Mental disorders in epilepsy
.pdf
|
Table 1 (cont.) |
Localization of the beginning of paroxysm and psychosis |
|
|
|
Epilepsy |
Schizophrenia |
With the use of quantitative MRI-mor- phometry in patients with the postiсtal psychoses is revealed an increase of the thickness of cortical layer in the right prefrontal region, in the right front cingulate cortex and in the right average temporal gyrus (J.M. DuBois, 2011)
Connections between the functional systems of the brain
In patients with the schizophrenia- |
|
like psychosis with epilepsy the |
|
EEG-spikes are located either in the |
|
temporal and frontobasal divisions |
|
or in the divisions of brain along the |
|
sagittal line (D.M. Psatta et al, 1991). |
|
Limbic structures are central in the |
|
formation of schizophrenia-like psycho- |
|
sis with epilepsy, but with the attrac- |
|
tion of frontal and parietal structures |
|
(F. Oyebode et al, 2008) |
|
|
|
A study is established with EEG and |
|
SPECT that the postictal mania and |
|
postictal psychotic episodes are con- |
|
nected with temporal and frontal lobe |
|
epilepsy (T. Nishida et al, 2006) |
|
|
|
With the use of MRI with the interictal |
With a MRI-study it is estab- |
epileptic psychosis is discovered the |
lished that the presence of the |
insignificant reduction of white matter |
symptoms of the first rank |
or the reduction of cortex in the fronto- |
K. Schneider with the schizo- |
temporal divisions of brain (D. Fluegel |
phrenia are connected with the |
et al, 2006; The I. Gutierrez-Galve |
reduction of the volumes of gray |
et al, 2012) |
matter in the limbic -paralimbic |
|
(cingulate and hippocampal gyri) |
|
regions (M. Suzuki et al, 2005) |
|
|
In comparison with the healthy con- |
In comparison with the healthy |
trol, with a MRI-study in patients with |
control, with a MRI-study in the |
the cognitive disorders with left-side |
untreated patients with schizo- |
of temporal epilepsy is noted the |
phrenia are noted the |
|
|
91
Table 1 (cont.)
Localization of the beginning of paroxysm and psychosis
Epilepsy |
Schizophrenia |
Dynamics of changes in the volume (concentration) of the gray and white matters of the brain
reduction of the thickness of gray and |
deviations of the volumes of gray |
white matters (not less than to 30%) |
and white matters in the thalam- |
in the orbitofrontal, lateral temporal |
ic and cortical (frontal, temporal |
and occipital zones (B. Hermann et al, |
and parietal) structures, tradi- |
2006; B. Bell et al, 2011) |
tionally examined as those inter- |
|
connected, are established also |
|
the disfunctional disturbances |
|
of frontal-limbic, frontotemporal, |
|
frontoparietal and frontal-occip- |
|
ital cortex connections (P. Danos |
|
et al, 2003; S.A. Mitelman et al, |
|
2005; S.S. Bangalore et al, 2009) |
Absence, according to the data of MRI- |
|
study, additional sequential reduc- |
|
tions of the gray matter of the brain |
|
with mesial temporal lobe epilepsy are |
|
interpreted as the sign of the absence |
|
of the progression of disease (D. Barron |
|
et al, 2012) |
|
Data of morphometry on the voxel ba- |
|
sis with MRI studies and data of MRS |
|
of thalamus reveal the reduction of the |
|
volume of the gray matter of the brain |
|
in the hippocampus and the thalamus, |
|
and also the neuronal disfunction of ip- |
|
silateral thalamus with “soft” tempo- |
|
ral-limbic epilepsy (D. Fojtiková et al, |
|
2007; A. Labate et al, 2008) |
|
Volumetry of the gray matter of the |
The established, with the use |
brain with the aid of the automated |
MRI of a study, decrease of the |
segmentation, according to the data |
volume of gray matter in the |
of MRI-study, shows the scales of the |
rear divisions of upper temporal |
structural damages of subcortical |
gyrus at the early stages of dis- |
structures and structures of the cer- |
ease is general for the disor- |
ebellum with mesial temporal lobe epi- |
ders of schizophrenic spectrum |
lepsy with “soft atrophy of hippocam- |
(T. Takahashi et al, 2006) |
pus” (C.R. McDonald et al, 2008) |
|
92
|
Table 1 (cont.) |
Localization of the beginning of paroxysm and psychosis |
|
Epilepsy |
Schizophrenia |
Morphometry on the voxel basis, ac- |
After 2-3 years in the patients |
cording to the data of MRI-study, re- |
with schizophrenia, that trans- |
veals the reduction of the volume of the |
ferred the first psychotic episode, |
gray matter of the brain of thalamus |
the greatest reduction of gray |
and frontal lobe with the progression |
matter is noted in the parietal |
of epileptic seizures (W. Huang et al, |
and temporal cortext, and the |
2011) |
greatest reduction of white mat- |
|
ter – in the frontal and temporal |
|
lobes (T.J. Whitford et al, 2006; |
|
2007) |
The participation of many regions |
Revealed, with the use of MRI |
of the brain beyond the limits of hip- |
and MRS studies, change in the |
pocampus in the pathogenesis of the |
brain, most noticeable in the |
chronic course of epilepsy with the sig- |
frontal lobes (increase of the vol- |
nificant atrophy of the gray and white |
ume of cerebro-spinal fluid in the |
matters of the brain, including of the |
cerebral grooves, the more ex- |
front nuclei of thalamus, pear-shaped |
pressed reduction of the volume |
cortex, cortical part of the amygdala, |
of the gray and white matters |
temporal and extra-temporal neocor- |
of the brain, the decrease of the |
tical regions, according to the data |
thickness of cortical layer and |
of MRI-studies, correlates with the |
volume of the brain as a whole), |
duration and the resistance of mesial |
they are noted in patients with |
temporal lobe epilepsy (J.W. Lee et al, |
the larger gravity of positive and |
1998; A.B. McMillan et al, 2004; |
negative symptoms (B.C. Ho et al, |
P.M. Gonçalves Of pereira et al, |
2003; T. Sigmundsson et al, |
2005; L. Bonilha et al, 2004, 2005, |
2003; S.A. Mitelman et al, 2007; |
2010; A.C. Coan et al, 2009; F. Bilevi- |
The I. Tomelleri et al, 2009; |
cius et al, 2010; A. Labate et al, 2010; |
W.H. Jung et al, 2011; A.M. Mc- |
S. Alhusaini et al, 2012; J. Li et al, |
Intosh et al, 2011; T. Asami et al, |
2012; J. Maarten et al, 2012) |
2012; F.A. Hazlett et al, 2012) |
The visualization of tensor diffusion, |
In the course of prospektive (with |
according to the data of MRI-study |
duration from 1 year to 15 years) |
of the white matter of the brain, re- |
MRI studies it is established that |
veals the interest of frontotemporal |
at the early stages of schizophre- |
connections during the progression |
nia (3-4 years) the rates of the |
of epilepsy (J.J. Lin et al, 2008; M. |
reduction of the volume of gray |
Liu et al, 2011; J.O’ Muircheartaigh |
matter in upper the temporal and |
et al, 2011; J.H. Kim et al, 2012) |
lateral occipital-temporal gyri |
|
in patients compose 2%-6% per |
|
year (T. Takahashi et al, 2009; |
93
|
Table 1 (cont.) |
Localization of the beginning of paroxysm and psychosis |
|
|
|
Epilepsy |
Schizophrenia |
|
|
|
2010; 2011). The rate of the re- |
|
duction of the volume of the gray |
|
matter of the brain is reduced |
|
to 0,59% per year at the more |
|
distant stages of disease, the |
|
white matter of temporal por- |
|
tion – 0,39%, frontal and parietal |
|
lobes – 0,32%, the volume of the |
|
brain as a whole – 0,07% per year |
|
(B. Olabi et al, 2011) |
The reduction of the volumes of gray |
Other authors (N.C. Andreasen |
matter in the limits and beyond the |
et al, 2011) confirm that the |
limits of hippocampus, and also vol- |
changes indicated are most seri- |
umes of the gray and white matters |
ous in the first years after the be- |
of the cerebellum, according to the |
ginning of disease, and they note |
data of MRI studies, is connected with |
that subsequently these changes |
an increase in the duration of epilepsy |
remain at the higher level also |
(L. Bohilha et al, 2006; T.O. Oyegbile |
in the correlation with the cogni- |
et al, 2011) |
tive disturbances only in the part |
|
of the patients |
“The evolution of fits”, the indices vid- |
|
eo-EEG of monitoring, by MRI investi- |
|
gations, and “psychiatric history” in the |
|
totality make it possible to consider the |
|
presence of the double-sided indepen- |
|
dent epileptic centers or double-sided |
|
sclerosis of hippocampus the weather- |
|
prognosis signs of the development |
|
of epileptic psychosis (A.M. Kanner, |
|
2008; The I. D’Alessio et al, 2008) |
|
As follows from the data in Table 1 , in the last 10-15 years there is a clear imbalance in favor of schizophrenia between the amount of structural and dynamic studies of changes in the volume of gray and white matter of the brain in epilepsy and schizophrenia. There are no comparative clinical neuromorphological research showing a correlation of morphological changes with personality changes, psychotic and cognitive disorders as epilepsy and schizophrenia. The refinement
94
of the diagnostic and prognostic criteria of mental disorders with epilepsy and schizophrenia through conducting of uniform clinico-neuro- morphological studies for the purpose of the creation of the comparable clinical data bases is necessary. In this case the comparative study of the speed of the reduction of the substance of the brain taking into account its preferred localization must be carried out in the comparison with prognostically significant clinical data, which characterize the progression of the disease, the type and stage of the flow.
The given considerations are prerequisite for the more detailed examination of the versions of syndromokinesis within the framework isolated by us stages of disease. But with them, these versions, the discussion will deal in the corresponding chapter with the examination of the clinical criteria of working prognosis.
This chapter we would like to complete with some assumptions about the pathogenesis of epilepsy, based on a comparison of our data with the data analysis of clinical and pathophysiologic correlations conducted by V.A. Carlov in his monograph in 1990.
Once again, the reservation that, based on its interpretation in the pathogenesis of epilepsy from the priority value for the prediction of the type of disease, we adhere to the following scheme of localization of the epileptic process: limbic epilepsy in the understanding of P.D. McLean (1952) or mediobasal temporal (mesiotemporal) epilepsy in the contemporary understanding, temporal epilepsy in the understanding of H. Landolt (1960) and frontal epilepsy.
The concept of limbic epilepsy does not coincide with the contemporary concepts about the varied structure of limbic system. However, P.D. McLean, the author of the term, not only recognized the limitations of the process of the epileptization of the divisions of the brain with it, but quite clearly limited the number of items mediobasal temporal structures belonging to this system: the hippocampus, amygdala, mediobasal temporal cortex. Adequate for the contemporary application of a term limbic epilepsy V.A. Karlov counted those cases of disease, with which the key element in the mechanisms of the adaptation of organism occupies the so-called limbic-reticular complex.
On the basis of the data analysis of his own clinical observations and literature data the author emphasizes that with the epileptic foci and the mediobasal divisions of temporal lobe the generalization of epileptic discharges, besides the associative and commissural connections, is achieved by means of the arch, the gyrus cinguli and
95
the strioamigdalorubral system. The bilateral synchronization of discharges and shaping of second and tertiary epileptic foci as a rule, occurs in such cases.
In this case the author indicates that epilepsy, which is manifested by the generalized bilateral-synchronous symmetrical discharges of complexes spike-wave 3 per second and with respect to this by simple absences, usually has favorable course, especially when epileptic activity on EEG is combined with the slow activity.
V.A. Karlov assumes that in the disturbances of vegetative and emotional reaction the disorganizing influence of the epileptic focus, which is located in the structures of the limbic-reticular complex, which accomplishes vegetative regulation, plays the leading role. He also adheres to the assumption about the fact that the presence of right-hemi- spheric foci in the limbic system leads to the making more active the right-hemispheric structures, which achieve a direct “emotionalding also to the reciprocal braking “rational” left-hemispheric structures.
Seizures with the olfactory, gustatory, vegetative-visceral disturbances are typical for patients with the epileptic foci in the amygdaline complex.
The following statements of the author, in our opinion, can be considered as illustrations to the more extended epileptization of temporal lobe.
The appearance of first dependent, and then independent secondary epileptic foci is, in the opinion of V.A. Karlov, the expression of one of the concrete mechanisms of universal phenomenon – the disorganizing influence of epileptic focus on the integrative activity of the brain.
In this case the decrease of GABA-ergic neurons in the epileptic focus may be the direct cause for the hyper-activity of epileptic neurons (S.E. Riback, 1983), all the more, as notes V.F. Karlov, under the action of valproate of sodium and barbiturates increases the content of GABA (gamma-aminobutyric acid) in the cerebral tissue. The low content GABA in the focus is, in turn, the consequence of the decrease of glutamate concentration, and the histidine, which is converted into the histamine, is the predecessor of glutamate. However, an increase in the content of histamine in the blood is generally characteristic for the patients with epilepsy, while an increase in the content of histamine in the cerebrospinal liquid – for the patients with temporal epilepsy.
The author emphasizes that the seizures, which are expressed exceptionally or predominantly in the disorders of psyche, appear
96
as a result of the neuron discharges in the temporal or, frequently, to frontal lobe. Déjà vu and never seen feeling, as a rule, take place for right-sided epileptic focus in the temporal lobe. The sensations of what already has heard and has never heard are more typical for the left-side localization of leasion, since they relate not to the sounds, but to audioverbal sphere. The seizures of automatism appear as the manifestations of the generalized seizure (absence) or more frequent than the partial – with the temporal and frontal focus.
With the formation of the epileptic system, which encompasses both the amygdaline complex, and hippocampus, which occurs after the long-standing course of epilepsy, seizures, according to the data of the author, acquire the most complex structure. The multihour forms of disease most heavily flow with the development of asynchronous seizures (epilepsy of sleep and wakefulness).
Finally, it should be said that for many years, V.A. Karlov published materials about verified cases of generalized seizures, including those in the form of status epilepticus caused by lesions in the frontal pole, mediobasal frontal cortex and the orbitofrontal parts of the frontal lobe of the brain.
Herewith “worst prognosis” the author noted in the cases of convulsive and polymorphous seizures with the beginning of disease at the age of up to 3 years with the bilateral mediobasal frontal and temporal localization of focus.
With the double-sided frontal foci V.A. Karlov and I.S. Tets (1977) noted the greatest degree of the manifestation of polymorphism and frequency of seizures, changes in personality and euphoric dementia. The right-hemispheric version of frontal epilepsy both authors characterized by the presence in the patients of the expressed euphoria, which is changed by the state of exaltation, sometimes with spite and aggression, anosognosia and by the disinhibition, which is combined with difficulty of movement of thinking, by explosiveness and by heavy dysphorias.
Epileptic dementia in the cases of the statement of mediobasal frontotemporal foci was noted by V.A. Karlov twice more frequently than with the presence of “purely temporal”, and “periodic disorders of psyche and change in the personality according to the epileptic type” – 1,3 times more frequent.
The twilight states of consciousness appear, according to his observations, in many years from the beginning of the disease against the background of polymorphous seizures with the predominance
97
of the frequent generalized convulsive seizures. In proportion to repetition and quickening of twilight states is observed the clear tendency toward their protracted course. However, against the background of the coming of dementia patients “both the epileptic seizures and the dreamy states gradually undergo reduction”.
Thus, our data about the clinico-pathogenetic correlations of epilepsy, which take place with the mental disorders, in many respects correspond to the views of V.A. Karlov for the development of epileptic process.
At the end of this chapter, let us give some related to the material presented at the 22 th International Congress on Epilepsy, in JuneJuly 1997 in Dublin.
Part of them was dedicated to a question about the dependence of clinical prognosis with epilepsy on the age of patients, at which they for the first time had seizures .
With the poor prognosis were connected focal seizures in children at the age of up to 2 years (A. Berger et al., M. Yoshida et al.). It was at the same time indicated that in children since the beginning of the seizures at the age from 2 months to 7 years the prognosis depends on the predominant type of seizure (O. Kanazava et al., K.L. Kwong et al., Z. Martinovic et al., F. Vigevano et al.). The earlier age of patients with the appearance of the first seizure was noted in the group of patients resistant to the therapy, than in the group with the well controlled seizures (W.J. Kim et al.). In the opinion of V. Lespinet et al., age, at which occurs the defeat of frontal lobe, can modify the normal functional organization of the brain.
Significantly more posts at the congress included the study of prognosis in various versions of epilepsy.
Conclusion of O. Aleksis et al. on that which the EEG-inspec- tion of patients by epilepsy indicates the presence of the connection between the value of defeat and clinical data in context considered here it can be given as the general conclusion. To some extent, this is consonant to the statement of W.F. Arts et al. about low suitability of International Classification of epilepsy in clinical epidemiological studies due to low prevalence of many epileptic syndrome in it.
Speaking about the mechanisms of epileptogenesis, including data on the physiology of the hippocampus and the neocortex, and the existence of sub-populations of internally explosive neurons involved in rhythmogenesis and synchronization, G. Avanzini justified the concept of recurrent paroxysmal changes in intracellular pola-
98
rization, simultaneous with spikes in the EEG. In this case the author, and also N. Varma specially focused attention on the fact that at present intensively is investigated the role of chain reconstruction of different structures of the brain, critical for epileptogenesis. G.V. Selitsky et al. showed that in the significant number of cases of epilepsy can be established the functional relations between the contralateral frontal, sincipital, temporal and occipital regions. The characteristic feature of diagonal cortical interhemispheric interactions with epilepsy the authors consider the fact that they reflect the functional plasticity of the brain, directed toward the organization of its integrative activity at the new level. K. Lehnerts et al. spoke, that three-dimensional-temporal changes in the neuronal complexes refer straight to the degree of epileptogenic disorders and make it possible to evaluate the extent of the space of primary epileptogenic region.
E. Baeta et al., O. Dogu et al., J. E. Festen et al. and others to one of the methods of investigating this process proposed to count the neuropsychological testing, which contributes to the explanation of localization and side of the epileptic focus, which lies at the basis of multifocal or diffuse disorders. Since, in the opinion of D. McMackin et al., mesiotemporal structures are important for consolidation and storing the tracks of memory, one should recognize that the study of the decline of the latter is the best method of localization of the disfunction of temporal lobe.
Sh. Bibileishvili named epileptic process the multilinc pathology with the alternating involvement of different cerebral mediator systems. Similarly A. Cerullo et al. treated data of their own studies, according to which resistance epilepsies, probably, were connected with many types of seizures in the course of the development of disease due to the plurality of the independent EEG-foci. On this base the patterns of second bilateral synchronism on EEG and partial epilepsy the authors proposed to consider the expression of the progressive epileptic involvement of brain. In contrast to epilepsy, connected with the tumors, with the epileptic disease, C.A. O’Donovan et al., consider beginning of seizure in patients with unilateral temporal epilepsy, with which are developed bitemporal epileptiform disorders, correlates with the arrangement of primary epileptiform disorders, and the development of contralateral deviations does not lead to the formation of contralateral focus.
In the plan of the participation of ontogenesis in the development of epileptic process the remark of M. Lendt et al. about the fact
99
that in connection with a sufficient maturity of the brain in adult the frontal pathology in them is not always connected with the functional insufficiency is of interest which coincides with our ideas, and observation of L. Kalinina about the fact that the clinical development of seizures with the age reflects involvement of “the younger structures of temporal lobe”. Interesting also is the communication of E Vigevano et al. about the fact that with the favorable family neonatal spasms for EEG in the period of paroxysms is typical the special rhythm with the beginning in the left or right central-occipital region and the propagation to entire hemisphere with the influence on the brain in general.
Equal interest to our study has the data of B.H. Landgrebe about the fact that the structural deviations in the temporal lobe with the disturbances of metabolism and blood circulation are frequent not only with the epileptic psychosis, but also with the schizophrenia, and in particular about the fact that the effect of the blocking of stellate ganglia demonstrates central noradrenergic mechanism with epileptogenesis and schizophrenia.
To finish this chapter seems expedient with indications of data about the value of the contemporary comprehensive instrument studies available in the literature, which can contribute to understanding the pathogenesis of epilepsy.
In the opinion of L.I. Wasserman (2010), in general, neuropsychological characteristics in the patients with epilepsy prove to be most frequently combined with the clinical signs, which determine the duration of disease, the frequency of seizures, special feature of paroxysmal manifestations and psychopathological disorders. To the greatest extent this relates to temporal lobe epilepsy. Specifically, with the lattest are revealed the positive correlations of clinical, EEG criteria and criteria of neuro-imaging of the side of the defeat of the brain. Probably, this is determined by the greatest frequency of appearance with temporal lobe epilepsy among all forms of the partial seizures of the for the second time generalized complex partial seizures, and also their neuro-physiological and neuro-radiological correlates (B. Hermann, M. Seidenberg et al, 1997, R. Appleton, 2004).
According to the author, the application of the standardized neuropsychological procedures, sensitive to the disorders of gnosis, praxis, speech and for memory, makes possible to reveal these disorders in patients with focal epilepsy and to accomplish on this basis topical diagnostics of the leading stricken areas of the brain,
100