难治性癫痫持续状态的预后及处理

难治性癫痫持续状态

的预后及处理四川省医学科学院·四川省人民医院神经内科孙红斌2012-11现状癫痫持续状态是神经内科的急重症，多数国家癫痫持续状态均需进入NICU进行处理，经过适当的药物治疗和病因治疗，近80%病例均可获得满意的疗效。生命体征稳定，神经元得到保护，脑电图痫样放电停止，并发症得到良好控制。01但仍有9-22%的病例癫痫发作和并发症难以控制，并成为难治性癫痫持续状态(refractorystatusepilepticus，RSE)。02二种以上药物治疗维持一小时以上，未能有效控制。Statusepilepticus(SE)thatisresistanttotwoantiepilepticcompoundsisdefinedasrefractorystatusepilepticus(RSE).Inthefewavailableretrospectivestudies,estimatedRSEfrequencyisbetween31%and43%ofpatientspresentinganSEepisode;almostallseemtorequireacomainductionfortreatment.WeprospectivelyassessedRSEfrequency,clinicalpredictors,andoutcomeinatertiaryclinicalsetting.RSEshowedaworseoutcomethannon-RSE(39%vs.11%formortality;21%vs.63%forreturntobaselineclinicalconditions).Only12patientswithRSE(41%)requiredcomainductionfortreatment.nineof128SEepisodes(22.6%)wererefractorytofirst-andsecond-lineantiepileptictreatments.SeverityofconsciousnessimpairmentanddenovoepisodeswereindependentpredictorsofRSE.非惊厥性癫痫持续状态（NCSE）长程视频脑电可明显提高诊断率和监测治疗效果Allninepatientswereright-handedwithsubacuteorchroniclefthemisphericlesionsonmagneticresonanceimaging(MRI).Allpatientshadmixedaphasia,threepresentingwithpersistentaphasiafromonsetandsixwithepisodicspeechimpairment,whichbecamepersistentinfiveofthesix.Theinitial30-minEEGdemonstratedelectrographicseizureinonlyfivepatients(56%),despitethepresenceofaphasiaduringtherecording.Lefthemisphericperiodiclateralizedepileptiformdischarges(PLEDS)wereseenintwopatients,andlefthemisphericslowingintwopatients.·Continuousvideo-EEGmonitoringconfirmedelectrographicseizureactivityinallninepatients.·Peakelectrographicseizurefrequencyvariedfromcontinuoustoonceevery2handwasnotassociatedwithfluctuationsinthespeechdeficit.·EEGseizuresresolvedabruptlyinthreepatientsandgraduallyoverupto4daysinsixpatients.·Clinicalimprovementwasdelayedineightoftheninepatients,andfourpatientsretainedsomeaphasiaatdischarge,2–4daysafterEEGseizureresolution.However,continuousEEGisnecessarytoconfirmthediagnosisandmonitortreatment,sinceclinicalsymptomsdonotcorrelatewithelectrographicseizureactivityanddonotprovidesufficientinformationtoguidetreatmentdecisions.StandardEEGissensitivefordetectionofabnormalitiesinthedominanthemisphereinpatientswithASE.处理流程保持呼吸道通畅或建立人工辅助呼吸维持水电解质及酸碱平衡积极寻找病因，对可能的病因进行处理药物治疗（1）戊巴比妥：是目前治疗难治性癫痫持续状态的标准疗法，对其中多数病例有效，有作者研究提示使用标准剂量治疗120min可使75%的病例停止发作，123min内可使80%的病例停止发作。初始负荷剂量5mg/kg静脉注射，再以0.5-3mg/kg·h连续静脉输注，直至发作停止或见暴发抑制脑电图。低血压，呼吸抑制，复苏延迟是其主要副作用。但需特别注意的是多项临床研究证实，用戊巴比妥停药后，如癫痫复发死亡率接近30%，原因尚不清楚。因而认为使用戊巴比妥后癫痫复发是预后不良的独立危险因素。12（2）咪达唑仑：是一种作用很强的苯二氮卓药物，对不同年龄段的RSE都有效。近年来广泛用来代替戊巴比妥。常用剂量，首剂静注，然后0.2-0.4mg/kg·h静脉输注1-3天。对血压、呼吸影响较小。（3）普鲁泊福（propofol）是一种非巴比妥类的麻醉药，能够增强GABA神经递质的释放。多个开放性试验证实起效时间为2-6min。部分研究者建议RSE应首先考虑普鲁泊福或者咪达唑仑，而不是戊巴比妥治疗。建议剂量是1-2mg静脉注射，然后以2-10mg/kg·h持续静脉输注射。01Propofol可能的副作用包括诱导癫痫发作，但并不常见，且在低于推荐剂量时出现。还可能出现中枢系统的兴奋状态，如强直、角弓反张、手足徐动症。儿童使用≥24h，有出现横纹肌溶解，难治性低氧症，酸中毒，心衰等副作用的报道。02（4）大剂量地西泮静脉滴注：地西泮是治疗SE的首选，但传统剂量对RSE无效，可静脉给药达0.01-0.03mg/kg·min，平均起效时间40min，持续用药时间120-226h，平均68h，83%的患者有效。可出现低血压，20%以上的病例需要机械通气。12利多卡因丙戊酸注射对部分可能有效，可试探性的观察治疗。Refractorystatusepilepticus(SE)isacurrentdailytherapeuticchallenge.Electroconvulsivetherapy(ECT),whichisfrequentlyusedtotreatpsychiatricdisorders,isknowntoraisetheseizurethreshold.Assuch,ECTcouldbeofmajorinterestinrefractorySE。·Inthispaper,weprovideabriefoverviewofECTinrefractorySE.Althoughnoplacebo-controlledoropen-labelstudyhasbeenpublishedontheefficacyorsafetyofECTinrefractorySE,eightcasereportshavebeenidentified.VIRGINIELAMBRECQA,B,*,FRE´DE´RICVILLE´GAC,REFRACTORYSTATUSEPILEPTICUS:ELECTROCONVULSIVETHERAPYASAPOSSIBLETHERAPEUTICSTRATEGY。EURJEPILEPSY(2012)

·SEcessationwasobtainedin80%ofcases,andcompleterecoverywasachievedin27%ofpatients.DespitetheheterogeneityoftheECTparametersusedinthesearticles,weidentifiedsomecommonfeaturesthatmayberecommendedfortheuseofECTinrefractorySE.·ECTmightbeaviabletherapeuticstrategyforthemostresistantandseverecasesofSE,particularlyafterthefailureoftwoi