结合导航系统的经颅磁刺激在功能区癫痫术前评估中的应用

Navigated transcranial magnetic stimulation in preoperative evaluation of epilepsy in functional zones

探讨神经导航下经颅磁刺激（nTMS）在功能区癫痫术前评估中的应用。方法选取陆军军医大学第二附属医院神经外科自2016年1月至2017年3月收治的药物难治性癫痫12例（致痫灶位于或邻近重要功能区），所有患者均应用nTMS定位手运动区和运动性语言功能区，同时与术中皮层电刺激（DCS）结果验证，观察术后手术疗效及功能区受损情况。结果12例患者术前nTMS均检测出手运动区，其中8例患者nTMS手运动区与术中DCS检测位置重合（差距〈0．5cm）；3例位置相邻（差距0．5～1cm）；1例因大脑半球萎缩后功能区漂移到对侧，无法行术中DCS验证而被排除。11例患者术前nTMS检测出运动性语言区，与术中DCS检测结果比较，二者位置关系为包含及重合者（差距〈0．5cm）有8例，位置相邻者有2例（差距0．5～1cm），1例差异较大（〉1．5cm）。术后随访6～18个月，EngelⅠ级患者8例，Ⅱ级患者2例，Ⅲ级患者1例，所有患者均未出现持续性功能损害。结论nTMS是一种准确、无创且安全的功能区定位技术，尤其适用于部分无法配合术中DCS的患者，可以为癫痫病灶切除和功能区保护提供可靠依据。

Objective To investigate the value of navigated transcranial magnetic stimulation （nTMS） in preoperative evaluation of epilepsy in functional zones. Methods Retrospective analysis was performed in 12 refractory epilepsy patients had functional cortical lesions and accepted surgery in our hospital from January 2016 to March 2017. The target surgery areas were considered in or near the functional areas by video electroencephalogram and stereotactic electroencephalography or Wada test, nTMS was used to identify the motor or language fianctional areas before surgery, and direct cortical stimulation （DCS） was performed during the surgery to identify the accuracy of nTMS. Treatment efficacies were evaluated 6-18 months after surgery. Results Hand motor areas were detected in all patients by nTMS, of which 72.7% patients （8/11, one severe hemispheric atrophy patient was excluded due to functional zone drift to the opposite） were coincided with intraoperative DCS （〈0.5 cm）, the deviation distance between 0.5 cm and 1 cm was noted in 27.3% patients （3/11）; motor speech areas were detected in l 1 patients with nTMS, 72.7% patients （8/11） were coincided with intraoperative DCS （〈0.5 cm）, the deviation distance between 0.5 cm and 1 cm was noted in 27.3% patients （3/11）, 18.2% patients （2/11） were for adjacent relationship, and one was with large difference （〉1.5 cm）. And 8 patients had Engel grading I outcome （seizure-free）, 2 had grading II outcome （almost seizure-free）, and one had grading III outcome （worthwhile improvement）. No persistent function deficits were noted. Conclusion The nTMS is an accurate, noninvasive and safe functional localization method, which can provide important information for epilepsy patients especially who are not suitable for invasive language evaluation in epilepsy surgery.