功能区皮层下小病灶相关性癫痫的手术治疗

Surgical treatment for secondary epilepsy by subcortex small focal lesion in functional areas

目的评价综合应用多种定位技术治疗功能区皮层下小病灶相关性癫痫的手术方法及效果。方法 58例功能区皮层下小病灶引起的癫痫患者,在立体定向仪导向下,开放直视手术切除病灶,术中皮层脑电图(ECoG)监测定位致痫灶,术中神经电生理监测(IOM)判断致痫区的功能以及二者的重叠程度,辅助以麻醉唤醒定位语言区、实时超声检查病变切除程度,根据监测结果分别采取致痫灶切除术、多处软膜下横切术(MST)或皮层低功率电凝热灼术妥善处理致痫灶。结果病灶全部切除52例,少量残留6例。病灶区域ECoG监测除波幅略有降低外无明显异常13例,行占位病灶切除术;ECoG明显异常,在非主要功能区8例,行占位病灶+周边致痫皮层切除术;ECoG明显异常而又在主要功能区37例,行占位病灶+功能区致痫皮层多处软膜下横切术(MST)或低功率电凝热灼术。ECoG监测发现痫样放电消失、基本节律大致恢复正常29例,仍残留少量棘波13例,残存较多棘波且基本节律轻到中度异常16例。随访1～5年,EngelⅠ级46例,EngelⅡ级8例,EngelⅢ级4例,总有效率100%。出现暂时性轻偏瘫17例,暂时性失语8例,无严重永久性并发症。结论综合应用立体定向引导、术中IOM、ECoG、麻醉唤醒及实时超声定位治疗功能区小病灶相关性癫痫,能够精准定位并切除病灶及处理致痫灶,避免损伤功能区,是一种微创、安全、有效的手术方法。

Objective To estimate surgical method, efficiency of comprehensive application multiple modern location technique for secondary epilepsy by subcortex small focal lesion in functional areas. Methods 58 consecutive patients suffering from secondary epilepsy by subcortex small focal lesion in functional areas were performed by operation. First, the stereotaxic apparatus guide to resect focal lesion completely. Second, accurate epileptogenic foci was localized by intra-operative electrocorticography （ECoG） monitoring, function and the mapping of neuronal structures of epileptic region was judged by intra-operative neurophysiologic monitoring（IOM）, intra-operative language zone localization under arousal from drugged state, real-time ultrasound monitoring removal degree of focal lesion. Then treated epileptogenic foci by resecting epileptogenic foci cortex, multiple subpial transaction（MST） and cortex lower output powers thermocoagulation. Results Focal lesion were total resected in 52 cases, most resection in 6 cases. Simple focal lesion was resected in 13 cases, focal lesion plus perilesional cortex of epileptogenic foci were ablated in 8 patients, 37 patients were performed by focal lesion plus perilesional cortex of epileptogenic loci lower output powers thermocoagulation or/and MST. Intrao-perative ECoG monitoring discover epileptiform discharge disappearance and basilie rhythm of EEG approximate recovery in 29 cases, still remaining a few spikes in 13 cases, remaining a lot of spikes as well basilic rhythm of EEG abnormal in 16 cases. Total patients were followed up from 1 year to 5 years, according to Engel＇s classification, 46 patients got Engel Ⅰ, 8 cases were Engel Ⅱand 4 patients were Engel Ⅲ, the total effective rate was 100%. Complications including temporality hemiparesis in 17 cases, temporality aphasia in 8 cases, no permanency and severe complications. Conclusion It is a safe, effective and microinvasive management that stereotactic combining with intrao-perative ECoG, IOM, Awake-Asleep-Awake and real-time ultrasound monitoring for secondary epilepsy by subcortex small focal lesion in functional areas. It can accurate locate and resect focal lesion completely and treat epileptogenic loci, avoid damagingfunctional areas.