Types and features of temporal lobe epilepsy

Causes of temporal lobe epilepsy

A number of factors can trigger the development of this disease. In some cases, the epileptogenic discharge does not occur in the temporal lobe of the brain itself, but comes there from other areas of the main organ of the central nervous system.

All reasons can be divided into two groups:

1. Perinatal (prematurity, fetal hypoxia, etc.).
2. Postnatal (allergies, alcohol addiction, poor circulation, vitamin deficiency, metabolic disorders, severe intoxication of the body).

Reasons determining the occurrence and development of temporal lobe epilepsy:

• birth injuries;
• fetal hypoxia;
• intrauterine infection (syphilis, rubella, etc.);
• asphyxia of a newborn child;
• traumatic brain injuries;
• neuroinfections (purulent meningitis, encephalitis, post-vaccination encephalomyelitis, neurosyphilis);
• tumor of the temporal lobe of the brain;
• vascular malformations;
• hemorrhagic and ischemic stroke;
• cerebral infarction;
• tuberous sclerosis;
• intracerebral hematoma;
• cerebral aneurysm;
• aneurysm or glioma;
• cortical dysplasia (congenital pathology of the cerebral cortex).

Scientists and doctors call postpartum trauma, which causes the death of neurons, to be one of the main reasons for the development of temporal lobe epilepsy. This phenomenon occurs as a result of hypoxia, ischemia, and damage due to contact with neurotransmitters. Sometimes the occurrence of temporal lobe epilepsy is observed together with febrile convulsions that last a long time, the development of mediobasal temporal sclerosis, the occurrence of which is the subject of debate and is not fully understood.

The likelihood of inheriting the disease is low. A child may become more predisposed to temporal lobe epilepsy when exposed to certain factors.

Causes and pathogenesis

The occurrence of temporal lobe epilepsy is associated with birth trauma or cerebral changes that develop in early childhood as a result of compression of the arteries of the temporal lobe or temporary compression.
In the areas of the temporal lobe that were extirpated, changes were found that are regarded as residual after various brain processes suffered in the first years of life. It is not yet possible to firmly say whether the focus that causes psychomotor seizures is always in the temporal lobe or whether it can also be in other places. Based mainly on electroencephalographic data, temporal lobe epilepsy is included in the group of focal epilepsies. Gibbs and Gastaut believe that in 50-60% of cases, and according to Banquo and Talleyrak, in 65% of focal epilepsies, the focus is localized in the temporal lobe or structures associated with it. According to some authors, patients with temporal lobe epilepsy make up 30-75% of the total number of people suffering from epilepsy. The frequency of temporal paroxysms is due to the low threshold of stimulation of the nervous structures of the temporal lobe of the brain and closely related formations of the limbic system. “Afterdischarges” here can continue for a long time after the cessation of electrical or chemical stimulation. Organic changes in psychomotor epilepsy are most often found in the orbital parts of the frontal and temporal cortex, hippocampal gyrus, hippocampus and dentate fascia, as well as in the amygdala complex.

Birth trauma is often the cause of both temporal lobe and genuine epilepsy.

Classification of temporal lobe epilepsy

In order to make a more accurate diagnosis of temporal lobe epilepsy and, as a result, prescribe adequate treatment, it is necessary to differentiate the type of temporal lobe epilepsy. For this purpose, there is a classification of this disease.

Temporal lobe epilepsy is divided into four types:

1. Lateral.
2. Amygdala.
3. Hippocampal.
4. Opercular (insular).

Sometimes the amygdala, hippocampal and insular are combined into one group - the amygdalohippocampal. Some scientists identify another type of temporal lobe epilepsy - botemporal (when the foci of the disease are localized in both temporal lobes of the brain). This type of temporal lobe epilepsy can develop either simultaneously in both temporal lobes, or according to the mirror principle (the lesion appears and develops first in one temporal lobe, and over time moves to the second).

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Simple partial seizures (aura)

They occur without disturbing the patient’s consciousness and often precede other, more complex partial attacks. Olfactory and gustatory seizures often accompany temporal lobe epilepsy (sensation of unpleasant odors and tastes). Sometimes there is an involuntary turn of the eyes towards the localization of the epilepsy focus, arrhythmia or chills. Patients complain of an inexplicable feeling of fear and hopelessness, distorted perception of time and shapes of objects, and sometimes distance to them, and visual hallucinations. In some cases, derealization is observed (a feeling of unreality of the surrounding world, a feeling that familiar objects or people seem completely unfamiliar and vice versa - when an unfamiliar environment seems familiar). In some cases, depersonalization is present (the patient is confused in his thoughts and believes that the body and thoughts do not belong to him, he can see himself from the outside). The twilight state can be either short-term or long-term (sometimes the duration is several days).

Main symptoms

Symptoms of temporal lobe epilepsy can be very different, and they largely depend on the type of seizure. With simple partial attacks, the patient’s consciousness is not disturbed at all. Their occurrence may be accompanied by an unpleasant taste in the mouth, and sometimes patients feel that they smell an unpleasant odor. Other signs of temporal lobe epilepsy include the following:

• cardiopalmus;
• chills;
• visual hallucinations.

The patient may not recognize his family and friends at all, and may not understand where he is. The state of detachment passes very quickly or lasts for several days.

Complex attacks generally occur with loss of consciousness and the occurrence of automatic movements. In some cases, it seems that a person is completely healthy, but through his behavior he can harm himself and other people. He can perceive the situation around him and the events taking place as what happened to him in the past.

At the initial stage of development, the diagnosis of epilepsy is quite difficult because the clinical picture does not have characteristic signs. Before or during an attack, the following symptoms of temporal lobe epilepsy are observed:

• excessive sweating;
• heartburn;
• pale skin;
• nausea;
• abdominal pain;
• feeling of lack of air;
• arrhythmia.

In advanced cases, the disease can provoke changes in the psyche, due to which a person becomes suspicious, forgetful, and aggressive. Closedness and decreased communication skills are also possible.

Complex partial seizures

They occur with impaired consciousness of the patient and automatisms (unconscious actions during attacks). Repeated chewing or sucking movements, lip smacking, frequent swallowing, patting, various grimaces, slurred muttering or repetition of individual sounds can often be observed. Restless hand movements (nervous rubbing, frantic fiddling with objects). Automatisms are sometimes similar to complex conscious movements - driving a car or traveling on public transport, actions that can be dangerous for others and for the patient himself, articulate speech. During such an attack, the patient is unable to respond to external stimuli, for example, when addressed to him. A complex partial attack lasts about two to three minutes. At the end of the attack, the patient does not remember what happened to him and feels a severe headache. In some cases, loss of motor activity or a slow decline without convulsions can be observed.

Varieties

At the moment, medical specialists divide the disease according to the degree of localization into four classes: amygdala, hippocampal, lateral and opercular. In addition, for convenience in making a diagnosis, doctors divided temporal lobe disease into two types: lateral and mediobasal. Also, some experts note the existence of a bilateral form of anomalous origin. It can occur with simultaneous involvement of two lobes, which is often noticeable in the perinatal form. In another situation, a “mirror” lesion may form as a result of the development of the disease.

Secondary generalized seizures

Observed as the disease progresses. During such attacks, the patient loses consciousness and is paralyzed by convulsions in all muscle groups. As temporal lobe epilepsy progresses, it leads to complex mental and intellectual disorders. There is memory deterioration, slowness in movements, emotional instability, and aggressiveness. The frequency and severity of seizures in temporal lobe epilepsy are variable and varied, characterized by spontaneity. The female body can react with menstrual irregularities. Symptoms of temporal lobe epilepsy can manifest themselves as symptoms of other diseases, which makes diagnosing the disease more difficult.

Prevention

No effective preventive methods have been found in medicine to prevent temporal lobe epilepsy. Therefore, patients are sent to a dispensary to perform therapeutic procedures when a disease is detected and to combat brain disorders.

If seizures do not occur, patients can perform any work except at heights, interaction with flames and mechanical devices that require constant concentration to operate.

To combat temporal lobe epilepsy, only timely and high-quality therapy is required to provide patients with a full, healthy existence.

Diagnosis of temporal lobe epilepsy

Diagnosis of temporal lobe epilepsy is quite difficult, especially in adults. Often a person does not know the symptoms of this disease, so he may simply not be aware of its presence. A person simply does not pay attention to simple partial attacks, but consults a doctor when complex attacks occur, which complicates the diagnosis and, accordingly, treatment of the disease. In addition, when diagnosing temporal lobe epilepsy, it must be differentiated from ordinary epileptic disease or from a tumor in the temporal region, which is also accompanied by epileptic seizures.

The most informative diagnostic method is an electroencephalogram. In case of temporal lobe epilepsy, the patient is characterized by normal indicators if the study was carried out in the period between attacks. The veracity of the data depends on the depth of localization of the epilepsy focus. If it is located deep in the structures of the brain, then the examination may also show normality even during the attack itself. For higher accuracy of examination data, invasive electrodes and sometimes electrocorticography are used (electrodes are applied directly to the cerebral cortex). In most cases (more than 90%), an electroencephalogram can detect changes at the time of an attack.

Diagnosis in children and adults

With this disease, it is necessary to visit a neurologist and psychotherapist. In adults, the disease is detected when secondary generalized seizures occur, since many patients do not notice the simple and complex partial seizures that precede them.

In children, as a rule, the disease is detected early, since parents bring them to a neurologist after detecting periodic blackouts and the appearance of behavioral disorders.

Neurological disorders are usually absent in this type of disease.

They develop only against the background of a brain tumor, hematoma or stroke. EEG, as a rule, does not detect any significant changes, so epileptics are prescribed polysomnography with EEG recording while the patient is sleeping to detect the focus of pathological activity.

To establish the exact cause of the disease, MRI and PET scans are recommended.

Drug treatment

Conservative therapy consists of the use of drugs carbamzepine, phenytoin, valproate, barbiturates. Treatment begins with monotherapy - a dose of carbamzepine is prescribed, which is gradually increased to 20 mg, in some cases - up to 30 mg per day. If the patient's condition does not improve, the dose can be increased until results improve or signs of intoxication appear (while taking the drug, doctors monitor the concentration of carbamzepine in the patient's blood). In difficult cases of secondary generalized attacks, the drug diphenin or depakine (valproate) is prescribed. Doctors believe that the effect of valproate is better than diphenine, especially since the second has a much more toxic effect on the body, especially on the cognitive system.

There is the following system of priority for prescribing medications for temporal lobe epilepsy:

• carbamzepine;
• valproates;
• phenytoin;
• barbiturates;
• polytherapy (using basic antiepileptic drugs);
• lamotrigine;
• benzodiazepine.

Polytherapy is used only if monotherapy is ineffective. Multiple combinations of basic and reserve antiepileptic drugs are possible. A reduction in attacks is observed when taking phenobarbital with diphenine, but this combination can significantly affect the central nervous system, having an inhibitory effect that provokes ataxia, decreased cognitive function, memory impairment, and has a negative effect on the gastrointestinal tract.

Drug therapy requires lifelong medication and careful monitoring by doctors. In approximately half of the cases, it is possible to completely stop the attacks with the help of properly selected medications.

Symptoms

The described pathological process originates at different time stages. For patients who suffer from medial disorders, the onset of the disease is accompanied by febrile seizures of an atypical nature. They are discovered in childhood, most often between the ages of 6 months and 6 years. After this, spontaneous remission is diagnosed around 3-4 years, resulting in the formation of psychomotor seizures of an afebrile nature.

In modern medicine, the following types of epi-attacks are distinguished:

• 
  A simple plan.

• Complex partials (CPS).
• Secondarily generalized (SGP).

Such situations are accompanied by maintaining a stable level of consciousness. Motor symptoms are noticeable in the form of difficulties in turning the head and eye orbits in different directions, fixing the hand or foot. At some points, taste and smell problems, auditory and visual hallucinations, and dizziness appear.

In addition to the above complaints, patients experience the following problems:

• Vestibular ataxia, accompanied by the illusion of deformation of the environment.
• Cardiac (pressure and distension in the area of ​​the heart organ), epigastric (pain in the abdominal cavity, nausea, gag reflexes, heartburn) and respiratory increases (choking, lump in the throat).
• Arrhythmia appears.
• Chills.
• Change in skin tone.
• Presence of fever.
• A feeling of acceleration or deceleration of the current moment, the perception of ordinary things, etc.
• Lack of response to various external factors.
• Problem with the musculoskeletal system
• Regular smacking, sucking and more.
• Facial deformities.
• Difficulties in the thinking process.
• Emotional instability.
• Disruptions in the menstrual cycle, decreased fertility, etc. in female representatives.
• Low libido and ejaculation disorders in men.

Surgery

In case of ineffectiveness of conservative therapy, intolerance to basic antiepileptic drugs even in the smallest permissible doses, or an increase in epileptic seizures that maladapt the patient, surgical treatment is resorted to. For surgical intervention, a mandatory factor is the presence of a clear epileptogenic focus. Surgical treatment is highly effective: about 80% of patients experience a significant reduction in the frequency and severity of attacks after surgery. In half of the operated patients, seizures disappear completely, social adaptation improves, and intellectual functions return. It is not recommended to resort to surgical intervention in case of severe general condition of the patient, severe mental and intellectual disorders. Temporal lobe epilepsy, the treatment of which is a complex and controversial procedure, requires constant monitoring by doctors.

Preoperative examination involves all possible types of neuroimaging (electrocorticogram, video-EEG monitoring, passing tests to identify the dominance of the cerebral hemisphere).

The neurosurgeon’s task is to eliminate the epileptogenic focus and prevent the movement and spread of epileptic impulses. The essence of the operation is to perform a temporal lobectomy and remove the anterior and mediobasal parts of the temporal region of the brain, the uncus, and the basolateral amygdala. There are risks with this type of surgery, and the patient should be informed about possible complications. Complications include Klüver-Bucy syndrome (hypersexuality, loss of feelings of modesty and fear), hemiparesis, mnestic disorders, complications after anesthesia.

How to overcome the disease?

Diagnosing the pathology is difficult because its symptoms in the early stages are mild. To clarify the diagnosis, it is necessary to undergo some examinations:

1. An electroencephalogram reveals convulsive activity in certain areas in the temporal region.
2. When performing an MRI, the causes of the disease are clarified: temporal lobe atrophy, mesial temporal sclerosis, vascular malformations, cysts, tumors.
3. PET reveals pathologies of the visual thalamus and basal ganglia, metabolic failure in the temporal region.

First aid at the onset of an epileptic attack is to move the person to a safe place where he is not injured. It is necessary to loosen the belt and unbutton the collar of the shirt. You can turn your head to the side and place a pillow or blanket under it.

There is no need to try to hold the epileptic’s mouth open with your fingers. It is better not to touch it at all to avoid injuring the person providing assistance. After the paroxysm, the patient falls asleep; there is no need to interrupt it.

For temporal lobe epilepsy, treatment is primarily aimed at reducing the frequency of seizures. Therapy usually begins with the prescription of 1 drug, the selected dose is individual and increases gradually. Carbamazepine is most often used.

If there is no effect, hydantoins, valproates, and barbiturates are recommended. If the temporal pathology progresses, then polytherapy is started. Remission is observed in approximately 35% of cases. Alcohol should be completely excluded.

Drug treatment of epilepsy

In case of illness, surgical intervention may be necessary to eliminate pathological foci, but in severe forms of epilepsy, surgical intervention becomes ineffective. Most often performed:

• resection of the temporal lobe of the brain;
• amygdalotomy;
• focal resection;
• selective hippocampectomy.

Sometimes complications occur during the postoperative period:

• paresis and muscle paralysis;
• incoherence of speech;
• mental disorders.

Prevention of pathology should be aimed at minimizing the negative effects on the developing fetus during pregnancy, maximizing the incidence of trauma during childbirth, as well as timely treatment of any ailments.

Prevention of epilepsy

Temporal lobe epilepsy is a neurological problem, the success of therapy and the prognosis of which depend on the timely elimination of the factors that provoked the process. The disease is most effectively treated in children under one year of age.

Among epileptics there are many people with brilliant minds, because the disease does not always lead to mental disorders. This suggests that you can live a full life with epilepsy, provided, of course, that you pay close attention to your health.