前颞叶切除术对癫痫患者记忆功能的影响

前颞叶切除术（anterior temporal lobectomy,ATL）是一种有效的控制颞叶癫痫发作的方法,在临床上应用较为广泛.然而,神经心理学方面的并发症,尤其是记忆能力的下降,是其显著而且相对常见的副作用.影响ATL术后记忆功能改变的因素很多,主要包括：手术的侧别,术前的功能水平,基础病理改变,发病年龄,发作控制程度,癫痫灶的数量,手术切除的程度以及手术效果等.这些因素互相关联,相互混杂,本文对这些影响因素的作用进行了综述.     

前颞叶切除术对癫痫患者记忆功能影响的临床研究

目的评估前颞叶切除术对癫痫患者记忆功能的影响。方法对30例颞叶癫痫病例往术前、术后2周和术后6个月以上时分别进行记忆测评,比较患者记忆评分的变化;对24例患者进行1H-MRS成像,评估1H-MRS值与韦氏记忆评分之间的相关关系。结果术前MQ均值与术后2周时有显著性差异,术后6个月以上较术后2周时有显著改善;短时记忆在术前、术后无明显变化;非海马硬化组中患侧NAA/Cr与术前、术后短时记忆差值有相关性,患侧NAA/(Cr Cho)以及健侧与患侧NAA/(Cr Cho)之差与术前、术后MQ差值有相关性。结论术后早期多数患者MQ、长时记忆、瞬时记忆有较明显下降,6个月以后有明显恢复,而短时记忆下降不明显。患侧海马1H-MRS值与术前、术后韦氏记忆评分之间存在一定的相关关系。     

前颞叶切除术对癫痫患者临床记忆商的影响

目的探讨前颞叶切除术前后癫痫患者临床记忆力的变化。方法58例颞叶癫痫患者均经前颞叶切除手术治疗,其中左侧手术者27例,右侧手术者31例。在手术治疗前后对其记忆商(MQ)进行测定,并比较分析手术预后、术前MQ与术后MQ的关系。结果51例预后EngleⅠ-Ⅱ级,其中术后MQ改善16例(31.4%),无变化30例,下降5例;7例预后Ⅲ-Ⅳ级,其中术后MQ无变化1例,下降6例;两组术后MQ改善率相差显著(P<0.01)。右侧手术者术后MQ评分均值显著高于术前(P<0.01),但左侧手术者手术前后MQ评分均值没有显著差异(P>0.05)。右侧手术组术后MQ改善率(35.5%,11/31)明显高于左侧手术组(18.5%,5/27)。术前MQ障碍者术后MQ改善率(38.5%,10/26)明显高于术前MQ优秀(0.0%,0/5)和中等者(22.2%,6/27)。结论经受了右侧前颞叶手术切除的癫痫病人术后MQ有明显改善,左侧手术者则无明显变化;颞叶癫痫患者的手术预后和术前MQ是影响其术后MQ变化的重要因素。     

单侧颞叶内侧癫痫发作间期癫痫放电模式对智商的影响

目的 探讨单侧颞叶内侧癫痫病人发作间期癫痫放电模式分型及其对智商的影响.方法 回顾性分析130例单侧颞叶内侧癫痫病例资料,针对病人发作间期癫痫放电模式进行分型,对比不同分型病例之间的智商差异.结果 颞叶内侧癫痫病例的发作间期癫痫放电模式,左侧分为3型:Ⅰ型放电局限于同侧额、颞区49例(63.64％),Ⅱ型放电波及对侧额...     

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。     

前颞叶切除术治疗颞叶顽固性癫痫(附13例报告)

我院自1995年5月～2001年10月采用前颞叶切除术治疗13例颞叶顽固性癫痫病人,很好地控制了癫痫发作,无死亡病例,并发症少,提高了患者的生存质量,现报告如下。     

颞叶癫痫患者颞叶切除术前后的记忆评估

目的探讨颞叶切除术对颞叶癫痫患者术后记忆功能的影响。方法回顾性分析2012年7月至2013年12月收治的17例颞叶癫痫患者的临床资料,采用成人韦氏量表测量患者颞叶切除术前及术后6个月记忆商（MQ）值。结果术前MQ平均值为（89.94±4.45）,术后6个月为（104.76±4.96）,差异显著（P〈0.05）。术前长时MQ值为（37.53±1.95）,术后为（40.53±1.70）,术后长时记忆改善不明显（P〉0.05）。术前短时记忆MQ值为（46.29±2.43）,术后为（54.94±3.18）;术前瞬时MQ均值为（6.12±1.37）,术后为（9.29±1.00）;术后短时及瞬时MQ均较术前有显著差异（P〈0.05）。EngleⅠ～Ⅱ级15例病人中,术后MQ较术前改善11例,无明显变化4例;EngleⅢ～Ⅳ级2例病人中,MQ值较术前下降1例,无改变1例。结论颞叶切除术可明显改善颞叶癫痫患者术后MQ。     

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。     

Employment after anterior temporal lobectomy

Purpose: To explore the effect of anterior temporal lobectomy on employment and define demographic and clinical predictors of postoperative employment in a large cohort with a prolonged observational period. Methods: Subjects had an anterior temporal lobectomy for refractory epilepsy. All had an assessment period of 4 years or more with documentation of demographic factors, employment status, and seizure frequency prospectively registered in a database at surgery and at each contact after surgery. McNemar chi‐square and a Wilcoxon matched pairs test were used to compare employment status before and after surgery. A multiple logistic regression assessed independent predictors of postoperative employment status based on preoperative employment status. Key Findings: Three hundred sixty‐nine patients were evaluated. Employment levels were higher and unemployment levels were lower after surgery (McNemar χ² = 3.96; p = 0.047). Working before surgery (Wald’s χ² = 22.69, p < 0.0001) and having a greater percent of seizure‐free years (Wald’s χ² = 34.43, p < 0.0001) were associated with being employed after surgery. Of 131 patients who were unemployed or homemakers before surgery, 67 (51.1%) became employed postoperatively, with a younger age at surgery, a younger age of epilepsy onset, and driving a motor vehicle associated with gaining employment. Of 172 patients who were working at baseline, 27 (15.7%) became unemployed or homemakers after surgery. Gender was the only variable associated with loss of employment, with women being more likely to become homemakers (χ² = 14.98, d.f. = 6, p = 0.02). Most students were working after surgery, with seizure control influencing outcome. Significance: Anterior temporal lobectomy is followed by reduced unemployment and underemployment, with elimination of seizures, relative youth, and operating a motor vehicle serving as the main driving forces for improvement. This is important information for patients and physicians who contemplate surgery as it helps define reasonable expectations, and provides further objective evidence for benefits beyond purely medical outcomes after epilepsy surgery.     

Long-term psychosocial outcomes of anterior temporal lobectomy

PURPOSE: To examine the long-term psychosocial outcomes of a consecutive series of patients who underwent anterior temporal lobectomy (ATL) compared with medically managed patients. This study focused primarily on actual long-term changes (mean, 5 years) in life performance. There are relatively few long-term controlled studies of actual lifetime performance changes. METHODS: The sample consisted of 61 adults who underwent ATL and 23 individuals who were evaluated for surgery but did not proceed to surgery and continued to receive medical management. Participants were interviewed 2-9 years after surgery. A structured clinical interview and review of medical records was conducted to obtain information regarding seizure frequency and psychosocial status, focusing on employment, education, driving status, financial assistance, and independent living. In addition, two questions regarding quality of life were included. Seizure frequency was evaluated for the year before the interview. RESULTS: Significant differences in psychosocial outcome were found between the surgery group and medical management group. Favorable psychosocial outcomes were more common among those who had surgery (46 vs. 4%). Results indicated that 68% of the surgery group exhibited improved psychosocial status compared with 5% of the medical management group. Individuals who had surgery were more likely to be driving, working full-time, living independently, and being financially independent. Remaining seizure free was not a prerequisite for improvements in psychosocial outcomes. CONCLUSIONS: Compared with medical management, surgery has a significant positive impact on psychosocial outcomes in terms of employment, independent living, driving, and financial independence. Additionally, a person does not necessarily have to be seizure free to achieve positive changes in psychosocial outcomes.     

Structural versus functional prediction of memory change following anterior temporal lobectomy

Decline in recent memory function is a significant risk for patients undergoing anterior temporal lobectomy. We report a patient with a febrile seizure history, complex partial seizures arising from the left anterior temporal lobe, and MRI evidence suggesting left hippocampal sclerosis, all of which indicate a low likelihood of significant postoperative memory decline. However, high normal verbal memory on neuropsychological testing and bilaterally normal Wada memory scores indicated increased risk for postoperative memory decline. Following left anterior temporal lobectomy, the patient displayed a significant decline in verbal recent memory that affected school performance. Despite the worsening in memory, the patient reported a significant improvement in his self-reported quality-of-life perception, demonstrating that factors other than change in cognitive performance are related to whether a patient considers epilepsy surgery worthwhile. In the present case, behavioral measures were superior to structural measures in predicting cognitive change following surgery.     

顽固性癫痫行前颞叶切除术的并发症

目的报告顽固性颞叶癫痫行前颞叶切除的并发症,探讨术后并发症的发生率、原因和预防措施。方法顽固性颞叶癫痫患者行前颞叶切除,术后出现急性脑梗死伴颅内感染、硬膜外血肿、轻偏瘫等情况,采取抗炎、抗脑水肿、抗凝治疗及清除血肿等治疗。结果首例病人卡马西平治疗随访1年,癫痫发作消失;第2例随访7年,癫痫发作消失;第3例癫痫消失,但残留轻偏瘫,后渐恢复,遗留左手指屈伸力差。结论血肿和感染是术后最频发的并发症,偏瘫(操作性偏瘫)是最严重的神经并发症,手术时损伤脉络膜前动脉是最可能导致偏瘫的原因。     

额颞开颅颞前叶切除术中颞肌处理的技术问题

目的额颞开颅、颞前叶切除术是外科治疗颞叶癫痫的基本术式,开颅术中颞肌的处理是一个关键环节,如果手术操作不当会产生颞肌萎缩等并发症。本文总结了我们手术的经验,根据额颞区的解剖特点,提出额颞开颅术中颞肌处理的一些基本原则和手术技巧,以预防术后颞肌萎缩等并发症的发生。方法通过对尸头的额颞区解剖研究和文献复习对颞肌的解剖特点进行分析,对手术进行改进:①额颞皮瓣成型时避免损伤颞浅动脉、面神经额支和颞支;②保留颞肌筋膜在颞骨颞上线上的附着点以便术后颞肌复位固定;③颞肌的剥离要自下而上在骨膜下逆向完整剥离;④保留较宽的肌蒂,不要横断太多的颞肌;⑤避免用单极电刀从颞骨上剥离颞肌。结果用以上手术技术开颅行颞前叶切除术68例,有3例术后发生颞区疼痛,特别是在咀嚼时疼痛。术后6个月至2年,43例获得随访,无一例发现颞肌萎缩。结论额颞开颅术中正确处理颞肌及其相关的血管和神经,不仅有利于手术的顺利进行,也可有效的预防颞肌萎缩等并发症的发生。     

Preserved proper naming following left anterior temporal lobectomy is associated with early age of seizure onset

PURPOSE: Anterior temporal lobectomy (ATL) is an effective surgical option for managing pharmacoresistant temporal lobe epilepsy. Many patients with left ATL develop postsurgical difficulties with proper name retrieval, although curiously, some patients have entirely intact proper naming following left ATL. Here, we tested the hypothesis that early age of seizure onset would be a reliable factor "protecting" patients from developing proper naming defects following left ATL. METHODS: Proper naming of unique persons (Famous Faces Test, 155 items) and places (Landmark Test, 65 items) was measured in 23 patients who had undergone left ATL for pharmacoresistant epilepsy. Data were collected for a number of variables, including age of seizure onset, age at surgery, handedness, IQ, and seizure outcome. The patients were sorted into two groups based on proper naming performance: (1) Unimpaired: 7 patients performed normally on both the Faces and Landmark tests; (2) Impaired: 16 patients performed abnormally on one or both of the tests. RESULTS: In support of our hypothesis, the Unimpaired group had a significantly earlier age of seizure onset (M = 2.1 years) than the Impaired group (M = 15.1 years). Moreover, a correlation analysis indicated a strong association between age of seizure onset and naming outcome (R =-0.569). The groups were comparable (and statistically indistinguishable) on nearly all other variables. CONCLUSIONS: These findings document the importance of age of seizure onset in predicting proper naming outcome following left ATL (with earlier being better), and extend understanding of brain reorganization and plasticity.     

Predictors of outcome after temporal lobectomy for refractory temporal lobe epilepsy

Objective – To identify predictors of outcome after epilepsy surgery in patients with temporal lobe epilepsy (TLE). Methods – Seventy‐six patients with normal magnetic resonance imaging (MRI) or hippocampal sclerosis on MRI who underwent anterior temporal lobe resections were included. Outcome 2 years after surgery was classified as good (Engel I and II) or poor (Engel III and IV). Gender, age at onset and duration of epilepsy, history of febrile convulsions, auras, right‐ or left‐sided TLE, memory ipsilateral to seizure onset (Wada test), hippocampal asymmetry (HA) and T2 relaxation time, amygdala, temporal lobe and hemispheral volume were tested for associations with outcome. Results – Sixty‐seven percent had a good outcome. Of all parameters tested, only a history of febrile convulsions and HA on quantitative MRI were significantly associated with a good seizure outcome. The absence of these parameters did not exclude a good outcome, but only five of 18 patients (28%) without HA and without a history of febrile convulsions had a good outcome. Conclusion – Febrile convulsions and HA were predictors of outcome after epilepsy surgery in TLE. Subtle volume loss in amygdala, temporal lobe or hemispheres and the memory ipsilateral to the side of resection were not associated with outcome.     

Health-related quality of life outcome in medically refractory epilepsy treated with anterior temporal lobectomy

PURPOSE: A prospective study to investigate health-related quality of life (HRQOL) outcome in patients with temporal lobe epilepsy treated with anterior temporal lobectomy (ATL). METHODS: The majority of the patients with medically refractory focal epilepsy had Quality of Life in Epilepsy-89 (QOLIE-89) assessment at the time of prolonged video/EEG monitoring as part of their presurgical evaluation. Thirty-seven patients who were not treated surgically constituted the control group, and 53 patients who underwent ATL made up the surgery group. Both control and surgery groups had HRQOL assessment repeated at approximately 1-and 2-year intervals. Repeated measures analysis of variance (ANOVA) was used to test for differences between the two groups. RESULTS: For the overall score and almost every scale, the surgery group had a higher baseline mean than the control group. Because of this baseline difference, change scores were used in further analysis. The overall score and 10 of 17 scales in QOLIE-89 showed significant HRQOL improvement after ATL, and the improvement was significant relative to score changes of the nonsurgical comparison group. Scores improved in overall QOL, emotional well-being, attention/concentration, language, social isolation, health perception, role limitations-physical, work/drive/social, health discouragement, and seizure worry. For the first five scales, there was group-time interaction; the improvement was significantly more on the 2-year than on the 1-year follow-up. When the surgery patients were divided into four categories (class IA-, completely seizure free; class IA+, seizure free with aura; class II, rare seizures; class III, worthwhile improvement in seizure control; and class IV, no improvement), the improved HRQOL in the surgery group was almost entirely contributed by the class IA- outcome patients who were totally seizure free. The class IA+ patients with continuing aurae and class II/III/IV patients had no significant improvement in their overall HRQOL scores at 1-or 2-year follow-up. CONCLUSIONS: Overall score and 10 of the 17 scales of QOLIE-89 significantly improved in patients with medically refractory temporal lobe epilepsy after ATL. For some scales, there was delay in the improvement to manifest. The HRQOL improvement was related to achieving an entirely seizure-free status (i.e., no seizures or aurae postoperatively).     

Levetiracetam may favorably affect seizure outcome after temporal lobectomy

Purpose: To study the prognostic implications of antiepileptic drug (AED) use on seizure freedom following temporal lobe resections for intractable epilepsy. Methods: Seizure outcome implications of epilepsy characteristics and AED use were studied in patients who underwent temporal lobectomy patients at the Cleveland Clinic between September 1995 and December 2006. Survival analysis and multivariate regression with Cox proportional hazard modeling were used. Complete seizure freedom was defined as a favorable outcome. Key Findings: Records of 312 patients were analyzed (mean ± standard deviation follow‐up 3.5 ± 1.7 years). The estimated probability of complete seizure freedom was 69% at 12 months (95% confidence interval [CI] 66–72%), and 48% at 36 months (95% CI 45–52%). The mean number of AEDs used per patient at the time of surgery was 1.78 (range 1–4), dropping to 1.02 at last follow‐up (range 0–4). Following multivariate analysis, a lower preoperative seizure frequency and perioperative use of levetiracetam predicted a favorable outcome (risk ratio [RR] 0.62, 95% CI 0.43–0.89, and RR = 0.57, 95% CI 0.39–0.83, respectively), whereas nonspecific pathology (RR 1.71, 95% CI 1.15–2.47) and a higher number of AEDs used at the time of surgery correlated with higher rates of seizure recurrence (whole‐model log‐rank test p‐value < 0.0001). Better outcomes within the levetiracetam group were seen despite a higher proportion of several poor prognostic indicators within this patient group, and started as early as 4 months after surgery, gradually increasing to a 15–20% survival advantage by 5 years. No similar outcome correlations were identified with another AED. Significance: AED use may be a potential new modifiable seizure‐outcome predictor after temporal lobectomy. This possible prognostic indicator is discussed in light of proposed seizure recurrence mechanisms.