癫痫的定义专题知识讲座

癫痫的定义专题知识讲座癫痫的定义专题知识讲座第1页癲癇定義1925,英人JHughlingJackson:腦部神經細胞不正常放電癲癇是由許多先天或後天原因所引发慢性腦病，其特徵是由於腦細胞過度放電(excessivedischarge)所引发反覆性發作(epilepticseizure)，伴隨多種類型臨床表現Seizure(癲癇發作):腦部異常放電症狀每個人都有可能(alcohol,drug,infection,excitingetc...)Epilepsy(癲癇症):反覆發作疾病狀態癫痫的定义专题知识讲座第2页癲癇定義Aura:前兆，希臘語“颱風前之微風”，發作前之警告，seizure一个别，本身就是simplepartialseizure。Automatism:自動症，automaticbehaviorduringseizurewithalteredconsciousness.Fit:發作。Ictus:發作。Ictal:relatedtoseizureitself.Postictal:immediatelyafterseizure.Interictal:betweenattacksofseizure,oftensymptomfree.癫痫的定义专题知识讲座第3页癲癇流行病學盛行率0.3-0.7%(平均每兩百人中一個)發生率30-70/100000(每年新增病例)

每九到十人中，有一人其一生中發生過一次或屡次癲癇發作(epilepticseizure)癫痫的定义专题知识讲座第4页癲癇發作(seizure)分類

InternationalClassificationofEpilepticSeizurePartial(localonset)局部發作Simplepartialseizure單純局部發作Complexpartialseizure複雜局部發作Partialseizurewithsecondarygeneralization局部發作演變成次發性全身發作Generalized(bilaterallysymmetricwithoutlocalonset)全身發作

GTCS,Absence….etc癫痫的定义专题知识讲座第5页癲癇(epilepsy)分類

InternationalClassificationofEpilepsies

andEpilepticSyndromeIdiopathicepilepsysyndromes(focalorgeneralized)BenignneonatalconvulsionsBenignchildhoodepilepsyChildhood/juvenileabsenceepilepsyJuvenilemyoclonicepilepsyunspecifiedSymptomaticepilepsysyndromes(focalorgeneralized)Westsyndrome(infantilespasms)Lennox-GastautsyndromeEpilepsiapartialiscontinuaOtherepilepsysyndromesofuncertainormixedclassification癫痫的定义专题知识讲座第6页SimplePartialSeizure單純局部發作Consciousnessnotimpaired意識清楚WithMotorsymptoms:simpleclonicconvulsion,Jacksnoianmarching,adversion…Somatosensoryorspecialsensorysymptoms:paresthesia,auditoryorvisualhallucination…Autonomicsymptoms:abdominalcramp,vomiting,vertigo…Psychicsymptoms:déjàvu,jamaivu,fear,anxiety…癫痫的定义专题知识讲座第7页SimplevisualSomaticsensoryJacksonianSMASimpleadversiveComplexadversiveVestibularAutonomicGustatoryVisceralAuditory癫痫的定义专题知识讲座第8页Jacksonianseizure癫痫的定义专题知识讲座第9页Adversiveseizure癫痫的定义专题知识讲座第10页ComplexPartialSeizure複雜局部發作(Psychomotorseizure,temporalepilepsy)ConsciousnessimpairedLimbiccortexinvolvedAmnesiaTwosubtypesSimplepartialonsetfollowedbyimpairedconsciousnessImpairedconsciousnessatonset癫痫的定义专题知识讲座第11页GeneralizedSeizure全身發作WithoutlocalonsetBilaterallysymmetricLossofconsciousness癫痫的定义专题知识讲座第12页GeneralizedSeizure

(Convulsiveornonconvulsive)Absenceseizure(petitmal)失神發作Myoclonicseizure肌抽躍發作Clonicseizure間代發作Tonicseizure強直發作Tonic-clonicseizure(grandmal)強直-間代發作Atonicseizure失張發作癫痫的定义专题知识讲座第13页AbsenceseizureOnset:4-10yr,usuallyresolvebyage20NoprodromeorauraSeizure:secondstomins,suddeninterruptionofconsciousness,automatismNopostictalphaseEasilyinducedbyhyperventilationorphoticstimulationIctalEEG:3Hzspikesandwaves癫痫的定义专题知识讲座第14页AtypicalAbsenceseizuresUsuallyoccursinpatientswithneurologicalordevelopmentalabnormalities.IctalEEG:<3Hzspikesandwaves.癫痫的定义专题知识讲座第15页Seizureclassification癫痫的定义专题知识讲座第16页癲癇原因Infantsandchildren

Adults

Nodefinitecausedetermined

Nodefinitecausedetermined

Birthandneonatalinjuries

Vascularlesions

Vascularinsults

Headtrauma

Congenitalormetabolicdisorders

Drugoralcoholabuse

Headinjuries

Neoplasia

infection

Infection

Neoplasia

Heredity

Heredity

癫痫的定义专题知识讲座第17页EtiologyofAcuteSymptomaticSeizuresStroke40-54%Toxic-metabolic15-30%Neoplasm8-10%Trauma4-10%Alcohol3-5%CNSinfection2-3%癫痫的定义专题知识讲座第18页癲癇診斷病史發作型態預兆或先兆(aura)臨床發作內容發作後症狀誘發原因過去病史家族史心理社會史頻率及叢集發作之型態發病年齡症狀改變與發展之經過對癲癇藥物之反應癫痫的定义专题知识讲座第19页癲癇診斷身體理學檢查普通理學檢查神經理學檢查實驗室檢驗血液生化(必要時腦脊髓液檢查)腦電圖(EEG)X-ray,CT,MRT,Cerebralangiography癫痫的定义专题知识讲座第20页Dormicum11499091Baseline癫痫的定义专题知识讲座第21页Voltagemapping61MEPC

11499091癫痫的定义专题知识讲座第22页11499091癫痫的定义专题知识讲座第23页61MEpilepsiaPartialisContinua11499091T2WIEEGMapSPECT癫痫的定义专题知识讲座第24页ClassificationofSeizureBasedonIctalSymptomsSensorialsphere(“aura”)Autonomicsphere(“autonomicseizure”)Consciousness(“dialepticseizures”)Motorphenomenon(“motorseizure”)癫痫的定义专题知识讲座第25页癲癇症治療I(原則)治療可能病因metabolicdisorders,infection,tumoretc...根據癲癇類型選擇藥物儘可能減少藥物種類，單一處方優於複方簡化給藥方式與劑量教導面對癲癇正確態度家庭、學校與社會支持癫痫的定义专题知识讲座第26页癲癇症治療II(casebycase)Givedrug???Firstattack:trauma,stroke,idiopathic

Stopdrug???months,years,forever癫痫的定义专题知识讲座第27页GoodprognosticfactorsforstoppingAEDsIdiopathicepilepsyChildhoodonsetEasytocontrolwithAEDsNormalneurologicalexam,normalintelligenceNormalEEGSeizurefree>3year癫痫的定义专题知识讲座第28页AntiepilepticdrugsAntiepileptogenesis:preventkindlingAntiepilepticactivity:fullykindledcanbetreated(seizurecontrol)---Blockvoltage-gatedNa+channelsBlockvoltage-gatedCa2+channelsIncreasingGABAtransmissionDecreasingGlutamatetransmission癫痫的定义专题知识讲座第29页Drugchoice癫痫的定义专题知识讲座第30页癫痫的定义专题知识讲座第31页癫痫的定义专题知识讲座第32页Idiosyncraticreactionsarenotdoserelated;rathertheyariseeitherfromanimmune-mediatedreactiontothedrugorfrompoorlydefinedindividualfactors,largelygenetic,thatconveyanunusualsensitivitytothedrug.癫痫的定义专题知识讲座第33页Dosingintervalsshouldusuallybelessthanone-thirdtoone-halfthedrug’shalf-lifetominimizefluctuationsbetweenpeakandtroughbloodconcentrations.癫痫的定义专题知识讲座第34页癲癇重積症；持續性癲癇狀態

(Statusepilepticus)連續發作超過10分鐘，反復發作間隔病人意識沒有清醒過來(NEngJMed.1998)高危險，高死亡率(8-20%)原因：cessationofdrugalcoholwithdrawalinfectionmetabolicdisorderscerebrovasculardisease癫痫的定义专题知识讲座第35页ConsequencesofstatusepilepticusOrgansDamageAcid-baseAcidosis–lactic,respiratoryHeartArrhythmiaLungPulmonaryedema,aspirationBoneShoulderdislocation,ribfractureMuscleRhabdomyolysis,myoglobinuria癫痫的定义专题知识讲座第36页癲癇重積症治療-IPreferenceAlternatives0min(recordtheexacttimeofativanIV)Lorazepam(2)2ampslowIVpush(mayrepeatafter10mins)Diazepam(10)1-2ampslowIVpush;mayrepeatafter10min3minValproate(400)2amp(15mg/kg)slowIVpush,then1.5ampIVFq8hPhenytoin(100)7amp(15-18mg/kg,50mg/min)IVFin20min,then1ampIVq8hIfGSzrecur(in10-40mins)Lorazepam(2)2ampslowIVpushDiazepam(10)1-2ampslowIVpushIfGSzrecur(in40-60mins)Midazolam(5)2ampslowIVpush,then0.05-0.4mg/kg/hrMidazolam(5)2ampslowIVpush,then0.05-0.4mg/kg/hr癫痫的定义专题知识讲座第37页癲癇重積症治療-IIPreferenceAlternativesIfpoorSzcontrolclinicallyorelectrophysiologicallyPropofol(200mg/20ml/amp)½amp(2mg/kg)sl