难治性癫痫手术治疗进展

磁共振成像技术与电生理技术为难治性癫痫的诊断提供了有力的技术支持。神经导航技术、手术中磁共振成像技术等提高了操作的准确性。其他新技术例如软膜下多重横切术、迷走神经直接或间接刺激术也有效应用于临床。通过研究经典神经外科切除手术与采用新技术在治疗上的差异,分析了目前难治性癫痫手术的治疗结果,证实手术治疗对于药物难治性癫痫患者是安全有效的。     

难治性癫痫手术治疗15例的体会

目的探讨难治性癫痫手术治疗方面的相关问题。方法通过对15例难治性癫痫患者的发作症状学分析、视频脑电检查、头颅磁共振检查等手段进行综合分析及术前评估后定位致痫灶,实施手术。术中进行脑电监测直至异常放电明显减少或消失。其中13例患者一次手术完成,2例患者先行埋藏电极后二次手术完成。术后随访半年-2年,了解癫痫发作情况。结果按照Engel分级,Ⅰ级和Ⅱ级视为显效,Ⅲ级为好转,Ⅳ级为无效。本组显效14例(93.3%),好转1例(6.6%),无效0例。结论若选择癫痫病例得当,手术治疗是一种安全、有效的治疗方法。     

伊藤氏色素减少症继发难治性癫痫1例手术治疗

目的总结伊藤氏色素减少症继发难治性癫痫的外科治疗经验。方法回顾性分析1例9岁伊藤氏色素减少症继发难治性癫痫患儿的临床资料,并结合相关文献进行分析。结果该患儿在术前全面评估后接受了左侧额叶癫痫病灶局限性切除术,术后癫痫发作得到了良好的控制,生活质量得以很大的提高。结论伊藤色素减少症继发难治性癫痫病变范围往往较大,但是在现有的神经影像和神经电生理的支持下能较好的将致痫病灶局限化,通过手术治疗,在不损伤患者重要神经功能的情况下可很好地控制癫痫发作,提高生活质量。     

36例难治性癫痫手术治疗及术后影响因素

目的总结难治性癫痫的外科治疗经验,分析手术治疗的效果以及手术影响因素。方法术前运用CT、MRI和脑电图等检查对癫痫病灶进行精确定位,全麻下行开颅癫痫病灶切除和变性脑组织切除,并依据患者不同情况结合其他外科治疗方法。手术在显微镜下进行,采用皮层脑电图和深部脑电图监测。结果术后2周内有7例患者出现语言功能障碍,5例患侧肌张力下降,2周后均逐渐恢复。术后随访1～4a,36例治疗后满意3例（8．3％）,显著改善18例（50．0％）,良好11例（30．6％）,较差4例（11．1％）,没有无改善病例。结论应用外科手术方法治疗难治性癫痫,根据癫痫病灶部位的不同,应用不同的手术方式,可以收到良好的治疗效果。     

儿童难治性癫痫的手术治疗

癫痫是儿童神经系统常见疾病之一,其发病原因、临床表现及治疗原则较成人癫痫具有明显差异.随着抗癫痫药物的不断创新、扩展及人们对癫痫的深入研究,大多数癫痫患儿可以得到理想的控制,但仍有部分患者经药物治疗无效而成为难治性癫痫,是外科干预治疗的潜在目标.近年来手术治疗难治性癫痫的技术得到迅速发展,特别是针对儿童难治性癫痫的手术治疗取得重大突破.目前用于儿童癫痫的外科治疗方法主要有切除性手术、毁损性手术、阻断通路手术和神经调控手术等.     

难治性癫痫显微手术治疗22例分析

我院1997年1月～2001年12月，对22例有颅内病灶的难治性癫痫施行显微手术，取得较满意的效果，现报告如下：     

精神外科治疗难治性癫痫性精神障碍1例报告

目的：精神外科治疗癫痫是我国目前治疗除药物治疗外的唯一手段。对一些反复发作难以控制的癫痫有明显效果。方法：口服C－P首剂50mg/日，丙戊酸钠0．2，2次／日给予氟哌啶醇10mg,2次／日肌注。治疗5天后，情绪稳定精神，主动接触，偶有攻击行为，无抽搐发作。会诊认为：（1）癫痫性精神分裂样精神病，（2）癫痫所致人格改变（病人在意识清晰下出现伤人，勒索行为，因人格改变不计后果凶狠，残暴，自控能力下降，近2年）在病室内屡发冲动，伤害他患，为避免出现意外建议行外科治疗。外科会诊，认为左侧颞叶及局限性白质损伤，经立体定向左侧颞叶切除术，局限性白质切断术。结果：外科手术成功，3天后病人意识清晰，言语流利，生命体征平稳，情绪稳定，无冲动行为故转回精神科继续治疗，经1个月口服药物治疗后，病人情绪平稳，无冲动伤人行为，主动于他人接触，故出院，回家治疗，随访1年，无抽搐发作，无攻击行为，情绪稳定，未发生意义，疗效显。结论：癫痫是由于大脑细胞异常过度放电，而引起的一过性，反复发作的临床综合征。癫痫性精神障碍发作类型很多，此病人有情绪变化，及人格改变，故出现伤人行为，病灶很难发现，大多与大脑优势半球颞叶有关，控制不良可能与杏仁核异常放电有关，此病人经多次脑电及MRI确认左侧颞叶及局限性白质损伤，故行左侧颞叶切除术及局限性白质切断术后病情明显得以控制，随访1年，未出现异常改变，可以证明外科治疗伴有人格改变的癫痫是可行治疗方法，但并不是所有的癫痫性精神障碍都可以行外科手术。     

在偶极子定位下显微手术治疗难治性癫痫30例临床分析

目的探讨偶极子定位方法在药物难治性癫痫术前致痫灶定位研究中的作用和准确性。方法对30例药物难治性癫痫患者的致痫灶进行术前偶极子定位,术中以皮层及深部电极加以验证,依据验证结果比较继发性癫痫和原发性癫痫偶极子定位的准确性,并对病灶、致痫灶进行手术处理,术后随访并分别比较继发性癫痫和原发性癫痫的手术治疗效果。结果偶极子对继发性癫痫致痫灶定位的准确性要高于原发性癫痫,经卡方检验,x±s=12.470,P=0.001统计学有显著性差异;两者的治疗结果,P=0.143差异没有显著性。结论偶极子定位是一种无创性的致痫灶定位方法,对继发性癫痫术前致痫灶定位准确,手术效果满意;对原发性癫痫或致痫灶多发、弥散,偶极子定位技术存在一定的局限性。     

难治性癫痫的手术治疗(附21例临床报道)

目的探讨癫痫的手术治疗和脑电图在癫痫手术中的作用.方法对21例经抗痫药物治疗无效或效果不佳的癫痫病人在皮质脑电图和深部脑电图的监测下进行手术治疗.结果21例均有效,无死亡和致残病例.随访到17例,满意11例,显著改善4例,良好1例,效果差1例.结论癫痫手术治疗均可获得一定的效果.脑电图在癫痫手术治疗中起着重要的作用.     

难治性癫痫手术效果评判时限

目的 总结分析难治性癫痫手术效果,以及手术后效果趋于稳定的时限。方法 对120例难治性癫痫手术患者进行长期追踪随访,并依照Engel分级对患者术后效果进行分类;比较患者术后半年,1年和远期（1年半以上）随访疗效,观察术后达到EngelⅠ-Ⅱ疗效比例的变化。结果 120例难治性癫痫手术患者中,术后半年随访发现：61％术后无癫痫再发,18％术后仅有先兆发作,7％偶有痫性发作（半年中小于2次）,痫性发作明显减少（痫性发作减少大于80％）为5％,手术效果不明显（痫性发作减少小于20％）占9％;术后1年随访发现：无癫痫再发为45％,术后仅有先兆为12％,术后偶有痫性发作为12％（1年中小于3次）,痫性发作明显减少为13％,手术效果不明显为18％。最近的随访结果如下（随访1．5～3年,平均1．8年）：无癫痫再发占43％,仅有先兆占13％,术后偶有痫性发作占14％,痫性发作明显减少占13％,手术效果不明显占17％。半年期随访预后和1年期随访预后中达到EngelⅠ-Ⅱ的比例有明显差异（组间差异有统计学意义,P〈0．05）,1年期随访预后与长期随访预后中达到EngelⅠ-Ⅱ的比例无明显差异（组间差异无统计学意义,P〉0．05）。结论 药物难治性癫痫术后半年期随访评判疗效不可靠,而1年期疗效预示术后长期效果。     

Lobar holoprosencephaly associated with heterotopic gray matter. A case disclosed in adulthood by epilepsy

A case of lobar holoprosencephaly associated with heterotopias of the grey matter is reported. The patient was a young woman whose cerebral malformation was revealed by epileptic seizures at the age of 22. There was no intellectual deficit. Computerized tomography and, chiefly, magnetic resonance imaging, enabled the study of the malformation.     

1例少突胶质瘤继发癫痫误诊分析

正1病例患者,男性,46岁,陕西渭南人。初以短暂意识丧失1分钟就诊。家属称两天前骑车转弯时突然倒地。事后患者无明显受伤,无嗜睡、昏睡等,但对当时情况不能清晰回忆。曾在综合医院做相关检查,神经系统查体未见异常。血常规、肝肾功、视频脑电图、头颅CT无明显异常。未予特殊治疗。10天后家人发现患者倒在沙发上,呼之不应,双眼上翻、口吐白沫、四肢屈曲、抽动。发作时伴口周发绀、小便失禁。再次来院就诊。详细追问病史,     

灰质异位所致癫痫的外科治疗

目的 探讨大脑灰质异位(HGM)与癫痫的关系,以及手术治疗的价值. 方法 回顾性分析解放军第四五八医院神经外科自2004年5月至2006年5月收治的6例HGM所致癫痫患者的临床特点、手术方式以及随访结果. 结果 6例患者中,4例行异位灰顶切除+皮层热灼,1例行异位灰顶切除+皮层热灼+前颞叶切除.1例行单纯皮层热灼.术后随访2～4年,5例至今未见发作,1例发作明显缓解. 结论 对于HGM所致的难治性癫痫,外科手术是一个有效的治疗方法.     

脑灰质异位症的MRI诊断

目的探讨脑灰质异位症影像学特征及与临床症状的关系。方法分析了36例经三名以上神经影像学医师诊断为脑灰质异位症病例。其中男性16例,女性20例,年龄在8个月～43岁,平均年龄中位值14.2±0.5岁。主要临床症状表现为癫疒间、智力低下、运动障碍。结果我们把灰质异位症分为5型:①室管膜下型(15例);②局灶性皮层下型(10例);③弥漫型(4例);④脑裂畸形型5例;⑤混合型(2例)。灰质异位症还常可并发其它的一些颅脑畸形。结论灰质异位症的诊断主要依据临床表现和影像学征象。不同类型的灰质异位症具有不同的临床表现。在诊断时应与其它病变进行鉴别。     

MR imaging of large heterotopic gray matter

One and a half year-old boy was admitted to our hospital with a history of intractable myoclonic epilepsy. Seizures were fairly controlled on carbamazepine, phenobarbital, diphenylhydantoin and clonazepam, but still occurred several times per month. Neurological examination showed mild psychomotor retardation. The CT and MR imaging studies showed both large heterotopic gray matter and supracerebellar arachnoid cyst. No enhancement was noted after the administration of contrast medium. No calcification was present. In the MR image, a large nodule in the right hemisphere showed almost the same signal intensity as the cortical gray matter. The right lateral ventricle was absent for a portion of the anterior horn. The sulci on the right parietal lobe were almost absent, suggesting the region of agyria.     

Exacerbation of partial seizures in a case with heterotopic gray matter using antiepileptic drugs

A two-year-old, right-handed girl was admitted to our hospital with a history of partial seizures. The first seizure, conjugated eye movements and head turning to the right, occurred at the age of 24 months. Later, she suffered from several seizures daily at the age of 34 months. At the age of 35 months, she was admitted to our hospital. On admission her neurological examination was normal. EEG showed a left parietal spike focus. A computed tomographic scan showed a small hyperdense area in the left parietal lobe without contrast enhancement. She was treated with carbamazepine (CBZ : 6 mg/kg/day). When seizures occurred several times within an hour, intravenous or rectal administration of diazepam (DZP : 0.3 mg/kg/dose) was added. However, she complained of sleepiness. The seizures occurred more frequently than before, 50 to 80 times daily, and became secondarily generalized. We thought that the exacerbation of the seizures resulted from the somnolence caused by DZP and CBZ. Consequently, these drugs were discontinued, and phenytoin was begun. She has since been free of seizures for two years. Approximately one year after the discontinuance of DZP and CBZ, heterotopic gray matter and abnormal gyri involving the left parieto-temporal lobe were found by magnetic resonance imaging (MRI). MRI is useful for detecting small heterotopic gray matter. To summarize this case, one should consider the possibility that excessive polytherapy induces seizures, particularly in patients with structural brain abnormalities such as heterotopic gray matter.     

Magnetic resonance imaging of heterotopic gray matter

Heterotopic gray matter was detected by means of magnetic resonance imaging in a 3-year-old girl with left hemiparesis and atonic seizures. In the inversion recovery sequence, a large area of decreased signal intensity was noted in the right centrum semiovale and differentiation of the right basal ganglia was not clear. We speculated that the brain malformation in our patient occurred at ten weeks conceptional age.     

中枢神经系统感染后继发难治性癫痫的病灶切除治疗

Previous studies have focused on medial temporal lobe epilepsy secondary to central nervous system infections. Several large-sample analyses of multi-lobe injuries or complications of medial temporal lobe epilepsy have been reported. The present study selected 29 patients (10 males and 19 females with a mean age of 18 years) with refractory epilepsy secondary to central nervous system infections (meningitis in 8, encephalitis in 21) from Beijing Functional Neurosurgical Institute from May 2006 to August 2008. All patients underwent computer tomography or magnetic resonance imaging, as well as electroencephalogram examinations; cortical electrodes were embedded in 11 patients. In addition, 13 (45%) patients underwent anterior temporal lobectomy, and 16 (56%) underwent extratemporal corcticectomy. Results showed that 18 (62%) patients obtained favorable outcomes following surgical treatment, including 80% with temporal lobe epilepsy and 50% with extratemporal epilepsy. Central nervous system infection was not a contraindication for epilepsy treatment, and identification of epileptic foci proved to be crucial. In addition, a young age at infection, as well as prolonged latent period from time of infection to initial afebrile seizure, were 2 predictive factors for all patients. Cortical electrodes significantly increased the detection rate of epileptic foci, but did not improve prognosis of foci excision.