联合应用皮质(癎)灶热灼术治疗继发性癫(癎)

目的分析总结继发性药物难治性癫癎的临床特点,讨论如何改进手术方法．将几种手术结合使用并对手术效果进行评价。方法回顾性分析4年来经显微手术治疗的16例继发性药物难治性癫癎病例．这16例术前均行VEEG监测及MRI检查,其中5例行头PET检查。手术在皮层脑电监测下进行,2例行单纯病灶切除术．13例行病灶切除＋灶旁皮层热灼术,1例行病灶切除一灶旁皮层热灼术十胼胝体切开术。结果所有病人随访6个月至4年．术后抗癫癎药减少．12例服用1种抗癫癎药,2例服用2种抗癫藕药。癫癎发作完全控制11例．显著改善3例。无变化2例．无明显并发症．无死亡。结论病灶切除＋灶旁皮层热灼术联合应用不但提高了控制癎性发作的疗效．还尽可能多地保护神经组织免遭切除或损害,这是治疗继发性药物难治性癫癎较合理和有效的方法。     

胼胝体切开治疗药物难治性癫痫105例分析

目的 探讨胼胝体切开术治疗药物难治性癫痫的适应证、手术方法、有效性及安全性.方法 1999年1月至2010年8月单纯采用胼胝体切开术治疗105例药物难治性癫痫患者,发作类型以容易致残的全身性强直一阵挛发作(48例)、全身性强直发作(32例)或失张力发作(25例)为主.其中58例行胼胝体前2/3切开,47例行前3/4切开.结果 术后随访13～150个月,所有患者术后继续正规服用抗癫痫药物,13例(12.4%)患者术后发作消失,59例(56.2%)发作频率减少大于75%,22例(21.0%)发作频率减少50%～75%,9例(8.6%)无明显改善,2例(1.9%)加重.围手术期没有死亡病例,手术并发症较轻,且多为一过性.结论 对于无法行致痫灶切除术的药物难治性癫痫患者,胼胝体切开术能有效减少癫痫全身性发作的频率和严重程度.     

Ⅰ期全胼胝体切开术治疗成人难治性癫痫的疗效分析

目的探讨Ⅰ期胼胝体全段切开治疗成人难治性癫痫的疗效及手术安全性。方法回顾性分析空军军医大学唐都医院癫痫中心2011年1月-2016年7月期间行胼胝体全段切开术的56例成人难治性癫痫患者临床资料,术后随访1~5年,结果14例(25.0%)患者达到术后完全无发作,19例(33.9%)发作减少90%以上,10例(17.9%)发作减少50%~90%,7例(12.5%)发作减少30%~50%,6例(10.7%)减少30%以下;其中47例(83.9%)患者跌倒发作消失。术后13例(23.2%)出现程度轻重不等的并发症,大多恢复良好;5例(8.9%)出现长期遗留感觉性失联合,无严重并发症及死亡病例。手术后患者生活质量改善率67.9%结论对于无法行局灶性切除的成人难治性癫痫患者,行Ⅰ期全胼胝体切开术对减少发作频率,消除跌倒发作,改善患者生活质量具有一定作用。     

胼胝体全段切开术治疗药物难治性癫■

目的研究胼胝体全段切开术治疗药物难治性癫■的安全性和有效性,并探讨其在二期切除性手术的作用。方法回顾性分析40例药物难治性癫■病例资料,发作类型:强直发作31例,跌倒发作14例,痉挛发作5例,强直-阵挛发作3例和肌阵挛发作3例。经术前评估后行胼胝体全段切开术,术后定期随访癫■控制情况,癫■控制疗效不佳者再行二期手术评估。结果术后随访1～3年,癫■控制达到EngelⅠ级10例,Ⅱ级11例,Ⅲ级12例,Ⅳ级7例,手术总有效率达82.5%;结果显示:跌倒发作和强直发作减少明显。术后并发症:急性失连接综合征4例,硬膜下积液3例,硬膜下积血1例,经相应处理后恢复正常。术后韦氏智力与记忆力较术前改善(均P 0.05)。术后间歇期脑电图(electroencephalogram,EEG)转化为一侧癫■样放电为主29例(72.5%),癫■发作能定侧13例(32.5%)。6例病人经再次评估后行二期致■灶切除术,二期手术后癫■无发作。结论胼胝体全段切开术是一种治疗药物难治性癫■安全有效的方法,同时还可改善病人神经认知功能,且有助于二期致■灶切除术的术前评估定位,但需要严格把握适应证。     

应用多种手术方式治疗顽固性癫(癎)的临床研究

目的针对不同类型的顽固性癫癎病人,评估单独应用癫癎病灶切除术与联合应用多种手术方式治疗癫癎临床效果。方法手术治疗顽固性癫癎病人80例,其中53例采用几种术式结合的方法;每个病人术前均经过2年以上的正规系统的抗癫癎药物治疗,仍不能控制癫癎发作,每月发作3~4次以上;癫癎发作形式为单纯部分性发作,复杂部分性发作,强直-阵挛性发作以及伴失神发作;采用的手术方式:术中均进行皮层脑电描记(EcoG);局部致癎灶切除术27例,局部致癎灶切除术 多处软膜下横纤维切断术(MST)11例,局部致癎癎灶切除术 MST 皮层热灼术9例,局部致癎灶切除术 胼胝体前部切开术 颞前叶及海马切除术 MST33例。结果80例手术病人术后无死亡,术后2例脑水肿,1例颅内出血,1例肾功能衰竭;术后均服用一种抗癫癎药物,随访6~24个月,51例癫癎临床发作完全消失(63.8%),12例较术前显著改善(15.0%),8例有效(10.0%),6例效果差(7.5%),3例无效(3.8%);手术总有效率为88.8%,优良率为78.8%。结论应用多种手术方式治疗顽固性癫癎有满意疗效。     

顽固性癫癎的外科联合手术治疗

目的探讨联合手术治疗顽固性癫癎的方法和临床疗效。方法对45例顽固性癫癎患者行联合手术治疗。手术方式:多处软脑膜下横切术(multiplesubpialtransection,MST)+致癎病灶切除+胼胝体前部切开术3例;MST+胼胝体前部切开术11例;MST+致癎病灶切除19例;MST+立体定向杏仁核海马毁损术12例。术中进行皮层电极及深部电极监测。结果术中进行皮层电极检测定位更精确。患者术后随访3-28个月,发作完全控制17例(37.78%),显著改善24例(53.33%),良好2例(4.44%),效差2例(4.44%),术后神经功能均保存完好。结论联合手术治疗顽固性癫癎是一种安全有效的方法。     

涉及中央区难治性癫(癎)的外科治疗

目的 探讨涉及中央区难治性癫(癎)的手术治疗.方法 3例患者术前除常规致癫(癎)灶评估外,还应用fMRI作皮质功能区定位.术中通过皮层EEG(ECoG)对致癫(癎)灶定位,通过皮层诱发电位(SEP)及皮质电刺激定位脑功能区,对位于功能区以外的致疒间灶行切除性手术,功能区内的致疒间灶行软脑膜下横行纤维切断术.结果 术后无神经功能障碍,术后3月,2例病人无癫(癎)发作,1例偶有部分性发作;术后8月,1例无发作,1例偶有部分性发作,1例减少75%发作. 结论术前功能区评估、术中电生理监测有助于保护皮质重要功能和提高手术癫(癎)控制率.     

胼胝体切开术治疗药物难治性全身性癫痫

目的评估胼胝体切开术对药物难治性全身性癫痫的有效性及安全性。方法 62例药物难治性全身性癫痫患者均行胼胝体切开术,其中46例患者行单纯胼胝体前部切开术,16例患者行胼胝体前部切开联合致痫灶切除术。结果平均随访5.4年,62例患者发作频率平均减少57.9%(P<0.01),其中9例发作停止,29例发作频率减少>50%,11例发作频率减少<50%,13例发作无变化或加重。46例行单纯胼胝体前部切开术的患者,术后癫痫发作频率平均减少53.5%(P<0.01);16例行胼胝体前部切开联合致痫灶切除术患者,术后癫痫发作频率平均减少62.0%(P<0.05),两者相较差异不显著(P>0.05)。预后按改良Engel分级,62例患者中,EngelⅠ级9例(14.5%),Ⅱ级12例(19.3%),Ⅲ级17例(27.4%),Ⅳ级24例(38.7%)。20例(32.2%)出现短期并发症,1例(1.6%)出现长期并发症。结论胼胝体切开术是一种治疗药物难治性全身性癫痫相对安全、有效的外科方法。胼胝体前部切开联合致痫灶切除术的疗效与单纯胼胝体前部切开术相近。     

岛周大脑半球离断术治疗儿童难治性癫癎

目的探讨岛周大脑半球离断术对儿童难治性癫癎的疗效。方法回顾性分析4例难治性癫癎病儿的临床资料,经过详细评估,均行岛周大脑半球离断术。结果手术过程顺利。病理结果提示:脑外伤后改变2例,Rasmussen脑炎1例,偏身惊厥-偏瘫-癫癎综合征1例。术后随访7～24个月,平均14.2个月,4例病人术后均无癫癎发作,达到Engle Ia级,生活质量改善明显。结论岛周大脑半球离断术对儿童一侧大脑半球病变引起的难治性癫癎疗效确切,手术并发症较少,对改善病儿生活质量有积极作用。     

迷走神经刺激术治疗药物难治性癫癎

目的研究迷走神经刺激术(VNS)对药物难治性癫癎的有效性和安全性。方法回顾性分析30例药物难治性癫癎病人的临床资料,给予术前评估后实施VNS,通过收集术后定期程控和随访结果,分析术后疗效和并发症。结果 VNS术后随访5～48个月,癫癎发作频率减少50%15例,无发作3例;其中术后发作频率达McHughⅠA级6例,ⅠB级1例,ⅡA级4例,ⅡB级4例,ⅢA级2例,ⅢB级7例,Ⅳ级2例,Ⅴ级4例。术后病人的韦氏智力商数均较术前提高(P0.05)。术后出现声音嘶哑3例,2～3周后自然恢复;皮肤破溃感染1例,取出刺激器。结论 VNS是一种安全、有效的辅助治疗药物难治性癫癎的方法,并能一定程度上改善病人神经认知功能和生活质量,但与术后程控密切相关。     

Outcome following corpus callosotomy

Although corpus callosotomy has been performed since 1940 to treat severe medically intractable seizures, there remains controversy as to when, or even if, the surgery should be done. Unlike most surgical therapies for epilepsy where the epileptic focus is removed, corpus callosotomy interrupts the propagation of epileptic discharges. The procedure is primarily used in patients with secondarily generalized seizures with or without drop attacks in whom focal resection is not possible. The goal of this surgery is to improve functioning and well-being. In this study, we retrospectively reviewed records from 28 patients undergoing corpus callosotomy to assess improvement following surgery. Parents and patients were also sent a questionnaire to assess quality of life. While surgery reduced the frequency of seizures, definite improvements in quality of life were limited only to patients with frequent daily drop attacks preoperatively. We believe corpus callosotomy offers a significant improvement of both seizure control and quality of life in children with frequent drop attacks of tonic, myoclonic, or atonic origin.     

Corpus callosotomy

Corpus callosotomy is a palliative surgical procedure that is suitable for some patients with intractable seizures who are not candidates for focal resective surgery. The rationale for this procedure is based on the hypothesis that the corpus callosum is a critical pathway for interhemispheric spread of epileptic activity. Efficacy and relatively low permanent morbidity in corpus callosotomy for medically intractable epilepsy have been demonstrated by more than six decades of experience. Callosotomy best ameliorates drop attacks (tonic and atonic seizures), though tonic-clonic, absence, and frontal lobe complex partial seizures often respond as well. In addition to seizure reduction, behavior and quality of life may improve. Hence, callosotomy is justified as a therapy for appropriate patients with intractable epilepsy.     

Treatment of seizures in subcortical laminar heterotopia with corpus callosotomy and lamotrigine.

Focal and generalized cortical dysgeneses are sometimes seen on the magnetic resonance images (MRI) of patients with epilepsy. Subcortical laminar heterotopia are bilateral collections of gray matter in the centrum semiovale that resemble a band or "double cortex" on MRI. We studied one male and two female patients with subcortical laminar heterotopia who had moderate to severe developmental delay, early-onset epilepsy, and medically refractory seizures. Atonic, atypical absence, tonic, myoclonic, complex partial, and generalized tonic-clonic seizures were recorded. Interictal and ictal electroencephalographic patterns were generalized and, less commonly, multifocal. Two years after corpus callosotomy, one patient was free of generalized tonic-clonic and atonic seizures, but the other patient who had undergone callosotomy had no significant reduction in seizure frequency. With lamotrigine treatment, the patient who had not had surgery had complete cessation of monthly episodes of status epilepticus and a dramatic reduction of generalized tonic-clonic seizures, and the other patient who received lamotrigine had a 50% reduction of her atonic seizures. In patients with subcortical laminar heterotopia, atonic and generalized tonic-clonic seizures can be substantially reduced or eliminated by corpus callosotomy or treatment with lamotrigine.     

Corpus callosotomy for intractable seizures in the pediatric age group

The results of corpus callosotomy in 18 patients 16 years old and younger are presented. Eighty-three percent of our patients have had a significant improvement from the surgery (a decrease in seizure frequency of greater than 80% or no longer having generalized atonic, tonic, or tonic-clonic seizures). The procedure seems to be well tolerated in young patients, and we have not noted a postoperative deterioration in behavior, memory, or language function in our patients. One of our patients died in status epilepticus 3 months after surgery. Nevertheless, we have not encountered any serious morbidity in our other patients. Corpus callosotomy can be considered for children with intractable seizures, especially when generalized atonic, tonic, or tonic-clonic (whether primary or secondary) seizures are the major seizure type.     

Seizure outcome after corpus callosotomy: the Taiwan experience

From September 1989 to August 1996, we performed anterior corpus callosotomy in 83 patients. Unfortunately, 9 patients were lost to follow-up. Among the remaining 74 patients, 59 had Lennox-Gastaut syndrome (evolved from infantile spasms in 22), 9 had complex partial seizures with or without secondary generalized seizures, 1 had multifocal independent epileptogenic foci (MISF) syndrome, 3 had hemiconvulsion-hemiplegia-epilepsy (HHE), and 2 had infantile spasms. All cases were followed up for at least 2 years after surgery. The highest rate of significant improvement (more than 50% reduction in seizure frequency) was noted in the patients with generalized tonic-clonic seizures, 82.1% of whom experienced significant improvement, followed by those with generalized tonic seizures (76.7%), atonic seizures (72.7%), myoclonic seizures (64.9%), atypical absences (58.6%), and complex partial seizure with or without secondary generalization (61.5%). Complete freedom from seizures was noted in 14 cases (18.9%). One patient had the anterior half of his right palm amputated following radial artery thrombosis complicated by insertion of an arterial line during anesthesia. Otherwise, there were no major postoperative complications except for brief mutism and multifocal jerks in some patients during the 1st postoperative week. Thus, we conclude that corpus callosotomy is a safe alternative treatment for all kinds of medically intractable seizures, especially generalized epilepsy. Received: 23 June 1999     

Refractory generalized seizures: response to corpus callosotomy and vagal nerve stimulation

PURPOSE: The vagal nerve stimulator (VNS) and corpus callosotomy can reduce seizure frequency when seizures are refractory to medications. However, the efficacy and safety of these two procedures have not been compared. This study evaluates the two procedures for generalized seizures. METHODS: All patients with refractory generalized seizures (generalized tonic-clonic, tonic, or atonic) who underwent a corpus callosotomy (anterior or complete) (n = 53) without other forms of epilepsy surgery and those who underwent VNS placement (n = 25) were evaluated for this study. Seizure response and procedure complications were evaluated. RESULTS: For those with a corpus callosotomy and generalized tonic-clonic seizures (n = 50), 79.5% had >or=50% decrease in the frequency of generalized tonic-clonic seizures, and 60% had >or=80% seizure reduction. For those with a VNS and generalized tonic-clonic seizures (n = 21), 50% had >or=50% seizure reduction, and 33% had >or=80% seizure reduction. Tonic and atonic seizures decreased after either VNS or a corpus callosotomy. The complication rate for corpus callosotomy was higher (21% all complications, 3.8% permanent) than that for VNS (8%; none permanent), but complications for both corpus callosotomy and VNS were rarely permanent. CONCLUSIONS: Both corpus callosotomy and VNS are effective in reducing generalized seizures. Corpus callosotomy is associated with greater efficacy but higher risk for complications, although these were generally transient.     

Outcome and long term follow-up after corpus callosotomy in childhood onset intractable epilepsy

Introduction Epilepsy surgery is a standard of care in the treatment of medically intractable epilepsy. Twenty five percent of patients with intractable epilepsy in childhood can be candidates for epilepsy surgery. Corpus callosotomy is a surgical treatment option for patients with potentially injurious drop attacks and disabling generalized seizures. Postoperative improvement of cognition and speech are important gains after epilepsy surgery particularly during childhood. The aim of this study is to evaluate the outcome of corpus callosotomy for the treatment of childhood onset medically intractable epilepsy in a developing pediatric epilepsy surgery center.Method We report 16 patients who underwent two thirds anterior corpus callosotomy for treatment of refractory seizures in childhood.Results All patients had drop attacks or multiple types of seizures, yet some showed focal onset with secondary generalization on electroencephalogram (EEG). One patient was seizure free (class 1 outcome), five had class 2A outcome, five had class 2B outcome, and five had class 3 outcome. Overall 11/16 (69%) of our patients improved significantly after anterior callosotomy.Conclusion Corpus callosotomy remains to be a fairly good choice of surgical treatment for childhood onset medically intractable epilepsy in selected patients.     

Corpus callosotomy for the treatment of intractable epilepsy in children

We report the results of anterior two-thirds corpus callosotomies in 20 children undergoing the procedure for intractable seizures. All children recovered from the callosotomy without significant neurological sequelae. Excellent results with regard to seizure frequency were found in 8 of 20 (40%) patients. Following surgery, generalized tonic-clonic seizures, tonic seizures, and atonic seizures were reduced from their preoperative frequency. Although all patients in the postoperative period continued on antiepileptic drugs, there was a significant reduction in the number of drugs used. There was no statistically significant relationship between outcome and age of onset of the seizures, presence or absence of mental retardation, computerized tomography or magnetic resonance imaging findings, presence of hemiplegia, and preoperative EEG abnormalities. Although anterior two-thirds corpus callosotomy may be valuable in reducing seizure frequency in some children, it is currently not possible to predict accurately which children will benefit from the procedure.     

Response of Multiple Seizure Types to Corpus Callosum Section

Twenty-four patients (16 men, 8 women) underwent corpus callosum section specifically for improvement of control of atonic or tonic seizures that resulted in falls and injuries. All patients suffered from multiple seizure types, including complex partial (CP) and tonic-clonic (TC) seizures, in addition to the tonic or atonic episodes. Preoperative seizure frequency was quantified for all types for 1 year immediately before surgery and for the most recent year since the procedure; average monthly counts were obtained for each seizure type. The period of follow-up since surgery averaged 43 months (range, 23-79 months). Statistically significant improvements were documented, not only for the atonic/tonic seizures (p less than 0.0001) for all patients, but also for TC seizures (17 patients; p less than 0.001) and CP seizures (20 patients; p less than 0.02). Six patients experienced an exacerbation of CP seizures postoperatively, and three developed new simple partial (SP) seizures. In all of the CP group and all three of the SP group, ictal video and EEG features suggested that the new seizures were an aborted expression of the previously generalized seizures. From these data, we conclude that callosotomy is an effective treatment for tonic, atonic, and TC seizures intractable to anticonvulsant medications. Three patients became seizure free. The procedure may also be useful for certain specific subgroups of CP epilepsy, but further studies are required before expanding callosotomy to intractable CP seizures not amenable to focal resection.