Научная статья "Протокол предхирургической диагностики для пациентов с фармакорезистентной формой эпилепсии" на английском языке из журнала "Астана медициналық журналы", специальный выпуск №4/2015
2, I.Bondareva 2, N.Djainakbaev 1, S.Savinov 2, I.Akchurina 1, R.Abedimova
1, I.Sitnikov 2, N.Mikhailova 2, G. Esimova 2
Kazakh-Russian Medical University, Almaty
SVS Laboratory of epilepsy, convulsive diseases research and family
after V.M. Savinov, Almaty
PRESURGICAL EVALUATION PROTOCOL FOR PATIENTS WITH PHARMACORESISTANT
Over recent years epileptology has made a huge breakthrough in
Kazakhstan. Based on the Kazakh-Russian Medical University the
Faculty of Functional Diagnostics with the course of neurophysiology was opened that has until today
trained more than 400 EEG and epileptology specialists. Practically in every city there is
equipment for long-term EEG monitoring. Since 2010 the National Center for Neurosurgery
has held operations for surgical treatment of epilepsy. An important role in
attaining a positive result of operative treatment of epilepsy is played by correct
Identification and confirmation of drugresistent, performance of
long-term ictal EEG monitoring, comparison of neurophysiological data with the
results of MRI, CT, MEG, PET and other neuroimaging methods form the basis of presurgical
Thereafter a patient is reviewed by a multidisciplinary council of
physicians where a decision is taken concerning one or another method of treatment or
Since 2010 the Faculty of Functional Diagnostics with the course of neurophysiology and SVS Laboratory of epilepsy, convulsive diseases
research and family monitoring named after V.M. Savinov have conducted a
presurgical study of epilepsy patients. This paper has summarized the experience and
presents developed evaluation protocols for patients with epilepsy who are candidates
for surgical treatment.
Key words: pharmacoresistence epilepsy, drugresistent epilepsy, EEG,
MRI, surgical treatment, epileptology.
11 years the SVS Laboratory of epilepsy, convulsive diseases research
monitoring named after V.M. Savinov and Faculty of Functional
Diagnostics with the
course of neurophysiology have been consistently developed
epileptology jointly with other
faculties and clinics. As a result, detectability of epilepsy
patients at early stages has increased
in tens of times. Accordingly, a percentage of achieving remission
and recovery has
also reached almost a worldwide level. After the Department of
Surgical Treatment of Epilepsy
was opened in the National Center for Neurosurgery in Astana, it made
combat severe, drugresistent forms. But,
unfortunately, many doctors and patients have no full and clear
indications for surgical treatment of epilepsy. As a consequence,
district neurologists and
epileptologists send patients to neurosurgeons without a prior
specialized in-depth examination
under a presurgical evaluation protocol. And even patients themselves without
a referral try to seek for an operative treatment without being aware
of whether they
need it or not.
doctors of the National Center for Neurosurgery lose time and
bed-days for patients many of whom either have no indications for
surgical treatment at
all, or have been chosen improper therapy.
order to optimize patients flows and develop clear criteria for
surgical treatment of
epilepsy, we have analyzed the international experience, attracted
specialists from Kazakhstan,
Russia, Greece, Turkey, Italy in the area of expert examination for
of epilepsy, and developed an evaluation protocol.
protocol for examination of candidates for surgical treatment of
epilepsy is critical
in order to organize a correct stage-by-stage approach in providing
analyze the international experience in preparing epilepsy patients
for operative treatment;
work out a methodology of long-term ictal video EEG monitoring;
develop schemes of drug dosage reduction to provoke seizures during
develop a presurgical evaluation protocol for patients with epilepsy
in order to select
candidates for surgical treatment.
examination was received by 1,200 patients who were admitted to the SVS
Laboratory from various clinics and cities of Kazakhstan with a
of pharmacoresistent epilepsy. Presurgical examination includes as
evaluation of a neurological status and consultation by a
determination of a level of antiepileptic drugs (AED) to exclude an
as well as general blood tests;
analysis of EEG available and performance of daily video EEG
consultation with a psychologist and geneticist;
high-resolution brain MRI under a protocol of search for an
with subsequent consultations by leading specialists;
where necessary, performance of brain CT, SPECT and PET;
for patients with the established true pharmacoresistence –
conducting long-term video
EEG monitoring with recording acute EEG – no less than 3 seizures
(from 3 to 7 days);
holding a multidisciplinary council of physicians upon the results of
participation of neurosurgeons-epileptologists,
psycholo-gists, MRI and CT specialists followed by decision
making concerning further tactics.
on the international experience patients undergo the following stages
1 – there was established a correct diagnosis: pharmacoresistence –
effect when using two tolerant, adequately selected and used AEDs of
the first line (either
in monotherapy, or in their combination) depending upon an epileptic
adults a period of use is at least 2 years [1-7]. At this stage 72%
of patients were filtered
out. The reasons were as follows: incorrect selection of an AED,
2 – long-term video EEG monitoring with mandatory recording of
all seizures are the same, then of at least two seizures, if they are
different, then of three seizures
[1,3-12]. At this stage 6% of patients were filtered out due to a
reason of seizures.
3 – MRI with a magnetic field induction of 1.5-3 Tesla with the use
protocol [2,5,6,7,13-15]. Taking into consideration that a
is often an epileptogenic substrate, it is necessary to use an
additional protocol of study
of mediobasal divisions of temporal lobes, including the performance
Cor and Ax: RealIR-obliqueCor. These images produced in skew axial
and skew coronal
planes demonstrate very well the structures of mediobasal divisions
of temporal lobes[2,15]. At
the initial stage in 20 patients out of those being examined there
were no MRI changes.
It is explained by the fact that radiation therapists are often
and do not use an epileptological protocol, and also low-resolution
MRI (1.0 Tesla
and less) is used with the section thickness of more than 2.0mm. After
repeated performance of MRI with the resolution of 1.5-3.0 Tesla
(under an epileptological
protocol) in increments of 1.0 and 2.0mm, in 10 patients there was detected
an epileptic substrate - FCD, mesial temporal sclerosis,
this stage no deviances on MRI shots were found in 18% of patients.
4 – in the absence of congruence of focuses on MRI and EEG such additional
methods of examination as PET and SPECT are to be held [1,5-7,11,13,]
5 – neuropsychological study to identify a cognitive and linguistic
to operation [1,5-7,13,14].
6 – multidisciplinary council of physicians to make a decision on
of patient management.
the results of presurgical diagnostics, only in 47 patients (4% of
all those examined)
a diagnosis of true drugresistence was established.
patients (6%) were recommended a ketogenic diet;
patients (23%) were recommended surgical treatment (4 patients (8%)
7 patients (17%) are prepared for being operated);
patients (23%) were recommended a vagus nerve stimulation (4 patients
operated, 7 patients (17%) are prepared for being operated);
the rest 22 patients (47%) were recommended additional methods of
localize an epileptogenic focus.
video EEG monitoring was held by means of device Nicolet one (made in
USA) – 44-channel, and neuron-spectrum (made in Russia) –
21-channel with the use of
modified Jasper scheme in a specialized ward where there are special
medicines for the first
aid treatment and an oxygen cushion.
EEG monitoring a preliminary talk with a patient and parents is held
following issues are discussed:
voluntary consent to the procedure;
goal of the examination;
difficulties that may be encountered;
complications (post-acute psychotic disorder, epileptic status,
muscle and extremities
predictable (insufficiency of one seizure) and unpredictable
(technical errors) circumstances;
keeping a seizure diary.
seizure diary filled in by a patient and thorough analysis of
seizures help to determine
a cyclicity of a seizure, a post-seizure behavior of a patient,
the period of stay in VEEG monitoring and expenses, accordingly. If
it is impossible to determine a circadian nature of seizures, then
of seizures is used: Three
days before EEG monitoring AED is reduced by 50% (if monotherapy), on the
day of examination AED is completely cancelled. If there is no
seizure, on the next day
- partial sleep deprivation (night sleep deprivation). On the third
day - partial deprivation
and hyperventilation within 5-6 minutes up to 4 times a day at a
patient has polytherapy, then the first AED is also reduced by 50%
three days before,
on the day of examination the rest (2 or 3) AEDs are reduced by 10%
with partial sleep
deprivation. On the second day - frequent hyperventilation with the
duration of 5-6 minutes.
On the third day - full cancellation of one of the drugs.
results of distribution by gender, localization of seizure onset, by
form of epilepsy
and changes on MRT are shown in Tables No. 1,2,3,4.
1 - Patient Distribution by Gender and Age.
Table 2 - Localization of Epileptic Discharge Onset.
Тable 3 - Distribution by Epilepsy Form.
Тable 4 - MRT Changes upon the Results of Studies.
1. Our study shows that out of 1,200 patients who were initially diagnosed a
pharmacoresistent form of epilepsy only 47 (4%) patients have true pharmacoresistence.
According to the international data, a percentage of pharmacoresistent forms varies from
10 to 30% [5,6], accordingly, patient management and diagnosing should be made more
2. An important role in attaining a positive result of operative treatment is played
by timely and correct presurgical evaluation of patients with hard-curable convulsions.
The data of world surveys, our activities experience and outcomes of the joint work with
neurosurgeons allowed creating a protocol of presurgical diagnostics of patients with
pharmacoresistent forms of epilepsy.
This response protocol contributes to minimizing time and means, thus helping to
reduce irreversible changes in a person related to long-term disease progression and
frequent convulsive seizures.
3. Only interdisciplinary councils of physicians should participate in final decision
making on operative treatment of epilepsy patients, such councils will include
neurologists-epileptologists, neurosurgeons, radiation therapists, psychologists.
4. Due to a possibility of complications during ictal long-term EEG monitoring
there emerges a need in creating specialized wards to register epileptic and non-epileptic
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Утебеков Ж.Е. 2, Бондарева И.В. 2, Джайнакбаев Н.Т. 1 , Савинов С.В. 2 ,
Абедимова Р.А. 1 , Акчурина Я.Е. 1 , Ситников И.Ю. 2 , Михайлова Н.В. 2 , Есимова
Г.Н. 2, Т.Н. Синицина 2
Қазақ-Ресей Медицина Университеті, Алматы
В.М. Савинов атындағы эпилепсия және тырыспалы мемлекеттердін
ЭПИЛЕПСИЯНЫҢ ЕМГЕ ТӨЗІМДІ ТҮРІМЕН АУРЫРАТЫН
НАУҚАСТАРДЫ ОТАҒА ДЕЙІНГІ ТЕКСЕРУЛЕРДІ ЖҮРГІЗУ ХАТТАМАСЫ
Бұл жұмыста жалпыланған тәжірибелер және хирургиялық емге үміткер
эпилепсиямен ауыратын науқастарды тексерістер жүргізу хаттамасы ұсынылған.
Науқастарды отаға дейінгі тексерулерді жүргізу хаттамасының қорытындысы
бойынша тек 4% (n=47) науқастарға ғана емге төзімді түрі қойылған. Дайындалған
алгоритм іс-жарасы диагноздың дұрыстыңын және емдеу тәсілдерін, эпилепсияның
нағыз емге төзімді тұрін дәлелдеуге және бағалауға мүмкіндік берді. Сонымен
қатар, ұзақ уақыт эпилепсиямен ауыратын науқастардың әлеуметтік және
медициналық бейімделуіне, өмір сүру салтының жақсаруына, неврологиялық
бұзылыстарды болдырмауға көмектесті.
Утебеков Ж.Е. 2 , Бондарева И.В. 2 , Джайнакбаев Н.Т. 1 , Савинов С.В. 2 ,
Абедимова Р.А. 1 , Акчурина Я.Е. 1 , Ситников И.Ю. 2 , Михайлова Н.В. 2 , Есимова
Г.Н., Синицина Т.Н. 2
Казахстанско- Российский Медицинский Университет, Алматы
SVS Лаборатория изучения эпилепсии, судорожных состояний и семейного
мониторинга им. Савинова В.М., Алматы
ПРОТОКОЛ ПРЕДХИРУРГИЧЕСКОЙ ДИАГНОСТИКИ ДЛЯ
ПАЦИЕНТОВ С ФАРМАКОРЕЗИСТЕНТОЙ ФОРМОЙ ЭПИЛЕПСИИ
В данной работе обобщен опыт и представлены разработанные протоколы
обследований пациентов с эпилепсией - кандидатов на хирургическое лечение. По
результатам проведенной предхирургической диагностики только у 4% (n=47)
пациентов был выставлен диагноз фармакорезистентность.
Разработанный алгоритм действия позволяет оценить правильность диагноза
и тактики лечения, определить истинные фармакорезистентные формы эпилепсии,
тем самым помогает пациентам, длительно страдающим от эпилепсии,
минимизировать неврологические нарушения, адаптироваться в социальном и
медицинском плане, улучшая качество жизни.