颅内电极监测结合神经导航治疗功能区难治性癫痫24例临床分析

目的探讨颅内电极监测结合神经导航技术在难治性癫痫手术中的疗效。方法对24例难治性癫痫患者行颅内电极置入长程脑电图监测(intracranial EEG,iEEG)进行致痫区定位,二次手术前行磁共振扫描,数据输入神经导航系统,手术当天进行导航注册配准,神经导航引导手术入路,术中结合颅内电极描记切除癫痫灶,尽可能减少功能区损伤。结果手术后致痫灶切除效果:EngelⅠ级19例,Ⅱ级4例,Ⅲ级1例。无术后神经功能障碍。结论颅内电极监测结合神经导航的应用可使难治性癫痫外科手术更精确,侵袭更小。     

额叶癫痫的特点及手术治疗

目的 :分析额叶癫痫的临床特征、发作期及发作间期脑电图特点 ,探讨额叶癫痫手术治疗。方法 :应用视频脑电图对 9例额叶癫痫患者进行长程监测 ,并对其中 6例记录颅内脑电图。分析癫痫发作的临床表现及脑电图特点 ,定位致痫灶 ,行手术切除。结果 :额叶癫痫的发作特点为 :发作频繁而短暂 ,以睡眠期发作为主 ,常见过度运动 ,姿势性强直 ,发声等发作症状。发作期可见棘波节律 ,广泛低幅快活动 ,节律性慢波等特征性脑电活动。颅内电极记录可清晰显示异常脑电活动的发作起源及扩散情况 ,有助于定位致痫灶。手术切除病灶及致痫灶 ,效果满意。结论 :额叶癫痫是一组具有特征性的癫痫综合征 ,颅内电极记录有助于揭示其脑电活动变化。对于难治疗性额叶癫痫 ,准确定位致痫灶是手术成功的关键。     

立体定向开放显微手术治疗脑内致痫小病灶

目的脑内致癫痫小病灶术前、术中的精确定位和病灶切除,是手术治疗效果的关键。探讨立体定向开放微创手术,皮层电极监测下切除脑内致痫小病灶的手术方法。方法53例症状性癫痫病例,CT、MR I检查有脑内小病灶(直径在0.5~3.0 cm),24 h视频脑电图确认致痫灶为脑内单发病灶。ASA 601S型立体定向仪CT引导辅助全麻环钻开颅,导针穿刺放置导管引导,显微镜下手术分离、切除病灶,皮层脑电图确认将致痫灶切除。结果病灶全切率达96.2%,术后50例得到随访,随访时间5~12个月,平均6.3个月,癫痫消失45例,脑电图检查记录到癫痫波11例,临床癫痫发作5例。因肺癌死亡3例。结论CT立体定向引导,显微手术切除颅内致痫小病灶,术中皮层电极确认将致痫灶切除,是一种定位精确、微创、安全、有效的治疗方法。     

术前视频脑电图及术中皮层脑电图定位继发性癫痫175例分析

目的探讨皮层脑电监测定位指导继发性癫痫手术切除方式、范围及术后疗效。方法对2005-06-2013-06我院神经外科收治的175例继发性癫痫患者术前行视频脑电监测定位,致痫灶与病灶相一致,相近或相侧的情况下,手术中再用皮层及深部电极行皮层脑电图监测定位,并在其指导下联合多种手术方式切除原发病灶及致痫灶,术后定期复查,随访6~60个月。结果根据ILAE疗效分级标准进行疗效评价:1级52例,2级41例,3级27例,4级26例,5级18例,6级11例,总有效率93.0%。结论对继发性癫痫发作患者,术前行视频脑电监测定位,术中再进行皮层脑电监测定位病灶与癫痫灶的关系,并在其指导下联合多种手术方法切除和处理癫痫灶,采取病灶+致痫灶的手术切除方法,可明显降低术后癫痫发生率。     

颞叶癫痫的致痫灶定位评估和外科治疗：附27例报告

目的 探讨颞叶癫痫的致痫灶定位评估手段和外科治疗的疗效和安全性。方法 回顾性 分析27 例2016 年8 月至2018 年11 月在深圳市第二人民医院和深圳大学总医院开展难治性颞叶癫痫患 者的临床资料。致痫灶评估检查包括：详尽的发作症状学,癫痫序列颅脑MRI,发作间期正电子发射断 层扫描（PET）,长程视频脑电图监测,癫痫神经心理评估资料和立体定向脑电图监测（SEEG）,多学科团 队讨论完成致痫灶和功能区定位后完成外科手术。结果 13例患者经Ⅰ期评估后直接行手术切除,14 例 经SEEG 置入后手术切除。所有患者随访时间为6～34 个月,平均为（19.93±9.00）个月。手术疗效采用 ILAE 分级标准,ILAE Ⅰ级22 例（81.48%）,ILAE Ⅱ级1 例（3.70%）,ILAE Ⅲ级2 例（7.41%）,ILAE Ⅳ级2 例 （7.41%）;SEEG 置入组的ILAE Ⅰ级比例（12/14）高于无SEEG 置入组（10/13）,MRI 阳性组的ILAE Ⅰ级比 例（16/19）高于MRI阴性组（6/8）,但两组比较差异无统计学意义。1例行SEEG置入术后颅内出血,1 例前颞 叶切除术后出现迟发性颅内血肿,2例患者出现一过性动眼神经热损伤,1例头皮切口愈合不良,4 例术后 颅内感染,无脑脊液漏,无视野缺损等并发症。结论 外科手术治疗难治性颞叶癫痫是安全有效的,详 尽的术前致痫灶定位评估和SEEG 置入可以提高手术疗效。     

神经导航引导海马病灶切除联合皮质热灼治疗顽固性颞叶内侧癫痫

目的探讨神经导航引导、皮质电极监测下对海马病灶进行致痫灶切除,辅助以皮质痫灶横纤维热灼术治疗顽固性颞叶内侧癫痫的临床价值。方法通过对16例海马病灶的顽固性癫痫的病人,术前进行24小时脑电图描记定位致痫灶,手术前进行磁共振扫描,数据输人神经导航系统,手术当天进行导航注册配准．术中进行颞叶皮质电极描记,并在导航棒引导下找寻海马病灶,完整切除并辅以皮质热灼治疗致痫灶。结果术后0．5～3年内随访,按Engel癫痫疗效分级：发作完全消失11例(68．8％),明显改善4例(25％),改善1例(6．2％)。结论神经导航有助于海马病灶的准确找寻与切除,在皮质电极监测下,辅助皮质热灼是治疗顽固性颞叶内侧癫痫的一种有效、安全的方法。     

儿童额叶癫痫的临床特征以及切除性手术预后研究——儿童癫痫中心的经验

目的 分析儿童额叶癫痫的临床特征、手术预后以及两者的相关性。方法 回顾性分析2017年1月—2019年12月复旦大学附属儿科医院三级癫痫中心收治并进行额叶致痫灶切除手术的额叶癫痫患儿18例,收集临床、头颅影像学、脑电图、智力发育以及病理等资料,术后随访至少2年以上并记录癫痫发作情况,利用单因素方法分析手术预后和临床表型之间的相关性。结果 18例患儿中男11例、女7例,平均手术年龄（6.8±2.73）岁,年龄范围21月龄～11岁,病程1个月～9年。17例表现为局灶性发作、1例表现为全面性癫痫性痉挛发作。发作间期额区放电11例、额区外多脑区放电7例,发作期额区起始9例、额区外起始9例。核磁共振成像阳性改变14例、阴性4例。病因分别为局部皮层发育不良14例、发育性肿瘤2例、结节性硬化和胶质增生各1例。致痫病灶直接切除11例、立体定向脑电图深部电极植入后致痫灶切除7例。根据Engel分级,术后2年Ⅰ级14例（77.8%）、Ⅱ级1例（5.6%）、Ⅲ级2例（11.0%）、Ⅳ级1例（5.6%）。术后预后在性别、起病年龄、病程、致痫灶侧别、核磁共振成像阳性发现、发作间期放电和发作期放电起始、病因、智力...     

脑深部电极监测在致痫灶定位中的应用

目的评估脑深部电极置入后对定位致痫灶及指导手术治疗的可靠性和安全性。方法对108例药物难治性癫病人行脑深部电极置入,其中采用立体定向电极置入77例,神经导航电极置入11例,术区徒手置入20例。根据头皮脑电图监测情况和脑深部电极提供的手术路径,行致灶切除。结果根据监测情况,头皮脑电图不能定位而通过深部电极定位98例,两者定位于不同区域7例,两者均不能定位3例。术后病理：局灶性皮质发育不良38例,颞叶内侧硬化42例,结节性硬化11例,神经节细胞胶质瘤7例,胶质增生9例,错构瘤1例。术后随访91例,时间6～36个月,Engle分级：Ⅰ级66例,Ⅱ级25例;复查脑电图,痫样异常放电消失或明显改善。术后并发脑出血5例,硬膜外血肿6例,蛛网膜下腔出血3例,电极因发作脱出或拔出1例,剧烈头痛3例,无死亡病例。结论初期评估不能明确定位的脑深部致痫灶,通过脑深部电极定位是安全、可靠的。     

头皮视频脑电监测结合颅内电极脑电监测在难治性癫痫手术中的应用

目的探讨颅内电极置入术在临床的应用时机、方法,评估头皮视频脑电图(scalp EEG,sEEG)与颅内电极脑电图(intracranial EEG,iEEG)两者监测技术在癫痫外科中的价值。方法对47例难治性癫痫患者,术前行头皮视频脑电图监测初步确定致痫灶部位,在参考非侵入性评估结果的基础上,采用颅内电极置入、长程脑电图监测技术进行致痫区定位,然后切除致痫灶。结果手术后致痫灶切除效果:EngelⅠ级29例,Ⅱ级10例,Ⅲ级7例,IV级1例。术后发生头皮脑脊液漏3例,修补缝合并延长拆线时间后愈合。1例出现少量硬膜外血肿,保守治疗后血肿吸收。无感染及死亡病例。结论头皮视频脑电图与颅内电极置入并进行长程脑电图两者监测是准确定位致痫区的一种有效、安全的方法。     

颅内电极埋藏在枕叶癫痫中的作用

目的探讨运用颅内电极埋藏进行视频脑电图监测在定位困难的枕叶癫痫中的作用。方法通过对9例枕叶癫痫但定侧定位困难的患者,向颅内可疑部位植入硬膜下条状电极,进行视频脑电图监测,记录发作间期及发作期脑电图变化,确定癫痫病灶起始区。通过手术切除致痫灶。结果本组9例埋藏时间为3～9d,平均5d,均记录到间歇期痫样放电及发作期脑电图情况。行枕叶局部皮层切除6例及枕叶切除3例。术后按照Engel评分,I级7例,II级2例。所有病例均未出现埋藏电极引起的并发症。结论在致痫灶定位困难的顽固性枕叶癫痫中,采用颅内电极埋藏进行脑电图监测,可以精确定位致痫灶,从而提高癫痫的治愈率。     

前额叶孤立术治疗顽固性癫痫

目的总结8例大脑前额叶孤立术治疗顽固性癫痫的临床经验,探讨采用完全额叶孤立术治疗顽固性癫痫的可行性。方法以大脑半球切开术及后象限切开术为基础术式,将彻底孤立致痫灶的概念引入这种病例的治疗中,对8例致痫灶切除术后无效的额叶癫痫患者施行了额叶孤立术,为保证前额叶彻底孤立,在额叶切开的同时离断前连合和胼胝体前部。术后随访16个月,16个月后对8例患者统一以Engel分级法评估手术疗效。结果 8例患者手术过程均顺利,2例术后发热,行腰大池引流术,均恢复良好。术后疗效评估Engel分级Ⅰ级(术后癫痫停止发作)5例,Ⅱ级(每年发作1~2例)2例,Ⅲ级(发作频率减少75%以上)1例。结论前额叶孤立术可能是治疗难治性额叶癫痫的比较有效的方法之一。     

ROSA引导下立体定向脑电图在儿童难治性癫痫手术中的作用

目的探讨机器人无框架立体定向手术辅助系统(ROSA)引导下颅内深部电极置入术在儿童难治性癫痫定位中的作用以及安全性、有效性。方法 2014年10月至2015年12月收治19例年龄在14岁以下药物难治性癫痫,经过术前无创评估,包括MRI、头皮脑电图、电-临床症状学、PET-CT等,应用ROSA机器人将电极置入颅内相应部位,然后行长程视频脑电图监测发作间期及发作期脑电图,确定癫痫灶起始,最终手术治疗。结果 19例患儿均成功置入电极,左侧置入11例,右侧置入7例,双侧置入1例;共置入深部电极222根,平均11.7根(8~17根)。置入电极后无出血、脑脊液漏、电极断裂、感染等并发症。19例均明确致痫灶,并全部行癫痫灶切除术,术后2例出现一过性轻偏瘫。术后随访12~24个月,Engel分级Ⅰ级15例(78.9%),Ⅱ级1例(5%),Ⅲ级1例(5%),Ⅳ级2例(11.1%)。结论 ROSA引导下立体定向脑深部电极置入术,微创、并发症少、安全性高,适合儿童难治性癫痫的外科治疗。     

Estereoelectroencefalografía en la evaluación prequirúrgica de epilepsias focales refractarias: experiencia de un centro de epilepsia

ObjectiveStereoelectroencephalography (SEEG) is a technique for preoperative evaluation of patients with difficult-to-localise refractory focal epilepsy (DLRFE), enabling the study of deep cortical structures. The procedure, which is increasingly used in international epilepsy centres, has not been fully developed in Spain. We describe our experience with SEEG in the preoperative evaluation of DLRFE.Material and methodsIn the last 8 years, 71 patients with DLRFE were evaluated with SEEG in our epilepsy centre. We prospectively analysed our results in terms of localisation of the epileptogenic zone (EZ), surgical outcomes, and complications associated with the procedure.ResultsThe median age of the sample was 30 years (range, 4-59 years); 27 patients (38%) were women. Forty-five patients (63.4%) showed no abnormalities on brain MR images. A total of 627 electrodes were implanted (median, 9 electrodes per patient; range, 1-17), and 50% of implantations were multilobar. The EZ was identified in 64 patients (90.1%), and was extratemporal or temporal plus in 66% of the cases. Follow-up was over one year in 55 of the 61 patients undergoing surgery: in the last year of follow-up, 58.2% were seizure-free (Engel Epilepsy Surgery Outcome Scale class I) and 76.4% had good outcomes (Engel I-II). Three patients (4.2%) presented brain haemorrhages.ConclusionSEEG enables localisation of the EZ in patients in whom this was previously impossible, offering better surgical outcomes than other invasive techniques while having a relatively low rate of complications.     

颅内电极埋藏在Lennox-Gastaut综合症中的应用(附10例临床分析)

目的探讨颅内电极埋藏术后进行视频脑电图评估在癫痫外科手术致痫灶定位困难的Lennox-Gastaut综合症中的使用。方法收集10例Lennox-Gastaut综合症致痫灶定位困难的患者,向颅内硬膜下植入条状电极,术后进行视频脑电图评估,记录发作间歇期及发作期脑电图变化,确定癫痫病灶的起始区,通过手术方式切除致痫灶。结果本组10例患者埋藏时间为2～7天,平均4天,均记录到间歇期及发作期脑电图情况。根据脑电图结果,行脑叶切除及胼胝体切开。术后按照Engel评分I级4例,II级2例,III级2例,IV级2例。所有病例均未出现埋藏电极引起的严重并发症。结论在致痫灶定位困难的Lennox-Gastaut综合症中,采用颅内电极埋藏进行视频脑电图检测,可以较准确定位主要致痫灶,从而提高Lennox-Gastaut综合症外科治疗有效率。     

27例学龄前难治性颞叶癫痫患儿临床报道

目的探讨学龄前难治性颞叶癫痫患儿影像学、电生理特点及手术方法和疗效。方法回顾性分析解放军联勤保障部队第九八八医院神经外科中心自2014年6月至2019年1月行手术治疗的27例学龄前难治性颞叶癫痫患儿资料,术前评估结合临床发作表现,MRI、磁共振波谱分析(MRS)、正电子发射断层扫描(PET-CT)等影像资料,以及发作间期和发作期视频脑电图(VEEG)资料;术中应用皮层脑电图(ECoG)与深部电极监测定位异常放电区域,指导手术切除致痫灶范围。术后采用Engel分级评估疗效。结果27例患儿均有典型颞叶癫痫临床表现,MRI发现一侧颞叶及海马异常信号影,发作间期及发作期VEEG提示异常放电起始于一侧额颞部。术中ECoG及深部电极监测均发现颞叶明显持续或阵发性尖波、棘波、棘慢复合波等癫痫样放电。27例患儿均采用标准前颞叶+病灶切除+周边异常放电颞叶皮质扩大切除术,其中2例患儿切除部分岛叶长回及额盖皮质热灼处理。随访6个月,EngelⅠ级患儿22例,EngelⅡ级患儿3例,EngelⅢ级患儿2例。结论早期手术、术中ECoG与深部电极联合监测下适度扩大切除范围是改善学龄前难治性颞叶癫痫患儿手术疗效的关键因素。     

Ictal SPECT analyzed by three-dimensional stereotactic surface projection in frontal lobe epilepsy patients

We analyzed preoperative ictal SPECT results from 18 frontal lobe epilepsy patients who underwent epilepsy surgery (mean age 22.9 years). Seizure onset at implanted subdural electrodes was defined as the epileptic focus in 16 of 18 patients. In two additional patients, the resected area on postoperative magnetic resonance images was defined as the epileptic focus. The radioisotope 99mTc-ECD was injected in all patients within 5 s after seizure onset. SPECT images were analyzed by three-dimensional stereotactic surface projection (3-D SSP). Areas of hyperperfusion identified by ictal SPECT were concordant with the site of epileptic focus in 11 patients (61.1%, concordant group) and were non-concordant in 7 patients (38.9%, non-concordant group). The non-concordant group had a higher number of patients with a history of acquired brain damages, such as encephalitis or brain surgery (p < 0.05). Only 3 of 11 patients in the concordant group showed areas of localized hyperperfusion within epileptic foci, whereas 8 patients showed areas of hyperperfusion extending to other regions. Ictal SPECT analyzed by 3-D SSP is useful as a mode of presurgical evaluation in frontal lobe epilepsy patients without a history of encephalitis or surgical treatment. We caution that rapid seizure spread may result occasionally in areas of hyperperfusion extending to adjacent or remote regions.     

Variatio delectat

The implantation of subdural electrodes and the implantation of intracerebral depth electrodes according to stereoelectroencephalography (SEEG) criteria are complementary invasive approaches for the presurgical assessment of epilepsy. As exemplified by a case of frontal lobe epilepsy, these two implantation strategies may lead to quite different results when applied consecutively in the same patient. Even if an evaluation with subdural electrodes yields only non-conclusive findings in a given case, SEEG can contribute decisively to a successful surgical treatment of epilepsy.     

额叶癫痫脑电模式分析

目的 探讨额叶癫痫的脑电模式特点.方法 回顾性分析2016年1月至2018年4月手术治疗的额叶有确切结构病灶或立体定向脑电图(SEEG)证实额叶起源的51例癫痫的临床资料,51例均行头皮视频脑电图(VEEG)监测,21例行SEEG监测.结果 ①VEEG表现:背景正常29例(56.86％),异常22例(43.14％);间...     

Invasive explorations in children younger than 3years

PurposeIn children with drug-resistant focal epilepsy who are candidates for surgery, invasive exploration is sometimes required. However, this is being controversially discussed for children younger than 3 years. The question of its necessity, feasibility and its risks is often raised, since it concerns primarily lesional epilepsy and a lesionectomy might be proposed right away. However, this attitude does not take into account the specificities of epilepsy at this age, including poor specificity of electroclinical semiology and the ongoing myelination challenging the interpretation of magnetic resonance imaging (MRI).MethodsWe retrospectively studied the records of children with drug-resistant epilepsy who were younger than 3 years of age at the time of their invasive exploration at our institution from 2000 to 2009. We reviewed the clinical, imaging and electrophysiological data, and included post-operative outcome for those who underwent surgery.Key findings26 Children met the inclusion criteria. All had drug-resistant epilepsy that started at an average of 5.2 months (range 0–20 months) with multiple daily seizures in all and developmental delay in 16. The average age at the time of exploration was 21.8 months (range 5–35). In 20 children, subdural electrodes in combination with two or three depth electrodes were implanted, and in six children aged over 2 years a stereo-electro-encephalography (SEEG) was performed. SEEG was considered technically difficult to achieve before the age of 2 years. The tolerance of invasive exploration was good with a 3% morbidity consisting of one subdural hematoma during exploration by subdural electrodes, evacuated without any particular sequelae. In 25 patients, the exploration permitted to propose a focal resection. The surgical intervention was in the frontal lobe in 12 cases, the parietal lobe in six, the occipital lobe in two patients, and the temporal lobe in one child who underwent an additional resection. Four children had a resection of two or three lobes. Five underwent a second surgery, following a second invasive exploration. Histologically, the resected tissue revealed focal cortical dysplasia in 21 cases (including three patients with tuberous sclerosis), two post-ischemic lesions, one dysembryoplastic neuroepithelial tumor, and one gangliglioma associated with dysplasia. The mean postoperative follow-up period was 51 months (range 4–110). For the children operated on twice, follow-up was counted from the second surgery on. Seventeen children (68%) had an outcome of Engel class 1. In five (20%), seizure frequency was significantly improved (Engel class 3). In two of three patients without improvement in seizure frequency (Engel class 4), a new SEEG is planned and the third is presently a candidate for hemispherotomy.SignificanceInvasive exploration is feasible, well tolerated and carries a low morbidity in children under 3 years of age. At this age, it is indicated for drug-resistant lesional epilepsy associated with developmental delay. It permits delineating the lesion, which is not possible with MRI. The choice of the technique is in part age-dependent. The discussion of its indication arises in the same way as in the older child.