癫痫发作的报警与预警

癫痫是一种最常见的神经系统疾病,特点为多数发作无诱因且难以预测。发作可导致合并症,包括外伤及癫痫猝死（Sudden unexpected death in epilepsy,SUDEP）,并致生活质量下降。过去20年广泛研究了发作的预警和报警,开发很多方法及设备,如头皮脑电图、颅内脑电图、肌电图、皮肤电变化、心率和心率变异性（Heart rate variability,HRV）。其中HRV是最有前景的方法。发作发放通过网络导致交感神经和副交感神经间不平衡并且改变了自主神经发放合并心率异常。过去20年用计算机方法开发了HRV的谱分析。HRV的变化早于脑电图发作和临床发作的开始。HRV可能是癫痫发作的预警和报警的指标。现在虽有很多关于癫痫的HRV算法,但是缺少标准的对于癫痫患者的方案,并且没有固定的监测模式,使之难以转化为临床实用,解决这个问题是十分重要的。总结出一个HRV评估的最低方案可用于所有癫痫患者的研究十分必要,可使HRV成为预警癫痫发作的有用工具。     

发作间期癫痫灶的~(18)F-FDG PET/CT显像研究

目的 探讨~(18)F-FDG PET/CT对发作间期癫痫灶定性定位诊断价值.方法 病人空腹4-6 h以上,空腹血糖3.9～6.1 mmol/L,肘静脉注射显像剂~(18)F-FDG0.12 mCi/kg体质量,平静休息40 min后行脑部PET3D及CT断层显像,层厚3.75 mm,PET图像行衰减校正及迭代法重建多层面,多幅显示,连续两个层面以上肉眼可辨的放射性改变(低代谢、高代谢区)为癫痫灶.同时根据癫痫灶对放射性示踪剂的摄取进行半定量测定.对于多发癫痫灶采用痫灶部位及对侧同一部位SUVmax与小脑SUVmax相比.每个病人开颅后根据术前脑电、PET/CT结果行颅内电极(条状脑皮质电极、脑深部电极)监测癫痫灶的脑电情况,证实~(18)F-FDG PET/CT结果.结果 38例患者中37例检出癫痫灶,术中脑电证实癫痫灶部位较准确,1例颞叶癫痫未检出.单痫灶较多痫灶准确.结论 ~(18)F-FDG PET/CT是一种无创伤性、高度灵敏、较有效的癫痫灶定位方法.     

发作期及发作间期痫性放电对癫痫的诊断价值

目的：探讨发作期及发作间期脑电图对癫痫诊断的意义。方法：对５６例癫痫患者常规脑电图（ＲＥＥＧ）与２４ｈ脑电图（ＡＥＥＧ）进行比较研究。结果（１）ＲＥＥＧ阳性率为３０％，而ＡＥＥＧ的阳性率为８６％；（２）不同类型癫痫在发作期和发作间期大脑活动的规律和特点，ＲＥＥＧ无１例记录到癫痫发作，而ＡＥＥＧ有２７例（４８％）记录到癫痫发作安全过程的大脑电活动变化，结论发作期的ＥＥＧ对确定癫痫类型有重要意义，全身     

探讨儿童部分性癫痫发作发作间期脑电图及与影像学的关系

目的探讨儿童部分性癫痫发作发作间期EEG及与影像学的关系。方法对67例部分性发作的癫痫患儿行长程录像脑电监测(VEEG)及影像学检查,分析发作间期EEG及与影像学的关系。结果与发作间期EEG正常的患儿比较,EEG异常患儿影像学正常率显著降低,影像学异常率显著增高(χ2=5.154,P=0.023)。发作间期异常放电51例患者中,42例(82.4%)间期放电与发作期部位一致,其中20例(47.6%)影像学检查正常,22例(52.4%)影像学检查异常,两者相比差异无统计学意义(P=0.726)。结论发作间期EEG异常部分性癫痫患儿,影像异常率高,大多数患儿发作间期放电与发作期起始放电部位一致。     

发作间期SPECT在癫痫外科中的临床应用

目的 探讨发作间期SPECT在顽固性癫痫患者术前致痫灶定位的临床应用价值。方法 本组57例患者，男43例，女14例，年龄3～40岁，病程1～24年。所有患者术前均行了EEG检查和CT／MRI检查，同时行发作间期SPECT检查。根据发作间期SPECT的结果，并结合EEG和CT／MRI检查结果对患者进行手术，术中将发作间期SPECT结果与ECoG监测进行对比，术后通过3年以上的随访，观察手术疗效。结果 SPECT与ECoG监测进行对比，发作间期SPECT对致痫灶的定侧率为94．74％，定位率为56．14％。术后3年以上随访显示手术的有效率为77．20％，优良率为52．63％。结论 发作间期SPECT在术前致痫灶定位上有一定的价值，但需结合EEG和CT／MRI，同时术中还应在ECoG监测下进行手术，以提高癫痫外科的疗效。     

发作间期癫痫样放电与认知功能损害的研究进展

癫痫患者常伴有与皮质功能紊乱相关的认知功能障碍,该障碍由反复发作的癫痫放电与传播、潜在的脑病理改变、癫痫发作的年龄、癫痫持续时间、癫痫发作频率、抗癫痫药物或手术等引起,发生率约为30%~50%,严重影响患者的生活品质[1]。有研究显示,频繁的发作间期癫痫样放电(interictal epileptic discharge,IED)对儿童和成人的认知功能存在损害[2-3]。现将IED与认知功能损害的研究进展综述如下。     

基于颞叶癫痫发作间期脑电数据图论的初步研究

目的对颞叶癫痫(TLE)患者发作间期清醒期和睡眠期视频EEG(V-EEG)数据进行分析,研究TLE患者左右侧颞区网络节点属性的改变及全脑平均路径长度的变化。方法收集32例TLE患者,将32例TLE患者进一步分为左侧17例和右侧15例,与24名性别、年龄相匹配的正常对照者清醒期及睡眠期脑电数据进行对比研究。分析颞区清醒期β节律、睡眠期δ节律,应用Matlab软件计算出相应节点不同时期的聚类系数及全脑平均路径长度的变化特点,将数据使用图论的方式表示出来,使网络特点可视化。结果TLE患者清醒期与睡眠期颞区的聚类系数、全脑平均路径长度均较正常组升高(均P<0.05)。致痫侧的聚类系数较非致痫侧的聚类系数升高(P<0.05)。TLE患者致痫区域部分节点的连接密度增加,传输性能及效率降低。结论TLE患者发作间期清醒期、睡眠期局部节点属性发生改变,且与致痫侧变化明显。     

癫癎患者发作间期心血管自主神经功能与心率变异性

目的　探讨癫　患者发作间期心血管自主神经功能与心率变异性（ＨＲＶ）的变化。方法　５１例癫　患者根据标准心血管自主神经功能试验结果分为阳性（ＡＮＦＴ＋）组及阴性（ＡＮＦＴ－）组,与正常对照组３６例对比,进行ＨＲＶ分析。结果　癫　患者发作间期心血管自主神经功能异常率为４５．１％,且病程越长异常率越高。癫　患者在ＨＲＶ时域分析及非线性定量分析指标上均较对照组降低,且以　ＡＮＦＴ＋组患者最明显。ＨＲＶ直方图、散点图亦有特征性改变,以ＡＮＦＴ＋组患者最为显著。结论　癫　患者发作间期心血管自主神经功能存在紊乱现象,这种现象可能与癫　患者的猝死发生有关,ＨＲＶ是测定这一变化的敏感方法。     

首次癫痫样发作的治疗

癫痫的患病率为0．5％左右，大约3．5％的人一生中出现过一次癫痫样发作。换一个角度说，约有3％的人一次发作后没有第二次或更多的发作，其他0．5％的人首次发作后以不固定的间隔反复发作，成为典型的癫痫患者。目前还没有准确的预测方法判断首次发作后就诊的患者今后是否会复发，这就出现了首次发作后是否需要治疗的问题。     

A systematic review and meta-analysis of heart rate variability in epilepsy and antiepileptic drugs

Purpose: Epilepsy is associated with near‐fatal and fatal arrhythmias, and sudden unexpected death in epilepsy (SUDEP) is partly related to cardiac events. Dysfunction of the autonomous nervous system causes arrhythmias and, although previous studies have investigated the effects of epilepsy on the autonomic control of the heart, the results are still mixed regarding whether imbalance of sympathetic, vagal, or both systems is present in epilepsy, and also the importance of anticonvulsant treatment on the autonomic system. Therefore, we aimed to investigate epilepsy and its treatment impact on heart rate variability (HRV), assessed by sympathetic and parasympathetic activity expressed as low‐frequency (LF) and high‐frequency (HF) power spectrum, respectively. Method: We performed a systematic review from the first date available to July 2011 in Medline and other databases; key search terms were “epilepsy”; “anticonvulsants”; “heart rate variability”; “vagal”; and “autonomous nervous system.” Original studies that reported data and/or statistics of at least one HRV value were included, with data being extracted by two independent authors. We used a random‐effects model with Hedges’s g as the measurement of effect size to perform two main meta‐analyses comparing LF and HF HRV values in (1) epilepsy patients versus controls; (2) patients receiving versus not receiving treatment; and (3) well‐controlled versus refractory patients. Secondary analyses assessed other time‐ and frequency‐domain measurements (nonlinear methods were not analyzed due to lack of sufficient data sets). Quality assessment of each study was verified and also meta‐analytic techniques to identify and control bias. Meta‐regression for age and gender was performed. Key Findings: Initially, 366 references were identified. According to our eligibility criteria, 30 references (39 studies) were included in our analysis. Regarding HF, epilepsy patients presented lower values (g ?0.69) than controls, with the 95% confidence interval (CI) ranging from ?1.05 to ?0.33. No significant differences were observed for LF (g ?0.18; 95% CI ?0.71 to 0.35). Patients receiving treatment presented HF values to those not receiving treatment (g ?0.05; 95% CI ?0.37 to 0.27), with a trend for having higher LF values (g 0.1; 95% CI ?0.13 to 0.33), which was more pronounced in those receiving antiepileptic drugs (vs. vagus nerve stimulation). No differences were observed for well‐controlled versus refractory patients, possibly due to the low number of studies. Regression for age and gender did not influence the results. Finally, secondary time‐domain analyses also showed lower HRV and lower vagal activity in patients with epilepsy, as shown by the standard deviation of normal‐to‐normal interval (SDNN) and the root mean square of successive differences (RMSSD) indexes, respectively. Significance: We confirmed and extended the hypothesis of sympathovagal imbalance in epilepsy, as showed by lower HF, SDNN, and RMSSD values when compared to controls. In addition, there was a trend for higher LF values in patients receiving pharmacotherapy. As lower vagal (HF) and higher sympathetic (LF) tone are predictors of morbidity and mortality in cardiovascular samples, our findings highlight the importance of investigating autonomic function in patients with epilepsy in clinical practice. Assessing HRV might also be useful when planning therapeutic interventions, as some antiepileptic drugs can show hazardous effects in cardiac excitability, potentially leading to cardiac arrhythmia.     

脑中风患者心率变异的初步分析

目的：探讨中风后植物神经的变化规律及其变化机制。方法：采用反映植物神经功能折心率变异指标，对其时域指标进行分析、应用方差分析及ｔ检验，比较了健康对照组与中风组的心率变异情况。结果：（１）中风组ＳＤＮＮ及ＨＲＶＩ均明显低于健康对照组。（２）中风组随病程的处长，其心率变异逐渐增高，到半年后基本恢复到对照组的水平。     

Sudden unexpected death in epilepsy associated with progressive deterioration in heart rate variability

We describe a patient with severe epilepsy who underwent serial measurements of heart rate variability (HRV) prior to his death from autopsy-confirmed sudden unexpected death in epilepsy (SUDEP). The significance of low HRV is discussed in relation to SUDEP risk. Progressive deterioration in HRV may be a risk factor for SUDEP.     

脑梗死后心率变异的常见临床因素分析

目的 研究脑梗死患者心率变异性(HRV)的特点及其影响因素,为脑梗死的治疗提供有意义的借鉴.方法 研究梅州市人民医院神经内科自2007年5月至2009年6月收治、经CT或MRI检查确诊的190例脑梗死患者的临床资料,以同期健康体检者50例做为对照,利用24 hHRV分析技术测定并比较心脏自主神经活性受损程度,再按照脑梗死患者的年龄、性别、梗死类型、病情程度、预后、梗死部位对病例进行分组并分析上述因素对患者HRV的影响.结果 脑梗死组患者HRV相关指标均低于对照组;≥60岁组患者HRV各项指标低于<60岁组;除总功率谱(TF)外,女性HRV指标均低于男性,腔隙性梗死患者HRV指标高于动脉粥样硬化性腩梗死和脑栓塞患者,GCS评分较低的患者HRV指标较低,预后为死亡的患者HRV指标最低,其次为好转、治愈患者.右岛叶梗死患者HRV时域指标低于其他梗死部位患者,差异均有统计学意义(P<0.05).结论 脑梗死患者自主神经系统失衡,早期动态监测HRV可以判断脑梗死患者脑功能损伤程度及病情演变趋势,有助于早期识别高危患者,指导临床治疗.     

Diffusion tensor imaging findings and their correlation with neuropsychological deficits in patients with temporal lobe epilepsy and interictal psychosis

PURPOSE: To examine frontotemporal white-matter integrity in patients with temporal lobe epilepsy (TLE) and interictal psychosis. METHOD: Patients with TLE and interictal psychosis (IP; n = 20) were compared with age-matched TLE patients without psychosis (NIP; n = 20). Patients had either no focal lesions or hippocampal sclerosis on conventional MRI. Complete diffusion tensor imaging (DTI) data were available in 18 IP and 20 NIP patients. A region-of-interest (ROI) approach was used to determine the DTI measures, fractional anisotropy (FA) and mean diffusivity (MD), in the middle frontal and middle temporal gyri. The relation between the DTI measures and neuropsychological tests previously identified as impaired in the IP group was examined. RESULTS: The IP group had significantly lower FA values in both frontal and temporal regions and significantly higher MD in bilateral frontal regions. We found that performance on some neuropsychological tests was significantly related to frontotemporal FA reductions. CONCLUSIONS: Our findings suggest that subtle abnormalities in the frontotemporal white matter of patients with interictal psychosis may be undetectable on conventional MRI. These abnormalities may contribute to the cognitive deficits detected in these patients.     

Analysis of RR variability in drug-resistant epilepsy patients chronically treated with vagus nerve stimulation

Vagus nerve stimulation (VNS) has been suggested as an adjunctive treatment for drug-resistant epilepsy when surgery is inadvisable. The overall safety profile of VNS seems to be favorable as only minor adverse effects have been described. The purpose of this study was to determine if cardiac vagal tone is eventually modified by short- and long-term VNS. The effects of short- and long-term VNS were evaluated in seven subjects with intractable epilepsy. Autonomic cardiac function has been carried out by means of a 24-h analysis of RR variability at baseline (t(0)), 1 month (t(1), short-term VNS) and 36 months after VNS initiation (t(2), long-term VNS). Frequency- and time-domain parameters were calculated. Periodic cardiological and neurological evaluations were performed.Clinically relevant cardiac effects were not observed throughout the study. Despite the limited number of patients and the variety of data among them, for all the patients, a common trend towards a nocturnal decrease in the high-frequency (HF) component of the spectrum was observed after long-term VNS (mean+/-S.D.: 40+/-18 normalized units (nu) at t(0), 38+/-17 nu at t(1), 18+/-10 nu at t(2); p<0.05 of t(2) vs. either t(0) or t(1)). The day-to-night changes in the power of low-frequency (LF) and HF components were significantly blunted after long-term VNS (LF day-to-night change: +16+/-13 nu at t(0) and +15+/-8 nu at t(1) vs. +3+/-13 nu at t(2), p<0.02; HF day-to-night change: -18+/-13 nu at t(0) and -13+/-11 nu at t(1) vs. +3+/-12 nu at t(2), p<0.003). No significant changes were observed with regard to the time-domain parameters of the heart rate variability.Throughout the neurological follow-up, one subject became seizure-free, three experienced a seizure reduction of >50%, two patients of <50% and one had no changes in his seizure frequency.Our findings suggest that long-term VNS might slightly affect cardiac autonomic function with a reduction of the HF component of the spectrum during night and a flattening of sympathovagal circadian changes, not inducing, however, clinically relevant cardiac side effects.     

Differential pattern of heart rate variability in patients with schizophrenia

The cardiac autonomic dysfunction has been reported in patients with schizophrenia. Heart rate variability (HRV) provides non-invasive indices of cardiac autonomic modulation. This study examined whether patients with schizophrenia may show a distinctive pattern of HRV compared to healthy controls. Nine measures of time, frequency and complexity domains were extracted from 5-min resting evaluation of HRV in 30 unmedicated patients with schizophrenia and 30 age- and gender-matched controls. In addition to inferential statistics, a hierarchical clustering (HC) was used to examine difference in the interrelationships among HRV measures between the two groups. Multivariate analysis of variance revealed a significant group effect. Significantly lower sample entropy (SampEn) and a trend towards a higher ratio of low- to high frequency (LF/HF) were observed in the schizophrenia group. In the results of HC using Ward's method, SampEn co-clustered with LF/HF ratio in patients with schizophrenia compared to the separation of LF/HF ratio in healthy controls. In concert with decreased parasympathetic activity, low complexity of heart rate dynamics may reduce adaptability of cardiovascular system to changes in internal or external environment, thus increasing the risk of cardiovascular events. Diverse HRV measures combined in a multivariate fashion appear to be useful in understanding the pattern of neurocardiac modulation in patients with schizophrenia.     

Clinical and psychopathological definition of the interictal dysphoric disorder of epilepsy

PURPOSE: Different authors suggested the occurrence of a pleomorphic affective syndrome in patients with epilepsy named interictal dysphoric disorder (IDD). We sought to investigate whether IDD occurs only in patients with epilepsy and to validate IDD features against DSM-IV criteria. METHODS: Consecutive patients with a diagnosis of epilepsy (E) or migraine (M) have been assessed using the BDI, MDQ, and the Interictal Dysphoric Disorder Inventory (IDDI), a questionnaire specifically created to evaluate IDD symptoms. Diagnosis of current and lifetime DSM-IV Axis I disorders was established using the MINI Plus version 5.0.0. RESULTS: A total of 229 patients (E = 117; M = 112) were evaluated. Females were significantly more represented in the migraine group (E = 46.5% vs. M = 73.3% p = 0.009), but there was no difference in age, duration of the disease, or education level. Patients with epilepsy were more likely to screen positively at MDQ (E = 17% vs. M = 5.3% p = 0.006) and to have a diagnosis of bipolar disorder (E = 14.5% vs. M = 4.5% p = 0.013) as compared to migraine patients. There was no between-groups difference in IDD prevalence (E = 17%; M = 18.7%) and IDDI total scores (E = 4.1 +/- 2.0 vs. M = 3.8 +/- 2.0). Validation of IDD against DSM-IV categories showed current major depression being the foremost diagnostic category correlated with IDD in both epilepsy (OR = 0.32-0.12-0.88, p = 0.028) and migraine (OR = 0.10, 95% CI = 0.02-0.49, p = 0.004) samples. Current anxiety disorder correlated with IDD only in migraine patients (OR = 0.19, 95% CI = 0.05-0.77, p = 0.02). CONCLUSION: IDD represents a homogenous construct that can be diagnosed in a relevant proportion of patients but it is not typical only of epilepsy, occurring in other central nervous system disorders such as migraine.