脑皮质电极探测在癫痫手术中的应用(附160例临床分析)

本文报告１６０例顽固性癫痫手术治疗中脑皮质电极的应用情况，其中胼胝体前２／３切开加额叶切除２０例，术前探查均为广泛爆发棘慢波，术后恢复正常１７例，残余单个尖波３例，大脑凸面功能区痫灶多软膜下横切术８４例（左４０例，右４４例）７９例术后棘波消失，５例明显减少，颞叶切除５６例（左３０例，右２６例），其中２０例行单纯前颞叶及海马杏仁核切除，３６例在切除后对颞叶新皮质痫灶行多软膜下横切术，术后棘波灶全部消     

单侧颞叶切除治疗颞叶癫痫20例疗效分析

颞叶癫痫是指致痫灶位于颞叶的癫痫,约占难治性癫痫的60%,颞叶切除是治疗难治性癫痫的一种经典、实用的手术方法,治疗效果好,经术后随访,70%患者术后效果优良。随着诊断与手术技术的改善,有效率可达90%以上。致痫灶的准确定位始终是癫痫外科     

术中颅内电极治疗颞叶癫痫8例分析

颞叶癫痫是指致痫灶位于颞叶的一类癫痫,约占难治性癫痫的60%。颞叶切除是治疗难治性癫痫的一种经典、实用的手术方法,治疗效果好,经术后随访,70%患者术后效果优良,随着诊断与手术技术的改善,疗效已达90%以上。致痫灶的准确定位始终是癫痫外科工作中的核心问题,是手术成功的决定性因素之一。     

外伤性癫痫的手术治疗

目的 探讨外伤性癫痫的致痫灶定位和手术方式选择. 方法 回顾性分析21例外伤性癫痫患者的临床资料,术前均行神经电生理学和神经影像学检查,结合临床表现综合定位致痫灶.采用病灶及周围皮层切除术12例,致痫灶切除加低功率皮层热灼术5例,前颞叶切除加杏仁核和大部分海马切除术3例,胼胝体切开术1例. 结果 经6个月～3年的随访,满意8例,显著改善6例,良好5例,效差2例,总有效率90%. 结论 外科手术是治疗难治性外伤性癫痫的一种重要方法,疗效取决于致痫灶的准确定位和多种手术方式的联合应用.     

脑电图在顽固性癫痫手术中定位价值的探讨

对颅内非占位性病变所致的顽固性癫痫抗痫药物难以控制,且病程较长,目前在治疗上采用的切除痫灶手术治疗方法效果显著。术前脑电图及术中皮层和深部电图对痫灶的定位、手术中能否准确寻找到痫灶、确定切除范围以及术后疗效影响甚大。而皮层及深部电图所记录的棘波或棘慢波综合则是痫灶定位确定切除范围的重要指征和依据。现将我们对18例顽固性癫痫术前、术中应用脑电图仪对痫灶定位的价值分析研究如下。1　临床资料本组18例,男11例,女7例。年龄12～30岁16例,30岁以上2例。病程3～15ａ16例,16～23ａ2例。发作类型:强直阵挛性发作12例,复杂部…     

18F-FDGPET定位致痫灶在癫痫外科治疗中的价值

目的：评价^18F-脱氧葡萄糖（FDG）PET定位致痫灶在癫痫外科治疗中的作用。方法：对30例难治性癫痫患者行EEG,MRI,PET检查,根据PET检查结果并参考EEG,MRI选择外科治疗方法（开颅手术,X刀治疗,立体定向手术）。开颅手术者,术中行皮层脑电图（ECoG）检查,术后送病理检查。所有患者均观察术后疗效。结果：致痫灶位于颞叶22例,颞叶外6例,额颞区2例,30例患者中16例。30例患者中16例行开颅手术,10例X刀治疗,4例立体定向手术。术后除2例癫痫发作无明显改善外,余28例发作明显减少或消失。结论：^18F-FDG PET检查术前定位致痫灶有助于选择手术方式,提高手术治疗效果。     

颅脑外伤后迟发性顽固性癫痫的病理与手术方式探讨

目的探讨颅脑外伤后迟发性顽固性癫痫的发病基础及最佳手术方式。方法取21例因颅脑外伤后迟发性顽固性癫痫接受手术治疗切除的颞叶新鲜标本,详细描述皮质分层结构,观察细胞的形态、数量和分布,分析海马组织的结构及其他病变组织的病理特点。结果颅脑外伤后脑叶软化灶和瘢痕增生是外伤性癫痫发生的病理基础,前颞叶切除标本最常见的病理改变是海马硬化合并颞叶皮质细胞结构不良(15例,占71.4%)。术后随访6个月~2年,疗效评价显示21例患者中疗效Ⅰ级14例、Ⅱ级4例、Ⅲ级3例;疗效满意66.7%(14/21),效果良好19.0%(4/21),疗效差14.3%(3/21)。结论颅脑外伤后迟发性顽固性癫痫最常见的颞叶病理改变是海马硬化和皮质细胞结构不良,这两种改变常伴随出现。目前对于该类患者仍推荐采用病理灶切除+标准前颞叶切除术治疗。     

18F-FDGPET定位致痫灶在癫痫外科治疗中的价值

目的评价18F-脱氧葡萄糖(FDG)PET定位致痫灶在癫痫外科治疗中的作用.方法对30例难治性癫痫患者行EEG、MRI、PET检查,根据PET检查结果并参考EEG、MRI选择外科治疗方法(开颅手术,X刀治疗,立体定向手术).开颅手术者,术中行皮层脑电图(ECoG)检查,术后送病理检查.所有患者均观察术后疗效.结果致痫灶位于颞叶22例,颞叶外6例,额颞区2例.30例患者中16例行开颅手术,10例X刀治疗,4例立体定向手术.术后除2例癫痫发作无明显改善外,余28例发作明显减少或消失.结论18F-FDGPET检查术前定位致痫灶有助于选择手术方式,提高手术治疗效果.     

难治性颞叶癫痫83例的手术治疗分析

目的:探讨难治性颞叶癫痫(ITLE)的外科治疗方法和效果。方法:83例ITLE患者,术前均行EEG、MRI检查,其中23例行PET,19例行SPECT检查。经测定位后,行手术治疗。其中30例行标准前颞叶切除,37例行标准前颞叶切除 胼胝体切开,16例行病灶切除 致痫灶切除。术中应用皮层电极或深部电极进行检测,并在显微镜下操作。结果:满意47例(56.6%),显著改善23例(26.5%),良好13例(15.6%)。术后无明显并发症,效果良好。结论:手术是ITLE的主要治疗手段,海马硬化和微血管畸形可能是ITLE发生的主要原因。     

~(18)F-FDG PET脑显像在癫痫图型、病灶定位及预后预测中的价值

目的　分析各种癫痫患者的18F 脱氧葡萄糖 (FDG)PET图像与致痫灶的关系 ,以期术前较准确地定位、选择手术适应证和预测疗效。方法　 73例癫痫患者 (男 5 1例 ,女 2 2例 ,平均年龄2 3 .3岁 )行FDGPET脑显像 ,并与同期脑电图和MRI结果进行比较。 40例进行了手术疗效随访 ,其中 8例术后复查了FDGPET ,并比较FDGPET、视频脑电图 (VEEG)、MRI对致痫灶术前定位的准确性及脑代谢改变的不同图型与手术疗效的关系。结果　① 72例癫痫患者发作间期皮层局灶为低代谢表现 ,仅 1例部分癫痫持续状态者表现出发作期的高代谢。②FDGPET病变定侧率高于VEEG ,低代谢灶检出率高于MRI。③ 40例手术患者中 ,属于Engels疗效分级I、II级的 30例手术切除部位应为确定的致痫灶 ,FDGPET、VEEG与MRI定侧定位准确性分别为 93 .3% ,73 3% ,5 3 3 % ,经 χ2 检验 ,差异有显著性 (P <0 .0 5 )。④单侧颞叶低代谢手术效果好 ;对部分双侧颞叶低代谢者 ,切除其代谢减低更严重的一侧 ,发作也会改善 ;颞叶外癫痫手术效果不如颞叶癫痫好 ;病灶局限者 ,手术效果优于伴有其他部位皮层代谢改变者 ;单侧多脑叶代谢改变者 ,半大脑切除术效果好 ;双侧大脑多脑叶弥漫性病变者 ,手术效果差。结论　FDGPET对癫痫灶定位的灵敏度和准确性优于VEEG和形态学     

Contribution of subtraction ictal SPECT coregistered to MRI to epilepsy surgery: a multicenter study

Objective  A multicenter prospective study was performed to assess the additional value of a subtraction ictal SPECT coregistered to MRI (SISCOM) technique to traditional side-by-side comparison of ictal- and interictal SPECT images in epilepsy surgery. Methods  One hundred and twenty-three patients with temporal and extratemporal lobe epilepsy who had undergone epilepsy surgery after evaluation of scalp ictal and interictal electroencephalogram (EEG), MRI, and ictal and interictal SPECT scans were followed up in terms of postsurgical outcome for a period of at least 1 year. Three reviewers localized the epileptogenic focus using ictal and interictal SPECT images first by side-by-side comparison and subsequently by SISCOM. Concordance of the localization of the epileptogenic focus by SPECT diagnosis with the surgical site and inter-observer agreement between reviewers was compared between side-by-side comparison and SISCOM. Logistic regression analysis was performed in predicting the surgical outcome with the dependent variable being the achievement of a good postsurgical outcome and the independent variables using the SISCOM, side-by-side comparison of ictal and interictal SPECT images, MRI, and scalp ictal EEG. Results  The SISCOM presented better concordance in extratemporal lobe epilepsy and less concordance in temporal lobe epilepsy than side-by-side comparison. Inter-observer concordance was higher in SISCOM than in side-by-side comparison. Much higher concordance of the epileptogenic focus by SPECT diagnosis with the surgical site was obtained in patients with good surgical outcome than in those with poor surgical outcome. These differences in concordance between good and poor surgical outcomes were greater in SISCOM than in side-by-side comparison. Logistic regression analysis showed the highest odds ratio of 12.391 (95% confidence interval; 3.319, 46.254) by SISCOM evaluation for concordance of the epileptogenic focus with the surgical site in predicting good surgical outcome. Conclusions  A SISCOM technique of ictal and interictal SPECT images provides higher predictive value of good surgical outcome and more reliability on the diagnosis of the epileptogenic focus than side-by-side comparison in medically intractable partial epilepsy.     

The usefulness of repeated ictal SPET for the localization of epileptogenic zones in intractable epilepsy

This study investigated whether repeated ictal single-photon emission tomography (SPET) is helpful in the localization of epileptogenic zones and whether it can provide information confirming that an area of increased perfusion is really the culprit epileptogenic lesion. Fifty-four repeated ictal SPET studies were performed in 24 patients with ambiguous or unexpected findings on the first ictal SPET study. These patients were enrolled from among 502 patients with intractable epilepsy in whom pre-operative localization of epileptogenic zones was attempted with a view to possible surgical resection. Video monitoring of ictal behaviour and EEGs was performed in all patients. Repeated ictal SPET was performed using technetium-99m hexamethylpropylene amine oxime (HMPAO) when there was no prominently hyperperfused area or when unexpected findings were obtained during the first study. Two ictal SPET studies were performed in 19 patients, three studies in four patients and four studies in one patient. The average delay between ictal onset and injection was 28 s for the first study and 22 s for the second, third and fourth studies. Using interictal SPET, ictal-interictal subtraction images were acquired and co-registered with the population magnetic resonance imaging (MRI) template. Invasive study and surgery were performed in 18 patients, and in these cases the surgical outcome was known. In the other six patients, epileptogenic foci were determined using MRI, positron emission tomography (PET) and ictal EEG findings. Two patients were found to have mesial temporal lobe epilepsy, two lateral temporal lobe epilepsy, eight frontal lobe epilepsy, three parietal lobe epilepsy and one occipital lobe epilepsy. The other eight had multifocal epilepsy. The first study was normal in 12 patients (group I) and indicated certain zones to be epileptogenic in the other 12 (group II). Among group I, the correct epileptogenic zone or lateralization was revealed at the repeated study in nine patients, while in the other three it was not. Among group II, six patients showed the same results at the second study, thus confirming that the initially identified zones were of epileptogenic significance. In the other six patients, different areas were identified on the first and second studies, and repeated ictal SPET corroborated multifocality of the ictal EEG findings in five. These results indicate that repeated ictal SPET is useful because it can yield new or additional information about the epileptogenic zones and can confirm that a region of interest is an epileptogenic zone or that the epilepsy is of multifocal origin.     

MRI与PET对癫痫病的诊断价值

癫痫是常见病,以颞叶癫痫最常见,药物难治性癫痫的术前准确定侧和定位是手术成功的关键。MRI对部分癫痫有很重要的诊断价值,特别是结合脑电图和功能性磁共振成像。但是对于MRI诊断阴性的癫痫病人,PET整体定位系统能解决其定位诊断问题。     

~(18)F-FDG PET-CT脑显像与EEG对颞叶癫痫灶术前定位价值的对比研究

目的对比18F-FDG PET-CT脑显像与EEG对颞叶癫痫灶术前定位的价值。方法回顾性分析经我院神经外科癫痫中心临床诊断为颞叶癫痫的患者152例,所有患者术前行18F-FDG PET-CT脑显像、长程/视频EEG检查,其中29例定位仍不确切者行颅内电极EEG检查,手术切除组织术后送病理检查,比较结果。结果 (1)本组152例患者PET-CT脑显像定位致痫灶的准确率为80.92%(123/152),长程或视频EEG定位致痫灶准确率为43.42%(66/152),两种检查方法定位致痫灶准确率差异有统计学意义(χ2=45.44,P<0.01);(2)本组29例患者颅内电极EEG定位致痫灶准确率为100%。结论发作间期18F-FDG PET-CT脑显像定位致痫灶灵敏、有效,其价值优于长程/视频EEG;18F-FDG PET-CT脑显像对颅内电极埋置有指导价值,两者联合使用,可以进一步提高致痫灶定位准确率。     

Temporal lobe epilepsy: Correlation of proton magnetic resonance spectroscopy and 18F-fluorodeoxyglucose positron emission tomography

Proton magnetic resonance spectroscopy (MRS) has demonstrated reduction of N-acetylaspartate (NAA) in the epileptogenic temporal lobe. However, the correlation of NAA reduction with cerebral metabolic abnormalities is unknown in temporal lobe epilepsy (TLE). Proton MRS and ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG/PET) were used to study 12 unilateral TLE patients with medically intractable seizures and 26 age-matched healthy volunteers. The epileptogenic temporal lobe of each patient was determined by both electroencephalography and FDG/PET. The NAA/choline-plus-creatine (NAA/(Cho+Cr)) ratio correlated significantly with the interictal glucose metabolism (r = 0.54, P 0.01) in 12 TLE patients. The mean NAA/(Cho + Cr) ratio in the epileptogenic temporal lobe was significantly less than that in the contralateral side (P < 0.01), and less than that in normal control temporal lobes (P < 0.0001). These results suggest that quantitative MRS abnormalities reflect underlying metabolic pathology in TLE.     

颞叶癫痫的功能MRI研究进展

颞叶癫■（TLE）是癫■中最常见的难治性类型,临床上对于药物难以控制的癫■,手术切除致■灶具有良好的治疗效果。随着MRI技术的迅速发展,功能磁共振成像（fMRI）在癫■研究中的优势越来越显著,尤其在癫■灶的定侧、定位方面明显优于常规MRI,具有更好的临床应用价值。fMRI对TLE脑网络、认知功能的研究,及在TLE病因、病理生理机制、治疗预后等方面的应用取得了诸多进展。     

癫痫的X刀治疗

目的 探讨X刀治疗继发性癫痫(SEp)和原发性颞叶癫痫(ITLEp)的方法。方法 使用24hEEG、CT、MRI对继发性癫痫灶定位，应用X刀损毁致痫灶治疗SEp40例；毁损剂量20～30Gy。应用X刀毁损杏仁核治疗ITLEp病人30例；毁损剂量140Gy；准直仪7～10mm；采用140Gy一次和分两次毁损治疗(每次间隔24h)。结果 40例SEp病人和30例ITLEp病人X刀治疗后4～24个月随访：50例病人癫痫发作完全停止(SEp32例，ITLEp18例)；20例病人发作减少50％以上；无并发症发生。结论 应用X刀毁损SEp致痫灶及杏仁核，可安全有效地治疗SEp和ITLEp。     

The evaluation of FDG-PET imaging for epileptogenic focus localization in patients with MRI positive and MRI negative temporal lobe epilepsy

Introduction

We studied the contribution of interictal FDG-PET ([18 F] fluorodeoxyglucose-positron emission tomography) in epileptic focus identification in temporal lobe epilepsy patients with positive, equivocal and negative magnetic resonance imaging (MRI).

Methods

Ninety-eight patients who underwent surgical treatment for drug resistant temporal lobe epilepsy after neuropsychological evaluation, scalp video EEG monitoring, FDG-PET, MRI and/or long-term intracranial EEG and with >12 months clinical follow-up were included in this study. FDG-PET findings were compared to MRI, histopathology, scalp video EEG and long-term intracranial EEG monitoring.

Results

FDG-PET lateralized the seizure focus in 95 % of MRI positive, 69 % of MRI equivocal and 84 % of MRI negative patients. There was no statistically significant difference between the surgical outcomes among the groups with Engel class I and II outcomes achieved in 86 %, 86 %, 84 % of MRI positive, equivocal and negative temporal lobe epilepsy patients, respectively. The patients with positive unilateral FDG-PET demonstrated excellent postsurgical outcomes, with 96 % Engel class I and II. Histopathology revealed focal lesions in 75 % of MRI equivocal, 84 % of MRI positive, and 23 % of MRI negative temporal lobe epilepsy cases.

Conclusion

FDG-PET is an accurate noninvasive method in lateralizing the epileptogenic focus in temporal lobe epilepsy, especially in patients with normal or equivocal MRIs, or non-lateralized EEG monitoring. Very subtle findings in MRI are often associated with histopathological lesions and should be described in MRI reports. The patients with negative or equivocal MRI temporal lobe epilepsy are good surgical candidates with comparable postsurgical outcomes to patients with MRI positive temporal lobe epilepsy.     

Brain SPECT imaging in temporal lobe epilepsy

Summary Temporal lobe epilepsy is diagnosed by clinical symptoms and signs and by localization of an epileptogenic focus. A brain SPECT study of two patients with temporal lobe epilepsy, using^99mTc-HMPAO, was used to demonstrate a perfusion abnormality in the temporal lobe, while brain CT and MRI were non-contributory. The electroencephalogram, though abnormal, did not localize the diseased area. The potential role of the SPECT study in diagnosis and localization of temporal lobe epilepsy is discussed.