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。     

颞叶癫痫的手术治疗效果及并发症回顾性分析(附69例临床报告)

目的探讨手术治疗颞叶癫痫的疗效及并发症。方法皮层电极及深部电极引导下手术治疗69例颞叶癫痫,其中前颞叶+海马杏仁核切除术67例,选择性海马杏仁核切除术2例。术前行PET、SPECT、MRI、EEG检查。结果 69例术后随访1~7.6年,满意63例,显著改善2例,良好1例,无效3例,有效率95.7%。其中癫痫完全消失60例,占87%。无死亡,暂时性偏瘫2例,占2.9%,轻度同向视野缺损6例,占8.7%,硬膜外血肿1例,记忆力减退3例。结论手术治疗颞叶癫痫的效果好;疗效与病例的选择及致癫灶的准确定位有关;部分并发症与手术技巧有关。     

微创锁孔入路选择性海马杏仁核切除治疗伴海马硬化的内侧颞叶癫痫

目的探讨经颞上沟-侧脑室锁孔入路选择性海马杏仁核切除术治疗难治性内侧颞叶癫痫的疗效及安全性。方法回顾性分析2014年9月~2016年3月南京军区南京总医院神经外科19例难治性内侧颞叶癫痫患者的临床资料。患者均采用颞上沟-侧脑室锁孔入路选择性海马杏仁核切除手术方式。结果术后复查头颅MRI示,手术切除范围满意。术后随访6~24个月,EngelⅠ级14例(73.6%)、Ⅱ级4例(21%)、Ⅲ级1例(5.4%),无严重手术并发症。结论经颞上沟-侧脑室锁孔入路选择性海马杏仁核切除术治疗难治性内侧颞叶癫痫安全有效;与传统手术入路相比,手术创伤小,手术时间缩短。     

颞叶癫痫:肿瘤性病变与海马硬化的手术治疗

目的：探讨由肿瘤及海马硬化所致的颞叶癫痫的手术治疗。方法：40例顽固性癫痫中，经MRI或CT诊断有19例内轴心性肿瘤性病变，有21例海马硬化，均行手术治疗，切除的标本进行组织学观察。结果：肿瘤性病变19例均作了肿瘤全切除加海马、杏仁核切除，海马硬化21例均作选择性海马、杏仁核切除术。40例中35例随访，随访时间为术后3个月至1年，5例失去联系。癫痫完全解除的有30例，5例仍需依赖药物治疗。结论：海马硬化是颞叶癫痫的主要原因，手术切除疗效满意。     

导航引导下保留侧脑室完整的颞叶癫痫手术26例体会

目的探讨神经导航下保留侧脑室完整的前颞叶海马、杏仁核切除术治疗颞叶癫痫的效果。方法将26例神经导航下保留侧脑室完整的前颞叶海马切除术后患者的术前Wada试验评估、术后并发症及癫痫控制情况进行分析。结果术后随访时间24～36月,EngelⅠ级22例（85％）,EngelⅡ级3例（11％）,EngelⅢ例（4％）。术后1例（4％）患者出现记忆减退症状,4例患者发生视野缺损。结论同时切除海马、杏仁核的标准前颞叶切除术为外科治疗颞叶癫痫的有效术式,术前Wada试验评估能很好的预测手术对患者记忆功能的影响,保留侧脑室完整的术式可减少视野缺损的发生。     

颞叶海绵状血管瘤继发性癫痫手术治疗的效果

目的探讨颞叶海绵状血管瘤继发性癫痫手术治疗的效果。方法回顾性分析我科自2011年3月~2015年6月手术治疗的8例颞叶海绵状血管瘤继发性癫痫患者的临床资料和随访结果。患者术前均行头颅MRI和长程视频脑电图监测等综合评估,术中行皮层脑电监测。结果患者术后随访1~5年;疗效按Engel分级,Ⅰ级5例,Ⅱ级2例,Ⅲ级1例。有4例患者手术2年后逐步停服抗癫痫药物。结论手术治疗颞叶海绵状血管瘤继发性癫痫可取得较好的效果。     

皮层脑电图监测在顽固性癫痫手术中的应用(附155例报告)

目的总结皮层脑电图在顽固性癫痫手术中的应用经验并评价手术疗效。方法 155例顽固性癫痫患者,术前行MRI、视频脑电图、单光子发射计算机断层成像与脑磁图检查,明确致痫灶,在皮层脑电图监测下手术。54例颞叶癫痫患者行颞叶前部与海马杏仁核显微切除术,47例颅内病灶患者行病灶与癫痫灶切除术,35例行癫痫灶切除术,19例致痫灶位于功能区的患者行皮层电凝及软脑膜下横纤维切断术。结果术后随访1~2年,按Engel分级:Ⅰ级88例,Ⅱ级46例,Ⅲ级13例,Ⅳ级8例。术后患者神经功能保持良好,未出现明显后遗症。结论在术前多种方法联合定位癫痫灶的基础上,应用皮层脑电图可以提高顽固性癫痫患者的手术疗效。     

选择性海马-杏仁核切除术治疗内侧颞叶癫痫85例分析

目的 采用选择性海马-杏仁核切除术治疗内侧颞叶癫痫85例，探讨手术入路的选择及治疗效果。方法 总结2000年～2004年85例选择性海马-杏仁核切除手术病例的术前临床表现、影像检查、视频脑电图和脑磁图所见以及外科手术方法，观察随访结果。结果 术后74．2％癫痫发作停止。Engel癫痫疗效分级：1级74．2％，2级16．5％，3级5．1％，4级4．2％。总有效率为95.8％。结论 选择性海马-杏仁核切除术对80％以上的内侧颞叶癫痫有效。颧弓翼点经颞下沟入路安全有效。颞底海马旁回入路可避免损伤颞叶新皮质。     

前颞叶切除术与选择性杏仁核海马切除术治疗颞叶癫痫的疗效对比

目的对比前颞叶切除术与选择性杏仁核海马切除术治疗颞叶癫痫发作的效果。方法回顾性分析天津市环湖医院神经外科2010-12—2016-08手术治疗的颞叶癫痫病例38例,其中14例进行前颞叶切除术,9例进行选择性杏仁核海马切除术,术后随访2～8 a,分析纳入的23例患者的基本信息、手术侧别、发作症状、病理学以及术后癫痫发作的Engel分级。结果在随访的23例患者中,达到满意控制(EngelⅠ～Ⅱ级)者18例(78.3%),其中前颞叶切除术组达到满意控制(EngelⅠ～Ⅱ级)者12例(85.7%),选择性杏仁核海马切除术组达到满意控制(EngelⅠ～Ⅱ级)者6例(66.7%)。经Fisher确切概率法检验,2组术后控制率差异无统计学意义(P0.05)。结论手术是治疗颞叶癫痫安全有效的方法,两种手术均可获得满意的临床效果。     

经颞下梭状回入路选择性海马杏仁核切除术治疗颞叶内侧癫痫

目的探讨经颞下梭状回入路选择性杏仁核海马切除术治疗颞叶内侧癫痫的手术方法、疗效及并发症。方法药物难治性颞叶内侧癫痫30例患者,经颞下切开梭状回,进入侧脑室颞角,选择性切除杏仁核海马及海马旁回等内侧颞叶结构。结果30例患者术后随访至少3年时间(36～61个月),无严重手术并发症。Engel癫痫疗效分级:I级22例(73.3%),II级6例(20%),III级1例(3.3%),IV级1例(3.3%)。结论经颞下梭状回入路选择性杏仁核海马切除术是治疗颞叶内侧癫痫的有效方法,对脑组织创伤小,可妥善保护语言区和视放射,安全性高。     

儿童期起病的颞叶癫痫术后疗效的预测因素分析

目的 探讨儿童期起病（起病年龄≤14岁）的颞叶癫痫术后疗效的预测因素。方法 回顾性分析2011年1月至2018年12月手术治疗的173例儿童期起病的颞叶癫痫的临床资料。术后随访12~101个月,平均（49.4±22.9）个月;末次随访采用Engel分级标准评估疗效,其中Ⅰ级为疗效良好,Ⅱ~Ⅳ级为疗效不佳。结果 173例中,Engel分级Ⅰ级135例（78.0%）,Ⅱ级8例（4.6%）,Ⅲ级20例（11.6%）,Ⅳ级10例（5.8%）。无严重手术相关并发症及手术死亡病例。多因素logistic回归分析显示,术前MRI显示脑部异常、热性惊厥史是儿童期起病的颞叶癫痫术后疗效良好的独立预测因素（P<0.05）。结论 儿童期起病的颞叶癫痫手术疗效良好。如果MRI显示脑部异常和/或伴热性惊厥史,建议采取手术治疗,可取得良好的效果。     

杏仁核海马立体定向射频热凝毁损术治疗内侧颞叶癫痫的临床研究

目的分析采用杏仁核海马立体定向射频热凝毁损术(SAHE)治疗内侧颞叶癫痫的方法、癫痫控制情况及神经心理学功能影响,评估SAHE的效果及安全性。方法选取48例内侧颞叶癫痫行外科手术治疗患者为研究对象,分析其一般资料、SAHE治疗方法及术后癫痫发作消失率、神经心理学功能术后检测情况。结果手术均顺利完成,术后随访6个月~2年,癫痫完全控制率为52.1%,治疗显效率为75.0%,总有效率为89.6%,术后11例(22.9%)患者出现轻度头痛,9例(18.8%)患者术后出现低热,均为给予特殊治疗,未影响后续治疗,后1周患者PIQ、VIQ、MQ有所下降,但是在之后的随访中发现患者术后6个月在神经心理功能各维度评测结果均已恢复至术前水平,术后1周患者PIQ、VIQ、MQ有所下降,但是在之后的随访中发现患者术后6个月在神经心理功能各维度评测结果均已恢复至术前水平。结论 SAHE对内侧颞叶癫痫的治疗效果显著,能够有效的减少术后癫痫发作次数,术后早期会对患者的语言、操作智商、记忆力有一定影响,但长远观察可恢复正常,安全性良好,值得临床推广应用。     

Morphometric MRI alterations and postoperative seizure control in refractory temporal lobe epilepsy

Refractory mesial temporal lobe epilepsy (mTLE) is a debilitating condition potentially amenable to resective surgery. However, between 40 and 50% patients continue to experience postoperative seizures. The development of imaging prognostic markers of postoperative seizure outcome is a crucial objective for epilepsy research. In the present study, we performed analyses of preoperative cortical thickness and subcortical surface shape on MRI in 115 of patients with mTLE and radiologically defined hippocampal sclerosis being considered for surgery, and 80 healthy controls. Patients with excellent (International League Against Epilepsy outcome (ILAE) I) and suboptimal (ILAE II–VI) postoperative outcomes had a comparable distribution of preoperative atrophy across the cortex, basal ganglia, and amygdala. Conventional volumetry of whole hippocampal and extrahippocampal subcortical structures, and of global gray and white matter, could not differentiate between patient outcome groups. However, surface shape analysis revealed localized atrophy of the thalamus bilaterally and of the posterior/lateral hippocampus contralateral to intended resection in patients with persistent postoperative seizures relative to those rendered seizure free. Data uncorrected for multiple comparisons also revealed focal atrophy of the ipsilateral hippocampus posterior to the margins of resection in patients with persistent seizures. This data indicates that persistent postoperative seizures after temporal lobe surgery are related to localized preoperative shape alterations of the thalamus bilaterally and the hippocampus contralateral to intended resection. Imaging techniques that have the potential to unlock prognostic markers of postoperative outcome in individual patients should focus assessment on a bihemispheric thalamohippocampal network in prospective patients with refractory mTLE being considered for temporal lobe surgery. Hum Brain Mapp 36:1637–1647, 2015. © 2015 The Authors Human Brain Mapping Published by Wiley Periodicals, Inc.     

Is Amygdalohippocampectomy Really Selective in Medial Temporal Lobe Epilepsy? A Study Using Positron Emission Tomography with 18Fluorodeoxyglucose

PURPOSE: Selective amygdalohippocampectomy (SAH) is a surgical technique effective for the treatment of medial temporal lobe epilepsy, which selectively removes the epileptogenic hippocampus and amygdala but spares the temporal neocortex. However, the benefit of SAH in terms of functional outcome is debated. In this study, we aimed to assess the metabolic consequences of SAH. METHODS: Volumetric magnetic resonance imaging (MRI) and fluorodeoxyglucose positron emission tomography (PET) studies were performed in nine patients with medial temporal lobe epilepsy associated with hippocampal sclerosis before and after SAH. Regions of interest were delineated on MRIs and then replaced on PET images using an automatic 3D image registration. We calculated absolute metabolic rates of glucose and normalized metabolic values in each region of interest. RESULTS: The comparison between preoperative and postoperative metabolic values showed a statistically significant worsening of the hypometabolism on the ipsilateral temporal pole on the superior and the hippocampal levels (p < 0.05 and 0.0045, respectively). A postoperative increase of the metabolic activity also was noted in the contralateral anterior hippocampus (p < 0.05) and the orbitofrontal cortex bilaterally (p < 0.002 and 0.001, respectively) CONCLUSIONS: SAH functional benefit is controversial. SAH worsened significantly the hypometabolism of a temporal structure that was not surgically removed (i.e., the temporal pole), and it improved postoperatively the metabolic activity in the contralateral hippocampus and the orbitofrontal cortex. Whether this postoperative improvement is linked to the selectivity of the surgical procedure must be further clarified.     

选择性海马切除在枕叶癫痫手术中的应用

目的 总结分析枕叶癫痫患者手术中联合选择性海马切除的手术治疗效果和经验.方法 回顾性分析2003年1月至2006年12月在我科接受手术治疗的20例向颢叶内侧传导的枕叶癫痫病例,统计患者的发病、检查及手术治疗情况,并介绍相关手术体会.17例(85%)为部分性发作继发强直.痉挛性发作为主,9例有颢叶先兆或口咽自动症,PET检查中9例有颞叶的代谢异常,MRI及MRS共发现有海马异常13例;脑电图确定癫痫灶位于枕叶外侧皮层8例.内侧皮层6例,枕颞交界区6例,发作期脑电图均显示明显向颢叶传导.手术均行枕叶致痫灶切除和经颞底海马结构切除术.结果 癫痫发作Engle分级示:I级16例,Ⅱ级2例,Ⅲ级2例.出现视野损害3例;推理智商无明显变化15例,下降4例,改善1例.结论 向颞叶传导为主的枕叶癫痫常可以有颢叶的先兆或自动症,并有影像学的异常,手术联合枕叶致痫灶切除和经颞底海马结构切除术,手术效果好.     

Value of extent of hippocampal resection in the surgical treatment of temporal lobe epilepsy

OBJECTIVE: Unilateral hippocampal atrophy is indicator of good surgical prognosis in patients with temporal lobe epilepsy (TLE). Some patients however do not become seizure free after surgery. We assessed if the extent of hippocampal and amygdala resection is associated with outcome. METHODS: Thirty patients with TLE with unilateral or clearly asymmetric hippocampal atrophy who underwent surgical treatment were evaluated concerning preoperative clinical variables and interictal EEG abnormalities. Amygdala and hippocampal resection was evaluated by post-operative MRI. We compared seizure free versus non-seizure free patients, and patients with good outcome (Engel's classes I and II) versus patients with poor outcome. RESULTS: There was significant association between the extent of hippocampal resection and the outcome. Pre-operative variables and interictal EEG abnormalities did not show relationship with outcome as documented in previous studies. CONCLUSION: The extent of hippocampal resection is associated with outcome. Incomplete resection of atrophic hippocampus may explain most surgical failures in patients with TLE due to unilateral hippocampal sclerosis.     

Significance of fornix atrophy in temporal lobe epilepsy surgery outcome

BACKGROUND: Previous magnetic resonance imaging (MRI) studies have shown concurrent fornix atrophy in a large proportion of patients with hippocampal atrophy. The contribution of the fornix as an independent preoperative determinant of surgical outcome is unknown. OBJECTIVE: To evaluate the contribution of the fornix as a determinant of surgical outcome in patients with preoperatively determined temporal lobe epilepsy. METHODS: We selected 78 patients who had undergone anterior temporal lobectomy for intractable temporal lobe epilepsy at the University of Alabama at Birmingham Epilepsy Center during a 24-month period. All patients underwent standard presurgical investigations and intracranial investigations when needed. Magnetic resonance imaging volumetric studies were performed prior to surgery using previously published techniques. Patients were assessed regularly for postoperative seizure control. Outcome after at least 3 years was evaluated using Engel's classification for epilepsy. The chi2 test was used to compare categorical data. RESULTS: Seventy-eight patients were included in this study. Eight patients were excluded because of inadequate follow-up. Thirty-five patients (44.9%) had unilateral isolated hippocampal atrophy exclusively on MRI volumetry, 29 (37.2%) had unilateral hippocampal atrophy with ipsilateral fornix atrophy, and 6 (7.7%) had isolated fornix atrophy without hippocampal atrophy. Twenty-eight patients (80%) in the unilateral hippocampal atrophy group were seizure free (ie, Engel class 1: patients who are completely seizure free with no aura and who do not receive antiepileptic drugs) compared with 21 patients (73%) in the fornix and hippocampal atrophy group (P =.57). All 6 patients with isolated fornix atrophy achieved an Engel's class 1 outcome. CONCLUSIONS: These findings suggest that identification of fornix atrophy with or without associated hippocampal atrophy is not an important preoperative determinant of surgical outcome. However, in the presence of a normal hippocampus, fornix atrophy may be valuable in predicting seizure-free outcome.     

Quantitative magnetic resonance imaging of the amygdala in temporal lobe epilepsy-clinico-pathological correlations (a pilot study)

PURPOSE: We carried out a pilot study of quantitative volumetric MRI of the amygdala in patients undergoing surgery for intractable temporal lobe epilepsy. We wished to explore whether amygdala volume correlated with pre-operative clinical variables and post-operative outcome.METHODS: Ten patients had detailed volumetric measurements of their amygdala and hippocampus according to operationalised anatomical criteria from an optimised MRI imaging sequence. A ratio of volumes from the unoperated to operated side was calculated. Surgical specimens were examined histologically for astrocytosis.RESULTS: The volumes of the amygdala and hippocampus on the operated side were significantly smaller than on the unoperated side. More severe astrocytosis appeared to go along with smaller volume ratios but the relationship was not significant. There were few significant correlations between volumes measures and clinical or outcome variables.CONCLUSION: Reductions in amygdala volume in the to-be-operated temporal lobe in patients with medically intractable epilepsy can be reliably detected using volumetric MRI. Accurate amygdala volume measures do not appear to exert a significant effect on clinical presentation and outcome in the presence of hippocampal volumes reductions, but may be useful in confirming bilateral pathology. Larger studies examining clinico-pathological correlations are recommended.     

Hippocampal sclerosis-Origins and imaging

The association between hippocampal sclerosis (HS) and epilepsy has been known for almost two centuries. For many years, HS was studied in postmortem series; however, since the mid-20th century, surgical specimens from temporal lobe resections have provided important new knowledge. HS is the most common pathology underlying drug-resistant mesial temporal lobe epilepsy (MTLE), a syndrome with a characteristic history and seizure semiology. In the early 1990s, it was recognized that magnetic resonance imaging (MRI) could detect HS. The standard MRI protocol for temporal lobe abnormalities uses coronal slices perpendicular to the long axis of the hippocampus. The MRI features of HS include reduced hippocampal volume, increased signal intensity on T(2) -weighted imaging, and disturbed internal architecture. The histopathologic diagnosis of HS is usually straightforward, with neuronal loss and chronic fibrillary gliosis centered on the pyramidal cell layer. There are several patterns or subtypes of HS recognized from surgical series based on qualitative or quantified assessments of regional neuronal loss. The pathologic changes of HS include granule cell dispersion, mossy fiber sprouting, and alterations to interneurons. There may also be more extensive sclerosis of adjacent structures in the medial temporal lobe, including the amygdala and parahippocampal gyrus. Subtle cortical neuropathologies may accompany HS. The revised classification of dysplasias in epilepsy denotes these as focal cortical dysplasias type IIIa. Sometimes, HS occurs with a second lesion, either in the temporal lobe or extratemporal, most often ipsilateral to the HS. HS on preoperative MRI strongly predicts good seizure outcome following temporal lobe resection (TLR). If adequate MRI shows no structural correlate in patients with MTLE, functional imaging studies are valuable, especially if they are in agreement with ictal electroencephalography (EEG) findings. Focal hypometabolism on 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) ipsilateral to the symptomatic temporal lobe predicts a good surgical outcome; the added value of (11) C-Flumazenil-PET (FMZ-PET) and proton magnetic resonance spectroscopy (MRS) is less clear. Surgical methods have evolved, particularly resecting less tissue, aiming to preserve function without compromising seizure outcome. Around two thirds of patients operated for MTLE with HS obtain seizure freedom. However, the best surgical approach to optimize seizure outcome remains controversial.