Departments of Clinical Neurosciences and Community Health Sciences and the Hotchkiss Brain Institute, University of Calgary, Division of Neurology, Foothills Medical Centre, 1403 29th Street NW, Calgary, AB T2N 2T9, Canada.
Nat Rev Neurol. 2012 Dec;8(12):669-77. doi: 10.1038/nrneurol.2012.181. Epub 2012 Sep 11.
Pharmacoresistance occurs in up to 30% of patients with epilepsy, and is most commonly associated with epilepsy of structural or metabolic origin, abnormal findings on brain imaging or examination, and failure to respond to the first two antiepileptic drugs. However, in patients presumed to have difficult to treat epilepsy, factors that might result in apparent treatment resistance (misdiagnosis of epilepsy, incorrect drug and/or dose, and lifestyle issues) must first be excluded and the diagnosis re-examined. Epilepsy is commonly misdiagnosed, especially in patients with syncope and psychogenic events. The initial steps in confirming the diagnoses of both epilepsy and pharmacoresistance are to obtain a detailed, reliable history and to conduct a careful review of all prior trials of antiepileptic drug therapy. Once the diagnoses of epilepsy and pharmacoresistance are confirmed, the seizure type, epilepsy syndrome, and expected course of the disorder dictate its medical and surgical management. Epilepsy surgery should be considered promptly in these patients, since few interventions are as effective as brain surgery in this setting, particularly in patients with focal pharmacoresistant epilepsy. This Review discusses the concept of pharmacoresistance and describes the approach to management of the patient with difficult to treat epilepsy, focusing on the important role of epilepsy surgery.
药物抵抗性在多达 30%的癫痫患者中出现，最常与结构性或代谢性起源的癫痫、脑成像或检查中的异常发现以及对前两种抗癫痫药物无反应相关。然而，在被认为患有难治性癫痫的患者中，必须首先排除可能导致明显治疗抵抗的因素（癫痫的误诊、药物和/或剂量不正确以及生活方式问题），并重新检查诊断。癫痫常常被误诊，尤其是在晕厥和心因性事件的患者中。确认癫痫和药物抵抗性诊断的初始步骤是获取详细、可靠的病史，并仔细审查所有先前的抗癫痫药物治疗试验。一旦确认了癫痫和药物抵抗性的诊断，发作类型、癫痫综合征以及疾病的预期病程决定了其医疗和手术管理。在这些患者中应迅速考虑癫痫手术，因为在这种情况下，很少有干预措施像脑部手术一样有效，特别是对于局灶性药物抵抗性癫痫患者。本综述讨论了药物抵抗性的概念，并描述了治疗难治性癫痫患者的方法，重点介绍了癫痫手术的重要作用。
