1

epilefsiis diagnostika da

mkurnaloba

klinikuri praqtikis erovnuli rekomendacia

(gaidlaini)

2

klinikuri praqtikis erovnuli rekomendacia (gaidlaini)

`epilefsiis diagnostika da mkurnaloba~ miRebulia

klinikuri praqtikis erovnuli rekomendaciebis (gaidlainebi)

da daavadebaTa marTvis saxelmwifo standartebis

(protokolebi) SemuSavebis, Sefasebis da danergvis erovnuli

sabWos 2007 wlis 21 martis #1 sxdomaze da damtkicebulia

saqarTvelos Sromis, janmrTelobisa da socialuri dacvis

ministris 2007 wlis 21 dekembris # 357/o brZanebiT.

3

epilefsiis diagnostika da mkurnaloba

1. daavadebis ganmarteba, sinonimebi, klasifikacia da

terminologia

epilefsia Tavis tvinis qronikuli daavadebaa da SeiZleba ganuviTardes

nebismieri asakis, sqesis, rasisa da socialuri fenis adamians.

daavadebis saxelwodeba warmodgeba berZnuli sityvidan “epilambanein”, da niSnavs `moulodnelobiT Sepyrobils~.

sinonimebi: `herkulesis daavadeba~, `komitetis daavadeba~, `RvTaebrivi

daavadeba~, `varskvlavTa daavadeba~, `mTvaris daavadeba~, `demonuri

daavadeba~ da sxva. saqarTveloSi: `bneda~, `mterdacema~, `avi zne~,

`krunCxva~.

biologiuri safuZveli Tavis tvinis neironebis normaluri aqtivobis

darRveva da paroqsizmuli gantvirTvebis aRmocenebis Sedegad

paTologiuri moqmedebis reJimSi gadarTvaa, rac klinikurad vlindeba

ganmeorebiTi epilefsiuri gulyriT, xolo eleqtro-

encefalografiulad - specifikuri paroqsizmuli cvlilebebiT.

klinikuri niSani: araprovocirebuli, ganmeorebiTi epilefsiuri

gulyrebi, romlebic SeiZleba iyos krunCxviTi an arakrunCxviTi.

epilefsiuri gulyra: Tavis tvinis neironebis gardamavali,

aranormaluri da gadaWarbebuli gantvirTvis Sedegia, rac klinikurad

vlindeba paroqsizmuli motoruli/ an sxva obieqturi fenomenebiTa Tu

subieqturi SegrZnebebiT, an am simptomTa kombinaciebiT.

epilefsiuri gulyris ZiriTadi maxasiaTeblebi: paroqsizmuloba,

ganmeorebadoba da stereotipuloba, romlebic eleqtro-

encefalogramaze aisaxeba maTTvis damaxasiaTebeli

eleqtrofiziologiuri cvlilebebiT. gulyra SeiZleba iyos krunCxviTi

da arakrunCxviTi.

krunCxviTi gulyra – Seteva mimdinareobs tonur-klonuri krunCxvebiT arakrunCxviTi gulyra - Setevas ar axlavs tonur-klonuri krunCxvebi

epilefsiuri gulyrebis saerTaSoriso klasifikaciiT gamoiyofilia

gulyris ori ZiriTadi tipi – fokaluri da generalizebuli (Commission, 1981). fokaluri (parcialuri) epilefsiuri gulyra aRmocendeba Tavis

tvinis lokalur ubanSi, SesaZloa gavrceldes Tavis tvinis sxva

ubnebze da gadaizardos meoradad generalizebul krunCxviT gulyraSi.

martivi fokaluri gulyra: Seteva mimdinareobs naTeli

cnobierebis fonze

4

rTuli fokaluri gulyra: Seteva mimdinareobs daTrgunuli

cnobierebis fonze.

fokaluri meoradad generalizebuli gulyra _ iwyeba martivi an rTuli fokaluri gulyriT da gadaizrdeba tonur-klonur

krunCxviT gulyraSi.

pirveladad generalizebul rogorc krunCxviT, ise arakrunCxviT

gulyras ar gaaCnia lokaluri sawyisi da Setevis generaciaSi Tavis

tvinis orive hemisfero erTdrouladaa CarTuli.

absansi (laT. `absentia~-`aq ar yofna~): cnobierebis wamieri (5-10

wm) gamoTiSva, romelsac eeg-ze Tan axlavs gantvirTvebis

specifikuri tipi – 3 pik-talRa/wamSi.

atipiuri absansi: cnobierebis wamieri (5-10 wm) gamoTiSva,

romelsac eeg-ze gantvirTvebis specifikuri tipis (3 pik-talRa

wamSi) nacvlad Tan axlavs gansxvavebuli paroqsizmuli

fenomenebi (araregularuli pik-talRovani aqtivoba, polipik-

talRovani paroqsizmebi, gulyrisas sawyisi maxviltalRovani 10-

20 rxeva/wamSi ritmi da sxv.)

mioklonuri gulyra: naTeli cnobierebis fonze kunTebis

calmxrivi an ormxrivi uecari swrafi SekrToma.

tonuri gulyra - Senaxuli cnobierebis an gonebis uecari

daTrgunvis fonze gamSleli (an, SedarebiT iSviaTad momxreli)

kunTebis uecari spazmi.

atonuri gulyra - kunTTa tonusis uecari daqveiTebis Sedegad

mowyvetiT vardna (drop atack)

febriluri krunCxva - generalizebuli epilefsiuri reaqciaa, romelic

viTardeba sxvadasxva eqstracerebruli, xSirad, virusuli daavadebis

dros sxeulis maRali temperaturis fonze (t > 38°C), an misi matebis procesSi.

araepilefsiuri gulyra: drois gansazRvruli periodiT pirovnebis

uecari da sayuradRebo qceviTi, aRqmiTi, azrobrivi an SegrZnebiTi

cvlileba, romelsac eleqtroencefalogramaze Tan ar axlavs

epilefsiuri gulyrisaTvis damaxasiaTebeli eleqtrofiziologiuri

cvlilebebi.

aqtiuri epilefsia: epilefsiiT daavadebuls uwyveti antiepilefsiuri

mkurnalobis fonze bolo 5 wlis manZilze hqonda Tundac erTi

epilefsiuri gulyra.

refraqtoruli epilefsia: epilefsiuri gulyrebi ar eqvemdebareba

adekvaturi mkurnalobis reJims (dauqvemdebarebeli epilefsia).

katamenialuri epilefsia (berZn. “catamenios”-menstruaciuli sisxldena): epilefsiis mimdinareobis tipi, rodesac epilefsiuri gulyrebis

aRmoceneba an gaxSireba ukavSirdeba menstruaciuli ciklis fazebs.

epilefsiuri sindromi: epilefsia, gulyraTa Soris periodSi,

SesaZloa, sruliad usimptomod mimdinareobdes, an vlindebodes

mravalferovani klinikuri da eleqroencefalografiuli fenomenebiT-

simptomebiT. aRniSnuli simptomebis, gulyraTa saxeobis, daavadebis

etiologiuri faqtorebis, eplefsiis manifestaciis asakisa da

5

mimdinareobis Taviseburebebis sxvadasxva kombinacia qmnis

erTmaneTisagan gansxvavebul, metnaklebad stereotipul

eleqtroklinikur epilefsiur sindromebs (Commission, 1989).

keTilTvisebiani da avTvisebiani epilefsiuri sindromebi: daavadebis mimdinareobisa da prognozis mixedviT ganasxvaveben epilefsiuri

sindromebis `keTil~ da `cudi~ mimdinareobis epilefsiebs.

epilefsiuri statusi (laT. - `epileptic state~) gadaudebeli samedicino

mdgomareobaa, romlis drosac epilefsiuri Setevebis mimdinareoba

gaxangrZlivebulia (30 wT-ze meti) an viTardeba iseTi TanmimdebrobiT,

romelTa Soris intervalebSi gulyris Sedegad darRveuli

nevrologiuri funqciebis sruli aRdgena ver eswreba. ganarCeven

epilefsiuri statusis or ZiriTad jgufs: krunCxviTi da arakrunCxviTi

gulyrebis statusi.

krunCxviTi gulyrebis statuss miekuTvneba – generalizebuli

tonur-klonuri krunCxvebis statusi;

arakrunCxviTi gulyrebis statuss miekuTvneba – martivi

parcialuri, rTuli parcialuri gulyrebis, absansebis,

miokloniebis da afaziuri statusi.

bioeleqtruli statusi – klinikuri gulyriTi simptomebis

gareSe mimdinare mdgomareoba, romelic mxolod

eleqtroencefalogramaze aisaxeba xangrZlivi epilefsiuri

gantvirTvebiT.

epilefsiur gulyraTa seria: statusisagan gansxvavebiT, iseTi

paTologiuri mdgomareobaa, rodesac xSir gulyrebs Soris periodSi

nevrologiuri funqciebis darRvevebis simptomebi ar vlindeba.

antikonvulsantebi: epilefsiis samkurnalo preparatebia, romlebic

sxvadasxva meqanizmebiT zrdian epilefsiuri krunCxviTi gulyrebis

zRurbls da aqveiTeben gulyris aRmocenebis SesaZleblobas. ganarCeven

Zveli, axali da uaxlesi Taobis antkonvulsantebs:

Zveli Taobis: warmoebulia 1990 wlamde,

axali Taobis: warmoebulia 1990-2000 wlebSi,

uaxlesi Taobis: warmoebulia 2000 wlis Semdeg.

antikonvulsantis plazmuri koncentracia: medikamentis Terapiuli

zemoqmedebis unaris mqone Tavisufali fraqciis koncentracia sisxlSi

(sisxlSi cirkulirebs medikamentis Tavisufali da plazmis cilebTan

SekavSirebuli fraqciebi).

antikonvulsantis Terapiuli koncentracia: Sualeduri monakveTi

preparatis aqtiur da toqsikur koncentraciebs Soris.

antikonvulsantis titracia: antikonvulsantis dozis matebis tempi.

monoTerapia: mkurnaloba erTi antikonvulsantiT.

poliTerapia: mkurnaloba ori da meti antikonvulsantiT.

kogniciuri funqciebi: “Cognitio” (laT._`codna~) - Tavis tvinis funqcia,

romelic uzrunvelyofs informaciis miRebas, damaxsovrebas,

yuradRebis koncentracias, problemaTa amoxsnasa da gadaWras.

6

cxovrebis srulfasovneba - Quality of Life: pirovnebis fizikuri,

socialuri, ekonomikuri da fsiqikuri mdgomareobiT kmayofileba;

janmrTelobasTan dakavSirebuli cxovrebis srulfasovneba – Health-related Quality of Life: rodesac adamianis janmrTelobis mdgomareoba ar aferxebs

sasicocxlo funqciebis Sesrulebas.

cxovrebis srulfasovnebis xarisxi: sicocxlis xangrZlivobaze

pirovnebis fizikuri, fsiqikuri, socialuri, fsiqologiuri da

msoflmxedvelobiTi gadaxrebis (darRvevebis) zemoqmedebis maCvenebeli.

janmrTelobasTan dakavSirebuli sicocxlis xarisxi: pacientis

fizikuri, socialuri, ekonomikuri da fsiqikuri mdgomareobiT

kmayofilebis maCvenebeli, romelic damokidebulia pacientis mier

profilaqtikuri da gamajansaRebeli RonisZiebebis Sedegebis

individuri aRqmis doneze.

epilefsiis prevalensi (gavrceleba): mocemuli droisaTvis populaciis

yovel 1000 sul mosaxleSi epilefsiiT daavadebili adamianebis

raodenoba;

epilefsiis insidensi (avadoba): populaciis yovel 100 000 sul

mosaxleze erTi wlis manZilze daavadebis axali SemTxvevebis

raodenoba.

sikvdiloba

sikvdilobis proporciuli sixSire: specifikuri mizeziT

gamowveuli sikvdilobis Sefardeba sikvdilobis zogad

populaciur maCvenebelTan;

sikvdilobis standartizebuli sixSire: asakisa da sqesis mixedviT

sakvlev jgufSi (mag. epilefsiiT daavadebulebSi) sikvdilobis

SemTxvevebis Sefardeba zogad populaciaSi imave asakisa da sqesis

individebSi sikvdilobis SemTxvevebis raodenobasTan.

specializebuli dawesebuleba: profiluri dawesebuleba, romelic

mowodebulia saTanado samecniero-praqtikul doneze marTos

konkretuli paTologia.

epilefsiis marTva: organizaciul-samarTleblivi da samkurnalo-

profilaqtikur RonisZiebaTa kompleqsi.

mtkicebulebis siZlieris done (msd): ganisazRvreba oTxi doniT I (iyofa Ia da Ib doneebad), II (iyofa IIa da IIb doneebad), III da IV;

Ia done - sistematuri mimoxilva an randomizebuli

kontrolirebuli kvlevis metaanalizi;

Ib done - bolodroindeli randomizebuli kontrolirebuli kvleva;

IIa done - ararandomizebuli bolodroindeli kargi dizainiT

warmoebuli kvleva;

IIb done - bolodroindeli kargi dizainiT warmoebuli

garkveulwilad eqsperimentuli, magaliTad, kohortuli kvleva;

III done – kargad dagegmili araeqsperimentuli kvleva SemTxvevis an

SemTxvevaTa seriebis aRweriT;

7

IV done – saeqsperto jgufis daskvna mdidari klinikuri

gamocdilebis da/an cnobili avtorebis Sexedulebebis ganxilvis

Semdgom.

rekomendaciis xarisxi (rx): gansazRvrulia rekomendaciis A, B, C da D xarisxebi. TiToeuli xarisxi Seesabameba mtkicebulebis siZlieris

dones:

A – eyrdnoba kvlevis Ia da Ib doneebs;

B - eyrdnoba kvlevis IIa da IIb doneebs, an gamomdinareobs I donis kvlevebidan;

C – eyrdnoba kvlevis III dones an gamomdinareobs kvlevis I da II

doneebidan;

D – eyrdnoba kvlevis IV dones an gamomdinareobs kvlevis I, II da

III doneebidan.

2. epilefsiis epidemiologia

epilefsia heterogenuli mdgomareobaa da misi epidemiologiuri

kvlevebi Zalze rTulia. aseTi kvlevebis sirTulis mizezebi Semdegia:

sxva daavadebebisagan gansxvavebiT, epilefsia epizoduri mdgomareobaa –

gulyraTa Soris periodebSi pacientis fsiqikuri, fizikuri da

eleqtroencefalografiuli monacemebi, SesaZlebelia srul normas

Seesabamebodes; Zalze xSirad, epilefsiis diagnozi efuZneba pacientis

Civilebs da, rac ufro mniSvnelovania, mowmeebis Cvenebebs.

diagnostikas arTulebs isic, rom epilefsiis garda sxva

paroqsizebuli mdgomareobebicaa Tanxlebuli cnobierebisa Tu sxva

SegrZnebebis SecvliT. epilefsiis epidemiologiis zusti monacemebis

dadgenas isic uSlis xels, rom iSviaTi an ,,susti’’ gulyrebis mqone

zogierTi pacienti ver grZnobs Setevas, an iviwyebs mas, an ar mimarTavs

eqims. epidemiologiuri kvlevisaTvis ,,miuwvdomelia’’ is pacientebic,

romlebic malaven sakuTar daavadebas maTdami sazogadoebis uaryofiTi

damokidebulebisa da socialuri stigmatizaciis gamo.

swored amitom, epilefsiis epidemiologiuri kvlevebi msoflios sul

ramdenime qveyanaSia warmoebuli da dadgenilia, rom epilefsiiT

daavadebulia msoflio mosaxleobis 1% (European White Paper on Epilepsy, 2001).

1987-1991 w.w., sarajiSvilis sax. nevrologiis institutis bazaze

arsebuli epilefsiis centris TanamSromelTa mier saqarTveloSi

Catarda epilefsiis randomizebuli, klasteruli epidemiologiuri

kvleva kardakar Semovlis meTodiT (Геладзе и соавт., 1995) (respodentTa

raodenoba: 11 996; saeWvo SemTxvevebis eeg-kvleva - 647 piri; dadasturebuli

diagnozi - 62 piri).

8

epidemiologiuri kvlevis Sedegebi maCvenebeli

msoflioSi

(WHO-s monacemebi, 2001)

saqarTveloSi

(1987-1991w.w. monacemebi) prevalensi

5-10:1000

asaki

gavrceleba :1000

0-10 w.w. 6.6 11-20 w.w. 6.2 21-30 w.w. 2.8 31-40 w.w. 2.9 41-50 w.w. 7.6 51 w.< 8.8 zogadad 5.67

insidensi

40-70:100 000 ganviTarebul qveynebSi 100-190/100 000 ganviTarebad qveynebSi Q

50:100 000

sicocxlis manZilze

erTjeradi epilefsiuri

gulyra

2-5% 5% (215 000 piri)

epilefsiis tipi

fokaluri/generalizebuli 60/40

60/40

mdedrobiTi/mamrobiTi

50/50 50/50

prognozi:

1. samedicino gamosavali

gulyraTa ganaxlebis riski epilefsiis mimdinareobis mixedviT: # epilefsiuri mdgomareoba epilefsia

zogadad foka

luri

generali

zebuli

1 pirveli araprovicirebuli epilefsiuri

gulyris ganmeorebis riski

27-81%

2 axlad diagnostirebuli epilefsiis

dros antiepilefsiuri mkurnalobis

Sedegad gulyrebis sruli Sewyveta.*

65-80% 16-43% 75-90%

3 qronikuli epilefsiuri gulyrebis

Camoyalibebis riski.*

20-30%

4 pirveli rigis antikonvulsantiT

mkurnalobis pirobebSi gulyrebis

sruli kupireba.**

70-80% 60-80%

80-90%

5 meore antikonvulsantis damatebis

SemTxvevaSi epilefsiuri gulyrebis

sruli kupireba.**

5%;

10%

6 antiepilefsiuri mkurnalobis moxsnis

Semdeg gulyrebis ganaxlebis riski.*

11-41% 20-40% 80-95%

9

7 epilefsiuri statusis ganviTarebis riski** 1-8% msd: * (Ia); ** (IIb).

sikvdiloba

epilefsiiT gamowveuli sikvdiloba

1. populaciurTan SedarebiT 2-3-jer ufro maRalia (msd – IIb); 2. yvelaze maRalia epilefsiis diagnozis dadgenidan pirveli 10

wlis ganmavlobaSi.

3. epilefsiuri statusiT gamowveuli sikvdiloba – statusis

SemTxvevaTa 10-20%-Si;

4. uecari sikvdilis SemTxvevebi - daavadebulTa 0,1%-Si.

proporciuli (psm) da standartizebuli sikvdiloba (ssm)

1. ssm epilefsiis mqone 0-40 w.w asakis pirebSi, mdedrobiTi sqesis

daavadebulebTan SedarebiT mamrobiT sqesSi ufro maRalia;

2. yvela saxis ssm epilefsiiT daavadebulTa Soris 2-3-jer ufro

maRalia, vidre populaciaSi;

3. suicidis psm da ssm maCveneblebi 5-jer ufro maRalia

populaciurTan SedarebiT;

4. populaciurTan SedarebiT avtoavariiTa da wyalSi daxrCobiT

sikvdilobis psm da ssm maCveneblebi mniSvnelovnad ufro

maRalia;

5. ssm mZimed mimdinare epilefsiebis dros ufro maRalia (3,8%),

vidre kupirebuli gulyrebiT mimdinare epilefsiebis dros (1,8%).

(msd – IIb);

2. fsiqo-socialuri gamosavali • daavadebis adekvaturi mkurnalobis, menejmentisa da fsiqo-

socialur pirobebSi daavadebulTa 90-95% srulfasovani

pirovnebaa;

• daavadebulTa 5-10%-s aReniSneba gonebrivi ganviTarebis CamorCena.

3. epilefsiis etiopaTogenezi epilefsia SeiZleba Tavis tvinis nebismieri dazianebis simptomi iyos.

amitom eqimi mxolod epilefsiuri gulyris faqtis konstataciiT ar

unda Semoifarglos da yvela SemTxvevaSi unda gaarkvios epilefsiis

ZiriTadi mizezi.

epilefsiuri sindromebis saerTaSoriso klasifikacia (Commission, 1989) gvTavazobs epilefsiebis sam etiologiur kategorias:

idiopaTiuri epilefsiebi ( 35%)

gulyraTa mizezi ucnobia; xSiria genetikuri formebi.

sindromTa sawyisi damokidebulia asakze, xasiaTdeba

keTilTvisebiani mimdinareobiT, mkurnalobis

efeqturobiT.

kriptogenuli anu SesaZlo simtomuri

epilefsiebi (25 %)

klinikuri niSnebiT (fokaluri gulyra,

neirofsiqologiuri kvleviT Tavis tvinis lokaluri

disfunqcia) savaraudoa simptomuri epilefsia, magram

neirovizualuri kvlevis Tanamedrove meTodebiT Tavis

tvinis dazianebuli ubnis gamovlena ver xerxdeba.

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simptomuri epilefsiebi ( 40%)

neirovizualuri kvleviT Tavis tvinSi dgindeba im

paTologiuri keris lokalizacia, romelic

epilefsiuri gulyrebis generaciisa da Sesabamisi

eleqtrografiuli paternebis aRmocenebis mizezia.

simptomuri epilefsiebis ZiriTadi etiologiuri faqtorebi sxvadasxva asakSi

asaki (w) 0 1 5 10 20 30 40 50 60

4. klinikuri simptomatika

epilefsiis klasikuri klinikuri simptomia araprovocirebuli,

ganmeorebiTi epilefsiuri gulyrebi.

epilefsiur gulyraTa saerTaSoriso klasifikaciiT (Commission, 1981), epilefsiuri keris lokalizaciisa da am ubnidan aRmocenebuli

paroqsizmuli aqtivobis tvinis sxva struqturebSi gavrcelebis

gaTvaliswinebiT, gamoyofilia gulyris ori ZiriTadi tipi: fokaluri

da generalizebuli.

epilefsiuri gulyrebis saerTaSoriso klasifikacia (Commission, 1981)* I. fokaluri gulyrebi A. martivi parcialuri

1. motoruli simptomebiT fokaluri motoruli marSis gareSe, fokaluri motoruli marSiT, versiuli, posturuli, fonatoruli 2. somatosensoruli an specifikuri sensoruli simptomebiT somatosensoruli, vizualuri (mxedvelobiTi), auditoruli, olfaqtoruli, gustatoruli, TavbruTi

3. avtonomiuri simptomebiT sifermkrTale, ofldena, piloereqcia, SegrZnebebi epigastriumSi, gugebis dilatacia, wamowiTleba

genetikuri epilefsiebi

samSobiaro travma

intrakraniuli

hemoragia

intrakraniuli

infeqciebi

Tavis tvinis travma

hipoqsia

hipoglikemia

hipokalcemia

alkoholi

narkotikebi cerebrovaskuluri

daavadebebi

febriluri gulyrebi

Tandayolili anomaliebi,

tuberozuli sklerozi

nivTierebaTa cvlis

daavadebebi

Tavis tvinis simsivneebi

11

4. fsiqikuri simptomebiT disfaziuri, dismnestiuri, kogniciuri, afeqturi, iluzoruli, struqturuli halucinatoruli

B. rTuli parcialuri

5. martivi parcialuri momdevno cnobierebis SecvliT • martivi parcialuri (A1-A4) momdevno cnobierebis SecvliT • avtomatizmebiT

2. dasawyisidanve cnobierebis SecvliT • mxolod cnobierebis SecvliT • avtomatizmebiT

C. parcialuri gulyra

meoradi

generalizaciiT (tonuri, klonuri,

tonur-klonuri)

1. martivi parcialuri (A) meoradi generalizaciiT 2. rTuli Parcialuri (B) meoradi generalizaciiT 3. martivi parcialuri (A) gardamavali rTulSi (B) Semdgomi

meoradi generalizaciiT

II. generalizebuli gulyrebi (krunCxviTi da arakrunCxviTi)

A. absansebi

1. tipiuri absansi (Petit mal) • mxolod cnobierebis SecvliT;

• susti klonuri komponentiT;

• atonuri komponentiT;

• tonuri komponentiT;

• avtomatizmiT;

• avtonomiuri komponentiT.

2. atipiuri absansi

• tonusis meti cvlilebiT vidre A1; • TandaTanobiTi dawyebiT da/an damTavrebiT

B. moklonuri

C. klonuri

D. tonuri

E. tonur-klonuri

F. atonuri

III. araklasificirebadi epilefsiuri gulyrebi

IV epilefsiuri statusi

*klasifikacia gamoiyeneba epileftologiaSi Sida samedicino momsaxurebisTvis

epilefsiebisa da epilefsiuri sindromebis saerTaSoriso klasifikacia (Commission, 1989)*

epilefsia, gulyraTa Soris periodSi, SesaZloa, sruliad usimptomod mimdinareobdes,

an vlindebodes mravalferovani klinikuri da eleqroencefalografiuli fenomenebiT.

aRniSnuli simptomebis, gulyraTa saxeobis, daavadebis etiologiuri faqtorebis,

eplefsiis manifestaciis asakisa da mimdinareobis Taviseburebebis sxvadasxva

kombinacia qmnis erTmaneTisagan gansxvavebul, metnaklebad stereotipul

eleqtroklinikur epilefsiur sindromebs

12

I lokalizaciadamokidebuli (kerovani, fokaluri, lokaluri, parcialuri) epilefsiebi) A. idiopaTiuri (pirveladi)

01. bavSvTa asakis keTilTvisebiani epilefsia centro-temporaluri pikebiT

02. bavSvTa epilefsia oqcipitaluri paroqsizmebiT

03. kiTxvis pirveladi epilefsia !

B. simptomuri (meoradi)

04. safeTqlis wilis epilefsiebi

05. Sublis wilis epilefsiebi

06. Txemis wilis epilefsiebi

07. kefis wilis epilefsiebi

08. bavSvTa qronikuli progresuli epilepsia partialis continua

09. sindromebi specifikuri gamRizianebliT aRZruli gulyrebiT

C. kriptogenuli (gansazRvravs etiologia, anatomiuri lokalizacia, gulyris tipi)

II. generalizebuli epilefsiebi

A. idiopaTiuri (pirveladi)

01. axalSobilTa keTilTvisebiani ojaxuri krunCxvebi

02. axalSobilTa keTilTvisebiani krunCxvebi

03. CvilTa keTilTvisebiani mioklonuri epilefsia

04. bavSvTa absans epilefsia (piknolefsia)

05. iuveniluri absans epilefsia

06. iuveniluri mioklonuri epilefsia (impulsiuri Petit mal)

07. epilefsiebi gamoRviZebis krunCxviTi gulyrebiT

08. sxva generalizebuli idiopaTiuri epilefsiebi

09. epilefsiebi specifikuri modalobis stimulebiT aRZruli gulyrebiT

B. kriptogenuli an simptomuri

10. vestis sindromi (infantiluri spazmi)

11. lenoqs-gastos sindromi

12. epilefsia mioklonur-astaturi gulyrebiT

13. epilefsia mioklonuri absansebiT

C. simptomuri (meoradi)

14. adreuli mioklonuri encefalopaTia

15. adreuli infantiluri epilefsiuri encefalopaTia eeg-ze gantvirTvaTa supresiiT

16. sxva simptomuri generalizebuli epilefsiebi

III.gaurkveveli epilefsiebi

A rogorc generalizebuli, ise fokaluri gulyrebiT

17. axalSobilTa gulyrebi

18. CvilTa mZime mioklonuri epilefsia

19. epilefsia ganuwyveteli piktalRovani aqtivobiT nel ZilSi

20. SeZenili epilefsiuri afazia (landau-klefneris sindromi)

21. sxva gaurkveveli epilefsiebi B.gaurkveveli generalizebuli da fokaluri maxasiaTeblebiT IV. specialuri sindromebi

A. situaciiT ganpirobebuli gulyrebi

22. febriluri krunCxvebi

23. izolirebuli gulyra an izolirebuli epilefsiuri statusi

24. gulyrebi mwvave an toqsikuri faqtorebis zemoqmedebisas (alkoholi, medikamentebi, eklamfsia,

metaboluri darRvevebi)

*klasifikacia gamoiyeneba epileftologiaSi Sida samedicino momsaxurebisaTvis

• epilefsiur gulyraTa da sindromTa saerTaSoriso klasifikaciebi gamoiyeneba

epileftologiaSi, Sida samedicino momsaxurebisTvis;

• saerTaSoriso samedicino-statistikuri sistema iyenebs epilefsiur

mdgomareobaTa saerTaSoriso klasifikacias

13

epilefsiur mdgomareobaTa saerTaSoriso klasifikacia (ICD-10)*

kodi

(ICD-10)

epilefsiuri mdgomareoba

(ICD-10)

G. 40 epilefsia

G .40. 0 idiopaTiuri fokaluri (parcialuri) epilefsiebi da fokaluri

epilefsiuri sindromebi

G. 40. 1 simptomuri fokaluri (parcialuri) epilefsiebi da epilefsiuri

sindromebi martivi fokaluri gulyrebiT

G. 40. 2 simptomuri fokaluri (parcialuri) epilefsiebi da epilefsiuri

sindromebi rTuli fokaluri gulyrebiT

G. 40. 3 idiopaTiuri generalizebuli epilefsia da epilefsiuri sindromebi

G. 40. 4 sxva generalizebuli epilefsia da epilefsiuri sindromebi

G. 40. 5 specifikuri epilefsiuri sindromebi

G. 40. 6 epilefsia araklasificirebuli krunCxviTi gulyrebiT (petit mal-iT an

mis gareSe) G. 40. 7 araklasificirebuli petit mal gulyrebi generalizebuli

krunCxviTi gulyrebis gareSe

G. 40. 8 sxva epilefsiebi

G. 40. 9 araklasificirebuli epilefsiebi

G. 41 epilefsiuri statusi

G. 41. 0 generalizebuli krunCxviTi gulyrebis statusi

G. 41. 1 absans gulyrebis statusi

G. 41. 2 rTuli fokaluri (parcialuri) gulyrebis statusi

G. 41. 8 sxva tipis gulyrebis epilefsiuri statusi

G. 41. 9 araklasificirebuli gulyrebis statusi

*klasifikacia gamoiyeneba saerTaSoriso samedicino moxmarebisaTvis

epilefsiis garTulebebi:

samedicino

fsiqo-socialuri

1. epilefsiuri statusi -1%

2. bronqopnevmonia – 1,7-7,9%;

3. mwvave alergiuli mdgomareobebi

(mkurnalobis sawyis etapebze) 5-10%;

4. depresia – ZiriTadad safeTqlis

wilis epilefsiiT daavadebulebSi

(20%);

5. postiqtaluri fsiqozi – 18%;

6. qronikuli fsiqozi -- 20%;

7. osteoporozi, travmatizmi (Zvlis

motexilobebi, qala-tvinis travmebi).

1. swavlis problemebi–32% (xSiria 18

wlis asakamde dawyebuli

epilefsiiT daavadebulebSi);*

2. qcevis problemebi (bavSvebSi)

3. samsaxuris problemebi;

4. ojaxis Seqmnis problemebi;

5. Svilosnobis problemebi;

6. sajariso saqmianobis problemebi,..

*msd: IV.

5. epilefsiis diagnostika

epilefsiis tipis zusti dadgena adekvaturi mkurnalobis umTavresi

winapirobaa. daavadebis diagnostika rTuli safexurebrivi procesia,

romelic pirveladi jandacvis rgolidan iwyeba.

etapobrivi sqema pirvelad manifestirebuli gulyris SemTxvevaSi

ojaxis eqimi, eWviT epilefsiis arsebobaze (ix. protokoli #1),

epilefsiis winaswari diagnozis dadgenis mizniT, pacients mimarTavs

nevrologTan.

14

I

II

pirveli etapi

pirveladi diagnostika pjd-doneze ojaxis eqimi - eWvi epilefsiis arsebobaze (protokoli #1) anamnezi _ epilefsiis arsebobaze eWvi gamoiTqmis da fiqsirdeba

ojaxis eqimis mier, Setevis detaluri aRwerilobisa (pacientisagan, an

ukeTes SemTxvevaSi, Setevis TviTmxilvelisagan) da sxva damatebiTi

monacemebis SejerebiT (ojaxuri anamnezi, socialuri anamnezi,

Terapiuli anamnezi).

saTanado trenirebis Semdeg ojaxis eqimi, klinikuri monacemebis

safuZvelze, pacients eWviT epilefsiis arsebobaze agzavnis

nevrologTan specializebuli momsaxurebisTvis (arareferensi).

nevrologi -epilefsiis winaswari diagnozi

epilefsiis winaswari diagnozi dgindeba nevrologis (arareferensi)

mier daavadebis mimdinareobis, gulyris tipisa da sxva damatebiTi

monacemebis safuZvelze.

Setevis detaluri aRweris sqema

nevrologi, epilefsiis winaswari diagnozis dadgenis SemTxvevaSi,

pacients mimarTavs specializibul dawesebulebaSi (ix. protokoli #1).

• winaswari diagnozi ar unda eyrdnobodes calkeuli simptomis

arsebobas an ararsebobas.

• epilefsiuri gulyris dasadastureblad, samedicino momsaxurebis

yvela doneze, kardinaluri mniSvneloba aqvs Setevis formulis

zedmiwevniT zust aRwerilobas:

15

gulyramde

rodis ganviTarda

gulyra? • asaki pirveli gilyrisas;

• SesaZlo mizezi (hiperTermia, mocimcime

Suqi, televizori, uZiloba, SimSili da

sxv.);

• raime daavadebis fonze (infeqcia, intoqsikacia);

• alkoholi, narkotikebi;.

• ZilSi, RviZilSi, gamoRviZebisas (saaTi);

orsulobis an menstruaciis fonze.

ra mdgomareobaSi

ganviTarda gulyra? • dgomisas, jdomisas, wolisas,

wamodgomisas, da sxv;

• xalxmraval adgilas, marto yofnisas.

gulyris dros

ra formiT gamov-

linda gulyra?

• waqceviT, uecari vardniT, CamuxlviT,

dajdomiT;

• mimdinare moqmedebis SewyvetiT, axali

qmedebis dawyebiT, umizno qceviT, bruniT

an wriuli moZraobebiT (mimarTuleba) da

sxv;.

• krunCxvebiT, nerwyvdeniT, enis mikvnetiT,

duJiT;

• vokalizaciiT, miokloniebiT,

avtomatizmebiT da sxv;

• sxvadasxva SegrZnebiT (sensoruli,

fsiqikuri, vegetatiuri).

cnobierebis done

Setevis dros • naTeli;

• Secvlili;

• daTrgunuli;

• dakarguli.

gulyris Semdeg

gulyris Semdgomi

mdgomareoba

• Setevis dasasruli uecaria Tu

TandaTanobiTi;

• agzneba, dezorientacia, Zilianoba;

• parezi, metyvelebis moSla, Tavis tkivili,

gulisreva, Rebineba;

• sxeulis temperatura;

• travmuli dazianebebi.

gulyris xangrZli-

voba

Tu SesaZlebelia, zusti an miaxloebiTi

diferenciuli diagnozi

paroqsizmuli motoruli fenomenebi, cnobierebisa da qcevis uecari

darRvevebi, SeteviTi vegetatiuri cvlilebebi epilefsiis garda sxva

daavadebebisTvisacaa damaxasiaTebeli. araepilefsiuri genezis

paroqsizmebi zogjer ise hgavs generalizebul an fokalur

epilefsiur gulyrebs, rom maTi diferencireba gamocdili

epileftologebisTvisac gaZnelebulia (msd III). epilefsiuri gulyrebi,

ZiriTadad, qvemoT CamoTvlili araepilefsiuri Setevebisagan unda

diferencirdes:

• sinkope;

• fsiqogenuri Setevebi;

• respiratorul-afeqturi Setevebi;

• tranzitoruli cerebruli iSemia;

• ZilTan dakavSirebuli darRvevebi;

• Sakiki;

qs r p r m r b

16

specialistebisTvis yvelaze rTulia epilefsiuri, sinkopaluri (msd III)

da fsiqogenuri (msd IV) Setevebis diferencireba da swored amitom,

epilefsiis diagnostikuri Secdomebi, ZiriTadad, aseTi mdgomareobebis

dros gvxvdeba.

epilefsiuri d sinkopaluri Setevebis diferenciuli diagnozi

parametrebi sinkope Eepilefsiuri gulyra

sxeulis mdebareoba Setevis

dawyebisas vertikaluri nebismieri

Setevis ganviTarebi periodi dRisiT dRisiT da RamiT

kanis feri Setevisas sifermkrTale normaluri an cianozuri

aura Tavbru, mxedvelobis

dabindva specifikuri

Setevis dasawyisi TandaTanobiTi uecari

Setevis xangrZlivoba 15-20 wm damokidebulia gulyris tipze

travmatizacia Zlier iSviaTad SesaZloa

enis mokvneta Zlier iSviaTad 30%

urinacia SesaZloa SedarebiT xSiria (30%)

Setevis Semdgomi

dezorientacia iSviaTad mosalodnelia

avtomatizmebi ara mosalodnelia

eeg interiqtalurad

(SetevaTa Soris periodi) norma

damaxasiaTebeli cvlilebebiT

an normaluri

eeg iqtalurad (Setevisas) Seneleba epilefsiuri fenomenebi

epilefsiuri da fsiqogenuri Setevebis diferenciuli diagnozi

parametrebi

fsiqogenuri gulyra E

epilefsiuri gulyra

gamomwvevi mizezi emociuri darRvevebi sxvadasxva

xangrZlivoba ZiriTadad 5 wT-ze meti ramdenime wamidan

5 wT-mde

17

motorika

rigidoba, opistotonusi,

aridebis mcdeloba, kidurebis

araregularuli moZraobebi,

Tvalebis naZaladevi daxuWva,

menjis qneva, Tavis gverdiTi

moZraoba.

stereotipuli, avtomaturi

qceva rTuli parcialuri

gulyrisas

mowmeebi xSirad maTi TandaswrebiT ara aqvs mniSvneloba

SeteveTa dRe-Ramuri

ganawileba dRisiT dRisiT an RamiT

urinacia SesaZloa SesaZloa

travmatizacia iSviaTia dasaSvebia

eeg iSviaTad epilefsiisTvis

damaxasiaTebeli fenomenebi epilefsiis maxasiaTeblebi

sugesciis Sedegad

gulyris imitacia xSiria iSviaTia

Sedegebis mixedviT nevrologis moqmedebis strategiebi:

nevrologi-epileftologi

daavadebis dawyebisa da mimdinareobis, Setevis detaluri aRwerilobis,

misi ganviTarebis xelSemwyobi mizezebis, daavadebis diferenciuli

diagnostikis srulyofili monacemebis SejerebiT nevrologs, umravles

SemTxvevaSi, SeuZlia miiRos epilefsiis winaswari diagnozis sasargeblo

an sapirispiro gadawyvetileba.

Seteva araepilefsiuria

Seteva epilefsiuria

pacienti igzavneba saTanado specialistTan

pacienti igzavneba nevrologTan

specializirebul dawesebulebaSi

epilefsiis saboloo

diagnostirebisaTvis.

• Tu aucilebelia specifikuri

gamokvlevebis warmoeba, pacients, mis

ojaxs da/an meurves unda miewodos

misi daavadebis Sesaxeb Sesabamisi

informacia, ganemartos specifikuri

gamokvlevebis saWiroeba da amis

Semdeg unda iqnas mimarTuli

Sesabamis specialistTan.

specializirebuli dawesebuleba

epilefsiis daskvniTi diagnostika

epilefsiuri gulyrebisa da sindromebis diagnostirebis procesSi unda vixelmZRvaneloT epilefsiis winaarmdeg mebrZoli saerTaSoriso ligis (Engel, 2001) mier mowodebuli Semdegi etapobrivi sqemiT:

1. gulyris xasiaTis dadgena: gulyris detaluri aRwera

(Setevis fenomenologia);

2. epilefsiuri gulyris klasifikacia: gulyris tipi/tipebi;

3. epilefsiuri sindromis klasificireba;

4. etiologiuri faqtoris gansazRvra;

5. davadebaTa saerTaSoriso klasifikaciis kriteriumebiT (DSM-IV) daavadebulis fsiqikuri ganviTarebis Sefaseba.

18

anamnezi – specializirebuli dawesebulebis nevrologma da

epileftologma ganmeorebiT unda Seagrovon daavadebisa da gulyris

mimdinareobis detaluri anamnezi. yuradReba unda miaqcion ojaxuri

anamnezis, daavadebulis fizikuri da fsiqikuri zrda-ganviTarebis,

gulyris mimdinareobis TiToeul umniSvnelo detalsac ki. aRniSnuli

procesi, rogorc wesi, 2-3 saaTi grZeldeba, zog SemTxvevaSi ki

ramodenime dRec ki arasakmarisia. umjobesia, Tu anamnezs cal-calke

Seagrovebs ori sxvadasxva epileftologi, radgan daavadebis

stigmatizaciis gamo, pacientis konkretuli eqimisadmi individuri

ganwyoba mniSvnelovnad ganapirobebs anamnezis srulyofilebis

xarisxs.

6. paraklinikuri gamokvlevebi

eleqtroencefalografiuli (eeg) gamokvleva

epileftologis mier srulyofili anamnezis Segrovebis Semdeg

dgindeba epilefsiis savaraudo tipi da iwyeba aucilebeli

paraklinikuri gamokvlevebi

eeg-kvleva

unda awarmoos eleqtrofiziologma, romelsac specialuri wvrTna aqvs

gavlili epilefsiis samedicino da fsiqo-socialur sakiTxebSi. eeg monacemebis Sefaseba (daskvna) unda awarmoos klinikurma eleqtrofiziologma (epileftologi-eleqtrofiziologi)

eeg-kvleva unda Catardes mxolod CamoTvlil SemTxvevebSi:

• epilefsiis diagnozis dasadastureblad;

• gulyris tipisa da epilefsiuri sindromis gasarkvevad;

• daavadebis swori prognozis gansazRvris mizniT;

• gulyris ganmeorebis riskis Sesafaseblad.

19

rodesac pacients gulyrebi aReniSneba sunTqvis gaxSirebis an

fotostimulaciis dros (televizori, kompiuteri da sxv),

aqtivaciuri cdebis Catarebisas gulyris ganviTarebis albaToba

maRalia. amitom, aseT SemTxvevebSi, fotostimulaciisa da

hiperventilaciis standartuli cdebi unda Catardes pacientTan,

misi ojaxis wevrebTan da/an meurvesTan gasaubrebis Semdeg.

neirovizualuri kvlevis meTodebi

neirovizualuri kvlevis meTodebi saWiroa Tavis tvinis im

struqturuli dazianebebis gamosavlenad, romlebmac SesaZloa

gamoiwvion epilefsiuri gulyrebi. amasTan, epilefsiiT

daavadebulebisTvis upiratesoba eniWeba Tavis tvinis birTvul-

magnitur-rezonansul (bmr) gamosaxvas. saWiroebis SemTxvevaSi,

gamokvleva unda Catardes pirveli gulyridan ori kviris ganmavlobaSi.

epilefsiis diagnostirebisTvis mxolod eeg-gamokvlevis monacemebs ar unda daeyrdnoT!

epilefsiis diagnozi dgindeba mxolod multidisciplinuri jgufis - epileftologi, neirofsiqologi da klinikuri eleqtrofiziologi

erToblivi gadawyvetilebis safuZvelze

.

pirveladi momarTvisas eeg-kvleva ar tardeba: • sinkopeze dasabuTebuli eWvis SemTxvevaSi;

• rodesac Setevis klinikuri maxasiaTeblebi (enurezi, Ramis SiSi da

a.S.) araepilefsiuri genezis sasargeblod metyvelebs;

• epilefsiis diagnozi gamosaricxia;

o sawyis etapze Zilisa da Zilis deprivaciis eeg-diagnostika ar gamoiyeneba;

o video-eeg-monitoringi da sxva specifikuri gamokvlevebi unda Catardes im SemTxvevebSi, rodesac gaZnelebulia epilefsiuri da

20

kompiuteruli tomografia (kt) gamoiyeneba mwvave nevrologiuri

paTologiis an bmr kvlevis ukuCvenebis SemTxvevebSi.

neirofsiqologiuri testireba

sxva damatebiTi gamokvlevebi: • sisxlis saerTo analizi, eleqtrolitebis, glukozis gansazRvra

sisxlis SratSi da sxva specifikuri testebi;

• Tu arsebobs dasabuTebuli eWvi sinkopeze, mizanSewonilia,

eleqtrokardiografiuli kvleva da kardiologis konsultacia.

sxva damatebiTi konsultaciebi saWiroebis SemTxvevaSi: • fsiqiatris konsultacia;

• endokrinologis konsultacia;

• reproduqtologis konsultacia da sxv.

bmr gamokvleva sasurvelia yvela SemTxvevaSi; aucilebelia, rodesac: • epilefsia iwyeba 2 wlamde an zrdasrul asakSi;

• anamnezi, klinikuri monacemebi da eeg gamokvleva miuTiTebs

fokaluri Setevis arsebobaze (keTilTvisebiani fokaluri

epilefsiis aSkara arsebobis garda);

• epilefsiis adekvaturi antikonvulsiuri mkurnalobis miuxedavad

gulyrebi ar wydeba.

ar aris aucilebeli: • idiopaTiuri generalizebuli epilefsiuri sindromebis dadgenis

SemTxvevaSi.

unda Catardes: • axladdiagnostirebul SemTxvevebSi, antikonvulsiuri mkurnalobis

dawyebamde pacientis kognituri funqciebis da emociuri sferos

Sesafaseblad;

• epilefsiis sindromologiuri diagnozis dasazusteblad;

• SemdgomSi kognitur funqciebze antikonvulsantebis SesaZlo zegavlenis

Sesafaseblad;

• rodesac vlindeba sirTuleebi swavlaSi, qcevaSi an emociur sferoSi;.

• bmr kvleviT vlindeba Tavis tvinis im ubnebis paTologia, romlebic metad

mniSvnelovania umaRlesi fsiqikuri procesebis ganxorcielebisaTvis.

• aRiniSneba mexsierebis daqveiTeba an sxva kognituri deficiti.

21

klinikuri da paraklinikuri gamokvlevebis monacemTa

sistematizacia:

fokaluri da generalizebuli epilefsiebis ZiriTadi maxasiaTeblebi:

parametri generalizebuli

epilefsiuri sindromebi fokaluri

epilefsiuri sindromebi

gamovlenis asaki

bavSvobis an pubertatis

asaki

nebismieri

gulyris tipebi absansi, mioklonia,

pirveladad

generalizebuli tonur-

klonuri krunCxviTi

gulyrebi (ZiriTadad

gamoRviZebis)

martivi parcialuri:

motoruli, somatosensoruli

an specifikuri sensoruli,

vegetatiuri, fsiqikuri

simptomebiT;

rTuli parcialuri –

cnobierebis SecvliT da

avtomatizmebiT;

meoradad generalizebuli

tonur- klonuri krunCxviTi

gulyrebi.

gulyris gamomwvevi

mizezi

Zilis deprivacia,

alkoholi,

fotostimulacia.

tvinis rezidualuri (pre, peri

da postnataluri) an

procesualuri

(sisxlZarRvovani, moculobiTi,

degeneraciuli,

neirometaboluri an anTebiTi)

daavadebebi.

genetikuri

ganpirobebuloba

xSiria iSviaTia (degeneraciuli

metaboluri daavadebebi).

anamnezSi febriluri

gulyra

iSviaTia xSiria

mentaluri statusi ZiriTadad normaluria ufro xSirad vlindeba

22

epilefsiuri keris Sesabamisi

simptomatika.

kerovani

nevrologiuri

niSnebi

ar vlindeba xSiria

eeg fotoparoqsizmuli

aqtivoba;

generalizebuli

bilateraluri aqtivoba

_ 3 pik-talRa/wamSi;

bilateraluri pik-

talRovani, polipikuri

an polipik-talRovani

aqtivoba.

epilefsiuri fenomenebis

aqtivacia

hiperventilaciis dros

fokaluri kerovani aqtivoba

birTvul-magnitur-

rezonansuli

kvlevis Sedegi

Tavis tvinis struqturuli

dazianeba ar vlindeba.

SemTxvevaTa 50-60%-Si dgindeba

etiologiuri faqtori

monacemTa sistematizaciis Semdgom

specializirebuli dawesebulebis nevrologis (epileftologis)

moqmedebis strategiebi

7. epilefsiis mkurnaloba farmakologiuri mkurnaloba specializirebul (referensi) dawesebulebaSi nevrologisa da

epileftologis mier daavadebis detaluri anamnezis Sekrebis,

gulyris tipebis dadgenis, neirofsiqologiuri da eeg-gamokvlevebis,

saWiroebis SemTxvevaSi neirovizualuri (kt, bmr) kvlevis, sxva

konsultaciebis monacemebis safuZvelze dgindeba epilefsiis

sindromologiuri diagnozi da iniSneba adekvaturi antikonvulsiuri

mkurnaloba.

epilefsia ar dadasturda

epilefsia dadasturda

pacienti igzavneba saTanado specialistTan

iwyeba adekvaturi antiepilefsiuri mkurnaloba

23

.

antiepilefsiuri mkurnalobis strategia

mkurnalobis dawyeba

antiepilefsiuri mkurnaloba ar unda daiwyos Tu:

• gulyra erTjeradia;

• gulyrebi Zalze iSviaTia (ramdenime weliwadSi erTxel);

• arsebobs gulyris gamomwvevi faqtorebi (alkoholizmi, narkomania, mwvave

metaboluri stresi, hiperTermia, emociuri stresi, Zilis nakleboba);

• SesaZlebelia Setevebis Tavidan acileba (fotosensitiuri epilefsiebi,

refleqsuri meqanizmebi);

• gamocdilma epileftologma, SesaZloa, mkurnalobisagan Tavi Seikavos

bavSvTa keTilTvisebiani epilefsiuri sindromebis SemTxvevebSi.

situaciuri gulyrebis marTva:

o alkoholuri (narkotikebis) abstinenciis da deliriumis SemTxvevaSi,

mizanSewonilia, benzodiazepinebis (diazepamis) xanmokle kursis Catareba,

epilefsiuri gulyrebis aRmocenebis riskis Sesamcireblad;

o Tavis tvinis mwvave travmis da/an neiroqirurgiuli Carevis SemTxvevaSi

antikonvulsantebiT profilaqtikuri mkurnaloba mizanSewonili ar aris;

o antikonvulsantebi, romlebsac pacienti Rebulobs Tavis tvinis mwvave

dazianebiT gamowveuli gulyrebis profilaqtikisTvis, TandaTanobiT unda

moixsnas.

pirveli araprovocirebuli gulyris Semdeg mkurnaloba

unda daiwyos Tu:

• pacients generalizebul gulyramde aReniSneboda fokaluri gulyrebi;

• pacients generalizebul gulyramde aReniSneboda miokloniebi an

absansebi;

• meore gulyris ganviTarebis riski maRalia;

• pacients aReniSneba kerovani nevrologiuri simptomebi;

• eeg-ze sarwmuno epilefsiuri fenomenebia;

• neirovizualuri meTodebiT vlindeba Tavis tvinis struqturuli

dazianeba;

• pacienti, misi ojaxis wevrebi da/an meurve dauSveblad miiCneven

gulyrebis ganmeorebas.

antikonvulsanti unda daniSnos nevrologma, romelsac specialuri ganaTleba aqvs miRebuli epilefsiis samedicino, fsiqo-socialur da

eleqtrofiziologiur sakiTxebSi.

24

1. antikonvulsantis SerCeva

saqarTveloSi registrirebuli antikonvulsantebi Zveli Taobis: fenobarbitali, fenitoini, benzodiazepinebi,

karbamazepini, natriumis valproati;

axali Taobis: lamotriJini, topiramati, gabapentini; uaxlesi Taobis: ar aris registrirebuli.

antikonvulsantebis efeqturoba epilefsiuri gulyris tipebis mixedviT

gulyris tipi pirveli rigis meore rigis sxva SesaZlo

ar

gamoiyeneba (auaresebs)

pirveladad

generalizebuli

valproati

lamotrigini

acetazolamidi

fenobarbitali*

vigabatrini

karbamazepini*

antiepilefsiuri preparatis SerCevis ZiriTadi kriteriumebi:

• gulyris tipi an tipebi;

• epilefsiuri sindromis tipi;

• Tanmxlebi daavadebebi;

• Tanmxlebi mkurnaloba;

• pacientis cxovrebis reJimi.

inglissa da amerikaSi Catarebulma farTomasStabianma gamokvlevebma cxadhyo,

rom epilefsiiT daavadebuli pacientebi, romlebic mkurnaloben pirveladi

jandacvis doneze, SemTxvevaTa 25-50%-Si Rebuloben araSesabamis

antikonvulsiur medikaments. gansakuTrebiT xSiria idiopaTiuri

generalizebuli epilefsiuri sindromebis SemTxvevebSi karbamazepinisa da

fenitoinis gamoyeneba (msd-IV), rac kategoriulad dauSvebelia, radgan es

preparatebi iwvevs arakrunCxviTi epilefsiuri gulyrebis (absansebisa da

miokloniebis) aRmocenebasa da gaxSirebas.

saqarTveloSi, 2005-2006 ww saxelmwifo programis `epilefsiis profilaqtika da

mkurnaloba~ farglebSi pacientTa gamokvlevebiT gamovlinda rom

daavadebulTa 70%-i Rebulobs araadekvatur mkurnalobas.

evropis epilefsiis akademiis (EUREPA), epilefsiis winaaRmdeg mebrZoli

saerTaSoriso ligisa (ILAE) da epilefsiis saerTaSoriso biuros (IBE) gadawyvetilebiT, miCneulia, rom epilefsiis diagnostireba da antiepilefsiuri

mkurnalobis daniSvna unda moxdes epileftologiis sakiTxebSi ganswavluli

nevrologis mier, saTanado gamokvlevebisa da konsultaciebis monacemTa

multidisciplinuri Sejerebis Semdeg.

25

tonur-klonuri topiramati* fenitoini*

absansebi valproati

eTosuqsimidi

lamotrigini

klonazepami

topiramati*

karbamazepini*

gabapentini

vigabatrini

miokloniebi valproati

klonazepami

lamotrigini

piracetami

topiramati*

karbamazepini*

gabapentini

vigabatrini

tonuri valproati

lamotrigini

klonazepami

topiramati*

acetazolamidi

fenobarbitali*

fenitoini*

karbamazepini*

atonuri valproati

lamotrigini

klonazepami

topiramati*

acetazolamidi

fenobarbitali

karbamazepini*

fenitoini*

fokaluri meoradi

generalizaciiT an

mis gareSe

karbamazepini*

lamotrigini

valproati

topiramati*

klobazami

gabapentini

fenitoini*

acetazolamidi

klonazepami

fenobarbitali*

* RviZlis fermentebis mainduqciebeli preparatebi.

antikonvulsantebis efeqturoba epilefsiuri sindromebis

mixedviT

epilefsiuri sindromi

pirveli rigis

meore rigis sxva SesaZlo

ar

gamoiyeneba (auaresebs)

bavSvTa absans-

epilefsia

eTosuqsimidi

lamotriJini

valproati

topiramati* karbamazepini*

fenitoini*

vigabatrini

iuveniluri absans-

epilefsia

lamotriJini

valproati

topiramati* karbamazepini*

fenitoini*

vigabatrini

iuveniluri

mioklonuri-

epilefsia

lamotriJini

valproati

klonazepami

topiramati*

acetazolamidi

fenobarbitali

karbamazepini*

fenitoini*

vigabatrini

mxolod

generalizebuli

tonur-klonuri

gulyra

valproati

lamotriJini

topiramati*

klonazepami

fenobarbitali*

fenitoini*

karbamazepini*

vigabatrini

fokaluri

epilefsiebi:

kriptogenuli an

simptomuri

karbamazepini*

lamotriJini

valproati

topiramati

gabapentini

fenitoini*

acetazolamidi

klonazepami

fenobarbitali*

primidoni*

infantiluri

spazmebi

steroidebi

vigabatrini

klonazepami

valproati

topiramati*

nitrazepami karbamazepini*

keTilTvisebiani

epilefsia

centrotemporalur

i pikebiT

karbamazepini*

lamotrJini

valproati

topiramati*

26

keTilTvisebiani

epilefsia

oqcipitaluri

paroqsizebiT

karbamazepini*

lamotriJini

valproati

topiramati*

mZimed mimdinare

bavSvTa asakis

mioklonuri

epilefsia

klonazepami

valproati

topiramati

fenobarbitali* karbamazepini*

lamotriJini

vigabatrini

gaxangrZlivebuli

pik-talRovani

aqtivoba nel ZilSi

klonazepami

eTosuqsimidi

lamotriJini

valproati

steroidebi

topiramati* karbamazepini*

vigabatrini

lenoqs-gastos

sindromi

lamotriJini

valproati

topiramati*

klonazepami

eTosuqsimidi

karbamazepini*

landau-klefneris

sindromi

lamotriJini

valproati

steroidebi

topiramati karbamazepini*

mioklonur-

astaturi epilefsia

klonazepami

valproati

topiramati*

lamotriJini

karbamazepini*

* RviZlis fermentebis mainduqciebeli preparatebi.

antikonvulsantebis asakobrivi SezRudvebi

antikonvul

santi

moqmedebis speqtri

asakobrivi zRvari

karbamazepini* fokaluri da generalizebuli tonur-

klonuri krunCxviTi gulyrebi

asaki SezRuduli ar

aris

klonazepami yvela tipis gulyris samkurnalod, garda

generalizebuli krunCxviTi gulyrebisa

asaki SezRuduli ar

aris

eTosuqsimidi

monoTerapiis saxiT - absansis

samkurnalod, rogorc damatebiTi

saSualeba - Tu sxva gulyrebs Tan

daerTvis absansi

asaki SezRuduli ar

aris

lamotriJini

(lamiqtali)

martivi/rTuli fokaluri, meoradad

generalizebuli da pirveladad

generalizebuli krunCxviTi gulyrebis

dros, lenoqs-gastos sindromis

SemTxvevaSi

gamonaklisis saxiT

iniSneba 12 wlamde

asakis bavSvebSi

fenobarbitali

*

yvela SemTxvevaSi, garda absansisa asaki SezRuduli ar

aris

fenitoini* fokaluri da meoradad generalizebuli

gulyrebis dros

asaki SezRuduli ar

aris

valproati

yvela tipis Setevis SemTxvevaSi asaki SezRuduli ar

aris

(sifrTxiliT 2 wlamde

asakis bavSvebSi da

pubertaciis periodSi)

topiramati*

(topamaqsi)

fokaluri da meoradad generalizebuli

gulyrebis SemTxvevaSi, lenoqs-gastos

sindromis dros

6 wlamde ar

gamoiyeneba

27

vigabatrini

monoTerapiul reJimSi uestis sindromis

dros, poliTerapiulad rezistentuli

fokaluri gulyrebis SemTxvevaSi

asaki SezRuduli ar

aris

* RviZlis fermentebis mainduqciebeli preparatebi.

2. antikonvulsantis dozireba

ZiriTadi antikonvulsantebis dRiuri doza da miRebis jeradoba

antikonvulsanti

dRiuri doza mg/kg/dReSi (Terapiuli koncentraciis zRvari)

miRebis jeradoba

preparatis sawyisi doza

(titracia kviraSi)

bavSvebi mozrdilebi

bavSvebi mozrdilebi

acetazolamidi

(diakarbi) 10-20

(40-100 mg/l)

10 – 25

(40-100 mg/l) 2 - -

karbamazepini

(finlepsini)

30

(3-12 mg/l)

10 – 25

(3-12 mg/l) 2 – 3 5 mg/kg/dR 100-200 mg

klonazepami

(rivotrili) 0,15 (0,015-0,075mg/l)

0,25 – 1,5 (p/os)

0,1 - 0,3 (i/v) 2 – 3 0.025 mg/kg/dR 0,25-0,5 mg

eTosuqsimidi

(suqsilepi) 10-40

(40-100 mg/l)

15 – 35

(40-100 mg/l) 2 – 3 10 mg/kg/dr 250-500 mg

gabapentini

(gabagama) 30-100

(2-20 mg/l)

30 – 45

(2-20 mg/l) 3 10 mg/kg/dR 300-600 mg

lamotriJini

(lamiqtali) -

5-15

(100-200 mg/l) 2

0.2 mg/kg/dR

(valproatTan

erTad)

12,5-25 mg

adekvaturi antiepilefsiuri preparatis doza unda SeirCes pacientis

wonaze gadaandariSebiT

28

2 mg/dR

valproatis

gareSe)

levetiracetami

(kepra)*

20-60 mg/kg

(6-20 mg/l)

30 – 40

(6-20 mg/l) 2 5-10 mg/kg 250-500 mg

fenobarbitali

(luminali)

3-7

10-40 mg/l)

4 – 8

(10-40 mg/l)

2 4 mg/kg/dR 25-50 mg

fenitoini

(difenini)

8-10

(10-20 mg/l)

4 – 8

(10-20 mg/l)

2 5 mg/kg/dR 100-200 mg

valproati

(depakini)

30

(30-120 mg/l)

20 – 40

(30-120 mg/l)

2 10 mg/kg/dR 150-300 mg

topiramati

(topamaqsi)

- 2-5 2 2 mg/kg/dR 12,5-25 mg

mkurnalobis sawyis etapze sasurvelia monoTerapia

frTxilad!

• epilefsiis sindromologiuri diagnozis Sesabamisi antikonvulsiuri

mkurnaloba unda daiwyos preparatis minimalurad dabali Terapiuli

dozebiTa da neli titraciiT, raTa Tavidan aviciloT wamlis gverdiTi

efeqtebi;

• pacients xelze unda mieces wamlis dozis matebis sqema;

• pacients unda Cautardes saganmanaTleblo saubari epilefsiis samedicino da

fsiqo-socialur sakiTxebze, mkurnalobis reJimisa da cxovrebis jansaRi wesis

mniSvnelobaze;

• pacients unda ganemartos, rom misi meTvalyureoba da mkurnalobis Semdgomi

etapebis monitoringi warimarTeba pjd-doneze;

• Tu referensis doneze epilefsiuri sindromis klasificireba SeuZlebelia

(SemTxvevaTa 20-25%), an dgindeba mZimed mimdinare epilefsiis diagnozi, aseT

SemTxvevebSi daavadebis marTva xdeba specializirebul dawesebulebaSi,

pacientebi da maTi meurveebi gafrTxilebuli unda iyvnen im wamlebis Sesaxeb,

romelTac SeuZliaT gulyrebis aRmoceneba an gaxSireba.

aminofilini, amfetamini (eqstazi da sxv.), tramadoli, antibiotikebi (penicilini, cefalosporinebi), antidepresantebi, antiqolinerguli preparatebi, Rebinebis sawinaaRmdego saSualebebi, aminazini, baklofeni, ciklosporini, kokaini, izoniazidi, ketamini, lidokaini, liTiumi, vinkristini, viagra.

29

Semdgomi qmedeba

daniSnuli mkurnalobis gamosavlis mixedviT ojaxis eqimisa da

nevrologis moqmedebis strategiebi

Setevebi grZeldeba, Tu:

o pacienti unda gaigzavnos pjd-doneze;

o misi Semdgomi meTvalyureoba unda awarmoos ojaxis eqimma da eqTanma

saTanado sqemebis mixedviT (protokolebi #1);

o nevrologma Tvalyuri unda adevnos daavadebis mimdinareobas.

adekvaturad SerCeuli antiepilefsiuri mkurnalobiT gulyrebis sruli

kupireba miiRweva pacientTa sam meoTxedSi

Tu pacienti icavs daniSnuli mkurnalobis reJims da gulyreba aRara aqvs,

unda SenarCundes wamlis igive Terapiuli doza;

1. adekvaturi antikonvulsantis doza araadekvaturia;

2. pacienti araregularulad Rebulobs preparats;

3. pacienti alkoholis an narkotikebis momxmarebelia.

4. epilefsiis diagnozi arasworia;

5. pacients aReniSneba Tavis tvinis progresirebadi

daavadeba (mag., simsivne);

6. daniSnulia arasaTanado antikonvulsanti.

menejments awarmoebs o ojaxis eqimi

o nevrologi;

menejments awarmoebs o nevrologi-

epileftologi

30

daniSnuli mkurnalobis fonze gulyraTa recidivis SemTxvevaSi ojaxis eqimis moqmedebis strategiebi

Tu pacienti arRvevs mkurnalobis reJims, saWiroa, misi

gaTviTcnobiereba antiepilefsiuri mkurnalobis reJimis dacvis

aucileblobis sakiTxebSi, rac mniSvnelovnad aumjobesebs mkurnalobis

efeqturobas (msd-Ib).

antikonvulsantebis gverdiTi efeqtebi

antikonvul santi

gverdiTi efeqti

idiosinkrazia

karbamazepini

diplopia*, Tavbru*, Tavis tkivili*,

gulisreva*, Zilianoba, neitropenia,

hiponatremia, hipokalcemia, oro-

facialuri diskinezia, ariTmia

wiTelas msgavsi gamonayari*,

agranulocitozi, aplastiuri

anemia, hepatotoqsiuroba,

fotosensitivoba, stivens-

jonsonis sindromi, mgluras

msgavsi sindromi,

Trombocitopenia,

fsevdolimfoma, teratogenoba

klonazepami

advilad daRla,* Zilianoba,*

sedacia*, Tavbru, ataqsia,

agznebadoba, agresia (bavSvebSi),

hiperkinezia (bavSvebSi),

hipersalivacia, bronqorea, fsiqozi,

gamonayari, Trombocitopenia

eTosuqsimidi

gulisreva,* anoreqsia, Rebineba,

aJitacia, Zilianoba, Tavis tkivili,

leTargia

gamonayari, multiformuli

eriTema, stivens-jonsonis

sindromi, mgluras msgavsi

sindromi, agranulocitozi,

aplastiuri anemia

fenobarbitali advilad daRla*, apaTia*, depresia*,

insomnia*(bavSvebSi),

makropapuluri gamonayari,

toqsikuri epidermuli

ojaxis eqimma da eqTanma unda Seagrovos informacia (protokoli #1):

• pacienti daniSnul droze regularulad Rebulobs Tu ara wamals;

• xom ar aviwydeba wamlis regularulad miReba;

• xom ar Rebulobs alkohols an sxva preparatebs,

• icavs Tu ara cxovrebis jansaR wess;

• wamals ver yidulobs ekonomikuri problemebis gamo da amitom ar

Rebulobs, an Rebulobs arasruli doziT (Cveuli SemTxvevaa

ganviTarebadi qveynebisTvis);

• vlindeba antikonvulsantiT paradoqsuli intoqsikacia.

mkurnalobis procesSi ojaxis eqimma da nevrologma gansakuTrebuli yuradReba unda miaqcios antiepilefsiuri

wamlebis gverdiT efeqtebs!

31

hiperkinezia*(bavSvebSi),

agznebadoba*(bavSvebSi), yuradRebis

gafantuloba*(bavSvebSi), agresia,

mexsierebis daqveiTeba, libidos

daqveiTeba, impotencia, foliumis

mJavis nakleboba, neonataluri

hemoragia, hipokalcemia,

osteomalacia,

nekrolizi, hepatotoqsiuroba,

`gayinuli beWis~ sindromi,

teratogenoba,

fenitoini

nistagmi*, ataqsia*, anoreqsia,

dispefsia, gulisreva, Rebineba,

agresia, depresia, Zilianoba, Tavis

tkivili, gulyrebis paradoqsuli

gaxSireba, megaloblasturi anemia,

hiperglikemia, hipokalcemia,

osteomalacia, neonataluri

hemoragia,

gamonayari*, akne*, RrZilebis

hipertrofia, hirsutizmi,

sisxlis daavadebebi, mgluras

msgavsi sindromi, sisxlis

SratSi imunoglobulin A -s

Semcireba, fsevdolimfoma,

periferiuli neiropaTia,

stivens-jonsonis sindromi,

diupuitrenis kontraqtura,

hepatotoqsiuroba,

teratogenoba

depakini

tremori*, wonis mateba*, anoreqsia,

dispefsia, gulisreva, Rebineba,

alopecia, kidurebis distaluri

nawilebis SeSupeba, Zilianoba,

hiperamonemia, amenorea,

mwvave pankreatiti,

hepatotoqsiuroba,

Trombocitopenia, stupori,

encefalopaTia, teratogenoba,

sakvercxis polikistozi

gabapentini

somnolencia*, Tavbru*, ataqsia*,

advilad daRla*, diplopia*,

paresTezia, amnezia

gulyrebis gaxSireba

lamotriJini

Zilianoba*, diplopia*, Tavis

tkivili*, ataqsia*, insomnia*,

tremori*, gulisreva, Rebineba,

agresia, agznebadoba,

gamonayari*, stivens-jonsonis

sindromi, toqsikuri

epidermuli nekrolizi,

RviZlis ukmarisoba,

aplastiuri anemia,

pancitopenia, Sinagani

organoebis mravlobiTi

dazianeba

vigabatrini

Zilianoba*, advilad daRla*, Tavis

tkivili*, ataqsia*, nistagmi*,

diplopia*, agznebadoba*, depresia*,

fsiqozi, agresia, wonis momateba,

stupori, tremori, koncentraciis

darRveva

mxedvelobis velis defeqti*,

gulyrebis gaxSireba

topiramati

anoreqsia*, wonaSi dakleba*,

yuradRebis koncentraciisa da

metyvelebis darRveva*,

paresTezia*, TirkmelkenWovani

daavadeba, mexsierebis daqveiTeba,

ataqsia

anhidrozi

*yvelaze xSiri gverdiTi efeqtebi

ojaxis eqimisa da eqTnis qmedebebi:

o pacients gaacnos antikonvulsantebis SesaZlo gverdiTi efeqtebi;

o damatebiT auxsnas, mkurnalobis dawyebidan pirveli Tvis ganmavlobaSi

gansakuTrebuli yuradReba miaqcios gamonayars, Zilianobasa da

Rebinebas;

o zemoaRniSnuli gverdiTi efeqtebis gamovlenisTanave informacia

miawodos nevrologs.

32

Tu pacients ar aReniSneba wamlis gverdiTi efeqtebi, icavs

mkurnalobis reJims, magram gulyrebis sruli Sewyveta ver xerxdeba,

ojaxis eqimma igi unda miavlinos nevrologTan (arareferensi)

antikonvulsantis dozis koreqciis mizniT [ix. protokoli #1]:

nevrologis qmedebebi:

gulyrebis recidivis SemTxvevaSi:

1. Tu pacientis mier mkurnalobis reJimis dacvis SemTxvevaSi,

gulyrebi mniSvnelovnad Semcirda, magram maTi sruli kupireba ar

momxdara, wamlis doza unda gaizardos saSualo Terapiul

dozamde da aRniSnuli doza SenarCundes oTxi kviris manZilze; Tu

bolo ori kviris manZilze gulyrebi Sewyda, SenarCundes

saSualo Terapiuli doza.

2. Tu gulyrebis sruli kupireba ver xerxdeba dozis momatebidan

oTxi kviris Semdegac, wamlis doza unda gaizardos maRal

Terapiul dozamde da aRniSnuli doza SenarCundes oTxi kviris

manZilze; Tu gulyrebi Sewyda, SenarCundes aRniSnuli doza.

3. Tu nevrologis mier antikonvulsantis dozis koreqciis Semdeg

gulyrebis kupireba an preparatis gverdiTi movlenebis likvidacia

ver xerxdeba, pacienti kvlav unda gaigzavnos referens-doneze

daavadebis mimdinareobis reviziisa da antiepilefsiuri

mkurnalobis koreqciis mizniT.

wamlis gverdiTi movlenebis SemTxvevaSi

• antiepilefsiuri preparatebis gverdiTi efeqtebis Tavidan

asacileblad saWiroa Seneldes wamlis dozis matebis tempi

(neli titracia);

• sisxlis analizSi umniSvnelo cvlilebebis gamo antiepilefsiuri

preparatis moxsna an Secvla mizanSewonili ar aris.

• Tu wamlis gverdiTi efeqtebis sruli Sewyveta ver xerxdeba

pacienti unda miavlinos referens-doneze.

33

3. antikonvulsantis Secvla

specializebuli dawesebuleba

4. meore antikonvulsantis CarTva (poliTerapia)

mkurnalobisadmi dauqvemdebarebloba (intractability)

• daavadebis monacemebis gadaxedvis (saWiroebis SemTxvevaSi –

gamokvlevebis) Semdeg, mkurnalobaSi unda CairTos sxva preparati

(alternatiuli - pirveli an meore rigis);

• pirveli (daniSnuli) preparati TandaTanobiT unda moixsnas

mxolod mas Semdeg, rodesac pacienti axal medikaments miiRebs

adekvaturi doziT.

Tu gulyrebi kvlav grZeldeba, saWiroa, gadaisinjos epilefsiis

diagnozi specializirebul dawesebulebaSi.

• Tu epilefsiis diagnozi eWvgareSea da gulyrebi kvlav grZeldeba,

mkurnalobaSi unda CairTos meore antikonvulsantic;

• piliTerapia gamoiyeneba mxolod im SemTxvevaSi, rodesac saTanado

dozis antiepilefsiuri preparatebiT monoTerapia ver

uzrunvelyofs gulyrebis srul kupirebas.

• rodesac kombinirebuli mkurnalobis sxvadasxva mcdelobas Sedegi

ar moaqvs, mkurnalobis reJimi unda daubrundes preparatebis im

kombinacias, romlis drosac mkurnaloba yvelaze efeqturi iyo.

34

daavadebulTa 20-25%-Si epilefsia ar eqvemdebareba adekvaturi

antiepilefsiuri mkurnalobis reJims (mag. uestis, lenoqs-gastos da

sxv sindromebi). aseTi refraqtoruli mimdinareobis epilefsiis

arsebobis SemTxvevaSi pacientma ojaxis eqimisa da nevrologis

meTvalyureobidan unda gadainacvlos epileftologis (referensis)

meTvalyureobis qveS.

5. antikonvulsantis moxsnis anu gamojanmrTelebis procesi

Setevebis ganaxlebis riski

• mkurnalobis fonze miRweuli xangrZlivi remisiis pirobebSi

bavSvebSi 20%-ia (msd-IIb), mozrdilebSi - 40% (msd- IIb). minimaluri riski (msd-Ib)

• Tavis tvinis organuli dazianebis ararseboba da normaluri

fsiqikuri statusi;

• iSviaTi gulyrebi mkurnalobis dawyebamde;

• mkurnalobis fonze gulyrebis ararseboba;

• mxolod erTi tipis gulyrebi;

• monoTerapiuli mkurnaloba;

• normaluri reproduqciul-endokrinuli statusi da

arakatamenialuri gulyrebi.

maRali riski (msd-Ib)

• idiopaTiuri generalizebuli epilefsiuri sindromebis dros,

gansakuTrebiT, iuveniluri mioklonuri epilefsiis SemTxvevebSi.

qronikuli epilefsia

• adekvaturi antiepilefsiuri mkurnalobis reJimis pirobebSi pacientTa

75-80%-s sruliad uwydeba gulyrebi;

• aseTi pacientebis 40-60%-s, mkurnalobis sruli kursis Catarebis Semdeg,

SesaZloa, moexsnas mkurnaloba

• es maCvenebeli gansxvavebulia epilefsiuri sindromebis mixedviT.

• im pacientebs, romelTac mkurnalobis fonze 2-3 wlis ganmavlobaSi

gulyra ar hqoniaT, mkurnalobis Sewyvetisa da sruli

gamojanmrTelebis kargi Sansi aqvT.

35

• uyalibdeba pacientebis 20-30%-s; isini saWiroeben xangrZliv

antikonvulsiur mkurnalobas (xSirad sicocxlis bolomde).

prognozulad kargi da cudi mimdinareobis epilefsiebi kargi prognozi*

cudi prognozi**

• bavSvTa asakis absans epilefsia;

• bavSvTa asakis keTilTvisebiani

epilefsia centro-temporaluri

pikebiT;

• bavSvTa asakis epilefsia

oqcipitaluri pikebiT

(panaiotopulosis sindromi);

• keTilTvisebiani neonaTaluri

idiopaTiuri krunCxvebi.

• uestis sindromi; • infantiluri epilefsiuri

encefalopaTia;

• axalSobilTa mZime mioklonuri

encefalopaTia;

• epilefsia partialis continua;

• lenoqs-gastos sindromi;

• progresuli mioklonuri

epilefsiebi;

• kortikaluri displaziis Sedegad

ganviTarebuli epilefsiebi.

msd: *(Ia); ** (Ib).

farmakologiuri mkurnalobis xangrZlivoba

farmakologiuri mkurnalobis xangrZlivobis dagegmva

bavSvebSi: mkurnalobis xangrZlivoba 2 welze naklebi ar unda iyos;

mozrdilebSi: mkurnaloba 5 weliwads mainc unda gagrZeldes.

unda dagegmos epileftologma (sd-Ia)

• pacientsa da misi ojaxis wevrebs unda miawodos informacia

antikonvulsantis moxsnis procesis gegmis, medikamentis dozis,

miRebis wesis, SesaZlo gverdiTi efeqtebisa da gulyrebis

ganaxlebis SemTxvevaSi Sesabamisi RonisZiebebis Sesaxeb.

• mkurnalobis moxsnis tempi, taqtika da pacientis sakontrolo

vizitis vadebi epileftologma mkafiod da mkacrad unda

SeaTanxmos pacientTan.

• epileftologma, fsiqologma da pacientma erToblivad unda

awon-dawonon gulyraTa xelaxali aRmocenebis (relafsi)

Sedegad pacientis fsiqikaze imedgacruebis mavne zegavlenis

Sedegebi.

36

medikamenturi mkurnalobis moxsnis safexurebi

konsultaciebi da gamokvlevebi referens-doneze

mkurnalobis pirveli weli

• epileftologis konsultacia: weliwadSi 3-4-jer

• eeg-gamokvleva: weliwadSi 3-4-jer

• neirofsiqologiuri gamokvleva: weliwadSi 2-jer (mkurnalobis

daniSvnamde/koreqciamde da mkurnalobis dawyebidan/koreqciidan 6

TveSi);

mkurnalobis Semdgomi wlebi

• epileftologis konsultacia: weliwadSi 1-2-jer

• eeg-gamokvleva: weliwadSi 1-2-jer

• neirofsiqologiuri gamokvleva: weliwadSi 1-jer an metjer

(nevrologis mier gansazRvruli saWiroebis mixedviT).

arafarmakologiuri mkurnaloba

epilefsiis qirurgiuli mkurnaloba

(dReisaTvis saqarTveloSi ar arsebobs)

rogorc aRvniSneT, epilefsiis adekvaturi reJimiTa da

antikonvulsiuri medikamentebiT mkurnalobis Sedegi pacientTa 25-30%Si

aradamakmayofilebelia. aseTi pacientebis nawilisaTvis mowodebulia

1. antiepilefsiuri mkurnaloba unda Sewydes specialistis

meTvalyureobiT, TandaTanobiT, minimum 3-6 Tvis ganmavlobaSi;

2. valproatTan da fenitoinTan SedarebiT, karbamazepinis,

benzodiazepinebisa da fenobarbitalis moxsnas ufro xangrZlivi

periodi sWirdeba (6 Tve - 1 weli);

3. erT jerze unda moixsnas mxolod erTi preparati;

4. medikamentis klebis yvela safexurze unda gakontroldes eeg.

5. hipersinqronuli eeg–fenomenebis aRdgenis SemTxvevaSi

antikonvulsantis odenoba unda gaizardos Terapiul dozamde da

mkurnaloba gaxangrZlivdes kidev 2 wliT.

37

qirurgiuli mkurnaloba. aRniSnuli meTodi dReisaTvis saqarTveloSi

araa danergili.

epilefsiis qirurgiuli mkurnalobis mizania refraqtoruli

epilefsiebis dros nevrologiuri da neirofsiqologiuri

garTeulebebis gareSe gulyraTa sixSiris Semcireba neiroqirurgiuli

intervenciis gziT.

epilefsiiT daavadebul pacientTa preoperaciuli SerCevis kriteriumebia:

• parcialuri epilefsia;

• medikamentebisadmi refraqtoruli gulyrebi;

• cxovrebis dabali xarisxi, rac gulyrebis maRali sixSiriT an

maTi xasiaTiTaa ganpirobebuli;

• daavadebis xangrZlivoba qirurgiul Carevamde aranakleb ori

wlisa;

• bavSvebsa da mozardebSi _ gulyrebis sixSirisa da simZimis

Sedegad (katastrofuli epilefsiebi) tvinis Semdgomi

ganviTarebisaTvis Seqmnili araxelsayreli pirobebi.

qirurgiuli procedurebi

• wina temporaluri lobeqtomia

• seleqtiuri amigdalo-hipokampeqtomia

• paTologiuri ubnebis amokveTa

• kalozotomia (wina ori mesamedi)

• hemisfereqtomia

• subpialuri transseqcia

• vagusis stimulacia

arafarmakologiuri, konservatiuli intervencia

meTodis mizani gulyraTa prevencia ufroa, vidre maTi mkurnaloba.

aseT SemTxvevebSi SeiZleba ganvixiloT intervenciis is RonisZiebebi,

romlebic ukve ganviTarebuli gulyris Semdgomi garTulebebis

prevencias gulisxmobs.

SemdgomSi gulyrebis prevenciis aseTi meTodebi, gamoiyeneba

medikamentur mkurnalobasTan erTad an maTgan damoukideblad iseT

pacientebSi, romlebsac aReniSnebaT:

• wminda refleqs-epilefsiebi spontanuri gulyrebis gareSe

(magaliTisaTvis – muqi saTvaleebis tareba fotosensitivobisas

da garkveuli usafrTxoebis wesebis dacva televizoris cqerisas);

• pirveli an Zalze iSviaTi epilefsiuri gulyrebi, romelTa

acileba SesaZlebelia maprovocirebeli faqtorebis (magaliTad,

alkoholi, Zilis deprivacia) aridebiT;

38

• pacientebi, romlebic principulad ewinaaRmdegebian medikamentur

mkurnalobas.

dReisaTvis, mkurnalobisa da gulyraTa profilaqtikis es meTodi

intensiuri Seswavlis stadiazea. gansakuTrebuli yuradReba eTmoba

relaqsaciur meTodebs da biologiuri ukukavSiris teqnikis

gamoyenebas.

epilefsiiT daavadebulTa gansakuTrebuli mdgomareobebis marTva

epilefsiuri statusi

• krunCxviTi da arakrunCxviTi epilefsiuri statusi daavadebis yvelaze

mniSvnelovani garTulebaa da aReniSneba epilefsiiT daavadebulTa 5-

10%-s (msd – Ia).

39

• krunCxviTi statusis mqone pacientebis 20%-Si mosalodnelia

letaluri gamosavali (msd – Ia).

etiopaTogenezi epilefsiur gulyraTa umravlesoba, dawyebidan mcire xnis Semdeg (5 wT-

mde), spontanurad wydeba. gulyris Sewyvetis mizezia Tavis tviniSi

agznebis Semakavebeli neiroqimiuri meqanizmebis aqtivacia.

epilefsiuri statusis SemTxvevaSi darRveulia gulyris

likvidaciisTvis aucilebeli paTofiziologiuri meqanizmebis

aqtivaciis procesi, veRar xorcieldeba agznebis SeCeraba da erTxel

aRmocenebuli gulyra aRar mTavrdeba. SemTxvevaTa 50%-Si statusis

gamomwvevi mizezebia antiepilefsiuri medikamentis uecari Sewyveta,

mwvave intrakraniuli daavadeba an moculobiTi procesebi, qala-tvinis

travma, alkoholizmi.

epilefsiuri statusis kategoriebi

ganarCeven krunCxviTi da arakrunCxviTi epilefsiuri gulyrebis statuss.

1. generalizebuli krunCxvaTi gulyrebis statusi;

2. arakrunCxviTi gulyrebis statusi (absansebi, rTuli parcialuri

gulyrebi);

3. fokaluri, martivi parcialuri gulyrebis statusi.

epilefsiuri statusis marTva

statusis marTvis amocanebi

1. sasicocxlo funqciebis dauyovnebeli da xangrZlivi

stabilizacia;

2. neironuli dacva (statusis Sewyveta);

3. statusis mizezisa da xelSemwyobi faqtorebis mkurnaloba

(meningiti da sxv);

40

4. statusis samedicino garTulebaTa prevencia (aspiracia,

diseminirebuli intravaskuluri koagulacia, Tirkmlis

ukmarisoba).

tonur-klonuri krunCxviTi statusi (Grand-mal statusi)

• aReniSneba epilefsiiT daavadebulTa 5%-s;

• SedarebiT xSiria bavSvebSi, gonebrivi CamorCenilobisa da tvinis

struqturuli dazianebis (upiratesad Sublis wilebis) mqone

pacientebSi.

SemTxvevaTa 50%-Si SesaZlebelia statusis xelSemwyobi faqtoris

gamovlena, romelTa Soris yvelaze mniSvnelovania antikonvulsantebis

an sxva medikamentebis uecari Sewyveta, alkoholizmi, mwvave

intrakraniuli daavadebebi, qalas travma an moculobiTi procesebi.

orsulobisas pirvelad ganviTarebuli epilefsiuri statusi,

SesaZlebelia, mogvianebiT epilefsiisa da reproduqciuli

endokrinuli daavadebebis ganviTarebis prediqtori iyos.

“Grand-mal” statusi paTologiuri mdgomareobaa, romelic saWiroebs

gadaudebel samedicino daxmarebas (ix. protokoli 2)

mioklonuri statusi

ganuwyveteli generalizebuli mioklonuri SekrTomebiT an maTi

seriebiT mimdinare mdgomareobaa.

ganasxvaveben mis or variants:

• wmindad mioklonuri statusi - gvxvdeba generalizebuli epilefsiiT

daavadebul im pacientebSi, romlebsac aqvT mioklonuri gulyrebi.

• simptomuri mioklonuri statusi - Tan axlavs degeneraciul

encefalopaTiebs (mag: progresul mioklonur epilefsias, ramsei-

hantis mioklonur naTxemismier dissinergias, laforas daavadebas,

sxvadasxva lipidozebs, metabolur, toqsiur da hipoqsiur

41

encefalopaTiebs).

arakrunCxviTi epilefsiuri statusi

statusis tipebi:

1. tipiuri absansebis statusi;

2. atipiuri absansebis statusi - rTuli parcialuri gulyrebis

statusi, an statusi, romelic xasiaTdeba eeg-ze subklinikuri

paroqsizmuli aqtivobiT.

statusis am formebis dros iSviaTadaa saWiro gadaudebeli samedicino

daxmareba, magram aucilebelia Setevebis daTrgunva benzodiazepinebiT,

raTa ar moxdes maTi gadazrda krunCxviT statusSi.

tipiuri absansebis statusi (sinonimebi da moZvelebuli

saxelwodebebia: uwyveti absans statusi, piknolefsiuri statusi, pik-

talRovani stupori, lenoqsis sizmrismieri mdgomareoba, Petit mal statusi, Epilepsia minor continua) aReniSneba tipiuri absansebis mqone

bavSvebis 5%-s;

martivi absansisa da absansebis seriisagan gansxvavebiT, absans-statusis

dros adgili ara aqvs xanmokle uecar garindebas, uazro

gamometyvelebiTa da cnobierebis sruli daTrgunviT. Setevis

klinikuri suraTi mravalferovania. cnobierebis daTrgunva SeiZleba

gamovlindes sxvadasxva xarisxis SeviwrovebiT: cnobierebis done

SeiZleba meryeobdes ZneladSesamCnevi dabneulobidan Rrma stuporamde.

absansebis statusis dros eeg-ze fiqsirdeba ganuwyveteli, frontaluri

aqcentuaciis pik-talRa 3 wamSi, xSirad araregularuli epilfsiuri

kompleqsebiT. statusi uecrad iwyeba da uecradve mTavrdeba an

gadaizrdeba krunCxviT statusSi. aseTi tipis statusi SeiZleba

ganuwyvetliv grZeldebodes ramodenime saaTis an dRis (iSviaTad

kvireebis manZilze) ganmavlobaSi.

absans statusi zogjer aramudmivi anu wyvetilia (wyvetili absans

statusi) da mudmivi absans statusisagan ar gansxvavdeba arc

klinikurad, arc eleqtroencefalografiulad. igi tipiuri absansebis

seriaa, romlis drosac wuTebis, saaTebis an dReebis ganmalobaSi

Tanmimdevrul absansebs Soris periodebSi cnobierebis (kogniciuri

funqciebis) sruli aRdgena ar xdeba, magram eeg-ze piktalRovani

gantvirTvebi qreba.

absansebis statusis Sewyveta SesaZlebelia diazepamis intravenuri

ineqciiT.

atipuri absansebis statusi aReniSneba pacientebs lenoqs-gastos

sindromiT. statusi gamovlindeba cnobierebis meryeobiT an stuporiT

da xSiri miokloniebiT. eeg ucvleli, an difuzuri neli pik-

talRebiTaa warmodgenili. statuss, Cveulebriv, win uZRvis saaTebis an

dReebis xangrZlivobis zogadi fizikuri da fsiqologiuri

42

mdgomareobis gauareseba xasiaTis, inteleqtualuri da motoruli

aqtivobis daTrgunvis fonze (fsevdodemencia, fsevdoataqsia). statusis

Sewyveta tradiciuli medikamenturi mkurnalobiT (diazepamis

intravenuri ineqcia) xSirad ver xerxdeba. aseTi statusi TandaTanobiT

ukuviTardeba da spontanurad qreba.

rTuli parcialuri gulyrebis statusi SeiZleba mimdinareobdes ori

variantiT:

1. erTmaneTis momdevno rTuli parcialuri gulyrebiT SeteveTa

Soris periodebSi cnobierebis sruli aRdgenis gareSe;

2. ganuwyveteli sizmrismieri mdgomareoba (Dreamy state) izolirebulad, an avtomatizmebis, fsiqosensoruli da

fsiqoafeqturi simptomebis TanxlebiT.

rTuli parcialuri gulyrebis statusis kardinaluri niSania meryevi

an mudmivi konfuzia da Secvlili cnobiereba. gamovlenis aseTi

Taviseburebis gamo xSirad garTulebulia parcialuri gulyrebis

statusis diferencireba fsiqiatriul mdgomareobisagan, ris gamoc

pacientebi SecdomiT Tavsdebian fsiqiatriul stacionarSi.

Sublisa da safeTqelis wils struqturebSi aRmocenebuli

statusisTvis damaxasiaTebelia sruli amnezia. tvinis sxva

struqturebidan (eqstratemporaluri) aRmocenebuli statusisas

cnobierebis dabindvis xarisxi naklebia, xolo momdevno afazia -

arasruli.

eeg ar aris tipiuri. igi sxvadasxva iqtaluri da interiqtaluri

fenomenebis ganuwyveteli an fragmentuli konglomeratiTaa

warmodgenili, da zogjer fiziologiuri ritmebiTaa Tanxlebuli.

martivi parcialuri gulyrebis statusi wminda, izolirebuli saxiT

Zalze iSviaTia.

martivi kerovani Setevebi gvxvdeba sxvadasxva paTologiisa da mravali

epilefsiuri sindromis SemTxvevebSi (Epilepsia partialis continua); xSiria

rasmusenis encefalitis, adreuli bavSvobis epilefsiuri

encefalopaTiebis, sxvadasxva dismetaboluri encefalopaTiebis dros.

praqtikaSi gamoyofen martivi parcialuri gulyrebis statusis or

variants:

1. motoruli simptomebiT;

2. motoruli simptomebis gareSe.

wamyvani elementaruli simptomis mixedviT yoveli maTgani kidev

SeiZleba daiyos somatomotorul, somatosensorul, adversiul da a.S.

qvetipebad.

somatomotorul gulyraTa statusi vlindeba xSiri ganmeorebadi

gulyrebiT upiratesad zeda kidursa da saxis imave naxevarSi jeqsonis

marSiT an mis gareSe. misi kerZo variantia Epilepsia partialis continua (koJevnikovis sindromi).

Epilepsia partialis continua calmxrivi, motoruli, upiratesad ritmuli,

iSviaTad - aritmuli klonuri an segmenturi mioklonuri gulyrebia.

etiologiuri faqtorebia rasmusenis an sxva saxis encefaliti, tvinis

infarqti, moculobiTi warmonaqmnebi. ganmeorebadi miokloniebi

43

viTardeba erTsa da imave adgilze, ar scildeba sawyis ubans da

upiratesad moicavs saxes an kidurebis distalur nawilebs. simptomebis

intensivoba cvalebadia. statusi dReebis, kvireebis da Tveebis,

zogjer wlebis ganmavlobaSi grZeldeba. eeg arainformaciulia.

daavadeba medikamenturi mkurnalobisadmi rezistentulia.

afaziuri epilefsiuri statusi aris afaziis ramodenime saaTis an

dRis xangrZlivobis epizoduri mdgomareoba, romelsac SeiZleba

daerTos aleqsia da agrafia.

epilefsiuri statusis yvelaze xSiri variantia (80-85%) generalizebuli tonur-klonuri krunCxviTi gulyrebis statusi.

krunCxviTi epilefsiuri statusis marTva statusis diferenciuli diagnostika - pirvel rigSi, epilefsiuri

statusi unda ganvasxvavoT sxva araepilefsiuri mdgomareobebisagan: diagnostika mdgomareobebi, romlebisganac unda

ganvasxvavoT krunCxviTi

(konvulsiuri) statusi

mdgomareobebi, romlebisganac unda

ganvasxvavoT arakonvulsiuri statusi

• moZraobiTi daavadebebi

• fsevdogulyrebis statusi

• tetanusi • avTvisebiani hiperTermia

• avTvisebiani neiroleptikuri

sindromi

• decerebraciuli spazmebi

• fsevdogulyrebis statusi

• disociaciuri mdgomareobebi • fuga • panikuri Seteva • hiperventilacia, SfoTva

• mwvave konfuziuri mdgomareoba

metaboluri encefalopaTiebis

dros

• tranzitoruli globaluri amnezia

• vertebrobazilaruli Sakiki statusis marTvis amocanebi:

1. sasicoxlo funqciebis dauyovnebeli da xangrZlivi stabilizacia;

2. neironuli dacva (statusis Sewyveta);

3. statusis mizezisa da xelSemwyobi faqtorebis mkurnaloba

4. statusis samedicino garTulebaTa prevencia

5.

krunCxviTi epilefsiuri statusis mkurnalobis etapebi:

1. gadaudebeli RonisZiebani (saswrafo daxmarebis brigada)

44

• sasunTqi gzebis ganvladobis Semowmeba;

• pacientis usafrTxo pozis uzrunvelyofa;

• sacicocxlo funqciebis stabilizacia (intravenuri kaTeteri,

sunTqvis sixSire, pulsi, arteriuli wneva, ekg, oqsihemometria da

sxva);

• swrafi zogadi da nevrologiuri gasinjva – diagnozis dazusteba

(maprovocirebel faqtorebad iTvleba meningiti, encefaliti,

Tavis travma, cerebruli infarqti, Tavis tvinis simsivne,

alkoholisa an narkotikebis moxsnis sindromi, metaboluri

darRvevebi. meningoencefaliti, intrakraniuli hipertenzia,

bavSvebSi infeqciuri daavadebebi).

2. gadaudebeli medikamenturi Terapia:

• sawyis etapze (0-30 wT) - gulyraTa SeCereba xanmokle moqmedebis

iseTi saSualebiT, rogoricaa diazepami SemTxvevaTa 70-80%-Sia

SesaZlebeli. igi keTdeba intravenurad doziT 0.2-dan 0.4 mg/kg

wonaze. diazepamis Sereva sxva wamalTan an gamxsnelTan ar

SeiZleba (Tu es ar aris miTiTebuli etiketze). ineqciis siCqare

ar unda aRematebodes 1-2 mg/wuTSi. erT jerze rekomendebulia

maqsimum 10 mg-is Seyvana. ineqciis gameoreba dasaSvebia 15 wuTSi

da kidev erTxel, aseve 15 wuTSi. am dros aucilebelia sunTqvisa

da arteriuli wnevis kontroli. orsulebSi diazepamis es

raodenoba ar iwvevs nayofis depresias. intravenuri Terapia

yovelTvis ar aris xelmisawvdomi. aseT SemTxvevaSi diazepamis

xsnaris (igivea rac intravenuri inieqciisaTvis) Seyvana SeiZleba

swor nawlavSic doziT 0.5 mg/kg wonaze: aavseT Sprici diazepamis

xsnariT, moxseniT nemsi, SeiyvaneT Sprici swor nawlavSi da

SeuSviT xsnari. aRniSnuli SeiZleba ganmeordes Tu gulyrebi 10

wuTze met xans grZeldeba. statusis kupireba diazepamis magier

SeiZleba daviwyoT barbituratebiT an fenitoiniT.

• stabiluri statusi (30-60 wT) - Tu statusis kupireba ar

xerxdeba pacienti intensiuri Terapiis ganyofilebaSia

gadasayvani. saWiroa fenitoinis intravenuri ineqcia

fiziologiur xsnarTan erTad. infuziis siCqarea fenitoinis 50

mg/wuTSi. saboloo dozaa 18-20 mg/kg. ineqciisas gansakuTrebuli

yuradReba unda mivaqcioT arteriul wnevas da kardiogramas.

fenitoinis maRalma dozebma SeiZleba gamoiwvion gulyrebis

provokacia. alternatiuli saSualebaa fenobarbitali doziT 10-

20 mg/kg. infuziis siCqarea 100 mg/wT-Si. yuradReba unda mivaqcioT

sunTqvis ritmsa da arteriul wnevas.

• dauqvemdebarebeli, refraqtoruli statusi (60-90 wT) – zemoT

aRniSnuli RonisZiebebis Semdeg, aucilebelia, intubaciuri

narkozi. pirveli rigis preparatebad Tiopentali an

fentobarbitalia mowodebuli.

• statusis mimdinareobisa da misi Sewyvetis Semdeg - saWiroa

mosalodneli garTulebebis Tvalyurisdevneba (acidozi,

hipotenzia, Tirkmlis ukmarisoba, infeqcia, tvinis SeSupeba).

45

3. epilefsiuri statusis Sewyvetis Semdeg - rac SeiZleba swrafad unda

daiwyos an aRdges racionaluri antikonvulsiuri mkurnaloba.

unda moiZebnos statusis gamomwvevi mizezi da mkurnaloba

warimarTos mis aRmosafxvrelad.

absansebis statusis mkurnaloba

karg da dauyovnebliv efeqts iZleva diazepamis intravenuri inieqcia.

misi uSedegobis SemTxvevaSi rekomendebulia valprois mJavis

peroraluri miwodeba.

parcialuri gulyrebis statusis mkurnaloba

martivi da rTuli simptomatikis mqone gulyrebis statusisaTvis

naCvenebia diazepamis, klonazepamis an fenitoinis intravenurad Seyvana (msd-Ib).

epilefsiuri statusis marTvis rekomendebuli sqema (msd-Ib)

qali da epilefsia

gulyrebis Sewyveta

generalizebuli krunCxviTi epilefsiuri statusi

30 wuTze naklebi xangrZlivobis statusi

fenitoini i.v an fenobarbitali i.v.

diazepami i.v.

racionaluri

antikonvulsiuri Terpia, statusis mizezebis dadgena

da maTi mkurnaloba

intubaciuri narkozi racionaluri

antikonvulsiuri Terpia, statusis mizezebis dadgena

da maTi mkurnaloba

30 wuTze meti xangrZlivobis statusi

diazepami i.v., da

fenitoini i.v an fenobarbitali i.v.

gulyrebi grZeldeba

gulyrebi grZeldeba

gulyrebis Sewyveta

gulyrebis Sewyveta

gulyrebi grZeldeba

46

mamakacebisagan gansxvavebiT, mdedrobiTi sqesis pacientebSi

gansakuTrebuli yuradReba unda mieqces reproduqciul-endokrinuli

sistemis kritikul periodebs-menarxe, menstruacia, orsuloba,

laqtaciisa da klimaqteruli periodebi, radgan aRniSnuli periodebi

xSiradaa Tanxlebuli gulyrebis gaxSirebiT. garda amisa

kontracefcia ojaxis dagegmvis ZiriTadi aspeqtia da gansakuTrebiT

mniSvnelovania epilefsiiT daavadebuli qalebisTvis.

janmrTeli qalebisagan gansxvavebiT, epilefsiiT daavadebuli qalebis

kontracefciuli preparatebis SerCevisas gasaTvaliswinebelia Semdegi

garemoebebi:

epilefsiis mkurnalobis fundamenturi principebi orive sqesis pacientebisTvis erTnairia:

• zusti diagnozi;

• racionaluri antiepilefsiuri mkurnaloba;

• mkurnalobisadmi pacientis daqvemdebareba.

• pubertatis asakis epilefsiiT daavadebuli gogonebis 40%-s

epilefsia ewyeba menarxesTan erTad;

• epilefsiiT daavadebuli qalebis 20%-s pirveli epilefsiuri

gulyra uviTardeba orsulobaSi;

• daavadebuli qalebis naxevarze mets Setevebi uxSirdeba

menstruaciis periodSi (katamenialuri epilefsia);

• epilefsiis mqone qalebis 25%-s aReniSneba reproduqciul-

endokrinuli darRvevebi da anovulatoruli ciklebi, 30%-ze

mets aReniSneba infertiloba.

• antiepilefsiur mkurnalobaze myofi qalebis axalSobilebSi

orjeraa gazrdili fetaluri malformaciebis ganviTarebis

riski (msd-Ia);

• enzimmainduqciebeli antikonvulsiuri mkurnalobis fonze

Zalze xSiria araefeqturi kontracefciis SemTxvevebi (msd-IV).

• estrogenSemcvelma konstraceptivebma, SeiZleba gaaaqtiuron

epilefsiuri gulyrebi;

• enzimmainduqciebelma antikonvulsantebma, SeiZleba,

daaqveiTos hormonuli kontracefciis efeqturoba.

47

daugegmavi orsuloba, romelic warumatebeli kontracefciis Sedegia,

mniSvnelovan problemebs uqmnis epilefsiiT daavadebul qals, radgan

orsulobis nagvianebi konstataciisas praqtikulad SeiZlebelia

orsulobis periodisaTvis aucilebeli mosamzadebeli antiepilefsiuri

mkurnalobis optimizaciis procesis ganxorcieleba.

epilefsiiT daavadebuli qalis orsulobisa da mSobiarobis marTva

orsuli qalebis 1% daavadebulia epilefsiiT.

epilefsiiT daavadebuli orsuli qalis antiepilefsiuri mkurnalobis ZiriTadi principebia

epilefsiiT daavadebuli qalisTvs gansakuTrebiT mniSvnelovania orsulobis dagegmva (msd- III):

epilefsiiT daavadebuli qalis meTvalyureoba erToblivad unda

awarmoos

• epileftologma, romelsac gavlili aqvs saTanado trenireba

reproduqtologiasa da ginekologiaSi;

• ginekolog-reproduqtologma, romelsac gavlili aqvs

specialuri trenireba epilefsiis samedicino da fsiqo-

socialur sakiTxebSi.

• gamoviyenoT gulyris tipisa da epilefsiuri sindromis Sesatyvisi pirveli rigis antikonvulsanti;

• sasurvelia monoTerapia medikamentis dasaSvebad dabali efeqturi doziT, gverdiTi movlenebisa da gulyrebis gareSe.

• pacients, romelsac gulyrebi ar hqonia daorsulebamde winamorbedi

ori wlis manZilze, individualuri monacemebis gaTvaliswinebiT,

SesaZlebelia, orsulobamde 1-2 TviT adre Seumcirdes

antikonvulsantis doza;

• pacienti, romelsac ugrZeldeba gulyrebi, saWiroebs antiepilefsiuri

mkurnalobis optimizacias. unda vcadoT monoTerapia preparatis

maqsimalurad dabali efeqturi doziT;

• monoTerapiisas SesaZlebelia preparatis dozis gazrda, xolo poli-

Terapiisas - mimdinare kombinaciuri mkurnalobis gamartiveba;

• pacienti, romelsac daorsulebamde gulyrebi ar hqonia, SesaZloa

davtovoT mimdinare mkurnalobaze (poliTerapiazec ki), Tu adgili ara

aqvs gverdiT movlenebs;

• Tu spina bifida-s ojaxuri anamnezi dadebiTia, sasurvelia, valproatiT,

karbamazepiniTa da topiramatiT mkurnalobisagan TavSekaveba;

• orsulobamde erTi Tvis, orsulobis pirveli trimestrisa da

mSobiarobamde bolo erTi kviris ganmavlobaSi, epilefsiiT daavade-

bulma qalma, yoveldRiurad unda miiRos 5 mg foliumis mJava;

• orsulobis bolo kviraSi pacients, romelic Rebulobs enzimmainduq-

cirebel antikonvulsantebs (karbamazepini, fenobarbitali, fenitoini),

48

zogad populaciasTan SedarebiT, epilefsiiT daavadebul qalebs

orsulobisa da mSobiarobis paTologiuri gamosavlis momatebuli

riski gaaCniaT. misi minimumamde dayvana SesaZlebelia antiepilefsiuri

mkurnalobisa da orsulobis monitoringis Tanamedrove meTodebis

gamoyenebiT.

epilefsiiT daavadebuli qalebis umravlesobas gulyrebis sixSire

orsulobisas ar ecvleba.

• epilefsia uaryofiTad ar moqmedebs orsulobaze (msd-IIb); • epilefsiis sababiT samedicino abortebis warmoeba, xSirad

gaumarTlebelia;

• epilefsiiT daavadebul orsul qalebSi sisxldenis riski ar

gansxvavdeba zogadpopulaciuri maCveneblebisgan;

• populaciasTan SedarebiT, nayofis perinaTaluri

sikvdilianoba 1,2-2,0-jer ufro xSiria (msd-III);

epilefsiiT daavadebuli qalebis 1,6%-s orsulobisas

uviTardeba epilefsiuri statusi (msd-Ib); • statusis dros dedis letaluri gamosavlis riski

momatebuli ar aris;

• dedis statusis dros nayofis sikvdilobis riski 2-4%-ia

• epilefsiiT daavadebuli qalebis 66,8%-Si orsulobisas

gulyraTa sixSire ar icvleba (msd-IIb); • orsulobisas daavadebuli qalebis 58,3% gulyrebi ara aqvs

(msd-Ib); • epilefsiiT daavadebuli orsuli qalebis 17,3%-s uxSirdeba

gulyrebi (msd-Ib); • epilefsiiT daavadebuli orsuli qalebis 15,9%-s umcirdeba

gulyraTa sixSire (msd-Ib); • mSobiarobisas gulyrebi uviTardeba epilefsiiT daavadebuli

qalebis 3,5 %-s (msd-Ib);

49

antikonvulsiur mkurnalobaze myofi epilefsiiT daavadebuli qalebis

bavSvebis 90%-ze meti janmrTelia; aseTi qalebis cocxladSobili

bavSvebis 4-11% avlens umwifrobis niSnebs; 6-7%-s aReniSneba fetaluri

hipotrofia; 7-8%-s apgaris Skalis dabali qulebi, 4-6%-s sxadasxva

saxis ganviTarebis simaxinjeebi.

orsulobis garTulebaTa Tavidan acilebis, mosalodneli anomaliebis

prevenciisa da drouli gamovlenis mizniT, pacienti saWiroebs

adekvatur, regularul sameano da epileftologiur meTvalyureobas.

epilefsiiT daavadebuli qalis orsulobis

monitoringis algoritmi

trimestri

I II III

1-jer

1-jer 1-jer

1-jer

_ 1-jer

1-jer

1-jer 1-jer

_

1-jer

(16-18kvira)

_

epilefsiiT daavadebuli orsulisaTvis aucilebeli wesebi

teratogenobis riski SederebiT maRalia (msd-Ia); • valproatiT, karbamazepiniT, fenobarbitaliT, fenitoiniTa da

topiramatiT kombinirebuli mkurnalobisas;

• gansakuTrebiT sariskoa valproatis, karbamazepinisa da

fenobarbitalis kombinaciebi.

orsulobis konstatacia

ojaxis eqimi

aucilebeli epileftologiuri gegmiuri gamokvlevebi • eeg-kvleva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

• sisxlSi antiepilefsiuri wamlis koncentraciis gansazRvra. . . . . . . . . . . . . . . .

• nayofis ultrasonografiuli kvleva . . . . .

• alfa-fetoproteinis gansazRvra orsulis

sisxlis SratSi . . . . . . . . . . . . . . . . . . . . . . . . . .

ginekologi

• gegmiuri gamokvlevebi

• meTvalyureoba

epileftologi

• antikonvulsiuri Terapiis

optomizacia;

• foliumis mJavis CarTva (5mg/dR);

50

mSobiaroba

epilefsiiT daavadebul qalebSi mSobiaroba, ZiriTadad,

fiziologiurad mimdinareobs (msd-Ib).

mSobiarobis periodSi ganviTarebuli statusis marTva mimdinareobs zogadi principebiTa da TanmimdevrobiT (ix. statusis marTva).

mSobiarobis Semdgom periodSi

• epilefsiiT daavadebuli qalis orsulobis faqti dauyovnebliv

unda ecnobos epileftologsa da ginekologs;

• orsulobisas epileftologis gareSe dauSvebelia daniSnuli

antieplefsiuri mkurnalobis moxsna, Secvla an preparatis dozis

Semcireba;

• orsuli unda moeridos gulyrebis maprovocirebel faqtorebs (uZiloba,

televizori, alkoholi an sxv.);

• antiepilefsiur mkurnalobaze myofma orsulma orsulobis me-17

kviramde aucileblad unda miiRos foliumis mJava (5 mg/dR);

• orsulebma, romlebic Rebuloben enzimmainduqciebel antikonvulsantebs

(karbamazepini, fenobarbitali, fenitoini, topiramati), orsulobis bolo

kviraSi unda miiRon vitamini `K” (20 mg/dR).

sakeisro kveTa naCvenebia mxolod im SemTxvevaSi, rodesac

• mSobiarobis periodisTvis aRmocendeba xSiri krunCxviTi

gulyrebi da maTi Sewyveta ver xerxdeba antikonvulsantebiT anu

mosalodnelia epilefsiuri statusi

• xSiri arakrunCxviTi Setevebis gamo daTrgunulia pacientis

cnobiereba da gaZnelebulia masTan kontaqti.

• epilefsiis mqone orsulebis 2-4%-s gulyrebi uviTardeba samSobiaro tkivilebis periodSi, mSobiarobisas an mSobiarobis Semdgom.

• mosalodnelia antikonvulsantis koncentraciis uecari zrda da

intoqsikaciis klinikuri niSnebis manifestacia. aseT

SemTxvevebSi epileftologis mier dauyovnebliv unda mowesrig-

des antiepilefsiuri preparatis doza;

• Tu meloginisa da axalSobilis mdgomareoba saSualebas iZleva,

epilefsiiT daavadebulma dedam bavSvi ZuZuTi unda kvebos!

51

febriluri krunCxva • febriluri krunCxva (fk) - generalizebuli epilefsiuri reaqciaa,

romelic viTardeba sxvadasxva eqstracerebruli, xSirad, virusuli

daavadebis dros sxeulis maRali temperaturis fonze. (t 38°C), misi matebis an uecari daqveiTebis procesSi.

• rodesac bavSvebSi gulyrebi viTardeba afebrilur an nervuli

sistemis anTebiTi daavadebebiT gamowveuli maRali temperaturis

fonze, fk-ad ar miiCneva.

sixSire

fk uviTardebaT 3 Tvidan 6 wlamde, ZiriTadad, 3 wlamde asakis

bavSvebs daavadebis manifestaciis piki 15 Tvis asakze modis.

vaJebSi ufro xSiria, vidre gogonebSi.

etiologia

organizmis individuri mzaoba;

genetikur winaswarganwyoba.

ganarCeven martiv da rTul febrilur krunCxvebs

febriluri krunCxvis ganviTarebis riski maRalia Tu:

• bavSvs nervuli sistema dazianebuli aqvs dabadebidanve;

• ojaxSi arsebobs fk-s an epilefsiis sxva SemTxvevac;

52

parametri martivi fk rTuli fk

gavrceleba (6 wlamde asakis

bvSvebSi)

3-5% 1%

gavrceleba fk-s Soris 70% 30%

xangrZlivoba <15 wT 15 wT<

gulyris tipi generalizebuli tonur-

klonuri krunCxvebi

fokaluri,

hemikonvulsiuri

24 saaTSi Semdgomi krunCxvis

ganviTarebis riski

minimaluri maRali

epilefsiuri statusis

ganviTarebis riski

minimaluri maRali

epilefsiis Camoyalibebis riski < 1% 6-15%

martivi da rTuli febriluri krunCxvis simptomebi

risk-

faqtorebi

fk-s ojaxuri SemTxvevebi;

tyupebi;

zrda-ganviTarebis Seferxeba;

axalSobilobis periodisTvis Cveuli cvlilebebis

droSi gaxangrZliveba (dabadebidan 28 dRis Semdegac);

bavSvis araregularuli ambulatoriuli meTvalyureoba;

Seteva martivi fk-s SemTxvevaSi rTuli fk-s SemTxvevaSi

Setevamde t =38%< bavSvis zrda-ganviTareba

normaluria;

bavSvis nevrologiuri

statusi normaluria

ojaxis romelime wevrs

bavSvobaSi hqonia martivi fk

virusuli infeqcia

t =38%< centraluri nervuli sistema

dazianebulia dabadebidanve

(samSobiaro travma,

ganviTarebis darRveva da a.S.)

Tavis tvinis anTebiTi

daavadeba (meningiti,

encefaliti, tvinis abscesi da

a.S.)

ejaxSi epilefsiis anamnezia

ojaxSi rTuli fk-s anamnezia

Setevis dros uecari dasawyisi;

cnobierebis daTrgunva 30wm-5 wT;

erTjeradi generalizebuli

tonur-klonuri krunCxvebi;

uecari dasawyisi;

cnobierebis daTrgunva 15 wT-

ze metxans;

ganmeorebadi fokaluri,

hemikonvulsiuri Setevebi;

xSirad axasiaTebs epilefsiur

statusSi gadazrda.

53

Setevis Semdeg simptomebi spontanurad ukuviTardeba

Zilianoba, moTenTiloba

mousvenroba, Wirveuloba

SeiZleba darCes xanmokle

kerovani simptomatika

Zilianoba, moTenTiloba

adinamia

diagnostika

gamokvlevebi martivi febriluri gulyrisas

rTuli febriluri gulyrisas

eeg ar aris saWiro

saWiroa

Tavis tvinis bmr

ar aris saWiro

saWiroa

sxva sasurvelia, Catardes sisxlis,

Sardis saerTo da sisxlis

bioqimiuri analizebi

eleqtrolitebis Semcvelobaze.

saWiroa sisxlis, Sardis

saerTo, sisxlis bioqimiuri

analizebi da sx.

febriluri krunCxvebis mkurnaloba

!

martivi rTuli

gulyra erTjeradia,

generalizebuli da xanmokle;

ojaxSi aravis hqonia aseTi

gulyra;

ojaxis arc erTi wevri araa

epilefsiiT avad;

fk-s ganviTarebamde bavSvs ar

hqonia nervuli sistemis raime

daavadeba Tu dazianeba.

krunCxvis xangrZlivoba 15 wT-ze metia;

krunCxva ganmeorda pirveli gulyridan

24 saaTis ganmavlobaSi;

krunCxvisas sxeulis temperatura 38°C-

ze dabalia;

krunCxva calmxrivia an moicavs sxeulis

romelime nawils (fokaluri gulyra);

krunCxvis Semdeg rCeba xanmokle dambla;

ojaxis romelime wevrs hqonda aseTi

krunCxva an aqvs epilefsia;

nervuli sistemis fk-mde arsebuli

daavadeba Tu dazianeba. temperaturis gamomwvevi mizezebis aRmofxvra

mSoblebis ganaTleba

gulyris dros

aucilebeli da

dauSvebeli procedurebis

sakiTxebSi;

sd-brigadis gamoZaxeba;

diazepamis ineqcia kunTSi:

erTjeradi doza: 0,5 mg/kg;

Cvili bavSvebisTvis

10 mg/dRe-RameSi

mcirewlovani bavSvebisTvis

20 mg/dRe-RameSi

diferencireba

febriluri krunCxva

54

febriluri krunCxvis meurveoba

fk-statusi

pacientis stacionireba intensiuri Terapiis blokSi

(ix. statusis marTva).

specializebuli gamokvlevebi

da mkurnaloba

pacientis xangrZlivi

meTvalyureoba pjd doneze

perioduli konsultaciebi

specializirebul

dawesebulebaSi

fk-kupirebulia

mimarTva specializirebul

centrSi gamokvlevebisa da

mkurnalobisaTvis

pacientis xangrZlivi

meTvalyureoba pjd doneze

mwvave infeqcia

sxeulis maRali temperatura

nivTierebaTa cvlis darRveva

SemdgomSi epilefsiis ganviTarebis riski

febriluri krunCxva

martivi

8-15% 1%

genetikuri mzaoba

(25%)

specializebul dawesebulebaSi

eeg, bmr da sxv gamokvlevebi;

18 Tvemde bavSvebSi Tav-zurg-

tvinis siTxis gamokvleva;

xangrZlivi profilaqtika (2-3

weli) valproatiT an

fenobarbitaliT.

sxva

egzogenuri

faqtorebi

pjd-doneze

ambulatoriuli

meTvalyureoba

rTuli

Tavis tvinis

dazianeba

krunCxvamde

asakobrivi

ganwyoba

gulyris Semdgomi meurveoba

55

8. epilefsiiT daavadebulebis fsiqo-socialuri reabilitacia da meTvalyureoba

adekvaturi antiepilefsiuri mkurnalobis fonze pacientis samedicino da fsiqosocialuri mdgomareobis meTvalyureobas erTdroulad awarmoebs:

• epilefsiis samedicino da fsiqo-socialur sakiTxebSi ganswavluli,

Sesabamisi licenziis mqone ojaxis eqimi da eqTani (msd-III) (ix.

protokoli #1),

• nevrologi (arareferensi) da misi eqTani (protokoli #1),

• sazogadoebrivi jandacvis specialisti;

• multidisciplinuri jgufi epileftologis, neirofsiqologis,

fsiqologisa da eleqtrofiziologis SemadgenlobiT.

epilefsiis mkurnaloba sakmaod rTuli da xangrZlivi procesia.

efeqturi gamosavlis SemTxvevaSi mkurnaloba, sul cota, 5 wlis

ganmavlobaSi, xSirad ki-sicocxlis bolomde grZeldeba. amasTan.

mkurnalobis efeqturobas gansazRvravs ara marto samedicino, aramed

mravali fsiqologiuri faqtori.

antiepilefsiuri mkurnalobis efeqturobis ganmsazRvreli

faqtorebi

• perioduli gamokvlevebi

specializirebul

dawesebulebaSi.

56

samedicino daavadebis diagnozis sizuste;

antiepilefsiuri mkurnalobis

adekvaturoba;

daavadebis monitoringis

siswore;

antiepilefsiuri mkurnalobis

reJimi.

fsiqo-socialuri daavadebisa da daavadebulis

mimarT pacientisa da misi

ojaxis wevrebis damokidebuleba;

mkurnalobis reJimisadmi

pacientis morCileba;

pacientis yofiTi, saswavlo,

samuSao da sazogadoebrivi

garemo;

sazogadoebaSi epilefsiis

stigmis xarisxi;

pacientis cxovrebis

srulfasovneba.

epilefsia erT-erTi yvelaze madiskriminirebeli, saidumloebebiTa da

crurwmenebiT moculi daavadebaa. epilefsiis Sesaxeb sazogadoebaSi

gavrcelebuli araswori da mcdari Sexedulebebi mraval problemas

uqmnis ara marto pacients, aramed mTel mis ojaxs ganaTlebis,

dasaqmebis, ojaxis Seqmnis, sazogadoebrivi urTierTobebisa da sxva

sakiTxebSi.

epilefsiis sakiTxebSi sazogadoebis gauTviTcnobierebloba

mniSvnelovnad moqmedebs daavadebulis mier sakuTari mdgomareobis

aRqmaze; epilefsia, rogorc mastigmatizebeli mdgomareoba, xels

uSlis mis socialur adaptacias, inteleqtualur Tu profesiul

srulyofas, aRrmavebs pirovnebis izolaciisa da emociuri

problemebis xarisxs.

diagnozi `epilefsia~ sakmaod mZime stresia pacientisa da misi ojaxis

wevrebisTvis, radgan sazogadoebaSi igi unarSemzRudav, saSiS da

miuRebel senadaa miaCneuli. igi mZime damRaa pacientis, mTeli misi

ojaxisa da STamomavlobisTvis. amitom, daavadeba TiTqmis yvela

SemTxvevaSi aRiqmeba rogorc dasamali da sasircxvilo mdgomareoba,

romelsac Tan axlavs mZime fsiqologiuri da socialuri Sedegebi:

• epilefsiiT daavadebuli bavSvebisa da mozardebis umravlesoba

moklebulia adekvatur saskolo-saganmanaTleblo process (msd-

IV);

• epilefsiiT daavadebulTa umravlesoba umuSevaria sazogadoebis

mxridan usafuZvlo ignorirebis gamo;

• daavadebulTa umravlesoba malavs sakuTar mdgomareobas,

erideba sazogadoebasTan urTierTobas da irCevs socialuri

izolaciis strategias;

• daavadebulTa Soris sakmaod xSiria depresiisa (50-60%) da

suicidis (25%) SemTxvevebi (msd- IV);.

aRniSnuli faqtorebi mniSvnelovnad aqveiTebs daavadebulTa

sicocxlis xarisxs da zemoqmedebs mkurnalobis efeqturobaze (msd-

IV);.

epilefsia, rogorc Tavis tvinis qronikuli mdgomareoba, ori

erTmaneTisagan ganuyofeli problemis momcvelia:

57

epilefsia

gulyra

samedicino problema

stigma

fsiqo-socialuri problema

epilefsiis stigma mniSvnelovnad aqveiTebs epilefsiiT daavadebuli

adamianebis cxovrebis srulfasovnebas. aseTi adamianebi sakuTar Tavs

invalidebad aRiqvamen maSinac ki rodesac fizikuri invalidobis

aranairi niSani ar gaaCniaT; maT bevrad dabali TviTSefaseba aqvT,

vidre sxva qronikuli daavadebis mqone pirebs da diagnozze,

ZiriTadad, SfoTviT, depresiiT, izolirebiTa da sakuTar TavSi

CaketviT reagireben.

58

epilefsiiT daavadebulTa cxovrebis srulfasovneba cxovrebis srulfasovneba - Quality of Life - pirovnebis fizikuri, socialuri,

ekonomikuri da fsiqikuri mdgomareobiT kmayofilebis maCvenebeli. srulfasovani cxovrebis fenomenebi da zemoqmedebis sferoebi: fenomeni

sfero

socialuri funqciobis mravalganzomilebianoba

• fizikuri;

• fsiqologiuri;

• socialuri;

• profesiuli;

• ekonomikuri;

• struqturuli.

individuroba

• ganwyoba,

• warmodgenebi,

• TviTaRqma.

fardobiToba

indivdis mier sakuTari mdgomareobis

cnobieri Tu aracnobieri Sedareba garemoSi

damkvidrebul kriteriumebTan.

cvalebadoba

obieqturi garemoebebis mixedviT subieqturi

warmodgenebis cvlileba.

epilefsiis mqone pirovnebis cxovrebis srulfasovneba damokidebulia

samedicino mdgomareobaze da mraval fsiqo-socialur faqtorze:

samedicino:

• daavadebis forma da simZime (gulyris tipi, sixSire, a.S.)

• antiepilefsiuri wamlis gverdiTi movlenebi.

socialuri:

• dasaqmeba; • daojaxeba;

• socialuri urTierTobebis SezRudva;

• siRaribe. fsiqo-socialuri: stigma

• subieqturi / realuri;

• ojaxuri urTierTobebi (hipermzrunveloba; izolacia);

• sazogadoebrivi azri da Sexeduleba.

fsiqologiuri:

• diagnozTan dakavSirebuli SfoTva da gancda;

• STamomavlobaze epilefsiis gadacemis SiSi;

• gankurnebis uimedoba; • depresia; • ususurobis gancda; • dabali TviTSefaseba.

59

epilefsiis efeqturi marTva adekvatur mkurnalobasTan erTad

epilefsiis mimarT pacientisa da sazogadoebis araadekvaturi

Sexedulebebisa da daavadebisadmi araswori damokidebulebebis

marTvasac gulisxmobs (msd-III).

vinaidan epilefsia mravalganzomilebiani daavadebaa da gavlenas

axdens pirovnebis cxovrebis sxvadasxva aspeqtze, daavadebulis

fsiqologiuri da neirofsiqologiuri mdgomareobis Sefaseba

aucilebelia ara mxolod daavadebis diagnostirebis procesSi, aramed

adekvaturi antiepilefsiuri mkurnalobis mosalodneli efeqturobis,

fsiqikuri invalidizaciis prevenciis, pacientTan da misi ojaxis

wevrebTan Semdgomi urTierTobisa da saganmanaTleblo strategiebis

gansazRvris, dagegmvisa da ganxorcielebisaTvis.

mkurnalobis efeqturobis xarisxi damokidebulia pacientis mier

sakuTari daavadebis Sesaxeb subieqturi warmodgenebis, codnisa da

samkurnalo/profilaqtikur procesSi misi Tanamonawileobis doneze

(msd-III); antiepilefsiuri mkurnalobis monitoringTan erTad saWiroa

daavadebulis fsiqologiuri mdgomareobis Sefaseba: pirovnebis

reagireba diagnozze `epilefsia~, mkurnalobis procesSi diagnozisadmi

pacientis damokidebulebebis cvlileba, mdgomareobasTan daavadebulis

fsiqologiuri gamklavebis tipi da sxva. aRniSnuli sakiTxebisa Tu

daavadebasTan dakavSirebuli zogadi adaptaciuri amocanebis

gansazRvra warmoebs pirvelad jandacvaSi.

ojaxis eqimis eqTani – romelsac miRebuli aqvs saTanado wvrTna

epilefsiis samedicino da fsiqo-socialur sakiTxebSi, informacias

agrovebs daavadebulisa da misi ojaxuri mdgomareobis Sesaxeb,

daavadebuls exmareba mkurnalobis reJimis dacvaSi, awarmoebs mis

mudmiv meTvalyureobas da aRniSnul informacias awvdis ojaxis eqims.

ojaxis eqimi, romelsac miRebuli aqvs saTanado wvrTna epilefsiis

samedicino da fsiqo-socialur sakiTxebSi, misTvis dadgenili

kompetenciis farglebSi, samoqmedo arealSi avlens daavadebis

arsebobis saeWvo SemTxvevebs da mimarTavs nevrologTan;

meTvalyureobas uwevs epilefsiiT daavadebul pirs, amowmebs daniSnuli

mkurnalobis reJims da saTanado analitikur informacias sistematurad

awvdis nevrologs;

nevrologi (arareferensi) - xelmZRvanelobs gafarToebuli

meTvalyureobis sqemebiT. saWiroebis SemTxvevaSi axdens

antiepilefsiuri preparatis dozis koreqcias. daavadebulis ojaxis

wevrebsa da/an meurves 3 TveSi erTxel awvdis srul informacias

pacientis mdgomareobis Sesaxeb, aseve, im RonisZiebebis Taobaze,

romlebic unda gatardes mkurnalobis reJimis darRvevis, preparatis

gamotovebis an sxva (gastrointestinuri problemebi, virusuli

infeqciebi, acrebi, respiratoruli daavadebebi) SemTxvevebSi.

• ferment-mainducirebeli preparatebis miRebis SemTxvevaSi awarmoebs

sisxlis formiani elementebis, RviZlis fermentebis, vitamin D-s da Zvlis metabolizmis ganmsazRvreli da sxva saWiro testebis

maCveneblebis (kalciumi, tute fosfataza) Sefasebas dadgenili

sqemebiT.

60

• bavSvebs, romlebsac aReniSnebaT swavlisa da qcevis problemebi,

mimarTavs neirofsiqologTan gamokvlevis da/an reabilitaciis

mizniT da Semdgom qmedebebs axorcielebs neirofsiqologis mier

mowodebuli sqemebis mixedviT.

socialuri muSaki aris specialurad ganswavluli piri, romelic

rutinuli, mizanmimarTuli socialuri urTierTobebiT xels uwyobs

epilefsiiT gamowveuli socialuri problemebis gadawyvetas, an

problemis simwvavis Semcirebas. socialuri muSaki iyenebs ojaxis

eqimis, eqTnisa da specialistis mier konkretuli pacientisaTvis

gansazRvrul fsiqo-socialuri sakiTxTa gadasawyvetad SemuSavebul

formats da martivi, popularuli eniT aTviTcnobierebs pacients

mkurnalobisa da reabilitaciis sakiTxebSi.

sazogadoebrivi jandacvis specialisti uzrunvelyofs epilefsiis

Sesaxeb samedicino da socialuri informaciis mopoveba-Segroebas;

axdens informaciis sistematizacias da gegmavs Sesabamis sazogadoebriv

jandacviT RonisZiebebs sxvadasxva miznobrivi jgufebis mixedviT, raTa

Seamciros epilefsiis stigmis xarisxi; rigi parametebis misaRebad da

gasazomad awarmoebs kvlevebs, miRebuli Sedegebis safuZvelze akeTebs

analizs da Sesabamis informacias, samoqmedo arealis mixedviT, awvdis

rogorc pjd, ise specializirebul (maT Soris epileftologiur)

samsaxurebs.

9. eTikur-samarTlebrivi da organizaciuli rekomendaciebi • gaidlainiT sargeblobisaTvis gaTvaliswinebulia bioeTikuri da

samedicino eTikuri kodeqsis aRiarebuli principebi; upiratesi

yuradReba eTmoba stigmatizaciis gamomwvevi faqtorebis

Sesustebasa da aRmofxvras;

• gaidlaini efuZneba saqarTvelos kanonmdeblobas, saqarTvelos

konstituciasa da kanonebs: `janmrTelobis dacvis Sesaxeb”,

`saeqimo saqmianobis Sesaxeb”, `pacientis uflebebis Sesaxeb”,

`fsiqikuri janmrTelobis Sesaxeb”, `patimrobis Sesaxeb”;

saqarTvelos Sromis kodeqss, saqarTvelos Sromis janmrTelobisa

da socialuri dacvis ministris Sesabamis brZanebebsa da

normatiul aqtebs;

• gaidlaini iTvaliswinebs im saerTaSoriso normebs, romlebic

aRiarebulia saqarTvelos saxelmwifos mier.

gaidlaini da Sesabamisi protokolebi iTvaliswineben jandacvis sistemis organizaciul mxares

• eqimTa, eqTanTa da specialistTa (m.S. arasamedicino profili,

romelic monawileobs gamosavlis Sedegis miRwevaSi),

pasuximgeblobebsa da kompetenciebs jandacvis sistemis pirveladi,

meoreuli da mesameuli doneebis mixedviT;

• pirveladi done iTvaliswinebs ojaxis eqimisa da eqTnis

valdebulebebs, sazogadoebrivi jandacvis sistemis momsaxurebis

sferoebs uSualod fizikuri piris, miznobrivi jgufebisa da

populaciis doneze;

61

• saswrafo da gadaudebeli momsaxurebis rgolis valdebulebebs,

qmedebebisa da mkurnalobis algoritmebs;

• epilefsiis hospitalur doneze marTvas – nevrologis

valdebulebebs, qmedebebsa da mkurnalobis sqemebs;

• uSualod specialistis (nevrologi, qirurgi, m.S. epileftologiis

dargSi specialuri wvrTnagavlili da serTificirebuli eqimi)

momsaxurebis kompetenciebsa da moqmedebis sqemebs.

• gaidlaini iTvaliswinebs epilefsiis erovnuli registris warmoebas,

daavadebis identifikaciasa da mravalparametrian diagnostikas

adekvaturi mkurnalobis warmarTvisaTvis.

• pirveladi da sazogadoebrivi jandacvis doneze gansakuTrebul

mniSvnelobas akisrebs socialuri muSakebisa da sazogadoebrivi

jandacvis specialistebis CarTvas, romelTa aqtivobac aucilebelia

epilefsiiT gamowveuli mentaluri da socialuri problemisadmi

swori damokidebulebebis formirebaSi da daavadebulis mier

problemasTan gamklavebaSi.

• specializirebuli momsaxurebis doneze aucileblad miiCnevs

nerofsiqologis CarTvas rogorc epilefsiis diagnostirebis, ise

fsiqo-socialuri reabilitaciisa da mkurnalobis gverdiTi

movlenebis Sefasebis procesSi.

momsaxurebis xarisxis Sefaseba iwarmoebs gaidlainis, Sesabamisi protokolebisa da Sida dawesebulebrivi debelebebis Sesabamisad. 10. praqtikaSi adaptaciisa da protokolebis SemuSavebis

rekomendaciebi. gaidlainma praqtikaSi adaptacia unda gaiaros etapobrivad.

I etapi – pilotireba jandacvis reformis moTxovnebis adekvatur

regionebSi, sadac moqmedebs pjd-s, sazogadoebrivi jandacvis,

referaluri da hospitaluri momsaxurebis dadgenili formatis

samsaxurebi. adaptaciis procesi unda daiwyos pirveladi janacvis

rgolidan (araumcires 6 Tvis periodisa).

II etapi – adaptacia imave regionebSi profiluri (nevrologiuri)

momsaxurebis doneze, araumcires 6 Tvisa;

III etapi – adaptacia mravalprofiluri momsaxurebis sistemaSi

(samSobiaroebi, saswrafo da gadaudebeli daxmarebebi) – 1 weli;

masalis statistikuri damuSavebisa da monacemTa analizis Semdgom

dazustebuli rekomendaciebi, protokolebis saxiT, saTanado wesiT

Seva normatiul regulaciebSi.

gaidlainisa da protokolebis praqtikuli aTviseba/danergva

xorcieldeba Sesabamisi kompetenciis mqone specialistebisa da

samsaxurebis xelSewyobiT.

62

gaidlainis danergvis meTodi: saswavlo modulebis SemuSaveba,

miznobrivi jgufebis (pjd-s, saz. jandacvis, nevrologebis, saswrafo

daxmarebis TanamSromlebis, reanimatologebis, pediatrebis,

ginekologebis, fsiqiatrebisa da fsiqologebis) treningebi vizualuri

da verbaluri masalebis miwodebiT.

11. gaidlainis gadasinjvisa da ganaxlebis vada gaidlainis gadasinjvisa vadaa ori weli;

ganaxlebis vada 3 weli. uaxlesi samecniero-teqnologiuri miRwevebis

safuZvelze, SesaZlebelia, dRis wesrigSi dadges gaidlainis

riggareSed ganaxlebis aucilebloba.

12. gaidlainis miRebis wyaro

gaidlaini Sedgenilia faqtze damyarebuli monacemebisa da

funqcionirebadi gaidlainebis analizis safuZvelze. sarwmunoebis

doneebi (Ia-IV). 1. National Institute for Clinical Excellence. Quick Reference Guide, The Epilepsies:

Diagnosis and Management of the Epilepsies in Adults in Primary and Secondary Care. October, 2004; Developed by the National Collaborating Centre for Primary Care; www.nice.org.uk

2. American Clinical Neurophisiology Society. Guideline 1: Minimum Technical Requirements for Performing Clinical Electroencephalography (2006). American Clinical Neurophisiology Society.

3. National Institute for Clinical Excellence. Quick Reference Guide, The Epilepsies: Diagnosis and Management of the Epilepsies in Children and Young People in Primary and Secondary Care, NICE October, 2004; Developed by the National Collaborating Centre for Primary Care; www.nice.org.uk

4. The Epilepsies: Clinical Practice Guideline, Appendix B, Pharmacological Treatment, 2004; AAN guidelines for Epilepsy (American Academy of Neurology) http://www.aesnet.org

5. Crawford P, Appleton R, Betts T, Duncan J, Guthrie E, Morrow J. Best practice guidelines for the management of women with epilepsy. The Women with Epilepsy Guidelines Development Group. Seizure 1999; 8:201-17.

6. Scottish Intercollegiate Guidelines Network. Diagnosis and Management of Epilepsy in Adults, 1997. http:// www.show.scot.nhs.uk/sign/html/htmtxt21.htm

7. NHS R&D Health Technology Assessment Programme. An RCT of long-term clinical outcames and cost-effectivness of stansard and new antiepileptic drugs, 2000. http://www.hta.nhsweb.nhs.uk/projdets/951301.htm

8. Commission on Epidemiology and Prognisis, International League Against Epilepsy. Guidelains for epidemiologic studies on epilepsy. Epilepsia 1993; 34:592-6.

9. Recommended Guidelines for Diagnosis and Treatment in Specialized Epilepsy Centers, Prepared by The National Association of Epilepsy Centers. Epilepsia 1990; Vol. 31:

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11. Epilepsy: From Synapse to Society. Practical Guide To Epilepsy. Edited by: J.W Sander, M.C. Walker and J.E. Smalls, 9-th Epilepsy Teaching Weekend, October 2003. St.Anne’s College, Oxford.

13. alternatiuli gaidlaini ar arsebobs

14. gamoyenebuli literatura: 1. Arzimanoglou, A., Guerrini, R., Aicardi, J (2004) Aicardi’s Epilepsy in Children.

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3. Commission on Classification and terminology of the International League Against Epilepsy. Proposal for revised classification of epilepsies and epileptic syndromes. Epilepsia 1989;30:389-99.

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5. Crager DE, Berry DT, Fakhoury TA, Cibula JE, Schmitt FA. A review of diagnostic techniques in the differential diagnosis of epileptic and nonepileptic seizures. Neuropsychol Rev. 2002;12:31-64.

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9. Engel JJ., Pedley TA. (1997) Epilepsy: A comprehencive textbook. Philadelphia: Lippincott-Raven Publishers.

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20. Hauser WA. Incidence and prevalence of Epilepsy. In Engel JJ, Pedly TA, eds. Epilepsy: A comprehensive Texstbook, pp 47-57. Philadelphia: Lippinkott-Reven Publishers, 1997.

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22. Jacoby A. Stigma, Epilepsy and Quality of Life. Epilepsy and Behaviour, 2002; 3: S10-S20.

23. Jallon P. and Latour P. Epidemiology of Idiopathic Generalized Epilepsies. Epilepsia, 2005; 46(Suppl. 9):10-14.

24. Kaplan PW. Assessing the outcomes in patients with nonconvulsive status epilepticus. Nonconvulsive status epilepticus in under diagnosed, potentially overtreated, and confunded by comorbidity. J Clin. Neuroph. 1999; 16: 341-52.

25. Knudsen GU. Febrile seizures: treatment and prognisis. Epilepsia 2000;41:2-9. 26. Kramer G.(2005) Epilepsy from A to Z. A Dictionari of Medical Terms. Stuttgart,

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Bourgeois BFD, eds. Pediatric epilepsy, pp 133-43. New York: Demos, 2001. 28. Meencke HJ. Pathological findings in childhood absence epilepsy. In Duncan JS,

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29. Mirian SB, Guaranha, Garzon E, Carlos A, Bucfpiguel, and all. Hyperventilation Revisited: Physiolodical Effects and Efficacy on Focal seizure Activation in the Era of Video-EEG Monitoring. Elilepsia 46(1):69-75, 2005.

30. Morrel, MJ. (2002) Epilepsy in Women. American Family Physician; Vol 66(8); 1489-94. 31. Morell M. Stigma and Epilepsy. Epilepsy and Behaviour 2002; 3: S21-S25 32. Nelson KB, Ellenberg JH. Prognosis in children with febrile seizures. Pediatrics 1978;

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and tolerability of the new antiepileptic drugs; commentary on the recently published practice parameters. Epilepsia 2004; 45:1646-9.

36. Patsalos PN, Perucca E. Clinically important drug interactions in epilepsy: interactions between antiepileptic drugs and other drugs. Lancet Neurol. 2003: 2:473-81.

37. Petersen I., Eeg-Olofsson O. The development of the electroencephalogram in normal children from the age of 1 through 15 year: non paroxismal activity. Neuropediatrie, 1971; 2: 247-304.

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38. Practice parameter: the neurodiagnostic evaluation of the child with a first simple febrile seizure. American Academy of Pediatrics. Provisional Committee on Quality Improvement, Subcommittee on Febrile Seizures. Pediatrics 1996; 97:769-72.

39. Reuber M, Elger CE. Psychogenic nonepileptic seizures: review and update. Epilepsy Behav. 2003;4:205-16.

40. Rubboli G, Parra J, Seri S, Takahashi T, and Thomas P. EEG Diagnostic Procedures and Special Investigations in the Assessment of Photosensitivity. Epilepsia 2004 (45); Suppl. 1:35-39.

41. Sander J. W., Walker M.C. and.Smalls J.E. (2003) Epilepsy: From Synapse to Society, Practical Guide To Epilepsy. 9-th Epilepsy Teaching Weekend; St. Anne’s College, Oxford.

42. Shorvon S, Perucca E, Fish D, Dodson E, eds. The treatment of epilepsy (2nd edition). Oxford: Blackwell Publishing, 2004.

43. Takahashi Y, Fujiwara T. Effectiveness of Broadcasting guidelines for photosensitive seizure prevention. Neurology 2004; 62: 990-3.

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45. Theodore WH. Implications of neuroimaging for the treatment of epilepsy. Ann Neurol 2003;53:296-8.

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47. Tsi M L., HUng K L. Topographic mapping and clinical analysis of benign childhood epilepsy with centro-temporal spikes. Brain, Dev. 1998, 20: 27-32.

48. Wheless JW. Nonpharmacologic treatment of the catastrophic epilepsies of childhood. Epilepsia 2004 (45); Suppl. 5: 17-22.

49. WHO Disease classification and coding systems DIMDI - ICD-10 WHO – 2006. mtkicebulebis siZlieris done I (Muir Gray), rekomendaciis xarisxi A (Cook et al).

50. Геладзе Т., Вирсаладзе М., Тоидзе О., и др. Некоторые Эпидемиологические Аспекты Эпилепсии в Восточной Грузии. Сборник трудов ИК и ЭН им. Сараджишвили. Из-во `Мегобари~; 1995: стр. 140-145.

damatebiTi saxelmZRvanelo literatura:

51. T. gagoSiZe, s. kasraZe (2003) _ epilefsiis fsiqo-socialuri

problemebi. Tbilisi, gamomc. `nekeri”.

52. o. ToiZe _ epilefsia pirvelad jandacvaSi, (diagnostikisa da

mkurnalobis ZiriTadi principebi), Tbilisi, 2003;

53. o. To Ze, s. kasraZe (2002) _ qali, epilefsia, reproduqcia. Tbilisi.

54. o. ToiZe, s. kasraZe, T. gagoSiZe, r. uruSaZe, T. lobJaniZe (2005) _

epilefsia. Tbilisi, gamomc. ,,nekeri”.

55. s. kasraZe, o. ToiZe, T. gagoSiZe (2004) _ epilefsia qalebSi -

problemebi, faqtebi. Tbilisi, gamomc. ,,nekeri”.

56. r. uruSaZe (2002) _ sazogadoebrivi jandacva. gamomcemloba `lega~.

15. avtorTa jgufi

`epilefsiis kontrolisa da prevenciis s/p centri”

oTar ToiZe, med. mecn. doqtori, evropis epilefsiis akademiis (EUREPA) sertificirebuli treneri;

66

sofio kasraZe, med. mecn. doqtori, epilefsiis kontrolisa da

prevenciis s/p centris direqtori;

daviT kvernaZe, med. mecn. doqtori, epilefsiis kontrolisa da

prevenciis s/p centris daskvniTi diagnostikis ganyofilebis

xelmZRvaneli;

kaxa gelaZe, nevrologi, epilefsiis kontrolisa da prevenciis s/p

centris pirveladi diagnostikis ganyofilebis xelmZRvaneli;

Tamar gagoSiZe, fsiqologiur mecn. doqtori; i. javaxiSvilis sax.

saxelmwifo universitetis socialur da politikur mecnierebaTa

fakukltetis neiro- da kognituri fsiqologiis mimarTulebis

profesori; epilefsiis kontrolisa da prevenciis s/p centris

neirofsiqologiuri samsaxuris xelmZRvaneli.

giorgi jafariZe, med. mecn. doqtori; epilefsiis kontrolisa da

prevenciis s/p centris eleqtrofiziologiuri laboratoriis

xelmZRvaneli.

Tengiz wulaZe, nevrologi. epilefsiis kontrolisa da prevenciis s/p

centris xarisxis kontrolis ganyofilebis xelmZRvaneli.

giorgi lomiZe, nevrologi-epidemiologi, epilefsiis kontrolisa da

prevenciis s/p centris epidemiologiuri kvlevebis xelmZRvaneli.

Tamar lobJaniZe, ssmu-s sazogadoebrivi jandacvis skolis

xelmZRvaneli.

ramaz uruSaZe, eqimi, epilefsiis kontrolisa da prevenciis s/p

centris konsultanti.

eqspertebi:

n. tatiSvili _ saqarTvelos a.laWyepianis sax. bavSvTa nevrologTa

da neiroqirurgTa asociacia;

i.qarosaniZe _ saojaxo medicinis profesionalTa kavSiri.

Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da

socialuri dacvis saministros janmrTelobis dacvis

departamenti;

lela woworia _ saqarTvelos Sromis, janmrTelobisa da

socialuri dacvis saministros janmrTelobis dacvis

departamenti.