微创锁孔入路选择性海马杏仁核切除治疗伴海马硬化的内侧颞叶癫痫

目的探讨经颞上沟-侧脑室锁孔入路选择性海马杏仁核切除术治疗难治性内侧颞叶癫痫的疗效及安全性。方法回顾性分析2014年9月~2016年3月南京军区南京总医院神经外科19例难治性内侧颞叶癫痫患者的临床资料。患者均采用颞上沟-侧脑室锁孔入路选择性海马杏仁核切除手术方式。结果术后复查头颅MRI示,手术切除范围满意。术后随访6~24个月,EngelⅠ级14例(73.6%)、Ⅱ级4例(21%)、Ⅲ级1例(5.4%),无严重手术并发症。结论经颞上沟-侧脑室锁孔入路选择性海马杏仁核切除术治疗难治性内侧颞叶癫痫安全有效;与传统手术入路相比,手术创伤小,手术时间缩短。     

神经导航锁孔入路选择性杏仁核海马切除术治疗内侧颞叶癫(癎)(附23例分析)

目的 探讨神经导航下锁孔入路选择性杏仁核海马切除术治疗内侧颢叶癫(癎)的疗效及手术经验.方法 回顾性分析23例药物难治性内侧颞叶癫(癎)的手术经验.均在无框架神经导航指引下,经颢部锁孔开颅,在显微镜下分开一小段颞下沟,切开侧脑室颢角前外侧壁后进入侧脑室,选择性切除杏仁核海马,并将海马旁回和钩回逐步吸除.结果 本组无严重手术并发症发生.术后随访24-57个月,Engel Ⅰ级(发作完全消失)17例(73.9%),Ⅱ级4例(17.4%),Ⅲ级2例(8.7%).结论 神经导航下经锁孔颞下沟入路选择性杏仁核海马切除术是治疗内侧颞叶癫(癎)的有效方法,手术创伤小,可妥善保护语言区和视放射,安全性高.     

经颞下梭状回入路选择性海马杏仁核切除术治疗颞叶内侧癫痫

目的探讨经颞下梭状回入路选择性杏仁核海马切除术治疗颞叶内侧癫痫的手术方法、疗效及并发症。方法药物难治性颞叶内侧癫痫30例患者,经颞下切开梭状回,进入侧脑室颞角,选择性切除杏仁核海马及海马旁回等内侧颞叶结构。结果30例患者术后随访至少3年时间(36～61个月),无严重手术并发症。Engel癫痫疗效分级:I级22例(73.3%),II级6例(20%),III级1例(3.3%),IV级1例(3.3%)。结论经颞下梭状回入路选择性杏仁核海马切除术是治疗颞叶内侧癫痫的有效方法,对脑组织创伤小,可妥善保护语言区和视放射,安全性高。     

经颞下回-侧脑室入路选择性海马杏仁核切除术治疗内侧颞叶癫痫

目的 探讨经颞下回-侧脑室入路选择性海马杏仁核切除术治疗内侧颞叶癫痫的手术方法 、疗效及并发症. 方法 对确诊为药物难治性内侧颞叶癫痫的62例患者,经颞部锁孔开颅,切除中前段颞下回,进入颞角前外侧区,选择性切除海马杏仁核及海马旁回等内侧颞叶结构.结果 62例患者术后随访至少24～80个月,无严重手术并发症;Engel癫痫疗效分级;Ⅰ级45例(72.6%),Ⅱ级12例(19.4%),Ⅲ级5例(8.0%). 结论 经颢下回-侧脑室入路选择性海马杏仁核切除术是治疗内侧颞叶癫痫的有效方法 ,其手术创伤小,可妥善保护语言区和视放射,安全性高.     

经皮层选择性海马杏仁核切除术治疗颞叶癫痫

目的 观察经皮层入路选择件海马含仁核切除术对颞叶癫痫的治疗效果及风险。方法 20例单侧海马硬化性顽崮性颞叶内侧癫痫患者，采用颢部开颅经颞中同侧脑室入路选择性海马杏仁核切除术治疗，随访至少1年以卜，采用Engel分级量表进行针对癫痫发作控制效果的评价。结果 Ⅰ级结果15例，Ⅱ级结果3例，Ⅲ级结果2例，无明显持久性并发症，无手术死亡。结论 在严格筛选的颞叶内侧癫痫，颞部开颅经颞中回皮层入路选择性切除海马含仁核术对治疗颞叶癫痫，安全有效。     

选择性海马杏仁核切除术治疗顽固性颞叶癫痫

目的 探讨选择性涨马杏仁核切除术治疗颞叶癫痫的机理、适应征及手术入路。方法 对２０例经ＥＥＧ和ＭＲ诊断为颞叶内侧癫痫病例实施海马杏仁核切除。结果 １０例颞叶癫痫患接受经颞底入路选择性涨马杏仁核切除,另１０例接受经颞极入路海马杏仁核切除。术后随访,所有患癫痫发作控制满意,无手术并发症发生。结论 选择性海马杏仁２核切中通过消除癫痫灶或阻断癫痫环路来治疗颞叶癫痫,深部电极提示有颞叶内侧放电或ＭＲ发现     

神经导航下锁孔入路选择性海马杏仁核切除术治疗内侧颞叶癫痫

目的 探讨神经导航下锁孔入路选择性海马杏仁核切除术治疗顽固性内侧颞叶癫痫的可行性.方法 总结分析18例神经导航下锁孔入路选择性海马杏仁核切除病例,所有病例均经过临床特征、影像检查、视频脑电监测、脑磁图检查确定为顽固性内侧颞叶癫痫.结果 随访结果显示72.2%病例术后癫痫发作停止.Engel癫痫疗效分级:Ⅰ级72.2%,Ⅱ级22.2%,Ⅲ级5.6%.结论 神经导航下锁孔入路选择性海马杏仁核切除术是一种安全可行的手术方法,疗效满意.     

不同手术入路治疗海马硬化性颞叶内侧癫痫的比较

目的 比较常用的四种手术方式在治疗海马硬化性颞叶内侧癫痫(MTLE/HS)中的优缺点.方法 106例顽固性MTLE/HS患者中23例行经皮层脑室入路选择性海马杏仁核切除术;23例行经侧裂选择性海马杏仁核切除术;30例行前内侧颞叶切除术;30例行经颞下选择性海马杏仁核切除术.随访6个月-9年.采用Engel分级量表评价癫痫治疗效果,并比较并发症发生率.结果 四种术式在对癫痫发作的治疗效果比较上差异无统计学意义,无手术死亡,在并发症发生率方面差异无统计学意义.结论 对于经严格筛选的MTLE/HS,四种手术方式在疗效和安全性方面相当,可根据个人手术经验加以选择.     

选择性海马-杏仁核切除术治疗内侧颞叶癫痫85例分析

目的 采用选择性海马-杏仁核切除术治疗内侧颞叶癫痫85例，探讨手术入路的选择及治疗效果。方法 总结2000年～2004年85例选择性海马-杏仁核切除手术病例的术前临床表现、影像检查、视频脑电图和脑磁图所见以及外科手术方法，观察随访结果。结果 术后74．2％癫痫发作停止。Engel癫痫疗效分级：1级74．2％，2级16．5％，3级5．1％，4级4．2％。总有效率为95.8％。结论 选择性海马-杏仁核切除术对80％以上的内侧颞叶癫痫有效。颧弓翼点经颞下沟入路安全有效。颞底海马旁回入路可避免损伤颞叶新皮质。     

经锁孔颞下入路选择性杏仁核海马切除术治疗颞叶内侧癫

目的探讨经锁孔颞下入路选择性杏仁核海马切除术治疗颞叶内侧癫的手术方法及疗效。方法回顾性分析29例颞叶内侧癫的病例资料,均在全麻下行后颞锁孔开颅,经梭状回造瘘进入侧脑室颞角,分块切除杏仁核海马及海马旁回等颞叶内侧结构。结果 29例病人术后平均随访43个月,Engel癫疗效分级:Ⅰ级24例,Ⅱ级2例,Ⅲ级2例,Ⅳ级1例。无失语、严重记忆力减退及视野缺损发生。结论选择性杏仁核海马切除术是治疗颞叶内侧癫的有效方法,创伤小,可妥善保护语言区、颞干和视放射。     

经侧裂选择性杏仁核海马切除术治疗颞叶内侧癫痫

目的 探讨经侧裂选择性杏仁核海马切除术(TSSAH)治疗颞叶内侧癫痫(MTLE)的效果和手术并发症.方法 对2005年至2008年采用TSSAH治疗的18例MTLE患者进行回顾性分析及随访.结果 海马海绵状血管瘤4例(其中2例合并海马硬化),胶质瘤2例,海马硬化12例.术后随访6-37个月,Engel分级Ⅰ级(无发作)12例,Ⅱ级(仅先兆或偶发作)2例,Ⅲ级(发作显著减少)2例,Ⅳ级(发作无变化)2例.术后视野缺损9例,术区血肿1例,颅内感染1例,动眼神经损伤1例,无死亡、偏瘫及语言障碍.结论 TSSAH治疗MTLE临床疗效满意.     

经额部和经颞部入路导航辅助下内镜手术治疗高血压性基底节区出血的对比分析

目的比较经额部和经颞部入路导航辅助下内镜手术治疗高血压性基底节区出血的临床疗效。方法回顾性分析2011年1月至2016年6月导航辅助下内镜手术治疗的60例高血压性基底节区出血的临床资料,28例采用经额入路(经额组),32例采用经颞入路(经颞组)。术后3个月采用GOS评分评估预后。结果经额组手术时间[(83±27)min]和经颞组手术时间[(81±30)min]无显著差异(P0.05)。经额组血肿清除率[(88±11)%]明显高于经颞组[(79±19)%;P0.05]。经额组预后良好率(67.86%;GOS评分4~5分)明显高于经颞组(40.63%;P0.05)。结论神经导航辅助下内镜手术治疗高血压性基底节区出血时,经额入路相对于经颞入路可以提高血肿清除率,改善预后,是较优的手术入路。     

Navigation-assisted trans-inferotemporal cortex selective amygdalohippocampectomy for mesial temporal lobe epilepsy; preserving the temporal stem

Objective: Selective amygdalohippocampectomy (SAH) can be used to obtain satisfactory seizure control in patients with mesial temporal lobe epilepsy (MTLE). Several SAH procedures have been reported to achieve satisfactory outcomes for seizure control, but none yield fully satisfactory outcomes for memory function. We hypothesized that preserving the temporal stem might play an important role. To preserve the temporal stem, we developed a minimally invasive surgical procedure, ‘neuronavigation-assisted trans-inferotemporal cortex SAH’ (TITC-SAH).

Methods: TITC-SAH was performed in 23 patients with MTLE (MTLE on the language-non-dominant hemisphere, n = 11). The inferior horn of the lateral ventricle was approached via the inferior or middle temporal gyrus along the inferior temporal sulcus under neuronavigation guidance. The hippocampus was dissected in a subpial manner and resected en bloc together with the parahippocampal gyrus. Seizure control at one year and memory function at 6 months postoperatively were evaluated.

Results: One year after TITC-SAH, 20 of the 23 patients were seizure-free (ILAE class 1), 2 were class 2, and 1 was class 3. Verbal memory improved significantly in 13 patients with a diagnosis of hippocampal sclerosis, for whom WMS-R scores were available both pre- and post-operatively. Improvements were seen regardless of whether the SAH was on the language-dominant or non-dominant hemisphere. No major complication was observed.

Conclusion: Navigation-assisted TITC-SAH performed for MTLE offers a simple, minimally invasive procedure that appears to yield excellent outcomes in terms of seizure control and preservation of memory function, because this procedure does not damage the temporal stem. TITC-SAH should be one of the feasible surgical procedures for MTLE.

Abbreviations: SAH: Amygdalohippocampectomy; MTLE: Mesial temporal lobe epilepsy (MTLE); TITC-SAH: Ttrans-inferotemporal cortex SAH; ILAE: International League Against Epilepsy (ILAE); MRI: Magnetic resonance imaging; EEG: Electroencephalography (EEG); FDG-PET: ⁸F-fluorodeoxyglucose (FDG)-positron emission tomography; ECoG: Electrocorticography; MEG: Magnetoencephalography; IMZ-SPECT: N-isopropyl-p(¹²³I)-iodoamphetamine single photon emission computed tomography; WMS-R: Wechsler Memory Scale-Revised.     

前颞叶切除术或选择性海马杏仁核切除术治疗顽固性内侧颞叶癫痫患者神经心理功能改变的研究

目的 探讨前颞叶切除术(ATL)或选择性海马杏仁核切除术(SAH)治疗顽固性内侧颞叶癫痫(MTLE)患者神经心理功能的改变情况。方法 选择2010年1月-2014年12月来本院接受ATL或SAH治疗的MTLE患者60例; 根据MTLE手术部位分为左颞部MTLE组(n=35)和右颞部MTLE组(n=25); 利用神经心理功能评分系统(DST、VMPT、WMSLM、WMS视觉、BNT、视觉技能、Stroop、WCST、分类、VFT)对患者术前及术后1年神经心理功能进行评分,比较2组患者左右颞部手术前后神经心理测试及手术前后左右颞部神经心理测试差异。结果 60例MTLE患者中35例(58.33%)左颞部MTLE,25例(41.67%)右颞部MTLE; 2组患者在性别、年龄、手术方式、癫痫发作平均年龄、病程、术前WAIS评分方面无显著性差异(P>0.05); 2组患者左右颞部手术前后神经心理测试比较显示,右颞部MTLE组术后在最大学习得分、短时记忆得分、长时记忆得分、第5卡片时间、矫正、转换错误方面与术前比较有显著差异(P<0.05); 左颞部MTLE组术后在合计得分方面与术前比较有显著差异(P<0.05); 2组患者手术前后左右颞部神经心理测试比较显示,左颞部MTLE组在回忆得分、识别得分、短时记忆得分方面显著高于右颞部MTLE组(P<0.05)。结论 尽管ATL或SAH治疗顽固性MTLE患者会引起部分常见的认知副作用,但该手术治疗也可提高患者部分认知功能。     

Short-term cognitive changes after surgery in patients with unilateral mesial temporal lobe epilepsy associated with hippocampal sclerosis

We investigated the short-term postoperative cognitive function of patients with unilateral mesial temporal lobe epilepsy associated with hippocampal sclerosis (MTLE/HS). Fourteen unilateral MTLE/HS patients who had undergone selective amygdalohippocampectomy (SAH) or anterior temporal lobectomy (ATL) were enrolled. Cognitive functions related to the frontal and temporal lobes were evaluated using a battery of neuropsychological tests administered before surgery and 3 months after surgery. The battery included the Verbal Fluency Test (VFT), Boston Naming Test (BNT), Stroop Color-Word Test (TST), Trail Making Test (TMT) and Wechsler Memory Scale (WMS). MTLE/HS patients demonstrated significantly improved postoperative performance on the TST regardless of the surgical method or side of resection. There was no significant difference in any of the other neuropsychological tests before and after surgery. After left-side resection, performance on the VFT and the TMT-B was worse than at baseline. After right-side resection, performance on the VFT and WMS short-term memory improved; however, these differences were not statistically significant. SAH patients exhibited improved TST performance but worse TMT-A performance; however, performance on all tests was not significantly different after surgery in ATL patients. In summary, MTLE/HS patients demonstrated improved frontal lobe-related cognitive function after surgery, but no such improvement in temporal lobe-related function was observed. Based on cognitive evaluation, right-sided MTLE/HS patients may be more appropriate surgical candidates than left-sided MTLE/HS patients. SAH may not be better than ATL in improving cognitive function. We hypothesise that postoperative cognitive changes depend on whether the excised cerebral regions are related to the neuropsychological functions examined by specific assessment instruments.     

Remifentanil-induced spike activity as a diagnostic tool in epilepsy surgery

Objectives –  To assess the value of remifentanil in intraoperative evaluation of spike activity in patients undergoing surgery for mesial temporal lobe epilepsy (MTLE).
Materials and methods –  Twenty-five patients undergoing temporal lobectomy for medically intractable MTLE were enrolled in the study. Electrocorticography (ECoG) recordings were performed on the intraventricular hippocampus and from the anterior inferior temporal and lateral neocortex before and after a 300 μg intravenous bolus of remifentanil. Spike activity was quantified as spike-count per minute.
Results –  A significant increase ( P  <   0.005) in spike activity was observed after administration of remifentanil in 23 of 25 patients (92%). Furthermore, two patients who did not have any spike activity on the baseline ECoG developed spikes after administration of remifentanil.
Conclusions –  The results suggest that remifentanil can enhance spike activity in the epileptogenic zone and reveal otherwise concealed epileptogenic tissue in patients with MTLE. Thus, remifentanil may prove to be an important diagnostic tool during surgical treatment for intractable focal epilepsy.     

Comparison of the keyhole trans-middle temporal gyrus approach and transsylvian approach for selective amygdalohippocampectomy: A single-center experience

Several approach routes exist for selective amygdalohippocampectomy (SAH); however, previous reports regarding a comparison of these routes are limited. Here, we compared trans-middle temporal gyrus (T2) SAH and transsylvian (TS) SAH in terms of seizure outcome, visual-field defect, memory function, and operation time in our institution. This retrospective study examined the data of 16 patients with medically intractable mesial temporal lobe epilepsy. Six patients underwent trans-T2 SAH and 10 patients underwent TS SAH between July 2014 and February 2019 in Osaka City University Hospital. In trans-T2 SAH, we performed a keyhole temporal craniotomy and a small corticotomy on T2. In TS SAH, we performed a 1.5 cm corticotomy along the inferior periinsular sulcus after opening the sylvian fissure. Amygdalohippocampectomy after reaching the inferior horn of the lateral ventricle was performed in the same manner in both procedures. The seizure outcome, visual-field defect, memory function, and operation time were retrospectively compared between the procedures. Seizure-free outcomes were achieved for six patients in the trans-T2 SAH and eight patients in the TS SAH group. There were no significant differences in the seizure outcome, visual-field defect, and memory function. The operation time was significantly shorter for trans-T2 SAH than TS SAH. The postoperative scar was less conspicuous for trans-T2 SAH. Trans-T2 SAH and TS SAH were comparable in terms of the seizure outcome, visual-field defect, and memory function. The operation time and length of the skin incision were shorter for trans-T2 SAH, suggesting that it may be preferable for general epilepsy surgeons.     

海绵状血管瘤致颞叶内侧癫痫手术入路选择

目的探讨引起癫痫的颞叶内侧不同部位海绵状血管瘤（cA）的手术入路选择。方法对3例位于颞叶内侧不同部位CA导致癫痫发作的患者,分别采取经侧裂入路、颞上沟入路及颞下回入路手术切除病灶。结果所有病例术中病灶显露满意,均予以完全切除。术后随访4～8个月,3例患者均无癫痫发作。结论对位于颞叶内侧不同部位的CA应根据病灶的部位选择不同手术入路,有利于充分显露并完全切除病灶。