難治性癲癇持續(xù)狀態(tài)的預(yù)后及處理

難治性癲癇持續(xù)狀態(tài)

的預(yù)后及處理四川省醫(yī)學(xué)科學(xué)院·四川省人民醫(yī)院神經(jīng)內(nèi)科孫紅斌2012-11現(xiàn)狀癲癇持續(xù)狀態(tài)是神經(jīng)內(nèi)科的急重癥，多數(shù)國(guó)家癲癇持續(xù)狀態(tài)均需進(jìn)入NICU進(jìn)行處理，經(jīng)過(guò)適當(dāng)?shù)乃幬镏委熀筒∫蛑委煟?0%病例均可獲得滿(mǎn)意的療效。生命體征穩(wěn)定，神經(jīng)元得到保護(hù)，腦電圖癇樣放電停止，并發(fā)癥得到良好控制。01但仍有9-22%的病例癲癇發(fā)作和并發(fā)癥難以控制，并成為難治性癲癇持續(xù)狀態(tài)(refractorystatusepilepticus，RSE)。02二種以上藥物治療維持一小時(shí)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.非驚厥性癲癇持續(xù)狀態(tài)（NCSE）長(zhǎng)程視頻腦電可明顯提高診斷率和監(jiān)測(cè)治療效果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.處理流程保持呼吸道通暢或建立人工輔助呼吸維持水電解質(zhì)及酸堿平衡積極尋找病因，對(duì)可能的病因進(jìn)行處理藥物治療（1）戊巴比妥：是目前治療難治性癲癇持續(xù)狀態(tài)的標(biāo)準(zhǔn)療法，對(duì)其中多數(shù)病例有效，有作者研究提示使用標(biāo)準(zhǔn)劑量治療120min可使75%的病例停止發(fā)作，123min內(nèi)可使80%的病例停止發(fā)作。初始負(fù)荷劑量5mg/kg靜脈注射，再以0.5-3mg/kg·h連續(xù)靜脈輸注，直至發(fā)作停止或見(jiàn)暴發(fā)抑制腦電圖。低血壓，呼吸抑制，復(fù)蘇延遲是其主要副作用。但需特別注意的是多項(xiàng)臨床研究證實(shí)，用戊巴比妥停藥后，如癲癇復(fù)發(fā)死亡率接近30%，原因尚不清楚。因而認(rèn)為使用戊巴比妥后癲癇復(fù)發(fā)是預(yù)后不良的獨(dú)立危險(xiǎn)因素。12（2）咪達(dá)唑侖：是一種作用很強(qiáng)的苯二氮卓藥物，對(duì)不同年齡段的RSE都有效。近年來(lái)廣泛用來(lái)代替戊巴比妥。常用劑量，首劑靜注，然后0.2-0.4mg/kg·h靜脈輸注1-3天。對(duì)血壓、呼吸影響較小。（3）普魯泊福（propofol）是一種非巴比妥類(lèi)的麻醉藥，能夠增強(qiáng)GABA神經(jīng)遞質(zhì)的釋放。多個(gè)開(kāi)放性試驗(yàn)證實(shí)起效時(shí)間為2-6min。部分研究者建議RSE應(yīng)首先考慮普魯泊?；蛘哌溥_(dá)唑侖，而不是戊巴比妥治療。建議劑量是1-2mg靜脈注射，然后以2-10mg/kg·h持續(xù)靜脈輸注射。01Propofol可能的副作用包括誘導(dǎo)癲癇發(fā)作，但并不常見(jiàn)，且在低于推薦劑量時(shí)出現(xiàn)。還可能出現(xiàn)中樞系統(tǒng)的興奮狀態(tài)，如強(qiáng)直、角弓反張、手足徐動(dòng)癥。兒童使用≥24h，有出現(xiàn)橫紋肌溶解，難治性低氧癥，酸中毒，心衰等副作用的報(bào)道。02（4）大劑量地西泮靜脈滴注：地西泮是治療SE的首選，但傳統(tǒng)劑量對(duì)RSE無(wú)效，可靜脈給藥達(dá)0.01-0.03mg/kg·min，平均起效時(shí)間40min，持續(xù)用藥時(shí)間120-226h，平均68h，83%的患者有效。可出現(xiàn)低血壓，20%以上的病例需要機(jī)械通氣。12利多卡因丙戊酸注射對(duì)部分可能有效，可試探性的觀察治療。Refractorystatusepilepticus(SE)isacurrentdailytherapeuticchallenge.Electroconvulsivetherapy(ECT),whichisfrequentlyusedtotreatpsychiatricdisorders,isknowntoraisetheseizurethreshold.Assuch,ECTcouldbeofmajorinterestinrefractorySE?！nthispaper,weprovideabriefoverviewofECTinrefractorySE.Althoughnoplacebo-controlledoropen-labelstudyhasbeenpublishedontheefficacyorsafetyofECTinrefractorySE,eightcasereportshavebeenidentified.VIRGINIELAMBRECQA,B,*,FRE′DE′RICVILLE′GAC,REFRACTORYSTATUSEPILEPTICUS:ELECTROCONVULSIVETHERAPYASAPOSSIBLETHERAPEUTICSTRATEGY。EURJEPILEPSY(2012)

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