半球性癫痫手术治疗的疗效分析

目的探讨外科手术治疗半球性癫痫的疗效,评价手术对患者的社会心理及认知功能的影响。方法 93例半球性癫痫患者经过综合评估后行手术治疗,其中Adams's术式30例,Rasmussen's术式7例,大脑半球切开术3例,多脑叶切除术24例,多脑叶切除联合胼胝体切开术29例。术后随访2.5年~6年3个月。手术疗效以Engel分级标准判定。结果术后癫痫控制情况:EngelⅠ级43例,Ⅱ级24例,Ⅲ级19例,Ⅳ7例。手术后早期患者的偏瘫无明显加重,肌张力及痉挛状态得到不同程度缓解,辅助系统康复训练后,肢体功能明显改善;高级皮层功能,生活自理能力和社会适应能力得到不同程度的提高。结论手术治疗半球性癫痫不仅可有效控制癫痫发作,患者的言语、肢体运动功能无恶化,神经心理功能和生活质量还有不同程度提高。而上述功能改善程度与年龄呈正相关。     

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。     

药物难治性癫痫首次手术失败的原因分析及再次手术的疗效

目的 探讨药物难治性癫痫首次手术失败的原因及再次手术的疗效。方法 回顾性分析2009年1月～2021年10月再次手术治疗的35例药物难治性癫痫病人的临床资料。末次随访,采用Engle分级评估疗效,其中Ⅰ～Ⅱ级为疗效优良,Ⅲ～Ⅳ级为疗效不佳。结果 首次手术失败的原因：致痫灶不完全切除12例,肿瘤复发10例,定位错误2例,原因不明11例。35例术后随访1～12年,中位数3.4年;末次随访,Engle分级Ⅰ级19例（54.3%）,Ⅱ级7例（20.0%）,Ⅲ级7例（20.0%）,Ⅳ级2例（5.7%）;疗效优良26例（74.3%）,其中致痫灶不完全切除病人的优良率为75.0%(9/12),肿瘤复发病人的优良率为100.0%(10/10),定位错误病人分优良率为100.0%(2/2),原因不明病人的优良率为45.5%(5/11)。结论 药物难治性癫痫首次手术失败后,综合评估失败原因,根据失败原因选择合适的手术方案,可获得良好预后;但是首次手术失败原因不明的病人,再次手术需谨慎。     

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].     

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。     

难治性癫痫术后抗癫痫药物的管理

难治性癫痫术后合理应用抗癫痫药物,是确保手术疗效和提高病人预后的重要因素。合理应用抗癫痫药物包括术后用药原则、何时减药、何时停药、及其注意事项。围手术期需要加大抗癫痫药物剂量,同时监测其血药浓度。预后评估较好的患者,术后无癫痫发作,1～2年可以停药。具有癫痫复发高危因素的患者,考虑长期服药。完全停药后不同年龄组的癫痫再发率不同,部分病人仍可以再次手术。     

药物难治性癫痫MRI表现与脑电图及病理对照研究

目的 探讨药物难治性癫痫发作间期MRI与脑电图(EEG)在致痫灶定位中的相关性以及MRI表现的病理学基础.方法 对40例药物难治性癫痫患者术前行传统MRI及视频EEG检查,并对其中25例颞叶癫痫患者行弥散加权像扫描.手术方式包括标准颞前叶切除术、选择性海马杏仁核切除术及致痫灶切除术等,对切除的脑组织进行病理学检查.结果 33例患者传统MRI检查结果显示的异常包括:海马硬化(16例)、脑发育不良(5例)、颞极蛛网膜囊肿(3例)、颅内肿瘤(3例)、脑软化灶(2例)、脉络膜裂囊肿(2例)、脑软化合并颞极蛛网膜囊肿(1例)和小脑萎缩(1例).发作间期颞叶癫痫患者发作侧海马表观弥散系数(apparent diffusion coefficient,ADC)值[(102.1±4.7)×10-5 cm2/s]较对侧[(84.6±5.9)×10-5 cm2/s]明显升高(t=12.7,P<0.01).所有癫痫患者发作间期EEG均呈异常改变.24例患者传统MRI检查所示病变区与发作间期EEG定位的致痫灶部位一致,4例患者传统MRI检查显示正常而其发作侧海马ADC值却较对侧增高.结论 传统MRI与ADC同时用于评价致痫灶优于任一单独应用者,如结合EEG将更有助于对癫痫的术前评价.     

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。     

难治性癫痫持续状态的药物治疗进展

难治性癫痫持续状态(RSE)是指使用常规抗癫痫治疗不能控制的持续癫痫发作超过1h的状态,有效控制癫痫发作是挽救患者生命、改善其预后的关键。此文回顾分析了2003-2005年国内外治疗RSE的有关文献,将其所用药物用法、用量及作用机制做一综述。     

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。     

药物难治性癫痫患者脑内多种耐药基因表达的初步研究

目的研究药物难治性癫痫患者与正常对照组脑内多种药物耐药基因（ＭＤＲ１）表达的情况。方法　选择１５例药物难治性癫痫患者和５例对照组患者的脑组织标本,用逆转录聚合酶链反应（ＲＴ－ＰＣＲ）技术,以Ｂ－ａｃｔｉｎ为内参照对ＭＤＲ１基因进行扩增,经琼脂糖凝胶电泳分别得到２２６ｂｐ和５４８ｂｐ的条带,通过照相、扫描、计算ＭＤＲ１／ｂ－ａｃｔｉｎ比值进行半定量分析。结果统计学处理提示,药物难治性癫痫患者脑内ＭＤＲ１的表达明显高于对照组（Ｐ＜０．０１）。结论　Ｐ－糖蛋白为ＭＤＲ１的产物,能将药物从脑内排入血循环而降低脑内药物浓度。药物难治性癫痫患者因脑内ＭＤＲ１的高表达,导致脑内抗癫痫药物（ＡＥＤ）浓度较低而耐药。故应用ＭＤＲ１抑制剂也许可以提高ＡＥＤ在脑内的药物浓度,使癫痫的药物治疗效果更令人满意。     

Surgical outcome and predictive factors in adult patients with intractable epilepsy and focal cortical dysplasia

OBJECTIVES: To determine the surgical outcome and prognostic factors in adult patients with intractable epilepsy and focal cortical dysplasia (FCD). MATERIALS AND METHODS: We retrospectively studied the operative outcome in 21 consecutive adult patients with FCD who underwent surgical treatment for intractable partial epilepsy. RESULTS: The mean age at surgery was 32.7 years (range, 18-58 years). The median post-operative follow-up was 2.5 years. The FCD was extratemporal in 11 patients, involved the temporal lobe in 10 patients, and was multilobar in eight patients. Eleven patients (52%) were rendered seizure-free, four patients (19%) had >95% reduction in seizures, and two patients (10%) had an 80-94% reduction in seizures. A seizure-free outcome was associated with shorter duration of epilepsy (P = 0.02). CONCLUSION: Adult patients with FCD may be candidates for surgical treatment of intractable partial epilepsy. Most individuals have neocortical, extrahippocampal seizures and approximately 50% of patients are rendered seizure-free.     

Efficacy of vagus nerve stimulation as a treatment for medically intractable epilepsy in brain tumor patients. A case-controlled study using the VNS therapy Patient Outcome Registry

PurposeVagus nerve stimulation (VNS) therapy is a procedure to control seizure frequency in patients with medically intractable epilepsy. However, there is no data on efficacy in the subset of these patients with brain tumors. The purpose of this study is to evaluate the efficacy of VNS therapy in patients with brain tumor-associated medically intractable epilepsy.MethodsData from the VNS therapy Patient Outcome Registry, maintained by the manufacturer of the device, Cyberonics Inc. (Houston, TX, USA), was queried to characterize the response of patients in whom a brain tumor was listed as the etiology of epilepsy. A case–control analysis was implemented and patient outcome was measured by Engel classification, median seizure response and responder rate (≥50% seizure reduction) using t-tests and chi-squared tests.ResultsIn 107 patients with an epilepsy etiology related to a brain tumor, seizure reduction was 45% at 3 months and 79% at 24 months with a responder rate of 48% at 3 months and 79% at 24 months. There was no statistical difference in seizure reduction compared with 326 case–control patients from the registry without brain tumors. There was no significant difference in anti-epileptic drug (AED) usage from baseline to 24 months post implant in either group.ConclusionsVNS therapy is equally effective in patients who suffer seizures secondary to brain tumors as in patients without history of a brain tumor. VNS therapy is a viable treatment option for patients with brain tumor associated medically intractable epilepsy, assuming cytoreductive and other adjuvant therapies have been fully explored.     

改良功能性大脑半球切除术治疗婴儿偏瘫伴顽固性癫(癎)(附9例分析)

目的探讨改良功能性大脑半球切除术治疗婴儿偏瘫伴顽固性癫疒间的疗效。方法总结9例小骨窗经侧裂功能性大脑半球切除术病人的临床资料。手术均采用侧裂表面4cm×5cm骨窗开颅,分开侧裂后经皮质进入侧脑室,完成功能性大脑半球切除手术。结果与常规功能性大脑半球切除术相比,手术时间明显缩短(平均4.2h)、术中需要输血比例(22.2%)降低。随访时间平均2.1年,Engel癫疒间疗效分级Ⅰ级6例,Ⅱ级2例,Ⅲ级1例。偏瘫改善6例(66.7%),语言改善5例(55.6%),行为改善8例(88.9%)。结论小骨窗经侧裂功能性大脑半球切除术,癫疒间控制效果满意,且可缩短手术时间,减少术中出血。     

Surgical treatment for epilepsy: a retrospective Swedish multicenter study

The characteristics of patients suffering from drug resistant epilepsy, including the results of the preoperative evaluation and epilepsy surgery were retrospectively analyzed in a Swedish multicenter 10-year cohort of children and adults. Altogether 152 patients (65 children and 87 adults) treated during the period 1980–1990 in three epilepsy centers were included and followed-up 2 years after surgery. Median age at onset of seizures was 4 years for the children and 12 years for the adults. A localization related epilepsy was present in 85% of the children and in 95% of the adults. The mean number of seizure types in the children was 1.7 (range 1–4) and in the adults 1.8 (range 1–4). The median monthly seizure frequency was 52 and 15 for children and adults respectively. Resective surgery was performed in 143 cases (94 temporal, 31 extratemporal, 9 multilobar and 9 major resection procedures) and palliative procedures in 16 cases (13 callosotomies and 3 stereotactic amygdalotomies). Postoperative neurological deficits were detected in 9% of the patients after temporal lobe resections and in 15% of the patients after extratemporal and multilobar resection procedures. Two years after resective surgery 53% of the children and 49% of the adults were seizure free. Another 25% of the patients had a more than 50% reduction of seizure frequency. In the postoperative non seizure free group of patients there was a negative correlation between decrease in weighted seizure severity and decrease in seizure frequency. This finding stresses the need for including other parameters than seizure frequency when evaluating the outcome of epilepsy surgery.     

Prognosis and clinical features of intractable epilepsy: A prospective study

Abstract  Of the epileptic patients who were treated for ≥ 5 years until the end of 1990 and had more than four seizures in 1990, 63 patients had been treated without interruption until the end of 1995. We analyzed their clinical courses from 1990 to 1995 prospectively. More than half the subjects were diagnosed with temporal lobe epilepsy. Twenty cases had presumed etiology, and 32 had neuropsychiatric complications. Of the subjects whose seizures were not controlled with conventional antiepileptic drugs (AED), 11 cases demonstrated significant improvement when new AED; that is, lamotrigine, vigabatrin, clobazam, topiramate, tiagabine or CGP33101 were added. However, 10 patients did not respond to new AED. Presumed etiology, neuropsychiatric complications, multiple epileptic foci in EEG and abnormalities on head CT or MRI were characteristics of the patients whose seizures were resistant to new AED.     

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。     

难治性颞叶癫痫的外科治疗(附35例临床分析)

目的总结并分析难治性颞叶癫痫患者术前定位、手术方式和经验。方法回顾性分析2009年6月至2011年6月,采用颞前叶+海马杏仁核切除术治疗的颞叶癫痫病人35例,其中术前MRI及术后病理证实伴有海马硬化者32例,所有病例术中均在皮层电极监测下切除颞叶皮质及同侧海马、杏仁核,手术后均应用抗癫痫药物治疗,术后随访1～3年。结果在35随访病例中,癫痫发作控制结果显示EngelⅠ级24例,Ⅱ级8例,Ⅲ级3例,Ⅳ级0例。其中有12例病人术后2年逐渐停用抗癫痫药物。结论联合应用VEEG、MRI及EcoG能准确确定致痫灶,提高颞叶癫痫手术疗效。手术方式选择及显微理念的应用,能有效减少术后并发症的发生,避免出现永久性神经功能缺失。     

Current management and surgical outcomes of medically intractable epilepsy

Epilepsy is one of the most common neurologic disorders in the world. While anti-epileptic drugs (AEDs) are the mainstay of treatment in most cases, as many as one-third of patients will have a refractory form of disease indicating the need for a neurosurgical evaluation. Ever since the first half of the twentieth century, surgery has been a major treatment option for epilepsy, but the last 10–15 years in particular has seen several major advances. As shown in relatively recent studies, resection is more effective for medically intractable epilepsy (MIE) than AED treatment alone, which is why most clinicians now endorse a neurosurgical consultation after approximately two failed regimens of AEDs, ultimately leading to decreased healthcare costs and increased quality of life.     

Calcified cysticercotic lesions and intractable epilepsy: a cross sectional study of 512 patients

Background

Neurocysticercosis is a major cause of epilepsy in developing countries and is endemic in Brazil. To test the hypothesis that the aetiological profile of patients with intractable epilepsy in Brazil includes neurocysticercosis, we conducted a cross sectional study investigating the aetiology of intractable epilepsy.

Methods

A total of 512 patients evaluated at the outpatient clinic for intractable epilepsy at the Ribeirão Preto School of Medicine were included in the survey. Medical intractability was determined on the basis of seizure incidence and severity, and response to appropriate epilepsy management. Neuroimaging included brain CT with non‐contrasted and contrasted phases and high resolution MRI. Patients were divided into neurocysticercosis and non‐neurocysticercosis groups according to previous diagnostic criteria.

Results

The most common epileptogenic lesions were mesial temporal sclerosis (MTS; 56.0%), malformations of cortical development (12.1%), and brain tumours (9.9%). Neuroimaging was normal in 8.7% of patients. Calcifications were found in 27% of patients and were significantly more common in patients with MTS than in those without MTS (p<0.001). Isolated neurocysticercosis was found in only eight patients (1.56%).

Conclusions

These data suggest that neurocysticercosis is an uncommon cause of intractable epilepsy, even in an endemic region such as Brazil, and that it may only represent a coexistent pathology. However, an analysis of our findings reveals that neurocysticercosis was more common in patients with MTS. This finding could suggest either that there is a cause‐effect relationship between MTS and neurocysticercosis, or that MTS and neurocysticercosis co‐vary with a missing variable, such as socio‐economic status.