癫痫的外科治疗

<正> 癫痫是由多种原因引起的、临床表王见为脑一过性功能障碍症候群的疾病,脑细胞的突然性异常放电导致癫痫患者出现发作性、反复性的脑功能紊乱。我国癫痫患病率约为7‰,目前有近千万癫痫患者,其中活动性癫痫占5‰。全部癫痫患者中约35%最终成为药物难治性癫痫患者,其中局限性发作约占活动性癫痫的70%。继发性癫痫中约2/3最终成为药物难治性癫痫。局限性发作、继发性癫痫中的药物难治性癫痫常需行切除性手术,是外科治疗的主要对象;遗传或代谢异常引起的特发性癫     

额叶癫痫的外科治疗

额叶癫痫是外科手术治疗的一种常见类型癫痫,约占癫痫外科手术病例的10%～20%.额叶位于大脑前部,包括中央沟以前的全部皮质区.额叶癫痫的外科治疗成败的关键在于如何准确定位致痫灶.额叶癫痫的外科治疗较颞叶癫痫复杂,其手术方式可分为两种:切除性手术和功能性手术.目前额叶癫痫外科治疗的有效率,各家报道不一,一般可达到50%～80%.     

药物难治性癫痫外科治疗展望

癫痫是危害较大的神经系统疾病,其发病率在4‰～6‰.在我国有近600万癫痫患者,其中20%～30%患者对内科药物治疗效果不佳,是癫痫外科治疗的主要目标[1,2].近二十年来,随着神经电生理技术和神经影像学的飞速发展,药物难治性癫痫患者的术前定位和评估取得了明显的突破,外科手术已成为癫痫治疗的一种重要手段[2].同时,随着外科麻醉和手术技巧的不断改进,尤其是显微神经外科技术的应用,使癫痫的外科治疗越来越安全有效,外科治疗已成为治疗药物难治性癫痫患者的主要手段[2,3].     

精神障碍性癫痫的外科治疗

精神障碍性癫痫是指智商(IQ)18岁前低于70分的癫痫发作。过去对该种癫痫是否外科治疗认识不一。随着癫痫诊治技术的进步,该病的外科治疗取得了良好效果。外科治疗方法有颞叶切除:治疗有效率达92％;颞叶外癫痫外科:致痫区+功能性皮质切除、额叶周边切除相当成功;多处软膜下横断:适用于功能性皮质致痫区;胼胝体切开:适用于失张力性发作、药物难治性发作、威胁生命的大发作;大脑半球切除:适用于一侧大脑半球萎缩、婴幼儿偏瘫和癫痫大发作,治疗后85％的病人发作停止。研究表明:术前IQ不能决定外科治疗癫痫的成败;低IQ病人致痫灶切除术后周边产生广泛致痫区,术后癫痫易复发;精神障碍是多因素的,该种病人不应列为手术禁忌症;外科治疗不仅使癫痫发作减少,同时也使脑功能恢复,精神障碍不同程度缓解。     

儿童癫痫的外科治疗策略

一、概述 WHO新近调查显示,我国的癫痫（epilepsy,EP）年发病率约为35～45／10万,患病率约7‰（其中活动性EP约为4．6‰）,而儿童EP（不含热性惊厥）的年发病率约为151／10万,患病率为3．45‰。由此可见,儿童EP是EP人群的主体,这种情况不仅在我国是这样,世界范围内也是如此。     

颞叶癫痫的外科治疗

颞叶癫痫为最常见的顽固性癫痫,是外科治疗的主要对象。本文就近年来有关颞叶癫痫外科治疗的依据和方法及各种手术入路的进展作一综述。     

88例顽固性癫痫的外科治疗

目的　探讨顽固性癫痫外科治疗的适应证、手术方法及临床疗效。方法　对 88例顽固性癫痫患者行外科治疗 ,其中 71例行立体定向手术 ,8例行胼胝体前部切开术 ,4例行前颞叶切除术 ,4例行致痫灶切除术 ,1例行致痫灶切除 前颞叶切除 多处软脑膜下横切术 (MST)。术后随访 1年以上。结果　 2 0例(2 2 .8% )癫痫发作完全消失 ;36例 (4 0 .9% )癫痫发作显著减少 ;15例 (17.1% )效果良好 ;疗效差 9例(10 .2 % ) ;无明显改善 7例 (7.9% ) ;死亡 1例 (1.1% )。手术总有效率为 80 .8% ,显效率为 6 3.7%。通过分析不同术式 ,发现以前颞叶切除术疗效最好 ,胼胝体切开术效果最差。结论　外科手术是治疗顽固性癫痫的一种有效方法 ,但手术前应准确定位致痫灶 ,并选择适当的手术方式 ,以取得最佳的治疗效果     

难治性癫痫的放射外科治疗

难治性癫痫 ,又称顽固性癫痫 ,指癫痫发作频繁、应用适当的第一线抗癫痫药物正规治疗且药物血浓度在有效范围内两年以上、仍不能控制发作且影响日常生活。约有 2 0 %的癫痫病人随着病情发展或治疗不当 ,可能转变为难治性癫痫。容易导致难治性癫痫的因素有 :(1)复杂部分性发作、婴儿痉挛及 L ennox- Gastaut综合征等 ;(2 )发作频繁 ,每天数次 ;(3)出现过癫痫持续状态 ;(4 )对发作频率判断错误 ;(5 )起病后延误治疗 ;(6 )不适当的多种药物联合应用 (包括中药 ) ;(7)同一期间内在几个医疗单位应用不同的治疗计划 ;(8)对合并的精神心理障碍认识…     

外科治疗顽固性癫痫的临床新认识

顽固性癫痫往往不能被药物所控制,而需要依靠外科手术进行治疗.文章根据国内外有关文献,从癫痫手术的机制、方式和疗效等方面阐述了顽固性癫痫外科治疗进展.认为外科手术能有效控制顽固性癫痫的发作,但仍需要进一步大规模随机对照临床试验进行评估.     

Surgical treatment for epilepsy

Nearly one-third of patients with newly diagnosed epilepsy will develop medically refractory seizure disorders. The initial response to antiepileptic drug therapy is highly predictive of long-term outcome. Patients with intractable epilepsy may have a progressive disorder that is medically, physically, and socially disabling. Surgical resection of the epileptogenic zone or lesional pathology, or both, may significantly reduce seizure tendency in selected patients. The present review supports the position that early and effective epilepsy surgery may not only render the patient with intractable partial epilepsy seizure-free, but also allow the individual to become a participating and productive member of society. Patients with surgically remediable epileptic syndromes should be identified early in the evaluation and treatment of their seizure disorders. Favorable candidates for focal cortical resection include individuals with medial temporal lobe epilepsy and partial seizures related to selected lesional pathology, e.g. primary brain tumor or vascular anomalies. In conclusion, surgical treatment of intractable partial epilepsy has been shown to compare favorably to antiepileptic drug therapy. Individuals rendered seizure-free may experience a significant improvement in quality of life. Patients who fail to respond to initial antiepileptic drug therapy should be “triaged” to a presurgical evaluation. Ictal semiology combined with structural magnetic resonance imaging and the electroclinical correlation may permit identification of candidates for early and effective surgical treatment.     

儿童蛛网膜囊肿伴癫癎的外科治疗(附13例报告)

目的 探讨儿童颅内蛛网膜囊肿（ａｒａｃｈｎｏｉｄ ｃｙｓｔ,ＡＣ）与癫癎的关系以及外科治疗方法。方法 手术治疗颅内蛛网膜囊肿伴癫癎的儿童１３例,其中额叶２例,顶叶１例,颞叶８例,枕叶２例,囊肿直径在３ｃｍ以下３例,３～６ｃｍ ９例,６ｃｍ以上１例,均采用颅内蛛网膜囊肿加致癎灶切除。结果 １３例病人中,完全不发作有４例,显著改善有７例,无变化２例。结论 儿童颅内蛛网膜囊肿伴癫癎具有脑皮质结构性异常,采用颅内蛛网膜囊肿加致癎灶切除效果较为理想。     

A population‐based study of newly diagnosed epilepsy in infants

Purpose: Most published data on infants presenting with epilepsy originate from hospital/specialist clinic settings and may therefore not be representative of the general population. We carried out a population‐based study to estimate the incidence of epilepsy onset in infants, to characterize the range of phenotypes and associated structural brain abnormalities, and to determine whether specific epilepsy diagnoses could be established at onset. Methods: Children between 1 and 24 months of age with new‐onset epilepsy were ascertained over 13 months from the residents in 15 boroughs of North London. Classification based on clinical information, electroencephalography (EEG), and neuroimaging data was undertaken independently by two pediatric neurologists. Neuroimages were reviewed by two neuroradiologists blinded to clinical details. Key Findings: A total of 57 children were enrolled giving an ascertainment‐adjusted incidence of 70.1 (95% CI [56.3, 88.5])/100,000 children ≤2 years of age/year (ascertainment 76%). The incidence was highest among Asian children. An electroclinical syndrome was identified in 24 (42%) cases of which 21 were epileptic encephalopathies. Magnetic resonance (MR) images of 51 cases (89% of the total cohort) were reviewed. These demonstrated positive findings in 37 (72%) of 51 cases, of which 26 (51%) of 51 were etiologically relevant, and included developmental malformations in 11 (21%) of 51. Significance: In a population setting infantile onset epilepsy presents mostly with complex phenotypes commonly associated with structural brain abnormalities. Routine MR imaging at presentation is therefore justified. However, identification of specific electroclinical syndromes remains difficult at onset.     

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.     

病灶性癫痫的手术治疗及影响其预后的因素分析

目的 探讨病灶性癫痫的手术方法，并分析影响手术预后的一些因素。方法 回顾性地分析自2001年4月～2003年4月之间在我研究所接受手术治疗的所有病灶性癫痫患者的临床资料。33例患者手术后随访时间皆在1年或1年以上。按照Engel疗效分级标准，将其分为效果满意组与不满意组，对术前临床特点、电生理情况、手术方法等因素进行分析比较。结果 手术后效果满意率为73％。下列因素与手术效果有相关性：癫痫患病时间、发作频率以及脑电图发作间期痫性放电是否局限在病灶的脑叶上。另一方面，比较发病时年龄、是否有既发全面强直阵挛性发作以及是否完全切除术中皮层脑电监测(ECoG)为阳性的皮层三个因素，两组间无显著差异。不满意组中，皮质发育不全的患者占多数。结论 对于病灶性癫痫，手术采用病灶与周围致痫灶同时切除的方法，可获得满意的效果。癫痫患病时间、发作频率以及脑电图发作间期痫性放电是否局限在病灶的脑叶上与手术的效果有一定的相关性。     

Outcome of hemispheric surgeries for refractory epilepsy in pediatric patients

BACKGROUND: Hemispheric brain lesions are commonly associated with early onset of catastrophic epilepsies and multiple seizure types. Hemispheric surgery is indicated for patients with unilateral intractable epilepsy. Although described more than 50 years ago, several new techniques for hemispherectomy have only recently been proposed aiming to reduce operatory risks and morbidity. MATERIALS AND METHODS: We present the clinical characteristics, presurgical workup, and postoperative outcome of a series of pediatric patients who underwent hemispherectomy for medically intractable epileptic seizures. Thirty-nine patients with medically intractable epilepsy underwent surgery from 1996 to 2005. RESULTS AND DISCUSSION: We analyzed demographic data, interictal and ictal EEG findings, age at surgery, surgical technique and complications, and postsurgical seizure outcome. There were 74.4% males. Tonic and focal motor seizures occurred in 30.8 and 20.5% of the patients. Most frequent etiologies were Rasmussen encephalitis (30.8%) and malformation of cortical development (23.1%). Postsurgical outcomes were Engel classes I and II for 61.5% of the patients. In general, 89.5% of the patients exhibited at least a 90% reduction in seizure frequency. All patients had acute worsening of hemiparesis after surgery. Basically, two surgical techniques have been employed, both with similar results, although a trend has been noted toward one of the procedures which produced consistently complete disconnection. Patients with hemispheric brain lesions usually have abnormal neurological development and intractable epilepsy. When video-EEG monitoring and magnetic resonance imaging show unilateral disease, the patient may evolve with a good surgical outcome. We showed that a marked reduction in seizure frequency may be achieved, with acceptable neurological impairments.     

Surgical treatment of epilepsy: our experiences with 34 children

Surgical treatment of medically intractable epileptic fits in children is highly specialized, owing to the specific etiology of epilepsies in this age group and the epileptogenic property of the brain in childhood. In our series of 340 patients operated on for medically intractable epileptic seizures, there were 34 (10%) patients up to 15 years of age (the youngest was 2 years old; mean age was 11 years). This group of patients comprises four subgroups: 9 patients with temporal foci, 6 patients with extratemporal foci, 16 patients with infantile hemiplegia and epilepsy, and 3 patients with epilepsia partialis continua (Kozhevnikov's disease). Preoperatively, detectable brain lesions were present in 30 (88%) cases, a much higher frequency than in adult surgical series. Postoperative follow-up so far is 1–14 years (mean, 4 years). Surgical outcome in this group of 34 patients is as follows: 21 (62%) are seizure-free, 8 (23%) have improved, and 5 (15%) have shown no improvement.     

Discontinuation of anticonvulsant medication after epilepsy surgery in children

PURPOSE: To evaluate the long-term outcome of medication-reduction/discontinuation trials after epilepsy surgery in pediatric patients. METHODS: Of the total Bonn pediatric surgical sample (1988-2001; n=251), we were able to obtain postsurgical follow-up data for 232 patients. We surveyed 140 of these patients by using a standardized telephone interview that addressed medication-reduction/discontinuation trials. RESULTS: Of the 140 surveyed patients, 102 completely discontinued medication. Seven of these patients had recurring seizures that were controlled again after restarting the medication. Of 102 patients, 101 were completely seizure free during the 3 months before the survey. Postsurgical epileptic events before the trial significantly increased the risk for recurring epileptic events after the trial. Two surveyed patients lost postsurgical seizure freedom after medication reduction. We were also able to identify from the records another nine patients with complete medication discontinuation and seven patients with medication reduction. Two of these latter patients lost postsurgical seizure freedom despite restarting their medication. The total rate of patients with medication-reduction/discontinuation trials was 55%. The seizure recurrence rate in these patients was 10%. Recurring seizures could not be controlled by restarted medication in 3% of the trials. Currently, 90% of patients with discontinuation trials were seizure free without medication. CONCLUSIONS: The reduction/withdrawal of anticonvulsant medication after successful epilepsy surgery has a low risk of seizure recurrence for pediatric patients in long-term follow-up, particularly in cases of complete postsurgical seizure freedom before the trial.