儿童原发性癫痫治疗指南(4)

儿童癫痫指南

an excellent outcome(25). A later-age Gastaut vari-ant of CEOPS is usually characterized by diurnalsimple partial seizures with visual hallucinations oramaurosis and migraine like headaches. This has avariable prognosis and can persist into adult life.Neuroimaging is considered in cases with an abnor-mal perinatal history or examination, atypical EEG,or poorly controlled seizures.

Treatment with AED is not required whenseizures are infrequent, but parental counseling is amust. In long term therapy, carbamazepine orvalproate are preferred. The syndrome may evolveatypically with frequent refractory seizures,scholastic deterioration and/or behavioral changes;more often with the use of carbamazepine,emphasizing the need of clinical monitoring (26).6. Idiopathic Generalized EpilepsiesChildhood absence epilepsy (Petit-mal, CAE)This should be suspected in a normal school agechild with frequent absence seizures often upto ahundred a day. These occur in the awake state withsudden staring, unresponsiveness and minor briefautomatisms, leading to interruption of ongoingactivity and unassociated with any post ictalabnormality(23). GTC seizures are unusual. Pre-cipitation of seizure by hyperventilation is a simpleclinical diagnostic test. Atypical absence seizures areprolonged, seen usually in catastrophic pediatricsyndromes with neurocognitive deterioration.An EEG showing a typical pattern characterizedby frontally predominant generalized bursts of 3 Hzspike wave complexes with abrupt onset is diagno-stic. There is no role for routine neuroimaging.Valproate and ethosuxsimide (presentlyunavailable) followed by lamotrigine(27) and thebenzodiazepines are the drugs of choice. Response toAEDs should be confirmed by repeat EEG withhyperventilation to check the disappearance oftypical EEG pattern. Treatment is for a minimumseizure free period of 2 years with a normal EEG atdiscontinuation.

Idiopathic generalized epilepsies of adolescentWhen a child presents with absence, myoclonic orgeneralized tonic, clonic seizures for the first timeafter 10 years, a diagnosis of idiopathic generalizedepilepsies of adolescent onset is considered. EEGshows generalized paroxysms of spike or polyspikeswave discharges. Photosensitivity is common.Juvenile myoclonic epilepsy (JME), juvenileabsence epilepsy (JAE) and epilepsies with onlyGTC seizures should also be considered indiagnosis(28).

JME presents in adolescents with history of earlymorning predominant upper limb myoclonic jerksleading to the patient dropping objects. This occursoften in sleep-deprived individuals, especially ifsuddenly awakened. JAE is similar to CAE, thoughthe numbers of absences are much less and the onsetis usually later. GTC seizures typically occur onawakening or in the evening(23).

Sodium valproate is the most effective drug inmost cases of idiopathic generalized epilepsies(29),but it may cause weight gain, hair loss, and menstrualirregularities and has a higher incidence of fetalteratogenicity. Therefore, lamotrigine may bepreferable in adolescent girls. Due to its lower cost,phenobarbitone may be used in poor patients withresource constrains, with only generalized tonicclonic seizures, but will not control myoclonic orabsence seizures. Carbamazepine and phenytoinmay worsen the syndromes. Lifestyle adjustmentsinclude avoiding precipitating factors like sleepdeprivation and alcohol consumption.

Seizure control is achieved in 80% withmonotherapy. Withdrawal of AEDs results in relapsein more than 90%, especially in JME and JAE, andoften need low dose lifetime medication. In cases ofepilepsies with only generalized tonic clonicseizures, a single trial of AED withdrawal after a 2years of seizure free interval may be tried, but risk ofrecurrence is high and lifetime AED may be needed.7. Investigations for EpilepsyElectroencephalography (EEG)When should an EEG be done?

EEG is recommended as a part of initial evaluation inall children presenting with an episodic event.Epileptiform abnormalities support a clinical

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