由美国神经病学学会和美国癫痫学会指南制定委员会制定的《成人不明原因癫痫首次发作管理指南》于4月20日在《神经病学》(Neurology)杂志上发表。

        编写委员会在指南中对相关问题进行了阐述，并根据美国神经病学学会的证据标准的分类系统回顾了已发表的研究，基于证据级别提出了以下推荐建议。

        1、应使不明原因癫痫首次发作的成人患者知晓其在首次发作后头两年内早期复发风险最大，为21—45%(A级);与风险增加有关的临床变量可能包括既往的脑损伤(A级)，脑电图(EEG)显示癫痫样异常(A级)，明显的脑部成像异常(B级)和夜行性癫痫(B级)。

        2、与第二次发生癫痫再进行治疗相比，首次发作即用抗癫痫药(AED)治疗有可能减少患者头2年内复发风险(B级)，但不改善其生活质量(C级)。从更长远来看(>3年)，首次发作后即用AED治疗不可能改善用持续癫痫缓解评估的患者预后(B级)。

        3、应告知患者AED不良事件(AE)风险范围从7%至31%不等(B级)，这些AE可能主要为轻度且是可逆的。

        4、对于患者首次发作后是否立即启动AED治疗，临床医生应根据个体化评估结果，即权衡复发风险与AED治疗后AE的利弊，考虑受教育后患者的偏好和即刻治疗并不改善癫痫缓解的长期预后但可减少随后2年癫痫风险的建议。

        ABSTRACT

        Objective: To provide evidence-based recommendations for treatment of adults with an unprovoked first seizure.

        Methods: We defined relevant questions and systematically reviewed published studies according to the American Academy of Neurology’s classification of evidence criteria; we based recommendations on evidence level.

        Results and recommendations: Adults with an unprovoked first seizure should be informed that their seizure recurrence risk is greatest early within the first 2 years (21%–45%) (Level A), and clinical variables associated with increased risk may include a prior brain insult (Level A), an EEG with epileptiform abnormalities (Level A), a significant brain-imaging abnormality (Level B), and a nocturnal seizure (Level B). Immediate antiepileptic drug (AED) therapy, as compared with delay of treatment pending a second seizure, is likely to reduce recurrence risk within the first 2 years (Level B) but may not improve quality of life (Level C). Over a longer term (>3 years), immediate AED treatment is unlikely to improve prognosis as measured by sustained seizure remission (Level B).

        Patients should be advised that risk of AED adverse events (AEs) may range from 7% to 31% (Level B) and that these AEs are likely predominantly mild and reversible.

        Clinicians’ recommendations whether to initiate immediate AED treatment after a first seizure should be based on individualized assessments that weigh the risk of recurrence against the AEs of AED therapy, consider educated patient preferences, and advise that immediate treatment will not improve the long-term prognosis for seizure remission but will reduce seizure risk over the subsequent 2 years. Neurology® 2015;84:1705–1713