难治性癫痫侵袭性评估中颅内皮层电极的应用与并发症分析

目的探讨在难治性癫痫术前评估中颅内皮层电极埋藏的方法与安全性。方法回顾性分析湘雅医院功能神经外科2014年4月～2017年6月开展的65例颅内皮层电极埋置患者的临床资料,总结颅内皮层电极埋置在癫痫术前评估中的经验。结果 65例患者均采用开颅埋置皮层片状电极,其中38例辅助埋置深部电极。患者术后平均监测时间为10. 8天(2～28天)。术后颅内血肿8例,其中硬膜外血肿4例,硬膜下血肿4例,有3例患者因硬膜外血肿行手术清除血肿,术后伤口脑脊液漏12例,术后颅内感染3例,均为并发脑脊液漏患者,脑水肿1例,电极脱出1例。无因并发症放弃监测病例,无埋置手术长期并发症及神经功能受损病例。结论颅内皮层电极埋置在癫痫外科中是一项重要的安全有效的侵袭性术前评估方法,术后出血及感染是主要的并发症,适当的术中、术后处理将有助于避免相关并发症。     

Tailored cortical resection following image guided subdural grid implantation for medically refractory epilepsy

The aim of this study was to report the safety and efficacy of tailored cortical resection based on image guided subdural electrode implantations in eight patients with medically refractory epilepsy. The patients were selected for multimodality image guided subdural grid implantation, inpatient invasive electroencephalography video monitoring and surgical resection of epileptogenic foci. All patients had frequent disabling, medically refractory seizures pre-operatively. At a minimum of 10 months post-resection all patients had a worthwhile improvement in seizure frequency, with 7 of the 8 (87.5%) having an excellent outcome (Engel Class I). Short-term complications of grid implantation were: one patient with a post-operative subdural haemorrhage and one patient with a transient fluctuating dysphasia. The only long-term complication was a mild, non-disabling dysarthria following resection near eloquent speech cortex in one patient. We conclude that tailored cortical resection following image-guided insertion of subdural grids is a reliable, safe and highly effective method for the treatment of medically refractory epilepsy in carefully selected patients.     

Risks and benefits of invasive epilepsy surgery workup with implanted subdural and depth electrodes

Purpose: In patients with pharmacoresistant focal‐onset seizures, invasive presurgical workup can identify epilepsy surgery options when noninvasive workup has failed. Yet, the potential benefit must be balanced with procedure‐related risks. This study examines risks associated with the implantation of subdural strip and grid, and intracerebral depth electrodes. Benefit of invasive monitoring is measured by seizure outcomes. Diagnostic procedures made possible by electrode implantation are described. Methods: Retrospective evaluation of invasive workups in 242 epilepsy surgery candidates and additional 18 patients with primary brain tumors implanted for mapping only. Complications are scaled in five grades of severity. A regression analysis identifies risk factors for complications. Outcome is classified according to Engel’s classification. Key Findings: Complications of any type were documented in 23% of patients, and complications requiring surgical revision in 9%. We did not find permanent morbidity or mortality. Major risk factor for complications was the implantation of grids and the implantation of electrode assemblies comprising strip and grid electrodes. Depth electrodes were significantly correlated with a lower risk. Tumors were not correlated with higher complication rates. Chronic invasive monitoring of 3–40 days allowed seizure detection in 99.2% of patients with epilepsy and additional extensive mapping procedures. Patients with epilepsy with follow‐up >24 months (n = 165) had an Engel class 1a outcome in 49.7% if epilepsy surgery was performed, but only 6.3% when surgery was rejected. Significance: The benefit of chronic invasive workup outweighs its risks, but complexity of implantations should be kept to a minimum.     

Depth versus subdural temporal electrodes revisited: Impact on surgical outcome after resective surgery for epilepsy

Objective

To study retrospectively the impact of electrode modality (subdural or depth electrodes) during presurgical assessment on surgical outcome after temporal lobectomy.

Results of surgery in patients with refractory extratemporal epilepsy with normal or nonlocalizing magnetic resonance findings investigated with subdural grids

PURPOSE: To study the efficacy of extensive coverage of the brain surface with subdural grids in defining extratemporal cortical areas amenable for resection in patients with refractory extratemporal epilepy (R-ExTE) and normal or nonlocalizing magnetic resonance imaging (MRI) scans. METHODS: Sixteen patients with R-ExTE were studied. Eleven patients had simple partial, eight had complex partial, and three had supplementary motor area seizures. Seizure frequency ranged from three per month to daily episodes. Interictal EEG showed large focal spiking areas in 11 patients, secondary bilateral synchrony in four, and was normal in one patient. Surface ictal recordings were nonlocalizing in six patients, and in 10, they disclosed large ictal focal spiking areas. MRI was normal in 10 patients, and in six patients, focal nonlocalizing potentially epileptogenic lesions were found. All patients were given an extensive coverage of the cortical convexity with subdural electrodes through large unilateral (n = 13) or bilateral (n = 3) craniotomies. Bipolar cortical stimulation was carried out through the implanted electrodes. RESULTS: Interictal invasive recording findings showed widespread spiking areas in 13 patients and secondary bilateral synchrony in three. Ictal invasive recordings showed focal seizure onset in all patients. There were six frontal, two parietal, one temporooccipital, four rolandic, and three posterior quadrant resections. Thirteen patients had been rendered seizure free after surgery, and three had > or =90% of seizure-frequency reduction. Pathologic findings included gliosis (n = 10), cortical dysplasia (n = 5), or no abnormalities (n = 1). Six patients had transient postoperative neurologic morbidity. CONCLUSIONS: Extensive subdural electrodes coverage seems to be an effective way to investigate patients with R-ExTE and normal or nonlocalizing MRI findings.     

颅内电极长程记录在癫痫外科中的应用价值

目的 探讨颅内电极长程记录在癫痫外科中的应用时机以及方法,评价其应用价值.方法 回顾性分析112例颅内电极植入患者的临床资料,包括电极类型、部位、电极植入方式以及并发症.结果 单纯硬膜下条状皮层电极植入87例,条状电极和深部电极联合植入9例,栅状电极植入13例,条状电极和栅状电极联合植入3例.左侧26例,右侧32例,双侧54例,监测时间24-192 h.脑脊液漏15例,胃肠道反应9例,脑脓肿2例,硬膜外血肿1例,术中硬膜下少量出血1例,无死亡病例.结论 颅内电极长程记录是确定癫痫致痫灶重要的定位手段,可应用于无创评估方法难以确定的致痫灶.     

颅内电极在功能区癫痫治疗中的应用

目的 探讨颅内电极在功能区癫痫治疗中致痫灶定位及功能区定位中的作用.方法 回顾性分析经我科治疗的涉及功能区的癫痫患者34例,经颅内电极植入明确致痫灶后,均行皮层电刺激定位功能区,根据致痫灶与功能区关系图决定治疗方案.结果 致痫灶与中央前后回相邻者10例,术中行单纯致痫灶切除术;与中央前后回部分重叠者14例,术中行非功能区致痫灶切除,功能区致痫灶皮层电凝热灼术;完全位于中央前后回皮层区域内者5例,术中行单纯皮层电凝热灼术.术后癫痫发作较术前明显减少,无明显术后功能缺失.结论 颅内电极植入是定位功能区癫痫致痫灶及功能区的有效方法.     

毫针蝶骨电极在癫痫诊断中的应用

目的探讨毫针蝶骨电极在癫痫诊断中的应用价值及常规脑电图加用蝶骨电极的指征。方法102例临床诊断为癫痫的患者于发作间期行常规脑电图及毫针蝶骨电极脑电图描记,分别对其癫痫波的检出率进行分析。结果经χ2检验分析,蝶骨电极脑电图可提高全身强直-阵挛发作、单纯部分性发作、复杂部分性发作3种发作类型癫痫的痫样放电检出率,其中以复杂部分性癫痫尤为显著;此外发现43例常规脑电图描记时耳垂单极导联可见单侧或双侧正相尖（棘）波或正相尖（棘）慢波,而在蝶骨电极描记时均记录到明显的癫痫波。结论蝶骨电极可提高癫痫患者的痫样放电检出率,常规脑电图描记发现耳垂单极导联出现正相尖（棘）波或正相棘（尖）慢波,加用蝶骨电极多可记录到典型的癫痫波,具有临床确诊价值,应列为临床脑电图的常规描记方法。     

Clinical relevance of quantified intracranial interictal spike activity in presurgical evaluation of epilepsy

PURPOSE: Electrocorticograms of 32 patients with medically intractable seizures, recorded through intracranial electrodes, were retrospectively analyzed. The objective was to assess whether quantitative analysis of interictal spikes may be used for delineation of the epileptogenic zone. METHODS: We used a newly developed computer program for automatic detection of interictal spikes and averaging procedures. This allowed determination of the earliest spike of each spike cluster, the maximal averaged spike amplitude, the highest spike frequency, and the shortest averaged spike duration at each recording site. RESULTS: The following results were obtained: (a) Within a zone 相似文献   

Detection of temporal lobe spikes: Comparing nasopharyngeal, cheek and anterior temporal electrodes to simultaneous subdural recordings

OBJECTIVE: To compare nasopharyngeal (NP), cheek and anterior temporal (AT) electrodes for the detection yield and localization of interictal spikes in temporal lobe epilepsy. METHODS: In patients evaluated for epilepsy surgery with subdural electrocorticography electrodes, we simultaneously recorded NP, cheek and AT electrodes. Two observers identified spikes in EEG traces and marked in which channels they occurred. Interobserver agreement was calculated using Cohen's kappa. For localization, data-sets with high interobserver agreement (kappa-value 0.4) were evaluated. The subdural distribution of NP and AT spikes was mapped. RESULTS: Seven patients were included, six were analyzed for localization. Only 1.5% of spikes recorded by cheek electrodes were not seen on temporal leads, while 25% of NP spikes were not seen on either. Spikes only recorded by NP electrodes had mesiobasal, while AT spikes had lateral temporal distribution. CONCLUSIONS: NP electrodes can increase EEG spike detection rate in temporal lobe epilepsy and are more useful than cheek electrodes. Spikes that are seen only on NP electrodes tend to be mesiobasal temporal lobe spikes. SIGNIFICANCE: Adding NP electrodes to scalp EEG can aid interictal spike detection and source localization, especially in short recordings like MEG-EEG.     

脑外伤开颅术后纵裂分离型硬膜下积液诊治分析

目的探讨脑外伤开颅术后出现纵裂分离型硬膜下积液产生的原因和治疗方法。 方法回顾性分析解放军第九四医院神经外科自2013年1月至2016年12月收治的22例脑外伤开颅术后出现纵裂分离型硬膜下积液的患者,通过高压氧、弹力绷带加压包扎、钻孔引流术、腰大池置管引流等治疗方法,观察积液减少情况。 结果纵裂分离型硬膜下积液患者均通过弹力绷带加压包扎联合高压氧治疗2周后,仅14例患者复查颅脑CT示积液有不同程度减少;3例经钻孔引流术或Ommaya囊抽液治疗有效,3例经腰椎穿刺或腰椎持续引流治疗有效,2例经积液-腹腔分流术治疗有效,8例患者行脑室-腹腔分流术治疗有效。 结论临床针对纵裂分离型硬膜下积液患者应根据头颅CT或MRI估计积液量,结合患者的病情采用恰当的方法治疗能取得良好的治疗效果。     

Outcome of resective surgery for intractable partial epilepsy guided by subdural electrode arrays

The aim of this paper was to evaluate the outcome and the factors predictive for a good prognosis of resective surgery for intractable partial epilepsy guided by subdural electrode arrays (SEA's) and operative electrocorticography. Sixty-four patients, aged 8–52 years, were evaluated with chronic SEAs in order to record interictal and ictal activity and delineate speech and motor areas by functionally mapping. Resection were individualized to each patient's SEA recorded electrocorticogram and operative electrocorticogram and functional mapping results (tailored resection). The follow-up time was a minimum of one year. Good seizure outcome was defined as seizure free from complex partial and secondary generalized seizures. After one year 70% of the patients with a temporal ictal focus was seizure free compared to 55% of the patients with an extratemporal focus. Complete resection of interictal or ictal fields as mapped with SEAs, gave better prognosis than partial resection. Patients with no postresection spikes had a better prognosis than patients with residual postresection spikes evaluated with operative electrocorticography. Sex, age, duration of epilepsy prior to surgery, extent of temporal lobe resection and structural abnormalities determined by MRI were not associated with a favorable seizure outcome after surgery. We conclude that complete resection of the interictal and ictal field mapped with SEA's and absence of postresection spikes on operative electrocorticography are associated with an excellent seizure outcome.     

Chronic subthreshold subdural cortical stimulation for the treatment of focal epilepsy originating from eloquent cortex

Medically refractory epilepsy remains a major medical problem worldwide. Although some patients are eligible for surgical resection of seizure foci, a proportion of patients are ineligible for a variety of reasons. One such reason is that the foci reside in eloquent cortex of the brain and therefore resection would result in significant morbidity. This retrospective study reports our experience with a novel neurostimulation technique for the treatment of these patients. We identified three patients who were ineligible for surgical resection of the intracranially identified seizure focus because it resided in eloquent cortex, who underwent therapeutic trial of focal cortical stimulation delivered through the subdural monitoring grid. All three patients had a significant reduction in seizures, and two went on to permanent implantation, which resulted in long‐term reduction in seizure frequency. In conclusion, this small case report provides some evidence of proof of concept of the role of targeted continuous neocortical neurostimulation in the treatment of medically refractory focal epilepsy, and provides support for ongoing investigations into this treatment modality. A PowerPoint slide summarizing this article is available for download in the Supporting Information section here .     

机器人立体定向辅助系统在癫痫外科深部电极植入中的应用价值

目的研究神经外科机器人立体定向辅助系统（robotized stereotactic assistant,ROSA）在癫痫外科中的应用价值。方法自2013年3月至6月,对11例顽固性癫痫患者,经过电一临床症状学、影像学、头皮脑电图等无创手段严谨的术前评估,设计颅内电极埋置方案。在ROSA引导下,定向植入脑深部电极。埋置电极后进行颅内脑电图长程监测,最终手术治疗。结果11例患者平均年龄26．3岁（13～48岁）,平均病史11．9年（1～23年）。共植入72根深部电极,1例患者进行单侧植入,10例系双侧植入。其中包括额叶17根,颞叶52根,岛叶3根。平均每根电极植入时间小于10分钟。术后复查CT,与术前MRI相融合之后分析,可见各电极末端位置与植入术前计划靶点位置基本一致,平均位置误差1．7mm（0．3～3．1mm）。1例患者在电极入路点有少量蛛网膜下腔出血,仅表现轻微头痛。本组患者均无显著的颅内出血等并发症发生。结论ROSA引导植入脑深部电极应用于顽固性癫痫的外科治疗,克服了传统的框架式立体定向仪应用的局限性,更加安全、精准、便捷。     

迷走神经刺激术治疗药物难治性癫痫的价值

尽管目前癫痫的药物治疗已取得较大进展,但仍有20％～30％的患者对癫痫药物治疗反应差,部分癫痫发作难以有效控制,即所谓的药物难治性癫痫。癫痫病灶切除术是治疗药物难治性癫痫的有效方法,但并非所有患者均能找到确切病灶,而且部分患者手术后效果不佳。1988年,迷走神经刺激术(vagus nerve stimulation,VNS)开始应用于治疗药物难治性部分性癫痫,为药物难治性癫痫提供了一种新的治疗方法。     

影像融合及颅内电极三维重建在癫痫术前计划中的应用

目的 探讨影像融合及颅内电极三维重建在癫痫术前计划中的应用价值。方法 对于行开颅颅内电极植入术以进行慢性皮层脑电评估的癫痫患者,获取其术前MRI及电极植入术后CT的影像资料,利用SynergyCranial软件将两种影像进行融合,并对颅内电极、脑表面及颅骨进行三维重建,以显示出颅内电极与骨窗、脑表面的相对位置,为致痫灶的定位及下一步手术计划的制定提供准确的解剖信息。结果 在2015年4月至8月共对10例需慢性皮层脑电监测的癫痫患者进行了开颅颅内电极植入术。通过术前MRI与电极植入术后CT影像融合技术,可以在MRI断层图像上观察到皮层电极中各触点与脑沟、脑回的相对平面位置,克服了术后无法行MRI检查的弊端。通过对影像融合后的颅内电极、脑表面及颅骨进行三维模型重建,可以立体直观地观察到颅内电极与脑表面和骨窗的相对空间位置,电极触点的重建成功率达90%。根据重建出的三维融合影像,结合皮层脑电图的监测结果,划定出致痫灶的位置与范围,制定手术计划,进行致痫灶切除术,术后所有患者均取得了良好效果。结论 在对行颅内电极监测的癫痫患者制定手术计划时,利用影像融合和颅内电极三维重建技术,可以获得更为准确且直观的致痫灶定位信息,有利于提高致痫灶切除术的准确性和安全性。