脑裂畸形继发难治性癫的微创外科治疗

目的探讨脑裂畸形继发难治性癫的致灶定位以及微创外科治疗方法。方法回顾性分析11例脑裂畸形继发难治性癫病人的临床资料,术前通过多模态神经影像和长程视频脑电图进行解剖与功能定位。在神经导航引导下使用皮质电极描记了解脑裂畸形病灶与癫波的关系,显微镜下将脑裂畸形的致灶切除。其中位于功能区的脑裂畸形,可使用功能MRI(fMRI)导航并辅以小功率皮质热灼。结果随访11例,时间12个月。术后癫发作完全消失9例,好转2例。结论多模态神经影像和长程视频脑电图可以对脑裂畸形继发的难治性癫进行致灶的解剖与功能定位,在保护脑功能的基础上将脑裂畸形的致灶切除是手术关键。     

难治性癫过度运动发作的临床特征与致灶定位

目的总结以过度运动发作为主要表现的药物难治性癫的诊疗经验。方法回顾性分析25例药物难治性癫病人的临床资料,均以过度运动发作为主要表现。根据症状特点、MRI、头皮视频脑电图及颅内脑电图监测,综合定位致灶,并行手术切除。结果切除额叶致灶23例,切除前颞叶致灶2例。神经病理学检查显示:皮质发育不良(FCD)Ⅰ型8例,FCDⅡ型12例,节细胞胶质瘤1例,皮质微发育不良1例,灰质异位1例,胶质瘢痕1例,海马硬化1例。术后随访12~60个月,按Engel分级:Ⅰ级19例,Ⅱ级2例,Ⅲ级2例,Ⅳ级2例。结论以过度运动发作为特点的难治性癫病人,其致灶主要位于额叶,但也可位于额叶外的脑区,准确切除致灶后疗效满意。     

皮质电刺激在功能区致灶手术中的应用

目的分析皮质电刺激在功能区致灶手术中的应用。方法回顾性分析8例功能区难治性癫病人的临床资料。根据视频脑电图及电刺激结果,确定致灶与功能区之间位置关系,术中保护功能区,最大程度切除致灶。结果手术顺利,术后2例左额叶软化灶病人术前肌力4级,术后无肌力下降;1例右枕叶皮质发育不良病人,术后视野部分缺损。随访6个月~3年,6例病人无癫发作,2例病人发作减少90%。Engel分级Ⅰ~Ⅱ级。结论皮质电刺激是定位大脑功能区的金标准,应用皮质电刺激治疗功能区癫可以在保留功能区的基础上最大程度切除致区,提高癫病人生活质量,更好地控制癫。     

脑磁图癫灶和皮层功能区定位在癫外科的应用

目的 探讨脑磁图在癫外科术前评估中的应用价值。方法 回顾性分析216例手术治疗顽固性癫病例,术前应用脑磁图辅助定位皮层癫灶及重要皮质功能区范围,其中18例将脑磁图与神经导航系统结合。结果 本组216例患者,按照Engel癫疗效分级,Ⅰ级71.75%,Ⅱ级10.19%,Ⅲ级8.80%,Ⅳ级9.26%。脑磁图癫灶定位与术中皮质脑电图定位符合率87.9%。无一例出现手术后永久神经功能障碍。结论 脑磁图是无创确定癫灶和功能区皮质空间位置关系的重要工具,脑磁图结合神经导航术前和术中的皮质功能区定位方法应用可使癫外科实现微侵袭和精确手术。     

中央区癫的外科治疗策略

目的探讨累及中央区癫的外科治疗方法。方法回顾性分析21例中央区癫病人的临床资料。术前行常规评估检查及神经功能评分。根据情况分别采用立体脑电描记(SEEG)、唤醒麻醉、神经导航、术中电生理监测、皮质直接电刺激等技术定位致灶及功能区,然后完成致灶切除。结果肿瘤继发癫18例:肿瘤+致灶全切12例,肿瘤全切+致灶热灼3例,仅切除肿瘤1例,肿瘤不完全切除+致灶热灼2例。局灶性皮质发育不良病例3例,SEEG定位后手术切除致灶。术后3个月,6例出现短暂神经功能障碍,2例永久性障碍。术后随访6~44个月,Engel分级:Ⅰ级15例,Ⅱ级3例,Ⅲ级2例,Ⅳ级1例。结论多技术联合运用于中央区癫手术,可提高致灶切除率和降低病残率,癫控制效果良好。     

SEEG及多技术联合评估在1例运动区致灶切除术中的应用

目的探讨多种技术联合评估在运动区致灶切除术中的应用。方法回顾性分析1例疑为运动区致灶病人的临床资料,术前f MRI-bold、Wada试验和SEEG功能区测定均显示运动区向对侧转移,SEEG脑电图显示病侧运动区起源的致灶,手术将病侧致区及运动区一并切除。结果术后运动功能无损害。随访15个月,癫无发作。结论对于运动功能已经转移的运动区起源的癫,可考虑手术将解剖上的运动皮质及致灶一并切除,以达到治愈癫的目的。     

功能神经导航和术中磁共振引导下精确切除毗邻大脑运动功能区的致(癎)病变

目的 评估功能神经导航和术中MRI引导对毗邻运动功能区致(癎)病变切除术的效果.方法 回顾性分析接受神经导航引导手术的14例癫(癎)病人,其中10例采用术中MRI.术前MRI扫描,融合影像,设计病变切除范围及入路,三维计划输入导航系统并投射至手术显微镜辅助手术.术中复查MRI,对残余病变重新定位,实施手术切除.术后定期进行随访.结果 病人均成功实施了功能神经导航,致(癎)病变、运动区皮质和锥体束投射在手术显微镜下,精确切除病变,同时运动区皮质和锥体束获得有效保护;术中MRI末次扫描提示致(癎)灶病变的切除范围达到术前计划.术后随访6～24个月,癫(癎)发作控制达Engel Ⅰ级12例,Engel Ⅱ级2例.未出现肢体肌力下降.结论 对于毗邻运动功能区的致(癎)病变,通过功能神经导航和术中MRI精准定位病灶和功能区,可以达到精准切除病变并保护正常脑功能的目的.     

局灶性皮质发育不良所致难治性癫痫的微创神经外科治疗

目的应用神经导航结合术中皮质电极描记,微创治疗局灶性皮质发育不良(focal cortical dysplasia,FCD)所致的难治性癫痫。方法 26例局灶性皮质发育不良所致的难治性癫痫患者,术前常规使用CT、磁共振成像(magnetic resonanceimaging,MRI)、长程视频脑电图(digital video signal and electroencephalogram,VEEG)、磁共振波谱分析(MR Spectroscopy,MRS)等检查,如病灶位于功能区则行功能性磁共振成像(functional magnetic resonance imaging,fMRI)。术中通过神经导航确定的病灶与ECoG确定的致痫灶位置及范围进行对比,了解两者的吻合程度及差异,综合分析后精确并标记出癫痫波的起源位置和范围,将局灶性皮质发育不良病灶和周边的致痫皮质切除;如致痫灶位于功能区或附近,在保留功能区皮质的基础上,给予低功率皮质热灼。结果术后病理结果:26例患者病理标本符合FCD。术后患者无明显并发症出现。根据Engel术后效果分级进行评估,Ⅰ级23例,Ⅱ级2例,Ⅲ级1例。结论神经导航结合术中皮质电极描记在局灶性皮质发育不良所致的难治性癫痫手术中,具有定位准确、损伤少的优点,在切除致痫灶的同时能最大程度保护脑功能。     

致灶切除治疗无病灶中央区癫

目的总结致灶切除术治疗无病灶中央区癫的诊治经验。方法回顾性分析11例无病灶中央区癫病人的临床资料,所有病人均放置颅内电极,采用皮质脑电图监测定位癫发作起源区,皮质电刺激定位功能区,采用术中唤醒行致灶切除术。结果随访11例,时间17~32个月,按照Engel分级:Ⅰ级3例,Ⅱ级3例,Ⅲ级2例,Ⅳ级3例。术后出现肢体功能障碍3例,其中2例分别于术后2周及3个月恢复;残留手指活动不灵1例。结论在颅内电极精确定位功能区及致灶的前提下,采用致灶切除术治疗无病灶中央区癫,可获得满意疗效。     

中央区纵裂癫的诊疗探讨

目的探讨中央区纵裂癫的诊治经验。方法回顾性分析6例癫病人的临床资料,术前均进行评估,包括临床表现、MRI、视频脑电图(VEEG)、加密电极、埋藏电极和(或)皮质脑电图(ECoG)、脑磁图(MEG)检查,确诊为中央区纵裂癫。通过皮质电刺激、立体定向引导、术中唤醒等方法,明确致灶、功能区的范围及相互位置关系,在皮质脑电图监测下行显微手术切除致灶。结果病变手术全切除3例,大部分切除3例。术后均无出血、感染等并发症出现,无麻醉意外发生。术后病理结果为:胶质增生1例,局灶性皮质发育不良Ⅱa1例、Ⅱb2例,脂肪瘤1例,海绵状血管瘤1例。随访6例,时间13～23个月,根据Engel分级:Ⅰ级5例,Ⅱ级1例。结论中央区纵裂癫表现特异,确诊后在精确定位致灶、功能区情况下,选择手术治疗,效果理想。     

磁共振阴性的局灶性脑皮质发育不良的手术治疗

目的探讨磁共振难以确定病灶的致痫性局灶性脑皮质发育不良的诊断和定位方法,提高手术治疗效果。方法回顾性分析联合应用视频脑电图(VEEG)、脑磁图(MEG)及术中皮层电极脑电图监测(ECo G)检查,诊断、定位并经手术后病理证实为局灶性皮质发育不良(FCD)的24例磁共振检查阴性的难治性癫痫患者的临床资料。结果 24例癫痫患者行手术治疗,病理FCDⅠa型5例,FCDⅠb型3例,FCDⅠc型5例,FCDⅡa型6例,FCDⅡb型5例。术后随访1~5年,EngelⅠ级9例,EngelⅡ级5例,EngelⅢ级8例,EngelⅣ级2例。结论联合应用VEEG、MEG和(或)ECo G技术有助于准确诊断和定位磁共振阴性的FCD,提高FCD致难治性癫痫的手术疗效。     

Intraoperative ultrasound to define focal cortical dysplasia in epilepsy surgery

Focal cortical dyplasia (FCD) is a frequent cause of medication-resistant focal epilepsy. Patients with FCD may benefit from epilepsy surgery. However, it is difficult to intraoperatively define lesion boundaries. In this case report we present a novel tool to identify FCD intraoperatively. A patient with frontal lobe epilepsy underwent resection of a left frontomesial FCD. Image guidance was achieved by intraoperative ultrasound, which depicted the lesion with a higher resolution than preoperative MRI. Postoperatively the patient remained seizure free. Intraoperative ultrasound may be helpful in identifying and targeting subtle epileptogenic lesions, which are difficult to visualize.     

Focal cortical dysplasia type IIb: completeness of cortical, not subcortical, resection is necessary for seizure freedom

Purpose: Focal cortical dysplasia type IIb (FCD IIb) lesions are highly epileptogenic and frequently cause pharmacoresistant epilepsy. Complete surgical resection leads to seizure freedom in most cases. However, the term “complete” resection is controversial with regard to the necessity of performing resections of the subcortical zone, which is frequently seen in these lesions on magnetic resonance imaging (MRI). Methods: We retrospectively analyzed 50 epilepsy patients with histologically proven FCD IIb. The extent of surgical resection was determined by SPM5‐based coregistration of the preoperative and postoperative MRI scans. Postoperative outcome was analyzed with regard to (1) the completeness of the resection of the cortical abnormality and (2) the completeness of the resection of the subcortical abnormality. Key Findings: Complete resection of the cortical abnormality led to postoperative seizure freedom (Engel class Ia) in 34 of 37 patients (92%), whereas incomplete cortical resection achieved this in only one of 13 patients (8%, p < 0.001). Among the patients with complete cortical resection, 36 had FCDs with a subcortical hyperintensity according to MRI. In this group, complete resection of the subcortical abnormality did not result in a better postoperative outcome than incomplete resection (90% vs. 93% for Engel class Ia, n.s.). Significance: Complete resection of the MRI‐documented cortical abnormality in FCD IIb is crucial for a favorable postoperative outcome. However, resection of the subcortical hyperintense zone is not essential for seizure freedom. Therefore, sparing of the subcortical white matter may reduce the surgical risk of encroaching on relevant fiber tracts. In addition, these findings give an interesting insight into the epileptogenic propensity of different parts of these lesions.     

功能磁共振导航辅助锁孔手术治疗脑皮质运动区占位性病变（附10例分析）

目的探讨功能磁共振导航（蹦砌）辅助锁孔手术治疗脑皮质运动区占位性病变的临床价值。方法回顾性分析10例涉及脑皮质运动区占位性病变的手术情况。术前均行fMRI扫描,将图像输入史赛克导航系统后指导锁孔手术入路的设计;术中根据运动激活区与病变的关系,实时利用导航引导手术切除病变。结果病变全切除8例（80％）,次全切除1例,部分切除1例。术后出现一过性肌力障碍加重4例,其他病人肌力水平同术前。术后3个月随访,肌力水平较术前均无恶化,且其中2例较术前改善。结论fMRI导航辅助锁孔手术治疗皮质运动区占位性病变,在最大程度切除病变的同时能有效保护神经功能。从而提高手术安全性,减少手术并发症．改善病人术后的生活质量。     

Epilepsy with dual pathology: Surgical treatment of cortical dysplasia accompanied by hippocampal sclerosis

Purpose: The presence of two or more epileptogenic pathologies in patients with epilepsy is often observed, and the coexistence of focal cortical dysplasia (FCD) with hippocampal sclerosis (HS) is one of the most frequent clinical presentations. Although surgical resection has been an important treatment for patients with refractory epilepsy associated with FCD, there are few studies on the surgical treatment of FCD accompanied by HS, and treatment by resection of both neocortical dysplastic tissue and hippocampus is still controversial. Methods: We retrospectively recruited epilepsy patients who had undergone surgical treatment for refractory epilepsy with the pathologic diagnosis of FCD and the radiologic evidence of HS. We evaluated the prognostic roles of clinical factors, various diagnostic modalities, surgical procedures, and the severity of pathology. Results: A total of 40 patients were included, and only 35.0% of patients became seizure free. Complete resection of the epileptogenic area (p = 0.02), and the presence of dysmorphic neurons or balloon cells on histopathology (p = 0.01) were associated with favorable surgical outcomes. Patients who underwent hippocampal resection were more likely to have a favorable surgical outcome (p = 0.02). Conclusions: We show that patients with complete resection of epileptogenic area, the presence of dysmorphic neurons or balloon cells on histopathology, or resection of hippocampus have a higher chance of a favorable surgical outcome. We believe that this observation is useful in planning of surgical procedures and predicting the prognoses of individual patients with FCD patients accompanied by HS.     

中央区癫痫的唤醒手术及疗效观察

目的 探讨唤醒下手术治疗中央区癫痫的临床效果.方法 回顾性分析我科手术治疗的548例癫痫患者的临床资料,12例符合本研究标准.综合评估后在相应部位埋置颅内电极,经颅内电极脑电图（Intraeranial-EEG i-EEG）确定癫痫起始区（epileptic onset zone,EOZ）、皮层电刺激（cortical electro-stimulation,CES）描记脑功能区后,在麻醉唤醒状态下切除EOZ区及周围异常组织,以更好的保留脑功能.对切除组织进行病理学研究.结果 EOZ位于中央前-后回者3例（左侧1例、右侧2例）、中央前回者6例（左侧2例、右侧4例）、中央后回者3例（左侧1例、右侧2例）.病理学证实：皮质发育不良7例（ⅡA型3例、ⅡB型2例、灰质异位2例）、脑囊虫2例、脑软化灶（胶质增生）2例、海绵状血管瘤1例.随访2～5年,均系统服用抗癫痫药物（2例遵医嘱停服）,癫痫发作完全消失（Engel-Ⅰ级）7例、有发作先兆且偶有发作（Engel-Ⅱ级）3例、发作次数减少（Engel-Ⅲ级）2例.手术后早期出现运动-浅感觉功能障碍者2例、单纯运动功能下降者5例、出现深-浅感觉功能减退者1例.经半年的功能康复训练,6例患者运动功能恢复、感觉功能部分恢复,2例患者仍轻偏瘫,但肢体远端精细功能部分恢复.结论 EOZ位于中央区也可行切除性手术,术中唤醒能更好的保护脑功能.     

Prospective magnetic resonance imaging identification of focal cortical dysplasia,including the non—balloon cell subtype

The purpose of this study was to determine the role of high-resolution T2-weighted fast multiplanar inversion-recovery (FMPIR) magnetic resonance (MR) imaging in detecting and delineating microscopic focal cortical dysplasia (FCD). We performed MR scans with FMPIR on 42 patients with suspected neocortical epilepsy. Ten MR studies were read prospectively as showing FCD; these case histories, electroencephalographic studies, and neuroimaging data were reviewed. Eight of these patients subsequently underwent focal cortical resection guided by intraoperative electrocorticography. The MR findings were correlated with pathological findings in these 8 patients. For purposes of radiological-pathological correlation, the FCD lesions were divided into two classes. Radiological classification was based on the absence (type A) or presence (type B) of T2 prolongation of the subcortical white matter. Pathological grading as type I or type II was based on a previously described pathological grading system. Specific MR findings associated with FCD included focal blurring of the gray-white matter interface (n = 9), thickening of the cortical ribbon (n = 7), and T2 prolongation of the subcortical white matter (n = 4). In 3 patients, the only MR finding that suggested FCD was localized blurring of the gray-white matter junction. In 2 of these 3 patients, the MR diagnosis of FCD could be made only by FMPIR. FCD was confirmed histologically in 7 of 8 patients, with insufficient tissue for complete histopathological evaluation in 1 case. Radiological classification of FCD agreed with pathological classification in 5 of 7 cases. Correlation of MR findings with intraoperative electrocorticography results indicated that the MR study localized the epileptogenic lesion correctly in 8 of 8 cases. Scalp ictal electroencephalographic studies localized the epileptogenic lesion in 5 of 8 cases; positron emission tomographic scans were focally abnormal in 3 of 3 cases. FMPIR MR imaging permitted accurate diagnosis and localization of FCD in all patients with pathologically proved FCD. MR identification of FCD aided presurgical planning and intraoperative management of these patients.     

Association between equivalent current dipole source localization and focal cortical dysplasia in epilepsy patients

We analysed the association between focal cortical dysplasia (FCD) visible in MRI and the location of equivalent current dipole (ECD) of single interictal scalp EEG spikes (IIS) in 11 epilepsy patients. We calculated several indicators of distance of ECDs to the FCD border. The results confirm some previous studies suggesting that the epileptogenic zone associated to the location of ECDs extends beyond the FCD visible in MRI. The analysis suggests the ECDs to be in a shell parallel to part of the FCD surface.