i. sruli.pdf · saxelwodeba warmodgeba berznuli sityvidan `epilambanein~, da nisnavs `moulodnelobit...

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I. 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 èpilambanein~, da niSnavs `moulodnelobiT Sepyrobils~. sinonimebi: `herkulesis daavadeba~, `komitetis daavadeba~, `RvTaebrivi daavadeba~, `varskvlavTa daavadeba~, `mTvaris daavadeba~, `demonuri daavadeba~ da sxva. saqarTveloSi: `bneda~, `mterdacema~, àvi 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 eleqtroencefalografiulad - 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 eleqtroencefalogramaze 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 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. àbsentia~-àq 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.)

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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 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

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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. 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. 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. msd - mtkicebulebis siZlieris done: ganisazRvreba oTxi doniT I (iyofa Ia da Ib doneebad), II (iyofa Ia da Ib doneebad), III da IV; rx – rekomendaciis xarisxi: ganisazRvrulia oTxi xarisxi da Seesabameba mtkicebulebis siZlieris dones: A - Ia da Ib; B - II a da II b; C – III; D – IV.

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II. epilefsiis epidemiologia

eplefsia 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).

epidemiologiuri kvlevis Sedegebi maCvenebeli

msoflioSi

(WHO-s monacemebi, 2001)

saqarTveloSi (1987-1991w.w. monacemebi)

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

prevalensi

5-10:1000

zogadad 5.67 insidensi

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

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

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prognozi:

1. samedicino gamosavali

gulyraTa ganaxlebis riski epilefsiis mimdinareobis mixedviT: epilefsia

# epilefsiuri mdgomareoba

zogadad foka luri

generalizebuli

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%

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. syvelaze 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. populaciasTan 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.

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III. 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.

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

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

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

B. rTuli parcialuri

1. 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

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

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

01. bavSvTa asakis keTilTvisebiani epilefsia centro-temporaluri pikebiT 02. bavSvTa epilefsia oqcipitaluri paroqsizmebiT 03. kiTxvis pirveladi epilefsia

!

B. simptomuri (meoradi) 01. safeTqlis wilis epilefsiebi 02. Sublis wilis epilefsiebi 03. Txemis wilis epilefsiebi 04. kefis wilis epilefsiebi 05. bavSvTa qronikuli progresuli epilepsia partialis continua 06. 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

01. vestis sindromi (infantiluri spazmi) 02. lenoqs-gastos sindromi 03. epilefsia mioklonur-astaturi gulyrebiT 04. epilefsia mioklonuri absansebiT

C. simptomuri (meoradi)

01. adreuli mioklonuri encefalopaTia 02. adreuli infantiluri epilefsiuri encefalopaTia eeg-ze gantvirTvaTa supresiiT 03. sxva simptomuri generalizebuli epilefsiebi

III.gaurkveveli epilefsiebi

A rogorc generalizebuli, ise fokaluri gulyrebiT

01. axalSobilTa gulyrebi 02. CvilTa mZime mioklonuri epilefsia 03. epilefsia ganuwyveteli piktalRovani aqtivobiT nel ZilSi 04. SeZenili epilefsiuri afazia (landau-klefneris sindromi) 05. sxva gaurkveveli epilefsiebi

B.gaurkveveli generalizebuli da fokaluri maxasiaTeblebiT IV. specialuri sindromebi

A. situaciiT ganpirobebuli gulyrebi

01. febriluri krunCxvebi 02. izolirebuli gulyra an izolirebuli epilefsiuri statusi 03. gulyrebi mwvave an toqsikuri faqtorebis zemoqmedebisas (alkoholi, medikamentebi, eklamfsia,

metaboluri darRvevebi)

*klasifikacia gamoiyeneba epileftologiaSi Sida samedicino momsaxurebisaTvis

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

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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.

• epilefsiur gulyraTa da sindromTa saerTaSoriso klasifikaciebi gamoiyeneba epileftologiaSi, Sida samedicino momsaxurebisTvis;

• saerTaSoriso samedicino-statistikuri sistema iyenebs epilefsiur mdgomareobaTa saerTaSoriso klasifikacias

11

V. 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

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, eWviT epilefsiis arsebobaze pacients 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

ojaxis eqimi, eWviT epilefsiis arsebobaze (ix. protokoli #1), epilefsiis winaswari diagnozis dadgenis mizniT, pacients mimarTavs nevrologTan.

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:

12

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.

gulyramde

ra mdgomareobaSi ganviTarda gulyra?

• dgomisas, jdomisas, wolisas, wamodgomisas, da sxv;

• xalxmraval adgilas, marto yofnisas. 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).

gulyris dros

cnobierebis done Setevis dros

• naTeli; • Secvlili; • daTrgunuli; • dakarguli.

gulyris Semdgomi mdgomareoba

• Setevis dasasruli uecaria Tu TandaTanobiTi;

• agzneba, dezorientacia, Zilianoba; • parezi, metyvelebis moSla, Tavis

tkivili, gulisreva, Rebineba; • sxeulis temperatura; • travmuli dazianebebi.

gulyris Semdeg

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; • eqstrapiramiduli darRvevebi.

13

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 epilefsiuri 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

epilefsiuri gulyra

gamomwvevi mizezi emociuri darRvevebi sxvadasxva

xangrZlivoba ZiriTadad 5 wT-ze meti ramdenime wamidan 5 wT-mde

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

14

Sedegebis mixedviT nevrologis moqmedebis strategiebi:

nevrologi-epileftologi

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

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 Seferxebis Sefaseba.

15

arasakmarisia. umjobesia, Tu anamnezs cal-calke Seagrovebs ori sxvadasxva epileftologi, radgan daavadebis stigmatizaciis gamo, pacientis konkretuli eqimisadmi individuri ganwyoba mniSvnelovnad ganapirobebs anamnezis srulyofilebis xarisxs.

VI. 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 eleqtrofiziologiur, samedicino da fsiqo-socialur sakiTxebSi.

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.

epilefsiis diagnostirebisTvis mxolod eeg-gamokvlevis monacemebs ar unda daeyrdnoT!

epilefsiis diagnozi dgindeba mxolod multidisciplinuri jgufis -

epileftologi, neirofsiqologi da eleqtrofiziologi erToblivi gadawyvetilebis safuZvelze.

16

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. kompiuteruli tomografia (kt) gamoiyeneba mwvave nevrologiuri paTologiis an bmr kvlevis ukuCvenebis SemTxvevebSi.

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 araepilefsiuri gulyrebis diagnostika.

bmr gamokvleva 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.

17

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.

klinikuri da paraklinikuri gamokvlevebis monacemTa

sistematizacia:

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.

18

monacemTa sistematizaciis Semdgom

specializirebuli dawesebulebis nevrologis (epileftologis) moqmedebis strategiebi

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 – cnobierebisSecvliT 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 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

epilefsia ar dadasturda

epilefsia dadasturda

pacienti igzavneba saTanado specialistTan

iwyeba adekvaturi antiepilefsiuri mkurnaloba

19

VII. 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.

.

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.

20

antiepilefsiuri mkurnalobis strategia

mkurnalobis dawyeba

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.

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.

21

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 tonur-klonuri

valproati lamotrigini topiramati*

acetazolamidi fenobarbitali* fenitoini*

vigabatrini karbamazepini*

absansebi valproati eTosuqsimidi lamotrigini

klonazepami topiramati*

karbamazepini*gabapentini vigabatrini

miokloniebi valproati

klonazepami lamotrigini piracetami topiramati*

karbamazepini*gabapentini vigabatrini

tonuri valproati lamotrigini


acetazolamidi fenobarbitali* fenitoini*

karbamazepini*

atonuri valproati lamotrigini


acetazolamidi fenobarbitali

karbamazepini*fenitoini*

fokaluri meoradi generalizaciiT an mis gareSe

karbamazepini* lamotrigini valproati topiramati*

klobazami gabapentini fenitoini*

acetazolamidi klonazepami fenobarbitali*

* RviZlis fermentebis mainduqciebeli preparatebi.

antiepilefsiuri preparatis SerCevis ZiriTadi kriteriumebi: • gulyris tipi an tipebi; • epilefsiuri sindromis tipi; • Tanmxlebi daavadebebi; • Tanmxlebi mkurnaloba; • pacientis cxovrebis reJimi.

22

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


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 centrotemporaluri pikebiT

karbamazepini* lamotrJini valproati

topiramati*

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*


23

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


eTosuqsimidi

monoTerapiis saxiT - absansis samkurnalod, rogorc damatebiTi saSualeba - Tu sxva gulyrebs Tan daerTvis absansi


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


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

vigabatrini

monoTerapiul reJimSi uestis sindromis dros, poliTerapiulad rezistentuli fokaluri gulyrebis SemTxvevaSi



24

2. antikonvulsantis dozireba ZiriTadi antikonvulsantebis dRiuri doza da miRebis jeradoba

dRiuri doza mg/kg/dReSi (Terapiuli koncentraciis

zRvari)

preparatis sawyisi doza(titracia kviraSi)

antikonvulsanti

bavSvebi mozrdilebi

miRebis jeradoba

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) 2 mg/dR valproatis gareSe)

12,5-25 mg

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

adekvaturi antiepilefsiuri preparatis doza unda SeirCes pacientis wonaze gadaandariSebiT

25

frTxilad!

Semdgomi qmedeba

daniSnuli mkurnalobis gamosavlis mixedviT ojaxis eqimisa da

nevrologis moqmedebis strategiebi

• 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, epileftologis meTvalyureobis qveS.

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;

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.

26

Setevebi grZeldeba, Tu:

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).

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

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!

27

antikonvulsantebis gverdiTi efeqtebi

antikonvulsanti

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), hiperkinezia*(bavSvebSi), agznebadoba*(bavSvebSi), yuradRebis gafantuloba*(bavSvebSi), agresia, mexsierebis daqveiTeba, libidos daqveiTeba, impotencia, foliumis mJavis nakleboba, neonataluri hemoragia, hipokalcemia, osteomalacia,

makropapuluri gamonayari, toqsikuri epidermuli 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 � -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

28

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.

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.

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-donez.e

29

3. antikonvulsantis Secvla

specializebuli dawesebuleba

4. meore antikonvulsantis CarTva (poliTerapia)

mkurnalobisadmi dauqvemdebarebloba (intractability)

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.

• 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.

• kombinirebuli mkurnalobis sxvadasxva mcdelobas Sedegi ar moaqvs,

mkurnalobis reJimi unda daubrundes preparatebis im kombinacias, romlis drosac mkurnaloba yvelaze efeqturi iyo.

30

5. antikonvulsantis moxsnis anu gamojanmrTelebis procesi Setevebis ganaxlebis riski

• mkurnalobis fonze miRweuli xangrZlivi remisiis pirobebSi bavSvebSi 20%-ia (msd-IIb), mozrdilebSi - 40%m(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

• 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).

• 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.

31

farmakologiuri mkurnalobis xangrZlivoba

farmakologiuri mkurnalobis xangrZlivobis dagegmva

medikamenturi mkurnalobis moxsnis safexurebi

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.

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.

32

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 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; • medikamtebisadmi 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.

33

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;

• 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.

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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).

• 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); 4. statusis samedicino garTulebaTa prevencia (aspiracia,

diseminirebuli intravaskuluri koagulacia, Tirkmlis ukmarisoba).

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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 gadaudebeli 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 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 iSvaTadaa saWiro gadaudebeli samedicino daxmareba, magram aucilebelia Setevebis daTrgunva benzodiazepinebiT, raTa ar moxdes maTi gadazrda krunCxviT statusSi.

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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 SeZleba 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 an ucvleli, an difuzuri neli pik-talRebiTaa warmodgenili. statuss, Cveulebriv, win uZRvis saaTebis an dReebis xangrZlivobis zogadi fizikuri da fsiqologiuri mdgomareobis gauareseba xasiaTis, inteleqtualuri da motoruli aqtivobis daTrgunvis fonze (fsevdodemencia, fsevdoataqsia). statusis Sewyveta tradiciuli medikamenturi mkurnalobisT (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.

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praqtikaSi gamoyofen martivi parcialuri gulyrebis statusis or variants: 1. motoruli simptomebiT da

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 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.

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krunCxviTi epilefsiuri statusis mkurnalobis etapebi: 1. gadaudebeli RonisZiebani (saswrafo daxmarebis brigada)

• 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). inieqciis siCqare ar unda aRematebodes 1-2 mg/wuTSi. erT jerze rekomendebulia maqsimum 10 mg-is Seyvana. inieqciis 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 barbituratebiT an fenitoiniT daviwyoT.

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

intensiuri Terapiis ganyofilebaSia gadasayvani. saWiroa fenitoinis intravenuri inieqcia 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 pentobarbitalia mowodebuli.

• statusis mimdinareobisa da misi Sewyvetis Semdeg - saWiroa

mosalodneli garTulebebis Tvalyurisdevneba (acidozi, hipotenzia, Tirkmlis ukmarisoba, infeqcia, tvinis SeSupeba).

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.

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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)

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

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qali da epilefsia

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:

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.

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.

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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, individuri monacemebis gaTvaliswinebiT, SesaZlebelia, orsulobamde 1-2 TviT adre Seumcirdes antikonvulsantis doza;

• pacienti, romelsac ugrZeldeba gulyrebi, saWiroebs antiepilef-

siuri mkurnalobis optimizacias. unda vcadoT monoTerapia preparatis maqsimalurad dabali efeqturi doziT;

• monoTerapiisas SesaZlebelia preparatis dozis gazrda, xolo po-

liTerapiisas - 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 daava-debulma qalma, yoveldRiurad unda miiRos 5 mg foliumis mJava;

• orsulobis bolo kviraSi pacients, romelic Rebulobs enzimmain-duqcirebel antikonvulsantebs (karbamazepini, fenobarbitali, fenitoini), unda daeniSnos vitamini `K~ (20 mg dReSi).

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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.

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.

• 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.

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

fenitoiniTa da topiramatiT kombinirebuli mkurnalobisas;

• gansakuTrebiT sariskoa valproatis, karbamazepinisa da fenobarbitalis kombinaciebi.

• 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).

43

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

orsulobis konstatacia

ojaxis eqimi

aucilebeli epileftologiuri gegmiuri gamokvlevebi

• eeg-kvleva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • sisxlSi antiepilefsiuri wamlis . . . . . . . . .

kon centraciis gansazRvra • nayofis ultrasonografiuli kvleva . . . . . • alfa-fetoproteinis gansazRvra orsulis

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

ginekologi • gegmiuri gamokvlevebi

• meTvalyureoba

epileftologi • antikonvulsiuri Terapiis

optomizacia;

• foliumis mJavis CarTva (5 mg/dR);

• 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).

44

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

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 epoleftologis mier dauyovnebliv unda mowes-rigdes antiepilefsiuri preparatis doza;

• Tu meloginisa da axalSobilis mdgomareoba saSualebas iZleva, epilefsiiT daavadebulma dedam bavSvi ZuZuTi unda kvebos!

45

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

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%

febriluri krunCxvis ganviTarebis riski maRalia Tu:

• bavSvs nervuli sistema dazianebuli aqvs dabadebidanve;

• ojaxSi arsebobs fk-s an epilefsiis sxva SemTxvevac;

46

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.

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 ara aris saWiro

saWiroa

Tavis tvinis bmr ara aris saWiro

saWiroa

sxva sasurvelia, Catardes sisxlis, Sardis saerTo da sisxlis bioqimiuri analizebi eleqtrolitebis Semcvelobaze.

saWiroa sisxlis, Sardis saerTo, sisxlis bioqimiuri analizebi da sx.

47

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

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

diferencireba

febriluri krunCxva

48

febriluri krunCxvis meurveoba

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

• perioduli gamokvlevebi specializirebul dawesebulebaSi.

49

VIII. 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

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

50

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:

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. epilefsiiT daavadebulTa cxovrebis srulfasovneba cxovrebis srulfasovneba - Quality of Life - pirovnebis fizikuri, socialuri, ekonomikuri da fsiqikuri mdgomareobiT kmayofilebais 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.

51

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.

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.

52

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.

• 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.

IX. 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.

53

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;

• 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.

X. 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.

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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.

XI. 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.

XII. gaidlainis miRebis wyaro gaidlaini Sedgenilia faqtze damyarebuli monacemebisa da funqcionirebadi gaidlainebis analizis safuZvelze. sarwmunoebis doneebi (Ia-IV). 1. National Institute for Clinical Excellence. Quick Reference Guide, The Epilepsies:

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

2. American Clinical Neurophisiology Society. Guideline 1: Minimum Technical Requirements

for Performing Clinical Electroencephalography (2006). American Clinical Neurophisiology Society.

3. National Institute for Clinical Excellence. Quick Reference Guide, The Epilepsies:

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

4. The Epilepsies: Clinical Practice Guideline, Appendix B, Pharmacological Treatment,

2004; AAN guidelines for Epilepsy (American Academy of Neurology) http://www.aesnet.org

5. Crawford P, Appleton R, Betts T, Duncan J, Guthrie E, Morrow J. Best practice guidelines

for the management of women with epilepsy. The Women with Epilepsy Guidelines Development Group. Seizure 1999; 8:201-17.

6. Scottish Intercollegiate Guidelines Network. Diagnosis and Management of Epilepsy in

Adults, 1997. http:// www.show.scot.nhs.uk/sign/html/htmtxt21.htm 7. NHS R&D Health Technology Assessment Programme. An RCT of long-term clinical

outcames and cost-effectivness of stansard and new antiepileptic drugs, 2000. http://www.hta.nhsweb.nhs.uk/projdets/951301.htm

8. Commission on Epidemiology and Prognisis, International League Against Epilepsy.

Guidelains for epidemiologic studies on epilepsy. Epilepsia 1993; 34:592-6. 9. Recommended Guidelines for Diagnosis and Treatment in Specialized Epilepsy Centers,

Prepared by The National Association of Epilepsy Centers. Epilepsia 1990; Vol. 31: Suppl. 1. www.naec-epilepsy.org 10. Primary Care Guidelines for the Management of females with Epilepsy (2004) Royal

Society of Medicine Press Ltd. www. rsmpress.co.uk

http://www.nice.org.uk/

http://www.nice.org.uk/

http://www.aesnet.org/

http://www.show.scot.nhs.uk/sign/html/htmtxt21.htm

http://www.naec-epilepsy.org/

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11. Epilepsy: From Synapse to Society. Practical Guide To Epilepsy. Edited by: J.W Sander,

M.C. Walker and J.E. Smalls, 9-th Epilepsy Teaching Weekend, October 2003. St.Anne’s College, Oxford.

XIII. alternatiuli gaidlainebi: `klinikuri praqtikis erovnuli rekomendaciebisa (gaidlainebi) da daavadebaTa marTvis saxelmwifo standartebis (protokolebi)~ saqarTvelos Sromis, janmrTelobisa da socialuri dacvis ministris 2006 wlis 27 martis # 94/n brZanebis Sesabamisi srulyofili gaidlaini qarTul enaze dReisaTvis ar arsebobs. damatebiTi saxelmZRvanelo literatura: 1. gagoSiZe T., kasraZe s. (2003) epilefsiis fsiqo-socialuri problemebi.

Tbilisi, gamomc. `nekeri”. 2. ToiZe o. epilefsia pirvelad jandacvaSi, (diagnostikisa da mkurnalobis

ZiriTadi principebi), Tbilisi, 2003; 3. TioZe o., kasraZe s. (2002) qali, epilefsia, reproduqcia. Tbilisi. 4. ToiZe o., kasraZe s., gagoSiZe T., uruSaZe r., lobJaniZe T. (2005)

epilefsia. Tbilisi, gamomc. ,,nekeri”. 5. kasraZe s., ToiZe o., gagoSiZe T. (2004) epilefsia qalebSi - problemebi,

faqtebi. Tbilisi, gamomc. ,,nekeri”. 6. uruSaZe r. (2002) sazogadoebrivi jandacva. gamomcemloba `lega~.

XIV. gamoyenebuli literatura:

1. Arzimanoglou, A., Guerrini, R., Aicardi, J (2004) Aicardi’s Epilepsy in Children. Lippincott Williams & Wilkins, Philadelphia, USA.

2. Basag FM. Behavioral aspects of pediatric epilepsy syndromes. Epilepsy Behav. 2004 (5); Suppl 1:S3-13.

3. Bergey G. K. Evidebce-based Treatment of Idiopathic Generalized Epilepsies with New Antiepileptic Drugs. Epilepsia, 2005; 46 (Suppl.9):161-168.

4. Black.TP. Management approaches to prolonged seizures and status epilepticus. Epilepsia 1999 (40) Suupl. 1: S 59-63;

5. Brobtkorb E. Management of epilepsy in people with Iearning difficulties. In: Shorvon S, Perucca E, Fish D, Dodson E, eds. The treatnent of epilepsy (2nd edition). pp 215-26. Oxford: Blackwell Publishing, 2004.

7. Colin D, Binnie, Hermann Stefan. Modern electroencephalography: its role in epilepsy management. Clinical neurophysiology, 1999; 110:1671-1697;

8. Commission on Antiepileptic Drugs of The International League Against Epilepsy. Guidelines for antiepileptic drug trials in children. Epilepsia1994;35:94-100.

9. 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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14. Engel J.Jr. A proposed diagnostic scheme for people with epileptic seizures and with epilepsy: Report of the ILAE Task Force on Classification and Terminology. Epilepsia 2001;42:796-803.

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16. European White Paper on Epilepsy (2001) www. EUCARE.

17. Fejerman N., Caraballo R., Tenembaum SN. Atypical evolution of benign localization related epilepsies in children: are they predictable? Epilepsia 2000; 41: 380-390;

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20. Forsgren L, Sidenvall R, Blomquist HK, Heijbel J. A prospective incidence study of febrile counvulsions. Acta Peadiatr Scand 1990;79:550-7.

21. French J.A., Kanner A.N., Bautista J., Abou-Khalil B., Broune T. et al. Efficacy and tolerability of the new antiepileptic drugs I: Treatment of new onset epilepsy: report of the Therapeutics and Technology Assessment Subcommittee and Quality Stansards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2004; 62:1252-60.

22. French J.A., Kanner A.N., Bautista J., Abou-Khalil B., Broune T. et al. Efficacy and tolerability of the new antiepileptic drugs II: Treatment of refractory epilepsy: report of the Therapeutics and Technology Assessment Subcommittee and Quality Stansards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2004; 62:1261-73.s

23. Gastaut H., Dictionary of Epilepsies. Part I: Definitions, Geneva, WHO 1973;

24. Gates JR. Nonepileptic seizures: Classification, coexistence with epilepsy, diagnosis, therapeutic approaches, and consensus. Epilepsy Behav. 2002;3:28-33.

25. Hart YM. Management of newly diagnosed epilepsy. In Shorvon S, perucca E, Fish D, Dodson E, eds. The treatment of epilepsy (2nd edition), pp 161-73. Oxford: Blackwell Publishing, 2004.

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

27. ILAE Commission Report. The epidemiology of the epilepsies: future dirrections. International League Againts Erilepsy. Epilepsia 1997;38:614-8.

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

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

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32. Kramer G.(2005) Epilepsy from A to Z. A Dictionari of Medical Terms. Stuttgart, Germany.

33. Kuzniecky RI. Neuroimaging in pediatric epileptology. In Pellock JM, Dodson WE, Bourgeois BFD, eds. Pediatric epilepsy, pp 133-43. New York: Demos, 2001.

34. Meencke HJ. Pathological findings in childhood absence epilepsy. In Duncan JS, Panayiotopulos CP, eds. Typical absences and related epileptic syndromes. pp.122-32, London: Cherchill Comunications Europe, 1995;

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

36. Morrel, MJ. (2002) Epilepsy in Women. American Family Physician; Vol 66(8); 1489-94.

37. Morell M. Stigma and Epilepsy. Epilepsy and Behaviour 2002; 3: S21-S25

38. Nelson KB, Ellenberg JH. Prognosis in children with febrile seizures. Pediatrics 1978; 61:20-7.

39. Panayiotopoulos CP., Typical absence seizures. in Gilman S Ed. Medlink Neurology, San Diego. S A: Arbor Publishing Corp., 2004.

40. Panayiotopoulos, T. (2005) The Epilepsies: Seizures, Syndromes and Management. Bladon Medical Publishing, Oxfordshire, UK.

41. Panayiotopoulos, C.P., Benhadis S.R., Covanis A., Dulac O., Duncan J.S., et al. Efficacy and tolerability of the new antiepileptic drugs; commentary on the recently published practice parameters. Epilepsia 2004; 45:1646-9.

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

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

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

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

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

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

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

49. The EURAP Study Group. Seizure control and treatment in pregnancy. Observations from the EURAP Epilepsy Pregnancy Registry. Neurology 2006; 66:354-360.

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

51. Tomson T., Gram L., Silanpaa M., and Johanessen S.I. (1997) Epilepsy and Pregnansy. Ed Petersfield, UK and Bristol, PA, USA.

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

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

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

XV. avtorebi `epilefrsiis kontrolisa da prevenciis s/p centri” oTar ToiZe, med. mecn. doqtori, evropis epilefsiis akademiis (EUREPA) sertificirebuli treneri; sofio kasraZe, med. mecn. kandidati, epilefsiis kontrolisa da prevenciis s/p centris direqtori; daviT kvernaZe, med. mecn. kandidati, 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.

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