立体定向病灶切除联合皮层热灼术治疗起源于中央区的癫(癎)

目的探讨立体定向病灶切除联合皮层热灼术治疗起源于中央区的癫(癎)的疗效.方法对27例以癫(癎)为首发表现的起源于中央区的癫(癎)病人采用立体定向开颅手术,切除病灶前先行皮层电极描记,确定癫(癎)波的范围,然后在显微镜下切除病灶,再次描记确定残余的癫(癎)波的位置,并使用皮层热灼术进行皮层热灼,直到癫(癎)波消失为止.结果27例病人中胶质瘤13例,脑囊虫病7例,脑膜瘤3例,皮层发育不全2例,海绵状血管瘤1例,炎症1例.手术中在切除病灶前使用皮层电极描记出癫(癎)波,病灶切除后在病灶周围仍残余有癫(癎)波,使用皮层热灼术热灼后癫波消失.27例病人手术后25例未再有癫(癎)发作,2例手术后一周内有癫(癎)发作一次,以后未再有癫(癎)发作.26例病人未出现神经功能损害症状加重,一例短期内出现偏瘫加重,经过对症处理后好转.结论立体定向病灶切除联合皮层热灼术治疗起源于中央区的癫(癎)是一种侵袭性小、疗效佳的手术方法.     

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。     

皮层脑电监测下颞叶病变合并癫的手术治疗

目的探讨皮层脑电监测下合并颞叶病变的癫手术治疗效果。方法 21例伴有癫症状的颞叶病变患者,术中通过皮层脑电图确定癫灶,切除病变后,切除或热灼可疑癫疒间灶。术后随访患者的癫发作情况。结果 21例患者切除颞叶病变前均可通过皮层脑电图探及疒间波,病变及疒间灶完全切除后,癫波消失者19例,2例功能区患者虽多次皮层热灼,仍可见偶发棘波。术后20例未再有癫疒间发作,1例有部分性发作,用抗癫疒间药可控制。结论术中皮层脑电监测切除或热灼癫灶是一种有效控制颞叶病变切除术后癫发作的方法。     

顽固性癫(癎)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 准确定位致病灶,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.     

手术方法治疗顽固性癫癎

目的对顽固性癫癎病人联合采用几种手术方法,对其临床疗效进行评价,以探讨不同类型顽固性癫癎的最佳治疗方案.方法手术治疗顽固性癫癎51例.术前均行头皮脑电视频连续监测,及MRI、SPECT检查.行单纯局部致癫癎病灶切除术7例,加行皮质软膜下横纤维切断术3例,加行皮质热灼术12例,加行皮质热灼术及胼胝体切开术5例;前颞叶切除术+皮质热灼术17例,立体定向核团毁损术6例,迷走神经刺激术1例.结果无手术死亡及术后并发症,随访3～24个月,手术总有效率90.2%,优良率70.6%.结论多种手术联合治疗顽固性癫癎病人安全、有效.     

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。     

涉及中央区难治性癫(癎)的外科治疗

目的 探讨涉及中央区难治性癫(癎)的手术治疗.方法 3例患者术前除常规致癫(癎)灶评估外,还应用fMRI作皮质功能区定位.术中通过皮层EEG(ECoG)对致癫(癎)灶定位,通过皮层诱发电位(SEP)及皮质电刺激定位脑功能区,对位于功能区以外的致疒间灶行切除性手术,功能区内的致疒间灶行软脑膜下横行纤维切断术.结果 术后无神经功能障碍,术后3月,2例病人无癫(癎)发作,1例偶有部分性发作;术后8月,1例无发作,1例偶有部分性发作,1例减少75%发作. 结论术前功能区评估、术中电生理监测有助于保护皮质重要功能和提高手术癫(癎)控制率.     

病灶切除辅助周围癎灶皮质横纤维热灼治疗继发性癫癎

目的 观察病灶切除加周围癎灶皮质横纤维热灼治疗继发性癫癎的临床效果。方法 对71例病灶切除加热灼的病人和78例单纯病灶切除病人的疗效进行对比分析。结果 病灶切除辅助热灼组效果优于单纯病灶切除组，两存在显性差异。病灶切除加热灼无术后并发症。结论 病灶切除辅助周围癎灶皮质热灼是治疗继发性癫癎安全有效的方法，长期疗效有待于进一步观察。     

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.     

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。     

立体定向开放显微手术治疗脑内致痫小病灶

目的脑内致癫痫小病灶术前、术中的精确定位和病灶切除,是手术治疗效果的关键。探讨立体定向开放微创手术,皮层电极监测下切除脑内致痫小病灶的手术方法。方法53例症状性癫痫病例,CT、MR I检查有脑内小病灶(直径在0.5~3.0 cm),24 h视频脑电图确认致痫灶为脑内单发病灶。ASA 601S型立体定向仪CT引导辅助全麻环钻开颅,导针穿刺放置导管引导,显微镜下手术分离、切除病灶,皮层脑电图确认将致痫灶切除。结果病灶全切率达96.2%,术后50例得到随访,随访时间5~12个月,平均6.3个月,癫痫消失45例,脑电图检查记录到癫痫波11例,临床癫痫发作5例。因肺癌死亡3例。结论CT立体定向引导,显微手术切除颅内致痫小病灶,术中皮层电极确认将致痫灶切除,是一种定位精确、微创、安全、有效的治疗方法。     

皮层电极描记配合立体定向切除癫痫灶

目的 评价皮层电极描记在立体定向切除癫痫灶手术中的应用和价值。方法 对25例以癫痫为首发症状的继发性癫痫患者采用MRI导向下，立体定向环钻开颅，切除病灶前行皮层电极描记，记录有无癫痫波和范围，切除病灶后再次描记，如仍有癫痫波，则在不影响神经功能的基础上将有癫痫波的皮层尽可能切除。结果 25例患者中有19例在切除病灶前记录到棘波、棘-慢波、尖波或尖-慢波，切除后有15例上述癫痫波完全消失，4例仍有散在的少许癫痫波；另有6例患者未记录到癫痫波，但表现为基本的节律异常，切除病灶后好转。25例患者中胶质瘤6例，脑囊虫病5例，蛛网膜囊肿3例，软化灶3例，皮层发育不全2例，血管畸形2例，转移癌2例，炎症1例，胶质细胞增生1例，病灶直径在0．8～4．7cm。手术后24例癫痫发作消失，1例仍偶有癫痫发作，比例能够被口服抗癫痫药物控制。手术后患者无神经功能损害加重。结论 皮层电极描记和立体定向方法相结合，既能明确癫痫灶的范围，又能以微侵袭的方法切除癫痫灶，尤其适用于直径小于4cm的癫痫灶的切除。     

立体定向辅助显微手术切除脑内海绵状血管瘤

目的 探讨利用立体定向技术,辅助皮层电极监测,开放显微手术切除导致顽固性癫痫的脑内海绵状血管瘤,提高微创手术的治疗效果.方法 26例顽固性癫痫病例,MRI示脑内海绵状血管瘤(直径在0.5～2.5 cm),视频脑电图检查诊断与MRI定位一致.10例采用常规显微手术切除,16例利用立体定向技术,放置硅胶管引导显微手术切除病灶,辅助皮层脑电图监测确认致痫灶切除.结果 手术时间:常规组为3.5小时,定向组为2.3小时.病灶全切率:常规组80%(8/10),定向组93.7%(15/16).全部病例得到随访,时间平均18个月,常规组癫痫消失8例,脑电图记录到癫痫波2例,临床癫痫发作2例.定向组癫痫消失14例,脑电图记录到癫痫波2例,临床癫痫发作1例.结论 在没有导航系统的条件下,立体定向引导显微开放手术,辅助皮层电极监测,切除以顽固性癫痫为症状的海绵状血管瘤是一种定位精确、微创、安全、有效的方法.     

MEG predicts epileptic zone in lesional extrahippocampal epilepsy: 12 pediatric surgery cases

PURPOSE: To discover whether the spatial distribution of spike sources determined by magnetoencephalography (MEG) provides reliable information for planning surgery and predicting outcomes in pediatric patients with lesional extrahippocampal epilepsy. METHODS: We retrospectively studied 12 children with extrahippocampal epilepsy secondary to cortical dysplasia (CD), tumor, or porencephalic cyst. We compared interictal MEG spike source locations and somatosensory evoked fields derived from equivalent-current dipole modeling with intraoperative or extraoperative electrocorticography (ECoG). RESULTS: MEG spike sources were found in proximity to the lesion in all patients and extended from lesions in five patients with CD. Marginal spike sources were noted in three patients with tumors, one patient with a cyst, and one with CD, and extramarginal sources in three patients with tumors. Three patients with tumors underwent lesionectomy only; two had further cortical excisions. One patient with CD underwent lesionectomy only, three had lesionectomy and cortical excisions, and two had lesionectomy and multiple subpial transection. Asymmetric MEG spike sources correlated with ECoG findings in all patients. Residual epileptiform discharges on postexcisional ECoG corresponded to spike sources in three patients with tumors and one patient with a cyst. Eleven patients have been seizure free for 1-6 years (mean, 4 years). One patient had residual seizures after incomplete excision of right temporal CD. CONCLUSIONS: MEG delineated asymmetric epileptogenicity surrounding lesions and the eloquent cortex. Complete tumor resection produced favorable outcomes despite residual postexcisional ECoG spikes and extramarginal MEG spike sources. CD characterized by clusters of MEG spike sources within and extending from lesions seen on magnetic resonance imaging (MRI) should be removed to prevent seizures.     

皮层脑电图辅助立体定向下手术治疗颅内钙化灶引起的难治性癫痫

目的研究立体定向下开放式手术联合术中皮层脑电图(ECoG)监测治疗颅内钙化灶性癫痫的手术方法、注意事项及效果。方法 21例颅内单发钙化灶引起的癫痫患者(其中主要功能区钙化灶9例),在立体定向仪导向下,开放直视手术,ECoG监测钙化灶周围皮层脑电活动情况,切除钙化灶后再次ECoG监测,确定致痫灶的范围及处理方式。结果所有钙化灶均被顺利切除。钙化灶区域ECoG监测无明显异常5例,表现为阵发性与动脉搏动相一致的单发性棘慢复合波发放9例,表现为明显癫痫样放电7例。单纯钙化灶切除术14例,钙化灶+周边增生组织+致痫皮层切除术4例,钙化灶切除+功能区致痫皮层低功率电凝热灼术3例。术后ECoG监测发现异常放电消失11例,仍残存轻中度痫样放电5例。无严重并发症。随访6个月～8年,EngelⅠ级16例,EngelⅡ级5例,总有效率100%。结论 ECoG监测是立体定向下手术治疗颅内钙化灶性癫痫的重要辅助手段,能够指导术中采取相应的手术方式切除钙化灶,妥善处理致痫灶,避免过多损伤脑皮层。     

幕上与癫痫有关的海绵状血管瘤的显微外科治疗

目的 探讨幕上表现于癫痫的颅内海绵状血管瘤外科治疗方法和效果.方法 25例幕上表现于癫痫的颅内海绵状血管瘤患者,根据术前影像学、脑电图表现与运动区的关系分为A、B二组.手术在皮层脑电图(ECoG)监测下进行,包括单纯切除血管瘤、切除血管瘤和切除含铁血黄素层,以及辅助部分皮层痫灶切除、皮层热灼或软膜下横切等.结果 本组海绵状血管瘤均令切除,2例术后有一过性轻度肢体功能障碍,无手术死亡.随访10个月-4.5年,A组9例,Engel Ⅰ级6例;Engel Ⅱ B级2例;Engel Ⅲ级1例.B组16例,均无发作.结论 幕上与癫痫有关的海绵状血管瘤在ECoG监测下做病灶和痫灶切除,是控制术后癫痫发作的有效手段;运动区和附近海绵状血管瘤由于手术没有完全切除致痫灶可能是术后癫痫控制率差的原因.     

伴有癫癇发作的脑内病灶的手术治疗

~~伴有癫癇发作的脑内病灶的手术治疗@张俊卿$厦门大学医学院中山医院神经外科!福建厦门361004 @邓志鸿$厦门大学医学院中山医院神经外科!福建厦门361004 @黄延林$厦门大学医学院中山医院神经外科!福建厦门361004 @杨芳裕$厦门大学医学院中山医院神经外科!福建厦门361004~~~~~~     

Electric cortical stimulation suppresses epileptic and background activities in neocortical epilepsy and mesial temporal lobe epilepsy.

OBJECTIVE: To evaluate the suppressive effect of electric cortical stimulation upon the seizure onset zone and the non-epileptic cortex covered by subdural electrodes in patients with neocortical epilepsy and mesial temporal lobe epilepsy (MTLE). METHODS: Four patients with medically intractable focal epilepsy had implanted subdural electrodes for preoperative evaluation. Cortical functional mapping was performed by intermittently repeating bursts of electric stimulation, which consisted of 50 Hz alternating square pulse of 0.3 ms duration, 1-15 mA, within 5 s. The effect of this stimulation on the seizure onset zones and on the non-epileptic areas was evaluated by comparing spike frequency and electrocorticogram (ECoG) power spectra before and after stimulation. A similar comparison was performed in stimulation of 0.9 Hz of the seizure onset zones for 15 min. RESULTS: When the seizure onset zone was stimulated with high frequency, spike frequency decreased by 24.7%. Logarithmic ECoG power spectra recorded at stimulated electrode significantly decreased in 10-32 Hz band by high frequency stimulation of the seizure onset zone, and in 14-32 Hz band by high frequency stimulation of the non-epileptic area. Low frequency stimulation of the seizure onset zone produced 18.5% spike reduction and slight power decrease in 12-14 Hz. CONCLUSIONS: Both high and low frequency electric cortical stimulation of the seizure onset zone have a suppressive effect on epileptogenicity. Reduction of ECoG fast activities after electric cortical stimulation suggests the augmentation of inhibitory mechanisms in human cortex.     

Identification and removal of an epileptogenic lesion using Ictal-EEG, functional-neuronavigation and electrocorticography.

PURPOSE: Cases with intractable epilepsy may present with multiple lesions in their brains. Ictal-EEG carries a great value in identification of the primary epileptogenic source. On the other hand, removal of low-grade tumors located around the eloquent cortex may be risky with conventional techniques. Functional-neuronavigation (f-NN) is the integration of functional magnetic resonance imaging and stereotactic technologies; and provides interactive data regarding localization of the motor cortex. This report presents a case with dysembryoplastic neuroepithelial tumor (DNET), which was removed using f-NN and electrocorticography (ECoG) techniques. METHODS: A 19-year-old patient with intractable complex partial and secondary generalized seizures is presented. MRI revealed a low-grade tumor located in right parietal region just behind the motor cortex, and a contralateral temporal arachnoid cyst. Ictal-EEG demonstrated the right parietal origin of the seizures. The patient underwent a right parietal craniotomy and tumor excision using f-NN and ECoG techniques intraoperatively. ECoG findings correlated with epileptogenicity of the parietal lesion. RESULTS: Postoperative course was uneventful. No postoperative deficit was observed. The patient was seizure free in eight months follow-up. Pathological examination reported the lesion as DNET. CONCLUSIONS: Ictal-EEG has a very important role in identification of the epileptogenic focus in cases with multiple brain lesions. Preservation of the functional cortex is the most prominent aim during lesional surgery of epilepsy. Intraoperative mapping using f-NN and ECoG supports the orientation of the neurosurgeon to the functional and epileptogenic cortical areas; and thus, increase the safety and efficacy of surgical procedures.     

Effect of sleep on interictal spikes and distribution of sleep spindles on electrocorticography in children with focal epilepsy.

OBJECTIVE: To determine how sleep with central spindles alters the spatial distribution of interictal spike frequency in children with intractable focal seizures, and whether such children have spindles arising from the medial temporal region in addition to the frontal-central region. METHODS: Seventeen children (age: 7 months-17 years) were studied using extraoperative electrocorticography (ECoG). RESULTS: Overall spike frequency across the subdural electrodes was greater during sleep with central spindles compared to wakefulness. In 13 children showing at least 1 spike/min in an electrode, the spatial distribution of spike frequency was similar during wakefulness and sleep; in addition, the spike frequency was greater in the seizure onset zones compared to the non-onset areas, regardless of wakefulness or sleep. Spindles were identified in the medial temporal region during sleep with central spindles in all 17 children. CONCLUSION: Overall spike frequency may be increased by sleep with spindles, but the spatial distribution of spike frequency appears similar during wakefulness and sleep in children with intractable focal seizures. SIGNIFICANCE: Both awake and sleep ECoG may be useful to predict seizure onset zones in children with intractable focal epilepsy. Medial temporal spindles are present in some children with focal epilepsy.