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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.
10
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
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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.
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13. alternatiuli gaidlaini ar arsebobs
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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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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.