癫痫诊疗中应用头皮脑电图偶极子定位的体会

目的总结癫痫诊疗中应用头皮脑电图偶极子定位在术前、术中、术后的意义。方法回顾性分析29例行偶极子源成像定位癫痫灶、17例进行手术治疗,术中与皮层脑电图、深部电极记录对比,参考手术治疗效果。结果术后随访无癫痫发作或偶有先兆发作12例,发作形式改变（术前大发作变为小发作）和发作次数减少75％以上3例,发作次数减少不到50％1例,无变化1例,手术总有效率为94％。结论头皮EEG偶极子的术前定位方法无创、准确,可避免创伤性检查用于癫痫病人的术前定位。     

头皮脑电图偶极子定位在癫癎外科中的应用研究

目的研究头皮脑电图(EEG)偶极子定位方法在癫痫手术病人中的应用价值及其准确性。方法在84例难治性癫痫手术病人中，术前在发作间期头皮EEG上用偶极子定位方法定出痫源发放(epileptogenic discharges)位置，术中以ECoG(皮层脑电图)及深电极记录确定致痫区，对比偶极子定位的准确性，按EcoG定出的位置直接对致痫区进行手术处理，术后随访手术效果。结果在颞叶癫痫，偶极子定位与EcoG及深电极定位完全一致；在额、顶、枕叶癫痫，偶极子位置误差为10～15mm。随访6～24个月(平均13个月)，80例中71％的病人无癫痫发作，25％的病人发作减少75％以上，手术有效率96％。结论头皮EEG的偶极子定位方法无创、准确，相当于脑磁图，可避免创伤性检查用于癫痫病人的术前定位。     

难治性癫痫的偶极子定位手术治疗

目的：探讨利用偶极子三维颅内癫痫病灶定位系统对难治性癫痫病患者致痫灶定位，进行外科手术治疗的效果。方法：对1999年8月至2001年6月在我院实施的259例难治性癫痫患者运用偶极子三维颅内癫痫病灶定位系统对难治癫痫患者致痫灶进行术前精确定位，指导采用相应多种方式手术治疗，并探讨其疗效及随访结果。结果：随访6-22月者180例，疗效满意112例，显著改善（发作减少75%以上）36例，良好（发作减少50%以上）22例，疗效差10例。总有效率为94%。显效率82%，未发现任何远期功能损害。结论：偶极子三维颅内癫痫病灶定位系统是目前用于明确癫痫病灶定位较为先进的方法，准确指导手术，可明显提高手术效果，并减少并发症的产生。     

难治性癫痫的外科治疗 (附47例报道)

目的 研究难治性癫痫的致痫灶精确定位和外科治疗方法,以减少癫痫发作次数和程度,改善患者生存质量。方法综合运用影像学、脑电图、PET．CT、脑功能皮层定位检查和偶极子定位与磁共振融合等方法,对47例难治性癫痫患者进行癫痫灶定位和外科手术治疗,并进行手术前后心理状况评估。结果随访评估疗效满意32例(68．1％),显著改善7例(14．9％),良好5例(10．6％),较差2例(4．3％),无改善1例(2．1％)。除1例巨大AVM术后有偏瘫,1例有计算障碍以外,无其他神经系统并发症．无死亡病例。结论综合应用影像学、电生理、核素检查和计算机图像融合技术,可以对大多数癫痫病灶的起源进行精确定位诊断,使难治性癫痫的外科治疗获得满意疗效。     

难治性癫痫手术效果评判时限

目的 总结分析难治性癫痫手术效果，以及手术后效果趋于稳定的时限。方法 对120例难治性癫痫手术患者进行长期追踪随访，并依照Engel分级对患者术后效果进行分类；比较患者术后半年，1年和远期（1年半以上）随访疗效，观察术后达到EngelⅠ-Ⅱ疗效比例的变化。结果 120例难治性癫痫手术患者中，术后半年随访发现：61％术后无癫痫再发，18％术后仅有先兆发作，7％偶有痫性发作（半年中小于2次），痫性发作明显减少（痫性发作减少大于80％）为5％，手术效果不明显（痫性发作减少小于20％）占9％；术后1年随访发现：无癫痫再发为45％，术后仅有先兆为12％，术后偶有痫性发作为12％（1年中小于3次），痫性发作明显减少为13％，手术效果不明显为18％。最近的随访结果如下（随访1．5～3年，平均1．8年）：无癫痫再发占43％，仅有先兆占13％，术后偶有痫性发作占14％，痫性发作明显减少占13％，手术效果不明显占17％。半年期随访预后和1年期随访预后中达到EngelⅠ-Ⅱ的比例有明显差异（组间差异有统计学意义，P〈0．05），1年期随访预后与长期随访预后中达到EngelⅠ-Ⅱ的比例无明显差异（组间差异无统计学意义，P〉0．05）。结论 药物难治性癫痫术后半年期随访评判疗效不可靠，而1年期疗效预示术后长期效果。     

非侵袭性检查定位致痫灶在癫痫外科治疗中的作用

目的 评价非侵袭性检查方法定位致痫灶在癫痫外科治疗中的作用。方法 对30例难治性癫痫病人行EEG、MRI、PET检查,根据3项检查结果选择外科治疗方法（开颅手术,X－刀治疗,立体定向手术）。开颅手术,术中行皮层脑电图（ECoG)检查。结果 致痫灶位于颞叶22例,颞叶外6例,额颞区2例。方法 开颅手术16例,X－刀治疗10例,立体定向手术4例。术后除2例发作无明显改善外,28例病人发作均明显减少或消失。结论 大部分难治性癫痫病人,尤其是颞叶癫痫,开颅致痫灶切除、放射外科、立体定向手术可以根据EEG、MRI、PET检查来定位,避免术前侵袭性EEG（如植入深部电极等）检查的危险性。     

病灶切除与热灼联合术在难治性癫痫治疗中的应用

目的 研究病灶切除与热灼联合手术方法治疗继发性、难治性癫痫的临床效果。方法 对291例继发性、难治性癫痫患采取病灶切除与热灼联合手术的治疗方法，并随访观察此种联合手术方法对难治性癫痫的控制效果：结果 采用病灶切除与热灼联合手术后，291例患中，有211例(72．5％)发作消失，有50例(17．2％)发作减少50％以上，对癫痫总的有效控制率为89．7％，随访1．5～4．0年，平均23个月，211例发作消失的患中有83例(39．3％)已停服抗癫痫药；同时，病灶切除与热灼联合术无永久性的术后并发症：结论 病灶切除与热灼联合术治疗继发性、难治性癫痫，安全并且治疗效果令人满意。     

36例难治性癫痫手术治疗及术后影响因素

目的总结难治性癫痫的外科治疗经验,分析手术治疗的效果以及手术影响因素。方法术前运用CT、MRI和脑电图等检查对癫痫病灶进行精确定位,全麻下行开颅癫痫病灶切除和变性脑组织切除,并依据患者不同情况结合其他外科治疗方法。手术在显微镜下进行,采用皮层脑电图和深部脑电图监测。结果术后2周内有7例患者出现语言功能障碍,5例患侧肌张力下降,2周后均逐渐恢复。术后随访1～4a,36例治疗后满意3例（8．3％）,显著改善18例（50．0％）,良好11例（30．6％）,较差4例（11．1％）,没有无改善病例。结论应用外科手术方法治疗难治性癫痫,根据癫痫病灶部位的不同,应用不同的手术方式,可以收到良好的治疗效果。     

软膜下横切联合手术治疗难治性癫痫

目的观察软膜下横切术联合其它治疗癫痫手术方法,对难治性癫痫的治疗效果.方法对15例难治性癫痫采用软膜下横切联合手术进行临床观察、分析,判断其治疗效果.结果15例难治性癫痫病人采用联合手术方法,术后除2例病人有不同程度功能障碍及较轻癫痫发作外,其余病人均得到满意治疗效果.随访13例,失随访2例.满意8例(61.54%),显著改善4例(30.77%),良好1例(7.69%),总有效率100%.结论软膜下横切联合手术是难治性癫痫有效的外科治疗方法.     

国产迷走神经刺激器治疗药物难治性癫痫的疗效分析(附11例报告)

目的探讨国产迷走神经刺激器治疗药物难治性癫痫的疗效分析。方法对11例药物难治性癫痫患者进行国产迷走神经刺激手术治疗,术后2~4周开机,分次调试参数,脉冲发生器输出电流从0.2mA逐渐增加,刺激时间为30s,间歇5min,频率20~25Hz,脉宽250~500us。结果本组共计11例,随访1年,1例(9%)病人术后发作完全停止;3例(27%)病人术后发作频率减少75%;3例(27%)发作频率减少50%以上;3例(27%)发作频率减少25~50%;1例(9%)无改善;63.6%的难治性癫痫患者发作减少50%以上。结论迷走神经刺激是治疗药物难治性癫痫安全、有效的方法,治疗效果与刺激时间及参数调节有关。     

Multimodal approach in the surgical treatment of refractory epilepsy associated with tuberous sclerosis complex: a series of three cases

We describe the surgical treatment of tuberous sclerosis complex (TSC)-related refractory epilepsy in three patients. All three had multiple daily seizures, and each had more than three cortical tubers. High-resolution magnetic resonance imaging, ictal and interictal scalp electroencephalogram (EEG), positron emission tomography, magnetoencephalography as well as acute and intracranial video-EEG were used to identify the epileptogenic tubers. After localization, five cortical tubers (two in the right temporal lobe in patient 1; one each in the left frontal and temporal lobes in patient 2; and one in the right frontal lobe in patient 3) were resected. At minimum follow-up of 13 months (range, 13-35 months), patient 3 had seizure remission; patient 2 had only rare seizures; while patient 1 had 60% reduction in seizure frequency. Successful epilepsy surgery is possible in patients of TSC with multiple tubers using the multimodal approach.     

Comparison of short-term outcome between surgical and clinical treatment in temporal lobe epilepsy: a prospective study.

OBJECTIVE: To compare the efficacy of medical and surgical treatment for refractory mesial temporal lobe epilepsy associated with hippocampal sclerosis (MTLE). METHODS: A prospective controlled non-randomized study of 26 patients with MTLE who underwent surgical treatment and 75 patients with MTLE who underwent medical treatment between August 2002 and October 2004. All patients failed to achieve seizure control with at least two first line antiepileptic drugs (AED) for partial seizures before entering the study. We used Kaplan-Meier survival analyses as a function of time of seizure recurrence to obtain estimates of 95% confident interval of seizure freedom and log-rank test to compare the status of seizure control between the two groups. RESULTS: The cumulative proportion of patients free of all seizures (Engel's class IA) was higher in the surgical group (73%) compared to the clinical group (12%) (p<0.0001). In the surgical group, 2 of 26 patients (7.7%) had transient adverse effects and 2 of 26 patients (7.7%) had a permanent deficit related to the surgical procedure. In the clinical group 7 patients (9.3%) major adverse events during follow-up, including burns and status epilepticus. CONCLUSIONS: Surgical treatment for patients with MTLE who failed to achieve seizure control with two previous AED regimens was more efficient than medical treatment with further trials of AED.     

Seizure Frequency and Duration of Epilepsy are Not Risk Factors for Postoperative Seizure Outcome in Patients with Hippocampal Sclerosis

PURPOSE: Despite accurate localization of the seizure focus, not all patients are seizure free after temporal lobectomy. This study determined risk factors for seizure recurrence in patients with proven hippocampal sclerosis. METHODS: The outcome from surgery was assessed in 56 consecutive patients with proven hippocampal sclerosis. The age at surgery, duration of epilepsy, history and age of febrile seizures, age of onset of epilepsy, sex ratio, laterality of seizure focus, and seizure frequency were compared between patients seizure free and those not seizure free, and those seizure and aura free and those with seizure recurrence including auras. RESULTS: During a mean follow-up of 38 months, 48 (86%) of 56 are seizure free. The mean age at surgery (37 vs. 36 years), duration of epilepsy (26 vs. 22 years), age (1.6 vs. 1.1 years), and occurrence (58 vs. 75%) of febrile seizures, age of onset of epilepsy (11 vs. 14 years), sex ratio (50 vs. 75% female), laterality of seizure focus (42 vs. 50% left), greater than weekly seizures (40 vs. 38%), and a history of (69 vs. 75%) and frequency of (2.10 vs. 2.38 per year) secondarily generalized seizures did not differ significantly between the two groups. Similarly there was no significant difference between patients seizure and aura free and those with seizure recurrence including auras. CONCLUSIONS: Clinical factors such as seizure frequency and duration of epilepsy are not risk factors for postoperative seizure recurrence.     

Identifying potential surgical candidates in patients with evidence of bitemporal epilepsy

PURPOSE: To determine which patients with evidence of medically refractory bitemporal epilepsy are potentially good candidates for surgical therapy. METHODS: We reviewed 42 adults with intractable seizures who were found to have bitemporal ictal onsets, based on scalp video-EEG long-term monitoring (LTM). All underwent invasive LTM before surgery. Surgical outcomes were classified as seizure free, >75% reduction in seizures, or <75% reduction in seizures, >or=1 year after resection. We related the following factors to outcome: (a). >75% preponderance of interictal scalp EEG discharges to one temporal region; (b). magnetic resonance imaging (MRI) findings; (c). lateralizing deficits on verbal or visual reproduction memory testing; and (d). memory failure with injection contralateral to side of surgery on Wada testing. RESULTS: Twenty-six (62%) of 42 patients had unilateral ictal onsets based on intracranial studies. Seizure freedom (occurring in 64% of this group), or >75% seizure reduction (found in 12% of subjects) occurred only when at least one of the following three factors was concordant with the side of surgery: preponderance of interictal scalp EEG discharges, unilateral temporal lesion on MRI, or lateralizing verbal or visual reproduction memory deficits on neuropsychological tests (p = 0.004). Seven subjects with bilateral ictal onsets based on intracranial studies had resections based on preponderance of seizures to one side, or other lateralizing noninvasive abnormality. Five of these (all of whom had >or=80% of seizures originating from one side) had >75% reduction in seizures. CONCLUSIONS: Invasive monitoring to pursue possible surgical therapy for patients with surface EEG evidence of bitemporal epilepsy may be justified only when some lateralizing feature is found in other noninvasive assessments.     

Pre-surgical evaluation and surgical outcome of 41 patients with non-lesional neocortical epilepsy.

Pre-surgical evaluation and the surgical treatment of non-lesional neocortical epilepsy is one of the most challenging areas in epilepsy surgery. The aim of this study was to evaluate the surgical outcome and the diagnostic role of ictal scalp electroencephalography (EEG), interictal (18)F-fluorodeoxyglucose-positron emission tomography (FDG-PET), and ictal technetium-99m hexamethylpropyleneamine oxime single photon emission tomography ( (99m)Tc-HMPAO SPECT). In 41 non-lesional neocortical epilepsy patients (16 frontal lobe epilepsy, 11 neocortical temporal lobe epilepsy, seven occipital lobe epilepsy, four parietal lobe epilepsy, and three with multifocal onset) who underwent surgical treatment between December 1994 and July 1998, we evaluated the surgical outcome with a follow-up of at least 1 year. The localizing and lateralizing values of ictal scalp EEG, interictal FDG-PET, and ictal SPECT were evaluated in those patients with good surgical outcome. Ictal scalp EEG had the highest diagnostic sensitivity in the localization of epileptogenic foci (69.7% vs. 42.9% for FDG-PET and 33.3% for ictal SPECT; P= 0.027). However, no significant difference was found in the lateralization of the epileptogenic hemisphere among the three modalities (78.8% for ictal scalp EEG, 57.2% for FDG-PET, and 55.5% for ictal SPECT; P= 0.102). During a mean follow-up of 2.77 +/- 1.12 years, 33 (80.5%) showed good surgical outcome (seizure free or seizure reduction >90%), including 16 (39.0%) seizure free patients. Ictal scalp EEG was the most useful diagnostic tool in the localization of epileptogenic foci. Interictal FDG-PET and ictal SPECT were found to be useful as complementary and, sometimes, independent modalities. Many patients with non-lesional neocortical epilepsy would benefit from surgical treatment.     

Long-Term Follow-Up of Stereotactic Lesionectomy in Partial Epilepsy: Predictive Factors and Electroencephalographic Results

We performed an extended follow-up study assessing the efficacy of stereotactic lesionectomy in 23 patients with foreign-tissue lesions and intractable partial epilepsy. Sixteen lesions involved functional or eloquent cortex as determined by anatomic localization. By definition, the surgical objective in these patients was excision of the lesion, and not the surrounding cerebral cortex. The mean duration of follow-up was 48.5 months (range 26-69 months). Seventeen patients (74%) had a significant reduction in seizures (greater than or equal to 90%) after lesionectomy. Thirteen patients (56%) had a class I operative outcome (seizure-free, single seizure episode, or auras only). Five of these patients were successfully discontinued from antiepileptic drug (AED) therapy. Patients with temporal lobe lesions were statistically less likely to be rendered seizure-free (p less than 0.05). Age at operation, duration of epilepsy, and underlying pathology were not significant predictors of seizure outcome. The anatomic distribution of extracranial EEG recorded epileptiform activity did not appear to be an important determinant of outcome. The absence of interictal epileptiform activity in the 3-month postoperative EEG correlated with a significant reduction in seizures. Long-term follow-up indicates that lesionectomy may be effective in select patients with medically refractory partial seizure disorders.     

脑电定位与手术治疗难治性癫痫疗效观察

目的 探讨难治性癫痫的术前、术中脑电图定位方法及手术疗效.方法 对621例难治性癫痫患者采用普通脑电图监测(REEG)、长程脑电图监测(AEEG)、视频脑电图监测(VEEG),结合患者病史特点及影像学结果进行综合定位;术中在皮层脑电图(ECoG)监测下依据脑电图定位及不同发作类型选择适合术式切除致痫灶,并观察术后疗效.结果 术后随访6月至4年,满意(术后无发作)340例,占55%;显著改善(发作减少＞75%)223例,占36%;良好(发作减少50%～75%)37例,占6%;效差(发作减少＜50%)21例,占3%;无加重病例;有效率达97%.结论 以脑电图监测为基本手段,采用综合定位的方法结合术中ECoG监测明确癫痫灶的部位和范围以指导手术,能有效防止并发症的发生,并取得良好的治疗效果.     

Effect of vagus nerve stimulation on adults with pharmacoresistant generalized epilepsy syndromes.

INTRODUCTION: Although vagus nerve stimulation (VNS) therapy is approved for the treatment of partial onset seizures, its efficacy for generalized seizures has not been fully evaluated. This Investigational Device Exemption assessed the outcome of VNS therapy among patients with generalized epilepsy syndromes. METHODS: Sixteen patients with pharmacoresistant generalized epilepsy syndromes and stable antiepileptic drug (AED) regimens were implanted with the VNS therapy device and were evaluated for changes in seizure frequency and type between baseline and follow-up of 12-21 months. RESULTS: The patients experienced a statistically significant overall median seizure frequency reduction of 43.3% (P = 0.002, Wilcoxon signed rank test) after 12-21 months of VNS therapy. Types of seizures that may involve a fall or collapse decreased with reductions in the frequency of myoclonic (60% reduction, n = 9; P = 0.016, Wilcoxon signed rank test), tonic (75% reduction, n = 8, NS), atonic (98.6%, n = 3, NS), and clonic seizures (86.7%, n = 1, NS). Conclusion: The benefits of reduced seizure frequency and reduced risk of injury merit consideration of VNS therapy for patients with pharmacoresistant generalized seizure syndromes.     

Hemispherectomy for catastrophic epilepsy in infants

PURPOSE: To report our experience with hemispherectomy in the treatment of catastrophic epilepsy in children younger than 2 years. METHODS: In a single-surgeon series, we performed a retrospective analysis of 18 patients with refractory epilepsy undergoing hemispherectomy (22 procedures). Three different surgical techniques were performed: anatomic hemispherectomy, functional hemispherectomy, and modified anatomic hemispherectomy. Pre- and postoperative evaluations included extensive video-EEG monitoring, magnetic resonance imaging, and positron emission tomography scanning. Seizure outcome was correlated with possible variables associated with persistent postoperative seizures. The Generalized Estimation Equation (GEE) and the Barnard's exact test were used as statistical methods. RESULTS: The follow-up was 12-74 months (mean, 34.8 months). Mean weight was 9.3 kg (6-12.3 kg). The population age was 3-22 months (mean, 11.7 months). Thirteen (66%) patients were seizure free, and four patients had >90% reduction of the seizure frequency and intensity. The overall complication rate was 16.7%. No deaths occurred. Twelve (54.5%) of 22 procedures resulted in incomplete disconnection, evidenced on postoperative images. Type of surgical procedure, diagnosis categories, persistence of insular cortex, and bilateral interictal epileptiform activity were not associated with persistent seizures after surgery. Incomplete disconnection was the only variable statistically associated with persistent seizures after surgery (p<0.05). CONCLUSIONS: Hemispherectomy for seizure control provides excellent and dramatic results with a satisfactory complication rate. Our results support the concept that early surgery should be indicated in highly selected patients with catastrophic epilepsy. Safety factors such as an expert team in the pediatric intensive care unit, neuroanesthesia, and a pediatric epilepsy surgeon familiar with the procedure are mandatory.