惊厥性癫癎持续状态患者220例的临床特征

目的 了解我院就诊的220例惊厥性癫癎持续状态(CSE)患者的临床特征,为CSE的针对性预防和治疗提供依据.方法 采用连续登记方法,前瞻性观察四川大学华西医院1996年1月至2007年10月住院的CSE患者,用Logistic回归方法分析CSE预后的预测因素.结果 纳入220例患者,其中农村患者102例(46.4%).首要病因为中枢神经系统(CNS)感染(72例,32.7%),其次为停(减)抗癫癎药物(34例,15.5%).接受抗惊厥治疗前持续时间中位数为2 h,总持续时间中位数为5 h,农村患者(分别为3.5、7.0 h)均长于城市患者(2.0、3.0 h,Z=-1.558、-3.433,均P<0.05).研究对象首选地西泮静脉推注或苯巴比妥肌肉注射治疗,35例难治性癫癎持续状态(RSE)接受静脉丙戊酸钠治疗,12例接受麻醉治疗,病死率15.9%.Logistic回归分析示CSE持续时间(χ2=20.941)、癫痫病史(χ2=4.910)、呼吸抑制(χ2=16.086)为影响CSE预后的独立因素(均P<0.05).结论 农村人口及癫癎患者是CSE发生的重要人群,CNS感染及停(减)抗癫癎药物是CSE的重要病因,我国抗惊厥治疗与欧洲癫持癎续状态指南差距较大.     

难治性癫痫持续状态患者的脑电图特征

目的 探究难治性癫痫持续状态(RSE)患者的脑电图(EEG)特征.方法 将60例全面惊厥性癫痫持续状态(GCSE)患者根据抗癫痫药物(AEDs)疗效分为RSE和非难治性癫痫持续状态(NRSE),比较两组患者EEG模式的差异.结果 所有患者中,与NRSE组比较,RSE组患者发作期EEG呈持续性放电比例更高,差异具有统计学意义(OR=5.44,95%CI=1.24~23.96,P=0.04).50例EGG呈间歇性演变的患者中,与NRSE组比较,RSE组患者发作间歇期EEG呈周期性放电与痫样放电的比例较高,差异有统计学意义(OR=29.75,4.12;95%CI=3.19~277.32,1.09~15.58;P<0.05);而RSE组患者发作后EEG为正常模式的比例较低,差异具有统计学意义(OR=0.11,95%CI=0.01~0.91,P=0.04).结论 GCSE患者如EEG出现持续性放电、周期性放电、发作间期痫样放电,应引起临床的高度重视,给以强化抗惊厥治疗.     

成人顽固性癫痫持续状态的临床分析

目的 探讨成人顽固性癫痫持续状态（RSE）的危险因素、临床特点、治疗及预后。方法 54例癫痫持续状态（SE）．58次发作事件，分为RSE组和非顽固性癫痫持续状态（NRSE）组．对病因、诱因、临床表现、辅助检查、预后等进行对比分析。结果 RSE占SE的43．1％，病毒性脑炎是RSE最主要的病因（P=0．001），相反，既往癫痫发作在NRSE中更常见（P=0．000），相应地药物治疗的改变引起的SE多为NRSE（P=-0．003）；RSE组GCS评分及预后较NRSE组均差（均P=0．000）。结论 SE经一、二线抗癫痫药治疗后仍有很大一部分难以控制，病毒性脑炎是导致RSE的一个重要病因，其预后较差．目前对RSE的治疗还缺乏十分合理的方案。     

难治性癫痫持续状态的药物治疗进展

难治性癫痫持续状态(RSE)是指使用常规抗癫痫治疗不能控制的持续癫痫发作超过1h的状态,有效控制癫痫发作是挽救患者生命、改善其预后的关键。此文回顾分析了2003-2005年国内外治疗RSE的有关文献,将其所用药物用法、用量及作用机制做一综述。     

难治性全面性癫痫持续状态的临床研究

目的 结合献研究12例难治性全面性癫痫持续状态(RSE)的治疗。方法 对患的病因、临床资料、治疗、预后进行分析。结果 12例RSE患控制6例，显效2例，有效2例，无效2例，总有效率83．3％，死亡3例，病死率25％。结论 RSE是神经系统危急症，积极有效的治疗可减少其对中枢神经系统的损害，改善患的预后，缩短住院时间。硫贲妥钠、异丙酚、利多卡因等是治疗RSE的有效药物。     

难治性癫痫持续状态的治疗进展

<正>癫痫持续状态(status epilepticus,SE)的发病率为10~61/10万,是神经科仅次于急性脑血管病的危急重症。即使给予足够、及时、恰当的抗癫痫药物以及病因治疗等综合处理,仍有约三分之一的患者发作难以控制,进展为难治性癫痫持续状态(refractor]ystatus epilepticus,RSE),其死亡率达16%~39%[1。RSE尚无统一定义,目前比较得到公认,在文献报道中应用较广泛的定义是:给予足够剂量的2~3种一     

脑炎后癫痫持续状态进展为难治性癫痫持续状态及超级难治性癫痫持续状态的早期预测因素

目的探讨脑炎后癫痫持续状态(SE)进展为难治性SE(RSE)及超级RSE(SRSE)的早期预测因素。方法根据疾病进展情况将89例脑炎后SE患者分为非RSE组、RSE组及SRSE组。比较各组临床资料。结果非RSE组、RSE组及SRSE组年龄、SE严重程度评分量表(STESS)评分、基于流行病学SE病死率评分(EMSE)评分、脑炎-非惊厥性癫痫持续状态(NCSE)-地西泮抵抗-影像异常-气管插管(END-IT)评分、GCS评分、急性生理与慢性健康评分Ⅱ(APACHEⅡ)及影像学特征、昏迷中的NCSE、对苯二氮艹卓类药物无反应、静脉撤药发作、气管插管、应用血管活性药物比率差异均有统计学意义(P<0.05~0.01)。多因素Logistic回归分析发现,EMSE(OR=1.176,95%CI:0.984~1.405,P=0.075)、静脉撤药发作(OR=10.164,95%CI:1.825~56.603,P=0.008)和昏迷中的NCSE(OR=7.577,95%CI:1.337~42.940,P=0.022)是SE演变为RSE和SRSE的早期预测因素。结论EMSE超过42.5分、静脉撤药发作和是否为昏迷中的NCSE是SE患者进展为难治性的早期预测因素。     

影响难治性癫痫持续状态预后的相关因素

难治性癫痫持续状态(RSE)是一种严重的神经科危急重症,且预后较差。目前对于影响RSE预后相关因素的研究国内外尚无统一观点。本文就近年来有关影响RSE预后的相关因素,如病因、年龄、并发症、发作类型等的研究进展做一简要阐述。     

癫痫持续状态63例急诊救治体会

目的探讨癫痫持续状态的急诊救治方法及效果。方法我院急诊科2011-06—2014-01共救治63例癫痫持续状态患者,收集其临床资料并进行回顾性分析,所有患者在给予吸氧、防护并保持呼吸道通畅的同时,以10~20mg地西泮静脉注射,速度控制在2mg/min,后以50~100mg加入500mL生理盐水中持续缓慢静滴,12h内滴完,根据发作情况调整滴速;同时采用100mg苯巴比妥钠肌内注射,q8h,对于难治性癫痫持续状态患者,采取水合氯醛30~50mL保留灌肠;对于不能控制癫痫发作者,采用0.5g硫喷妥钠+20mL生理盐水缓慢静滴,0.2g苯妥英钠鼻饲,3次/d,同时控制脑水肿的发生,以5mg地塞米松+250mL 20%甘露醇快速静滴,q8h。结果 63例患者中60例癫痫大发作逐渐控制,其中临床控制24例,显效20例,有效16例;癫痫持续状态控制时间(服药到症状消失)4h内25例,4~12h19例,12~24h内16例;3例患者虽经治疗24h以上,症状减轻,但仍处于昏迷状态,最后死亡,其中2例死于病毒性脑炎并脑水肿,脑疝形成,1例死于脑出血并发脑疝形成。结论有效而及时的急诊救治措施可有效控制癫痫持续状态,稳定患者的生命体征,改善预后,提高生存质量。     

儿童癫痫持续状态的临床特点、治疗及预后分析

目的探讨儿童癫痫持续状态(SE)的临床特点、治疗策略及预后。方法回顾性分析2015年1月至2019年10月空军军医大学唐都医院神经外科收治的36例儿童SE患者的临床资料。采用抗癫痫药物、麻醉药物等控制SE后,根据患儿的具体情况进一步行手术(24例)或药物治疗(12例)癫痫。观察SE的控制情况、癫痫的预后及相关并发症。结果36例患儿的年龄均≤14岁,其中≤3岁者22例;症状性SE 29例,特发性SE 7例;惊厥性SE 32例,非惊厥性SE 4例;可控性SE 25例,难治性SE(RSE)8例,超难治性SE(SRSE)3例;有诱发因素者29例;影像学异常者24例;脑电图显示大脑异常放电者35例,放电抑制者1例。36例患儿中,28例采用抗癫痫药物治疗后SE完全控制,8例给予了麻醉药物。33例SE完全控制,1例部分有效(为RSE患儿),2例无效者均死亡(均为SRSE患儿);控制时间为10 min至72 h(中位时间为40 min)。13例出现SE治疗的相关并发症。共33例患儿获得随访,随访时间为(2.5±1.4)年(1.0~5.5年)。手术治疗的24例患儿中,5例发生手术相关并发症;术后随访EngleⅠ级者20例,Ⅱ级者4例。采用药物治疗的9例患儿,发作频率降低≥50%者6例,发作频率降低<50%者3例。结论低龄尤其是≤3岁者SE高发,大部分患儿为症状性且有明显诱因,影像学异常者多见,脑电图均异常;抗癫痫药物和麻醉药可控制大部分SE,但RSE和SRSE患儿的疗效差;手术治疗对预防症状性SE及改善其预后效果较好。     

Diagnostic Difficulties and Treatment Implications

Summary: Differentiation between types of epileptic seizures has been aided in recent years by the introduction of intensive neurodiagnostic techniques and the development of increasingly detailed classification systems. Paradoxically, these developments have not simplified the task of matching the appropriate antiepileptic drug to a particular seizure type. It is reasonable to assume that anticonvulsant drugs will have different effects on different types of seizures, but faulty, circular reasoning can enter the picture if one also assumes that responses of seizures to different drugs signify different seizure types. There are several examples of differential diagnoses that can fall prey to this problem, including the diagnosis between partial seizures with secondary generalization and generalized tonic-clonic seizures, and the diagnosis between complex partial seizures and absence seizures with automatisms, among others. Considerations of etiology in future classification systems can further complicate the problem: should one then choose an anticonvulsant drug on the basis of individual seizure type or on the basis of the type of epilepsy? Ramifications of this issue extend even to the drug approval process. Official sanction is not given for use of a drug for a seizure type not included in the original efficacy studies, even if later scientific evidence shows that seizure type to be related to a type that is included. New trials must be undertaken. These problems arise from how we choose to classify seizures.     

Cognitive Dysfunction Associated with Antiepileptic Drug Therapy

Summary: Epilepsy is frequently associated with cognitive dysfunction. However, the reasons for this correlation are unclear. Possible influential factors include patient age; duration, frequency, etiology, and type of seizures; hereditary factors; psychosocial issues; and antiepileptic drug (AED) therapy. Whereas many of these factors are beyond the physician's control, AED therapy is one element that can be addressed in treatment decisions by recognizing the potential cognitive effects of particular AEDs. For example, phenobarbital impairs memory and concentration; phenytoin affects attention, problem solving ability, and performance of visuomotor tasks. In contrast, carbamazepine may affect concentration, while valproate would appear to have minimal effects on cognition. Moreover, cognitive effects of AEDs are amplified with coadministration of multiple anticonvulsants (polytherapy). A review of studies on the cognitive effects of monotherapy with AEDs, as opposed to those of polytherapy, provides evidence that drug-related cognitive dysfunction can be reversed if patients are switched to a simpler therapeutic regimen. Future research should be directed toward developing reliable measures for assessing and monitoring cognition, and understanding the particular cognitive side effects of each AED. Physicians also need to revise their opinions about which side effects are "tolerable" for epileptic patients.     

Epilepsy and anomalies of neuronal migration: MRI and clinical aspects

Neuronal migration disorders are the result of disturbed brain development. In such disorders, neurons are abnormally located. In diagnosing these conditions, magnetic resonance imaging is superior to any other imaging technique. This enables us to improve our knowledge of the clinical correlates of neuronal migration. With reference to migrational disorder, a retrospective study of all 303 patients with epileptic seizures referred for magnetic resonance imaging during a 3-year period was performed, 13 patients (aged 12-41, mean age 27) were identified. They represent 4.3% of the entire study group. Of the patients with known epilepsy, 6.7% and of the mentally retarded, 13.7% had migrational disorders. Four patients had schizencephaly as the dominant finding, one was classified as hemimegalencephaly, 2 had isolated heterotopias, and 6 had localized pachy- and/or poly-microgyria. The clinical pictures are complex. Ectopias of grey matter are recognised foci of epilepsy, but from an epileptological and a clinical viewpoint little attention has been given to these disorders. The present study shows that malmigration is not rare in epilepsy patients, especially not in the mentally retarded.     

Carbamazepine Efficacy in Adults With Partial and Generalized Tonic-Clonic Seizures

Summary: Carbamazepine and phenytoin are drugs of choice in initial monotherapy for adult partial and secondarily generalized tonic-clonic seizures. These designations reflect the results of the Veterans Administration Epilepsy Cooperative Study Group of 1985. An earlier comparative study of carbamazepine and phenytoin by Ramsay and associates found both drugs equally effective in controlling new-onset seizures. Among the advantages of carbamazepine is that it causes relatively few cognitive and dysmorphic side effects. Its disadvantages are its unavailability in parenteral formulation and its metabolic autoinduction. The latter must be compensated for by planned dosage increases to maintain therapeutic plasma steady-state levels during the first 2 or 3 months of treatment. Carbamazepine is judged a drug of choice in the treatment of these secondarily generalized tonic-clonic seizures, and the drug of choice in children, adolescents, and women susceptible to the dysmorphic side effects associated with other anticonvulsant agents.     

Etiologic and Preventive Aspects of Epilepsy in the Child–Bridging the Gap Between Laboratory and Clinic

Summary: Four broad categories of basic phenomena are pertinent to developing ways to prevent epilepsy. These include mechanisms of epileptogenesis, ictal initiation and temporary entrainment by the seizure discharge of normally functioning brain, seizure propagation, and control mechanisms that function both to restrain the cascade of epileptic events culminating in a seizure and to arrest the epileptic event and restore the interictal state. In newborns and children, hypoxia-ischemia is a major factor leading to epileptogenesis, and several schemes are proposed to classify, quantify, and prevent hypoxic-ischemic encephalopathy. Control mechanisms must be better understood in order to develop prophylactic recommendations for epilepsy, and an experimental model of "kindling antagonism" may increase our understanding of these. Programs of prevention of seizures in children will evolve only if basic researchers and clinicians work productively together to develop an adequate understanding of factors important in epileptogenesis and antiepileptogenic control mechanisms.     

Classification of methods in transcranial Electrical Stimulation (tES) and evolving strategy from historical approaches to contemporary innovations

Transcranial Electrical Stimulation (tES) encompasses all methods of non-invasive current application to the brain used in research and clinical practice. We present the first comprehensive and technical review, explaining the evolution of tES in both terminology and dosage over the past 100 years of research to present day. Current transcranial Pulsed Current Stimulation (tPCS) approaches such as Cranial Electrotherapy Stimulation (CES) descended from Electrosleep (ES) through Cranial Electro-stimulation Therapy (CET), Transcerebral Electrotherapy (TCET), and NeuroElectric Therapy (NET) while others like Transcutaneous Cranial Electrical Stimulation (TCES) descended from Electroanesthesia (EA) through Limoge, and Interferential Stimulation. Prior to a contemporary resurgence in interest, variations of transcranial Direct Current Stimulation were explored intermittently, including Polarizing current, Galvanic Vestibular Stimulation (GVS), and Transcranial Micropolarization. The development of these approaches alongside Electroconvulsive Therapy (ECT) and pharmacological developments are considered. Both the roots and unique features of contemporary approaches such as transcranial Alternating Current Stimulation (tACS) and transcranial Random Noise Stimulation (tRNS) are discussed. Trends and incremental developments in electrode montage and waveform spanning decades are presented leading to the present day. Commercial devices, seminal conferences, and regulatory decisions are noted. We conclude with six rules on how increasing medical and technological sophistication may now be leveraged for broader success and adoption of tES.     

Predisposing and Causative Factors in Childhood Epilepsy

Summary: We review information from large studies of defined populations, examining the role of known factors and especially of prenatal and perinatal factors in contributing to nonfebrile seizure disorders of early childhood. We depend especially, but not exclusively, on the recently completed analyses from the Collaborative Perinatal Project of the National Institute of Neurological and Communicative Disorders and Stroke, the NCPP. About 4% of children in the NCPP who had at least one non-febrile nonsymptomatic seizure by the age of 7 years had a previous seizure during acute neurologic illness, such as meningitis or during the acute illness after trauma. Many such seizures should potentially be preventable. Of children with seizures, 10% had had a neonatal seizure and 13% had had a febrile seizure. Among the hundreds of prenatal and perinatal factors explored as predictors of childhood seizure disorders, the principal predictors identified were congenital malformations of the fetus, cerebral and noncerebral; family history of certain neurologic disorders; and neonatal seizures. In agreement with the British National Child Development Study, labor and delivery factors in the NCPP appeared to contribute very little to childhood seizure disorders. Maldevelopment, rather than damage at birth to an initially intact nervous system, appeared to be the more common mechanism. Most seizure disorders of early childhood remained unexplained by the large set of prenatal and perinatal characteristics examined.     

Treatment Considerations in Anticonvulsant Monotherapy

Summary: The long-standing practice of polypharmacy in treating epilepsy is giving way to use of monotherapy. Monotherapy can improve seizure control as well as reduce the risk of serious idiosyncratic reactions, dose-related side effects, and complex drug interactions. Monotherapy also offers improved compliance and cost-effectiveness. The basis of monotherapy is accurate diagnosis and assessment of the patient's seizure type(s), followed by selection of a single appropriate anticonvulsant drug. Many patients currently treated with multiple anticonvulsants can be successfully converted to monotherapy with a carefully monitored program in which troublesome and redundant drugs are gradually withdrawn from the therapeutic regimen.     

Anticonvulsant Drugs and Cognitive Function: A Review of the Literature

Summary: Alterations of cognitive function are separate from disturbances of behavior seen in association with epilepsy. The nature of the cognitive disability may to a certain extent depend on the seizure type. Partial seizures, mainly derived from a temporal lobe focus, impair memory tasks, while generalized seizures seem to have more effect on attentional abilities. A number of studies, reviewed in this paper, suggest that anticonvulsant drugs further impair cognitive function. Maximal impairments are seen in patients receiving polytherapy: rationalization of polytherapy improves cognitive abilities. Studies in children and adults have allowed differentiation of the effects of various commonly used antiepileptic agents. Maximal cognitive deficits are seen with. phenytoin, while phenobarbital and sodium valproate induce moderate disturbances, and carbamazepine seems relatively free from such toxicity. Further research is needed on the interrelationship between types of seizure disorders, types of anticonvulsant medications, and cognitive function.     

Dextromethorphan: Cellular Effects Reducing Neuronal Hyperactivity

Summary: Dextromethorphan is a dextrorotary morphinan without affinity for opioid receptors, commonly used as an antitussive medication. During the past 5 years, interest in the compound and its demethylated derivative, dextrorphan, has been revived because additional neuroprotective and an-tiepileptic properties were found in in vitro studies, animal experiments, and a few clinical cases. Both morphinans are able to inhibit N -methyl-D-aspartate (NMDA) receptor channels and voltage-operated calcium and sodium channels with different potencies. The inhibition of the NMDA receptor is believed to be the predominant mechanism of action responsible for the anticonvulsant and neuroprotective properties of the compounds.