开颅手术治疗顽固性癫(癎)138例分析

目的评价顽固性癫痫的致痫灶定位方法和皮层电极监测下致痫灶切除,加行多处软脑膜下横纤维切断术（MST）治疗癫痫的疗效。方法对138例顽固性癫痫病人的致病灶,采用CT＋MRI＋EEC＋单光子发射计算机体层摄影（SPECT）＋皮层脑电图（ECoG）联合检测定位。对检出的阳性病灶在皮层电极监测显微镜下行致痢灶切除,切除后检测仍有癫痫波者加行MST;致痫灶位于重要功能区者单行MST。结果致痫灶阳性检出率86％。皮层电极监测显微镜下致痂灶切除加MST,术后91％的病人癫痫发作停止,一年后约15％的病人复发,但症状较术前减轻,持续时间较术前短。结论CT＋MRI＋EEG＋SPECT＋ECoG联合检测,对手术定位具有较高价值。皮层电极监测下致痫灶切除术及MST创伤轻微、效果比较可靠、治愈率高、并发症少、复发率低。病灶及致痫灶的不完全切除和形成皮层软化及疤痕,可能是导致癫痫复发的重要原因。     

难治性癫痫的致痫灶定位及手术治疗研究

目的评价难治性癫痫的致痫灶定位方法和皮层电极监测下致痫灶切除,加行多处软脑膜下横纤维切断术(MST)治疗癫痫的疗效。方法对47例难治性癫痫病人的致痫灶,采用CT MRI EEG 单光子发射计算机体层摄影(SPECT) 皮层脑电脑(ECoG)联合检测定位。对检出的阳性病灶在皮层电极监测显微镜下行致痫灶切除,切除后监测仍有癫痫波者加行MST;致痫灶位于重要功能区者单行MST。结果致痫灶阳性检出率86%。皮层电极检测显微镜下致痫灶切除加MST,术后91%的病人癫痫发作停止,半年后约15%的病人复发,但症状较术前减轻,持续时间较术前短。结论CT MRI EEG SPECT ECoG联合检测,对手术定位具有较高价值。皮层电极监测下致痫灶切除术及MST创伤轻微、效果比较可靠、治愈率高、并发症少、复发率低。病灶及致痫灶的不完全切除和形成皮层软化及疤痕,可能是导致癫痫复发的重要原因。     

立体定向联合术中皮层电极、神经电生理监测治疗功能区皮层下小肿瘤性癫痫

目的 评价采用立体定向联合术中皮层脑电图(ECoG)、神经电生理监测(IOM)治疗功能区皮层下小肿瘤性癫痫的手术方法及效果、并发症. 方法 解放军第153医院神经外科自2006年6月至2011年6月共收治功能区皮层下小肿瘤引起的癫痫患者15例,均在立体定向仪导向下,开放直视手术准确切除肿瘤,ECoG监测定位致痫灶,IOM判断致痫灶与功能区的重叠程度,分别采取切除术、多处软膜下横切术(MST)或皮层低功率电凝热灼术处理致痫灶.总结分析患者的手术方法及疗效. 结果 本组肿瘤全切13例,次全切2例;瘤周致痫灶切除4例,瘤周致痫灶MST或/和皮层低功率电凝热灼术11例;术毕ECoG监测发现痫样放电消失、基本节律大致恢复正常6例,仍残留少量棘波6例,残存较多棘波且基本节律轻到中度异常3例;无严重永久性并发症;随访1～3年,肿瘤原位复发2例,Engel分级Ⅰ级10例,Ⅱ级3例,Ⅲ级2例,总有效率100％.结论 立体定向联合术中ECoG、IOM治疗功能区皮层下小肿瘤性癫痫,能够精准定位并切除肿瘤及处理致痫灶,避免损伤功能区,是一种微创、安全、有效的手术方法.     

痫灶切除辅助性脑皮层横行纤维热灼治疗功能区癫痫的临床研究

目的：采用低功率热灼的方法，毁损脑皮层的横行纤维，治疗功能区顽固性癫痫，观察该方法在临床的实用性和有效性。方法：124例难治性癫痫患者，手术切除非功能区致痫灶后，辅助热灼功能区的致痫灶或癫痫样放电。非功能区致痫灶切除后，功能区致痫灶热灼前后均行皮层脑电图监测。病理观察热损伤的深度和范围。结果：热灼后肉眼下见：皮层呈红白相间的条纹状改变，与多软膜下横纤维切断术（MST）类似。显微结构见：热损伤仅在脑浅皮层（Ⅰ-Ⅱ）。随访108例术后病例1-5年，癫痫发作消失的占75.9%，总有效率91.7%。术后9例病人出现一过性的功能障碍，但均在一周左右恢复。结论：非功能区致痫灶切除辅助功能区致痫灶热灼，其疗效肯定，方法安全可靠，易在临床推广。     

术中脑电监测在癫痫手术中的应用分析

目的讨论术中脑电监测在癫痫手术中的应用意义。方法40例难治性癫痫患者，术中采用日本光电9200脑电描记系统。应用皮层电极，在致痫灶靶区皮层，对癫痫起源部位进一步精确定位，手术切除致痫灶，并在皮层脑电图（ECoG）监测下进行病灶扩大切除、胼胝体切开或多处软膜下横切（MST），术后常规应用抗癫痫药物。结果全部患者在预定的癫痫灶局部均可记录到癫痫波；病变及癫痫灶切除后即时检测，显示痫性放电明显减少24例，其中3例非功能区海绵状血管瘤，瘤体切除后仍可见大量棘波，扩大切除周围皮质，棘波显著减少；3例功能区胶质瘤患者虽经MST后，棘波有一定改善，仍可见一定量棘波；12例海马硬化及1例海马萎缩术后，仍存在一定量棘波。术后疗效评价，按照Engel分级评价为：Ⅰ级27例，Ⅱ级6例，Ⅲ级4例，Ⅳ级3例；总有效者37例，有效率达92．5％。结论在癫痫手术中运用脑电监测，可以进一步精确定位致痫灶，指导手术中正确切除癫痫灶及预示手术效果，有助于提高手术治疗的有效性，在癫痫外科治疗中具有一定应用价值。     

多处软脑膜下横纤维切断术治疗难治性癫痫的应用研究

目的：总结多处软脑膜下横纤维切断术（multiple subpial transection,MST)与其他术式联合应用治疗难治性癫痫的疗效。方法：195例难治性癫痫患，部分性发作81例，全面性发作114例。根据手术前脑电图、SPECT、PET、CT及MR定位检查，结合术中皮层电极脑电图探测结果，划出致痫灶地域图，于显微镜下先行致痫灶及颞叶基底部切除或胼胝体切开；而后对周围或广泛性棘波发放区施行多处软脑膜下横纤维切断，最后经皮层电极脑电图探查显示病变区癫痫样波形完全消失即完全手术。结果：195例患，行大脑半球广泛单纯性MST39例（20.00%）；大脑半球表面蛛网膜粘连带切除减压 MST21例（10.78%);颞尖部及颞叶基底部切除 颞叶新皮质MST39例（20.00%）；大脑半球局限性病变及致痫带切除 广泛性MST50例（25.64%）；病灶周边局限性MST16例（8.21%)；胼胝体前2、3切开 双额叶前部MST30例（15.38%）。无一例发生手术死亡，亦未出现严重并发症。随访80例患，优45例（56.25%），良20例（25.00%），中9例（11.25%)，差6例（7.50%），有效率为92.50%，显效率为81.25%。结论：联合应用MST与致痫灶切除、颞叶内基底区切除或胼胝体切开是治疗难治性癫痫患的有效方法，值得推广应用。     

功能区皮层下小病灶相关性癫痫的手术治疗

目的评价综合应用多种定位技术治疗功能区皮层下小病灶相关性癫痫的手术方法及效果。方法 58例功能区皮层下小病灶引起的癫痫患者,在立体定向仪导向下,开放直视手术切除病灶,术中皮层脑电图(ECoG)监测定位致痫灶,术中神经电生理监测(IOM)判断致痫区的功能以及二者的重叠程度,辅助以麻醉唤醒定位语言区、实时超声检查病变切除程度,根据监测结果分别采取致痫灶切除术、多处软膜下横切术(MST)或皮层低功率电凝热灼术妥善处理致痫灶。结果病灶全部切除52例,少量残留6例。病灶区域ECoG监测除波幅略有降低外无明显异常13例,行占位病灶切除术;ECoG明显异常,在非主要功能区8例,行占位病灶+周边致痫皮层切除术;ECoG明显异常而又在主要功能区37例,行占位病灶+功能区致痫皮层多处软膜下横切术(MST)或低功率电凝热灼术。ECoG监测发现痫样放电消失、基本节律大致恢复正常29例,仍残留少量棘波13例,残存较多棘波且基本节律轻到中度异常16例。随访1～5年,EngelⅠ级46例,EngelⅡ级8例,EngelⅢ级4例,总有效率100%。出现暂时性轻偏瘫17例,暂时性失语8例,无严重永久性并发症。结论综合应用立体定向引导、术中IOM、ECoG、麻醉唤醒及实时超声定位治疗功能区小病灶相关性癫痫,能够精准定位并切除病灶及处理致痫灶,避免损伤功能区,是一种微创、安全、有效的手术方法。     

多软膜下横切术治疗功能区顽固性癫痫

目的对于致痫灶位于脑的主要功能区的癫痫病人,采用多软膜下横切术(MST),达到既可控制癫痫的发作,又能保护皮质的正常功能.方法选择20例继发性癫痫病人,术前均做神经影像学、脑电图和神经心理学检查;术中硬脑膜切开后,先用皮质电极核实致痫灶的方位和范围,然后切除远离功能区的病灶,再用横切刀切断功能区痫性放电的神经元树突,最后用皮质电极复查,直至棘波消失.结果除1例无改善外,其他19例都得到了不同程度的控制.满意6例,显著改善6例,良好5例,效差2例,无改善1例,总有效率为95%.永久性重要功能缺失和残疾,无手术死亡率.结论MST它能使脑主要功能区癫痫,在不引起任何机能障碍的情况下,使痫性发作得到有效的控制.     

唤醒麻醉和术中功能定位切除临近语言区致痫灶(附3例报告)

目的 探讨切除功能区致痫灶的手术策略及术后疗效.方法 在唤醒麻醉下应用术中皮层电刺激确定语言功能区,根据功能区边界选择处理致痫灶.评价患者的功能结果及癫痫控制程度.结果 3例患者术后随访,均未出现语言障碍,癫痫发作完全控制,符合Engel分级Ⅰ级.致痫灶全切2例,近全切+致痫皮层热灼1例.结论 借助唤醒麻醉进行术中皮质电刺激确定语言功能区准确、安全、可靠.唤醒麻醉下进行术中皮质电刺激结合影像学资料、借助颅内皮层电极的皮质电刺激进行功能区定位,能够最大可能地切除致痫灶而最小化功能区的损害.     

涉及中央区难治性癫痫的外科治疗

目的探讨涉及中央区难治性癫痫的手术治疗。方法3例患者术前除常规致痫灶评估外,还应用fMRI作皮质功能区定位。术中通过皮层EEG（ECoG）对致痫灶定位,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痫灶行切除性手术,功能区内的致痫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例病人无癫痫发作,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痫控制率。     

Epilepsy and anomalies of neuronal migration: MRI and clinical aspects

Neuronal migration disorders are the result of disturbed brain development. In such disorders, neurons are abnormally located. In diagnosing these conditions, magnetic resonance imaging is superior to any other imaging technique. This enables us to improve our knowledge of the clinical correlates of neuronal migration. With reference to migrational disorder, a retrospective study of all 303 patients with epileptic seizures referred for magnetic resonance imaging during a 3-year period was performed, 13 patients (aged 12-41, mean age 27) were identified. They represent 4.3% of the entire study group. Of the patients with known epilepsy, 6.7% and of the mentally retarded, 13.7% had migrational disorders. Four patients had schizencephaly as the dominant finding, one was classified as hemimegalencephaly, 2 had isolated heterotopias, and 6 had localized pachy- and/or poly-microgyria. The clinical pictures are complex. Ectopias of grey matter are recognised foci of epilepsy, but from an epileptological and a clinical viewpoint little attention has been given to these disorders. The present study shows that malmigration is not rare in epilepsy patients, especially not in the mentally retarded.     

Classification of methods in transcranial Electrical Stimulation (tES) and evolving strategy from historical approaches to contemporary innovations

Transcranial Electrical Stimulation (tES) encompasses all methods of non-invasive current application to the brain used in research and clinical practice. We present the first comprehensive and technical review, explaining the evolution of tES in both terminology and dosage over the past 100 years of research to present day. Current transcranial Pulsed Current Stimulation (tPCS) approaches such as Cranial Electrotherapy Stimulation (CES) descended from Electrosleep (ES) through Cranial Electro-stimulation Therapy (CET), Transcerebral Electrotherapy (TCET), and NeuroElectric Therapy (NET) while others like Transcutaneous Cranial Electrical Stimulation (TCES) descended from Electroanesthesia (EA) through Limoge, and Interferential Stimulation. Prior to a contemporary resurgence in interest, variations of transcranial Direct Current Stimulation were explored intermittently, including Polarizing current, Galvanic Vestibular Stimulation (GVS), and Transcranial Micropolarization. The development of these approaches alongside Electroconvulsive Therapy (ECT) and pharmacological developments are considered. Both the roots and unique features of contemporary approaches such as transcranial Alternating Current Stimulation (tACS) and transcranial Random Noise Stimulation (tRNS) are discussed. Trends and incremental developments in electrode montage and waveform spanning decades are presented leading to the present day. Commercial devices, seminal conferences, and regulatory decisions are noted. We conclude with six rules on how increasing medical and technological sophistication may now be leveraged for broader success and adoption of tES.     

Hepatic Considerations in the Use of Antiepileptic Drugs

Summary: Virtually all of the major antiepileptic drugs (AEDs) can cause hepatotoxicity, although fatal hepatic reactions are rare. The mechanisms, incidences, and risk profiles for such reactions differ from drug to drug. With carbamazepine and phenytoin, hepatotoxicity may be due to drug hypersensitivity. Although the profiles of patients at risk have not been well-defined for these two antiepileptic drugs, it would appear from reports in the literature that older adolescents and adults are at higher risk than children of developing serious or fatal hepatotoxicity. Once hepatotoxicity develops, mortality rates are 10–38% with phenytoin and 25% for carbamazepine. The risk profile for valproate fatal hepatotoxicity has been more clearly defined. Those at primary risk of fatal hepatic dysfunction are children under the age of 2 years who are receiving multiple anticonvulsants and also have significant medical problems in addition to severe epilepsy. The risk is considerably lower for patients over the age of 2 years on valproate monotherapy. In contrast to the risk profile with other AEDs, adults receiving valproate as monotherapy have the lowest risk of hepatotoxicity. Fatal hepatic dysfunction coincident with valproate may be the result of aberrant drug metabolism. Concomitant use of AEDs that induce microsomal P450 enzymes (e.g., phenytoin and phenobarbital) may enhance the production of a toxic metabolite, and hence the greater risk of hepatotoxicity with polypharmacy.     

Vascular Malformations and Epilepsy: Clinical Considerations and Basic Mechanisms

Summary: Vascular malformations (VMs) are associated with epilepsy. The natural history of the various VMs, clinical presentation, and tendency to provoke epilepsy determine treatment strategies. Investigations have probed the mechanisms of epileptogenesis associated with these lesions. Electrophysiologic changes are associated with epileptogenic cortex adjacent to VMs. Putative pathophysiologic mechanisms of epileptogenesis include neuronal cell loss, glial proliferation and abnormal glial physiology, altered neurotransmitter levels, free radical formation, and aberrant second messenger physiology.     

Neonatal Seizures: Problems in Diagnosis and Classification

Summary: The clinical identification of neonatal seizures is critical for the recognition of brain dysfunction; however, diagnosis is often difficult because of the poorly organized and varied nature of these behaviors. Current classification systems are limited in their ability to communicate motor, autonomic, and electroencephalo-graphic features of seizures precisely and to provide a basis for uniform effective diagnosis, therapy, and determination of prognosis. Recent investigations of neonates, utilizing bedside electroencephalographic/polygraphic/ video monitoring techniques, have provided the basis for improved diagnosis and classification of seizures in the newborn. These studies have demonstrated that not all clinical phenomena currently considered to be seizures require electrocortical epileptiform activity for their initiation or elaboration. In addition, the specific clinical character of the phenomena considered to be seizures, the clinical state of the infant, and the character of the EEG indicate the probable pathophysiological mechanisms involved and suggest probable etiologies, prognosis, and therapy. Similarities between animal models that demonstrate reflex physiology and neonates with motor automatisms and tonic posturing suggest that these clinical behaviors may not be epileptic in origin but, rather, primitive movements of progression and posture mediated by brainstem mechanisms. Although not all clinical behaviors currently considered to be neonatal seizures may have similar pathophysiological mechanisms, they are clinically significant because they all indicate brain dysfunction.     

Valproate Monotherapy in the Management of Generalized and Partial Seizures

Summary: For decades, therapeutic tradition has promoted the concept of polypharmacy in the management of epilepsy. In recent years, however, studies have shown that, for most patients, monotherapy can provide comparable or better seizure control than administration of multiple anticonvulsants, while diminishing the potential for adverse reactions, drug interactions, and poor compliance. Valproate is an important monotherapeutic agent that is highly effective in the control of idiopathic primary and secondarily generalized epilepsies, and partial seizures that do not generalize. Comparative studies have found that valproate is at least as effective as phenytoin and carbamazepine in the treatment of generalized and partial seizures. Given the similar efficacy, other factors such as pharmacokinetics and side effects may therefore determine anticonvulsant selection for monotherapy.     

Carbamazepine Efficacy and Utilization in Children

Summary: Carbamazepine is effective for preventing partial and generalized tonic-clonic seizures in children. Although absence epilepsies are more common in children than adults, an estimated 80% of children with epilepsy have seizure types or epilepsies that are potentially responsive to carbamazepine. The differential diagnosis of ictal staring is an especially important issue in children because absence and atypical absence seizures are more prevalent in children than adults. Age-related pharmacokinetic differences and drug interactions are major considerations in children. On average, children have higher clearance rates of carbamazepine, shorter half-lives, and higher ratios of carbamazepine-10, 11-epoxide to carbamazepine than adults. In addition, children with severe epilepsy are more likely to require multiple-drug therapy, which can lead to complex drug interactions. When carbamazepine is administered along with valproate, drug protein binding interactions can cause intermittent side effects.     

Un nouveau cadre conceptuel de travail pour la psychiatrie

In an attempt to place psychiatric thinking and the training of future psychiatrists more centrally into the context of modern biology, the author outlines the beginnings of a new intellectual framework for psychiatry that derives from current biological thinking about the relationship of mind to brain. The purpose of this framework is twofold. First, it is designed to emphasize that the professional requirements for future psychiatrists will demand a greater knowledge of the structure and functioning of the brain than is currently available in most training programs. Second, it is designed to illustrate that the unique domain which psychiatry occupies within academic medicine, the analysis of the interaction between social and biological determinants of behavior, can best be studied by also having a full understanding of the biological components of behavior.