VEEG、ECoG、结合MRS定位致痫灶评价(附23例临床分析)

目的探讨在颞叶病变继发颞叶癫痫(Temporal lobe epilepsy,TLE)患者中应用长程视频脑电图(VEEG)、颅脑磁共振波谱分析(MRS)联合皮层脑电图(ECoG综合定位致痫灶指导手术切除致痫灶范围,评价TLE术后临床效果。方法病历资料选自2016年1月至2017年12月期间在蚌埠市第三人民医院癫痫研究所就医的既往有癫痫发作临床症状及不同医院脑电图结果提示有颞叶脑电异常初步依据纳入、排除标准选取病历资料完整的23例颞叶病变继发TLE的患者行手术治疗,术前完善VEEG及MRS检查,术中联合ECoG再检测致痫灶指导手术切除范围,术后采用Engel标准评价手术效果。结果应用VEEG与MRS两种检查分别阳性对不同病因组患者致痫灶定位中,术中在ECoG再检测指导下与MRS、VEEG定位致痫灶比较,MRS与ECoG一致率为95.65%,高于VEEG与ECoG的一致率65.22%,差异有统计学意义(χ~2=6.769,P0.05);在ECoG再检测指导下手术治疗的23例继发性TLE患者,术后随访12～27个月,依据Engel评价标准,结果示:EngelⅠ级18例,EngelⅡ级3例,EngelⅢ级1例,EngelⅣ级1例,术后均无严重并发症及死亡病例,术后临床效果达到显著有效共22例,显著有效率为95.65%。结论术中联合ECoG再检测致痫灶并指导手术切除范围,可显著提高手术治疗效果,TLE患者术后显著有效达95.65%;对一般经济条件需要手术治疗的患者,术前应用MRS与VEEG综合定位致痫灶与术中联合ECoG再检测致痫灶是颞叶病变继发TLE患者一种很好的选择,可避免昂贵的检查费用,获得满意疗效。     

视频脑电图与发作期SPECT对痫灶定位的对比研究

Objective To investigate the value of ictal single photon emission computed tomography and VEEG in localization of epileptogenic foci for intractable epilepsy. Method The data of ictal SPECT and VEEG were reviewed from 48 patients with intractable epilepsy, all the results were analyzed and compared with each other. Surgical treatment were performed on 48 cases. Results The positive rate of ictal SPECT and VEEG localization was 94% and 96% respectively. The rate of complete coincidence of the two methods was 46% (22/48), partial coincidence was 29% (14/48). Comparing ictal SPECT with video EEG in the ratio of lateral and focal epileptic foci localization, twenty - seven of 48 patients had an Engel Class Ⅰ outcome after surgery and an additional ten patients had rare seizure (Engel Class Ⅱ), and eight patient had a decrease in seizure frequency (Engel Class Ⅲ) , no marked chang (Engel Class Ⅳ) in three patients. In Engel Class Ⅰ and Class Ⅱ outcome cases, there were 33 (out of 37) cases came from its coincidence of ictal SPECT and VEEG localization. Conclusions VEEG combined with ictal SPECT can increase the accuracy on localization of epileptogenic foci for intractable epilepsy.     

顽固性癫痫病人术前综合评估在致痫灶定位中的应用

目的　探讨常规脑电图 (REEG)、视频脑电图 (VEEG)、MRI、SPECT检查对癫痫病的诊断及术前综合评估在致痫灶定位中的意义。方法　对 6 8例顽固性癫痫病人行REEG、VEEG、MRI及SPECT检查 ,对 4 4例顽固性癫痫病人术中行皮层电极 (ECoG)和深部电极监测 ,同时对REEG、VEEG、MRI和SPECT用于癫痫病人的诊断和致痫灶的定位价值进行对比研究。结果　 6 8例癫痫患者中REEG局灶棘波检出 30例 (4 1.1% ) ,VEEG局灶棘波检出 5 1例 (75 % ) ,经统计学分析局灶棘波检出率在两者之间有显著性差异 (P <0 .0 1)。SPECT异常 32例(80 % ) ,MRI异常 4 7例 (6 9.1% )。在 4 4例行癫痫手术治疗的病人中 ,ECoG与VEEG定位一致 39例 (88.7% ) ,与MRI异常部位一致 33例 (75 % ) ,1例VEEG异常部位与MRI不一致的病例 ,经ECoG证实致痫灶为VEEG异常部位。结论　VEEG对于癫痫的诊断及致痫灶的定位有相当重要的临床价值 ,优于REEG和MRI。通过临床表现、影像学、功能性检查尤其是VEEG联合检查 ,对顽固性癫痫病人致痫灶的定位具有较大的应用价值     

视频脑电图与发作期SPECT对痫灶定位的对比研究

Objective To investigate the value of ictal single photon emission computed tomography and VEEG in localization of epileptogenic foci for intractable epilepsy. Method The data of ictal SPECT and VEEG were reviewed from 48 patients with intractable epilepsy, all the results were analyzed and compared with each other. Surgical treatment were performed on 48 cases. Results The positive rate of ictal SPECT and VEEG localization was 94% and 96% respectively. The rate of complete coincidence of the two methods was 46% (22/48), partial coincidence was 29% (14/48). Comparing ictal SPECT with video EEG in the ratio of lateral and focal epileptic foci localization, twenty - seven of 48 patients had an Engel Class Ⅰ outcome after surgery and an additional ten patients had rare seizure (Engel Class Ⅱ), and eight patient had a decrease in seizure frequency (Engel Class Ⅲ) , no marked chang (Engel Class Ⅳ) in three patients. In Engel Class Ⅰ and Class Ⅱ outcome cases, there were 33 (out of 37) cases came from its coincidence of ictal SPECT and VEEG localization. Conclusions VEEG combined with ictal SPECT can increase the accuracy on localization of epileptogenic foci for intractable epilepsy.     

顽固性癫癎病人的术前综合评估(附40例报告)

目的探讨常规脑电图(REEG)、视频脑电图(VEEG)、MRI、SPECT检查对癫病人术前综合评估致灶定位的意义。方法对40例顽固性癫病人进行REEG、VEEG、MRI及SPECT检查,其中32例行手术治疗,术中行皮质电极(ECoG)和深部电极监测,同时对REEG、VEEG、MRI、SPECT定位致灶的情况进行对比研究。结果REEG异常40例,局灶棘波17例(42.5%);VEEG异常40例,局灶棘波35例(87.5%),两组局灶棘波检出率有显著性差异(P <0.01)。SPECT异常32例(80%),MRI异常31例(77.5%)。在32例手术病人中,VEEG与ECoG病灶一致者30例(93.7%),MRI与ECoG一致者27例(84.3%)。结论VEEG、MRI、EEG、SPECT检查结合临床表现,对顽固性癫病人术前致灶的定位和指导手术治疗有较大的应用价值。     

儿童非病灶性癫痫的临床研究

目的 对儿童非病灶性癫痫致痫灶功能定位、手术方式、手术疗效和手术前后认知功能改变的情况进行研究.方法 对21例经外科治疗的非病灶性癫痫患儿的术前定位、手术疗效和手术前后认知功能的改变进行回顾性分析,并以随机选择的20例健康学龄期儿童作为对照组.结果 21例患者中,手术疗效按Engel标准随访1年后,Ⅰ级13例,Ⅱ级4例,Ⅲ级3例,Ⅳ级1例.手术前后事件相关电位和学习障碍筛查量表结果显示术前组与对照组、术后组P300潜伏期差异均有统计学意义.结论 术前联合视频脑电图(VEEG)、fMRI、单光子发射断层扫描(SPECT)对致痫灶进行功能定位,结合其临床特点采用不同的手术治疗方式,加上术中使用皮层电极监测,是治疗儿童非病灶性癫痫的有效途径,能很好地改善患儿的认知功能障碍.     

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。     

VEEG在难治性癫痫术前致痫灶定位中的价值

目的 探讨视频脑电图(VEEG)、单光子发射计算断层扫描(SPECT)、正电子发射断层扫描(PET)技术在术前进行致痫灶定位中的价值.方法 175例手术治疗的难治性癫痫患者,术前全部行VEEG检查,59例行VEEG +蝶骨电极记录,46例行PET致痫灶定位,61例行SPECT定位.并与术中皮层脑电图(ECoG)的结果进行比较.结果 术前VEEG定位、VEEG+蝶骨电极记录、PET检查及SPECT检查与术中ECoG致痫灶定位符合率分别为67.42%、74.57%、54.84%和52.45%.结论 VEEG在致痫灶定位中有重要的价值;对于颞叶内侧深部癫痫而言,术前以VEEG +蝶骨电极记录定位更为准确.     

在MRI、VEEG、DLM定位下手术治疗难治性癫痫

目的 探讨在MRI、长程视频脑电图(VEEG)、无创头皮偶极子(DLM)定位下手术治疗难治性癫痫的治疗效果.方法 对25例药物难治性癫痫患者术前进行MRI、VEEG、DLM检查,并依据检查结果,在术前对致痫灶进行定位,部分患者参考磁共振波谱分析、正电子发射断层扫描结果,术中以皮层及深部电极验证,分别或同时进行病灶、前颞叶切除、皮层低功率热灼术.结果 24例术后随访1-5年,失访1例.按Engel分级,Ⅰ级22例,Ⅱ级2例,无Ⅲ级及以下病例.结论 MRI、VEEG、DLM定位下,部分病例参考磁共振波谱分析、正电子发射断层扫描结果,手术治疗难治性癫痫可以获得满意效果.     

智力评估在耐药性癫痫定侧中的价值

目的探讨智力评估对耐药性癫痫致痫灶的定侧价值。方法回顾性对比分析2011年8月~2013年8月经手术治疗的耐药性癫痫,筛选出105例有随访记录的且其术前智力评估结果中操作得分(PIQ)和言语得分(VIQ)差值大于15分的成人耐药性癫痫患者,比较IQ低值侧其与电生理+影像学得出的综合定位结果,并结合术后疗效分析。结果两者相一致组78例(78/105),吻合率74%。术后随访2~4年,标准按Engel分级,总优良率79%(Ⅰ级+Ⅱ级),83例。其中一致组有70例,占84.3%,非一致组13例,占15.7%。两组疗效对比,一致组优良率为89.7%(70/78),非一致组为48.1%(13/27),两者经统计学处理有显著差异(P0.01)。结论智力评定VIQ与PIQ差值大于15分,其低值侧对致痫灶侧评估有参考价值,可作为术前评估定侧参考指标之一。     

儿童难治性癫痫的外科治疗

目的 分析儿童难治性癫痫的病因、外科手术的适应证和预后.方法 回顾性分析采用外科手术治疗342例儿童癫痫的经验.结果 皮质发育障碍是本组儿童难治性癫痫的最重要病因,占18.4%.药物难治性癫痫综合征占13.5%.术后疗效Engel Ⅰ级158例,Ⅱ级76例,Ⅲ级61例,Ⅳ级47例.平均智商(1Q)从术前的69.2分提高到79.8分.术前显示智力低下者术后亦有明显改善.结论 早期外科干预能有效地控制癫痫发作、改善智力损害,智力低下不应是外科治疗的禁忌证.同时,正确认识儿童难治性癫痫的病凶和病理埘儿童癫痫的外科治疗具有重要作用.     

小儿顽固性癫痫的外科治疗

目的回顾性分析2002年6月至2007年6月间,在我院接受手术治疗的142例儿童顽固性癫痫患者的手术经验。方法术前评估和术中脑电检查显示为局灶性改变者行致痫灶切除或脑叶切除和（或）多软膜下横纤维切断（MST）。检查提示一侧半球为主多灶性改变者,术中行多脑叶切除联合MST和/或胼胝体部分切开。结果本组随访1～5年,平均3年。142例中有65例获得I级（Engel分级）,34例获得Ⅱ级,25例为Ⅲ级预后。有效率87.3%,效果优良率为69.7%。平均总智商（FIQ）从术前的65.4分提高到80.9分,癫痫病程和术前药物难治的时间越短,智商改善越明显。本组有16例出现暂时性的并发症,无手术死亡。结论对小儿顽固性癫痫患者,只要病例选择适当,手术方式合理,其手术效果是令人满意的,对这类患儿的早期外科干预,不仅可以有效地控制癫痫发作,而且可改善已有的智力损害和减少生活残疾。     

Interictal PET and ictal subtraction SPECT: Sensitivity in the detection of seizure foci in patients with medically intractable epilepsy

Purpose: Interictal positron emission tomography (PET) and ictal subtraction single photon emission computed tomography (SPECT) of the brain have been shown to be valuable tests in the presurgical evaluation of epilepsy. To determine the relative utility of these methods in the localization of seizure foci, we compared interictal PET and ictal subtraction SPECT to subdural and depth electrode recordings in patients with medically intractable epilepsy. Methods: Between 2003 and 2009, clinical information on all patients at our institution undergoing intracranial electroencephalography (EEG) monitoring was charted in a prospectively recorded database. Patients who underwent preoperative interictal PET and ictal subtraction SPECT were selected from this database. Patient characteristics and the findings on preoperative interictal PET and ictal subtraction SPECT were analyzed. Sensitivity of detection of seizure foci for each modality, as compared to intracranial EEG monitoring, was calculated. Key Findings: Fifty‐three patients underwent intracranial EEG monitoring with preoperative interictal PET and ictal subtraction SPECT scans. The average patient age was 32.7 years (median 32 years, range 1–60 years). Twenty‐seven patients had findings of reduced metabolism on interictal PET scan, whereas all 53 patients studied demonstrated a region of relative hyperperfusion on ictal subtraction SPECT suggestive of an epileptogenic zone. Intracranial EEG monitoring identified a single seizure focus in 45 patients, with 39 eventually undergoing resective surgery. Of the 45 patients in whom a seizure focus was localized, PET scan identified the same region in 25 cases (56% sensitivity) and SPECT in 39 cases (87% sensitivity). Intracranial EEG was concordant with at least one study in 41 cases (91%) and both studies in 23 cases (51%). In 16 (80%) of 20 cases where PET did not correlate with intracranial EEG, the SPECT study was concordant. Conversely, PET and intracranial EEG were concordant in two (33%) of the six cases where the SPECT did not demonstrate the seizure focus outlined by intracranial EEG. Thirty‐three patients had surgical resection and >2 years of follow‐up, and 21 of these (64%) had Engel class 1 outcome. No significant effect of imaging concordance on seizure outcome was seen. Significance: Interictal PET and ictal subtraction SPECT studies can provide important information in the preoperative evaluation of medically intractable epilepsy. Of the two studies, ictal subtraction SPECT appears to be the more sensitive. When both studies are used together, however, they can provide complementary information.     

结节性硬化症致难治性癫痫的手术处理

目的探讨手术治疗结节性硬化症所致难治性癫痫的适应证、方法和预后。方法回顾性分析了我院从2002年1月至2006年6月间,采用外科手术治疗10例结节性硬化症伴难治性癫痫的经验。术前评估和术中脑电检查显示为局灶性改变者行致痫灶切除、脑叶切除或多软膜下横纤维切断（MST）。检查提示一侧半球为主多灶性或弥漫性改变者,术中行多脑叶切除为主的联合手术方式。结果本组随访1～4年,平均2.5年。10例患者中有6例获得I级（Engel分级）,3例获得Ⅱ级,1例为III级。平均智商（IQ）从术前的59.6分提高到74.2分。本组3例患者出现暂时性的并发症,无手术死亡。结论外科手术是治疗结节性硬化症所致难治性癫痫的良好手段。表现为单致痫灶的患者预后较佳,虽有多结节,但临床资料、脑电图、影像学资料吻合的多致痫灶亦具有较好的手术效果。     

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.     

125例颞叶癫手术远期疗效分析

目的评价颞叶癫手术的远期疗效。方法回顾性分析125例颞叶癫手术患者,术前、术后进行全面评估。结果本组125例无手术死亡及严重并发症,术后随访2～3a,疗效按Engel的标准评定,Engel’s效果分级：I级（术后无癫发作）81例（64.80%）,Ⅱ级（极少发作,1～2次/a）20例（16.00%）,Ⅲ级（发作频率减少75%以上）16例（12.80%）,Ⅳ级（发作频率减少75%以下）8例（6.40%）,总有效率93.6%。结论外科手术治疗颞叶癫是一种安全、有效的方法,疗效理想。     

脑磁图定位顽固性癫痫手术治疗51例临床分析

目的　探讨脑磁图在顽固性癫痫术前评估的价值。方法　术前对 5 1例顽固性癫痫患者行脑磁图、磁共振及视频脑电检查 ,结合术中皮层脑电图分别进行选择性海马杏仁核切除术、标准前颞叶切除术及致痫灶切除术等手术 ;并用脑磁图定位神经导航下手术切除致痫灶 2例 ,神经导航下海马杏仁核切除 2例。结果　术后发作完全停止的占 76 5 % ,发作减少 >75 %的占 11 8% ,发作减少>5 0 %的占 5 8% ,发作减少不足 5 0 %的占 5 8% ;脑磁图与视频脑电及皮层脑电图的定位符合率分别为 82 %和 96 % ;脑磁图对内侧颞叶癫痫的定位敏感性较差 ;脑磁图定位导航手术可在切除致痫灶的同时保护脑的重要结构。结论　脑磁图是一项灵敏的无创性癫痫灶定位方法 ,是癫痫外科术前评估中的一项技术突破     

小儿难治性癫痫综合征的外科治疗

目的总结外科手术治疗27例小儿难治性癫痫综合征病人的经验。方法术前评估和术中脑电检查显示为局灶性改变者行致痫灶切除、脑叶切除或多软膜下横纤维切断(MST)。检查提示一侧半球为主多灶性改变者,术中行多脑叶切除联合MST或(和)胼胝体部分切开。结果本组随访1-8年,平均4.5年。27例病人中有14例获得Ⅰ级(Engel分级),8例获得Ⅱ级,3例为Ⅲ级。平均智商(IQ)从术前的61.4分提高到75.0分,癫痫病程和术前药物难治的时间越短,智商改善越明显。本组4例病人出现暂时性的并发症,无手术死亡。结论对小儿难治性癫痫综合征进行早期外科干预,可以有效地控制癫痫发作、改善智力损害和避免生活残疾。     

结节性硬化合并婴儿痉挛症的外科治疗

目的 探讨结节性硬化所致婴儿痉挛症的手术适应证、方法和预后.方法 回顾性分析采用外科手术治疗17例结节性硬化症伴婴儿痉挛症的经验.结果 术后疗效按Engel分级,Ⅰ级11例,Ⅱ级4例,Ⅲ级2例.术前评估为单致痫灶的2例患者均为Ⅰ级.局限在一侧大脑半球的8例多灶性癫痫患者中,6例Ⅰ级,2例Ⅱ级.双侧大脑半球均有致痫灶但以一侧为主的7例患者中,3例Ⅰ级,2例Ⅱ级,2例Ⅲ级.平均智商(IQ)从术前的52.6分提高到61.8分.结论 结节性硬化所致婴儿痉挛症具有良好的外科预后,对部分药物难治性患者在评估确定责任结节后可以考虑进行外科干预.

Abstract：

Objective To investigate the surgical indications, methods and outcomes of infantile spasms with tuberous sclerosis(TS). Method Surgical treatment of 17 infantile spasms patients with TS was reviewed. Single epileptogenic tuber or lobe was resected when a focal epileptic discharge was indicated according to preoperative evaluation and EcoG, and multiple lobes or tubers resection were chosen to deal with hemisphere limited multiple epileptic foci. Anterior corpus callosotomy was added when contralateral hemisphere showed epileptic discharges. Results Acording to follow - up of 3 years in average after surgery, 11 patients had an Engel Class Ⅰ outcome, 4 patients had rare seizure ( Engel Class Ⅱ ), and 2 patients had a reduction in seizure frequency (Engel Class Ⅲ ). The mean IQ of patients was improved from 52.6 to 61. 8. Conclusions Epilepsy surgery in tuberous sclerosis with infantile spasms showes a favourable outcome,and surgical intervention should be considered in some intractable infantile spasms after corresponding tuber is derermined.