Senile epilepsy
Introduction
Introduction to senile epilepsy The onset of adulthood epilepsy is called late onset epilepsy. The clinical choice is 20 years old as the starting point of age, and those who have epilepsy over 60 years old are called late-onset epilepsy or senile epilepsy (senileepilepsy). Epilepsy in the elderly is mostly secondary, and its etiology, diagnosis, treatment, etc. are not the same as epilepsy in other age groups, and have their own characteristics. basic knowledge The proportion of illness: 0.001% Susceptible people: good for people over 60 years old Mode of infection: non-infectious Complications: hemorrhagic stroke
Cause
Causes of senile epilepsy
Cerebrovascular disease (20%):
Epilepsy can occur in various cerebrovascular diseases, accounting for 30% to 40% of the etiology of senile epilepsy, mainly ischemic vascular disease. In hemorrhagic cerebrovascular disease, epilepsy occurs in the acute phase or is the first symptom; Ischemic cerebrovascular disease can occur in the acute phase, with approximately 33% occurring subsequently.
Brain tumors (20%):
It is also a common cause of senile epilepsy, including meningioma, brain metastases, gliomas, especially meningioma, which increases with age. Epilepsy can often be the first symptom of brain tumors, which is more common than symptoms of increased intracranial pressure. .
Brain trauma (15%):
Epilepsy in the elderly is not uncommon because of traumatic brain injury, such as brain injury, intracranial hematoma, brain contusion, etc., often with seizures.
Brain atrophy (10%):
The initial study concluded that diffuse brain atrophy is an important cause of epilepsy in the elderly, and recent studies have found that focal brain atrophy has more chances of developing epilepsy.
Metabolic disease: (10%):
1 Diabetes: non-keto hyperglycemia, ketoacidosis, hyperosmolar coma, etc. can be combined with epilepsy.
2 uremia: late stage of uremia due to severe disorders of water, salt and electrolytes often occur epilepsy.
Chronic alcoholism (10%):
Ethanol epilepsy is common in Western countries, but it is rare in China.
Pathogenesis
The pathogenesis of epilepsy is complicated. The pathogenesis of epilepsy in the elderly is not fully understood. In recent years, due to the advancement of neurobiochemistry and molecular biology, it is further recognized that its pathogenesis is closely related to the neurotransmitters of the central nervous system. The reduction of the central nervous system inhibitory transmitter -aminobutyric acid and the increase of the excitatory transmitter glutamate, intracellular calcium overload and the disorder of certain ions inside and outside the cell such as sodium, chlorine, magnesium, etc., also have epilepsy There is also a relationship between onset and heredity. Three epilepsy genes have been found in patients with idiopathic epilepsy and their families, and four epilepsy genes and one mitochondria have been found in patients with progressive myoclonic epilepsy and their families. DNA mutation gene.
Prevention
Senile epilepsy prevention
Older patients, like patients of any other age, should avoid activities and work that are immediately dangerous when they occur, such as swimming, driving a vehicle, aerial work, etc. Some known predisposing factors: lack of sleep, excessive fatigue, height Tension, excessive drinking and alcohol abuse should be avoided. People should be persuaded to take regular medication, regular life and proper physical exercise.
Complication
Senile epilepsy complications Complications hemorrhagic stroke
Common clinical complications, accidental stroke and moderate disease.
Symptom
Symptoms of senile epilepsy Common symptoms Calcium influx dysfunction dysfunction myoclonus psychomotor activity dysfunction paralysis imitative automatic syndrome senile tremor automatic disease frontal lobe epilepsy...
The clinical manifestations of epilepsy are often divided into two aspects: epileptic seizures and epilepsy. (This section is mainly classified by seizures) is the main clinical manifestation. In 1981, the International Anti-Epilepsy Alliance based on clinical manifestations and EEG at the onset. The classification of seizures has been used internationally.
1. Partial seizures (local onset of seizures)
(1) Simple partial seizures (without disturbance of consciousness):
1 has motor symptoms.
2 have a somatosensory or special feelings.
3 have autonomic symptoms.
4 have mental symptoms.
(2) complex partial seizures (with disturbance of consciousness):
1 There is a simple partial seizure, followed by a disturbance of consciousness.
2 At the beginning, there is a conscious disorder:
A. Only the disturbance of consciousness.
B. Automated disease.
(3) Partial seizures are secondary to a generalized episode:
1 simple partial seizures secondary.
2 complex partial seizures secondary.
2. Comprehensive seizures (symmetric seizures on both sides, no local symptoms at the onset of the attack)
(1) Absence of seizures.
(2) Myoclonic seizures.
(3) clonic seizures.
(4) tonic seizures.
(5) tonic-clonic seizures.
(6) Tension-free episodes.
3. Unclassified seizures Because the epilepsy in the elderly is mostly secondary, the clinical seizure form of senile epilepsy is mostly partial seizures. Among them, simple partial seizures, very few people show complex partial seizures, senile epilepsy The occurrence of the lesion is not necessarily parallel to the size of the lesion and the severity of the disease, but is related to the location of the lesion. The incidence of the frontal, apical, and temporal lobes is the highest. Previous data show that the type of seizures in the elderly is tonic-clonic. Sexual seizures are predominant. In fact, this may be an illusion. It is due to the lack of EEG data, and the secondary tonic-clusters that originate in the local and then rapidly spread into bilateral cerebral hemispheres. The seizure mistakenly believes that the primary tonic-clonic seizure has almost no seizures.
After the seizure in the elderly, the state of paralysis can last for a long time, at least 14% of patients continue for more than 24 hours, some patients can even last up to 1 week, and after the onset of paralysis (Todd's Palsy) is more common, especially prone to post-stroke epilepsy The patient may be confused with another stroke.
Examine
Examination of senile epilepsy
When combined with infection, blood leukocytes can be elevated.
1. Head X-ray film diagnosis of head plain film examination is an important method for X-ray examination of central nervous system diseases. It can provide an important diagnostic basis for the diagnosis of some diseases in the brain. The diagnosis of epilepsy can mainly provide the following clues:
(1) Increased intracranial pressure: epileptic patients secondary to intracranial space-occupying lesions, the head flat film can show various manifestations of increased intracranial pressure, such as: 1 cranial suture separation: infant cranial and childhood cranial suture separation obvious. 2 brain back pressure increased. 3 Sella changes: manifested as bone resorption and enlargement of the sella, saddleback disappeared, cortical blur and interruption.
(2) Pathological calcification: Many structural lesions that produce epilepsy will have different degrees of pathological calcification. Tumor calcification is more common. According to the location of calcification and the characteristics of calcification, it helps the localization of tumors. Important reference value, such as meningioma in the form of sand or agglomerate, craniopharyngioma is mostly arc-shaped, calcification of oligodendroglioma occurs in the cerebral hemisphere, alternating with strips, arteriovenous malformation 15% Calcification may occur, some infectious diseases such as cysticercosis calcification are more common, tuberculosis may have non-specific nodular calcification, and chronic brain abscess may have linear calcification.
(3) skull bone changes: some structural changes leading to epilepsy can cause changes in skull bone, such as tumor invasion leading to bone destruction, long-term stimulation of lesions can lead to local bone hyperplasia, increased intracranial pressure can lead to bone The plate is thinned, the bone density is reduced, and the inner plate is blurred.
2. X-ray computed tomography (CT) CT has great value in the diagnosis of brain diseases. Since the results of CT examination of 6,500 patients in Gastaut in 1996, the value of CT in the diagnosis of epilepsy has been public. It is recognized that the abnormal detection rate of CT examination of epilepsy varies from report to report, most of them are between 30% and 50%. The positive rate of CT examination is related to the type and case of seizure. The partial abnormal CT rate is 52% to 68%. The complex partial epilepsy is between 40% and 70%. The CT abnormal rate is higher in patients with localized neurological signs and abnormal EEG. The adult abnormal rate increases with age.
In patients with epilepsy, the main manifestations of CT abnormalities are as follows:
(1) Brain atrophy: brain atrophy is the most common type of CT scan abnormality in patients with epilepsy, accounting for more than 50% of the abnormal rate. It can be divided into two types: diffuse brain atrophy and localized brain atrophy. Diffuse brain atrophy is the main type. The manifestations of cortical atrophy and sulci, ventricular enlargement, localized brain atrophy mainly manifested as unilateral or regional ventricle, cerebral cistern, cerebral sulcus enlargement, it is generally believed that the age of onset of epilepsy patients is larger, the longer the course of disease, the more common brain atrophy, epilepsy The type of seizure is obviously related to brain atrophy. It has been reported that 75% of localized authors have brain atrophy, and 79% of localized authors with localized hair, but some people think that the incidence of brain atrophy is higher in patients without epilepsy. There is no practical clinical significance for epilepsy.
(2) intracranial tumors: intracranial tumors are an important cause of epilepsy. The detection rate of CT for intracranial tumors is as high as 95%. CT examination can find the location, size, number and shape of tumors, and can also make some tumors. Qualitative diagnosis, different tumors, CT manifestations vary, and its basic CT signs are:
1 tumor itself signs: regular or irregular abnormal density mass shadow, can be high density, medium density, low density, but also irregular density, intratumor can be combined with necrosis, hemorrhage or calcification, enhanced to varying degrees Intensive, but grade I astrocytoma is often not enhanced, while meningioma is enhanced, and the enhanced morphology may be uniform or irregular enhancement or annular enhancement or large lesion nodular enhancement.
2 Occupation effect: Tumors will push the surrounding brain tissue to produce displacement. Generally, the larger the tumor, the more obvious the occupational signs. The malignant tumors often have obvious peritumoral edema, and the occupational signs are more obvious than benign tumors.
3 peritumoral edema: most malignant tumors have peritumoral edema, especially brain metastases, the most obvious peritumoral edema, often cause the midline structure of the brain to shift to the contralateral side, forming the cerebral palsy, CT is the brain stem push Pressure shift, deformation.
4 secondary hydrocephalus: any brain tumor, as long as the ventricular system is oppressed, resulting in blocked cerebrospinal fluid circulation, can form obstructive hydrocephalus, especially in the pineal region and cerebellar palsy, a few intraventricular Brain tumors, such as choroid plexus papilloma, can secrete cerebrospinal fluid, increase the amount of cerebrospinal fluid, and can also form non-obstructive hydrocephalus. The common brain tumors in epileptic patients include glioma, brain metastases, meningioma and so on.
(3) cerebrovascular disease: cerebrovascular disease is one of the common causes of secondary epilepsy, mainly seen in cerebral infarction, cerebral arteriovenous malformation, arteriovenous malformation, etc. CT findings of cerebral infarction are low-density images in the brain. The infarction caused by occlusion of the cortical artery is wedge-shaped. The old infarction can be seen with cystic cavity formation or scar with focal brain atrophy. Small vessel occlusion can cause irregular low-density foci in deep white matter. The cerebral artery malformation hemorrhage appears on CT image. High-density spotted and arcuate vascular clusters.
(4) Brain trauma: CT abnormality rate of post-traumatic epilepsy can reach 69%-85%. CT examination is mainly important for intracranial hematoma caused by traumatic brain injury, skull fracture, localized cortical atrophy and substantial damage of brain lobe. Diagnostic value.
(5) Intracranial infection: Acute brain abscess is often the cause of seizures. CT can be seen with irregular low-density shadow and space-occupying effect. After the formation of abscess membrane, CT can see high-density annular cyst, enhanced scanning cyst display enhancement. Shadow; viral encephalitis can be seen in the plaque-like low-density area of the brain parenchyma; cerebral cysticercosis often occurs epilepsy, multifocal edema area can be seen in early CT, small ring-enhanced nodules can be seen after enhancement, and typical cases can be seen scattered in the brain. A high-density small nodule.
(6) Abnormal brain development: abnormal brain development is one of the causes of epilepsy. Common brain development abnormalities include transparent septal defect, corpus callosum dysplasia, traffic hydrocephalus, arachnoid cyst, congenital brain penetrating malformation cyst, brain Tissue ectopic, nodular sclerosis, etc. CT examination of most brain abnormalities can be diagnosed.
Diagnosis
Diagnosis and diagnosis of senile epilepsy
Diagnostic criteria
The diagnosis of epilepsy includes three aspects: first, to determine whether it is epilepsy, and secondly to determine the type of seizure, and finally to find out the cause.
A seizure of 2 or more elderly people over 60 years old can be diagnosed as epilepsy in the elderly. The clinical history is decisive. EEG and related tests are the most important auxiliary examination for the diagnosis of epilepsy. EEG abnormalities are mostly characterized by focal slow wave activity, while epileptic discharge is less common than other age groups.
What type of seizure is also a major component of the diagnosis of epilepsy, which may suggest that epilepsy is idiopathic, or secondary, and provides an important basis for treatment.
Because epilepsy in the elderly is almost secondary epilepsy, it is very important to find the cause. The common causes are cerebrovascular disease, brain tumor, brain trauma, brain CT, MRI, etc. It is very helpful to find these causes, caused by diabetes. In addition to the clinical manifestations of diabetes, fasting glucose tolerance test is helpful for diagnosis, other rare causes: brain parasitic diseases, in addition to imaging examination, blood and cerebrospinal fluid related immunological examination is of great significance.
Differential diagnosis
Epilepsy in the elderly needs to be differentiated from the following diseases:
Syncope
Syncope is also a short-term disturbance of consciousness. When a short-term disturbance of consciousness occurs in elderly patients, it is first necessary to identify syncope and epilepsy. There is often no aura in syncope, autonomic symptoms, no rules of tonic-clonic seizures, and paralysis after seizures, although sometimes syncope occurs. There may be myotonia and short muscle myoclonus, but it is slower than the occurrence of epileptic seizures. At first, there are dizziness, nausea, and black eyes and other symptoms before loss of consciousness. In elderly patients, the important cause of syncope is heart. Sexually, and convulsion itself can induce arrhythmia and lead to loss of consciousness. When physical examination and routine EEG are negative results, and clinically suspected cardiogenic, patients should be recommended to do 24h dynamic EEG and ECG monitoring. Meaningful for differential diagnosis.
2. Transient ischemic attack
Because cerebrovascular disease is a common cause of epilepsy in the elderly, patients can present both symptoms, as well as Todd's paralysis, which is common in elderly patients with epilepsy, and a longer post-onset state, making it more difficult to distinguish from transient ischemic attacks. In particular, simple partial seizures and vertebral-basal ischemic attacks are difficult to distinguish clinically. Although EEG is sometimes normal, other forms of epilepsy and other signs are helpful for differential diagnosis.
Migraine
Frequent headaches after seizures, especially tonic-clonic seizures, allergies of migraine can simulate seizures, especially in children, but migraine duration is longer, and EEG has no epileptic discharge Identify both.
