癫持续状态的急救与护理

癫持续状态是指癫发作持续时间长或反复发作、间歇较短的各种癫状态。临床上可引起意识、运动、行为和植物神经等不同障碍,若不及时控制,轻者造成大脑不可逆性损害,重者危及病人生命,故应作急症处理。本文收集了2004-01~2007-07住院的癫持续状态患者28例,由于抢救及时,护理得当均在较短时间内控制惊厥,意识恢复。现将抢救与体会总结如下。1临床资料本组28例,男18例,女10例。年龄8~63岁,平均25岁。大发作20例,小发作3例,局部发作5例。发作前有明显诱因22例,不明诱因6例。发作持续时间最长10h,最短2h,平均时间4h。28例癫持续状态发…     

癫持续状态大鼠内质网应激预适应对海马神经元保护作用的实验研究

目的探讨2-脱氧葡萄糖诱导内质网应激预适应对癫持续状态大鼠海马神经元的保护作用及其可能机制。方法采用2-脱氧葡萄糖连续腹腔注射诱导内质网应激,并在此基础上制备氯化锂-匹罗卡品癫持续状态大鼠模型。Nissl染色观察癫持续状态后海马神经元损伤情况、计数海马CA1和CA3区存活神经元数目;免疫组织化学检测海马CA3区内质网应激标志物葡萄糖调节蛋白78(GRP78)和X盒结合蛋白1(XBP-1)表达变化。结果与癫持续状态组相比,癫持续状态后第7天时内质网应激预适应组大鼠海马存活神经元数目增加,以CA1区显著(t=5.353,P=0.000)。癫持续状态组大鼠发作后6 h,海马CA3区GRP78和XBP-1表达水平升高且高于对照组(均P=0.000),于发作第2天达峰值水平(均P=0.000);内质网应激预适应组大鼠发作前海马CA3区GRP78和XBP-1表达即高于对照组(均P=0.000),GRP78在发作后24 h和2 d时维持在峰值水平(均P=0.000),XBP-1在发作后24 h达峰值水平(P=0.000);内质网应激预适应组大鼠海马CA3区GRP78和XBP-1表达在癫持续状态前,以及癫持续状态后6、12、24 h均高于癫持续状态组(均P=0.000),至第2和7天时与癫持续状态组之间差异无统计学意义(P0.05)。结论经2-脱氧葡萄糖诱导的内质网应激预适应对癫持续状态大鼠海马神经元具有保护作用,而XBP-1-GRP78信号转导通路的活化可能是其机制之一。     

妊娠期癫(癎)发作和抗癫(癎)药物对胎儿脑神经元突触素的影响

目的探索妊娠期癫发作和抗癫药对胎儿脑神经元突触素p38(synaptophysin)的影响,以加深对妊娠期癫发作危害胎儿脑发育的认识。方法6月龄引产胎儿分为3组:1组为妊母正常组(6例),2组为妊母应用抗癫药物控制发作组(6例),3组为妊母未应用抗癫药物控制发作组(6例)。运用免疫组化法检测突触素p38在各组胎儿脑部颞叶海马旁回的变化。结果1组免疫组化切片阳性表达产物光密度值(OD)为0.17±0.05,2组为0.16±0.08,3组为0.11±0.07,1、2组阳性表达产物无显著差异(P>0.05),而1、2组分别与3组比较,均有差异(P<0.05),p38在妊母未应用抗癫药物控制发作组胎儿海马旁回中的表达较妊母正常组及妊母应用抗癫药物控制发作组明显减少。结论研究结果表明妊期癫发作对胎儿脑发育的危害比抗癫药物对胎儿的毒性更大。     

丙戊酸治疗成人癫(癎)致血浆肉毒碱下降

目的观察丙戊酸(valproic acid,VPA)治疗成人癫患者后患者血浆游离肉毒碱改变规律,并探讨导致其改变的相关因素。方法VPA治疗组为41例成人癫患者,其中接受VPA单药治疗者33例,联合其他抗癫药物治疗者8例,30例非VPA治疗的成人癫患者作为癫对照组,包括其他抗癫药物治疗的患者14例,和未进行药物治疗的患者16例。33名同龄健康者作为正常对照,用酶循环法测定血浆游离肉毒碱浓度,3组间进行比较。结果VPA治疗组血浆游离肉毒碱浓度(31.43±11.75μmol/L)明显低于正常对照组(43.25±12.57μmol/L)和非VPA治疗的癫对照组(40.71±12.83μmol/L,P均<0.05)。血浆游离肉毒碱浓度与VPA剂量、VPA疗程、其他抗癫药物、年龄、性别、血ALT、AST无相关性。结论VPA治疗成人癫可能导致血浆游离肉毒碱水平下降,其下降程度和VPA无剂量和疗程依赖性,也不受患者的生理状态以及其他抗癫药物的影响。     

P-糖蛋白和多药耐药相关蛋白1在脑室内注射红藻氨酸癫(癎)动物模型皮质内的表达

目的研究P-糖蛋白(PGP)和多药耐药相关蛋白1(MRP1)在脑室内注射红藻氨酸(KA)癫动物模型皮质内的表达。方法脑室内注射KA6、24h及1周后处死动物,采用逆转录-聚合酶链反应(RT-PCR)和免疫组织化学方法,观察PGP和MRP1在皮质的表达。结果KA注射24h后PGPmRNA(1.58±0.14)和免疫阳性细胞(19.36±1.64)在皮质表达显著增加,与空白对照组(mRNA0.73±0.06,免疫阳性细胞8.21±0.79)比较差异有统计学意义(P<0.05),1周后PGPmRNA(0.92±0.09)和免疫阳性细胞(8.42±0.84)表达下降至对照组水平;注射KA后MRP1表达逐渐升高,24h后MRP1mRNA(1.72±0.15)和免疫阳性细胞(26.36±2.32)表达显著增加,与空白对照组(mRNA0.87±0.07,免疫阳性细胞10.88±0.96)比较差异有统计学意义(P<0.05),1周后MRP1mRNA(1.57±0.12)和免疫阳性细胞(24.51±2.27)表达仍高于空白对照组(P<0.05)。结论KA诱发的癫动物模型皮质内PGP、MRP1表达增强,可能参与了癫耐药的发生。     

热性惊厥史与青少年癫病因关系临床分析

目的分析有热性惊厥史的青少年癫患者临床特点和治疗情况,探讨热性惊厥史与青少年癫之间的关系。方法对发病年龄18岁的青少年癫患者的病因进行回顾分析,总结单纯性和复杂性热性惊厥患者癫发作特点、辅助检查和服药情况。结果符合癫诊断标准的4595例患者中发病年龄18岁者2699例占58.74%,其中原发性癫1573例占58.28%、继发性癫1126例占41.72%。青少年继发性癫以热性惊厥(297例占26.38%)为主要病因,其中单纯性热性惊厥200例、复杂性热性惊厥97例,均以部分性发作为主(χ2=4.933,P=0.026)。有热性惊厥史患者神经影像学(χ2=38.083,P=0.000)和神经电生理学(χ2=4.469,P=0.035)异常检出率明显增加;其中服药率约为66.67%(198/297),服用传统抗癫药物者占70.20%(139/198)。结论青少年继发性癫病因较为复杂,以热性惊厥为主要病因。无论单纯性或复杂性热性惊厥均以部分性发作常见,仍以传统抗癫药物为主,约1/3患者未服药或未正规服药。     

戊四氮致癎大鼠海马S-100β蛋白变化及其相关性研究

目的　探讨戊四氮致疒间 大鼠脑内海马区S 10 0 β蛋白的变化与癫 疒间 发作持续时间和发作强度之间的关系。方法　应用免疫组化法检测惊厥组、癫疒间 持续状态组和对照组大鼠海马内S 10 0 β蛋白阳性细胞数的变化。结果　惊厥组大鼠海马内S 10 0 β蛋白阳性细胞数于致 疒间 后 12h开始增加 ,2 4h达高峰 ,72h恢复 ,与对照组相比差异有显著性 (P <0 0 1)。癫疒间 持续状态组大鼠海马内S 10 0 β蛋白在 12h、2 4h均有明显增加 ,较惊厥组更为显著。两组相比差异有显著性 (P <0 0 1)。结论　致疒间 大鼠海马内S 10 0 β蛋白阳性细胞数及染色强度与癫疒间 持续时间及发作强度有关 ,提示S 10 0 β蛋白可作为临床上判断癫 疒间 后脑损伤、特别是神经胶质细胞损伤的一种较灵敏而特异的指标。     

脑卒中后继发癫与性发作临床分析

目的总结和探讨脑卒中患者继发癫与性发作的发病率、病因、发病特点、诊断、治疗、预后及两者差异。方法回顾性分析我院近4 a来治疗的1 125例脑卒中患者的临床资料,对82例病例的发病时间、次数、脑电图情况及治疗、预后进行分析、研究。结果脑卒中患者继发癫及性发作的发病率为7.29%(82/1 125),累及皮层者发病率高。早期发作49例中36例仅发作1次,发作2次以上者9例,其中4例发生癫持续状态。迟发者33例中发作2次以上者有30例。40例行脑电图检查异常者仅12例。早期发作多为性发作,不需抗癫治疗,迟发者多为卒中后癫,需正规抗癫治疗。结论脑卒中后继发癫的发病率明显低于目前报道,许多诊断为癫者实际上仅是性发作,大多数卒中后癫及性发作预后较好,但癫持续状态预后差。     

非惊厥性癫(癎)持续状态

非惊厥性癫(癎)持续状态(NCSE)系临床常见但易忽视的癫(癎)持续状态(SE)发作类型,据估计,占所有癫(癎)持续状态的20%～50%.2004年,英国癫(癎)研究基金会(ERF)将非惊厥性癫(癎)持续状态定义为:由于持续性癫(癎)样脑电活动导致的一系列非惊厥临床征象[1].     

儿童癫癎发作后血清催乳素的变化及临床意义

报道 本文应用放射免疫法测定了４９例患儿各种不同发作类型的癫■发作后及２４例非癫■患儿的血清催乳素（ＰＲＬ）水平,结果癫■患儿组血清ＰＲＬ水平为（３８．６ ±１７．５）μｇ／Ｌ;非癫■患儿组为（１３．６ ±４．２）μｇ／Ｌ;１０ 例正常儿童对照组为（１１．８±２．５）μｇ／Ｌ。癫■患儿组与正常儿童对照组相比,Ｐ＜０．０１,差异有显著性。非癫■组与正常儿童对照组相比,差异无显著性。虽然整个癫■患儿组发作后血清ＰＲＬ水平显著升高,但不同癫■发作类型发作后血清ＰＲＬ水平有不同的变化。全身性强直－阵挛发作患…     

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(EMS...     

Status epilepticus in stroke: report on a hospital-based stroke cohort

OBJECTIVE: To evaluate occurrence rate, clinical data, and prognostic factors of status epilepticus (SE) after stroke. METHODS: From 1984 to 1994, 3,205 patients were admitted to the Department of Neurology at our institution with first-time strokes. A total of 159 of these patients had first-time poststroke seizures. Among these 159 patients, cases of SE were identified and evaluated. RESULTS: SE was recognized in 31 patients (19%). In 17 patients, SE was the first epileptic symptom (initial SE), and in 4 patients, stroke began with SE (S-SE). In the 14 remaining patients, SE occurred after one or more seizure(s). After a mean follow-up period of 47 months, neurologic deterioration occurred after SE in 15 patients. This deterioration was permanent in two patients. Fifteen patients died; in five patients, death was directly related to SE. Eight of the 17 patients with initial SE and all 14 patients with SE after one or more seizure(s) developed other seizures or SE. S-SE, however, was not a predictive factor for additional seizure(s). CONCLUSIONS: Status epilepticus is common among patients with poststroke seizures. Although the immediate prognosis of patients with status epilepticus is poor, status epilepticus as the presenting sign did not necessarily predict subsequent epilepsy.     

Nonconvulsive status epilepticus due to cefepime in a patient with normal renal function

Status epilepticus and encephalopathy have been reported with use of cephalosporins in patients with renal failure. We here report the case of a 79-year-old patient with normal renal function who developed subtle mental status changes during cefepime therapy for urinary tract infection. Emergent electroencephalography revealed evidence of nonconvulsive status epilepticus (NCSE), which responded initially to lorazepam. Later, the patient's NCSE gradually resolved only after cefepime was discontinued, with mental status returning to baseline as the electroencephalography changes resolved. It should be recognized that cefepime therapy can cause NCSE even in the presence of normal renal function. Measurement of serum concentrations and changes in dosing guidelines can probably prevent NCSE during cefepime therapy.     

Treatment of status epilepticus]

Status epilepticus (SE) is a condition requiring emergency care. There are convulsive SE, non-convulsive SE including complex partial status and absence status, non-convulsive electric SE and pseudostatus epilepticus, although convulsive SE is the most common. Diagnosis of status epilepticus of complex partial seizures (CPS) and absence seizures was significantly delayed because delays in seeking medical attention were common. The seizures were generalized convulsive SE in 84% and CPS status in 16%, and the overall mortality rate was 15% in 41 SE patients of our study. EEG monitoring is important to make or exclude the diagnosis of SE. Diazepam is the first choice medication and effective in the management of SE, and lately, lorazepam, midazolam, propofol and pentobarbital etc as emergency therapy. Phenytoin is also considered first-line agent in the emergency management of SE. Repetitive transcranial magnetic stimulation (rTMS) led to a prolonged latency for seizure induction after an intraperitoneal injection of pentylenetetrazol (PTZ) and effectively prevented the development of status epilepticus of PTZ-induced convulsions in the rats. Our data suggest that rTMS has suppressive effects on the neuronal excitability in rats. These effects are anticonvulsive and suggest the possibility of therapeutic use of rTMS in the patients with refractory seizures.     

Recherche étiologique lors d’un état de mal épileptique

Because of the wide range of etiologies which may provoke status epilepticus (SE), physical examination, laboratory tests and neuroimaging must be conducted according to a well-designed hierarchical system. While implementing intensive care management, clinicians must of course search for curable causes but also consider the possible interaction of multiple factors and hidden diseases favoring or triggering SE. Causes of SE in idiopathic or cryptogenic epilepsy and new-onset SE do not correlate but careful analysis of serum chemistry and neuroimaging abnormalities must nevertheless be conducted with the specific objective of establishing an etiological diagnosis.     

The etiology and diagnosis of status epilepticus

Status epilepticus (SE) is a common, serious, potentially life-threatening, neurologic emergency characterized by prolonged seizure activity. Generalized convulsive status epilepticus (GCSE) is the most widely recognized form of SE. Direct consequences of convulsive movements from SE can result in injury to the body and brain. Nonconvulsive status epilepticus (NCSE) is underrecognized, with controversy surrounding the consequences and treatment. High mortality rates with GCSE have been noted in the past. New treatments for SE are emerging with new parenteral drug formulations as well as new agents for refractory SE, offering an opportunity to improve outcome. Special drug delivery systems, drug combinations, and neuroprotective agents that prevent the subsequent development of epilepsy may soon emerge as future options for treating SE.     

Neurosurgical treatment of medically intractable status epilepticus

Medically intractable status epilepticus can be defined as status epilepticus (SE) that persists or recurs despite medical treatment with intravenous agents that suppress cortical activity. We describe the successful neurosurgical treatment of three patients with medically intractable status epilepticus who responded either to focal resection, multiple subpial transection, or callosal section. The duration of medically intractable status epilepticus before surgery ranged between 23 and 42 days, and multiple medical complications occurred during the failed medical therapy. We suggest that patients with medically intractable status epilepticus who fail to respond to three courses of cerebral suppressant therapy for approximately 2 weeks be considered for surgical treatment in the absence of any known remitting etiology. Focal resection and/or subpial transection is preferred for intractable partial SE with focal electrographic changes or a focal lesion demonstrated by structural or functional neuroimaging. Corpus callosotomy may be used for patients with generalized or non-localizable intractable status epilepticus.     

Pediatric status epilepticus: a perspective from Saudi Arabia

The purpose of this study was to assess risk factors and management of status epilepticus and non–status epilepticus seizures at a community hospital in Saudi Arabia. The research design was a prevalence study of a convenience sample of pediatric seizure episodes admitted to a 350-bed hospital from 1992 to 1997. The mean age at presentation was 2 years, 10 months, 43% of patients had no history of seizures, and 17% were transferred from other hospitals. Fifty-nine (28%) of 212 seizure episodes were status epilepticus (SE). These SE episodes were significantly more likely than non–SE episodes to be associated with a history of seizures, prior antiepileptic drug (AED) therapy, the presence of an acute etiology, and prolonged duration of seizures before hospitalization. SE episodes were also significantly more likely than non–SE episodes to receive an inappropriate AED, to require intensive care unit admission, to suffer morbidity, and to have SE recurrence at follow-up; however, the difference in mortality was not significant. In conclusion, children with SE were more likely than those with non–SE seizures to have a history of seizures and acute brain insults, prolonged seizure duration before hospitalization, and less optimal management and outcomes. Management of SE in this referral population can be improved by more rapid access to appropriate medical care.     

Refractory status epilepticus: frequency, risk factors, and impact on outcome

BACKGROUND: Refractory status epilepticus (RSE) is a life-threatening condition in which seizures do not respond to first- and second-line anticonvulsant drug therapy. How often RSE occurs, risk factors that predispose to this condition, and the effect of failure to control seizures on clinical outcome are poorly defined. OBJECTIVE: To determine the frequency, risk factors, and impact on outcome of RSE. DESIGN: Retrospective cohort study. SETTING: Large academic teaching hospital. PATIENTS: Consecutive sample of 83 episodes of status epilepticus in 74 patients (mean age, 63 years). MAIN OUTCOME MEASURES: Refractory status epilepticus was defined as seizures lasting longer than 60 minutes despite treatment with a benzodiazepine and an adequate loading dose of a standard intravenous anticonvulsant drug. Factors associated with RSE were identified using univariate and backward stepwiselogistic regression analyses. RESULTS: In 57 episodes (69%), seizures occurred after treatment with a benzodiazepine, and in 26 (31%), seizures occurred after treatment with a second-line anticonvulsant drug (usually phenytoin), fulfilling our criteria for RSE. Nonconvulsive SE (P=.03) and focal motor seizures at onset (P=.04) were identified as independent risk factors for RSE. Eleven (42%) of 26 patients with RSE had seizures after receiving a third-line agent (usually phenobarbital). Although mortality was not increased (17% overall), RSE was associated with prolonged hospital length of stay (P<.001) and more frequent functional deterioration at discharge (P=.02). CONCLUSIONS: Refractory status epilepticus occurs in approximately 30% of patients with SE and is associated with increased hospital length of stay and functional disability. Nonconvulsive SE and focal motor seizures at onset are risk factors for RSE. Randomized controlled trials are needed to define the optimal treatment of RSE.     

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。