枕叶癫痫致痫灶位置与发作症状学的关系

The relationship between the location of epileptogenic focus and the simiology in occipital epilepsy

目的：本文通过明确枕叶癫痫致痫灶位置、视觉先兆和第一运动症状学，试图解释致痫灶位置和发作症状学的关系。方法：回顾性分析在三九脑科医院已行致痫灶切除手术、且术后随访至少1年未再出现发作的纯枕叶癫痫患者9例（其中4例经过立体定向脑电植入，5例直接手术治疗），使用枕叶集群分区方法明确枕叶致痫灶位置，按照病程记载的视觉先兆，回放术前评估时发作期录像，明确第一个运动症状学；回放4例患者的立体定向脑电图（SEEG）资料，明确发作起始和早期扩散区；阐述致痫灶位置和发作症状学之间的关系。结果：有视觉先兆的患者共7例，占78％，其中有两种视觉先兆的患者共3例。致痫区在枕叶背内侧、腹内侧和内侧表面（累及集群1、2、3）的患者4例，其中4例出现视觉缺失，还有1例合并出现单纯视幻觉。致痫区在枕叶背外侧和外侧面（累及集群4、5、8）的患者4例，产生复杂视幻觉。以自动运动为第一运动症状学的患者共6例，占67％，致痫区在枕叶背内侧、腹内侧和后下区（累及集群1、2、8），其中2例SEEG证实异常电活动的传播通过颞叶产生。以轴一肢带性强直为第一运动症状学的患者1例，致痫灶位于枕叶背内侧、内侧表面和背外侧（累及集群2、3、4）。以复杂运动为第一运动症状学的患者1例，致痫区位于枕叶外侧面（累及集群5），SEEG证实复杂运动时异常电活动并不向相邻组织传播。以偏转发作为第一运动症状学的患者1例，致痫区位于枕叶背内侧（累及集群2），SEEG证实偏转发作并不产生于同侧的额眼区。结论：枕叶癫痫致痫灶位置与发作症状学相关；枕叶背内侧、腹内侧和内侧表面的致痫区容易产生视觉缺失；枕叶背外侧和外侧面的致痫区容易产生复杂视幻觉；枕叶背内侧、腹内侧和后下区的致痫灶容易出现自动运动；枕叶背内和背外侧均受累的致痫灶可以产生轴性强直；枕叶外侧面的致痫灶可以出现复杂运动；而枕叶背内侧的致痫灶可以出现偏转发作，后3种症状学均可能通过投射纤维产生。

Objective：To explore the relationship between the location of epileptogenic focus （EF） and the semeiology of occipital epilepsy. Methods：Nine patients with occipital epilepsy were collected who experienced surgical treatment and free from epileptic seizure for at last one year between January 2014 and December 2016. Of 9 patients, 4 cases undergone stereotaxis EEG （SEEG） and then had surgical treatment, the other 5 experienced surgical treatment directly. Occipital Cluster analysis was applied to i＋ dentify the location of EF. The first motor semeiology was determined by recording the visual aura and reviewing the video of seizure semeiology. Seizure onset and the early spreading area was detected by SEEG to explore the relationship between the position of EF and the semeiology of occipital epilepsy. Results：7 patients presented visual aura, including 3 cases with two types of visual aura. EF in 4 patients was located in dorsal , ventral medial and medial surface （ cluster 1,2,3） with optical amnesia, including 1 case with visual hallucination. EF in other 4 patients was located in occipital dorsal laterial and laterial （cluster 4,5,8） with complex visual hallucination. 6 cases＇ EF in occipital dorsal, ventral medial and in- ferior area （cluster1, 2,8） presented automoter movement as the first motor semeiology, including 2 cases verified by SEEG that the abnormal electricity activity occured through the temporal lobe. One case pres- ented axial tonic and the EF was located in dorsal medial, medial surface and dorsal lateral medial （ cluster 2,3,4）. Comptexmoter was recognized as the first motor semeiology, in one patient , the location of epileptogenic zoon was in the lateral of occipital （cluster 5） and SEEG verified that abnormal electricity activities did not spread to adjacent tissues. Versive seizure was recorded as the first motor semeiology in one patient, whose EF was located in the dorsal medial surface （cluster 2）, SEEG proved that versive seizure did not originate from ipsilateraI frontal eye. Conclusion： The location of occipital EF is associated with the seizure semeiology, Epileptic onset originated from occipital dorsal and ventrial medial and medial surface may lead to optical amnesia. Seizure originating from occipital dorsal lateral and lateral may cause complex visual hallucination. Seizure originating from occipital dorsal and ventrial medial and inferior may produce automated motion. Axial tonic may occur when EF is in occipital dorsal medial and lateral. Seizure from occipital lateral may lead to complexmotor. Epileptic onset originating from occipital dorsal medial may cause versive seizure. Versive seizure, complexrnotor and axial tonic may be produced by projection fiber.