Научная статья "Протокол предхирургической диагностики для пациентов с фармакорезистентной формой эпилепсии" на английском языке из журнала "Астана медициналы? журналы", специальный выпуск №4/2015
Z.Utebekov
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
1
Kazakh-Russian Medical University, Almaty
2
SVS Laboratory of epilepsy, convulsive diseases research and family
monitoring named
after V.M. Savinov, Almaty
A
PRESURGICAL EVALUATION PROTOCOL FOR PATIENTS WITH PHARMACORESISTANT
EPILEPSY
Abstract
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
presurgical diagnostics.
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
examination.
Thereafter a patient is reviewed by a multidisciplinary council of
physicians where a decision is taken concerning one or another method of treatment or
surgical intervention.
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.
ACTUALITY
Over
11 years the SVS Laboratory of epilepsy, convulsive diseases research
and family
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
possible to
combat severe, drugresistent forms. But,
unfortunately, many doctors and patients have no full and clear
understanding of
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.
Therefore,
doctors of the National Center for Neurosurgery lose time and
tertiary care
bed-days for patients many of whom either have no indications for
surgical treatment at
all, or have been chosen improper therapy.
In
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
surgical treatment
of epilepsy, and developed an evaluation protocol.
Such
protocol for examination of candidates for surgical treatment of
epilepsy is critical
in order to organize a correct stage-by-stage approach in providing
surgical services
in epileptology.
GOALS
AND OBJECTIVES
-
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
EEG monitoring;
-
develop a presurgical evaluation protocol for patients with epilepsy
in order to select
candidates for surgical treatment.
MATERIALS
AND METHODS
Presurgical
examination was received by 1,200 patients who were admitted to the SVS
Laboratory from various clinics and cities of Kazakhstan with a
provisional
diagnosis
of pharmacoresistent epilepsy. Presurgical examination includes as
follows:
-
evaluation of a neurological status and consultation by a
neurologist-epileptologist;
-
determination of a level of antiepileptic drugs (AED) to exclude an
inadequate dosage,
as well as general blood tests;
-
analysis of EEG available and performance of daily video EEG
monitoring;
-
consultation with a psychologist and geneticist;
-
high-resolution brain MRI under a protocol of search for an
epidemiological block
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
examination with
participation of neurosurgeons-epileptologists,
neurologists-epileptologists,
neurophysiologists-epileptologists,
psycholo-gists, MRI and CT specialists followed by decision
making concerning further tactics.
RESULTS
Based
on the international experience patients undergo the following stages
of examination:
Stage
1 – there was established a correct diagnosis: pharmacoresistence –
absence of
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
syndrome. In
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,
inadequate dosage,
low adherence.
Stage
2 – long-term video EEG monitoring with mandatory recording of
seizures; if
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
non-epileptological
reason of seizures.
Stage
3 – MRI with a magnetic field induction of 1.5-3 Tesla with the use
of anepileptological
protocol [2,5,6,7,13-15]. Taking into consideration that a
hippocampus change
is often an epileptogenic substrate, it is necessary to use an
additional protocol of study
of mediobasal divisions of temporal lobes, including the performance
of Flair-oblique
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
insufficientlyqualified
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,
heterotopions. At
this stage no deviances on MRI shots were found in 18% of patients.
Stage
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,]
Stage
5 – neuropsychological study to identify a cognitive and linguistic
deficit prior
to operation [1,5-7,13,14].
Stage
6 – multidisciplinary council of physicians to make a decision on
further tactics
of patient management.
Upon
the results of presurgical diagnostics, only in 47 patients (4% of
all those examined)
a diagnosis of true drugresistence was established.
Of
them:
- 3
patients (6%) were recommended a ketogenic diet;
- 11
patients (23%) were recommended surgical treatment (4 patients (8%)
were operated,
7 patients (17%) are prepared for being operated);
- 11
patients (23%) were recommended a vagus nerve stimulation (4 patients
(8%) were
operated, 7 patients (17%) are prepared for being operated);
-
the rest 22 patients (47%) were recommended additional methods of
examination to
localize an epileptogenic focus.
DISCUSSION
Long-term
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.
Before
EEG monitoring a preliminary talk with a patient and parents is held
and the
following issues are discussed:
-
voluntary consent to the procedure;
-
goal of the examination;
-
expected outcome;
-
difficulties that may be encountered;
-
complications (post-acute psychotic disorder, epileptic status,
muscle and extremities
joints damage);
-
predictable (insufficiency of one seizure) and unpredictable
(technical errors) circumstances;
-
keeping a seizure diary.
A
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,
thereby
minimizing
the period of stay in VEEG monitoring and expenses, accordingly. If
it is impossible to determine a circadian nature of seizures, then
stage-by-stage induction
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
2-hour interval.
If 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.
The
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.
Table
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.
CONCLUSIONS
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
thoroughly.
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
paroxysmal states.
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Т?ЙІН
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
1
?аза?-Ресей Медицина Университеті, Алматы
2
В.М. Савинов атында?ы эпилепсия ж?не тырыспалы мемлекеттердін
лабораториясы, Алматы
ЭПИЛЕПСИЯНЫ? ЕМГЕ Т?ЗІМДІ Т?РІМЕН АУРЫРАТЫН
НАУ?АСТАРДЫ ОТА?А ДЕЙІНГІ ТЕКСЕРУЛЕРДІ Ж?РГІЗУ ХАТТАМАСЫ
Б?л ж?мыста жалпылан?ан т?жірибелер ж?не хирургиялы? емге ?міткер
эпилепсиямен ауыратын нау?астарды тексерістер ж?ргізу хаттамасы ?сыныл?ан.
Нау?астарды ота?а дейінгі тексерулерді ж?ргізу хаттамасыны? ?орытындысы
бойынша тек 4% (n=47) нау?астар?а ?ана емге т?зімді т?рі ?ойыл?ан. Дайындал?ан
алгоритм іс-жарасы диагнозды? д?рысты?ын ж?не емдеу т?сілдерін, эпилепсияны?
на?ыз емге т?зімді т?рін д?лелдеуге ж?не ба?алау?а м?мкіндік берді. Сонымен
?атар, ?за? уа?ыт эпилепсиямен ауыратын нау?астарды? ?леуметтік ж?не
медициналы? бейімделуіне, ?мір с?ру салтыны? жа?саруына, неврологиялы?
б?зылыстарды болдырмау?а к?мектесті.
РЕЗЮМЕ
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
1
Казахстанско- Российский Медицинский Университет, Алматы
2
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.
