颞叶内侧型癫痫海马杏仁复合体发作间期的痫性放电特征与范围

目的探索颞叶内侧型癫痫海马杏仁复合体区发作间期痫性放电的特征与范围,为立体定向射频毁损提供可靠依据。方法 235例经多导长程视频脑电加偶极子定位检查提示为颞叶内侧型癫痫患者,经机器人辅助定位在海马杏仁复合体区植入深部电极,监测并分析其放电特征与范围,根据监测结果实施射频毁损术。结果 235例患者均检测到发作间期的痫性放电,共6种形式;痫性放电中心部位波动于靶点下20 mm至靶点上10mm。平均位于靶下6.3507±5.0325 mm。放电范围在垂直于颞叶长轴方向为5~35 mm,平均14.2639±5.1011mm。颅底与放电中心的距离波动于2~25 mm,平均为9.0097±2.9232 mm。结论颞叶内侧型癫痫的痫性放电部位与传统定位的靶点有一定差异,且放电范围各不相同,应以深部电极监测结果实施毁损。     

Dreamy states and psychoses in temporal lobe epilepsy: Mediating role of affect

Abstract Among 104 patients with temporal lobe epilepsy treated in our clinic between 1992–1995, thirteen patients with repeated dreamy states were evaluated for affective manifestations of dreamy states and their relationship with psychotic states. The types of dreamy states were classified as déjà vu, jamais vu and reminiscence. The affective experiences during dreamy states were evaluated as positive, negative or neutral. As a result, seven patients had déjà vu and/or reminiscence: seizure manifestations in four of these patients were affectively evaluated as positive (familiar and/or pleasurable), and three as neutral. Six cases had experience of jamais vu: five of them were affectively evaluated as negative (mostly fear), and one as neutral.
Psychiatrically, only four patients with jamais vu accompanied by feelings of fear had mental disorders: a chronic paranoid-hallucinatory state in two cases, a chronic paranoid state in one case, and obsessive-compulsive symptoms in one case. Other patients who had positive or neutral affect did not demonstrate psychiatric disturbances. Thus, most patients with jamais vu were accompanied by negative affect of fear, and those patients with jamais vu tended to show more psychotic symptoms than those with reminiscence or déjà vu, which were associated with positive or neutral affects. Based on these results, we discuss the possibility that repeated negative feelings associated with jamais vu are one of the causes for developing epileptic psychoses.     

Psychomotor epilepsy and psychosis

In a controlled investigation of paranoid hallucinatory chronic or episodic epileptic psychoses, the social data, psychopathological symptoms and the psychological test findings (WAIS, Rorschach, object-sorting, proverb-interpretation and the Stroop test) were analyzed in order to delineate the characteristics of the psychotic syndrome and to evaluate the significance of organic etiological factors. The study comprised 45 patients with complex partial epilepsy followed by psychosis after median 23 years, and 34 control patients with the same type of epilepsy of median 30 years' duration. Among the psychotic symptoms, simple, mostly empathizable persecutory delusions and auditory hallucinations predominated. The affect tended to remain appropiate, and autistic traits were uncommon. In accordance with this finding of a relatively circumscribed psychotic personality disturbance, psychotic test indicators were infrequent in the psychological tests, the Rorschach test 28%, and the object-sorting test 18% of the cases. The poorer test performances in the WAIS and the Stroop tests, and the preponderance of organic Rorschach test signs in the psychotic group indicate that organic cerebral damage is of etiological significance in paranoid epileptic psychosis.     

颞叶癫痫患者发作间期脑活动的静息态脑磁图研究

目的用脑磁图合成孔径磁场测定(SAMg2)技术分析左侧颞叶癫痫患者与正常对照者的脑电活动差异,评估左侧颞叶癫痫患者发作间期脑活动的改变。方法给20例左侧颞叶癫痫患者及20名健康志愿者(正常对照组)进行静息态脑磁图检查,通过CTF软件中的合成孔径磁场测定技术计算所有受试者的SAMg2值;计算后,使每位受试者的SAMg2值与其对应的3D-MRI进行融合。结果与正常对照组比较,左侧颞叶癫痫患者颞叶及其内侧结构的SAMg2值显著升高,而双侧视觉皮质等颞叶以外脑区的SAMg2值降低。左侧颞叶癫痫患者异常区域的脑活动与癫痫发作频率密切相关,而性别、年龄的影响无统计学意义。结论左侧颞叶癫痫是一种多灶性的网络疾病,具有复杂的癫痫网络和脑功能缺失网络。     

A magnetization transfer imaging study in patients with temporal lobe epilepsy and interictal psychosis.

BACKGROUND: Findings from previous neuropathological and neuroimaging studies in patients with epilepsy and interictal psychosis have been inconclusive, and both focal and widespread brain abnormalities have been reported. Thus, further investigation with advanced in vivo magnetic resonance imaging (MRI) techniques, such as magnetization transfer imaging, capable of detecting more subtle brain abnormalities, is warranted. METHODS: Twenty patients with temporal lobe epilepsy and interictal psychosis were compared with 20 nonpsychotic patients. Patients were matched with respect to conventional MRI findings. Each group comprised of 10 patients with hippocampal sclerosis (6 left, 4 right) and 10 patients without focal lesions on MRI. A voxel-based analysis was used for the group comparisons. RESULTS: Voxel-based analysis revealed significant reductions of magnetization transfer ratio (an index of signal loss derived from magnetization transfer imaging) in the left superior and middle temporal gyri in the psychotic patients for the subgroup of patients with no focal lesions on MRI. There were no significant volumetric differences between the psychotic and nonpsychotic patients. CONCLUSIONS: Focal cortical magnetization transfer ratio abnormalities in the left temporal lobe unrelated to volume changes can be demonstrated in some temporal lobe epilepsy patients with interictal psychosis. Our findings might reflect subtle neuropathological abnormalities that are undetected by conventional MRI.     

Cortical abnormalities and their cognitive correlates in patients with temporal lobe epilepsy and interictal psychosis

Purpose: To determine whether cortical abnormalities are more severe and widespread in patients with temporal lobe epilepsy (TLE) and interictal psychosis (IP) compared to those with TLE only (NIP) and healthy controls (HC), and to explore the associations between cortical parameters (area, thickness and volume), psychotic symptoms, and cognitive performance. Methods: Twenty‐two patients with IP (9 male; 10 hippocampal sclerosis, HS), 23 TLE nonpsychotic (NIP) patients (11 male; 13 HS) matched for duration of epilepsy and 20 HC participated. Surface‐based morphometry (SBM) was used to measure cortical parameters. Cognition was examined in IP and NIP patients. Associations between cortical parameters and cognition were examined using linear mixed models adjusted by age, gender, and brain volume. Key Findings: IP patients had an earlier onset of epilepsy, more status epilepticus, and worse cognitive performance than NIP patients. In IP patients, cortical thickness was reduced in the inferior frontal gyrus (IFG), and their current IQ was associated with decreases in area, but not thickness, in regions of the frontotemporal cortex. Significance: IP likely reflects the interplay of psychosis‐related genetic factors and the cumulative effects of seizure activity on the brain. Cortical thinning in the IFG, a region implicated in schizophrenia, is likely to be related to seizure activity, whereas changes in IQ, associated with reductions in area of frontotemporal cortex, may be related to the presence of psychosis.     

Postoperative psychoses in epileptic patients after temporal lobectomy

Introduction – Psychosis is the most severe psychiatric complication after epilepsy surgery. Patients and methods – We evaluated postoperatively at 1 year the psychoses of a series of 57 adult patients with intractable epilepsy who underwent temporal lobe surgery. Results – Five patients (8.8%) developed postoperative psychosis. Two (3.5%) of these 5 revealed postictal psychotic episodes in connection with persisting seizures, both of them had had similar episodes even preoperatively. Two patients (3.5%) exhibited a definite and one patient (1.8%) a probable de novo schizophrenia. Conclusion – Our findings clearly emphasize the need for careful postoperative psychiatric follow-up for patients with temporal lobectomy.     

伴海马硬化的颞叶内侧癫痫的外科治疗(附22例临床分析)

目的探讨伴海马硬化的颞叶内侧癫痫的手术疗效。方法对22例术前诊断伴海马硬化的颞叶癫痫患者,在术中脑电监测下行颞前叶及颞叶内侧结构切除术。结果术后病理诊断均为海马硬化。术后无重大并发症,随访均无癫痫发作。结论伴海马硬化的颞叶内侧癫痫的手术效果良好,确诊后应尽早手术治疗。     

Analogy between psychosis antedating epilepsy and epilepsy antedating psychosis

Purpose: Patients with recurrent epileptic seizures after the development of psychosis (Psychosis‐Epilepsy) have been regarded as belonging to a different clinical entity from those with epilepsy antedating the development of psychosis (Epilepsy‐Psychosis). However, clinical characteristics of patients with Psychosis‐Epilepsy have not been well described, except for early German studies. We aimed to estimate the reliability of distinction between Psychosis‐Epilepsy and Epilepsy‐Psychosis by comparing their clinical characteristics. Methods: Among 312 patients with epilepsy and psychosis enrolled in this multicenter study, 23 patients had Psychosis‐Epilepsy and 289 patients had Epilepsy‐Psychosis (i.e., interictal psychosis). Demographic (i.e., sex, age at time of evaluation, and intellectual functioning), psychiatric (i.e., age at onset of psychosis, subtype of psychosis, duration of psychotic episode, and a family history of psychosis), and epileptic (i.e., age at onset of epilepsy, subtype of epilepsy, seizure type, and a family history of epilepsy) characteristics of both groups were compared. Key Findings: Clinical characteristics, either in their psychoses or epilepsies, except for age‐related variables, were equivalent between patients with Psychosis‐Epilepsy and those with Epilepsy‐Psychosis. Time intervals between onset of psychosis and that of epilepsy in the two groups showed a normal distribution curve. Significance: The presence of many common features and the linear distribution of the time intervals did not fully support that Psychosis‐Epilepsy and Epilepsy‐Psychosis were two distinctly different entities. Among certain patients who have genetic vulnerabilities to both psychoses and seizures, psychosis may develop either antedating or postdating the development of epilepsy. These findings may suggest a necessary reconceptualization of psychoses in epilepsy.     

伽玛刀治疗颞叶癫痫38例初步报道

目的 探讨伽玛刀治疗颞叶癫痫的方法与效果.方法 1998年1月至2004年12月,应用旋转式伽玛刀治疗颞叶癫痫38例.伽玛刀治疗方法:单侧杏仁核、海马及海马旁回18例,颞叶前部(包括杏仁核、海马、诲马旁回)及额叶后份18例,双侧杏仁核2例.治疗剂量:杏仁核、海马边缘剂量20～35Gy, 50%等剂量曲线.额、前颞叶边缘剂量10～15 Gy,50%等剂量曲线.结果 38例随访1.5～8年,平均3.45年.满意(EngelⅠ)9例(23.68%),显著改善(EngelⅡ)12例(31.57%),良好(Engel Ⅲ)7例(18.43%),无效(Engel Ⅳ)10例(26.32%).总有效率73.68%.3例出现迟发性放射性水肿反应,经应用激素、甘露醇,2例水肿消退,另1例靶区坏死,而行开颅术切除坏死灶.无神经功能障碍,无死亡病例.结论 本组结果初步提示,伽玛刀治疗颞叶癫痫安全、有效.由于伽玛刀治疗癫痫不同于常规手术,疗效评定至少应在治疗后1年以上.伽玛刀用于治疗癫痫,为期尚短,许多问题如适应证的选择、靶点的选择、安全有效的照射剂量、迟发性放射反应的预防、疗效的评定及统计标准等,需不断地探索解决.     

Medial temporal lobe epilepsy associated with misplacement of a ventricular shunting catheter

We report the case of a 35-year-old woman who developed right medial temporal lobe epilepsy associated with misplacement of a ventricular shunting catheter in the apex of the right temporal lobe. At 8 years of age, the patient had undergone total removal of a cerebellar astrocytoma and placement of a Torkildsen's ventriculo-cisternal shunt for obstructive hydrocephalus. Although the postoperative course was uneventful, she developed medically intractable psychomotor seizures with secondary generalization at 24 years of age. CT revealed that the tip of the shunting catheter was misplaced in the apex of the right temporal lobe, through the posterior and inferior horn of the right lateral ventricle. Intraoperative electrocorticography revealed frequent paroxysmal activity in the hippocampus, so hippocampectomy as well as removal of the shunting catheter was performed. Postoperatively, the patient became seizure-free, and pathological examination revealed hippocampal sclerosis.     

Theory of mind in frontal and temporal lobe epilepsy: cognitive and neural aspects

Purpose: Theory of mind (ToM) is an important prerequisite to social behavior. This study evaluated ToM in patients with temporal (TLE) or frontal lobe epilepsy (FLE) aiming to determine the cognitive aspects, severity, and pathophysiologic mechanisms of ToM impairment in focal epilepsy. Methods: One hundred thirty‐eight patients with TLE (n = 109) or FLE (n = 29) and 69 healthy subjects underwent the Faux Pas task (FPT), which evaluates the recognition and comprehension of others’ mental states, and neuropsychological tests for other cognitive functions. Key Findings: Factor analysis of all test scores yielded two ToM factors (Recognizing faux pas, FP; Excluding nonexistent FP) distinct from the Control, Language, Matching, and Praxis factors. With respect to healthy subjects, both TLE and FLE patients showed correct exclusion of nonexistent FPs but significantly lower recognition and comprehension of real FPs. FLE patients were also impaired with respect to TLE patients. In the whole patient group, schooling and group membership predicted ToM impairment. In FLE patients, the comprehension of mental states was predicted by disease duration, whereas TLE patients’ comprehension of affects and intentions was associated with early age of seizure onset and medial temporal lobe sclerosis (MTLS). Significance: Focal epilepsy impairs advanced ToM abilities. FLE may affect online performances owing to long‐lasting dysfunctions of the prefrontal areas. MTLS may provoke selective ToM deficits due to medial temporal damage, prefrontal dysfunctions, or early interference with cognitive development. Future studies are needed to determine the implications of ToM impairment on behavior and quality of life.     

发作间期PET和MR海马像在难治性颞叶癫癇术前定侧中的应用

目的 探讨发作间期18FDG-PET和MR海马像在难治性颞叶癫(?)（TLE）致(?)源术前定侧中的价值。方法 对17例药物难治性TLE患者术前定侧资料及术后随诊情况进行分析。结果 本组患者中,有12例（71％）患者MR显示海马硬化（HS）,海马萎缩与信号改变常共存,T2加权像和FLAIR序列有利于显示信号的改变。HS侧多提示为致(?)源侧。PET检查均显示有至少一侧颞叶低代谢改变,并常多发或范围弥散。PET与MR的定侧准确率分别是100％（13/13）、77％（10/13）,经x2检验两者间无差异（P>0.05）。结论　18FDG-PET和MR海马像在致(?)源定侧中的作用是互补的,当颞叶低代谢侧与海马硬化侧相一致时手术效果较好。     

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。     

Multifactorial etiology of interictal behavior in frontal and temporal lobe epilepsy

Purpose: Based on discussions on the so called “epileptic personality” in patients with epilepsy, interictal behavioral impairments in frontal and temporal lobe epilepsies were examined in a multivariate approach that took demographic, clinical, and neuropsychological determinants into consideration. Methods: A total of 428 patients with epilepsies originating from the temporal (TLE; 84%) or frontal (FLE; 16%) lobes were examined in regard to personality (Fragebogen zur Persönlichkeit bei zerebralen Erkrankungen [FPZ], a clinical personality questionnaire) and mood (Beck Depression Inventory [BDI I]). Prevalence of impaired behavioral domains was determined. Etiologically relevant determinants of behavioral problems were identified via multiple regression analyses. Key Findings: Elevated depression scores (BDI) were evident in 42% of the patients, and not different in TLE and FLE. In regard to personality, introversion together with low mood, sociability, and self‐determination, as well as problems with interpersonal communication were frequent. The TLE group tended to show greater neuroticism and introversion, while FLE appeared more associated with behavioral aspects of an organic psychosyndrome. Multivariate analyses revealed demographic characteristics (age, gender, education), clinical aspects (psychiatric history, affected hemisphere, mesial pathology, seizure frequency, cognitive functions), and treatment (antiepileptic drug treatment) as relevant determinants, explaining up to 30% of the behavior. Significance: Behavioral abnormalities in patients with frontal or temporal lobe epilepsy are common but on the average mostly mild. Within a multivariate etiological model, localization (mesial yes/no) and lateralization (left > right) dependent behavioral problems in TLE and FLE seem to be overshadowed by other variables, of which patients’ and their families’ psychiatric history, patient characteristics and pharmacological treatment appear of major importance. Better education and cognitive capabilities may be discussed as protective features.     

发作间期PET和SPECT检查对颞叶癫痫定位诊断价值

目的：探讨发作间期１８Ｆ－脱氧葡萄糖（ＦＤＧ）正电子发射断层扫描（ＰＥＴ）和９９ｍＴｃ－己撑半脱氨酸（ＥＣＤ）单光子发射断层扫描对顽固性颞叶癫痫（ＴＬＥ）的定位诊断价值。方法：５３例脑电图（ＥＥＧ）定位明确的顽固性ＴＬＥ患者分别行发作间期１８Ｆ－ＦＤＧＰＥＴ和９９ｍＴｃ－ＥＣＤＳＰＥＣＴ检查。其中２１例磁共振（ＭＲＩ）显示有结构性病变并与ＥＥＧ定位结果一致。结果：ＭＲＩ异常组均在ＰＥＴ和ＳＰＥＣＴ相应部位出现低代谢和低灌注表现。ＭＲＩ正常组，ＰＥＴ定位准确性为８４．５％，显著高于ＳＰＥＣＴ的５６．３％（Ｐ＜０．０５）。结论：对于无结构性病变的颞叶癫痫，发作间期ＰＥＴ检查有较高的定位诊断价值，ＳＰＥＣＴ的临床意义相对较小     

Transient psychosis in a girl with epilepsy and continuous spikes and waves during slow sleep (CSWS)

A normally developed and healthy 6-year-old girl suffered the onset of epilepsy with generalized tonic-clonic seizures and atypical absences. Initially the EEG showed epileptiform activity over the temporal and parietal regions, later there were episodes of bilateral synchronous spike-wave activity with a frequency of 1.5–2.5 Hz. After a few months, deterioration of cognitive and behavioural functions appeared and gradually increased with the development of a fullblown disintegrative psychosis that went on for several months. Sleep EEG recordings showed the characteristic abnormality described as continuous spikes and waves during slow sleep. Later there was a remarkable improvement of neuropsy chiatric functions but a second outbreak of psychosis seems to have left the girl, who is now 9 years of age, with severe mental impairment.     

MRI与PET在颞叶癫癎中定位价值的比较

目的 比较ＭＲＩ及ＦＤＧ－ＰＥＴ在颞叶癫癎致癎灶定位中的价值,探讨癫癎外科术前定位的方法以及手术预后的判断。方法 以手术后癫癎控制状况为标准,对３０例颞叶癫癎患者的术前ＭＲＩ和ＦＤＧ－ＰＥＴ的结果进行比较,分析ＭＲＩ及ＰＥＴ各自在癫癎致癎灶定位中的价值。结果ＭＲＩ有良好的脑结构分辨能力,对于症状性癫癎的定位价值高,当ＭＲＩ显示海马硬化时,对致癎灶定位的意义大,术后癫癎发作完全控制的可能性大。发作间期ＰＥＴ对于颞叶癫癎定位的敏感性高于ＭＲＩ,但ＰＥＴ低代谢的范围往往超过致癎灶。与ＰＥＴ的目测方法比较,ＰＥＴ半定量分析并不能提高致癎灶定位的准确性及对手术效果的预测。结论　ＭＲＩ与ＰＥＴ检查结合可以提高致癎灶定位的准确性及对手术效果的预测,减少颅内记录的应用。