has become available on the basis of other medical institutions: Scientific and Practical Rehabilitation Center "Bonum" (2005, Sagutdinova E.Sh.), Center for Mental Health of Children and Adolescents (2007, Tomenko T.R.).

Work to improve surgical approaches in the treatment of epilepsy continues at the Sverdlovsk Regional Oncology Center, the Ural Interterritorial Neurosurgical Center named after. prof. D.G. Schaefer. (Shershever A.S., Lavrova S.A., Sokolova O.V.).

The list of dissertations on the problem of epilepsy defended by specialists from Sverdlovsk-Ekaterinburg illustrates the above.

CANDIDATE DISSERTATIONS:

1. 
   Belyaev Yu.I. Epileptic seizures in a brain tumor clinic (1961)
2. 
   Ivanov E.V. Stereotactic method in diagnosis and treatment temporal lobe epilepsy (1969)
3. 
   Bein B.N. The importance of EEG activation in the diagnosis and surgical treatment of temporal lobe epilepsy (1972)
4. 
   Boreyko V.B. Mental disorders in indications and long-term results of surgical treatment of patients with temporal lobe epilepsy (1973)
5. 
   Myakotnykh V.S. Course of focal epilepsy (according to long-term follow-up) (1981)
6. 
   Nadezhdina M.V. Dynamics of focal epileptic activity in patients with temporal lobe epilepsy (1981)
7. 
   Klein A.V. Histological and ultrastructural changes in neurons and synapses in the epileptic focus in patients with temporal lobe epilepsy (1983
8. 
   Shershever A.S. Prognosis of epilepsy after operations on the temporal lobe (1984)

1. 
   Perunova N.Yu. Comparative assessment of variants of the course of the main forms of idiopathic generalized epilepsy (2001)
2. 
   Sorokova E.V. An integrated approach to the treatment of drug-resistant forms partial epilepsy (2004)
3. 
   Tereshchuk M.A. Clinical features and quality of life of patients with cryptogenic partial and idiopathic forms of epilepsy (2004)
4. 
   Agafonova M.K. Features of the course of epilepsy in pregnant women (2005)
5. 
   Sulimov A.V. The influence of factors of the perinatal period on the development and course of partial epilepsy in school-age children (2006).
6. 
   Lavrova S.A. Electrophysiological criteria for predicting the results of stereotactic epilepsy surgery (2006)
7. 
   Koryakina O.V. Clinical and immunological features of the course of epileptic paroxysms in children and the rationale for immunocorrective therapy (2007)
8. 
   Tomenko T.R. Clinical, encephalographic and neuropsychological characteristics of children with benign epileptiform childhood patterns (2008)

DOCTORAL DISSERTATIONS:

1. Nesterov L.N. Clinic, issues of pathophysiology and surgical treatment of Kozhevnikov epilepsy and some diseases of the extrapyramidal system (1967)

2. Belyaev Yu.I. Clinic, diagnosis and surgical treatment of temporal lobe epilepsy (1970)

3. Scriabin V.V. Stereotactic surgery for focal epilepsy (1980)

4. 
   Bein B.N. Subclinical and clinical disorders of motor function in patients with epilepsy (1986)
5. 
   Myakotnykh V.S. Cardiovascular and neurological disorders in patients with initial epileptic manifestations (1992)

1. 
   Shershever A.S. Ways to optimize surgical treatment of drug-resistant epilepsy (2004)
2. 
   Perunova N.Yu. Improving the diagnosis and organization of treatment for idiopathic generalized forms of epilepsy (2005)

INFORMATION ABOUT THE NON-PROFIT PARTNERSHIP “EPILEPTOLOGISTS OF THE URAL”
The non-profit Partnership “Epileptologists of the Urals” was created on the initiative of a group of epileptologists from Yekaterinburg (decision on state registration dated October 16, 2009, main state registration number 1096600003830).

The goal of the Partnership in accordance with the concepts of the World League Against Epilepsy (ILAE), the International Bureau of Epilepsy (IBE), and the Global Company “Epilepsy from the Shadows” is comprehensive organizational and methodological assistance in the development of care for patients with epilepsy in the Ural region.

The subjects of activity of the NP "Epileptologists of the Urals" are: formation and implementation research programs on epilepsy in the region; creation and maintenance of the Partnership website; organizing and conducting thematic conferences, lectures, educational seminars; preparation and implementation of thematic scientific, methodological, educational and popular literature; support for the introduction into practice of modern methods of diagnosis, treatment, rehabilitation of patients with epilepsy; assistance in providing patients with epilepsy with quality medical care, including medications; promoting educational work on the problems of epilepsy, as well as the implementation of international agreements on problems related to treatment, social rehabilitation and improving the quality of life of patients with epilepsy; attracting the attention of government authorities and society as a whole to the problems of patients with epilepsy.

The meeting of founders elected Doctor of Medical Sciences to the Council of the NP “Epileptologists of the Urals”. Perunova N.Yu. (Chairman), Doctor of Medical Sciences Professor Shershever A.S., Ph.D. Sulimov A.V., Ph.D. Sorokova E.V., Ph.D. Tomenko T.R. (secretary).

NP "Epileptologists of the Urals" - address for correspondence:

620027, Ekaterinburg, Sverdlova st. 30-18.

M.t. 89028745390. E-mail: perun@ mail. ur. ru(Perunova Natalia Yurievna)

Email: epiur@ yandex. ru(Tomenko Tatyana Rafailovna)