顽固性癫癎的外科联合手术治疗

目的探讨联合手术治疗顽固性癫癎的方法和临床疗效。方法对45例顽固性癫癎患者行联合手术治疗。手术方式:多处软脑膜下横切术(multiplesubpialtransection,MST)+致癎病灶切除+胼胝体前部切开术3例;MST+胼胝体前部切开术11例;MST+致癎病灶切除19例;MST+立体定向杏仁核海马毁损术12例。术中进行皮层电极及深部电极监测。结果术中进行皮层电极检测定位更精确。患者术后随访3-28个月,发作完全控制17例(37.78%),显著改善24例(53.33%),良好2例(4.44%),效差2例(4.44%),术后神经功能均保存完好。结论联合手术治疗顽固性癫癎是一种安全有效的方法。     

应用多种手术方式治疗顽固性癫(癎)的临床研究

目的针对不同类型的顽固性癫癎病人,评估单独应用癫癎病灶切除术与联合应用多种手术方式治疗癫癎临床效果。方法手术治疗顽固性癫癎病人80例,其中53例采用几种术式结合的方法;每个病人术前均经过2年以上的正规系统的抗癫癎药物治疗,仍不能控制癫癎发作,每月发作3~4次以上;癫癎发作形式为单纯部分性发作,复杂部分性发作,强直-阵挛性发作以及伴失神发作;采用的手术方式:术中均进行皮层脑电描记(EcoG);局部致癎灶切除术27例,局部致癎灶切除术 多处软膜下横纤维切断术(MST)11例,局部致癎癎灶切除术 MST 皮层热灼术9例,局部致癎灶切除术 胼胝体前部切开术 颞前叶及海马切除术 MST33例。结果80例手术病人术后无死亡,术后2例脑水肿,1例颅内出血,1例肾功能衰竭;术后均服用一种抗癫癎药物,随访6~24个月,51例癫癎临床发作完全消失(63.8%),12例较术前显著改善(15.0%),8例有效(10.0%),6例效果差(7.5%),3例无效(3.8%);手术总有效率为88.8%,优良率为78.8%。结论应用多种手术方式治疗顽固性癫癎有满意疗效。     

顽固性癫癎的联合性手术治疗分析

目的探讨顽固性癫癎的几种联合性手术治疗的临床效果。方法48例顽固性癫癎患者中,10例病灶位于功能区,采用病灶切除加多处软脑膜下横切(MST);22例病灶及致癎灶位于非功能区,采用病灶、致癎灶切除加周边区MST;11例病灶位于侧裂、前颞叶内或癎灶位于颞叶内,采用病灶、前颞叶切除加颞叶新皮层MST;3例致癎灶广泛存在于一侧或双侧大脑半球,采用广泛性额叶MST加胼胝体前2/3切开。结果本组48例无手术死亡及严重并发症。术后随访0.5~5年,平均3.4年。有效率(发作频率减少50%以上)91.67%,显效率(发作频率减少75%以上)81.25%,效差或无效8.33%。结论顽固性癫癎的联合性手术治疗疗效确切可靠。     

多处软膜下横纤维切断术联合其他术式治疗顽固性癫癎手术疗效分析

目的总结多处软膜下横纤维切断术(MST)联合其他术式治疗顽固性癫癎的手术经验.方法回顾性分析163例顽固性癫癎病人的临床资料.根据术前脑电图、单光子发射断层扫描(SPECT)、正电子发射断层扫描(PET)、CT及MRI检查,结合术中皮质电极脑电图探测结果,标出致癎灶地域图.在显微镜下先行脑结构性病灶切除.反复复查皮质脑电图,对周围和广泛性棘波发放区施行MST,直至皮质脑电图结果正常.结果术后疗效优(癫癎发作完全消失)52例(31.9%),良(偶有发作)83例(50.9%),中(发作频率减少50%)10例(6.1%),差15例(9.2%),无改善3例(1.9%);手术总有效率88.9%.结论采用MST联合其他术式治疗癫癎疗效较好,可提高病人的生活质量.     

多处软膜下横切术在功能区癫癎手术中的应用

目的 探讨对致癎灶位于脑主要功能区的癫癎病人,采用病灶切除加多处软膜下横切术(multiple subpial transection,MST)的治疗效果.方法 选择20例继发性癫癎病人,在术中硬脑膜切开后,先用皮层电极核实致癎灶的方位和范围,在显微镜下切除非功能区的病灶及其周围的皮层致癎灶;对功能区的病灶也予以切除.第二次用皮质脑电图检查,对功能区存在的或残留的致癎灶(棘波),使用软膜横切刀,切断癎性放电传导的神经元树突.最后用皮层电极复查,如仍有棘波存在,再补行几道横切,直至脑电波全部趋于正常为止.结果 在癫癎控制方面,除1例无改善外,其他14例都得到不同程度的控制.随访1～35个月,满意6例,显著改善6例,良好5例,较差2例,无改善1例,总有效率为95%.结论 MST能使脑主要功能区癫癎在不引起任何机能损害的情况下,术后癎性发作得到有效的控制,是神经外科目前治疗功能区顽固性癫癎的有效方法之一.     

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。     

胼胝体切开术治疗儿童药物难治性癫(癎)

目的 探讨胼胝体切开术治疗无法行局灶性切除的儿童药物难治性癫(癎)的安全性及有效性.方法 回顾性分析113例儿童药物难治性癫(癎)病人的临床资料,均行胼胝体切开术.结果 术后发作完全消失77例(68.1％),发作减少90％以上21例(18.6％),其中失张力性发作病人术后发作完全消失和发作减少90％以上者分别占94.1％和5.9％,而全身强直性发作病人为8.3％和75.0％.术后出现短暂的主动性语言减少3例,并在术后6-8d内恢复.随访113例,时间12个月～5年,病人精神发育状态均有不同程度的改善,无发作加重病例.结论 胼胝体切开术是治疗儿童药物难治性癫(癎)的一种安全有效的方法,特别是对失张力性发作和全身强直性发作效果更佳.     

联合应用皮质(癎)灶热灼术治疗继发性癫(癎)

目的分析总结继发性药物难治性癫癎的临床特点,讨论如何改进手术方法．将几种手术结合使用并对手术效果进行评价。方法回顾性分析4年来经显微手术治疗的16例继发性药物难治性癫癎病例．这16例术前均行VEEG监测及MRI检查,其中5例行头PET检查。手术在皮层脑电监测下进行,2例行单纯病灶切除术．13例行病灶切除＋灶旁皮层热灼术,1例行病灶切除一灶旁皮层热灼术十胼胝体切开术。结果所有病人随访6个月至4年．术后抗癫癎药减少．12例服用1种抗癫癎药,2例服用2种抗癫藕药。癫癎发作完全控制11例．显著改善3例。无变化2例．无明显并发症．无死亡。结论病灶切除＋灶旁皮层热灼术联合应用不但提高了控制癎性发作的疗效．还尽可能多地保护神经组织免遭切除或损害,这是治疗继发性药物难治性癫癎较合理和有效的方法。     

顽固性癫痫的手术治疗(附16例报告)

目的探讨顽固性癫癎的致癎灶定位和术式选择。方法回顾分析16例顽固性癫癎患者的临床资料,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癎灶。采用病灶及周围皮层切除7例;前颞叶切除加杏仁核和大部分海马切除4例;病灶及周围皮层切除加低功率皮层热灼术5例。结果经6个月至2年的随访,满意6例,显著改善6例,良好2例,效差2例。结论准确定位致癎灶,选择恰当的手术方式是外科治疗顽固性癫癎取得良好效果的关键。     

皮层脑电图监测在颅脑病变伴发癫(癎)手术中的应用

目的 探讨皮层脑电图监测在颅脑病变伴发癫(癎)手术中的应用价值.方法 回顾分析58 例皮层脑电监测下手术切除病变及致(癎)灶患者临床资料.结果 所有患者在切除病变后复查皮层脑电图仍有(癎)样放电,其中37 例行扩大皮层切除,18 例加行皮层热灼术,3 例加行MST.术后1 /2 ～6 年随访发现癫(癎)控制达到EngelⅠ级32 例,EngelⅡ12 例,Engel Ⅲ级3 例,Engel Ⅳ 11 例,术后癫(癎)控制有效率为84.48%.结论 对于颅脑病变伴发癫(癎)的患者,应在皮层脑电图监测下进行手术,且在切除病变的同时一并将致(癎)灶切除.     

Seizure outcome after surgery for epilepsy due to malformation of cortical development

PURPOSE: To explore seizure outcome after surgery for focal epilepsy due to malformation of cortical development (MCD), with focus on the role of MRI. METHODS: Thirty-five patients who had surgery for intractable focal epilepsy due to MCD identified by preoperative MRI and confirmed by histopathologic analysis of resected tissue were studied. Patients were aged 3 months to 47 years (median, 14 years) at the time of surgery. Duration of follow-up was 1 to 7.9 (mean, 3.4) years. RESULTS: At latest follow-up, 17 patients (49%) had Engel Class I outcome with no seizures or auras only; eight patients (23%) had Class II outcome, with rare disabling seizures; seven patients (20%) had worthwhile improvement; and three patients (9%) had no improvement. Seizure-free outcome tended to be more frequent among patients who had complete resection of unilateral MCD (excluding hemimegalencephaly) based on postoperative MRI (7/12; 58%), compared with patients with unilateral MCD who had incomplete resection (3/11; 27%), but the difference was not significant. The frequency of seizure-free outcome did not differ significantly between children (8/14; 57%), adolescents (7/15; 47%) or adults (2/6; 33%); between patients who had daily (12/24; 50%), weekly (4/9; 44%), or monthly (1/2; 50%) seizures preoperatively; between patients who had temporal (2/6; 33%) or extratemporal or multilobar resections (14/28; 50%); or between patients who were (9/16; 56%) or were not (8/19; 42%) studied with subdural electrodes. Results for all analyses were similar when analyzed at latest available follow-up or at 1 year after surgery. CONCLUSIONS: Surgery can offer seizure-free outcome for approximately one half of carefully selected patients with intractable focal epilepsy due to MCD. Complete resection of the MRI-apparent lesion may improve the likelihood for favorable outcome. MRI evidence of hemimegalencephaly or bilateral MCD suggests a low likelihood for postoperative freedom from seizures.     

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。     

Long-term developmental outcome in patients with West syndrome after epilepsy surgery

It has been hypothesized that early seizure control may prevent children with intractable epileptic spasms (ES) from developmental regression and may contribute to better developmental outcome. The effectiveness of surgery for ES has been reported. We investigated long-term post-operative outcomes of seizure control and development in patients with symptomatic West syndrome (S-WS) who underwent epilepsy surgery. Six children who underwent surgical intervention for intractable ES were retrospectively investigated. Cortical malformations were observed on pre-operative MRI in all patients, with hemispheric or multilobar involvement in four children and focal lesions in two. Following surgery, we measured motor function, developmental age (DA), language skills, and sociopsychological function for up to 7years (mean, 4.9years). Post-operative seizure outcome was Engel Class I (n=4) or III (n=2). Motor function and DA was increased following surgery in six and five patients, respectively. Two patients started to speak in sentences following focal resection. Autistic features were noted in four of the five examined patients post-operatively. None of the patients showed developmental regression following surgery. Epilepsy surgery for S-WS with ES may result in good seizure control and improvement in motor development. Improvement in cognitive function was modest in this small cohort of children and autistic features were noted post-operatively in a substantial proportion of the children. While seizure control can be obtained by epilepsy surgery, early intervention for sociopsychological comorbidities may be warranted in children with S-WS.     

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。     

Evaluation with alpha-[11C]methyl-L-tryptophan positron emission tomography for reoperation after failed epilepsy surgery

PURPOSE: Reoperation after failed cortical resection can alleviate seizures in patients with intractable neocortical epilepsy, provided that previously nonresected epileptic regions are accurately defined and removed. Most imaging modalities have limited value in identifying such regions after a previous surgery. Positron emission tomography (PET) using alpha-[11C]methyl-L-tryptophan (AMT) can detect epileptogenic cortical areas as regions with increased tracer uptake. This study analyzed whether increased cortical AMT uptake can detect nonresected epileptic foci in patients with previously failed neocortical resection. METHODS: Thirty-three young patients (age 3-26 years; mean age, 10.8 years) with intractable epilepsy of neocortical origin, and a previously failed cortical resection performed at various epilepsy centers, underwent further presurgical evaluation for reoperation. AMT-PET scans were performed 6 days to 7 years after the first surgery. Focal cortical areas with increased AMT uptake were objectively identified and correlated to ictal EEG data as well as clinical variables (age, postsurgical time, etiology). RESULTS: Cortical increases of AMT uptake were detected on the side of the previous resections in 12 cases. In two patients scanned shortly (within a week) after surgery, diffuse hemispheric increases were observed, without any further localization value. In contrast, in 10 (43%) of 23 patients scanned >2 months but within 2.3 years after surgery, focal cortical increases occurred, concordant with seizure onset on ictal EEG. Age, etiology (lesional vs. cryptogenic), epileptiform EEG activity during PET, or time of the last seizure were not significantly related to the presence of increased AMT uptake. All patients with localizing AMT-PET, who underwent reoperation, became seizure free (n = 5) or showed considerable improvement of seizure frequency (n = 2). CONCLUSIONS: AMT-PET can identify nonresected epileptic cortex in patients with a previously failed neocortical epilepsy surgery and, with proper timing for the scan, can assist in planning reoperation.     

Surgery for drug resistant partial epilepsy in children with focal cortical dysplasia: anatomical-clinical correlations and neurophysiological data in 10 patients

Objective:To analyse a population of children with focal cortical dysplasia operated on for drug resistant partial epilepsy, with emphasis on clinical features, seizure semiology, interictal and ictal EEG and stereo EEG findings, histological and topographical characteristics of the lesions, extension and localisation of cerebral excision, and its postoperative effect on seizure frequency. Methods:10 patients were studied, aged between 26 months and 11 years (median 6 years). Magnetic resonance imaging (MRI) abnormalities were unilobar (temporal 3, frontal 2), bilobar (2), or multilobar (1); the two patients with negative MRI suffered from frontal seizures. Presurgical diagnostic steps varied in complexity and invasiveness depending on the anatomical/electrical/clinical features of each patient. In four patients they included only scalp video EEG monitoring, and in six, also invasive recordings using stereotactically implanted intracerebral electrodes. Surgery consisted of corticectomy plus lesionectomy in all cases. Results:70% of the patients were seizure-free after a minimum postoperative follow up of 25 months. These included three patients with temporal lesions and four of seven patients with other lobar or multilobar extratemporal localisation. One patient had improvement in seizure control. Outcome was poor in multilobar patients, but a class Ia outcome was obtained in one case after partial lesionectomy associated with bilobar corticectomy. All patients showed developmental improvement. Conclusions:Analysis of the data in these patients allowed the production of an "anatomical-clinical concordance" list, which appeared to be correlated with the diagnostic steps performed. Carrying out a stereo EEG exploration in the most complex cases proved useful in defining the epileptogenic zone in extratemporal and multilobar epilepsies. Stereo EEG recordings facilitated a tailored resection of extralesional cortex.     

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.     

Cortical resection with electrocorticography for intractable porencephaly-related partial epilepsy

PURPOSE: We evaluated the results of cortical resection of epileptogenic tissue for treatment of intractable porencephaly-related epilepsy. METHODS: We examined clinical features, electrophysiological data, surgical findings, and seizure outcomes after cortical resection in eight patients with intractable epilepsy related to porencephalic cysts. RESULTS: All eight patients had hemiparesis. Five retained motor function in the hemiparetic extremities; six retained visual fields. All had partial seizures, six with secondary generalization. Seven patients had simple and three had complex partial seizures (CPSs); two also had drop attacks. Four patients had multiple seizure types. Long-term scalp video-EEG (LVEEG) localized interictal epileptic abnormalities that anatomically corresponded to the cyst location in three patients. LVEEG recorded ictal-onset zones in five; these anatomically corresponded to the cyst location in three of the five. EEG recorded generalized seizures in two patients, hemispheric in one, and multifocal in two. Intraoperative electrocorticography (ECoG) revealed interictal epileptic areas extending beyond the margins of the cyst in seven patients. We resected ECoG-localized interictal epileptic areas completely in five patients and partially in two. Cortical resection was based on seizure semiology and LVEEG in one patient whose ECoG showed no epileptiform discharges. After a minimum follow-up of 1 year, six patients had excellent seizure outcome (Engel class I), and two had a >90% seizure reduction (Engel class III) without complications. CONCLUSIONS: Cortical resection guided by ECoG allows preservation of motor function and visual field and provides an effective surgical procedure for treatment of intractable epilepsy secondary to porencephaly.     

Operative Strategies for Patients with Cortical Dysplastic Lesions and Intractable Epilepsy

Summary: Cortical dysplastic lesions (CDLs) are usually identified by magnetic resonance imaging (MRI). Clinical, electrographic and histologic findings suggest that focal CDLs (FCDLs) are highly epileptogenic, often involve the rolandic cortex, and can present variable degrees of histopathologic abnormalities. An ictal or "ictal-like" bursting pattern of electrographic activity was recorded over dysplastic cortex in 65% of our patients. Resective surgery can eliminate or significantly reduce seizure frequency in many medically intractable patients, depending on lesion location, degree, and extent of histopathologic abnormalities. Best results are achieved when complete or major excision of both the MRI-visible lesion and the cortical areas displaying ictal electrographic activity can be performed. This is more likely when the degree of histopathologic abnormality is mild to moderate or when the lesion is in a temporal lobe. More severe histopathologic abnormalities and central insular or multilobar lesions usually lead to less favorable results: either major excision of the visualized lesion is impractical or the lesion is microscopically more extensive than shown by MRI. Multilobar resection or hemispherectomy for patients with infantile spasms associated with CDLs and for patients with hemimegalencephaly are often associated with dramatic improvement in seizure control. Callosot-omy can be performed in selected patients with diffuse CDLs who have intractable drop attacks.