摘要
目的：探讨颞叶癫痫的术前定位手段,术中皮层脑电监测下致痫灶的切除及术后并发症控制。
方法：湘雅二医院自2006年5月到2009年4月共行手术治疗87例颞叶癫痫患者。所有患者术前均行视频脑电图(V-EEG)和影像学(MRI)检查、术中行皮层脑电图(ECoG)检查、术后行影像学(MRI)复查。本文进行回顾性分析了术前评估定位手段,术中脑电监测的意义。
结果：所有患者根据视频脑电图(V-EEG)和MRI等无创检查定位了致痫灶。术中用皮层脑电图(ECoG)作监测,明确痫灶的部位和范围.术后至少常规服用抗癫痫药物2年,根据临床发作情况、脑电图检查结果决定是否停药。本组随访1-2年。疗效按Engel的标准评定,71例(81.6%)患者无癫痫发作(Engel-Ⅰ级),12例(13.8%)患者临床发作明显减少(Engel-Ⅱ级),4例(4.6%)患者仍有癫痫发作(Engel-Ⅲ级),但程度减轻,发作时间缩短。80例(91.2%)患者的神经心理功能均有不同程度改善。
结论：应用显微外科技术治疗颞叶癫痫是一种安全、有效的方法；术前进行视频脑电图(V-EEG)和MRI对颞叶癫痫致痫灶精确定位,对设计切除方式有重要参考价值。术中用皮层脑电图(ECoG)作监测,明确痫灶的部位和范围,以免术后残留痫灶。同时切除病灶及致痫灶是控制癫痫发作、改善预后的有效手段,及减少并发症,提高疗效的关键。
Objective:To explore the methods of presurgical location in patients with temporal lobe epilepsy,electrocorticogram (ECoG).monitoring in the surgical treatment of temporal lobe epilepsy and control of postoperative complications.
Methods:The clinical data of 87 postoperative patients from 2nd XiangYa Hospital, from 2006 to 2009, who underwent surgical treatment of temporal lobe epilepsy were retrospectively analyzed. All the patients were monitored by Video electroencephalography(VEEG) and Magnetic Resonance Imaging(MRI) before operation, by electrocorticogram (ECoG)monitoring in the operation. Patients were closely monitored with MRI postoperative.
Results:All patients according to the video electroencephalogram (VEEG) and magnetic resonance imaging (MRI) located epileptogenic zone as a noninvasive check. By using electrocorticogram (ECoG)monitoring in the operation,we can know the position and range of epileptogenic zone better.Taking an antiepileptic drug at least 2 year after operation, According to the clinical onset, EGG results determineed whether withdrawal.87 patients were followed up for 1 year to 2 years, the clinical attack was controlled completely in 71(81.6%) patients(Engel-Ⅰ), the times of clinical attack were decreased significantly in 12(13.8%) patients(Engel-Ⅱ),4(4.6%) patient still to remain epileptic seizure, but the degree relieved, and the seizure time shortened(Engel-Ⅲ). The nerves psychological function improved to different extent in 80patients(91.2%).
Conclusions:Using microsurgical techniques for the treatment of temporal lobe epilepsy is a safe and effective method. On preoperative video electroencephalogram (VEEG) and magnetic resonance imaging (MRI) of temporal lobe epilepsy epileptogenic zone resection for accurate positioning, design method had important reference value. By using electrocorticogram (ECoG)monitoring in the operation,we can know the position and range of epileptogenic zone better. While epileptogenic zone resection of the lesion and control seizures, improve the prognosis of effective means, and reduce the complications, enhance the curative effect of the key.
引文
[1]Berkovic SE.Surgical treatment of temporal lobe epilepsy[J].Neurol Neurosurg Psyhciatry,2002,73:470～473.
[2]安宁,杨辉,张可成.颞叶癫痫的手术治疗效果分析[J].第三军医大学学报,2003,20(25)：1824-1826.
[3]谭启富.颞叶癫痫手术治疗的经验与教训[J].中国临床神经外科杂志,2006,8(11)：450-451.
[4]Yasargil MG, Teddy PJ, Roth P. Selective amygdalohippocampectomy: Operative anatomy and surgical tech-nique. Adv Tech Stand Neurosurg,1985,12:93.
[5]刘绍明,李龄,周游.颞叶内侧区域的应用解剖研究.功能性和立体定向神经外科杂志,1993,7：18.
[6]Engel J Jr. Outcome with respect to epileptic seizures. In:Engel J Jr ed. Surgical treatment of the epilepsies. NewYork:Raven Press,1987; 533.
[7]刘绍明,李龄·颞叶癫痫的手术治疗·中华神经外科杂志,1996,11：344·
[8]Kilpatrick C, Cook M, Matkovic Z, et al. Seizure frequency and duration of epilepsy are not risk factors for postoperative seizure outcome in patients with hippo-campal sclerosis [J]. Epilepsia,1999,40 (7):899.
[9]Radhakrishnan K, So E, Silbert PL, et al. Predictors of outcome of anterior-temporal lobectomy for intractable epilepsy:a multivariateanalysis[J]. Neurology, 1998,51:4654.
[10]Ounsted C, Glaser GH, Lindsay J, Richards P. Focal epilepsy with mesial temporal sclerosis after acute meningitis [J]. Arch Neurol,1985,42(11):1058-1100.
[11]Schulz R, Ebner A. Prolonged febrile convulsions and mesial temporallobe epilepsy in an identical twin [J]. Neurology,2001,57 (2):318-320.
[12]Andre V, Marescaux C, Nehlig A, et al. Alterations of hippocampal GABAergic system contribute to development of spontaneous recurrentseizures in the rat lithium-pilocarpine model of temporal lobe epilepsy [J]. Hippocampus,2001,11(4): 452-468.
[13]Engel J Jr. International League Against Epilesy. A proposed diagnostive scheme for people with epileptic seizures and with epilepsy:report of the ILAF task force on classification and Terminology. Epilepsia,2001,42 (6):796-803.
[14]Engel J, Surgical treatment of epilepse.2nd ed, Newyork Rave Press, 1993.587-591
[15]Aure T, Barsi P, Bone B, et al. History of simple febrile seizures is associated with hippocampal abnormalities in adults. Epilepsia,2008,49 (9): 1562-1569
[16]Boon P, Callianuw L, Reuck J, et al. Clinical and neurophysiological correlation in patients with refractory partial epilepsy and intracranial structural lesions. ActaNeurochir (Wien),1994,128:68.
[17]Boon, P, MR-scan and focal lesions. Acta Neurol Scand[Suppl],1994.153: 106.
[18]Awad IA, Rosenfield J, Ahl H, et al. Intractable epilepsy and structural lesions of the brain:mapping, resectionstrategies and seizure outcome. Epilepsia, 1991,32:179.
[19]吴建伟,宋兆祺.癫痫病人MRI海马结构体积测定；中华放射学杂志,1998,32(4)：224-227
[20]Yoo SY, Chang KH, Song IC, et al. Apparent diffusion coefficient value of the hippocampus in patientswith hippocampal sclerosis and in healthy volunteers. AJNR,2002,23(5):809-812
[21]Wang R, Li SY, ChenM, et al. Diagnostic value of interictal diffusion-weighted imaging in evaluation of intractable temporal lobe epilepsy. Chin Med Sci J,2008,23 (2):68-72
[22]Assaf BA, Mohamed FB, Abou-Khaleda KJ, et al. Diffusion tensor imaging of the hippocampal formation in temporal lobe epilepsy. AJNR,2003,24 (9): 1857-1862
[23]Arfanakis K, Hermann BP, Rogers BP, et al. Diffusion tensor MRI in temporal lobe epilepsy. Magn Reson Imaging,2002,20 (7):511-519
[24]Nilsson D, Go C, Rydenhag B, et al. Bilateral diffusion tensor abnormalities of temporal lobe and cingulate gyrus white matter in children with temporal lobe epilepsy. Epilepsy Res,2008,49 (12):2220-2228
[25]Cukiert A, Cukiert CM, ArgentoniM, et al. Outcome after corticoamygdalohippocampectomy in patients with refractory temporal lobe epilepsy and mesial temporal sclerosis without preoperative ictal recording. Epilepsia.2008 Aug 19.
[26]Uijl SG, Leijten FS, Arends JB, et al. Decision-making in temporal lobe epilepsy surgery:the contribution of basic noninvasive tests. Seizure.2008,17(4): 364-373.
[27]Cavus I, Pan JW, Hetherington HP, et al. Decreased hippocampal volume onMRI is associated with increased extracellular glutamate in epilepsy patients. Epilepsia.2008,49(8):1358-1366.
[28]Pulsipher DT, SeidenbergM, Morton JJ, et al. MRI volume loss of subcortical structures in unilateral temporal lobe epilepsy. Epilepsy Behav,2007,11 (3):424-429.
[29]Feichtinger ttner O, EderH. Efficacy and safety of radiosurgical callosotomy:a ret rospective analysis. Epilepsia,2006,47 (7):1184-1191.
[30]JokeitH, OkujavaM, Wooremann FG, et al. Memory MfRI lateralizes temporal lobe epilepsy. Neurology,2001,57(11):1786-1793.
[31]Salek-HaddadiA, Friston KJ, Lemieux L, et al. Studying sponta2neous EEG activity wit h MfRI. Brain Res Rev,2003,43 (9):110-133.
[32]Cendes F, Andermann F, PreulMC, et al. Lateralization otermporal lobe epilepsy based on regional metabolic abnormalities in proton magnetic resonance spectroscopic images. AnnNeurol,1994,35 (2):211-216
[33]Hetherington H, Kuzniecky R, Pan J, et al. Pronton nuclea magnetic resonance spectroscopic imaging of human temporalobe epilepsy at 4. IT. Ann Neurol, 1995,38 (5):394404
[34]Briellmann RS, MarkWellard R, Masterton RA, et al. Hippocampal sclerosis:MR prediction of seizure intractability. Epilepsia,2007.48 (2):315-323
[35]Lu JJ, Ren LK, Feng F, et al. Metabolic abnormalities in mesial temporal lobe epilepsy patients depicted by proton MR spectroscopy using a 3.0 t MR scanner. Chin Med Sci J.2006,21(4):209-213.
[36]Hammen T, Schwarz M, Doelken M, et al.1H-MR spectroscopy indicates severity markers in temporal lobe epilepsy:correlations between metabolic alterations, seizures, and epileptic discharges in EEG. Epilepsia.2007,48 (2):263-269.
[37]FojtikovaD, BrazdilM, Skoch A, et al. Magnetic resonance spectroscopy of the thalamus in patients with mesial temporal lobe epilepsy and hippocampal sclerosis. Epileptic Disord.2007, Suppl 1:S59-67.
[38]FoldvaryN,Klem G,Hammel J, eta.l The localizing value ofEEG in focal epilepsy. JNeurology,2001,57:20-22.
[39]赵志和,蔡敏芳,漆化华,等.视频脑电图在癫痫诊断中的应用价值[J].医学临床研究,2004,21(1)：83-85
[40]谭郁玲.临床脑电图与脑电地形图学.第1版.北京：人民卫生出版社,1999,269-270
[41]梁少辉,肖湛,李展鹏,等.同步录像脑电图(VEEG)与皮层脑电图(ECoG)在难治性癫痫灶切除手术中的作用.现代电生理学杂志,2004,11,(4)：15-17.
[42]Rosenow F, Luders H. Presurgical evaluation of epilepsy. Brain,2001,124(9):1683
[43]李天栋,白红民,蒋晓星,等.皮层脑电图监测下切除有癫痫症状的脑肿瘤.立体定向和功能性神经外科杂志,2004,17(2)：85-87.
[44]Onal C, Otsubo H, Araki T et al. Complications of invasive subdural grid monitoring in children with epilepsy. J Neurosurg,2003,98(5):1017
[45]Benbadis SR, O'Neill E, Tatum WO et al. Outcome of prolonged video-EEG monitoring at a typical referral epilepsy center. Epilepsia,2004,45(9):1150
[46]Engel J Jr, Kuhl DE, PhelpsME, et al. comparative localization of epileptic foci in partial epilepsy by PCT and EEGAnn Neurol,1982,12(6):529-537.
[47]Vinton AB, Carne R, Hicks RJ, et al. The extent of resection of FDG-PET hypometabolism relates to outcome of temporal lobectomy. Brain,2007,130 (pt 2): 548-560.
[48]Uijl SG, Leijten FS, Arends JB, et al. The added value of [18F]-fluoro-D-deoxyglucose positron emission tomography in screening for temporal lobe epilepsy surgery. Epilepsia,2007,48 (11):2121-2129
[49]Mohamed A, Eberl S, Fulham MJ, et al. Sequential 123 iiododexetimide scans in temporal lobe epilepsy:comparison with neuroimaging scans (MR imaging and 18F-FDG PET imaging). J NuclMed Mol Imaging,2005,32 (2):180-185
[50]Kuruvilla A, Flink R. Intraoperative electrocorticography in epilepsy surgery:useful or not [J]. Seizure,2003,12:577～584.
[51]Zumseg D, Wiezer HG. Presurgical evaluation:currentrole of invasive EEG [J]. Epilepsia,2000,41 (Supp13):S55～60.
[52]Chen X, Sure U, Haag A, et al. Predictive value of electrocorticography in epilepsy patients with unilateral hippocampal sclerosis undergoing selective amygdalohippocampectomy [J]. Neurosurg Rev,2006,29:108～113.
[53]Alarcon S, Seone JJG, Binnie CD, et al. Origin and propagation of interictal discharges in the acute electrocorticogram:implications for pathophysiology and surgical treatment of temporal lobe epilepsy [J]. Brain,1997,120:2259～2282.
[54]Kanazawa 0, Blume WT, Girvin JP. Significance of spikes at temporal lobe electrocorticography [J]. Epilepsia,1996,37:50～55.
[55]Tran TA, Spencer SS, Javidan M, et al. Significance of spikes recorded on intraoperative electrocorticographu in patients with brain tumor and epilepsy [J]. Epilepsia,1997,38:1132～1139.
[56]Li LM, Cendes F, Andermann F, et al. Surgical outcome in patients with epilepsy and dual pathology [J].Brain,1999,122:799～805.
[57]蔡立新,李勇杰,张国君,等.颞叶病灶性癫痫的手术治疗[J].中华外科杂志,2007,45：103-106.
[58]McKhann GM, Schoenfeld MJ, Born DE, et al. Intraoperative hippocampal electrocorticogrphy to predict the extentof hippocampal resection in temporal lobe epilepsysurgery [J]. J Neurosurgery,2000,93:44～52.
[59]Oliveira PA, Garzon E, Caboclo LO, et al. Can intraoperative electrocorticography patterns predict surgical outcome in patients with temporal lobe epilepsy second-ary to unilateral mesial temporal sclerosis [J]. Seizure,2006, 15:541～551.
[60]周昌贵.脑皮质电图的临床应用[J].临床脑电学杂志,1995,,4(3)：187-189
[61]Keene DL, Whiting S, Ventureyra EC. Electrocorticography [J]. Epileptic Disord,2000,2(1):57
[62]林元相,张义成,康德智,等.痫灶切除方式对顽固性癫痫手术疗效的影响.立体定向和功能性神经外科杂志,2001,14(2)：80
[63]Levesque MF, Nakasate N. Epileptogenieity of structural lesions and the zone of seizure origin. Surgical implications. Epilepsia,1991,32:27
[64]齐洪武,王政刚,张卫宁,等.显微切除痫灶治疗颞叶顽固性癫痫的疗效分析[J].西南军医,2007,9(2)：38-40.
[65]马志国,杨辉,安宁,等.难治性癫痫显微外科治疗的疗效分析[J].中华显微外科杂志,2006,29(3)：192-193.
[66]吴逊.癫痫和发作性疾病.北京：人民军医出版社,2001.150-151.
[67]Paolicchi JM, Jayakar P, Dean P, et a.l Predictors of outcome in pediatric epilepsy surgery.Neurology,2000,54:642-647.
[68]Majores M, Schoch S, Lie A, et a.l Molecular neuropathology of temporal lobe epilepsy:complementary approaches in animalmodels and human disease tissue.Epilepsia,2007,48(Suppl2):4-12.
[1]Auriel E, Chistik V, Blatt I. Efficacy and safety of leve-tiracetam(keppra) add-on treatment in adult patients with refractory epilepsy in two tertiary centers [J]. Harefuah,2007,146(4):269.
[2]Halatchev VN. Epidemiology of epilepsy-recent achieve-ments and future [J]. Folia Med (Plovdiv),2000,42(2):17.
[3]孙红斌,王学峰.神经系统疾病的理论与实践[M].成都：四川科学技术出版社,1997.190.
[4]Barcia JA,Barcia-Salorio JL,Lopez Gomez L,et al. Stereotactic radiosurgery may be effective in the treatment of idiopathic epilepsy:report on the methods and results in a series of eleven cases[J].Stereotact Funct Neurosurg,1994,63(1-4):271-279
[5]Regis J,Rey M.Bartolomei F,et al. Gamma knife surgery in mesial temporal lobe epilepsy.a prospective multicenter study[J]. Epilepsia,2004,45(5):504-515
[6]李冰,芮东红,沈香春,等.难治性癫痫的伽玛刀治疗[J].立体定向和功能性神经外科杂志,2003,16(2)：84-85
[7]Barcia-Salorio JL,Gerda M,Ciudad J,et al. Reponse of experimental epileptis focus to focal ionizing radiation[J]. Appl Neurophysicol,1987,50:359
[8]Malis L,Rose JE,Kruger L,et al. Production of laminar lesions in the cerebtal cortex by deuteron irradiation[M]//Haley TJ SniderRs(eds). Response of the nercous system to ionizing radiation.New York:Academic Press,1962:359-368
[9]谭启富.癫痫的脑立体定向手术[M]//吴逊.神经病学.北京：人民军医出版社,2001：388-389
[10]Regis J,Roberts DW. Gamma knife radiosurgery relative to microsurgery: epilepsy [J]. Stereotact Funct Neurosurg,1999,72(Supp11):11-21
[11]Schachter SC.Antiepileptic drug therapy:general treatment principles and application for special patient populations[J].Epilepsia,1999,40(9):S20.
[12]Kwan P,Brodie MJ.Early identification of refractory epilepsy[J].NEngl J Med,2000,342(5):314.
[13]Kwan P.Brodie MJ.Effectiveness of first antiepileptic drug[J].Epilepsia,2001,42(10):1255.
[14]Brodie MJ,Yuen AW.Lamotrigine substitution study:evidence for synergism with sodium valproate?105 Study Group[J].Epilepsy Res,1997,26(3):423.
[15]沈鼎烈.临床癫痫学[M].上海：上海科学技术出版社,1994.210.
[16]吴立文,卢强.癫痫患者的合理停药[J].Clinical Medication Journal,2005,3(3):27.
[17]McOonagh J,Stephen LJ,Dolan FM,et al.Peripheral retinal dysfunction in patients taking vigabatrin[J].Neurology,2003,61(12):1690.
[18]Beyenburg S,Bauer J,Reuber M.New d rugs for the treatment of epilepsy:a practical approach[J].Postgraduate Medical Journal,2004,80(948):581.
[19]Halatchev VN.Epidemiology of epilepsy-recent achievements and future[J].Folia Med(Plovdiv),2000,42(2):17.
[20]Loscher W.Current status and future directions in the pharmacotherapy[J].Trends Pharmacol Sci,2002,23(3):113.
[21]Brodie MJ.Do we need any more new drug treatment for epilepsy[J].Epilepsy Res,2001,45(13):3.
[22]Larsson LC,Widner H.Neural tissue xenografting[J].Scand J immunol,2000;52(3):249-256.
[23]刘金民,江涛,李得民.近10年中医药治疗癫痫的系统评价[J].中国中医基础医学杂志,2006,12(12)：955-957.
[24]刘桑.针灸治疗癫痫临床研究进展[J].河北医学,2008,30(3)：331-332.
[25]‘袁树斌,文武,梁昕,等.伽玛刀治疗颞叶癫痫38例初步报道[J].立体定向和功能性神经外科杂志,2007,20(1)：10-14.
[26]万衡,于文生,袁树斌,等.颞叶癫痫伽玛刀治疗效果评判时限[J].中国临床神经外科杂志,2007,12(11)：662-664.
[27]余军武,于向龙,于雷,等.伽玛刀与手术治疗颞叶癫痫的对比研究[J].立体定向和功能性神经外科杂志,2008,21(3)：148-151.
[28]Kwan P, Brodie MJ. Early identification of refractory epilepsy [J]. N Eng J Med,2000,342:314.
[29]冯文,高晋健,廖述才,等.颞叶癫痫的手术治疗[J].四川医学,2007,28(3)：300-301.
[30]杨卫东,毓青,浦佩玉,等.一侧混合性颞叶癫痫的联合微创手术治疗[J].立体定向和功能性神经外科杂志,2007,20(3)：137-140.
[3l]朱丹,华刚,郭强,等.神经导航下锁孔入路选择性海马杏仁核切除术治疗内侧颞叶癫痫[J].立体定向和功能性神经外科杂志,2007,20(3)：133-136.
[32]Tellez-Zenteno JF, McLachlan RS, Parrent A. et al. Hippocampal electrical stimulation in mesial temporal lobe epilepsy[J]. Neurology,2006,66:1490-1494.
[33]Chkhenkeli SA, Sramka M, Lortkipanidze GS, et al. Electrophysiological effects and clinical results of direct brain stimulation for intractable epilepsy[J].Clin Neurol Neurosurg,2004,106:318-329.
[34]Velasco M, Velasco F, Velasco AL, et al.Subacute electrical stimulation of the hippocampus blocks intractable temporal lobe seizures and paroxysmal EEG activities[J]. Epilepsia,2000,41:158-169.
[35]Vonck K, Boon P, Achten E, et al. Long-term amygdalohippocampal stimulation for refractory temporal lobe epilepsy[J]. Ann Neurol,2002,52:556-565.
[36]Albensi BC, Ata G. Activation of long-term synaptic plasticity causes suppression of epileptiform activity in rat hippocampal slices[J]. Brain Res,2004,998(1):56-64.
[37]Manola CH, Velasco M,Velasco F,et al. Evaluation of GABA system and cell damage in parahippocampus of patients with temporal lobe epilepsy showing antiepileptic effects after subacute electrical stimulation[J]. Epilepsia,2004,45(5): 459-466.
[38]Salanova V,Worth R.Neurostimulators in epilepsy[J].CurrNeurol Neurosci Rep,2007.7(4):315-319.
[39]Boon PK, Vonk.Deep brain stimulation in patients with refractory temporal epilepsy[J]. Epilepsia,2007,48(8):1551-1560.
[40]Kuncel AM, Grill WM. Selection of stimulus parameters for deep brain stimulation [J]. Clin Neurophysiol,2004,115(11):2431-2441.
[41]Bjorklund A,Lindvall O.Cell replacement therapies for central nervous system disorders[J].Nat Neurosci,2000;3(6):537-544.
[42]Gensburger C, Labourdette G, Sensenbrenner M. Brain basic fibroblast growth factor stimulates the proliferation of rat neuronal precursor cells in vitro [J]. FEBS Lett,1987,217(1):1-5.
[43]Westerlund U, Svensson M, Moe MC, et al. Endoscopi-cally harvested stem cells:a putative method in future auto-transplantation [J]. Neurosurgery,2005, 57 (4):779-784.
[44]Dennis A, Ashok K. Clinical prospects for neural grafting therapy for hippocampal lesions and epilepsy [J]. Neuro-surgery,2003,52(3):632-641.
[45]Kim JH, Auerbach JM, Rodriguez-Gomez JA, et al. Dopamine neurons derived from embryonic stem cells function in an animal model of Parkinson's disease [J]. Nature,2002,418(6893):50-56.
[46]汪朝阳,杨立业,郑佳坤,等.神经干细胞移植在癫痫外科治疗中的应用[J].中华临床神经外科杂志,2006,11(6)：364-366.
[47]Thompson KW.Genetically engineered cells with regulatable GABA production can affect afterdischarges and behavioral seizures after transplantation into the dentate gyrus[J].Neuroscience,2005;133(4):1029-1037.
[48]Jabs R,Pivneva T,Huttmann K.Synaptic transmission onto hippocampal glial cells with hGFAP promoter activity[J].JCell Sci,2005;118(16):3791-3803.