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。     

颞叶癫痫与海马硬化

原发性颞叶癫痫与海马硬化有关,海马硬化的形成可能是一复杂的动态演变过程。本文就两者的因果关系加以探讨,并对海马硬化的病理及有关命名、临床表现等方面进行了综述,提出了海马硬化MRI 诊断标准。强调指出,MRI 是诊断海马硬化安全可靠的方法。     

不同手术入路治疗海马硬化性颞叶内侧癫痫的比较

目的 比较常用的四种手术方式在治疗海马硬化性颞叶内侧癫痫(MTLE/HS)中的优缺点.方法 106例顽固性MTLE/HS患者中23例行经皮层脑室入路选择性海马杏仁核切除术;23例行经侧裂选择性海马杏仁核切除术;30例行前内侧颞叶切除术;30例行经颞下选择性海马杏仁核切除术.随访6个月-9年.采用Engel分级量表评价癫痫治疗效果,并比较并发症发生率.结果 四种术式在对癫痫发作的治疗效果比较上差异无统计学意义,无手术死亡,在并发症发生率方面差异无统计学意义.结论 对于经严格筛选的MTLE/HS,四种手术方式在疗效和安全性方面相当,可根据个人手术经验加以选择.     

合并海马硬化的颞叶内侧型癫痫的网络分析

目的在只有海马硬化为可见核磁共振病灶的颞叶内侧癫痫中,很多患者合并新皮质的局灶性皮质发育不良(FCD)。本文旨在探讨两者的癫痫网络差异。方法回顾性分析79例颞叶内侧型癫痫患者。所有患者行前颞叶切除术,术后随访至少1年无癫痫发作。根据病理将其分为单纯海马硬化组(HS)和合并新皮质FCD(FCD Ⅲa)组。将每个病人的术前发作间期~(18)FDG-PET数据标准化后,利用Matlab下的SPM(statistical parametric mapping)工具包分析两组间的代谢差异。结果 FCD Ⅲa组和HS组,无论是左侧还是右侧,其发病年龄、病史、性别以及发作期的主要症状学出现的频率均无明显差异。而FCD Ⅲa组的癫痫网络明显大于HS组,有差异的脑区主要在颞叶新皮质、额叶内侧面,缘上回和中央前后回。结论 FCD Ⅲa的癫痫网络要比单纯海马硬化所致的颞叶癫痫范围要大而且更复杂。遇到海马硬化所致的颞叶癫痫,要充分考虑到FCD Ⅲa的可能性,必要时行立体脑电明确新皮质的切除范围。     

选择性杏仁核-海马切除术对内侧颞叶癫痫病人神经心理学的影响

目的 探讨选择性杏仁核-海马切除术（SAH）对内侧颞叶癫痫病人认知功能的影响。方法 回顾性分析2009年1月~2017年5月接受SAH治疗的67例内侧颞叶癫痫的临床资料,术前、术后3个月和术后1年均行详细的神经心理学评估,包括智商、记忆商和语言功能。结果 36例行左侧SAH,31例行右侧SAH。术后1年,癫痫控制效果达到Engel分级Ⅰ级50例,Ⅱ级7例,Ⅲ级8例,Ⅳ级2例。术后3个月,左侧手术病人言语功能、记忆商较术前明显降低（P<0.05）,右侧手术病人言语理解指数、语义流畅性测验明显改善（P<0.05）;术后1年,无论是左侧手术病人,还是右侧手术病人,智商、记忆商、言语功能较术后3个月略改善（P>0.05）;手术前后视觉记忆均无明显变化（P>0.05）。结论 海马硬化性内侧颞叶癫痫行SAH后,左侧手术病人会出现比较明显的言语和记忆功能减低。     

MRI海马特殊扫描在颞叶癫痫海马硬化诊断中的应用

目的：确定癫痫病因和定位癫痫病灶对制定手术方案及判断预后至关重要。近年来研究证实70％－90％的慢性癫痫的病人都存在一定程度的结构异常。高清晰度MRI的出现对顽固性癫痫诊断具有划时代的意义。本研究就MRI在评估颞叶癫痫海马硬化中的作用作初步探讨。方法：对顽固性颞叶癫痫26例应用MRI对病人进行海马特殊扫描。结果：在26例顽固性颞叶癫痫病人行海马特殊MRI扫描中，海马和杏仁核区低恶度脑胶质瘤2例，脑囊肿1例，小AVM1例，脑脓肿1例。海马硬化19例（10右侧，7例左侧，2例双侧）。2例未见异常，MRI所示结构异常率为92％（24／26），海马硬化率为73％。前颞叶萎缩18例，侧脑室颞角的不对称性22例，T2加全像高信号表现11例。颞叶癫痫海马硬化MRI主要表现为：1、前颞叶萎缩；2、侧脑室颞角的海马硬化MRI主酹现为：1、前颞叶萎缩；2、侧脑室颞角的不对称性；3、海马萎缩；4、T2加全像高信号表现；5、海马内结构的丢失。结论：应用MRI海马特殊扫描技术诊断颞叶癫痫海马病变其准确率为92％，其对诊断颞叶癫痫海马病变具有较高的实用价值。     

耐药性颞叶内侧癫痫发作前期海马脑电特征分析

目的 观察耐药性颞叶内侧癫痫患者发作前期海马电极脑电活动特点,为判断和切除癫痫病灶提供神经电生理学依据.方法 对16例非侵入性手段难以明确病灶的耐药性颞叶内侧癫痫患者进行双侧海马电极监测,患者停用抗癫痫药在非麻醉状态下监测48～72 h,分析癫痫发作前期海马电极脑电图资料,探讨耐药性颞叶内侧癫痫发作前期海马电极脑电活动特点.结果 16例发作间期记录到背景活动基础上出现局限于某几个电极点的阵发性高幅慢波1例、发作性快波节律1例、棘波或棘尖慢复合波14例,视为异常脑电活动;经过48～ 72 h监测,10例监测到33次临床癫痫发作,发作起始期海马电极均可记录到清晰可辨的癫痫样脑电波形.结论 颞叶内侧癫痫临床发作起始期海马电极癫痫样放电清晰可辨,部位局限,易于确定癫痫性活动起源部位.对于非侵入性手段难以判断癫痫样放电起源的颞叶内侧癫痫可采用脑立体定向技术植入海马深部电极进行脑电监测.     

伴海马硬化性内侧颞叶癫痫发病机制的研究进展

<正>伴海马硬化性内侧颞叶癫痫是最常见的癫痫综合征之一,发病人数日益增多,但其病因未明、发病机制仍不清楚,因此阐明其发病机制有利于对颞叶癫痫的理解,并为癫痫的早期风险评估、诊断、预后和治疗的临床工具开发提供依据。本文主要对其基本病理组织学特征,与癫痫相关基因,及其相关的病理生理过程等方面进行综述。     

海马硬化型癫痫颞叶的病理学及c-fos、c-jun表达研究

目的研究海马硬化型颞叶癫痫（TLE）患者颞叶皮层神经元的变性凋亡以及c—fos、c-jun表达，并与海马的相应变化进行比较。方法14例颞叶和海马标本制成脑片后，用尼氏染色和TUNEL染色观察神经细胞变性和凋亡，并计数神经细胞数量；同时，研究c—fos和c-jun表达以反映癫痫发作对神经元损伤的程度和范围。结果颞叶皮层的神经细胞数量明显减少且形态异常，并有较多的凋亡细胞，伴有胶质细胞增生，而且有c—fos和c-jun的大量表达；其表现与海马的相应变化相似，但颞叶的胶质细胞增生更为明显。与对照组比较差异有统计学意义（P〈0．01或P〈0．05）。结论除海马外，颞叶神经细胞和胶质细胞的病理改变可能参与海马硬化型TLE的发生和传播过程。     

伴海马硬化的颞叶癫痫患者的临床特点及手术治疗

目的探讨颞叶癫痫海马硬化的临床特点及手术治疗的效果。方法伴海马硬化的颞叶癫痫患者18例,其中男10例,女8例;年龄12~37岁,病程3~10年。癫痫复杂部分性发作10例,部分性发作继发全身性发作2例,全身强直-痉挛性发作6例。结合患者的临床表现、MRI检查和视频脑电图(V-EEG)监测结果,对这18例患者行前颞叶切除术(包括大部分海马和杏仁核)。结果所有患者术中皮层和深部电极脑电图均发现颞叶皮层海马、杏仁核有异常放电,术后病理检查均证实海马硬化的诊断。术后18例患者均出现发热,但经过抗炎、腰椎穿刺及支持治疗后渐好转。术后1年以上的随访发现16例癫痫发作完全消失,2例术后较术前显著改善,仅偶有癫痫发作,但均长期服用抗癫痫药物。结论对于颞叶癫痫伴有海马硬化的患者,如果同时脑电图又发现有同侧颞叶痫样放电,则可以考虑行该侧前颞叶切除术(包括大部分海马和杏仁核),若手术切除彻底,其术后疗效也较满意。     

Metals and electrolytes in sclerotic hippocampi in patients with drug‐resistant mesial temporal lobe epilepsy

An altered metal and electrolyte profile has been implicated in the pathologic mechanisms of chronic epilepsy; however, no study has comprehensively measured hippocampal concentrations of these elements in patients with mesial temporal lobe epilepsy and hippocampal sclerosis (mTLE‐HS). We therefore analyzed hippocampi of 24 patients with drug‐resistant mTLE‐HS (mean age 35.6 ± 9.4 years) who underwent anterior temporal lobe resection and amygdalohippocampectomy and 17 hippocampi obtained by autopsy from 13 controls (mean age 40.5 ± 12.9 years), using inductively coupled plasma optical emission spectrometry (ICP‐OES). Epileptic hippocampi showed significantly lower concentrations (μg/g of tissue) of copper (HS: 2.34 ± 0.12; control [C]: 3.57 ± 0.33; p < 0.001), manganese (HS: 0.205 ± 0.030; C: 0.409 ± 0.064; p = 0.004), and potassium (HS: 2,001 ± 59; C: 2,322 ± 61; p < 0.001), and increased sodium levels (HS: 1,131 ± 22; C: 1,040 ± 25; p = 0.010). Zinc, iron, calcium, and magnesium levels did not differ in HS and controls. In summary, copper and manganese levels are deficient, whereas iron level is unchanged in hippocampi from patients with mTLE‐HS. Our results provide a basis for understanding the potential involvement of different metals and electrolytes in the pathology of HS. A PowerPoint slide summarizing this article is available for download in the Supporting Information section here .     

Neuronal apoptosis in the resected sclerotic hippocampus in patients with mesial temporal lobe epilepsy.

To further confirm at the molecular level that neuronal apoptosis occurs in mesial temporal sclerosis (MTS), the main substrate of mesial temporal lobe epilepsy (MTLE), 24 resected sclerotic hippocampi from 24 patients with drug-resistant MTLE associated with MTS were studied microscopically, electronmicroscopically and immunohistochemically, with detection of expression of apoptosis-associated genes including bcl-2, p53, bax, fas and caspase-3. Early apoptosis changes were found morphologically in hippocampi from three patients with MTLE using transmission electron microscopy. Positive immunostained neurons for bcl-2, p53, fas and caspase-3 were found in the sclerotic hippocampi of 19/24, 14/24, 22/24 and 20/24 patients respectively, which was statistically different from controls. Correlative analysis showed the expression of p53, fas and caspase-3 were positively correlated with seizure frequency. Apoptosis may contribute to MTS, and seizures may induce apoptosis, and thus contribute to neuronal loss in MTS.     

Depression in patients with temporal lobe epilepsy is related to mesial temporal sclerosis

Depression is a frequent psychiatric symptom in epilepsy and has been related to epilepsy of temporal origin, especially of left-sided foci. No study differentiated the precise localization of the epileptogenic lesion within the temporal lobe. Regarding this issue, we evaluated depression assessed by the Beck Depression Inventory in 60 patients with temporal lobe epilepsy, with particular consideration of morphological abnormalities within the temporal lobe (mesial temporal sclerosis (MTS) versus neocortical lesions) and lateralization of the lesion. Multivariate analyses indicated significant higher depression scores in MTS independent of the lateralization of the lesion. Depression was a good indicator for MTS but not vice versa. Hence, MTS can be discussed as a predisposing factor for the development of mood disorders in focal epilepsy.     

Prognostic factors in patients with mesial temporal lobe epilepsy

Purpose:   To disclose clinical, electrophysiologic, and neuroradiologic factors correlated to prognosis in patients with mesial temporal lobe epilepsy (MTLE).
Methods:   One hundred thirty-six MTLE patients were studied for family history, clinical characteristics, instrumental data [electroencephalography (EEG), video-EEG, neuroimaging], and outcome. The population was divided into drug-resistant (DR: 108 patients, 79.4%) and non–drug-resistant (NDR: 28 patients, 20.6%) groups; all variables were analyzed in the two groups.
Results:   The comparison between the two groups shows a relation between resistance to therapy and febrile seizures (FS) (DR 43.5% vs. NDR 17.8%, p = 0.008), mesial temporal sclerosis (MTS) (DR 64.8% vs. NDR 32.1%, p = 0.0025), early age at seizure onset (DR 23.1% vs. NDR 3.6% p = 0.0160), and epileptiform interictal abnormalities (DR 89.7% vs. NDR 68%, p = 0.010). FS were more frequent in patients with MTS than in patients without (46.28% vs. 26.3%, p = 0.0199). Sixty-nine patients underwent surgery and 85.3% of them had a good outcome.
Conclusion:   MTLE is a heterogeneous syndrome. Establishing the factors responsible for and associated with drug resistance is important for therapeutic purposes, as prompt diagnosis of drug resistance must lead to early surgical management. This study shows that FS, MTS, early age at seizure onset, and epileptiform interictal abnormalities are negative prognostic factors and that FS are related to MTS.     

Sex differences in patients with mesial temporal lobe epilepsy

Possible sex differences in the pattern of interictalhypometabolism were investigated, and also seizure spread in patients with mesial temporal lobe epilepsy (n=48) and hippocampal sclerosis (MTLE). Male patients (n=21) more often had a frontal lobehypometabolism ipsilateral to the seizure onset (p<0.0001) and aspread of epileptiform activity to this region (p=0.001). By contrast,female patients more often exhibited hypometabolism (p=0.0052) and anictal spread to the contralateral temporal lobe (p=0.0097). Thesefindings suggest sex differences in spatial distribution of braindysfunction in MTLE, perhaps reflecting sexual dimorphism in regionalcerebral connectivity.

     

伽玛刀治疗颞叶内侧癫痫疗效分析(附26例临床分析)

目的探讨伽玛刀治疗颞叶内侧癫痫的方法与疗效。方法2000年9月至2005年1月应用伽玛刀治疗颞叶内侧癫痫患者共26例,病程平均8年（4～42年）。治疗范围包括杏仁核,海马及部分海马旁回,50％等剂量曲线边缘剂量平均19Gy（15～20Gy）。结果随访0．7～5．03年,平均1．13年。26例患者中有10例发作完全消失,发作频率减少在50％以上的患者16例（62％）,在随访时间大于1．5年的9例患者中有6例发作完全消失,发作频率减少在50％以上的患者7例（77．8％）。所有患者中21例复查了核磁共振（MRI）,有14例在术后12个月前后出现局部水肿及血脑屏障破坏。全部病人未见头痛、记忆力下降、视束损伤等并发症。结论初步结果显示伽玛刀治疗颞叶内侧癫痫安全、有效,最终疗效评估仍需大量病例长期随访确定。     

Surgical outcome of patients with mesial temporal lobe epilepsy related to hippocampal sclerosis

Seizure outcome in mesial temporal lobe epilepsy related to hippocampal sclerosis (MTLE-HS) that was evaluated according to a noninvasive protocol was assessed in 165 patients and reported using both Engel's and ILAE classifications. The mean postoperative follow-up was 5.0 +/- 2.7 years. At the end of first year, 77.1% of patients were in Engel-I, and 52.7% were in ILAE-I. Antiepileptic drugs (AEDs) were discontinued in 41 patients (42.7%), all remained seizure-free for >or= 2 years that could be accepted as "cure." Thirty-six patients had recurrences, 19 had running-down phenomena. Anterior temporal lobectomy (ATL) was performed in 27 patients with a better outcome when compared to patients operated by selective anterior hippocampectomy. Clinical risk factors for better and worse outcome, which show some similarity in different reports, seem to veil the main reason, which is the accurate delineation of epileptogenic zone considering the presence of different subgroups and underlying developmental pathologies.     

海马硬化型颞叶癫疒间海马组织中P-gp、p53和凋亡探讨

目的探讨海马硬化型颞叶癫疒间患者海马组织中P-gp、p53、凋亡的表达和意义。方法对17例海马硬化型颞叶癫疒间患者的手术标本分别进行免疫组化检查P-gp,p53;原位末端标记检测细胞凋亡;免疫印迹法检测P-gp,p53。结果对照组P-gp主要在血管内皮细胞表达,未见p53阳性细胞,仅有散在凋亡细胞;癫疒间组P-gp分布在血管内皮细胞和胶质细胞,14例有p53阳性细胞,均有凋亡细胞;免疫印迹法P-gp,p53表达较对照组明显增加。结论海马硬化型颞叶癫疒间患者海马组织中有P-gp、凋亡异常表达,p53可能发挥了调节作用。     

The significance of corpora amylacea in mesial temporal lobe epilepsy

Temporal lobe epilepsy (TLE) associated with mesial temporal sclerosis (MTS), mesial TLE (MTLE), is the commonest medically refractory adult epilepsy syndrome. Corpora amylacea (CoA) have been shown to be a marker of MTS. We compared 9 patients with MTS who had dense deposition of CoA in their hippocampi with 25 patients with MTS who did not have CoA. The patients with CoA were significantly older and they showed a trend towards having a significantly longer duration of epilepsy. The postoperative seizure outcome at 2 years was not different in the 2 groups. Our results could indicate the progressive nature of the pathology of MTS, probably indicating excitotoxic damage due to recurrent seizures, but they need to be verified by clinicopathological correlation among a larger number of patients with MTLE.     

Prefrontal hypofunction in patients with intractable mesial temporal lobe epilepsy

We compared the cognitive functions and interictal cerebral glucose metabolism of 11 patients with mesial temporal lobe epilepsy (MTLE) with frequent seizures to those of 10 patients with MTLE with rare seizures; the groups were matched for age, sex, education, IQ, and focus side. The frequent-seizure group had more set-shifting impairment that correlated with glucose hypometabolism in the prefrontal cortices. Our results suggest that frequent seizures in MTLE are associated with hypofunction of the prefrontal cortex.