癫癎减停药后复发危险因素分析

Risk factors for recurrence after drug withdrawal in epilepsy

目的回顾性分析癫癎发作获得控制患者减停药后复发情况及相关危险因素,以为临床应用提供参考依据。方法采用单因素分析和向前逐步法多因素非条件Logistic回归分析评价311例癫癎发作获得控制且减停药≥2年患者的癫癎复发危险因素。结果 311例患者,癫癎复发率为34.73%(108/311),其中在医师指导下减停药者280例,癫癎复发率为29.29%(82/280),停药后1年内复发率为26.43%(74/280),停药后2年内复发率为28.21%(79/280)。单因素分析结果显示,青少年期发病、成年期发病、肌阵挛发作、青少年肌阵挛癫癎、症状性部分性癫癎、减药前大发作频率>10次、成年期减药、成人减药前无发作时间<4年、减药时间<6个月及减药前脑电图显示癎样放电共10项因素是减停药后癫癎复发的危险因素,差异具有统计学意义(均P<0.05)。多因素非条件Logistic回归分析结果显示,青少年期发病、成年期发病、青少年肌阵挛癫癎、症状性部分性癫癎、成人减药前无发作时间<4年、减药时间<6个月及减药前脑电图显示癎样放电为减停药后癫癎复发的主要危险因素(均P<0.05)。结论癫癎减停药应该注重个体化原则。儿童期发病的癫癎患者发作控制1～2年可考虑减停药,成年患者发作控制>4年方可考虑减停药,减药时间应≥6个月。青少年期发病、成年期发病、青少年肌阵挛癫癎、症状性部分性癫癎及减药前脑电图显示癎样放电者,减停药后癫癎复发风险高,减停药需慎重。

Objective To assess the recurrence rate of epilepsy attributable to antiepileptic drugs （AEDs） withdrawal in seizure-free epileptic patients, and to determine the risk factors for seizure recurrence. Methods Three hundred and eleven seizure-free epileptic; patients who were followed at least 2 years after AEDs withdrawal at our epilepsy center between 1990 and 2003 formed the study population of this＇retrospective study. The patients were classified in different groups to clarify the risk factors according to sex, age of onset, family history of epilepsy, febrile seizure, events in perinatal or childhood history, history of previous encephalitis, history of head trauma, neuroimaging, neurological examination, type of seizure, type of epilepsy or epileptic syndrome, numbers of generalized tonic-elonic seizure （GTCS） before AEDs withdrawal, history of status epilepticus （SE）, time period between onset of the first seizure and start of AEDs treatment, time period between starting AEDs treatment and the last seizure, time period between the last seizure and AEDs withdrawal, age of AEDs withdrawal, numbers of seizure before AEDs withdrawal, duration of taper period, and the presence of electroencephalogram （EEG） epileptiform abnormalities before AEDs withdrawal. Unconditional Logistic regression analysis was performed for those factors which were significant after univariate analysis.Results Of 311 patients （183 men, 128 wemen）, overall recurrence rate was 34.73% （108/31l）. Of the 280 patients whose AEDs withdrawal were proposed by doctor, overall recurrence rate was 29.29% （82/280）, the post-withdrawal recurrence rate at 1-year was 26.43% （74/280） and at 2-year was 28.21% （79/280）. Univariate analysis results showed that patients who were more likely to have seizure recurrence included onset at adolescent, onset at adult, myoclonic seizure, juvenile myoclonic epilepsy （JME）, symptomatic partial epilepsy, more than 10 times of GTCS before AEDs withdrawal, less than 4 years of seizure-free before AEDs withdrawal in adults, less than 6 months of taper period, and the presence of EEG epileptiform abnormalities before AEDs withdrawal （P 〈 0.05, for all）. In unconditional Logistic regression analysis, onset at adolescent, onset at adult, JME, symptomatic partial epilepsy, less than 4 years of seizure-free before AEDs withdrawal in adults, less than 6 months of taper period, and the presence of EEG epileptiform abnormalities before AEDs withdrawal （P〈0.05, for all） were the main risk factors for seizure recurrence after AEDs withdrawal. Conclusion The decision to discontinue AEDs treatment necessitates evaluation of each patient individually. Most children with epilepsy deserve a chance to attempt discontinuation of AEDs treatment once they have achieved 1-2 years seizure-free, while more than 4 years of seizure-free is a reasonable time for adults to consider discontinuation of AEDs treatment, and the taper period should not be less than 6 months.Adolescent and adult onset patients, JME, symptomatic partial epilepsy, and the presence of EEG epileptiform abnormalities before AEDs withdrawal require more cautious follow-up because of the high risk of recurrence.