皮层脑电图辅助立体定向下手术治疗颅内钙化灶引起的难治性癫痫

目的研究立体定向下开放式手术联合术中皮层脑电图(ECoG)监测治疗颅内钙化灶性癫痫的手术方法、注意事项及效果。方法 21例颅内单发钙化灶引起的癫痫患者(其中主要功能区钙化灶9例),在立体定向仪导向下,开放直视手术,ECoG监测钙化灶周围皮层脑电活动情况,切除钙化灶后再次ECoG监测,确定致痫灶的范围及处理方式。结果所有钙化灶均被顺利切除。钙化灶区域ECoG监测无明显异常5例,表现为阵发性与动脉搏动相一致的单发性棘慢复合波发放9例,表现为明显癫痫样放电7例。单纯钙化灶切除术14例,钙化灶+周边增生组织+致痫皮层切除术4例,钙化灶切除+功能区致痫皮层低功率电凝热灼术3例。术后ECoG监测发现异常放电消失11例,仍残存轻中度痫样放电5例。无严重并发症。随访6个月～8年,EngelⅠ级16例,EngelⅡ级5例,总有效率100%。结论 ECoG监测是立体定向下手术治疗颅内钙化灶性癫痫的重要辅助手段,能够指导术中采取相应的手术方式切除钙化灶,妥善处理致痫灶,避免过多损伤脑皮层。     

皮层脑电图监测下继发性癫痫的手术治疗

目的 回顾分析皮层脑电图(ECoG)监测下致痫灶切除治疗继发性癫痫的手术情况,探讨ECoG对继发性癫痫的治疗价值.方法 通过术中ECoG监测,对原发灶切除结合外周皮层低功率热灼的方法治疗62例继发性癫痫(其中脑膜瘤15例,胶质瘤18例,海绵状血管瘤15例,蛛网膜囊肿5例,外伤后软化灶5例,表皮样囊肿2例,动静脉畸形2例)的观察,分析ECoG监测在继发性癫痫手术中的意义.结果 术后常规脑电图检查均未见癫痫波,术后无一例死亡或出现新的功能障碍.术后随访10个月-3年,2例尚有部分性发作,但发作频率减少在90%左右,应用抗癫痫药物治疗后未再有癫痫发作.结论 对于颅脑占位性病变合并的继发性癫痫,术中ECoG监测对于指导癫痫灶的处理是必不可少的.     

皮层脑电图监测在致痫灶切除术中的应用(附96例报告)

目的 探讨皮层脑电图(ECoG)监测在癫痫手术中指导切除致痫灶的价值.,方法 2005年12月至2008年6月期间,96例难治性癫痫患者在经过详细的术前评估后,进行了手术治疗.术中先切除癫痫病灶,再行描记EcoG,监测异常放电是否消失;若癫痫波仍大量存在,则进一步切除病灶周围的致痫灶,直至EcoG监测异常放电消失或明显减少.结果 术后随访12～44个月.根据Engel疗效分级标准进行疗效评价.Engel Ⅰ级45例,Ⅱ级22例,Ⅲ级17例,Ⅳ级12例.手术有效率达到87.50%.结论 术中应用EcoG监测能大大提高致痫灶空间定位的准确性,有效地指导癫痫的手术.     

隐源性癫痫致痫灶最常见好发部位及相关病理特征

目的 回顾性分析隐源性癫痫致痫灶最常见的好发部位及手术切除标本的病理改变,探讨隐源性癫痫致痫灶的发病机制.方法 通过向26例头部CT、MRI等影像学检查无特异性表现的患者颅内可疑脑区植入皮层电极及深部电极,行长程视频脑电监测,记录发作间期及发作期脑电图变化,确定癫痫病灶起始区,手术切除致痫灶并送病理,术后定期随访.结果 26例均可以明确致痫灶,其中癫痫发作单独起源于颞叶新皮层及颞叶内侧的13例,占本组病例的50％;送检标本病理结果显示胶质细胞增生、皮层分层紊乱25例,占本组病例的96.15％,其中伴有海马硬化14例.术后随访1年以上,Engel Ⅰ级15例,Engel Ⅱ级8例,Engel Ⅲ级2例,Engel Ⅳ级1例.无严重并发症及手术死亡病例.结论 颞叶新皮层及颞叶内侧是隐源性癫痫致痫灶最常见的好发部位,皮层发育不良是隐源性癫痫手术切除标本中常见的病理改变,其中海马硬化是颞叶内侧常见的病理改变.颞叶新皮层及颞叶内侧病理改变不仅经常相伴出现,而且病理改变轻微.通过外科干预,效果较满意.按Engel分级,位于颞叶新皮层及颞叶内侧的病例手术疗效较其他好,Engel's分级均在Ⅱ级以上.     

VEEG、ECoG、结合MRS定位致痫灶评价(附23例临床分析)

目的探讨在颞叶病变继发颞叶癫痫(Temporal lobe epilepsy,TLE)患者中应用长程视频脑电图(VEEG)、颅脑磁共振波谱分析(MRS)联合皮层脑电图(ECoG综合定位致痫灶指导手术切除致痫灶范围,评价TLE术后临床效果。方法病历资料选自2016年1月至2017年12月期间在蚌埠市第三人民医院癫痫研究所就医的既往有癫痫发作临床症状及不同医院脑电图结果提示有颞叶脑电异常初步依据纳入、排除标准选取病历资料完整的23例颞叶病变继发TLE的患者行手术治疗,术前完善VEEG及MRS检查,术中联合ECoG再检测致痫灶指导手术切除范围,术后采用Engel标准评价手术效果。结果应用VEEG与MRS两种检查分别阳性对不同病因组患者致痫灶定位中,术中在ECoG再检测指导下与MRS、VEEG定位致痫灶比较,MRS与ECoG一致率为95.65%,高于VEEG与ECoG的一致率65.22%,差异有统计学意义(χ~2=6.769,P0.05);在ECoG再检测指导下手术治疗的23例继发性TLE患者,术后随访12～27个月,依据Engel评价标准,结果示:EngelⅠ级18例,EngelⅡ级3例,EngelⅢ级1例,EngelⅣ级1例,术后均无严重并发症及死亡病例,术后临床效果达到显著有效共22例,显著有效率为95.65%。结论术中联合ECoG再检测致痫灶并指导手术切除范围,可显著提高手术治疗效果,TLE患者术后显著有效达95.65%;对一般经济条件需要手术治疗的患者,术前应用MRS与VEEG综合定位致痫灶与术中联合ECoG再检测致痫灶是颞叶病变继发TLE患者一种很好的选择,可避免昂贵的检查费用,获得满意疗效。     

颅内电极埋藏在枕叶癫痫中的作用

目的探讨运用颅内电极埋藏进行视频脑电图监测在定位困难的枕叶癫痫中的作用。方法通过对9例枕叶癫痫但定侧定位困难的患者,向颅内可疑部位植入硬膜下条状电极,进行视频脑电图监测,记录发作间期及发作期脑电图变化,确定癫痫病灶起始区。通过手术切除致痫灶。结果本组9例埋藏时间为3～9d,平均5d,均记录到间歇期痫样放电及发作期脑电图情况。行枕叶局部皮层切除6例及枕叶切除3例。术后按照Engel评分,I级7例,II级2例。所有病例均未出现埋藏电极引起的并发症。结论在致痫灶定位困难的顽固性枕叶癫痫中,采用颅内电极埋藏进行脑电图监测,可以精确定位致痫灶,从而提高癫痫的治愈率。     

术中脑电监测在癫痫手术中的应用分析

目的讨论术中脑电监测在癫痫手术中的应用意义。方法40例难治性癫痫患者，术中采用日本光电9200脑电描记系统。应用皮层电极，在致痫灶靶区皮层，对癫痫起源部位进一步精确定位，手术切除致痫灶，并在皮层脑电图（ECoG）监测下进行病灶扩大切除、胼胝体切开或多处软膜下横切（MST），术后常规应用抗癫痫药物。结果全部患者在预定的癫痫灶局部均可记录到癫痫波；病变及癫痫灶切除后即时检测，显示痫性放电明显减少24例，其中3例非功能区海绵状血管瘤，瘤体切除后仍可见大量棘波，扩大切除周围皮质，棘波显著减少；3例功能区胶质瘤患者虽经MST后，棘波有一定改善，仍可见一定量棘波；12例海马硬化及1例海马萎缩术后，仍存在一定量棘波。术后疗效评价，按照Engel分级评价为：Ⅰ级27例，Ⅱ级6例，Ⅲ级4例，Ⅳ级3例；总有效者37例，有效率达92．5％。结论在癫痫手术中运用脑电监测，可以进一步精确定位致痫灶，指导手术中正确切除癫痫灶及预示手术效果，有助于提高手术治疗的有效性，在癫痫外科治疗中具有一定应用价值。     

皮质脑电图在脑海绵状血管瘤所致癫痫手术中的应用研究

目的 研究皮质脑电图(ECoG)在脑海绵状血管瘤(BCA)所致癫痫手术中的作用.方法 对经正规抗癫痫治疗无效的85例BCA致癫痫患者,在ECoG监测下进行致痫灶定位,指导手术治疗.术后对患者进行随访及疗效评定.结果 术中ECoG监测发现本组患者的BCA病变区均存在棘波发放,而术前头皮EEG仅56例存在棘波,术中ECoG还发现31例患者有新的致痫灶.所有患者在ECoG监测下进行致痫灶切除(非功能区)或低功率热灼术(功能区).术后平均随访3.4年,疗效满意(癫痫发作完全消失)61例(71.8％),良好(发作减少≥50％)18例(21.2％),差(发作减少＜50％)6例(7.1％);总有效(满意+良好)率92.9％.结论 ECoG监测可在BCA所致癫痫手术中准确定位致痫灶,明显提高手术的疗效.     

中央区纵裂癫痫的手术治疗

目的 探讨中央区纵裂癫痫的诊断及手术治疗方法. 方法 选择自2007年6月至2008年4月在河北省人民医院功能神经外科就诊并接受手术治疗的6例中央区纵裂癫痫患者,常规术前评估(包括MRI、头皮脑电图、MEG、加密头皮脑电图、颅内埋藏电极及皮层电刺激联合定位致痫灶和功能区)后在皮层脑电临测下行手术切除,切除组织进行病理检查,术后随访发作情况、腩电图和并发症. 结果 经术前评估致痫灶均位于中央区纵裂区,经手术治疗后5例患者术后无发作,达到Engle Ⅰ级;1例EngleⅡ级,发作明显减少.术后病理结果显示,6例患者中局灶性皮层发育不良3例,胶质增生、脂肪瘤和海绵状血管瘤各1例.术后脑电图显示,大致正常脑电图3例,少量慢波3例. 结论 中央区纵裂癫痫在精确定位下可行手术切除,手术效果良好,无严重并发症.     

颅内埋藏电极及皮层电刺激在脑中央区致痫灶切除术中的联合应用(附7例报告)

目的 探讨颅内埋藏电极和皮层电刺激技术在脑中央区致痫灶切除术中的作用.方法 对7例术前怀疑致痫灶临近或累及大脑中央区的癫痫患者,将颅内电极置于硬膜下或皮层表面,行长程皮层脑电图(ECoG)监测及皮层电刺激,确定致痫灶和大脑中央区范围及二者位置关系.术中在保护中央区的前提下,最大限度切除致痫灶.术后随访6～12个月,根据Engel's术后效果分级和Karnofsky生活状态量表(KPS)评分进行评估.结果 :7例患者术后均无癫痫发作,达到Engel's I级,KPS评分结果较术前提高.结论 :颅内埋藏电极及皮层电刺激联合应用,可指导脑中央区致痫灶的手术,在切除致痫灶的同时保护脑中央区,达到既控制癫痫发作又无术后严重功能障碍的目的 ,可显著提高患者生活质量.     

Utility of electrocorticography in the surgical treatment of cavernomas presenting with pharmacoresistant epilepsy

Aim. To describe the general aspects of cavernomas and epilepsy and review the available literature on the utility of electrocorticography (ECoG) in cerebral cavernoma surgery. Methods. We searched studies in PubMed, MedLine, Scopus, Web of Science, and Google Scholar (from January 1969 to December 2013) using the keywords “electrocorticography” or “ECoG” or “prognosis” or “outcome” and “cavernomas”. Original articles that reported utility of ECoG in epilepsy surgery were included. Four review authors independently selected the studies, extracted data, and assessed the methodological quality of the studies using the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions, PRISMA guidelines, and Jadad Scale. A meta‐analysis was not possible due to methodological, clinical, and statistical heterogeneity of included studies. We analysed six articles with a total of 219 patients. Results. The most common surgical approach was lesionectomy using ECoG in the temporal lobe with Engel I outcome range from 72.7 to 100%. Conclusions. Small controlled studies suggest that ECoG‐guided resection offers the best functional results in seizure control for subjects undergoing cavernoma surgery, especially in the temporal lobe.     

Prediction of postoperative outcome with special respect to removal of hemosiderin fringe: a study in patients with cavernous haemangiomas associated with symptomatic epilepsy.

PURPOSE: In this study 30 patients with symptomatic epilepsy caused by cavernomas were investigated in a postoperative follow up study to assess predictors for postoperative outcome with respect to indications, time and approach of surgery. METHODS: Thirty patients with cavernomas refractory to medical treatment were scheduled for surgery based on the findings of high-resolution MR imaging and intensive EEG-video monitoring. Postoperative outcome of epilepsy was assessed by follow-up examinations based on the basis of classification by Engel and the International League against epilepsy (ILAE). RESULTS: The following variables were associated with good postoperative outcome: (1) complete resection of hemosiderin fringe surrounding the cavernoma was correlated to less postoperative seizure frequency versus incomplete resection of the hemosiderin fringe according to the outcome protocol of ILAE. (2) Lower duration of epilepsy at the time of operation was correlated to a better postoperative outcome with a benefit for recovery. (3) Absence of hemorrhage before surgery and unifocal seizure onset was a predictor for a favorable outcome, whereas bilateral or multifocal seizure onset zones showed poorer postoperative outcomes. (4) In patients with dual pathology (hippocampal sclerosis in addition to a cavernoma), lesionectomy plus hippocampectomy as opposed to lesionectomy only, had a better outcome than single lesionectomy. CONCLUSION: Postoperative outcome in patients with cavernomas should be the topic of further prospective multicenter studies involving a large number of patients. In addition to the ideal operation time and handling of dual pathology the role of extended resection including perilesional hemorrhages should be taken into account.     

Seizure outcome after resection of cavernous malformations is better when surrounding hemosiderin-stained brain also is removed

PURPOSE: Considering the epileptogenic effect of cavernoma-surrounding hemosiderin, assumptions are made that resection only of the cavernoma itself may not be sufficient as treatment of symptomatic epilepsy in patients with cavernous malformations. The purpose of this study was to test the hypothesis whether seizure outcome after removal of cavernous malformations may be related to the extent of resection of surrounding hemosiderin-stained brain tissue. METHODS: In this retrospective study, 31 consecutive patients with pharmacotherapy-refractory epilepsy due to a cavernous malformation were included. In all patients, cavernomas were resected, and all patients underwent pre- and postoperative magnetic resonance imaging (MRI). We grouped patients according to MRI findings (hemosiderin completely removed versus not/partially removed) and compared seizure outcome (as assessed by the Engel Outcome Classification score) between the two groups. RESULTS: Three years after resection of cavernomas, patients in whom hemosiderin-stained brain tissue had been removed completely had a better chance for a favorable long-term seizure outcome compared with those with detectable postoperative hemosiderin (p=0.037). CONCLUSIONS: Our study suggests that complete removal of cavernoma-surrounding hemosiderin-stained brain tissue may improve epileptic outcome after resection of cavernous malformations.     

颞叶癫痫致痫灶定位方法准确性临床研究

目的探讨颞叶癫痫致痫灶综合定位方法的准确性,总结出简便准确的综合定位程序。方法回顾性分析60例手术治疗的难治性颞叶癫痫患者资料,分析归纳所采用的不同致痫灶综合定位方法,并以此将病例分为5组：A组为磁共振（MRI）阳性＋视频脑电图（VEEG）＋皮层及深部电极（ECoG及DEEG）组,B组为MRI阳性＋VEEG＋单光子发射计算机断层成像（SPECT）＋ECoG及DEEG组,C组为MRI阳性＋VEEG＋正电子发射计算机断层显像-计算机体层扫描（PET-CT）＋ECoG及DEEG组,D组为MRI阴性＋VEEG＋SPECT＋ECoG及DEEG组,E组为MRI阴性＋VEEG＋PET-CT＋ECoG及DEEG组。所有病例均获随访,按Engel分级进行术后疗效评估,以Ⅰ～Ⅲ级作为效果良好的评价标准,并作为致痫灶定位准确的标准,通过统计学分析,计算出各种方法的定位准确率,对不同综合定位程序的定位能力做出评价。结果致痫灶准确定位病例A组16例（16/18）,B组10例（10/11）,C组16例（16/17）,D组3例（3/4）,E组8例（8/10）;A、B、C三组间定位能力无显著差异,D、E组明显低于A、B、C三组,D组定位能力最差。结论 MRI结果阳性且与VEEG一致者可定位致痫灶;MRI阴性而VEEG与PET-CT结果一致者可定位致痫灶;术中皮层及深部电极监测是致痫灶再定位及指导手术的标准。     

合并癫痫的幕上低级别胶质瘤病人癫痫预后的影响因素分析

目的探讨合并癫痫的幕上低级别胶质瘤病人癫痫预后的影响因素。方法回顾性分析2015年6月至2019年1月手术治疗的80例合并癫痫的幕上低级别胶质瘤的临床资料。术后1年,采用Engel分级评估癫痫预后,Ⅰ级为预后良好,Ⅱ~Ⅳ级为预后不良。用多因素logistic回归分析检验影响癫痫预后的影响因素;受试者工作特征(ROC)曲线分析术前癫痫发作频率预测癫痫预后的价值。结果80例中,术后癫痫预后良好59例,预后不良21例。多因素logistic回归分析结果显示,异柠檬酸脱氢酶(IDH)1突变和术前癫痫发作频率高是胶质瘤病人术后癫痫的独立危险因素(P<0.05),全切肿瘤和术后化疗是保护性因素(P<0.05)。术前癫痫发作频率预测癫痫预后的ROC曲线下面积为0.805(95%置信区间0.685~0.914;P<0.05);当术前癫痫发作频率≥2次/月时,预测术后癫痫预后不良的灵敏度和特异度分别为92.86%和46.85%。结论IDH1突变和术前癫痫发作频率高是合并癫痫的幕上低级别胶质瘤病人癫痫预后不良的危险因素,而肿瘤全切除和术后化疗明显改善癫痫预后。     

Cerebral cavernous angioma: a potentially benign condition? Successful treatment in 16 cases.

Cerebral cavernous angioma (cavernoma) has previously been treated by resection for all presentations when surgically resectable. In this retrospective series of 16 cases, it is demonstrated that, for those patients presenting with epilepsy alone, surgery is often unnecessary. Diagnosis can be made radiologically and excellent seizure control can be obtained with medications. In the authors' experience, those cavernomas symptomatic as epilepsy rarely cause major haemorrhage and the need for surgery as prophylaxis against bleeding in this group is unproven.     

Cortical resection with electrocorticography for intractable porencephaly-related partial epilepsy

PURPOSE: We evaluated the results of cortical resection of epileptogenic tissue for treatment of intractable porencephaly-related epilepsy. METHODS: We examined clinical features, electrophysiological data, surgical findings, and seizure outcomes after cortical resection in eight patients with intractable epilepsy related to porencephalic cysts. RESULTS: All eight patients had hemiparesis. Five retained motor function in the hemiparetic extremities; six retained visual fields. All had partial seizures, six with secondary generalization. Seven patients had simple and three had complex partial seizures (CPSs); two also had drop attacks. Four patients had multiple seizure types. Long-term scalp video-EEG (LVEEG) localized interictal epileptic abnormalities that anatomically corresponded to the cyst location in three patients. LVEEG recorded ictal-onset zones in five; these anatomically corresponded to the cyst location in three of the five. EEG recorded generalized seizures in two patients, hemispheric in one, and multifocal in two. Intraoperative electrocorticography (ECoG) revealed interictal epileptic areas extending beyond the margins of the cyst in seven patients. We resected ECoG-localized interictal epileptic areas completely in five patients and partially in two. Cortical resection was based on seizure semiology and LVEEG in one patient whose ECoG showed no epileptiform discharges. After a minimum follow-up of 1 year, six patients had excellent seizure outcome (Engel class I), and two had a >90% seizure reduction (Engel class III) without complications. CONCLUSIONS: Cortical resection guided by ECoG allows preservation of motor function and visual field and provides an effective surgical procedure for treatment of intractable epilepsy secondary to porencephaly.     

应用神经导航与术中磁共振成像辅助颅内海绵状血管瘤诱发癫痫的外科治疗(英文)

OBJECTIVES:Cure from seizures due to cavernomas might be surgically achieved dependent on both,the complete removal of the cavernoma as well as its surrounding hemosiderin rim.High field intraoperative MRI imaging(iopMRI)and neuronavigation might play a crucial role to achieve both goals.We retrospectively investigated the long-term results and impact of intraoperative 1.5T MRI(iopMRI)and neuronavigation on the completeness of surgical removal of a cavernous malformation(CM)and its perilesional hemosiderin rim as well as reduction of surgical morbidity.METHODS:26 patients(14 female,12 male,mean age 39.1years,range:17~63 years)with CM related epilepsy were identified.Eighteen patients suffered from drug resistant epilepsy(69.2%).Mean duration of epilepsy was 11.9 years in subjects with drug resistant epilepsy(n=18)and 0.3 years in subjects presenting with firsttime seizures(n=8).We performed 24 lesionectomies and two lesionectomies combined with extended temporal resections.Seven lesions were located extratemporally.RESULTS:Complete CM removal was documented by postsurgical MRI in all patients.As direct consequence of iopMRI,refined surgery was necessary in 11.5%of patients to achieve complete cavernoma removal and in another 11.5%for complete resection of additional adjacent epileptogenic cortex.Removal of the hemosiderin rim was confirmed by iopMRI in 92%of patients.Two patients suffered from mild(7.7%)and one from moderate(3.8%)visual field deficits.Complete seizure control(Engel class 1A)was achieved in 80.8%of patients with a mean follow-up period of 47.7 months.DISCUSSION:We report excellent long-term seizure control with minimal surgical morbidity after complete resection of CM using our multimodal approach.     

Factors contributing to resectability and seizure outcomes in 44 patients with ganglioglioma

OBJECTIVES: The purpose of this retrospective study was to evaluate causes contributing to surgical resectability and seizure outcomes depending on various clinical and surgical factors. PATIENTS AND METHODS: The records of 44 patients with gangliogliomas surgically treated between April 1986 and March 2007, were retrospectively reviewed to assess presenting symptoms, resectability and seizure outcomes. RESULTS: Tumors were located in the supratentorial areas in 33 cases, the infratentorial area in 9 cases and the spinal cord in 2 cases. Thirty-five cases underwent gross total removal and 9 cases underwent subtotal resection. Only 2 cases underwent postoperative radiotherapy and 2 cases underwent gamma knife surgery. Twenty-six patients presented seizure symptoms of which 22 cases were located in temporal lobe and 4 cases were located in the extratemporal lobe. Twenty-three patients (88.5%) were seizure-free after surgery. Two patients were Engel class II and another was Engel class III. CONCLUSION: We concluded that tumor location and seizure-presenting symptoms are good predictors of gross total removal. Gross total removal of ganglioglioma had a better chance of leaving the patient seizure free after surgery rather incomplete resection. Our data do not support the concept that surgical methods, invasive monitoring and surrounding cortical malformation correlated with seizure-free outcome.