致灶切除治疗难治性癫

目的探讨皮层脑电图扫描下致灶切除术治疗难治性癫的术前评估及致灶病理学意义。方法对67例经临床诊断为难治性癫的患者应用神经影像、神经电生理及功能性检查等方法进行术前综合评估,确定致灶。然后在皮层脑电图描记下行致灶切除,对切除的致灶组织送病理检查。结果术后综合疗效评定:1年内癫发作消失23例,显进进步18例,进步17例,无变化5例,失访4例,总有效率为84.6%;病理结果:有肿瘤、动静脉畸形、灰质异位、表皮样囊肿、炎性肉芽肿、脑软化、粘连性蛛网膜炎、海马硬化,其他还有蛛网膜增厚、脑组织神经变性、胶质细胞增生及变性,部分病例伴有陈旧性出血、含铁血黄素沉着、淋巴细胞浸润或者血管增生、管壁增厚,伴有小疤痕形成或继发性囊肿形成等。无1例无异常。结论神经电生理、影像学及功能检查的联合应用是术前评估致灶的重要方法。而脑电图、颅内电极与数字视频脑电结合,将患者的发作期表现与脑电信息同步记录保存是分析癫异常放电定位致灶的最佳方法。致灶切除术是难治性癫的有效治疗手段,致灶组织均存在结构性病理改变。     

A double-blind, placebo-controlled study of topiramate in adult patients with refractory partial epilepsy

PURPOSE: The efficacy and safety of topiramate (TPM) as adjunctive therapy in the treatment of adult Chinese patients with refractory partial epilepsy were investigated in a randomized, double-blind, placebo-controlled study. METHODS: A total of 46 patients who had four or more complex partial seizures with or without secondary generalization within an 8-week baseline phase were enrolled. Patients were assigned randomly to receive TPM (n = 23) or placebo (n = 23). TPM or placebo was titrated to target doses of 300 mg/d for 6 weeks and maintained at stabilized levels for another 8 weeks. Concomitant antiepileptic drugs remained at constant previous levels during the trial. RESULTS: In all, 41 patients completed the trial (TPM group, n = 20; placebo group, n = 21). The proportion of patients with a > or =50% reduction from baseline in complex partial seizures was 11 of 23 (47.8%) in the TPM group and 3 of 23 (13.0%) in the placebo group (p = 0.01). In addition, patients treated with TPM had significantly better investigator (p = 0.014) and patient (p = 0.0005) global assessment scores than patients in the placebo group. Adverse events were mostly mild and transient, with no significant differences between treatment groups. Two patients with TPM therapy complained of weight loss. Routine blood cell counts and other laboratory results showed no significant changes from baseline in either treatment group. CONCLUSIONS: TPM 300 mg/d is effective and well tolerated as treatment for refractory partial epilepsy in adults.     

Efficacy and safety of lacosamide as an adjunctive therapy for refractory focal epilepsy in paediatric patients: a retrospective single‐centre study

Aim. Lacosamide is an antiepileptic drug approved for the treatment of focal epilepsy in adult patients. The aim of this observational study was to review our centre's experience with lacosamide and to characterize its effectiveness and tolerability as an adjunctive antiepileptic drug in a retrospective cohort of children with refractory focal epilepsy. Methods. We retrospectively reviewed the medical records of 22 patients who received lacosamide from November 2009 to April 2014 at the CHU Ste‐Justine, University of Montreal. Treatment responders were defined as children with a ≥50% reduction in seizure frequency compared to baseline, and this was determined three months after the initiation of treatment and at the last follow‐up visit. Results. We included 14 boys and eight girls with a mean age of 12.9 years (SD: 5.2; range: 5.2–20.7 years) at the initiation of treatment. The average length of follow‐up was 11.9 months. Patients had previously received an average of 7.5 antiepileptic drugs. The mean number of concomitant antiepileptic drugs was 2.3. The mean initial and maintenance doses were 2.9 and 8.4 mg/kg/d, respectively. Thirteen (59%) and ten (45%) patients were responders after three months of treatment and at the last follow‐up visit, respectively. One became seizure‐free. Adverse effects were reported in 11 patients and none were severe. Responders and non‐responders were identical with respect to all studied parameters except gender, with the proportion of responders being greater in girls than in boys (75% vs 29%; p=0.035). Conclusion. Our study adds evidence that lacosamide appears to be a safe and effective adjunctive therapy for children with refractory focal epilepsy.     

Postictal psychosis: a retrospective study in patients with refractory temporal lobe epilepsy

Postictal psychosis (PIP) represents 25% of the psychoses seen in epileptic patients. A high frequency of bilateral independent epileptiform activity has been observed in patients with PIP. The objective of this study was to determine the frequency of PIP in patients with temporal lobe epilepsy (TLE) who underwent video-EEG monitoring and to investigate possible differences between PIP and control patients. METHODS: Clinical, electroencephalographic and neuroimaging data of 5 PIP patients with TLE were compared with data of 50 patients with TLE without psychotic antecedents. Patients with a past history of interictal psychosis were excluded. RESULTS: From 55 patients, 5 were patients with PIP and 50 controls. 31 (62%) were men, 9 (16.4%) had a previous history of encephalitis and 6 (10.9%) of status epilepticus. The mean age was 42.2 years (S.D. 12.93). Mean age at epilepsy onset was 16.95 years (S.D. 12.93) and mean seizure frequency 5seizures/month (S.D. 1.87). The frequency of PIP was 5/55 (9.1%). Previous history of status epilepticus was more frequent in PIP patients than in controls (p: 0.019). PIP patients more frequently had a non-lateralizing ictal EEG than controls (p: 0.001). Bitemporal lobe dysfunction revealed by neuropsychological studies was greater than expected by the observed lesion on MRI studies in patients with PIP. Moreover, the presurgical study was less conclusive in PIP than in control patients (p: 0.049). CONCLUSIONS: PIP is observed in up to 9% of patients with TLE undergoing video-EEG monitoring and most often develops in patients with bitemporal lobe dysfunction.     

A 10 year retrospective study of surgical outcomes of adult intracranial pilocytic astrocytoma

Pilocytic astrocytomas (PA) are benign neoplasms commonly located in the cerebellum with a peak incidence in the first two decades of life. PA occurrence in adults is rare and very little information is available in the literature about tumour characteristics in this population. This study retrospectively identified 20 adults with PA. The characteristics of the tumour, treatment modalities and patient outcomes are discussed, as well as identifying factors that may be associated with worse prognosis. The mean age at diagnosis was 27 years. The majority of PA were located in the posterior fossa. Other tumour locations included the cerebral hemispheres, brainstem, tectal plate and optochiasmatic region (optic chiasm, hypothalamus and third ventricle). All patients in this study underwent surgery, two received adjuvant chemotherapy and one received adjuvant radiotherapy. Tumour recurrence occurred in six patients and two eventually died from the disease. When achieved, complete tumour resection was found to be curative. Tumour location affects extent of surgical resection; tumours in inaccessible locations were associated with higher rates of recurrence. Overall survival and progression free survival rates were 87% and 60% respectively. The degree of surgical resection and tumour location were found to affect prognosis. Unfavourable outcomes were observed in these adults with PA compared to those expected for a younger population, suggesting a possible association between age and outcome.     

Postoperative hemodynamic management in patients undergoing resection of cerebral arteriovenous malformations: A retrospective study

Strict control of blood pressure (BP) has been recommended in patients after surgical resection of cerebral arteriovenous malformations (AVM) to prevent postoperative hyperemic complication. The aim of this study was to review the postoperative hemodynamic management in patients after surgical resection of cerebral AVM and the incidence of postoperative intracranial hemorrhage and/or cerebral edema. After the ethics approval, we retrospectively reviewed the medical records of 207 adult patients who underwent elective surgical resection of cerebral AVM from Jan 2005 to Oct 2016 in a single university hospital. We determined the incidence of postoperative symptomatic intracranial hemorrhage and/or cerebral edema, and reviewed the quality of postoperative BP control during the first 72 h postoperatively. Two hundred and seven patients who underwent cerebral AVM resection were included. The median (IQR) of postoperative maximal systolic BP target was 110 (100–120) mmHg but the range was 90–150 mmHg. Failed hemodynamic control was consistently found in half of the patients during the first 72 h postoperatively. The incidence of postoperative intracranial hemorrhage and/or cerebral edema was 4.4% (9/207 patients). All 9 of these patients experienced a hypertensive event prior to their postoperative hyperemic complication. Two patients required induced hypertension to treat postoperative symptomatic cerebral edema. We concluded that postoperative intracranial hemorrhage and/or cerebral edema is not an uncommon complication after surgical resection of cerebral AVM. Further studies are required to develop a more effective strategy to implement strict BP control in the postoperative period.     

Vagus nerve stimulation therapy in pediatric patients with refractory epilepsy: retrospective study.

This six-center, retrospective study evaluated the effectiveness, tolerability, and safety of vagus nerve stimulation in children. Data were available for 125 patients at baseline, 95 patients at 3 months, 56 patients at 6 months, and 12 patients at 12 months. The typical patient, aged 12 years, had onset of seizures at age 2 years and had tried nine anticonvulsants before implantation. Collected data included preimplant history, seizures, implant, device settings, quality of life, and adverse events. Average seizure reduction was 36.1% at 3 months and 44.7% at 6 months. Common adverse events included voice alteration and coughing during stimulation. Rare adverse events, unique to this age group, included increased drooling and increased hyperactivity. Quality of life improved in alertness, verbal communication, school performance, clustering of seizures, and postictal periods. We concluded that vagus nerve stimulation is an effective treatment for medically refractory epilepsy in children.     

Postoperative adverse outcomes in surgical patients with epilepsy: a population-based study

Purpose: People with epilepsy are more likely than healthy people to experience comorbidities and complications in various medical situations. However, the prevalence of postoperative complications, mortality, and use of medical resources in surgical patients with epilepsy has not been studied. The purpose of this study is to examine whether epilepsy is an independent risk factor for postoperative adverse outcomes of patients receiving major surgery. Methods: Retrospective cohort study using the National Health Insurance Research Database to identify patients with epilepsy who underwent major surgery in Taiwan between the years 2004 and 2007. For each case, four age‐ and sex‐matched participants without epilepsy were included. Preoperative comorbidities in the 24 months before surgery were identified. Eight major postoperative complications, overall 30‐day mortality, and in‐hospital utilization of medical resources (including length of hospital stay, percentage of postoperative intensive care unit admissions, and in‐hospital medical expenditures) served as the major outcome measurements. Comorbidities, status of receiving renal dialysis, teaching hospital status, types of surgery, and patients living in urban or rural areas were adjusted by multivariate logistic regression. Key Findings: A total of 13,103 participants with epilepsy and 52,412 without were included. Patients with epilepsy have significantly more preoperative comorbidities and demonstrated more risks of any postoperative complications (odds ratio 2.02, 95% confidence interval 1.90–2.14). Consumption of in‐hospital medical resources was also significantly higher in patients with epilepsy, but no significant differences in postoperative mortality rates between the two groups were noted. Significance: Stroke was identified as the most significant postoperative complication for surgical patients with epilepsy. Patients, especially those with previous hospitalization or emergency visits due to the disease, confronted significantly higher postoperative complication rates, and consumed more in‐hospital medical resources without differences in overall mortality rates. Further revision of health care standards to provide early recognition of postoperative complications and better management for surgical patients with epilepsy is needed.     

Selection of adult patients for surgical treatment of epilepsy

ABSTRACT— The ideal treatment for epilepsy would produce complete control without toxicity and without side effects.
The physician would like to have surgical therapy as an option for those patients who are not completely free of seizures and for those who are free of seizures but suffer toxic side effects.
Surgery for epilepsy has now become an option that should be considered along with various medical treatment options. The success rates have increased and the complication rates decreased dramatically at those centers performing surgery on a substantial number of cases a year. Patients with complex partial seizures with a clear-cut unilateral temporal lobe focus and highly stereotyped seizures are by far the best candidates for surgery. In the hands of several major epilepsy programs significant improvement in seizure frequency is achieved in greater than 90 per cent of patients.
Patients with sudden drop attacks or uncontrolled generalized tonic-clonic seizures can benefit from section of the corpus callosum. Good results are seen in 85 per cent of the cases.     

Three-dimensional preoperative maps of hippocampal atrophy predict surgical outcomes in temporal lobe epilepsy

The authors used surface-based anatomic mapping to detect features of hippocampal anatomy that correlated with surgical outcomes in patients undergoing surgery for mesial temporal lobe epilepsy with hippocampal sclerosis. Compared with a seizure-free group, hippocampal profiles for the non-seizure-free group had greater diffuse ipsilateral atrophy and more region-specific contralateral atrophy in the anterior, lateral hippocampus. These atrophic regions may indicate areas of increased epileptogenicity, contributing to poorer surgical outcomes.     

A pilot trial with modified Atkins' diet in adult patients with refractory epilepsy

OBJECTIVES: At Ghent University Hospital, the feasibility and efficacy of the modified Atkins' diet was evaluated in adult patients with refractory epilepsy. The Atkins' diet restricts carbohydrate intake and was originally designed for weight loss. PATIENTS AND METHODS: During a 6-month trial period, a carbohydrate restriction of 20g/day was in place. During a 36h hospital admission, patients were instructed about the diet. Patients underwent clinical neurological testing, EEG, ECG, blood and urine analyses and mood evaluation before and during the trial. Seizure frequency and side effects were recorded in seizure diaries and followed up at monthly clinic visits. RESULTS: Eight patients were included in the study. Three out of eight patients followed the diet for 6 months. One out of three patients showed a >50% seizure reduction, 1/3>30%, and 1/3<30%. Side effects such as constipation and diarrhoea were mild and occurred mainly during the initial week of the diet. Patients reported improved concentration and well being. This was confirmed by improved scores on the Beck Depression Inventory Scale. CONCLUSION: This pilot study shows that the modified Atkins' diet is feasible in an adult population, and that seizure frequency reduction is possible. The results need to be confirmed in larger prospective, controlled studies with comparison groups.     

中央区癫痫的手术治疗及预后分析

目的 探讨治疗中央区癫痫的手术方法及提示手术预后的相关因素.方法 以自2006年10月至2008年3月北京功能神经外科研究所连续收治的21例中央区癫痫患者为研究对象,行致痫灶切除术.术后随访12个月以上,Engel分级Ⅰ、Ⅱ级为预后良好,分析与预后良好相关的因素.结果 Engel分级Ⅰ、Ⅱ级共14例(67%).MRI可见病变与MRI无病变相比,预后良好率较高(P<0.05);病理为局灶性皮质发育不良患者与其他病理患者相比,预后良好率较低(P<0.05).结论 中央区癫痫经精确定位功能区及致痫灶,行致痫灶切除,总体预后良好.MRI可见病变提示预后良好,病理为局灶性皮质发育不良较其他病理改变预后差.

Abstract：

Objective The purpose of the study was to investigate effective surgical procedure for perirolandic epilepsy and the predictor for good outcomes.Method We collected 21 subjects who underwent epilepsy surgeries consecutively in Beijing Institute of Functional Neurosurgery with the epileptogenic zone located in perirolandic areas from October 2006 to March 2008.Over 12-month following up and Engel Ⅰ and Ⅱ taken as "good" outcomes,we analyzed the predicting factors for good outcomes.Results At the end of follow up,Engel class Ⅰ and Ⅱ were 14 cases(67% ).Patients with lesion in MRI obtained better outcomes and patients with focal cortex dysplasia( FCD) pathology obtained worse outcomes regarding the rate of Engel class Ⅰ + Ⅱ( P < 0.05).There were no serious functional deficits.Conclusions Surgical resection of epileptogenic zone for periroladic epilepsy can achieve good outcomes.Patients with lesion in MRI predicted better outcomes and FCD pathology predicted worse outcomes.     

术前头皮长程视频脑电图表现与颞叶癫痫手术预后的关系

目的 探讨术前头皮长程视频脑电图(VEEG)发作间期放电、发作期起始侧别与颞叶癫痫(TLE)患者手术预后的关系.方法 回顾性分析75例颞叶癫痫手术治疗患者的临床资料.患者术后经过1～9年的随访,根据手术后有、无癫痫发作将患者分为发作组和无发作组.另外按两组患者中术前头皮脑电图发作间期放电及发作期起始侧别分组,比较各组患...     

A prospective investigation of depression and adverse outcomes in patients undergoing vascular surgical interventions: A retrospective cohort study using a large mental health database in South London

BackgroundPatients with depression are more susceptible to cardiovascular illness including vascular surgeries. However, health outcomes after vascular surgery among patients with depression is unknown. This study aimed to investigate associations of depression with post-operative health outcomes for vascular surgical patients.MethodsA retrospective observational study was conducted using data from a large mental healthcare provider and linked national hospitalization data for the same south London geographic catchment. OPCS-4 codes were used to identify vascular procedures. Health outcomes were compared between those with/without depression including length of hospital stay (LOS), inpatient mortality, and 30 day emergency hospital readmissions. Predictors of these health outcomes were also assessed.ResultsVascular surgery was received by 9,267 patients, including 446 diagnosed with depression. Patients with depression had a higher risk of emergency admission for vascular surgery (odds ratio [OR] 1.28; 1.03, 1.59), longer index LOS (IRR 1.38; 1.33–1.42), and a higher risk of 30-day emergency readmission (OR 1.82; 1.35–2.47). Patients with depression had higher inpatient mortality after adjustment for sociodemographic status (1.51; 1.03, 2.23) but not on full adjustment, and had longer emergency readmission LOS (1.13; 1.04, 1.22) after adjustment for sociodemographic factors and cardiovascular disease. Correlates of vascular surgery hospitalization among patients with depression included admission through emergency route for longer LOS, inpatient mortality, and 30-day hospital readmission.ConclusionPatients with depression undergoing vascular surgery have substantially poorer health outcomes. Screening for depression prior to surgery might be indicated to target preventative measures.     

脑膜瘤术前影像学信息与手术结果的相关性分析

目的 探讨脑膜瘤的术前影像信息对肿瘤切除程度、手术并发症及死亡情况的影响. 方法 回顾性分析南方医科大学珠江医院神经外科自2008年1月至2011年6月收治的的172例脑膜瘤手术患者的影像资料,包括肿瘤部位、肿瘤大小、神经血管包绕、肿瘤侵袭性、肿瘤边界、肿瘤形状、肿瘤增强程度、瘤周水肿,筛选出影响肿瘤切除程度、手术并发症及死亡的因素,然后对有统计学意义的因素进行Logistic逐步回归分析. 结果 肿瘤部位、肿瘤大小、肿瘤侵袭性、肿瘤形状及肿瘤边界是影响肿瘤是否残留的5个独立危险因素,其中肿瘤侵袭性是主要因素;肿瘤部位、肿瘤大小、神经血管包绕、肿瘤增强程度是影响是否出现手术并发症的4个独立危险因素,其中肿瘤部位是主要因素;肿瘤部位、肿瘤大小是影响是否死亡的2个独立危险因素,其中肿瘤部位是主要因素. 结论 脑膜瘤术前影像信息特别是肿瘤部位、肿瘤大小、肿瘤侵袭性、神经血管包绕这4个主要因素能够比较客观、准确地判断和评估脑膜瘤切除程度、手术并发症及死亡情况,其中肿瘤侵袭性是肿瘤残留的最重要影响因素,而肿瘤部位是手术并发症、死亡的最重要因素.     

Psychiatric comorbidity in refractory focal epilepsy: A study of 490 patients

We studied the prevalence and associated factors of psychiatric comorbidities in 490 patients with refractory focal epilepsy. Of these, 198 (40.4%) patients had psychiatric comorbidity. An Axis I diagnosis was made in 154 patients (31.4%) and an Axis II diagnosis (personality disorder) in another 44 (8.97%) patients. After logistic regression, positive family history of psychiatric comorbidities (O.R. = 1.98; 95% CI = 1.10–3.58; p = 0.023), the presence of Axis II psychiatric comorbidities (O.R. = 3.25; 95% CI = 1.70–6.22; p < 0.0001), and the epileptogenic zone located in mesial temporal lobe structures (O.R. = 1.94; 95% CI = 1.25–3.03; p = 0.003) remained associated with Axis I psychiatric comorbidities. We concluded that a combination of clinical variables and selected structural abnormalities of the central nervous system contributes to the development of psychiatric comorbidities in patients with focal epilepsy.