药物难治性抽动秽语综合征的立体定向手术治疗

Stereotactic surgery for medically intractable Tourette syndrome

目的 总结立体定向一侧丘脑腹外侧核 （VL） /板中间核 （LM） 加ZI区毁损联合双侧扣带回前部 （AC） 毁损治疗药物难治性抽动秽语综合征 （TS） 的经验。 方法 回顾性分析36例TS的临床资料，术前均行脑电图、脑影像学、脑PET等检查，抽动情况以耶鲁抽动量表 （YGTSS） 评价，强迫观念程度以耶鲁-布朗强迫量表 （YBOCS） 评价。手术采用MRI引导下立体定向射频毁损方式，治疗组23例病人接受一侧ZI＋VL/LM联合双侧AC毁损治疗，对照组13例病人接受一侧ZI＋VL/LM毁损治疗。 结果 2组病人在ZI＋VL/LM毁损术后YGTSS评分均显著降低 （均P ＜0.05），肢体抽动、发声和总体抽动情况均有显著改善。治疗组双侧AC毁损术后YBOCS评分明显下降 （P ＜0.05），强迫症状的控制也有显著效果 （P ＜0.05）；对照组术后强迫症状无明显改善。随访36例，时间23~36个月，均未出现意识障碍、偏瘫、失语等严重并发症。 结论 一侧ZI＋VL/LM可以有效地控制TS病人肢体和发声抽动，联合AC毁损对TS伴发的严重强迫症状也有良好疗效。

Objective To summarize the treatment experiences of stereotactic unilateral zona incerta （ZI） and ventralateral/lamella medialis thalamotomy （VL/LM） combined with bilateral anterior cingulotomy （AC） for medically intractable Tourette syndrome （TS）. Methods Clinical data of 36 patients with medically intractable TS were analyzed retrospectively, who received electro- encephalography, brain imaging and brain PET examinations before operation. The severity of tics and obsessive compulsive behavior （OCB） were evaluated by Yale global tics scale score （YGTSS） and Yale-Brown obsessive compulsive scale （YBOCS） respectively. The surgery was performed through stereotactic radiofrequency guided by MRI, including 23 patients who underwent unilateral ZI and VL/LM combined with bilateral AC as treatment group and 13 who only underwent unilateral ZI and VL/LM as control group. Results YGTSS of patients in two groups significantly decreased （both P〈0.05）, and the motor tics, phonic tics and overall impairment of TS patients were improved significantly after unilateral ZI and VL/LM. YBOCS of patients in treatment group decreased （P〈0.05） and OCB was relieved significantly after bilateral AC （P〈0.05）, while there was no obvious change of OCB in control group after surgery. Thirty-six patients were followed up for 23 to 36 months and no severe complications such as conscious disturbance, hemiplegia and aphasia occurred. Conclusions Unilateral ZI and VL/LM can control the motor and phonic tics of TS patients effectively, which combined with AC also can relieve the concomitant OCB in TS.