Treiman D M
Neurology Service, DVA West Los Angeles Medical Center, California.
Epilepsia. 1993;34 Suppl 5:S17-23. doi: 10.1111/j.1528-1157.1993.tb05919.x.
Several special situations in the management of epilepsy require specific treatment strategies. Recurrence rates after a single seizure vary between 26 and 71%. Antiepileptic drug (AED) therapy should be initiated after a first seizure only when a definitive diagnosis of epilepsy can be made. Although several AEDs have been shown to be anti-epileptogenic in animal models, no data yet prove the efficacy of any AED in preventing the development of post-traumatic or postoperative epilepsy. Therefore, there is no rational basis for prophylactic treatment with AEDs. The incidence of epilepsy rises dramatically after the age of 50 years. Similtaneously, many physiological changes increase the potential for adverse effects and drug interactions when AEDs are used in the elderly. Careful attention to changing pharmacokinetic parameters is necessary when that group of patients is being managed. Pregnancy also brings about physiological changes that may either increase or decrease the seizure frequency. The risk of fetal malformations is approximately double in children born to mothers with epilepsy compared with children born to nonepileptic mothers. The risk is dose-dependent and increases with the number of AEDs. All AEDs may cause fetal malformations; valproate and carbamazepine increase the risk of spina bifida. Nonetheless, the best AED for a woman who wants to become pregnant is the AED that best controls her seizures, which should be given at the lowest possible effective dose. Discontinuation of AEDs can be considered after 2-4 years of complete seizure control. Most of the risk of relapse occurs within the first 6 months. Status epilepticus (SE) is a medical emergency. The most common form of SE is generalized convulsive status epilepticus, in which the patient may present with either overt or subtle convulsions. Because of the potential for neuronal damage, all electrical as well as clinical seizure activity must be completely stopped for treatment of SE to be considered successful.
癫痫管理中的几种特殊情况需要特定的治疗策略。单次发作后的复发率在26%至71%之间。仅在能够明确诊断为癫痫时，才应在首次发作后开始抗癫痫药物（AED）治疗。尽管在动物模型中已显示几种AED具有抗癫痫发生作用，但尚无数据证明任何AED在预防创伤后或术后癫痫发展方面的疗效。因此，没有合理的依据使用AED进行预防性治疗。50岁以后癫痫发病率急剧上升。同时，许多生理变化增加了老年人使用AED时出现不良反应和药物相互作用的可能性。在管理该组患者时，必须仔细关注不断变化的药代动力学参数。怀孕也会带来生理变化，可能增加或减少癫痫发作频率。癫痫母亲所生子女患胎儿畸形的风险约为非癫痫母亲所生子女的两倍。该风险与剂量相关，并随AED数量的增加而增加。所有AED都可能导致胎儿畸形；丙戊酸盐和卡马西平会增加脊柱裂的风险。尽管如此，对于想要怀孕的女性来说，最佳的AED是能最好地控制其癫痫发作的药物，应给予尽可能低的有效剂量。在完全控制癫痫发作2至4年后可考虑停用AED。大多数复发风险发生在头6个月内。癫痫持续状态（SE）是一种医疗急症。SE最常见的形式是全身惊厥性癫痫持续状态，患者可能出现明显或细微的惊厥。由于存在神经元损伤的可能性，所有电发作以及临床发作活动必须完全停止，才能认为SE治疗成功。
