选择性杏仁核海马切除术治疗颞叶内侧型癫(癎)疗效分析

目的 探讨选择性杏仁核海马切除术对治疗颞叶内侧型癫(癎)的疗效.方法 选择颞叶脑电异常与海马硬化同侧病例10例,其中单纯部分性发作继发全身性发作2例,复杂部分性发作5例(3例继发全身性发作),全身强直-阵挛性发作3例.经颞底海马旁回入路切除杏仁核海马.结果 术后病人均恢复良好.所有病例均随访1 a以上,6例发作完全缓解(EngelⅠ、Ⅱ级,60%),2例缓解明显(Engel Ⅲ级,20%),1例轻度缓解(Engel Ⅳ级,10%),1例病人术后半年自行停药造成癫(癎)复发.结论 对伴同侧海马硬化的颞叶内侧型癫(癎)患者行选择性杏仁核海马切除术(经颞底海马旁回入路)疗效显著,可改善性发作情况.     

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.     

伴海马硬化的颞叶癫痫患者的临床特点及手术治疗

目的探讨颞叶癫痫海马硬化的临床特点及手术治疗的效果。方法伴海马硬化的颞叶癫痫患者18例,其中男10例,女8例;年龄12~37岁,病程3~10年。癫痫复杂部分性发作10例,部分性发作继发全身性发作2例,全身强直-痉挛性发作6例。结合患者的临床表现、MRI检查和视频脑电图(V-EEG)监测结果,对这18例患者行前颞叶切除术(包括大部分海马和杏仁核)。结果所有患者术中皮层和深部电极脑电图均发现颞叶皮层海马、杏仁核有异常放电,术后病理检查均证实海马硬化的诊断。术后18例患者均出现发热,但经过抗炎、腰椎穿刺及支持治疗后渐好转。术后1年以上的随访发现16例癫痫发作完全消失,2例术后较术前显著改善,仅偶有癫痫发作,但均长期服用抗癫痫药物。结论对于颞叶癫痫伴有海马硬化的患者,如果同时脑电图又发现有同侧颞叶痫样放电,则可以考虑行该侧前颞叶切除术(包括大部分海马和杏仁核),若手术切除彻底,其术后疗效也较满意。     

难治性颞叶癫痫的外科治疗(附35例临床分析)

目的总结并分析难治性颞叶癫痫患者术前定位、手术方式和经验。方法回顾性分析2009年6月至2011年6月,采用颞前叶+海马杏仁核切除术治疗的颞叶癫痫病人35例,其中术前MRI及术后病理证实伴有海马硬化者32例,所有病例术中均在皮层电极监测下切除颞叶皮质及同侧海马、杏仁核,手术后均应用抗癫痫药物治疗,术后随访1～3年。结果在35随访病例中,癫痫发作控制结果显示EngelⅠ级24例,Ⅱ级8例,Ⅲ级3例,Ⅳ级0例。其中有12例病人术后2年逐渐停用抗癫痫药物。结论联合应用VEEG、MRI及EcoG能准确确定致痫灶,提高颞叶癫痫手术疗效。手术方式选择及显微理念的应用,能有效减少术后并发症的发生,避免出现永久性神经功能缺失。     

颞叶内侧癫痫的两种术式对发作控制的对比分析

目的观察前颞叶切除术和选择性海马、杏仁核切除术对颞叶内侧癫痫的发作控制效果是否有差别。方法 2009年1月至2010年12月在我科行前颞叶切除术的67例颞叶内侧患者为A组;2011年6月至2013年5月在我科行选择性海马、杏仁核切除术的46例颞叶内侧患者为B组;统计分析两组术后1年发作控制为Engel I-II级和Engel III-IV级的人数。结果 A组Engel I-II级56例(83.58%),Engel III-IV级11例(16.42%);B组Engel I-II级40例(86.95%),Engel III-IV级6例(13.05%)。经χ2检验两组术后对MTLE发作的控制率无统计学差异,χ2=0.243,P0.05。结论前颞叶切除术和选择性海马、杏仁核切除术对颞叶内侧癫痫发作都能获得良好的控制,两者疗效无明显差异。     

选择性杏仁核海马切除术治疗颞叶内侧型癫疗效分析

目的探讨选择性杏仁核海马切除术对治疗颞叶内侧型癫的疗效。方法选择颞叶脑电异常与海马硬化同侧病例10例,其中单纯部分性发作继发全身性发作2例,复杂部分性发作5例（3例继发全身性发作）,全身强直-阵挛性发作3例。经颞底海马旁回入路切除杏仁核海马。结果术后病人均恢复良好。所有病例均随访1a以上,6例发作完全缓解（EngelⅠ、Ⅱ级,60%）,2例缓解明显（EngelⅢ级,20%）,1例轻度缓解（EngelⅣ级,10%）,1例病人术后半年自行停药造成癫复发。结论对伴同侧海马硬化的颞叶内侧型癫患者行选择性杏仁核海马切除术（经颞底海马旁回入路）疗效显著,可改善性发作情况。     

PET-MRI影像融合技术在颞叶癫痫手术中的应用

目的探讨PET-MRI影像融合技术在海马硬化所致颞叶癫痫病人颞前叶切除范围评估中的指导价值。方法 2013年1月至2015年1月前瞻性收集手术治疗海马硬化所致单侧颞叶癫痫10例,根据PET-MRI融合影像显示的低代谢范围决定颞前叶手术切除范围。术后3个月复查PET-CT及MRI,随访1年以上,评估手术短期并发症及癫痫控制情况。结果发作间期PET检查均表现为受累侧颞前叶低代谢,2例合并对侧颞叶代谢减低。术后病理示局灶皮层发育不良Ⅰ型8例,Ⅱ型2例。术后短期没有出现偏瘫、失语、记忆力严重下降。术后平均随访1.9年,EngelⅠa级8例,EngelⅠb级1例,EngelⅠc级1例。结论海马硬化所致颞叶癫痫根据术前PET-MRI融合影像有助于精准定位颞前叶的切除范围,手术对癫痫控制效果良好。     

前颞叶切除术与选择性杏仁核海马切除术治疗颞叶癫痫的疗效对比

目的对比前颞叶切除术与选择性杏仁核海马切除术治疗颞叶癫痫发作的效果。方法回顾性分析天津市环湖医院神经外科2010-12—2016-08手术治疗的颞叶癫痫病例38例,其中14例进行前颞叶切除术,9例进行选择性杏仁核海马切除术,术后随访2～8 a,分析纳入的23例患者的基本信息、手术侧别、发作症状、病理学以及术后癫痫发作的Engel分级。结果在随访的23例患者中,达到满意控制(EngelⅠ～Ⅱ级)者18例(78.3%),其中前颞叶切除术组达到满意控制(EngelⅠ～Ⅱ级)者12例(85.7%),选择性杏仁核海马切除术组达到满意控制(EngelⅠ～Ⅱ级)者6例(66.7%)。经Fisher确切概率法检验,2组术后控制率差异无统计学意义(P0.05)。结论手术是治疗颞叶癫痫安全有效的方法,两种手术均可获得满意的临床效果。     

儿童难治性颞叶癫痫的手术治疗

目的 探讨儿童难治性颞叶癫痫术前评估和手术方法 及影响癫痫预后的因素.方法 回顾性分析2007年7月至2009年2月手术治疗的21例儿童难治性癫痫患者中得到随访的19例临床资料,主要为复杂部分性发作.多数患者有腹部不适等发作先兆和咂嘴等发作时伴随自动动作.MRI扫描15例异常.6例行PET扫描均异常.头皮脑电图示局灶痫性放电7例,多灶痫性放电12例.施行一侧颞前叶+海马、杏仁核切除术15例,一侧颞前叶、海马、杏仁核+部分额叶皮层切除术4例.结果 随访12-30个月,癫痫发作结果 ,Engel Ⅰ级13例;Ⅱ级3例;Ⅲ级1例;Ⅳ级2例.随访期间对4例进行神经心理学评估,2例明显好于术前.无永久性神经缺损并发症.术后切除标本病理诊断结果 为颞叶皮层发育不良和颞叶内侧硬化等.结论 颞叶切除治疗儿童难治性癫痫多数预后良好.该手术安全、并发症少.发作表现、EEG以及神经影像学检查对致痫灶定位相互符合时,预示预后良好.早期手术可能对患儿的神经心理学改善有帮助.     

24例难治性颞叶癫痫手术患者病例分析

目的了解难治性颞叶癫痫手术治疗的现状和预后效果。方法回顾性分析2011年4月—2014年6月于淄博昌国医院经手术治疗且临床及随访资料完整的24例难治性颞叶癫痫手术患者,其中男14例,女10例。年龄16~44岁,平均(24.40±6.26)岁,平均病程(12.50±8.42)年。分析患者的临床特点和预后情况。结果 24例患者均有海马硬化,行"颞前叶及颞内侧结构切除术"。经过5~7年的随访,术后癫痫发作情况达到EngelⅠ级20例(83.3%),EngelⅡ级2例(8.3%),EngelⅣ级2例(8.3%)。结论 24例患者以海马硬化和皮质发育不良多见,手术治疗效果较好。临床上为改善难治性癫痫患者预后,应视情况尽早行手术治疗。     

MRI-guided laser interstitial thermal therapy for treatment of medically refractory non-lesional mesial temporal lobe epilepsy: Outcomes,complications, and current limitations: A review

There is a new focus on minimally invasive treatments for medically refractory mesial temporal lobe epilepsy (MTLE). MRI-guided laser interstitial thermal therapy (MRgLITT) is one such minimally invasive procedure, which utilizes MRI guidance and real-time feedback to ablate an epileptogenic focus. A total of 38 patients presenting exclusively with MTLE and no other lesions (including neoplasia), who underwent MRgLITT were reviewed. We evaluated a number of outcome measures, including seizure freedom, neuropsychological performance, complications, and other considerations. Eighteen (53%) had an Engel class I outcome, 10 patients had repeat procedures/operations, and 12 post-procedural complications occurred. Follow-up time ranged from 6 to 38.5 months. There was a decreased length of procedure time, hospitalization time, and analgesic requirement when compared to open surgery. In cases of well-localized MTLE this procedure may offer similar (albeit slightly lower) rates of seizure freedom versus traditional surgery. MRgLITT may be an alternative treatment option for high risk surgical patients and, more importantly, could increase referrals for surgery in patients with medically refractory MTLE. However, data is limited and long-term outcomes have not been evaluated. Further investigation is required to understand the potential of this minimally invasive technique for MTLE.     

Electroclinical characteristics of posterior lateral temporal epilepsy

The current study aimed to investigate the electroclinical differences between mesial temporal lobe epilepsy (MTLE) and posterior lateral temporal lobe epilepsy (PLTLE). All patients had Engel class I outcomes after surgery for at least one year. In MTLE patients, the epileptogenic zone was inside the boundary of a standard temporal lobectomy, whereas in PLTLE, the epileptogenic zone was behind the boundary of a standard temporal lobectomy. Febrile convulsion, history of psychic aura, oroalimentary automatism, and diffuse interictal epileptiform discharges were more frequent in MTLE. Theta wave and increasing heart rate were more evident at the seizure onset in MTLE, whereas an ictal onset fast rhythm was more evident in PLTLE. Tonic head turning was more frequent in PLTLE. Distinguishing between MTLE and PLTLE was easier than distinguishing MTLE from lateral TLE (LTLE), which may be helpful in planning epilepsy surgery. Combinations of these manifestations and signs can provide vital clues to distinguish between MTLE and PLTLE.     

Stereotactic radiofrequency amygdalohippocampectomy: Does reduction of entorhinal and perirhinal cortices influence good clinical seizure outcome?

Purpose: Stereotactic radiofrequency amygdalohippocampectomy (SAHE) has been modified recently in our center for the therapy of mesial temporal epilepsy (MTLE). It has promising clinical results comparable with microsurgical amygdalohippocampectomy despite smaller volume reduction of the hippocampus. We hypothesized that the extent of perirhinal and entorhinal cortex (PRC, EC) reduction could explain the clinical outcome. Therefore, we performed, retrospectively, volumetric analysis of PRC and EC and compared it with the seizure control. Methods: Twenty‐six consecutive patients with MTLE treated by SAHE were included. PRC and EC volumes were measured from magnetic resonance imaging (MRI) records obtained before and 1 year after SAHE. The clinical outcome was assessed each year after SAHE using Engel’s classification. Key Findings: Twenty‐six patients were analyzed. The volume of PRC decreased by 46 ± 17% (p < 10⁻¹²); EC volume decreased by 56 ± 20% (p < 10⁻¹⁰). Two years after the procedure, 73% of patients were classified as Engel’s I, 19% as Engel’s II; in 2 (8%) the treatment failed (were reoperated). Eighteen patients finished 3 years follow‐up; 72% of them were classified as Engel’s I, 17% as Engel’s II, and in 2 (11%) above‐mentioned patients the treatment failed. Thirteen patients finished 4 years of follow‐up, 11 of them as Engel’s I. There was no significant correlation of the clinical outcome to PRC and EC volume reductions. Significance: The clinical effect of SAHE is not clearly explained by the volume reductions of PRC and EC (nor of the hippocampus and the amygdala). It promotes opinion that the extent of resection/destruction is not important for seizure outcomes.     

Epilepsy surgery in patients with bilateral temporal lobe seizures: A systematic review

We explored the association between magnetic resonance imaging (MRI) lesion, degree of seizure laterality on intracranial electroencephalography (iEEG), and seizure outcome in patients with ambiguous or presumed bilateral temporal lobe epilepsy (BiTLE) on scalp EEG. We systematically reviewed the literature using Embase and MEDLINE up to May 31, 2012. Patients with bilateral iEEG, temporal lobe surgery, and follow‐up ≥1 year were included. We undertook three separate analyses on patients whose scalp EEG showed ambiguous onset or BiTLE (1) group data of those whose iEEG demonstrated unilateral TLE, (2) group data of those whose iEEG demonstrated BiTLE, (3) individual patient analysis in those with BiTLE for whom iEEG seizure laterality data were provided. Of 1,403 patients with ambiguous or presumed BiTLE on scalp EEG, 1,027 (73%) proved to have unilateral TLE on iEEG and contributed to the first analysis. Of these, 58% had Engel class I and 9% Engel class II outcomes. Of 132 patients in the second analysis (true BiTLE), Engel class I and II outcomes were achieved in 23% and 14%, respectively. Of 41 patients in the third analysis, 66% and 2% had Engel class I and II outcomes, respectively. The median proportion of seizures ipsilateral to the resection on iEEG did not differ between BiTLE patients with Engel class I–II (76%) and Engel III–IV (78%) outcomes (p = 0.87). Patients with ambiguous or independent bitemporal seizure onset on scalp EEG achieved good surgical outcomes. Overall, a significantly higher proportion of patients achieved good outcomes when iEEG showed unilateral TLE (67%) than when it showed true BiTLE (45%). However, the degree of seizure lateralization in those with BiTLE was not associated with seizure outcome, and it has a limited role in selecting the side of surgery.     

Prognostic value of the consistency of lateralizing ictal features and ictal EEG in patients undergoing temporal lobectomy for refractory complex partial seizures.

PURPOSE: Ictal and postictal clinical manifestations have lateralizing value in the presurgical evaluation of intractable seizures. The consistency and frequency of these signs during seizures and the associated implications for postoperative seizure outcome are unknown. METHODS: The videotaped complex partial seizures of 49 patients with known postoperative outcomes greater than 2 years after temporal lobectomy were blindly reviewed for: (1) unilateral hand posturing (UHP), (2) unilateral hand automatism (UHA), (3) forced and nonforced head turning (HT), and (4) postictal dysphasia (PID). The presence and laterality of each assessable sign were recorded. Data were analyzed as follows: (1) the prevalence of each sign in patients with Engel class 1 and Engel class 2-4, and (2) the postsurgical outcome when the sign was present in more than or less than 50% of the seizures for each patient. We reviewed patients' presurgical work-up, specifically ictal EEG and MRI. RESULTS: The prevalence of UHP, UHA, HT, and PID was similar for Engel class 1 and Engel class 2-4 patients. Engel class 1 outcome when UHP, UHA, HT, and PID were present for greater than 50% of seizures was no different compared to when these signs were present for less than 50% of seizures. Patients who had concordant ictal EEG and MRI abnormalities had the best postsurgical outcome. CONCLUSIONS: The consistency and frequency of ictal manifestations in the presurgical evaluation of complex partial seizures does not predict seizure outcome. The presence of any specific lateralizing sign need not be present in every complex partial seizure for the sign to hold predictive value. Concordant ictal EEG and MRI abnormalities are still the best predictors of outcome.     

Outcome and life prospects after surgical management of medically intractable epilepsy in patients under 18 years of age

A retrospective analysis of seizure outcome and quality of life assessment was done in 64 patients under 18 years of age with medically refractory epilepsy who underwent 64 primary and 16 repeat operative procedures in an attempt to control their epilepsy. At least 2 years' follow-up data were available for each patient. Operative procedures were 44 temporal lobe resections; 16 extratemporal resections; and 4 hemispherectomies. Effective control of previously intractable seizures was obtained in most patients: 55%, 11%, and 17% achieved Engel class I, II, and III status, respectively. Successful seizure control was thus obtained in 83%, while 17% (Engel class IV) failed to improve significantly after operation. Quality-of-life measures parallelled the improvements in seizures control, being highest in Engel I, outcome group and lowest in Engel IV outcome group. In appropriately selected pediatric and adolescent patients with medical refractory epilepsy, surgical management can offer a safe and effective adjunct to medication. Received: 25 March 1997     

Factors contributing to resectability and seizure outcomes in 44 patients with ganglioglioma

OBJECTIVES: The purpose of this retrospective study was to evaluate causes contributing to surgical resectability and seizure outcomes depending on various clinical and surgical factors. PATIENTS AND METHODS: The records of 44 patients with gangliogliomas surgically treated between April 1986 and March 2007, were retrospectively reviewed to assess presenting symptoms, resectability and seizure outcomes. RESULTS: Tumors were located in the supratentorial areas in 33 cases, the infratentorial area in 9 cases and the spinal cord in 2 cases. Thirty-five cases underwent gross total removal and 9 cases underwent subtotal resection. Only 2 cases underwent postoperative radiotherapy and 2 cases underwent gamma knife surgery. Twenty-six patients presented seizure symptoms of which 22 cases were located in temporal lobe and 4 cases were located in the extratemporal lobe. Twenty-three patients (88.5%) were seizure-free after surgery. Two patients were Engel class II and another was Engel class III. CONCLUSION: We concluded that tumor location and seizure-presenting symptoms are good predictors of gross total removal. Gross total removal of ganglioglioma had a better chance of leaving the patient seizure free after surgery rather incomplete resection. Our data do not support the concept that surgical methods, invasive monitoring and surrounding cortical malformation correlated with seizure-free outcome.     

Potentially misleading extratemporal lobe lesions in patients with temporal lobe epilepsy

From a series of 217 consecutive temporal resections for intractable epilepsy between 1993 and 2000, we identified all patients with large non-neoplastic extratemporal lesions. Only patients with known postsurgical outcomes with follow up for more than two years were included. Fifteen patients were identified. All patients had a history of medically refractory epilepsy with clinical and ictal evidence of mesial temporal seizure onset. Eleven patients had extratemporal lesions ipsilateral to the seizure focus, whereas four patients had the lesions contralateral to the seizure focus. Nine of the 15 patients had evidence of hippocampal atrophy on magnetic resonance imaging (MRI). Following temporal resection, nine of these patients (60%) became seizure free (Engel class 1A), two patients were free of disabling seizures only (Engel class 1B), and two patients had a few early seizures but then became seizure free for at least two years (Engel class 1C). Two patients had significant improvement (Engel class 2). Thus, the finding of large extratemporal lesions on MRI was potentially misleading. When clinical semiology and ictal EEG recordings provide evidence of temporal onset seizures, anterior temporal resection should be considered in patients with extratemporal lesions.     

Delayed complications after Gamma Knife surgery for intractable epilepsy

Despite the controversy concerning the clinical usefulness of Gamma Knife surgery (GKS; Elekta AB, Stockholm, Sweden) for intractable epilepsy, this treatment modality has attracted attention due to its low invasiveness. We report the long-term outcomes of four patients, focusing particularly on the efficacy and complications of GKS. We reviewed the data of four patients with medically intractable epilepsy who underwent GKS between 1998 and 2000 at our hospital. The marginal dose to the 50% isodose line was 24 Gy in one patient and 20 Gy in the remaining three patients. Two of the four patients were treated in the right temporal lobe, one was treated in the left parietal lobe, and one was treated in the right frontal lobe. The mean follow-up was 12.5 years (range 12–14 years). One patient was seizure free (Engel class IA) 24 months after GKS, and two patients failed to show any seizure reduction (Engel class IVA). However, a clear aggravation was evident in one patient (Engel class IVC). All four patients underwent resective surgery due to radiation necrosis (RN) 7, 10, 10 and 12 years after GKS. Three patients were seizure free (Engel class IA), and one was considered to have Engel class IB status following the resective surgery. GKS treatment resulted in insufficient seizure control and carried a significant risk of RN after several years. Drawbacks such as a delay in seizure control and the risk of RN should be considered when the clinical application of this treatment is evaluated.