摘要
目的探讨皮层体感诱发电位(Co-SEP)、皮层运动诱发电位(Co-MEP)和皮层脑电监测(ECoG)及术中唤醒联合应用指导的功能区及其邻近部位致痫灶及致痫病灶的手术治疗及疗效。
方法30例癫痫患者,术前通过症状学、神经影像学、神经电生理检查综合评估,均行长程视频脑电监测(VEEG)、头计算机断层扫描(CT)、头核磁共振成像(MRI),其中行正电子发射断层扫描(PET-CT)检查22例,行脑磁图(MEG)检查17例,行功能性磁共振成像(fMRI)9例,明确致痫灶或/和致痫病灶位于功能区及其邻近部位,位于左侧者13例,右侧16例,双侧者1例,病变位于中央沟前者14例,中央沟后者16例。术中27例患者应用气管插管,静脉复合麻醉,大骨瓣开颅,根据术前影像学、手术切口位置及术中所见,大致决定出中央沟的位置,放置条带状电极尽量与中央沟垂直,电极与中央沟之间的角度不小于45。,通过Co-SEP的N20-P25与P22-N33的位相倒置确定中央沟的位置,随后,再将条状电极调整至中央前回的位置,以条状电极的触点为刺激电极,刺激强度由2 mA开始,1 mA递增,最大不超过25mA,直到引出分化良好的Co-MEP波形。用邮票式号码纸标记可以引出的Co-MEP的位置。有3例患者应用喉罩,静脉复合麻醉,打开硬脑膜前,停用麻醉药物,打开硬脑膜,待患者完全清醒后,进行语言测试,皮层电刺激,根据患者连续自发性语言的中断、命名错误、对答错误,依次定位运动性语言区、感觉性语言区,将语言区进行标记,随后恢复全麻状态,再将片状电极铺于皮层表面,记录有异常痫性放电的区域,避开应用Co-SEP、Co-MEP、术中唤醒皮层电刺激及术前fMRI定位的感觉区、运动区及语言区,切除致痫灶及致痫病灶,对位于上述功能区上的异常放电区域,进行多处软膜下横纤维切断术(MST)或皮层热灼术,再次行ECoG监测,反复上述过程,直至棘波明显减少或者消失。术后随访6-12个月,观察患者神经功能保留情况、癫痫发作缓解情况、肿瘤切除情况及预后。
结果致痫病灶完全切除12例,部分性切除15例,未切除3例；27例患者的致痫灶均累及中央区,切除中央区之外部分,3例患者病灶位于优势半球,累计语言区3例；位于中央区及语言区的致痫灶,行多处软膜下横切术(MST)及皮层热灼术。30例病人术后随访6-18个月,发作控制疗效按Engel标准：Ⅰ级17例；Ⅱ级7例；Ⅲ级3例；Ⅳ级3例。行术中唤醒的3例患者,1例于术后第三天出现部分运动性失语症状,2例于术后第二天出现感觉性失语,加强脱水及神经营养治疗,症状均于术后1周后好转。未行术中唤醒者,1例于术后5天,出现对侧肢体肌力下降,；1例于术后一周内尿失禁,精神淡漠,2者均予脱水及神经营养药物后,症状有所缓解,三个月后复查,症状均消失。所有病人术后均无永久性肢体神经功能障碍。脑胶质瘤患者于术后均行常规放、化疗,术后均6个月复查头MRI,全切者,未显示肿瘤复发,次全切患者中有两例胶质母细胞瘤Ⅳ级的分别又于术后8个月和10个月又出现癫痫发作,复查MRI,肿瘤复发,行二次手术治疗,其余患者未见明显影像学变化。
结论术中联合Co-SEP、Co-MEP、ECoG及术中唤醒技术,能有效的指导脑功能区及其邻近部位继发性癫痫的手术治疗,在避免重要功能皮层损伤的同时,最大限度切除病变,使患者得到最佳的术后癫痫发作的缓解,极大的提高患者的生存及生活质量。
Objective To evaluate the value of cortical sensory evoked potentials (Co-SEP) and motor evoked potentials(Co-MEP)combined with the electrocorticogram (ECoG) and awake craniotomy in epilepsy surgery with the epileptogenic focus in central area.
Method 30 cases of epilepsy by symptomatology, neuroimaging, electrophysiological examination comprehensive assessment before surgery,the patients who received PET-CT examination in 22 cases,accepted the EEG examination in 17 cases, fMRI in 9 cases, clear epileptogenic focus and/or epileptogenic lension in the district and adjacent parts, In the left side in 13 cases, right 16, and 1 case of bilateral. Application of intraoperative tracheal intubation and intravenous anesthesia, large trauma craniotomy, according to the preoperative findings determing the approximate location of the central sulcus,as far as possibal to place the banded electrode Perpendicular to the central sulcus,the angle between the central sulcus and the electrode at least greater than 45°,through the Co-SEP of the N20-p25 and P22-N33 of the phase inverted to determine the location of the central sulcus.Subsequently, adjust the position of the electrode strip to the central gyrus, the stimulus intensity starting from 2 mA,and with 1mA increments,the maximum not more than 25mA,unit it leads to well-differentiated Co-MEP waveform,then used the number paper marked the position of which can led to the Co-MEP. There are three patients who were treated with laryngeal mark, and intravenous anesthesia., positioning the motor speech area,sensory language area,the language area will be marked. Then spread on the cortical surface of the electrode sheet to record unusual epileptic discharge areas, avoid the sensory areas,motor areas and the language areas which localization through the use of Co-SEP, Co-MEP and intraoperative language testing, then removal the epileptic foci and the epileptogenic lesions, if the foci or lesiongs in the functional area, If not, we can choose MST or bipolar coagulation technique, the process was repeated until the spikes disappeared or significantly decreased.The results were observed for 6～12 months after the surgery. Observation including reservations of the neurological function, the improvement in seizures, and completeness of tumor resection and the tumor recurrence.
Results Complete resection of eppileptogenic lesions in 12 cases,15 cases of partial resection,no resection in 3 cases. All patients with epileptic foci involving both the central area, removal of areas outside the central part, where lesion in the dominant hemisphere, a total of 3 cases of the language areas. Located in the central area and language areas of the epileptogenic zone, under the MST and cortical bipolar coagulation technique.30 patients were followed up for 6 to 18 month, according to Engel seizure control efficacy standards:17 cases reached toⅠlevel; 7 reached toⅡlevel; 3 reached toⅢlevel; and 3 reached toⅣlevel The 3 patients who received awake craniotomy,1 cases occurred symptoms of partial motor aphasia in the third day of postoperative, and 2 cases showed sensory aphasia at the after day of the postoperative, and through enhance dehydration and neurotrophic treatment, the symptoms were recovery after 1 week of the operation In The other patients,1 cases showed contralateral limb muscle strength decline in the 5 days after operation,1 of urinary incontinence and spiritual apathy in a week after surgery, both the cases were symptoms eased after dehydrated and neurotrophic drugs were used, and after three months of review, the symptoms disappeared. All patients had no permanent motor dysfunction. In glioma patients underwent rountine postoperative radiotherapy and chemotherapy,and reviewed the MRI after 6 months of the surgery, the patients who received total resection did not show tumor recurrence, subtotal in two cases with glioblastoma, appeared seizures at 8 months and 10 months after surgery respectively, review the MRI,tumor recurrence,and the patients underwent secondary surgery, and there is no significant imaging changes in the remaining patients.
Conclusion the application of Intraoperative monitor of Co-SEP, Co-MEP combined the ECoG and evoked craniotomy in epilepsy surgery, Can effectively guide the epilepsy surgery in the brain central area,avoid injury the important brain function, while the maximum remove of the lesions.
引文
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