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専攻医てんかん
はじめの一歩!
さめじま
→基本、1回目の発作であればてんかんと
は診断しない
→1回目の発作でルーチンで脳波やMRIを施
行する必要ない
旗の台では2回目の発作後に脳波+内服開
始(保護者と相談して)、
外来MRIとすることが多いようです
てんかんとは
•少なくとも2回の非誘発性発作が24時間以
上の間隔でおこっている
•1回の非誘発性発作と今後10年間に60%
以上の再発性が予見される
•何らかのてんかん症候群と診断される
問診で聞くこと
• いつ(覚醒時、ぼんやりしているとき、就寝時)、頻度
• 症状の持続、意識の有無、まひの有無
• 誘因(発熱、入浴、睡眠不足、ゲームなど)
• 発作様式(けいれん、非けいれん、どの部位から始
まるか)
• 頭部・顔面の様子(口部自動症など伴うか)
• 外傷、咬舌、尿失禁
• 最終発作
• 家族歴
診断フローチャート
てんかん発作型
・焦点発作:発作に関与する大
脳半球が片側に限局する
・全般発作:両側大脳半球が
発作に関与する
・未分類てんかん発作
てんかんの診断は
発作型とてんかん症候群国際
分類(ILAE,2010年)に従って
おこなう
予後の予測
• 初回発作後にてんかん性異常波を認めるのは18-
56%(J Clin Neurophysiol 2010)
• 3回以降の脳波検査でてんかん性異常波が出現する
ことは少ない(Epilepsia 2014)
• 脳波異常がすべててんかんというわけではないがて
んかん発症率は脳波異常なしの場合と比較して2倍
( J Clin Neurophysiol 2010)
→初回発作後に緊急で脳波検査を行う必要はないが、
検査で異常波を認めるようであれば再度発作を起こ
す可能性は高い
治療
• 初回非誘発性発作は2回目以降に治療開始しても長期予
後はかわらない(Lancet 2005)
• 非誘発性発作後経過観察して、再発自主性てんかん発作
あれば抗てんかん薬を開始する
• 維持量の1/3程度で開始し、1~4週ごとに増量する
• 焦点発作(60-70%)→CBZ 10-20mg/kg/day 分2
• 全般発作(20-30%)→VPA 10-30mg/kg/day 分2
• 未分類てんかん発作(1-10%)→VPA10-30mg/kg/day 分2
治療
• 中心・側頭部に棘波を示す自然終息性てんかん(旧称:
BECT)やPanayiotopoulos症候群では発作頻度次第では治
療開始を保留してよい
• 効果判定は発作頻度やQOLへの影響、脳波の変化を評価
する
• 効果判定および副作用の評価を行いながら治療域までは
薬剤投与量を調節していく
• 抗てんかん薬の血中濃度は量を変更して目標濃度を決め
たいときや副作用の評価目的、薬理動態の変化が疑われ
るときなどに行う(Epilepsia 2008)
治療
• 小児では2年以上発作が寛解してから治療終結を考慮する
(寛解2年未満での治療群では長期治療群と比較して再燃リ
スクが高い(Cochrane Rev 2015))
• 薬剤抵抗性てんかん(2剤使用しても1年が抑制されない)で
は全般性強直間代性発作の頻度が高いと知的予後は悪い
(Epilepsia 2005)
• てんかん患者の予期せぬ突然死(SUDEP)は発作頻度が最
も強く関連し、次いで若年発症と罹患期間がリスクとなり
(Epilepsia 2005)、てんかん患者死因の2-17%をしめる
(Neurology 1998)

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てんかん