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1、脑卒中后癫痫脑卒中后癫痫广州协佳癫痫病医院广州协佳癫痫病医院 http:/ http:/ 概述概述自自1864年年Jackson首首次次报报道道脑脑血血管管疾疾病病与与癫癫痫痫的的关关系系以以来来,人人类类已已认认识识到到脑脑血血管管疾疾病病,特特别别是是脑脑卒卒中中是是癫癫痫痫最最为为常常见见的的病病因因之之一一。脑脑卒卒中中病病程程中中的的各各种种类类型型癫癫痫痫发发作作特特别别是是强强直直-阵阵挛挛发发作作持持续续状状态态对对患患者者的的病病程程进进展展和和预预后后存存在在不不良良影影响响。因此因此,在临床工作中脑卒中与癫痫在临床工作中脑卒中与癫痫,应给予足够的关注和重视。应给予足够的关
2、注和重视。http:/ epilepsy)，是是指指脑脑卒卒中中前前无无癫癫痫痫病病史史,在在脑脑卒卒中中后后一一定定时时间间内内出出现现的的癫癫痫痫发发作作并并排排除除脑脑部部和和其其它它代代谢谢性性病病变变,一一般般脑脑电电监监测测到到的的痫痫性性放放电与脑卒中部位具有一致性。电与脑卒中部位具有一致性。post-strokeseizurestroke-relatedseizureMyint PK, et al Post-stroke seizure and post-stroke epilepsy Postgradmed J, 2006, 82: 568-572http:/ CF, et
3、alSeizures after Stroke: a prospective multicenter studyArchneurol, 2000, 57: 1617-22Hesdorffer DC, et al. Is a first acute symptomatic seizure epilepsy? Mortality and risk for recurrent seizure. Epilepsia, 2009;50(5):1102-8.http:/ EL, Annegers JF, Hauser WA, OBrien PC, Whishnant JP. Population- bas
4、ed study of seizure disorders after cerebral infarction. Neurology 1996;46:350355.http:/ EL, Annegers JF, Hauser WA, OBrien PC, Whishnant JP. Population- based study of seizure disorders after cerebral infarction. Neurology 1996;46:350355.Kammersgaard LP, Olsen TS. Poststroke epilepsy in the Copenha
5、gen stroke study: incidence and predictors. J Stroke Cerebrovasc Dis. 2005;14(5):210-4.http:/ A, et al. Early seizures in patients with acute stroke: frequency, predictive factors, and effect on outcome. Vasc Health Ris Manag, 2008, 4(3):715-20Leone MA, et al. Risk factors for a first epileptic seiz
6、ure after stroke: a case control study. J Neurol Sci, 2009;277(1-2):138-42.Hauser WA, Annegers JF, Kurland LT. Incidence of epilepsy and unprovoked seizures in Rochester, Minnesota: 19351984. Epilepsia 1993;34:453468.http:/ Lszl, Diszeghy Pter. Epileptic seizures after stroke. Clin Neurosci/Ideggy S
7、zle 2006;59(56):201215.http:/ JM,et al. Early seizures in cerebral vein and dural sinus thrombosis: risk factors and role of antiepileptics. Stroke, 2008, 39(4): 1152-8.http:/ 钠泵衰竭钠泵衰竭 钠离子大量内流钠离子大量内流 细胞膜稳定性破坏细胞膜稳定性破坏过渡去极化过渡去极化 痫性放电痫性放电脑梗塞脑梗塞出血后脑血管痉挛出血后脑血管痉挛畸形血管盗血畸形血管盗血脑水肿脑水肿应激致激素应激致激素水平变化水平变化水电解质、酸水
8、电解质、酸碱平衡破坏碱平衡破坏谷氨酸释放谷氨酸释放BBB损伤损伤含铁血黄素含铁血黄素http:/ of Clinical Elect roneurophysiology (China) , September 2005 ,Vol . 14 , No. 3http:/ HM. Seizures and epilepsies after stroke. Nervenarzt, 2009, 80(4):405-14. 痫性发作与卒中类型的关系痫性发作与卒中类型的关系http:/ CF, Alexandrov AV, Bellavance A,et al.Seizures after stroke:a
9、 prospective multicenter study.Arch Neurol. 2000;57:1617-1622Kaplan-Meier生存曲线生存曲线http:/ E, et al. Neurology, 1989, 39:1089 Berger AR, et al. Neurology, 1988, 38:1363http:/ Gadoth MD and Hen Hallevi. lIMAJ 2011, 13: 314Israehttp:/ 2011;3:289293Japanhttp:/ CF, Alexandrov AV, Bellavance A,et al.Seizure
10、s after stroke:a prospective multicenter study.Arch Neurol. 2000;57:1617-16221897 patients available for analysis. During the study, seizures occurred in 168 patients (8.9%), including 140 (8.6%) of 1632 with ischemic stroke and 28 (10.6%) of 265 with hemorrhagic stroke. http:/ Reuck J, Van Maele G
11、. Status epilepticus in stroke patients. Eur Neurol, 2009; 62(3):171-5. http:/ S, Moulin T, Berger E,et al. Seizures and epilepsy following strokes: recurrence factors. Eur Neurol. 2000;43(1):3-8.http:/ ，出血性卒中939例(18.7%)死亡率：死亡率：30天天36.2% vs 16.8% P0.0001 1年后年后 48.6% vs 27.7% P0.001神经功能损害严重神经功能损害严重CN
12、S 5.20.3 vs 7.50.05 P0.0001 住院时间延长住院时间延长 22.62.6 vs 16.30.3 P0.0001残疾残疾(出院Rankin评分) 4.41 vs 3.15 P =0.0001医疗资源消耗严重医疗资源消耗严重Burneo JG, et al. Impact of seizures on morbidity and mortality after stroke: a Canadian multi-centre cohort study. European Journal of Neurology, 2010, 17: 528http:/ slow waves
13、: 39.0% Focal slowing : 19.5%Focal sharp and slow waves:9.8%Focal spikes & slow waves:4.9%Focal sharp waves:4.9% Focal spike waves:2.4% PLEDS : 2.4% Normal EEG 17.1% Maimoona Siddiqui, Urooj Yaqoob, Asia Bano, et al. EEG findings in post stroke seizures: an observational study. Pak J Med Sci, 2008 .
14、 24(3): 386-389.23.4%10%20%100%5%78%EEG-PLEDSilverman IE，Restrepo L,. Mathews G.Poststroke Seizures.Arch Neurol. 2002;59:195-202SubacuteSeizureIncidenceinThrombolysis-treatedIschemicStrokePatientsCanadaOf400eligiblepatients,4%developedpost-strokeseizures:62.5%withinoneweek(early)and37.5%after1weekbu
15、twithinthehospitalstay(late).Atrialfibrillationwasmorecommoninthosewith(56.3%)thanwithout(36.1%)seizures(P=0.04).Deathduringadmissionwasmorelikelyinthosewhosustainedseizures(37.5%)comparedtothosewithoutseizures(17.6%)(P=0.03).CouillardP,etal.NeurocritCare.2011Dec13.Epubaheadofprinthttp:/ IE，Restrepo
16、 L,. Mathews G.Poststroke Seizures.Arch Neurol. 2002;59:195-202Carotidartery stenting: Seizures are related predominantly to hypoperfusion and also occur in 1% of cases.http:/ with patients with coiled aneurysms,patients with clipped aneurysms had a higherincidenceofin-hospitalcomplications(37.2%ver
17、sus24.5%ofpatients;P0.0001).Higher incidences were observed for seizure(P=0.01).VergouwenMD,etal.Stroke,2011;42(11):3093-8.http:/ 是否应在首次卒中后癫痫发作开始是否应在首次卒中后癫痫发作开始AEDsAEDs治疗治疗? ? 药物选择药物选择 哪种哪种AEDsAEDs最适合卒中患者最适合卒中患者? ?何时停药何时停药 2 2年？年？http:/ P, Montavont A, Nighoghossian N. Neurlology 2006;67(S4):S3S9htt
18、p:/ (IV (IV类证据，优良临类证据，优良临床实践床实践) )。20092009年未更新年未更新http:/ J, Wood E. Antiepileptic drugs for the primary and secondary prevention of seizures after stroke. Cochrane Database Syst Rev, 2010, (1):CD005398.http:/ age 72）中中的的研研究究评评价价CBZ，LTG(lamotrigine)，GPB(gabapentin)的疗效的疗效SANAD研究研究一项卒中后癫痫的一项卒中后癫痫的LTG与
19、与CBZ的随机对照研究的随机对照研究http:/ 2011 荷兰荷兰 随机对照安慰剂试验随机对照安慰剂试验卒中卒中7天内口服左乙拉西坦天内口服左乙拉西坦1500mg/d，3个月个月结论：预防卒中后癫痫不可行结论：预防卒中后癫痫不可行入组率低：入组率低：Only16patientswereincludedinthistrial.癫痫发作的评估、合并用药、出院后治疗、药物不良反应癫痫发作的评估、合并用药、出院后治疗、药物不良反应van Tuijl JH,et al. Early treatment after stroke for the prevention of late epileptic
20、seizures: a report on the problems performing a randomised placebo-controlled double-blind trial aimed at anti-epileptogenesis.Seizure, 2011,20(4):285-91.http:/ 2年治疗的患者癫痫再发的风险下降，但停止治疗后癫痫年治疗的患者癫痫再发的风险下降，但停止治疗后癫痫风险与未接受治疗的患者比较无显著差异。风险与未接受治疗的患者比较无显著差异。Gilad R, Lampl Y, Eschel Y, Sadeh M. Antiepileptic t
21、reatment in patients with early postischemic stroke seizures: a retrospective study. Cerebrovasc Dis 2001;12:3943.http:/ of management in the elderly with epileptic seizures . 219Difficulties in diagnosing epileptic seizures in the elderly.219Frequency of seizures and their severity in the elderly .
22、220EEG and other investigative procedures in the elderly. 220Physiological and other changes in the elderly that may affect AEDs . 221Principles of AED treatment in the elderly. 221PrinciplesofAEDtreatmentintheelderlyA Clinical Guide to Epileptic Syndromes and their Treatment. Revised Second Edition
23、. Based on the ILAE classifications and practice parameter guidelines. Springer Healthcare Ltd 2010http:/ Clinical Guide to Epileptic Syndromes and their Treatment. Revised Second Edition. Based on the ILAE classifications and practice parameter guidelines. Springer Healthcare Ltd 2010http:/ D级证据）级证据）孤立发作一次或急性期的痫性发作控制后，不建议长期使用抗癫痫药物孤立发作一次或急性期的痫性发作控制后，不建议长期使用抗癫痫药物（推荐，推荐，D D级证据）级证据）脑卒中脑卒中2 23 3个月后再发的癫痫，建议按癫痫的常规治疗进行长期药物治个月后再发的癫痫，建议按癫痫的常规治疗进行长期药物治疗（疗（推荐，推荐，D D级证据）级证据）卒中后癫痫持续状态，可按癫痫持续状态的治疗原则进行处理（卒中后癫痫持续状态，可按癫痫持续状态的治疗原则进行处理（推荐，推荐，D D级证据）级证据）脑血管畸形手术切除的适应证脑血管畸形手术切除的适应证 药物不能控制的癫痫频繁发作药物不能控制的癫痫频繁发作http:/
