皮层电极监测下切除致痫性脑胶质瘤的临床研究

目的探讨致痫性脑胶质瘤的手术治疗方法。方法术中使用皮层电极和深部电极对相应部位皮层脑电进行监测，确定痫性放电的部位及范围，行肿瘤切除＋致痫灶切除、皮层热灼或软膜下横切。肿瘤切除后再行脑电监测，若仍有癫痫波，再行切除。结果本组51例中，38例肿瘤全切，8例次全切，5例部分切除。术后一过性偏瘫或失语8例。随访6～57个月，按谭氏分级：Ⅰ级32例，Ⅱ级7例，Ⅲ级5例，Ⅳ级4例，V级3例；胶质瘤复发8例，且均伴有癫痫发作。结论皮层电极监测下切除致痫性胶质瘤是治疗伴有癫痫症状的脑胶质瘤的有效方法，能提高患者的生存质量。     

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。     

术前视频脑电图及术中皮层脑电图定位继发性癫痫175例分析

目的探讨皮层脑电监测定位指导继发性癫痫手术切除方式、范围及术后疗效。方法对2005-06-2013-06我院神经外科收治的175例继发性癫痫患者术前行视频脑电监测定位,致痫灶与病灶相一致,相近或相侧的情况下,手术中再用皮层及深部电极行皮层脑电图监测定位,并在其指导下联合多种手术方式切除原发病灶及致痫灶,术后定期复查,随访6~60个月。结果根据ILAE疗效分级标准进行疗效评价:1级52例,2级41例,3级27例,4级26例,5级18例,6级11例,总有效率93.0%。结论对继发性癫痫发作患者,术前行视频脑电监测定位,术中再进行皮层脑电监测定位病灶与癫痫灶的关系,并在其指导下联合多种手术方法切除和处理癫痫灶,采取病灶+致痫灶的手术切除方法,可明显降低术后癫痫发生率。     

皮层电极监测下切除致痫性脑胶质瘤的临床研究

目的使用皮层电极监测切除致痫性脑胶质瘤，探讨致痫性脑胶质瘤的治疗方法。方法本组病人43例。EEG示轻度异常脑电图9例，巾度异常脑电罔26例，重度异常脑电图8例。CT或MRI检查皆可见占位病变。常规手术开颅显露相应部位脑皮层使用皮层电极对脑电进行监测。确定大体致痫范围，行肿瘤切除。肿瘤切除后再行脑电监测，若仍有癫痫波，根据皮层电极之定位切除致痫灶。结果22例病人行显微镜下肿瘤全切除，15例病人近全切除肿瘤．6例病人次全切除肿瘤。术后随访6个月～6年。34例(79．1％)病人癫痫症状消失，7例(16.3％)病人癫痫发作次数明显减少，2例(4．7％)病人癫痫症状未见好转。总有效率(93．7％)。结论以癫痫为主要症状的脑肿瘤病人．只有在切除胶质瘤时一并切除致痫灶，才是治疗肿瘤并根治癫痫的最佳方法。皮层电极监测下切除致痫性脑胶质瘤是治疗有癫痫症状的脑胶质瘤的有效方法。     

伴有癫痫发作的脑内病灶的手术治疗

目的 研究伴有癫痫发作的脑内病灶的手术治疗效果。方法 本组24例病人中，EEG示13例有局部痫样波，5例局灶慢波，6例正常。在皮质脑电图(ECoG)监测下手术．11例痫灶位于病灶表面或紧邻其边缘，行病灶 痫灶切除；8例痫灶距病灶10mm以上，其中6例位于非功能区，行病灶 痫灶切除；2例位于功能区，行病灶切除及热凝痫灶皮质；2例痫灶位于前颞叶深部，行前颞叶及病灶切除。3例ECoG正常，仅行病灶切除。结果 21例痫灶切除病人中，15例(71％)术后癫痫完全消失，2例(10％)发作显减少，4例(19％)发作减少。结论 对伴有癫痫发作的脑内病灶病人，术中ECoG及深部电极有助于精确定位痫灶；切除病灶、痫灶，效果良好。     

额叶癫痫的特点及手术治疗

目的 :分析额叶癫痫的临床特征、发作期及发作间期脑电图特点 ,探讨额叶癫痫手术治疗。方法 :应用视频脑电图对 9例额叶癫痫患者进行长程监测 ,并对其中 6例记录颅内脑电图。分析癫痫发作的临床表现及脑电图特点 ,定位致痫灶 ,行手术切除。结果 :额叶癫痫的发作特点为 :发作频繁而短暂 ,以睡眠期发作为主 ,常见过度运动 ,姿势性强直 ,发声等发作症状。发作期可见棘波节律 ,广泛低幅快活动 ,节律性慢波等特征性脑电活动。颅内电极记录可清晰显示异常脑电活动的发作起源及扩散情况 ,有助于定位致痫灶。手术切除病灶及致痫灶 ,效果满意。结论 :额叶癫痫是一组具有特征性的癫痫综合征 ,颅内电极记录有助于揭示其脑电活动变化。对于难治疗性额叶癫痫 ,准确定位致痫灶是手术成功的关键。     

难治性癫痫的外科治疗(附36例临床分析)

目的探讨难治性癫痫的致病灶定位和术式选择。方法回顾分析36例难治性癫痫患者的临床资料,术前均行视频脑电监测(VEEG)和CT/MR检查,结合临床症状定位致痫灶。采用颞前叶及海马、杏仁核切除+广泛致痫皮层低功率电凝热灼25例;额叶癫痫+周围皮层低功率皮层热灼术5例,病灶及周围皮层切除+低功率皮层热灼术4例,行单侧病灶切除+胼胝体前部切开+致痫皮层低功率电凝热灼2例。结果经6个月至3年的随访,满意29例,显著改善5例,良好2例。结论部分性发作的癫痫患者,最可靠的治疗方法是致痫灶的切除,但对于全面性发作的病人,其致痫区往往比较广泛而无法切除,联合皮层热灼术可以减少发作频率、减轻发作程度和改变发作形式,提高治疗效果。准确定位致病灶,选择恰当的手术方式是外科治疗难治性癫痫取得良好效果的关键。     

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。     

皮层电极监测下切除致痫性脑胶质瘤的临床研究

目的使用皮层电极监测切除致痫性脑胶质瘤,探讨致痫性脑胶质瘤的治疗方法.方法本组病人35例,男19例,女16例.术前行EEG、CT或MRI检查.EEG示轻度异常脑电图7例,中度异常脑电图22例,重度异常脑电图6例.CT或MRI检查皆可见占位改变.其中额叶11例,颞叶8例,额顶叶7例,顶叶5例,颞枕叶3例,岛叶深部1例.常规手术开颅显露相应部位使用VEEG1161型伟思脑电图仪对皮层脑电进行监测.监测范围包括全部肿瘤,重点于肿瘤周边脑组织.确定大体致痫范围,行肿瘤切除.肿瘤切除后再行脑电监测若仍有癫痫波,根据皮层电极之定位切除致痫灶.直至致痫灶全部切除.对疑有深部癫痫灶者,使用深部电极经皮层穿刺对深部脑组织进行监测描记.对重要脑功能区予以保护.结果全部病人皆行显微镜下肿瘤全切除.病理证实星形细胞瘤8例,间变性星形细胞瘤13例,少突胶质细胞瘤7例,间变性少突胶质细胞瘤5例,胶质母细胞瘤2例.术后随访6个月～5年.未再发生癫痫者29例(82.9%);总有效率94.3%.结论只有在切除胶质瘤时一并切除致痫灶,才是治疗肿瘤并根治癫痫的最佳方法.使用皮层电极监测胶质瘤的切除,具体很多优点.     

枕叶癫痫的临床特征分析及手术治疗

目的：癖结枕叶癫痫的临床特征及手术效果,方法：对病人进行电生理学,CT,MRI及ECT检查,手术中行皮层脑电监测,结果,枕叶癫痫病人31例,年龄3至34岁,临床主要表现有视觉异常发作,头偏转,颞叶样或（及）额顶样发作,头皮脑电显示31例病人中30例枕叶或枕叶及周围脑叶出现棘波,CT检查27例中24例异常,MRI检查9例中8例异常,ECT检查13例中11例术区皮层血流减少,所有病人均在皮层脑电监测下切除病灶,术后随访到22例（时间1至4年）,11列无痫发作,其余明显好转,结论,枕叶癫痫的临床特点包括,视觉异常发作,癫痫发作形式多样,枕叶区域异常脑电及影像学改变,手术切除病灶能获得好效果。     

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.     

伴有癫癇发作的脑内病灶的手术治疗

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难治性癫过度运动发作的临床特征与致灶定位

目的总结以过度运动发作为主要表现的药物难治性癫的诊疗经验。方法回顾性分析25例药物难治性癫病人的临床资料,均以过度运动发作为主要表现。根据症状特点、MRI、头皮视频脑电图及颅内脑电图监测,综合定位致灶,并行手术切除。结果切除额叶致灶23例,切除前颞叶致灶2例。神经病理学检查显示:皮质发育不良(FCD)Ⅰ型8例,FCDⅡ型12例,节细胞胶质瘤1例,皮质微发育不良1例,灰质异位1例,胶质瘢痕1例,海马硬化1例。术后随访12~60个月,按Engel分级:Ⅰ级19例,Ⅱ级2例,Ⅲ级2例,Ⅳ级2例。结论以过度运动发作为特点的难治性癫病人,其致灶主要位于额叶,但也可位于额叶外的脑区,准确切除致灶后疗效满意。     

惊吓性癫痫的临床、脑电图特征及手术治疗

目的 探讨惊吓性癫痫的临床、脑电图(EEG)特征及手术治疗效果.方法 回顾性分析经抗癫痫药物或手术治疗的9例惊吓性癫痫的临床资料,总结发作症状学,头皮EEG,颅内EEG及头颅MRI特点,随访手术治疗效果.结果 所有患者的多数发作均由惊吓诱发,仅2例存在少量自发发作.8例MRI发现结构性病变,头皮EEG显示多灶性或局灶性癫痫样放电.2例行颅内电极监测,对致痫灶进行了较精确的定位.5例手术治疗,3例大脑半球切除术,2例局部癫痫灶切除.术后随访6-30个月(平均18.6个月),Engel Ⅰ级4例,Engel Ⅲ例1结论多数惊吓性癫痫患者存在脑的结构性损害,损害范围通常广泛,并均包含初级感觉运动区或辅助性感觉运动区.惊吓性癫痫多药物难治,手术治疗可取得较好的效果,明显改善患者的预后.

Abstract：

Objective To study the clinical, scalp and intracranial electroencephalogram (EEG) characteristics of startle epilepsy, and its outcome of surgical treatment. Methods The clinical data of 9 patients with startle epilepsy who were treated in our hospital were reviewed retrospectively. Their scalp and intracranial EEG, and MRI were investigated. Results All of the patients were diagnosed as startle epilepsy, and most of seizures were provoked by sudden unexpected stimuli. MRI showed extensive lesions in 8 cases, scalp EEC showed mulifocality or focal epilepsic discharge in all. Intracranial electrodes monitoring were performed in 2 patients to locate the epileptogenic zone. Five patients were treated surgically, 3 of them were operated with hemispherectomy, and 2 with focal cortex resection. During 6-30 months follow up, the seizure outcome were Engel I grade in 4,and Engel Ⅲ grade in 1. Conclusions Most of the patients with startle epilepsy has brain lesions involving the perisensorimotor or supplementary sensorimotor area, and were refractory. Resective surgery may get satisfactory outcome.     

Positron emission tomography in presurgical localization of epileptic foci

The success of cortical resection for intractable epilepsy of neocortical origin is highly dependent on the accurate presurgical delineation of the regions responsible for generating seizures. In addition to EEG and structural imaging studies, functional neuroimaging such as positron emission tomography (PET) can assist lateralization and localization of epileptogenic cortical areas. In the presented studies, objectively delineated focal PET abnormalities have been analyzed in patients (mostly children) with intractable epilepsy, using two different tracers: 2-deoxy-2-[18F]fluoro-D-glucose (FDG), that measures regional brain glucose metabolism, and [11C]flumazenil (FMZ), that binds to GABAA receptors. The PET abnormalities were correlated with scalp and intracranial EEG findings, structural brain abnormalities, as well as surgical outcome data. In patients with extratemporal foci and no lesion on MRI, FMZ PET was more sensitive than FDG PET for identification of the seizure onset zone defined by intracranial EEG monitoring. In contrast, seizures commonly originated from the border of hypometabolic cortex detected by FDG PET suggesting that such areas are most likely epileptogenic, and should be addressed if subdural EEG is applied to delineate epileptic cortex. In patients with cortical lesions, perilesional cortex with decreased FMZ binding was significantly smaller than corresponding areas of glucose hypometabolism, and correlated well with spiking cortex. Extent of perilesional hypometabolism, on the other hand, showed a correlation with the life-time number of seizures suggesting a seizure-related progression of brain dysfunction. FMZ PET proved to be also very sensitive for detection of dual pathology (coexistence of an epileptogenic cortical lesion and hippocampal sclerosis). This has a major clinical importance since resection of both the cortical lesion and the atrophic hippocampus is required to achieve optimal surgical results. Finally, the author demonstrated that in patients with neocortical epilepsy, FDG PET abnormalities correctly regionalize the epileptogenic area, but their size is not related to the extent of epileptogenic tissue to be removed. In contrast, complete resection of cortex with decreased FMZ binding predicts good surgical outcome suggesting that application of FMZ PET can improve surgical results in selected patients with intractable epilepsy of neocortical origin.     

Paradoxical lateralization of non-invasive electroencephalographic ictal patterns in extra-temporal epilepsies

Video-electroencephalographic (EEG) ictal recordings play an important role in the pre-surgical evaluation of patients with medically refractory focal epilepsy. Paradoxical lateralization of the scalp EEG ictal onset patterns, consistently contralateral to the side of the proven epileptogenic lesion is rare but important to recognize, with possible implications on patient management. We searched the database of the University of Munich Epilepsy Monitoring Unit for patients with extratemporal epilepsies, with scalp EEG ictal patterns consistently contralateral to the proven epileptogenic zone. All available clinical, EEG and imaging data were reviewed. Dipole source analysis of EEG seizure onset was performed where possible. Four patients were identified, who had proven paradoxical lateralization of scalp EEG ictal patterns, demonstrated by seizure freedom after epilepsy surgery, data from invasive electroencephalography, or imaging and seizure semiology. Parasagittal lesions on MRI brain scan were found in three cases. Invasive recordings with subdural electrodes were performed in one patient. Dipole source analysis of EEG seizure onset was possible in two patients, helping to correctly lateralize the ictal EEG pattern in one patient. Patients with midline or near midline neocortical seizure foci may show paradoxical lateralization of the ictal EEG, likely due to the spatial orientation of the cortical generators in the medial regions of the cerebral hemispheres. These patients may have excellent surgical outcome despite the apparently discordant EEG findings, making this an important phenomenon to be recognized in clinical practice.     

Ganglioglioma and Intractable Epilepsy: Clinical and Neurophysiologic Features and Predictors of Outcome After Surgery

Summary: Purpose: To review the clinical, neurophysiologic, and radiological data of patients with ganglioglioma who had undergone evaluation and surgery in our Epilepsy Program.
Methods: The medical and neurophysiologic records of 38 patients with intractable epilepsy and ganglioglioma were re- viewed. Data underwent statistical analysis.
Results: There were 28 temporal and 10 extratemporal resections, with a mean age at seizure onset of 10.5 years and mean age at surgery of 22 years. Five tumor resections performed earlier were recorded. Twenty-nine patients had auras and 20 had secondarily generalized seizures. All 28 patients with temporal tumor had complex partial seizures. Preoperative MRI demonstrated the tumor in 36 of 36 patients: 17 of 29 demonstrated gadolinium enhancement, and 17 of 36 had mass effect. Scalp interictal sharp waves were present in 32 patients, and in 15 they were multiregional. In two patients, scalp EEG seizure onset was from the hemisphere contralateral to the tumor. Postoperatively, 79% of patients (30 of 38) were seizure-free (Engel's class I) at 6 months, 72% at 1 year (26 of 36), and 63% at 2 years (20 of 32). Excellent outcome was associated with a lower age at operation (p = 0.008), shorter duration of epilepsy (p = <0.01), absence of generalized seizures (p = <0.01), and no epileptiform discharges on a postoperative EEG (p = 0.01).
Conclusions: Good surgical outcome is expected in patients with ganglioglioma despite years of medically resistant seizures. Good outcome may be achieved despite EEG findings that may conflict with tumor location, and is more likely when surgery is performed relatively soon after epilepsy onset.     

难治性枕叶癫痫的术前定位与手术治疗

目的探讨难治性枕叶癫痫的术前定位与手术方法。方法对经手术治疗且随访时间6个月以上的9例枕叶癫痫患者的临床资料进行回顾性分析。采用发作症状评估、影像学检查、长程视频头皮脑电图监测、颅内电极脑电图记录等方法综合术前定位。根据术前定位确定的致痫灶部位与范围采用不同的手术方法。7例病人采用颅内电极置入术来精确定位。局部枕叶皮层切除2例,枕叶大部或全部切除4例,全枕叶或后头部脑叶离断3例;同期经枕入路切除或离断颞叶内结结构3例。结果术后随访6个月至2年,术后癫痫无发作6例,发作1次1例,发作减少90%以上2例。结论难治性枕叶癫痫经手术治疗可以取得较好的疗效,颅内电极脑电图记录有助于致痫灶准确定位,并指导术中切除部位与功能保护。     

A Comparison of Magnetoencephalography, MRI, and V-EEG in Patients Evaluated for Epilepsy Surgery

PURPOSE: To determine the efficacy and relative contribution of several diagnostic methods [ictal and interictal scalp and intracranial EEG, magnetic resonance imaging (MRI), and magnetoencephalography (MEG)] in identifying the epileptogenic zone for resection. METHODS: This was a prospective study using a masked comparison-to-criterion standard. Fifty-eight consecutive patients with refractory partial epilepsy from two university comprehensive epilepsy programs were studied. Patients who were evaluated for and underwent epilepsy surgery were recruited. The main outcome measure was the efficacy of each diagnostic method to identify the resected epileptogenic zone, when referenced to surgical outcome. RESULTS: MEG (52%) was second only to ictal intracranial V-EEG in predicting the epileptogenic zone for the entire group of patients who had an excellent surgical outcome (seizure free or rare seizure). In a subanalysis, for patients who had temporal lobe surgery, this same relation was seen (MEG, 57%, ictal intracranial V-EEG, 62%). With extratemporal resection, ictal (81%) and interictal (75%) intracranial EEG were superior to MEG (44%) in predicting the surgery site in those patients with an excellent outcome. Finally, for all patients who had a good surgical outcome, MEG (52%) was better than ictal (33%) or interictal (45%) scalp VEEG in predicting the site of surgery. CONCLUSIONS: These results indicate that MEG is a very promising diagnostic method and raise the possibility that it may obviate the need for invasive EEG in some cases or reduce the length of scalp EEG evaluation in others.