Aktuelle Neurologie 2018; 45(10): 737-748
DOI: 10.1055/a-0591-2214
Übersicht
© Georg Thieme Verlag KG Stuttgart · New York

Erster epileptischer Anfall im erwerbsfähigen Alter: Prognose-adaptiertes Management

First Epileptic Seizure During Working Age: Prognosis-Adapted Management
Ulrich Specht
Epilepsie-Zentrum Bethel, Krankenhaus Mara, Bielefeld
,
Christian G. Bien
Epilepsie-Zentrum Bethel, Krankenhaus Mara, Bielefeld
› Author Affiliations
Further Information

Publication History

Publication Date:
25 April 2018 (online)

Zusammenfassung

Hintergrund Die Frage des angemessenen Managements nach einem ersten epileptischen Anfall verursacht nicht selten Unsicherheit. Dies betrifft vier Themenbereiche: die Diagnostik; die Einschätzung des Rezidivrisikos; die Beratung des Patienten bezüglich einer antiepileptischen Pharmakotherapie sowie deren weiterer ärztlicher Begleitung; und die sozialmedizinische Bewertung (Fahreignung, berufliche Eignung).

Methodik Zusammenfassung der relevanten Datenlage zu diesen Themenfeldern und daraus abgeleitete Empfehlungen zum praktischen Umgang mit ersten epileptischen Anfällen im erwerbsfähigen Alter.

Ergebnis Nach der Klärung, ob es sich um einen epileptischen Anfall gehandelt hat, dient die Diagnostik einerseits dazu, akut-symptomatische und potenziell behandlungsbedürftige Ursachen zu erkennen, andererseits zur Abschätzung des Rezidivrisikos. Dieses hängt weniger davon ab, ob eine Epilepsie diagnostiziert werden kann. Risikoerhöhend sind vielmehr – auch additiv – das Vorliegen folgender Merkmale: epilepsietypische Aktivität im EEG, bildgebender Nachweis einer Hirnläsion, zerebrale Vorerkrankung oder Auftreten des Anfalls aus dem Schlaf. Je höher das Rezidivrisiko, desto stärker scheint der rezidivprophylaktische Effekt einer antiepileptischen Pharmakotherapie zu sein und desto eher wird man dafür optieren. Die Entscheidung hierüber wird gemeinsam mit dem Patienten getroffen unter Berücksichtigung seiner Präferenzen und seiner sozialen Situation (z. B. Angewiesensein auf die Fahreignung, berufliche Besonderheiten). In der weiteren Begleitung kommt der Sicherung der Adhärenz eine entscheidende Rolle zu. Für die Frist bis zur Wiedererlangung der Fahreignung und der Eignung, bestimmte berufliche Tätigkeiten (wieder) auszuüben, gibt es verbindliche Regelungen.

Abstract

Background Appropriate management after the first epileptic seizure often causes uncertainty in diagnostics, the assessment of the risk of recurrence, patient counselling on antiepileptic pharmacotherapy as well as further medical supervision and the assessment of driving ability and job suitability.

Methodology Summary of the relevant data on these topics and recommendations derived therefrom for the practical handling of first epileptic seizures at working age.

Results After identifying the epileptic nature of the seizure, diagnostics aims at identifying acute-symptomatic and potential treatment-requiring causes; in addition, it enables estimation of risk of seizure recurrence. This risk depends less on whether “epilepsy” can be diagnosed; rather, the following points indicate an increased recurrence risk: epileptiform activity in the EEG, imaging evidence of a potentially epileptogenic brain lesion, existing cerebral neurological disease, or onset of seizure from sleep. The higher the risk of recurrence, the stronger seems the prophylactic effect so that earlier antiepileptic pharmacotherapy will be considered. The decision on this is taken together with the patient, taking into account his preferences and his social situation (driving license, job characteristics). With subsequent medical supervision, the assurance of adherence plays a crucial role. There are regulations regarding the seizure-free period before reapplying for a driverʼs license and carrying out certain occupational activities.

 
  • Literatur

  • 1 Fisher RS, Acevedo C, Arzimanoglou A. et al. ILAE official report: a practical clinical definition of epilepsy. Epilepsia 2014; 55: 475-482
  • 2 Beghi E, Carpio A, Forsgren L. et al. Recommendation for a definition of acute symptomatic seizure. Epilepsia 2010; 51: 671-675
  • 3 Berg AT, Shinnar S. The risk of seizure recurrence following a first unprovoked seizure: a quantitative review. Neurology 1991; 41: 965-972
  • 4 Hesdorffer DC, Benn EK, Cascino GD. et al. Is a first acute symptomatic seizure epilepsy? Mortality and risk for recurrent seizure. Epilepsia 2009; 50: 1102-1108
  • 5 Brown JWL, Dunne JW, Fatovic DM. et al. Amphetamine‐associated seizures: Clinical features and prognosis. Epilepsia 2011; 52: 401-404
  • 6 Hesdorffer DC, Logroscino G, Cascino G. et al. Risk of unprovoked seizure after acute symptomatic seizure: effect of status epilepticus. Ann Neurol 1998; 44: 908-912
  • 7 Lawn N, Lieblich S, Lee J. et al. Are seizures in the setting of sleep deprivation provoked?. Epilepsy Behav 2014; 33: 122-125
  • 8 Pohlmann-Eden B, Schreiner A, Mika A. Diagnostische and prognostische Implikationen des ersten epileptischen Anfalles im Erwachsenenalter. Fortschr Neurol Psychiatr 1994; 62: 147-154
  • 9 Firkin AL, Marco DJ, Saya S. et al. Mind the gap: Multiple events and lengthy delays before presentation with a “first seizure”. Epilepsia 2015; 56: 1534-1541
  • 10 Hauser WA, Rich SS, Lee JR-J. et al. Risk of recurrent seizures after two unprovoked seizures. N Engl J Med 1998; 338: 429-434
  • 11 Kho L, Lawn N, Dunne J. et al. First seizure presentation: do multiple seizures within 24 hours predict recurrence?. Neurology 2006; 67: 1047-1049
  • 12 Bonnett LJ, Tudur-Smith C, Williamson PR. et al. Risk of recurrence after a first seizure and implications for driving: further analysis of the Multicentre study of early Epilepsy and Single Seizures. BMJ 2010; 341: c6477
  • 13 Bonnett LJ, Marson AG, Johnson A. et al. External validation of a prognostic model for seizure recurrence following a first unprovoked seizure and implications for driving. PLoS One 2014; 9: e99063
  • 14 Josephson C, Leach J-P, Duncan R. et al. Seizure risk from cavernous or arteriovenous malformations. Prospective population-based study. Neurology 2011; 76: 1548-1554
  • 15 Harden C, Huff J, Schwartz T. et al. Reassessment: Neuroimaging in the emergency patient presenting with seizure (an evidence-based review). Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2007; 69: 1772-1780
  • 16 Ho K, Lawn N, Bynevelt M. et al. Neuroimaging of first-ever seizure. Contribution of MRI if CT is normal. Neurol Clin Pract 2013; 3: 398-403
  • 17 Krumholz A, Wiebe S, Gronseth GS. et al. Evidence-based guideline: Management of an unprovoked first seizure in adults: Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2015; 84: 1705-1713
  • 18 Elger CE, Berkenfeld R. S1-Leitlinie Erster epileptischer Anfall und Epilepsien im Erwachsenenalter. Deutsche Gesellschaft für Neurologie. Hrsg. Leitlinien für Diagnostik und Therapie in der Neurologie. 2017 Online: www.dgn.org/leitlinien [abgerufen am 12.11.2017]
  • 19 Bast T, Bauer J, Berkenfeld R. et al. Erster epileptischer Anfall und Epilepsien im Erwachsenenalter. Akt Neurol 2017; 44: 603-636
  • 20 National Institute for Clinical Excellence (NICE). Clinical guideline CG137: The epilepsies: The diagnosis and management of the epilepsies in adults and children in primary and secondary care. Last updated: February 2016. https://www.nice.org.uk/guidance/cg137 [Zugriff: 29.11.2017]
  • 21 Debicki DB. Electroencephalography after a single unprovoked seizure. Seizure 2017; 49: 69-73
  • 22 Wiebe S, Tellez-Zenteno JF, Shapiro M. An evidence-based approach to the first seizure. Epilepsia 2008; 49 (Suppl. 01) 50-57
  • 23 von Podewils F, Suesse M, Geithner J. et al. Prevalence and outcome of late‐onset seizures due to autoimmune etiology: A prospective observational population‐based cohort study. Epilepsia 2017; 58: 1542-1550
  • 24 Wolf P. Non-medical treatment of first epileptic seizures in adolescence and adulthood. Seizure 1995; 4: 87-94
  • 25 Marson A, Jacoby A, Johnson A. et al. Immediate versus deferred antiepileptic drug treatment for early epilepsy and single seizures: a randomised controlled trial. Lancet 2005; 365: 2007-2013
  • 26 Specht U. Medikamenten-Compliance bei Epilepsie. Nervenarzt 2008; 79: 662-668
  • 27 Musicco M, Beghi E, Solari A. et al. Treatment of first tonic-clonic seizure does not improve the prognosis of epilepsy. First Seizure Trial Group (FIRST Group). Neurology 1997; 49: 991-998
  • 28 Tudur SmithC, Marson AG, Chadwick DW. et al. Multiple treatment comparisons in epilepsy monotherapy trials. Trials 2007; 8: 1-10
  • 29 Glauser T, Ben-Menachem E, Bourgeois B. et al. Updated ILAE evidence review of antiepileptic drug efficacy and effectiveness as initial monotherapy for epileptic seizures and syndromes. Epilepsia 2013; 54: 551-563
  • 30 Marson AG, Al-Kharusi AM, Alwaidh M. et al. The SANAD study of effectiveness of carbamazepine, gabapentin, lamotrigine, oxcarbazepine, or topiramate for treatment of partial epilepsy: an unblinded randomised controlled trial. Lancet 2007; 369: 1000-1015
  • 31 Bundesanstalt für Straßenwesen. Begutachtungs-Leitlinien zur Kraftfahreignung. Stand 14.08.2017. 2017 https://www.bast.de/DE/Verkehrssicherheit/Fachthemen/BLL/Begutachtungsleitlinien-2017.pdf?__blob=publicationFile&v=12) (12.01.2018). Bergisch Gladbach: Bundesanstalt für Straßenwesen
  • 32 Second European Working Group on Epilepsy and Driving. Epilepsy and driving in Europe. A report of the second European Working Group on Epilepsy and Driving, an advisory board to the Driving Licence Committee of the European Union. Final report. https://ec.europa.eu/transport/road_safety/sites/roadsafety/files/pdf/behavior/epilepsy_and_driving_in_europe_final_report_v2_en.pdf [Zugriff: 12.01.2018]
  • 33 Lindsten H, Stenlund H, Edlund C. et al. Socioeconomic prognosis after a newly diagnosed unprovoked epileptic seizure in adults: a population-based case-control study. Epilepsia 2002; 43: 1239-1250
  • 34 Holland P, Lane S, Whitehead M. et al. Labor market participation following onset of seizures and early epilepsy: Findings from a UK cohort. Epilepsia 2009; 50: 1030-1039
  • 35 Ausschuss Arbeitsmedizin der Gesetzlichen Unfallversicherung. unter Mitarbeit von: Berkenfeld R. et al. Berufliche Beurteilung bei Epilepsie und nach erstem epileptischen Anfall (DGUV-Information 250-001). Berlin: Deutsche Gesetzliche Unfallversicherung; 2015
  • 36 Specht U, Coban I, Bien CG. et al. Risk factors for early disability pension in patients with epilepsy and vocational difficulties – Data from a specialized rehabilitation unit. Epilepsy Behav 2015; 51: 243-248
  • 37 Specht U, May TW, Rohde M. et al. Cerebellar atrophy decreases the threshold of carbamazepine toxicity in patients with chronic focal epilepsy. Arch Neurol 1997; 54: 427-431
  • 38 Brandt C, Labudda K, Illies D. et al. Schnelle Erkennung einer depressiven Störung bei Menschen mit Epilepsie. Der Nervenarzt 2014; 85: 1151-1155
  • 39 Löwe B, Decker O, Muller S. et al. Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Medical care 2008; 46: 266-274
  • 40 Löwe B. Gesundheitsfragebogen für Patienten (GAD-7) [Generalizied Anxiety Disorder Scale-7]. In. 2015 https://www.google.de/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwi-kJ6A96zYAhXRKVAKHWyHCRYQFggnMAA&url=https%3A%2F%2Fwww.uke.de%2Fdateien%2Finstitute%2Finstitut-und-poliklinik-f%25C3%25BCr-psychosomatische-medizin-und-psychotherapie%2Fdownloads%2Fgesundheitsfragebogen-gad-7.pdf&usg=AOvVaw2p815ifKRX-TWo0vfX6Ey0 [28.12.2017]
  • 41 Lutz MT, Helmstaedter C. EpiTrack: tracking cognitive side effects of medication on attention and executive functions in patients with epilepsy. Epilepsy Behav 2005; 7: 708-714
  • 42 Krumholz A, Wiebe S, Gronseth G. et al. Practice Parameter: evaluating an apparent unprovoked first seizure in adults (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2007; 69: 1996-2007
  • 43 Hoppe M. Schlaf, Epilepsie und EEG. Klin Neurophysiol 2008; 39: 224-229
  • 44 Deutsche Rentenversicherung. Leitlinie zur sozialmedizinischen Beurteilung bei Neurologischen Krankheiten. 2010
  • 45 Velissaris SL, Wilson SJ, Newton MR. et al. Cognitive complaints after a first seizure in adulthood: influence of psychological adjustment. Epilepsia 2009; 50: 1012-1021
  • 46 Zaccara G, Franciotta D, Perucca E. Idiosyncratic adverse reactions to antiepileptic drugs. Epilepsia 2007; 48: 1223-1244
  • 47 Müffelmann B, Bien CG. Pharmakologische Epilepsietherapie bei Kinderwunsch und in der Schwangerschaft [Pharmacological treatment of women with epilepsy before and during pregnancy]. Nervenarzt 2016; 87: 1115-1126
  • 48 Hoppe C, Poepel A, Elger CE. Epilepsy: accuracy of patient seizure counts. Arch Neurol 2007; 64: 1595-1599
  • 49 Brigo F, Igwe SC, Erro R. et al. Postictal serum creatine kinase for the differential diagnosis of epileptic seizures and psychogenic non-epileptic seizures: a systematic review. J Neurol 2015; 262: 251-257
  • 50 May TW, Berkenfeld R, Dennig D. et al. Patientsʼ perspectives on management and barriers of regular antiepileptic drug intake. Epilepsy Behav 2018; 79: 162-168
  • 51 Elwes RD, Chesterman P, Reynolds EH. Prognosis after a first untreated tonic-clonic seizure. Lancet 1985; 2: 752-753
  • 52 First SeizureTrial Group. Randomized clinical trial on the efficacy of antiepileptic drugs in reducing the risk of relapse after a first unprovoked tonic-clonic seizure. Neurology 1993; 43: 478-483
  • 53 Hopkins A, Garman A, Clarke C. The first seizure in adult life. Value of clinical features, electroencephalography, and computerised tomographic scanning in prediction of seizure recurrence. Lancet 1988; 1: 721-726
  • 54 Annegers JF, Shirts SB, Hauser WA. et al. Risk of recurrence after an initial unprovoked seizure. Epilepsia 1986; 27: 43-50
  • 55 Hart YM, Sander JWA, Johnson AL. et al. National General Practice Study of Epilepsy: recurrence after a first seizure. Lancet 1990; 336: 1271-1274
  • 56 Hauser WA, Rich SS, Annegers JF. et al. Seizure recurrence after a 1st unprovoked seizure: an extended follow-up. Neurology 1990; 40: 1163-1170
  • 57 Kim LG, Johnson TL, Marson AG. et al. Prediction of risk of seizure recurrence after a single seizure and early epilepsy: further results from the MESS trial. Lancet Neurol 2006; 5: 317-322