Epilepsy

I. INTRODUCTION
Epilepsy is known as one of the well-known diseases in the world (2000 years BC). In Indonesia the disease has been long known in the community, as evidenced by the existence of vernacular terms for these diseases such as convulsions, epilepsy, and piggy banks, although such an understanding of this disease is still lacking. Inherent belief in many countries stated that epilepsy is a disease of the curse of God, so that patients not treated or even hidden.
Epilepsy seizures are a manifestation rather than an excessive loss of electrical charge of the central nervous system neurons. Epilepsy manifests as brain disorders with different etiologies but brush with a single typical symptoms, a chronic disorder that is not only characterized by recurrent seizures (seizure), but also a variety of media and psychosocial implications.
Based on extensive and focused part of the brain attack, epileptic seizures can be classified:
a. Partial (focal): due to cessation of electrical charge in one place or more localized and not spread to other parts of the brain. Partial seizures are divided into simple where consciousness undisturbed, complex seizures which affect awareness, and partial seizures followed by generalized seizures.
b. General: usually has a focus which then spread to other parts. Manifestation of symptoms initially involve both hemispheres.



II. Etiology
Etiology epilepsy can be divided into two groups:
1. Idiopathic Epilepsy
In some patients, the cause of epilepsy is unknown and usually patients show no defects of the brain and also not stupid.
2. Symptomatic epilepsy
Varied causes of symptomatic epilepsy: cortical disgenesis, cerebral malformations, genetic diseases (although relatively small between 5-10%, down syndrome, neurodegenerative disorders, inborn errors metabolism), disorders of blood circulation. Moreover, it can also according age are exposed.
There are also some trigger factor that may facilitate the occurrence of attacks, namely:
1. Sensory factors: light flashing, sounds shocking and hot water
2. Mental factors of emotion, stress
3. Systemic factors include fever, infectious diseases, certain drugs (phenothyazines, chlorporamid), hypoglycemic and physical exhaustion.
Although it is not the cause of epilepsy, but may influence the timing and frequency of attacks

III. INCIDENCE AND EPIDEMIOLOGY
Epilepsy ranks second from neurological disease after circulatory disorders of the brain. The incidence of epilepsy is estimated to 0.5% of the population. Prevalence varies across the globe, an estimated 4-7 ‰, while in Indonesia is estimated 900,000 to 1.8 million people.
Incidence based on:
1. Age: the incidence of epilepsy varies according to age, the highest at an early age, reaching a nadir at the age of adulthood, and rise again in old age. 75% of cases occur before age 20.
2. Sexes: males more than females and most often found in children first
3. Race: on almost all the races there in the world

IV. ANATOMY
Part of the brain is divided into two, namely the left and right cerebral hemispheres are called (figure 1). Each hemisphere is divided over the lobes frontal lobe, temporal lobe, parietal lobe and occipital lobe. The four lobes have different functions. Each lobe affecting adjacent body part of it.
The function of each lobe are as follows:
1. Frontal lobe function as an area planner, solving problems and expressing emotions (prefrontal), whereas posterior areas of functioning in the movement. At the bottom is the area of speech
2. Left and right temporal parts have different functions, namely: the left side of the area of language understanding and speech, while the right area as the area responsible for emotion. The sides of the lobes are often a source of seizures.
3. Parietal lobe is responsible as the sensory areas of pain, temperature, pressure and touch.
4. Occipital lobe is the primary area for vision

V. Pathogenesis
The human brain has about 100 billion nerve cells called neurons, these neurons that carry signals from the brain to other parts of the body. Each neuron produces electric energy but neurotransmitter responsible for spreading it. In general, epilepsy occurs because of decreased membrane potential of nerve cells in the brain due to pathological processes, mechanical force or toxic which in turn cause the release of the electrical charge of these nerve cells. Some studies suggest a role of acetylcholine as a substance that degrades post synaptic membrane potential. When acetylcholine was pretty buried in the surface of the brain, the electrical discharge of nerve cells facilitated cortical acetylcholine produced by cholinergic nerve cells and seeps out from the surface of the brain. In consciousness-alert alert more acetylcholine which seeps from the surface of the brain than during sleep, as well as the obvious result of brain tumor, infection or brain injury, the amount of acetylcholine more than in the healthy brain, thus the local accumulation of acetylcholine.
Local accumulation of acetylcholine must reach a certain concentration to be lowered so that the membrane potential loss of electric charge can occur, it is gradual.
In the idiopathic type of grand mal epilepsy, or epilepsy involving disturbed consciousness, influenced by the release of electrical charge by intra laminaris thalami nuclei, known also as the core centre cephalic, which is the terminal of the ascending trajectory aspesifik that determines consciousness. Whenever there is absolutely no input there arose a comma. In grand mal, because the cause could not be ascertained, came off the electric charge on the nucleus of the intra laminar thalamic in excess. Excessive stimulation of this thalamo cortical produce spasms throughout the body and simultaneously block the nerve cells that maintains awareness of maintaining consciousness receives efferent impulses from the outside so that consciousness is lost.
Riset results indicate that part of the rostral reticular substantial mecensefalon that can do the blockade for a moment against the intra laminar nuclei talamik thus momentarily lost consciousness without convulsions in skeletal muscle, known as petit mal.
Path physiology of epilepsy

VI. CLINICAL SYMPTOMS
Patients experience a sensation, movement or abnormal psychological disorders, depending on the affected brain regions.
Side of the brain affected by symptoms
Twitching in the muscles of the frontal lobe of certain
Hallucinations occipitals lobe scintillation light
Parietal lobe Numbness or tingling of certain parts of the body
Hallucinations temporal lobe picture of complex and repetitive behaviors such as walking around in circles
Anterior temporal lobe chewing movements, lip movements kiss
Anterior temporal lobe in Hallucinations of smell, either both pleasant and unpleasant
While based on the classification of symptoms that can appears are as follows:
1. Partial Seizures
- Simple partial seizures with consciousness remained normal: a). with motor symptoms of seizures jacsonian, symptoms begin in one particular body part (e.g. hand or foot) and then spread to the limbs, in line with the spread of electrical activity of brain, b). with symptoms somatosensoric followed by a simple hallucination involving the five senses and with vertigo, c) the autonomic nervous disorders with symptoms of epigastria pain, sweating, etc., d). with symptoms of psychological disorders in the form of dysphasia, disamnesia.
- Complex partial seizures began with the loss of patient contact with the surrounding environment for 1-2 minutes. The patient became unsteady, moving arms and legs in an odd way and without purpose, noises are meaningless, incapable of understanding what others say and refused to help. The confusion lasted several minutes, and followed by complete healing.
2. Generalized seizures
- Myoclonic seizures, myoclonic seizures occur in a sudden contraction, while some can be strong or weak muscles or all of the muscles, once or repeatedly. Resurrection can be found at all ages.
- Clonic seizures, the seizures is no tonic component, muscle spasms occur only kelojot. Found particularly in children.
- Tonic seizures, the seizures are no clonic components, only the muscles become stiff, also found in children.
- Convulsive Seizures (tonic-clonic seizures, grand mal) usually starts with abnormal electrical charge on a limited area of the brain. The patient suddenly collapsed, rigid muscles, seizures lasted ¼ - ½ minutes, breathing deeply, hyper salivation, may also urinate. Can be directly aware of the complaints tired, aching, and headache.
- Absence seizures (petit mal) begin in childhood, usually before age 5. Not having a seizure and other dramatic symptoms of grand mal. The patient just stared, his eyelids quivering or twitching face muscles for 10-30 seconds. Patients did not respond to its surroundings but not falling, fainting or jerky.
- Status epileptics is the most serious seizures, where seizures occur continuously, not stopping. Very strong muscle contractions, can not breathe properly and the electrical charge inside the brain is widespread. If not promptly treated, can damage the heart and brain are settled and the patient could die.
3. Seizure not classified
Included in this group is to rise in the baby form of the rhythmic movements of the eyeball, chewing, movement such as swimming, chills, or breathing suddenly stops for a moment.
VII. DIAGNOSIS
In making the diagnosis is required:
1. Anamnesis to the symptoms presented by people who witnessed the attack in people with epilepsy. As the patient comes to the circumstances do not fit, so the picture of convulsions largely based on history. It often relies on knowledge about patterns of convulsions inspectors and intelligence witnesses in describing convulsions. Tonic-clonic seizures will not escape observation, but may include convulsions general, primary or secondary that needs to be asked hallucination, automatism movement, partial movement of the extremities with or without creeping, psychic events that strange, Todd paralysis which may indicate presence of partial convulsions. Simple partial seizures can be divided of complex partial seizures of consciousness.
2. Laboratory to determine the cause of treatable
a. Measure sugar, calcium and sodium in the blood
b. Assessing liver function and kidney
c. Counting the number of white blood cells (increased numbers indicating infection)
3. Other Investigations
a. EEG (Electroencephalography) is that measures electrical activity in the brain. Anomaly of EEG have a high correlation with epileptic seizures are epileptic form activity, namely in the form of sharp waves, spike waves, sharp slow, slow spikes.
b. EKG (electrocardiogram) is performed to determine the existence of tumors or brain cancer, strokes, scarring and damage due to head injuries.
For the diagnosis of epileptic syndromes required data type convulsions, EEG data and other data.

VIII. DIAGNOSIS
Syncope, cardiac disorders, circulatory disorders of the brain at first glance, hypoglycemia, intoxication, breath holding spells, hysteria, narcolepsy, favor nocturnal, sleep paralysis migraine.

IX. MANAGEMENT
The first step in epilepsy management is to ensure that patients suffering from seizure disorders like epilepsy and not circumstances. The second step involves the selection of anticonvulsant drugs.
Management of primary therapy in patients with epilepsy is medication to prevent seizures or to reduce the frequency, so that patients can lead normal lives. In the epileptic syndrome, or disease epilepsy, when structural abnormalities, metabolic or endocrine curable not found, then the goal of treatment is to improve patient quality of life by eliminating or reducing the frequency without causing undesirable side effects.
If the cause is a tumor, infection, sugars or sodium is abnormal, then the states must be treated first. If this situation was resolved, then the seizure itself does not require treatment if the cause can not be cured or controlled in total, it would require anti-seizure to prevent further seizures. About a third of patients experiencing recurrent seizures. The rest is just experiencing a time of attack.
Family of the patient must be trained to help people with epilepsy in the event of an attack. One important step is to keep patients from falling, loosening his clothes (especially in the neck), and put a pillow under the patient's head. If unconscious, should be tilted position for easier breathing and should not be left alone until it is completely conscious and able to move normally. If found brain abnormalities are limited, usually performed surgery to remove the nerve fibers that connect both sides of the brain. Surgery is performed if the medication does not successfully cope with epilepsy or the side effects can not be tolerated.
• Medical Treatment
The drugs are usually given to patients who experience recurrent seizures. Status epilepticus is an emergency, because it's anti-seizure drugs given in high doses intravenously. Anti-seizure drugs are very effective but also can cause side effects. One of them is cause drowsiness, whereas in children causes hyperactivity.
Routinely performed blood tests to monitor kidney function, liver and blood cells. Anti-seizure medications taken by prescription from a doctor. Use of other drugs along with anti-seizure medications have permission and doctor's knowledge, because it can change the anti-seizure drugs in the blood.
The drugs used to treat seizures:
This type of epilepsy drug side effects may occur
Generalized carbamazepine, a partial amount of red blood cells and white blood is reduced
Etoksimid Petit mal number of white blood cells and red blood cells is reduced
Gabapetin Partial Quiet
Lamotrigine Generalized, partial skin rash
Generalized phenobarbital, partial Calm
Phenytoin Generalized, partial Swollen gums
Primidon Generalized, partial Calm
Valvorat Infantile Seizures, petit mal weight gain, hair loss
Table. 2
Some basic principles to consider:
1. In the convulsions are very rare and can be eliminated originators factors, medication should be considered
2. Treatment given after the diagnosis; This means patients have more than two times the same convulsions.
3. The drug is given tailored to the type of convulsions
4. We recommend using mono therapy because in this way will be reduced toxicity, ease of monitoring, and avoiding drug interactions
5. Drug dose adjusted individually
6. Evaluation results
If you fail in treatment, find the cause:
• One etiology: metabolic disorders, neoplasm that are not detected, the disease centers degenerates arrangement neuron
• Provision of anti-epileptic drugs irregularly
• Poor lighting: irregular drug ingestion
• Emotional factors as the originator
• Includes intractable epilepsy
7. Treatment was stopped after the convulsions disappeared for a minimum of 2-3 years.
Treatment was stopped gradually by lowering the dose.
In adults and difenilhidantoin carbamazepine can be used as a sole treatment early on with partial epileptic syndromes. Karbamazepins indiosinkrasi and bone marrow depression, hepatotoxicity, but the long-term use did not affect cognition. Blood tests and liver physiology can be done 3-4 times a year.

X. Prognosis
Prognosis of children who suffer from epilepsy depends on a variety of medical factors, social and psychological. In general, the prognosis of epilepsy associated with several factors such as frequency of seizures, presence or absence of neurological or mental deficit, the type and duration of seizures.
Patients seeking treatment epilepsy regular 1 / 3 will be free to attack at least 2 years, and if more than 5 years after the last attack the drug is stopped, the patient no longer suffered seizures, said to have been in remission. An estimated 30% of patients will not experience remission while taking the drug with less regularly. After remission, the possibility of repeated attacks most often found in tonic-clonic seizures and complex partial seizures. Similarly a young age is more prone to relapse after remission.