Prevention of sudden unexpected death in epilepsy: A realistic goal?
Prevention of sudden unexpected death in epilepsy: A realistic goal?
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DOI：
10.1111/epi.12180
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发表时间：
2013-05-01
期刊：
影响因子：
5.6
通讯作者：
Tomson, Torbjorn
中科院分区：
文献类型：
--
作者：
Ryvlin, Philippe;Nashef, Lina;Tomson, Torbjorn
癫痫猝死（SUDEP）是耐药性癫痫最严重的后果之一，目前尚无循证预防措施。有效预防的发展取决于以下因素：（1）更好地了解 SUDEP 的病理生理学，以确定最合适的干预目标；（2）识别 SUDEP 的危险因素，以便设计可行的临床试验，以测试高危人群的针对性干预措施。最重要的已知危险因素是全身性强直阵挛发作 (GTCS) 的发生和频率，这是一种引发大多数目击 SUDEP 的癫痫类型。因此，预防 SUDEP 的一种可能方法是通过最佳的医疗管理和患者教育来最大限度地降低 GTCS 的风险。然而，是否可以通过更频繁地审查抗癫痫治疗和早期转诊进行术前评估来预防难治性癫痫患者的 SUDEP，仍有待观察。预防 SUDEP 的另一个假设策略是降低 GTCS 引起的发作后呼吸窘迫的风险。这可以通过使用格子枕头、提供夜间监督、增强发作间期血清素能张力以及降低阿片或腺苷引起的发作后脑干抑制来实现。在实施 SUDEP 试验之前，可以首先对替代标志物进行测试，例如癫痫监测单元 (EMU) 中的发作后缺氧。还应提高动车组的安全性，以避免在该情况下发生 SUDEP。最后，应鼓励流动 SUDEP 预防设备的开发，但也提出了许多未解决的问题。
Sudden unexpected death in epilepsy (SUDEP) represents one of the most severe consequences of drug-resistant epilepsy, for which no evidence-based prevention is available. Development of effective prevention will depend on the following: (1) better understanding of the pathophysiology of SUDEP to define the most appropriate targets of intervention, and (2) identification of risk factors for SUDEP that would allow for the design of feasible clinical trials to test targeted interventions in high-risk populations. The most important known risk factor is the occurrence and frequency of generalized tonicclonic seizure (GTCS), a seizure type that triggers the majority of witnessed SUDEP. Therefore, one likely way to prevent SUDEP is to minimize the risk of GTCS with optimal medical management and patient education. However, whether one might prevent SUDEP in patients with refractory epilepsy by using more frequent review of antiepileptic treatment and earlier referral for presurgical evaluation, remains to be seen. Another hypothetical strategy to prevent SUDEP is to reduce the risk of GTCS-induced postictal respiratory distress. This might be achieved by using lattice pillow, providing nocturnal supervision, reinforcing interictal serotoninergic tone, and lowering opiate- or adenosine-induced postictal brainstem depression. Promising interventions can be tested first on surrogate markers, such as postictal hypoxia in epilepsy monitoring units (EMUs), before SUDEP trials can be implemented. EMU safety should also be improved to avoid SUDEP occurrence in that setting. Finally, the development of ambulatory SUDEP prevention devices should be encouraged but raises a number of unsolved issues.