由美國神經病學學會和美國癲癇學會指南製定委員會製定的《成人不明原因癲癇首次發作管理指南》於4月20日在《神經病學》(Neurology)雜誌上發表。
編寫委員會在指南中對相關問題進行了闡述，並根據美國神經病學學會的證據標準的分類係統回顧了已發表的研究，基於證據級別提出了以下推薦建議。
1、應使不明原因癲癇首次發作的成人患者知曉其在首次發作後頭兩年內早期複發風險最大，為21—45%(A級);與風險增加有關的臨床變量可能包括既往的腦損傷(A級)，腦電圖(EEG)顯示癲癇樣異常(A級)，明顯的腦部成像異常(B級)和夜行性癲癇(B級)。
2、與第二次發生癲癇再進行治療相比，首次發作即用抗癲癇藥(AED)治療有可能減少患者頭2年內複發風險(B級)，但不改善其生活質量(C級)。從更長遠來看(>3年)，首次發作後即用AED治療不可能改善用持續癲癇緩解評估的患者預後(B級)。
3、應告知患者AED不良事件(AE)風險範圍從7%至31%不等(B級)，這些AE可能主要為輕度且是可逆的。
4、對於患者首次發作後是否立即啟動AED治療，臨床醫生應根據個體化評估結果，即權衡複發風險與AED治療後AE的利弊，考慮受教育後患者的偏好和即刻治療並不改善癲癇緩解的長期預後但可減少隨後2年癲癇風險的建議。
ABSTRACT
Objective: To provide evidence-based recommendations for treatment of adults with an unprovoked first seizure.
Methods: We defined relevant questions and systematically reviewed published studies according to the American Academy of Neurology’s classification of evidence criteria; we based recommendationson evidence level.
Results and recommendations: Adults with an unprovoked first seizure should be informed that their seizure recurrence risk is greatest early within the first 2 years (21%–45%) (Level A), and clinical variables associated with increased risk may include a prior brain insult (Level A), an EEG with epileptiform abnormalities (Level A), a significant brain-imaging abnormality (Level B), and a nocturnal seizure (Level B). Immediate antiepileptic drug (AED) therapy, as compared with delay of treatment pending a second seizure, is likely to reduce recurrence risk within the first 2 years (Level B) but may not improve quality of life (Level C). Over a longer term (>3 years), immediate AED treatment is unlikely to improve prognosis as measured by sustained seizure remission (Level B).
Patients should be advised that risk of AED adverse events (AEs) may range from 7% to 31% (Level B) and that these AEs are likely predominantly mild and reversible.
Clinicians’ recommendations whether to initiate immediate AED treatment after a first seizure should be based on individualized assessments that weigh the risk of recurrence against the AEs of AED therapy, consider educated patient preferences, and advise that immediate treatment will not improve the long-term prognosis for seizure remission but will reduce seizure risk over the subsequent 2 years. Neurology® 2015;84:1705–1713
