难治性癫痫持续状态的预后及处理ppt课件

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。 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( refractory status epilepticus， RSE)。,诊 断,二种以上药物治疗维持一小时以上，未能有效控制。,*Jan Novy, yGiancarlo Logroscino, Refractory status epilepticus: A prospective observational study。 Epilepsia, 2010，51(2):251256,Status epilepticus (SE) that is resistant to two antiepileptic compounds is defined as refractory status epilepticus (RSE). In the few available retrospective studies, estimated RSE frequency is between 31% and 43% of patients presenting an SE episode; almost all seem to require a coma induction for treatment. We prospectively assessed RSE frequency, clinical predictors, and outcome in a tertiary clinical setting.,*Jan Novy, yGiancarlo Logroscino, Refractory status epilepticus: A prospective observational study。 Epilepsia, 2010，51(2):251256,Twenty-nine of 128 SE episodes (22.6%) were refractory to first- and second-line antiepileptic treatments. Severity of consciousness impairment and de novo episodes were independent predictors of RSE. RSE showed a worse outcome than non-RSE (39% vs. 11% for mortality; 21% vs. 63% for return to baseline clinical conditions). Only 12 patients with RSE (41%) required coma induction for treatment.,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,Eric J. Ericson, Elizabeth E. Gerard，Aphasic status epilepticus: Electroclinical correlation，Epilepsia, 52(8):14521458, 2011,All nine patients were right-handed with subacute or chronic left hemispheric lesions on magnetic resonance imaging (MRI). All patients had mixed aphasia, three presenting with persistent aphasia from onset and six with episodic speech impairment, which became persistent in five of the six. The initial 30-min EEG demonstrated electrographic seizure in only five patients (56%), despite the presence of aphasia during the recording. Left hemispheric periodic lateralized epileptiform discharges (PLEDS) were seen in two patients, and left hemispheric slowing in two patients.,Eric J. Ericson, Elizabeth E. Gerard，Aphasic status epilepticus: Electroclinical correlation，Epilepsia, 52(8):14521458, 2011, Continuous video-EEG monitoring confirmed electrographic seizure activity in all nine patients. Peak electrographic seizure frequency varied from continuous to once every 2h and was not associated with fluctuations in the speech deficit. EEG seizures resolved abruptly in three patients and gradually over up to 4 days in six patients. Clinical improvement was delayed in eight of the nine patients, and four patients retained some aphasia at discharge, 24 days after EEG seizure resolution.,8,Eric J. Ericson, Elizabeth E. Gerard，Aphasic status epilepticus: Electroclinical correlation，Epilepsia, 52(8):14521458, 2011,预后,*Jan Novy, yGiancarlo Logroscino, Refractory status epilepticus: A prospective observational study，Epilepsia, 51(2):251256, 2010,*Jan Novy, yGiancarlo Logroscino, Refractory status epilepticus: A prospective observational study，Epilepsia, 51(2):251256, 2010,*Jan Novy, yGiancarlo Logroscino, Refractory status epilepticus: A prospective observational study，Epilepsia, 51(2):251256, 2010,处理流程,保持呼吸道通畅或建立人工辅助呼吸 积极寻找病因，对可能的病因进行处理 维持水电解质及酸碱平衡 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/kgh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。,（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0.15-0.2mg/kg，然后 0.2-0.4mg/kgh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/kgh持续静脉输注射。 Propofol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。,（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/kgmin，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。,（5）利多卡因 （6）丙戊酸注射,（7）电休克治疗,对部分可能有效，可试探性的观察治疗。 Refractory status epilepticus (SE) is a current daily therapeutic challenge. Electroconvulsive therapy (ECT), which is frequently used to treat psychiatric disorders, is known to raise the seizure threshold. As such, ECT could be of major interest in refractory SE。 In this paper, we provide a brief overview of ECT in refractory SE. Although no placebo-controlled or open-label study has been published on the efficacy or safety of ECT in refractory SE, eight case reports have been identified.,Virginie Lambrecq a,b,*, Frede ric Villega c, Refractory status epilepticus: Electroconvulsive therapy as a possible therapeutic strategy。Eur J Epilepsy (2012),Virginie Lambrecq a,b,*, Frede ric Villega c, Refractory status epilepticus: Electroconvulsive therapy as a possible therapeutic strategy。Eur J Epilepsy (2012), SE cessation was obtained in 80% of cases, and complete recovery was achieved in 27% of patients. Despite the heterogeneity of the ECT parameters used in these articles, we identified some common features that may be recommended for the use of ECT in refractory SE. ECT might be a viable therapeutic strategy for the most resistant and severe cases