伴有结构性病变颞叶癫(癎)的外科治疗

目的:对伴有结构性病变颞叶癫患者的外科治疗进行回顾性分析,探讨术前评估、手术方式和术中监测对病灶切除和术后癫控制的意义。方法:伴有结构性病变颞叶癫患者74例,术前进行全面详细评估,并进行病灶和致灶定位,术中在EcoG描记辅助下行病灶+致灶切除,术后随访6-48月。结果:术前V-EEG检查异常者59例(80%),MRI检查阳性者70例(95%),余4例行PET检查示颞叶局部代谢减低;术中EcoG描记异常放电者61例(82%);术后随访EngelⅠ级51例(70%),EngelⅡ级13例(18%),EngelⅢ级5例(7%),EngelⅣ级5例(7%)。结论:对伴有结构性病变颞叶癫患者术前进行全面评估,联合神经影像学检查、V-EEG、临床表现和其它术前评估手段对病灶和癫灶定位具有重大意义。在神经影像学和电生理指导下,行病变切除术+致灶切除术(或阻断性活动扩散的手术,如多处软膜下横切),可获得较好疗效。     

脑磁图在癫(癎)诊断和治疗中的应用

目的应用脑磁图(MEG)技术对致灶进行定位,比较其与头皮脑电图(EEG)在神经影像学方法的应用价值,探讨MEG技术对癫灶定位的应用前景。方法对113例癫患者进行手术治疗,术前均通过临床症候学、头皮EEG、MRI、MEG检查,进行MEG与其他检查方法和临床症候学在定侧、定叶诊断的对比研究。手术在皮层EEG及脑深部EEG监测下进行,手术治疗结果以Engel疗效分级评价。所有手术标本常规行光镜检查。结果113例患者中MEG定位局限于单个叶的为91例,头皮EEG仅为30例。术前致灶定位依据多种检查结果和临床症候学综合定位。MEG与MRI、临床症候学在定侧诊断准确性方面比较差异有显著性。MEG与MRI在定叶诊断准确性方面的比较差异有显著性。36例术前头皮EEG表现为双侧或全导癫波的癫患者,其中有34例MEG表现为单侧癫波,具有定侧诊断的意义。结论头皮EEG、MRI、正电子发射计算机断层扫描(PET)、临床症候学均不足以做出独立精确的致灶定位诊断,综合比较MEG比上述方法定侧和定叶的准确性高。MEG空间分辨率、时间分辨率高,有助于区分致灶和镜灶。     

难治性癫相关脑肿瘤及瘤样病变42例临床病理研究

目的探讨难治性癫相关脑肿瘤及瘤样病变的临床病理特征。方法对因难治性癫接受致病灶切除术并经病理诊断为脑肿瘤及瘤样病变的患者临床资料进行回顾性研究。结果患者42例,平均发病年龄11.1岁,平均病程10.5年,头颅核磁共振检查多见异常信号表现(95.2%,40/42),多位于颞叶(76.2%,32/42)。组织学分类最多为节细胞胶质瘤(40.5%,17/42),肿瘤常伴有局灶性皮质发育不良(61.9%,26/42)。免疫组化:21例CD34(+)、23例nestin(+)。结论难治性癫相关脑肿瘤及瘤样病变诊断应强调临床、影像和病理学特点的综合判断,nestin免疫组化染色对诊断与鉴别诊断有一定的应用价值。     

双侧颞叶海马病变致药物难治性癫的外科治疗

目的探讨双侧颞叶海马病变致药物难治性癫的外科手术治疗方法及效果。方法 5例MRI显示双侧颞叶病变的患者,临床症状、核磁共振成像（MRI）、长程视频脑电监测（V-EEG）及正电子发射断层显像-计算机断层显像（PET-CT）等检查均不能定位起源病灶,行MRI引导立体定向下双侧海马深部电极置入术,对术后V-EEG,综合分析结果,确定起源病灶侧别后行手术治疗。结果术后随访半年以上,按照Engel的疗效判断标准：Ⅰ级4例（行起源侧前颞叶海马杏仁核切除术）,Ⅱ级1例（行起源侧海马神经调控治疗）。结论对双侧颞叶海马病变致药物难治性癫,通过立体定向下双侧海马深部电极置入术及术后长程V-EEG方法,综合分析结果能较准确确定癫起源灶,同时也能成功指导外科手术。     

儿童癫认知障碍研究进展

癫是儿童时期的常见病,多发病,约30%的癫患儿同时伴有认知功能障碍,主要表现为注意力、记忆力、推理判断及学习能力的下降。其原因是多方面的,包括致疒间灶部位、不同发作类型、发病年龄、病程、发作频率、抗癫药物及家庭社会因素均影响患儿认知。应用神经心理学评定量表、事件相关电位及功能影像学检查可以测量认知功能损伤程度。通过综合治疗可提高癫患儿的认知功能。     

幕上肿瘤伴发癫(癎)的精确定位和手术疗效分析

目的 探讨幕上肿瘤伴发癫(癎)的精确定位价值和手术治疗效果,研究肿瘤与致(癎)灶的关系.方法 对121例(胶质瘤Ⅰ级15例、Ⅱ级35例、Ⅲ～Ⅳ级12例,脑膜瘤32例,脑转移瘤10例,海绵状血管瘤15例,室管膜瘤2例)临床上以癫(癎)为首发症状的幕上肿瘤患者术前、术后癫(癎)发作情况等,临床资料进行回顾性分析.结果 采用术前影像和脑电结合定位、术中皮层脑电再次定位的方法,对肿瘤和癫(癎)灶同时切除,无手术死亡.癫(癎)发生率最高在额叶,最低在枕叶.癫(癎)灶与肿瘤的关系:位于同一部位者50例;致(癎)灶位于肿瘤一侧或近旁者28例;致(癎)灶位于肿瘤远隔部位(＞2 cm)25例;检测不到致痫灶者18例.失访18例,103例随访1～9年,31例术后早期仍有小发作,83例不再服抗癫(癎)药物癫(癎)症状完全消除.结论 在幕上肿瘤伴发癫(癎)患者中,致(癎)灶与肿瘤灶存在一定的差异性.在开颅切除肿瘤的同时必须明确致(癎)灶的位置和范围,一并切除才能达到良好的手术效果.     

癫(癎)发病机制研究进展

癫的发作与大脑神经元异常同步放电有关,是影响人类健康的一大类疾患。本文综合国内外最新研究进展,从离子通道、神经递质受体、突触重塑、神经胶质细胞及皮质发育多方面探讨癫发病机制,以期对癫的形成有进一步认识。     

癫(癎)相关死亡的流行病学研究进展

癫是由大脑神经元反复过度放电引起的,发作性、突然性、短暂性的大脑机能障碍,是一种临床综合征。目前,癫相关的死亡问题越来越受到医生和患者的关注。了解癫死亡情况及其危险因素,早期识别高危患者将有助于降低癫的疾病负担。     

立体定向放射外科治疗难治性癫

近年随着神经影像学、神经电生理的发展,国内外报道立体定向放射外科治疗(stereotactic radiosurgery,SRS)顽固性癫的病例数明显增多。现结合文献,就SRS治疗顽固性癫在治疗机制、适应证、靶区设定、照射剂量、疗效及并发症等方面的进展综述如下。1历史回顾[1-3]Leksell于19     

脑卒中后继发癫28例临床分析

脑卒中后继发癫在临床并不少见,可以发生在脑卒中的急性期或中风数月甚至数年之后.癫发作后可导致慢性脑病、脑萎缩,局灶神经症状使致残及致死率增加[1],严重影响患者生存质量.本科自1998年1月至2008年2月共收治脑卒中患者310例,其中发生继发癫患者28例(9%),报告如下.     

皮层脑电图监测辅助显微手术治疗脑肿瘤继发癫痫预后评估

[目的]评估皮层脑电图(ECoG)监测下显微手术切除肿瘤并处理致痫灶对伴癫痫症状脑肿瘤患者的预后.[方法]65例伴有癫痫症状的脑肿瘤患者,术中通过ECoG确定癫痫灶,应用显微手术切除肿瘤组织后,再根据ECoG所确定的癫痫灶进行切除或热灼,术后观察患者癫痫发作情况并随访3～72个月.[结果]65例患者切除肿瘤前均可通过ECoG描记到癫痫波,切除肿瘤后,癫痫波完全消失者59例.术后57例癫痫发作停止,8例发作程度减轻,3例胶质瘤复发失去随访.[结论]针对脑肿瘤继发性癫痫患者,术中在ECoG监测下切除致痫灶或同时进行皮层热灼,是一种控制术后癫痫继续发作的有效治疗方法.     

EEG-fMRI同步联合对局灶性癫痫的定位

目的 采用脑电图功能磁共振l司步联合的方法,用于局灶性癫痫患者的术前定位.方法 11例局灶性癫痫患者,术前行脑电图功能磁共振同步联合检查,观察癫痫发作间期,痫样放电所致的腩活动情况,并结合同步EEG检查结果、术后病理及定期随访的情况对fMRI结果进行分析.结果 10 例(10/11)患者均在颅内原有病灶周围发现明显的 fMRI信号激活区,并与同步EEG检查的痫样放电脑区基本一致.术后病理证实病灶周围存在导致癫痫发作的病理性改变,术后随访证实11例患者均取得满意的手术效果.讨论局灶性癫痫间期痫样放电引起的血氧水平依赖性效应可用于癫痫灶的定位,脑电图功能磁共振同步联合的检查技术结合,可用于局灶性癫痫的术前定位.     

18F-FDG PET显像与EEG在颞叶癫痫致痫灶定位价值上的对比研究

目的：通过对62例难治性癫痫患者进行前瞻性研究,对18F-FDG PET显像与EEG在颞叶癫痫致痫灶定位上的价值进行对比研究。方法：对62例临床确诊颞叶癫痫并接受手术治疗的患者进行前瞻性研究。所有患者均进行发作间期PET-CT脑显像检查和长程/视频EEG检查,细致分析图像,并将所得检查结果与术后病理进行比较,利用统计学方法对二者的诊断准确率进行对比分析。结果：18F-FDG PET显像准确定位42例癫痫患者病灶位置,头皮EEG准确定位致痫灶30例,准确率分别为67.7%及48.4%,二者比较有显著统计学差异（P<0.05）。18F-FDG PET显像结果表现较多样,影像分析应细致、审慎。结论：发作间期PET-CT脑显像检查定位颞叶癫痫致痫灶优于长程/视频EEG检查,但因其价格较昂贵,临床可首选EEG定位癫痫,EEG定位困难时选择PET显像可明显提高致痫灶定位准确性。     

Concussive Convulsions: Emergency Department Assessment and Management of a Frequently Misunderstood Entity

Immediate concussive convulsions are an unusual but dramatic sequela to head injuries. Previously believed to be an epileptic phenomenon, they are now thought to be a brief traumatic functional decerebration that results from loss of cortical inhibition. With concussive convulsions generally occurring within seconds of head impact and lasting up to several minutes, patients are initially in a tonic phase, followed by a clonic convulsion. A postictal phase is generally brief if it occurs at all with these episodes. Patients with isolated concussive convulsions have no evidence of structural brain injury as assessed with neuroimaging studies or physical examination. Neuropsychological testing often demonstrates transient cortical dysfunction consistent with the concussive episode. The long-term outcome for patients with isolated concussive convulsion is universally good, with no long-term neurologic sequelae and no increased incidence of early or late posttraumatic epilepsy. Emergency department management should focus on evaluation of the associated concussive injury. The concussive convulsion requires no specific therapy, and antiepileptic medication is not indicated.     

BOLD correlates of continuously fluctuating epileptic activity isolated by independent component analysis

Combined EEG/fMRI recordings offer a promising opportunity to detect brain areas with altered BOLD signal during interictal epileptic discharges (IEDs). These areas are likely to represent the irritative zone, which is itself a reflection of the epileptogenic zone. This paper reports on the imaging findings using independent component analysis (ICA) to continuously quantify epileptiform activity in simultaneously acquired EEG and fMRI. Using ICA derived factors coding for the epileptic activity takes into account that epileptic activity is continuously fluctuating with each spike differing in amplitude, duration and maybe topography, including subthreshold epileptic activity besides clear IEDs and may thus increase the sensitivity and statistical power of combined EEG/fMRI in epilepsy. Twenty patients with different types of focal and generalized epilepsy syndromes were investigated. ICA separated epileptiform activity from normal physiological brain activity and artifacts. In 16/20 patients, BOLD correlates of epileptic activity matched the EEG sources, the clinical semiology, and, if present, the structural lesions. In clinically equivocal cases, the BOLD correlates aided to attribute proper diagnosis of the underlying epilepsy syndrome. Furthermore, in one patient with temporal lobe epilepsy, BOLD correlates of rhythmic delta activity could be employed to delineate the affected hippocampus. Compared to BOLD correlates of manually identified IEDs, the sensitivity was improved from 50% (10/20) to 80%. The ICA EEG/fMRI approach is a safe, non-invasive and easily applicable technique, which can be used to identify regions with altered hemodynamic effects related to IEDs as well as intermittent rhythmic discharges in different types of epilepsy.     

Independent component analysis of interictal fMRI in focal epilepsy: comparison with general linear model-based EEG-correlated fMRI

The general linear model (GLM) has been used to analyze simultaneous EEG-fMRI to reveal BOLD changes linked to interictal epileptic discharges (IED) identified on scalp EEG. This approach is ineffective when IED are not evident in the EEG. Data-driven fMRI analysis techniques that do not require an EEG derived model may offer a solution in these circumstances. We compared the findings of independent components analysis (ICA) and EEG-based GLM analyses of fMRI data from eight patients with focal epilepsy. Spatial ICA was used to extract independent components (IC) which were automatically classified as either BOLD-related, motion artefacts, EPI-susceptibility artefacts, large blood vessels, noise at high spatial or temporal frequency. The classifier reduced the number of candidate IC by 78%, with an average of 16 BOLD-related IC. Concordance between the ICA and GLM-derived results was assessed based on spatio-temporal criteria. In each patient, one of the IC satisfied the criteria to correspond to IED-based GLM result. The remaining IC were consistent with BOLD patterns of spontaneous brain activity and may include epileptic activity that was not evident on the scalp EEG. In conclusion, ICA of fMRI is capable of revealing areas of epileptic activity in patients with focal epilepsy and may be useful for the analysis of EEG-fMRI data in which abnormalities are not apparent on scalp EEG.     

Three-dimensional neuroimaging in diagnosis and surgical treatment for epilepsy

Development of functional neuroimaging is contributed to diagnosis and treatment in epilepsy patients. The dipole analysis of interictal spikes on EEG or MEG provides 3D-localization of the irritable zone. Interictal and ictal CBF-SPECT reveals the local change in CBF associated to epileptic focus. Three-dimensional stereotactic surface projection (3D-SSP) of SPECT is useful to recognize the seizure generation area. Furthermore, Subtraction ictal SPECT coregistration of MRI (SISCOM), that is fusion image of anatomical and functional brain images, is beneficial to understand the localization of seizure-induced hyperperfusion area. During epilepsy surgery, image-guided system makes less-invasive and accurate surgery possible. Functional image-guided surgery for epilepsy will be available in near future.     

磁源性影像对脑海绵状血管瘤伴发癫痫的术前评价

目的：探讨磁源性影像（MSI）对脑海绵状血管瘤（CA）伴发癫痫患者的癫痫灶定位价值,为癫痫外科手术提供依据。方法：对13例脑CA伴发癫痫的患者进行了MRI和MSI检查。观察CA与MSI所确定的癫痫灶之间的位置关系。所有13例患者均经手术治疗。结果：13例患者中,11例CA位置与MSI所确定的癫痫灶位置距离<2cm,2例>2cm。按照Engel分级标准,所有患者均为1级,术后（6～53个月）随访12例患者术后癫痫未发作,1例癫痫发作1次。结论：MSI能明确CA与癫痫灶之间的位置关系,对术前制定手术计划有重要意义。     

脑结构和功能MR成像研究儿童失神癫痫进展

儿童失神癫痫(CAE)是常见儿童癫痫综合征，以频发的一过性意识障碍伴脑电图(EEG)双侧同步性广泛棘慢波放电(GSWD)为特征。无创神经成像技术有助于探索CAE患儿大脑结构变化，从而阐述其发生发展机制。本文就脑结构和功能MR成像研究CAE进展进行综述。     

Localization of abnormal discharges causing insular epilepsy by magnetoencephalography

The insula, one of the five cerebral lobes of the brain, is located deep within the brain and lies mainly beneath the temporal lobe. Insular epilepsy can be easily confused and misdiagnosed as temporal lobe epilepsy (TLE) because of the similar clinical symptoms and scalp electroencephalography (EEG) findings due to the insula location and neuronal connections with the temporal lobe. Magnetoencephalography (MEG) has higher sensitivity and spatial resolution than scalp EEG, and thus can often identify epileptic discharges not revealed by scalp EEG. Simultaneous scalp EEG and MEG were performed to detect and localize epileptic discharges in two patients known to have insular epilepsy associated with cavernous angioma in the insula. Epileptic discharges were detected as abnormal spikes in the EEG and MEG findings. In Patient 1, the sources of all MEG spikes detected simultaneously by EEG and MEG (E/M-spikes) were localized in the anterior temporal lobe, similar to TLE. In contrast, the sources of all MEG spikes detected only by MEG (M-spikes) were adjacent to the insular lesion. In Patient 2, the sources of all MEG spikes detected simultaneously by EEG and MEG (E/M-spikes) were localized in the anterior temporal lobe. These findings indicate that MEG allows us to detect insular activity that is undetectable by scalp EEG. In conclusion, simultaneous EEG and MEG are helpful for detecting spikes and obtaining additional information about the epileptic origin and propagation in patients with insular epilepsy.