EDITORIAL ARTICLES
NEWS
The International League Against Epilepsy (ILAE) has developed and approved the Operational classification of seizure types 2017 and the Classification of the Epilepsies 2017 . According to the ILAE 2017 Operational classification of seizure types, seizures can be initially divided into focal or generalized; and the seizure onset is of crucial importance in this case. Focal seizures are optionally subdivided into focal aware seizures and focal impaired awareness seizures. Several new types of generalized-onset seizures were implemented. Specific motor and non-motor classifiers may be added. Unknown onset seizures are placed separately. Three levels of diagnostics are specified in the 2017 ILAE Classification of the Epilepsies: seizure type (defined in accordance with the 2017 ILAE Operational classification of seizure types), epilepsy type (focal, generalized, combined generalized and focal, unknown), and epilepsy syndrome. An etiologic diagnosis should be considered at each step along the diagnostic pathway. A patient ’s epilepsy may be classified into more than one etiological category. The term “benign” is replaced by the terms “self-limited” and “pharmacoresponsive” to be used where appropriate. The term “developmental and epileptic encephalopathy” can be applied in whole or in part where appropriate. The 2017 Operational classification of seizure types and the 2017 ILAE Classification of the Epilepsies can be helpful both in routine clinical practice and scientific research that will assist in improving epilepsy care and quality of life of patients with epilepsies.
ORIGINAL ARTICLES
Objective. To study concentration of valproats in children with epilepsy, newborns and infants with episyndrome using therapeutic drug monitoring (TDM) in routine clinical practice.
Materials and methods. 75 children aged 1-18 years and 59 preterm newborns aged 0-90 days receiving valproic acid drugs were included in the study. Valproic acid concentration was measured using high performance liquid chromatography (HРLC).
Results. Therapeutic concentration was achieved in 77.3% of children aged 1-18 years with an average daily dose of 25.94 mg/kg (1021.4 mg); overtherapeutic concentrations were registered in 9.3% of the cases. Concentration of valproic acid tended to decrease along with children’s age. Among children aged 1-18, a direct correlation between the daily dose (in mg/kg) and concentrations of valproates was observed: r=0.42 for Cmin and r=0.50 for Cmax. There was no correlation between age and concentration. In newborns, therapeutic concentration was achieved only in 33.9% of the cases with an average daily dose of 43.4 mg/kg (82.6 mg); overtherapeutic concentrations were registered in 11.9% of the cases. Significant differences in average daily doses and concentrations of valproic acid were found in newborns under 1 month of age; overtherapeutic concentrations in the group of preterm newborns under 1 month were observed in 23.5% of the cases versus 9.5% in the group of newborns of 2-3 months of age (p=0.07). Weak inverse correlation between age and concentration of valproic acid was seen in newborns: r=-0.25 for Cmin and r=-0.24 for Cmax. There was no correlation between the dose and concentration of valproic acid, this explains unpredictability of the dose response in the group of preterm newborns and low rates of achieving therapeutic concentrations.
Conclusion. Specific features of valproic acid pharmacokinetics in newborns and children are associated with specific TDM parameters identified within the study; these findings show high value of TDM.
Objective: to estimate the role of MR – tomography in epilepsy diagnostics. We have analyzed the main protocol used for examination of patients with epileptic seizures in anamnesis, as well as a number of modern techniques, which help to get additional information about both structural and functional changes in the brain. We have described several types of pathological changes detected by us during examination of the patients from this group.
Objective. To investigate the main features of sleep disorders in patients with three main forms of epilepsy and its impact on the quality of life.
Materials and methods. One hundred and fifty patients with different forms of epilepsy (including idiopathic, cryptogenic, and symptomatic) aged 17-64 years were enrolled. The following parameters were evaluated: presence of sleep disorders (estimated using special questionnaires developed by the Somnological Center of the Ministry of Health of the Russian Federation), presence of daytime sleepiness according to the Epworth scale, level of anxiety and depression according to the hospital scale (HADS), quality of life (analyzed using the QOLIE-89 questionnaire).
Results. Patients in all three groups experienced daytime sleepiness, difficulty falling asleep and maintaining sleep at night, problems with final awakening. We found a reliable correlation between the daytime sleepiness at rest or during activities with the subjective sleep characteristics, difficulty falling asleep and maintaining sleep, level of anxiety, and the values from QOLIE-89 questionnaire (quality of life).
Conclusion. Our findings demonstrate the obligatory nature of the circadian rhythm sleep disorders in all three groups of epileptic patients. The differences in the subjective sleep characteristics between the groups (depending on the form of epilepsy: symptomatic/cryptogenic and idiopathic) can be compared with the psychological characteristics of the patients with these forms of epilepsy.Childhood absence epilepsy (CAE) is an idiopathic generalized epilepsy, which could be attributed to genetic forms according to the latest proposals of the Commission on Classification and Terminology of the International League Against Epilepsy (2016). CAE has specific clinical and encephalographic characteristics. Data regarding cognitive impairment in children with CAE is still controversial. There are some attempts to introduce more strict diagnostic criteria to be able to define the disease course and prognosis of this form of epilepsy. These are the criteria proposed by Panayiotopoulos C. P. in 2005.
Objective. To asses specific features of CAE taking into account the criteria of Panayiotopoulos C. P. (2005).
Materials and methods. We have retrospectively analyzed 186 cases of CAE in children; study participants were divided into groups according to Panayiotopoulos’s criteria (2005).
Results. Children from the group allocated in accordance with Panayiotopoulos’s criteria had neither generalized tonic-clonic seizures (GTCS) nor myoclonic seizures; control of absence seizures was achieved in 94.3% of the cases; almost 90% of children in this group received monotherapy with mean treatment duration of 2.8 years.
Conclusions. The use of more precise diagnostic criteria for CAE will help to predict clinical course of this form of epilepsy and its outcome.Objective. To identify predictive factors of favourable outcomes in children with drug resistant epilepsy (DRE) associated with structural brain changes, who received surgical treatment.
Methods. We performed a retrospective analysis of surgical treatment in 239 children with drug resistant epilepsy treated at the Pediatric Neurosurgery Department of the A. L. Polenov Russian Neurosurgical Institute from 2004 to 2014. The age of the patients varied between 2 and 18 years. The follow-up time ranged from 1 year to 10 years (on average 4.3 years).
Results. According to magnetic resonance imaging (MRI), 223 (93.3%) patients had different structural brain changes. Among the patients, 47 (21.1%) had cerebral cicatrix, gliosis, cysts and atrophic changes, 33 (14.8%) had malformations of the cortical development, 43 (19.3%) had benign brain tumors, 47 (21.1%) had vascular malformations, 21 (9.4%) had arachnoid cysts, 12 (5.4%) had hippocampal sclerosis, 11 (4.9%) had phacomatosis, 5 (2.2%) had Rasmussen’s encephalitis, and 4 (1.8%) had hypothalamic hamartoma. Positron emission tomography revealed the areas of gray matter hypometabolism in the brain, which correspond to the areas of a metabolic deficiency around the epileptic focus. Favorable long-term outcomes of epilepsy surgery (class I according to Engel scale) were registered in 67.6% of the cases. The most favorable results (class I according to Engel scale) were achieved after lesionectomy (81.9%), temporal resections (78.4%), and hemispherectomy (72.7%).
Conclusions. The most important predictive factors of favorable outcomes after epilepsy surgery are as follows: detection of epileptogenic morphological changes of the brain, completeness of resection of an epileptic and epileptogenic areas, and absense of seizures in the early postoperative period.
Pharmacotherapy of epilepsy requires deep knowledge of anti-epileptic drugs (AEDs), including the following issues: spectrum of therapeutic efficacy and therapeutic strength, adverse effects (especially severe and life-threatening adverse reactions); specific features of pharmacokinetics, pharmacodynamics, and drug interactions; titration rate, the need for laboratory tests during treatment, pharmacoeconomic components. The main properties of antiepileptic drugs are defined by their mechanisms of action. Today, particular attention is paid to the drugs with broad spectrum activity, which give an ability to use them in patients with so-called undifferentiated epilepsies. In this article, the authors describe their own experience in optimization of antiepileptic therapy in a group of 141 patients with various forms of epilepsy. This new optimized strategy implies inclusion of modern broad spectrum AEDs in treatment schemes along with the reduction in use of narrow spectrum drugs. Moreover, polytherapy was used in most of the cases after treatment regimen correction. All the measures allowed to achieve remission in about half of the patients with epilepsy earlier considered as incurable.
SCIENTIFIC SURVEYS
Antiepileptic drugs are frequently associated with a risk of adverse effects, which have an impact on the tolerability and success of treatment. Patients who develop intolerable adverse effects have to discontinue treatment early after initiation or to switch to another antiepileptic drug. A long-term management strategy for the patients with such a long-lasting chronic disease as epilepsy should include both effective seizure control and early detection of adverse drug events, ensuring prognosis, prevention and minimizing side effects, which is quite important. All these measures are expected to improve adherence to treatment, quality of patients’ life and control of epilepsy.

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