神经影像联合术中神经电生理监测指导运动区继发性癫痫手术

目的 探讨血氧水平依赖功能核磁共振成像(BOLD-fMRI)、弥散张量成像(DTI)联合术中皮层体感诱发电位(Co-SEP)、运动诱发电位(MEP)及皮层脑电图监测(ECoG)在M1区继发性癫痫手术中的应用价值.方法 对19例M1区继发性癫痫患者,男13例,女6例,病史0.5个月至20年,术前行BOLD-fMRI、DTI检查显示手功能激活区和投射纤维束及其与致痫病灶的毗邻关系,术中应用Co-SEP、MEP及ECoG,进一步明确M1区的位置及指导致痫病灶和致痫灶切除,尽可能保护神经功能;术后复查BOLD-fMRI了解神经功能保留情况.结果 12例可见激活区及纤维束位于致痫病灶边缘,余6例则因致痫病灶挤压、而移位,1例胶质瘤病灶边缘与M1区和皮层下白质纤维紧密接触.术中均通过Co-SEP位相倒置界定中央沟,2例与解剖学及影像学位置不一致;并分别于口轮匝肌、大鱼际肌、小鱼际肌或趾短屈肌等处引出MEP;术毕复查MEP仍存在.ECoG监测显示19例病灶及其附近皮层可见棘波发放,其中15例致痫灶与M1区有部分重叠,经处理后致痫区皮层棘波明显减少或消失.少突胶质细胞瘤病例病灶因紧邻运动区,为次全切,余者病灶全切;致痫灶全切者16例.术后观察6～12个月,患者癫痫发作改善程度达Engel Ⅲ级及以上者18例;复查BOLD-fMRI激活区较前范围增大,DTI显示投射纤维束与对侧趋于对称;2例术后出现一过性失语或轻偏瘫,无病例出现永久性神经功能障碍;胶质瘤患者随访期间未见复发征象.结论 BOLD-fMRI、DTI联合术中神经电生理监测指导M1区继发性癫痫手术,可优势互补,能有效指导M1区病灶和致痫灶的切除及神经功能的保留,提高患者生活质量.

Applications of blood oxygenation level dependent-functional magnetic resonance imaging, diffusion tensor imaging and inraoperative neurophysiology monitoring in secondary epileptic surgery in M1 area

Objective To explore the applications of blood oxygenation level dependent-functional magnetic resonance imaging(BOLD-fMRI), diffusion tensor imaging(DTI)and cortical somatosensory evoked potentials(Co-SEP), motor evoked potentials(MEP)and lectrocorticogram(ECoG)in secondary epileptic surgery of primary motor area(M1).Methods In 19 patients, preoperative BOLD-fMRI were performed to display the relationship between active zone, fiber bundle and epileptogenic lesions.Besides,Co-SEP, MEP and ECoG were also carried out intra-operatively to direct the resection of epileptogenic lesion and epileptogenic focus.At the same time, the nervous functions were protected as much as possible.Then fMRI was performed again to ensure that the post-operative nervous function was excellent.Results In preoperative BOLD-fMRI and DTI examinations, active zone and fiber bundle could be seen at the edge of lesions(n = 12);range reduced, become deformed or removed(n = 6);glioma epileptogenic lesion was close-up with M1(n = 1).The central sulcus was confirmed by Co-SEP in all cases.And two cases were inconsistent with anatomical location;Stimulating precentral gyrus, MEP were elicited post-operatively from orbicularis oris, muscle of thenar, hypothenar muscle or flexor digitorum brevis.Under the monitoring of ECoG, spike-wave was monitored in all cases.Of these, epileptogenic focus was in M1(n = 15).After treatment, spike-wave were reduced significantly or disappeared.At a post-operative follow-up of 6-12 months, seizure improvement has achieved Engel Ⅲ level or above(n = 18).On re-examinations of BOLD-fMRI and DTI, active zone became bigger than before and fiber bundle was symmetric with opposite side.Two of 19 cases had transient motor aphasia incompletely or hemiparesis.No permanent neurological dysfunction occurred.There was no relapse in cases of glioma.Conclusion BOLD-fMRI and Co-SEP, MEP and ECoG are complementary in M1 of secondary epilepsy surgery.It is effective to preserve nervous functions and enhance the quality of life for patients with epilepsy.