伽玛刀治疗顽固性癫痫的长期随访研究

Gamma knife radiosurgery for intractable epilepsy:a long-term follow up study

目的评估伽玛刀（γ刀）放射外科治疗药物难治的顽固性癫痫的长期疗效和安全性。方法1996年4月至1999年6月连续用γ刀治疗不同发作类型的顽固性癫痫患者47例,37例获得满意随访。术前研究包括详细病史、体检、脑电图、脑地形图、SPECT、MRI、智商测定和学习工作能力评估。应用LeksellB型γ刀,靶点包括杏仁核、海马前部、脑软化灶、胼胝体,采用单/多靶点定向照射。靶点边缘剂量选择低剂量（10-15 Gy）照射脑软化灶,中等剂量（25-60Gy）进行毁损。随访内容包括癫痫发作改变过程、脑电图、神经影像、学习工作能力、心理承受力及生活质量评估。结果随访8-11年,平均（9.4±1.5）年,疗效按国内外通用评价标准分级：优（EngelⅠA-D）24例（64.9%）,显著改善（EngelⅡA-D）11例（29.7%）,明显改善（EngelⅢA-B）2例（5.4%）。开始显效时间3-13个月,80%以上在治疗后8-12个月,疗效高峰在治疗后8-18个月,2年以后仍有改善病例。除暂时性脑水肿5例和永久性额叶损害精神症状1例外,未发生其他并发症,无死亡病例。结论γ刀放射外科治疗顽固性癫痫能明显改善和终止药物难治性癫痫发作,并发症较少,患者学习工作能力、生活质量、心理承受力治疗前后比较无减退。癫痫灶的识别和定位至今仍是难题,故γ刀治疗前严格选择病例,治疗靶点确定要有充分依据,严格控制剂量、容积,以提高疗效,降低并发症。

Objective To evaluate the long term efficacy and adverse effects of gamma knife radiosurgery （GKRS） in the treatment of pharmacoresistant epilepsies and to define the role of GKRS for intractable epilepsy. Methods From April 1996 to June 1999,47 patients with intractable epilepsy were treated with GKRS at our center. We evaluated 37 consecutive patients by means of serial EEG, MRI, clinical evaluations and questionnaires. The pre-GKRS investigations included EEG, BEAM, SPECT, MRI, neuropsyehological testing, and quality of life evaluations. The target included the amygdala, anterior hippocampus,callus and other epileptogenic lesions. Prescription peripheral doses varied from 10 - 15 Gy to 25 -60 Gy according to the location and number of targets. Results At a median follow-up period of 9.4 years （ range,8 to 11 years） ,64.9% of the patients （24 of 37） were seizure free （ Engel ⅠA-D ） , Engel ⅡA-D 29.7% （ 11 of 37 ） , and Engel ⅢA-B 5.4% （2 of 37 ）. Five patients had transient brain edema. Only one patient had permanent neuropsyehologieal deterioration. The quality of life was significantly better than that before GKRS. Conclusions GKRS offers patients with intractable epilepsy prospects of long-term good efficacy with only minor and often resolvable side effects. GKRS should be considered an appropriate strategy for pharmacoresistant seizures.