顶叶癫痫--从症状学分析到定位诊断

Parietal lobe epilepsy-from semiology to localization

目的:通过对顶叶癫痫发作症状学、致痫区定位、相关皮质受累区的研究,揭示顶叶癫痫症状学和相关皮质网络的关系.方法:本研究入选2017年3月至2018年6月期间,通过立体定向脑电图(stereoelectroencephalography,SEEG)完成致痫区定位诊断,并进行外科手术及术后随访确诊的顶叶癫痫病例17例.对其发作期颅内电极脑电图、症状学进行分析,并对皮质受累区、症状学成分进行聚类分析、Kendall相关分析,获得二者的相关性.结果:皮质聚类分析将顶叶皮质分为3个组,第Ⅰ组又分为3个亚组.第Ⅰa组包括顶内沟前部、顶内沟后部、后扣带回背侧部、后扣带回腹侧部、楔前叶后部、顶枕沟;显著相关症状学成分包括强迫性眼球凝视、对称性面肌强直、过度运动、双侧非对称性强直姿势、复杂运动.第Ⅰb组包括顶上小叶,与中央前回、中央前沟聚为一类;显著相关症状学成分包括对侧上肢、下肢强直/强直阵挛、强迫性眼球凝视.第Ⅰc组包括楔前叶前部、扣带沟缘支,与中扣带回聚为一类;显著相关症状学为双侧非对称性强直、过度运动、强迫性眼球凝视,与对称性面肌强直存在一定的相关性.第Ⅱ组顶叶皮质为顶下小叶,包括角回、缘上回,与颞叶聚为一类;显著相关症状学包括自动运动、复杂运动,另外角回与强迫性眼球凝视、缘上回与对侧偏转发作具有一定的相关性.第Ⅲ组顶叶皮质为顶盖区,包括中央盖后部和缘上回盖部,与中央前回聚为一类;相关症状学包括对侧面肌强直/强直阵挛、眼睑阵挛/快速眨眼、躯干/双侧近端强直.从症状学角度看,对侧肢体强直/强直阵挛与顶上小叶、楔前叶前部相关性较大.对侧面肌强直阵挛、眼睑阵挛与中央盖、缘上回盖部相关.双侧非对称性强直、双侧面部对称性强直、过度运动均和后扣带回、楔前叶存在相关性.躯干/双侧近端强直与顶盖具有一定的相关性.对侧上肢远端强直/强直阵挛与顶叶皮质无明显相关性.自动运动与角回、缘上回、颞叶相关性明显.强迫性眼球凝视与顶内沟、后扣带回、楔前叶相关性明显.结论:顶叶皮质结构及功能复杂,导致顶叶癫痫症状学复杂多样.发作期SEEG、症状学成分聚类及相关分析有助于阐述二者间的关联性.

Objective: To investigate the correlation between the semiological components and involved cortical areas through detailed analysis of parietal epileptic seizure semiology and the ictal SEEG. Method: From January 2014 to October 2015, 17 patients with parietal lobe epilepsy undertook SEEG examination to decide the epileptogenic zone and cortical resection to receive seizure-freedom confirmed by postsurgical follow-up. Semiology and ictal SEEG of the cases' 238 seizures were analyzed in detail. and cluster analysis followed by Kendall correlations of certain semiological components and cortical areas were used to manifest the localization value of semiological components. Result: According to the cortical cluster analysis, the cortical areas during the ictal period were catego rized into 3 groups. Group I was further classified as la. Ib and Ic. Group la included anterior and posterior intraparietal sulci? dorsal and ventral aspect of posterior cingulate cortex, posterior aspect of precuneus and parieto-occipital sulci.. Forced eye stare, symmetric facial tonic, hypermotor, bilateral asymmetric tonic posture and complexmotor had significant correlation with cortical Group la. Superi or parietal lobule was classified as Group Ib with precentral gyri and sulci. Contralateral tonic or tonicclonic seizure and forced eye stare were significantly correlated with Group Ib. Group Ic included anterior precuneus, marginal ramus of cingulate sulci, and significantly correlated with bilateral asymmetric tonic posture hypermotor and forced eye stare. Inferior parietal lobule including supramarginal gyri and angular gyri were classified with temporal lobe as Group Ⅱ and significantly correlated with automotor. complexmotor. Angular and supramarginal gyri were also correlated with forced eye stare and versive seizure respectively. Parietal opercular areas, including central and supramargincal operculum were categorized as GroupⅢ and correlated with contralateral facial tonic or tonic-clonic, eyelids clonic seizure, and trunk or bilateral proximal tonic posture. Contralateral tonic or tonic-clonic seizures were higher correlated with superior parietal lobule, anterior precuneus, while contralateral facial tonic or tonic-clonic seizure and eyelids clonia were correlated with central and supramarginal opercula. Bilateral asymmetric tonic posture, symmetric facial tonic and hypermotor seizure were all correlated with posterior cingulate cortex and precuneus. Trunk or bilateral proximal tonic correlated with parietal opercular regions. Automotor was significantly correlated with inferior parietal lobule and temporal lobewhile forced eye stare was correlated with intraparietal sulci. precuneus and posterior cingulate cortex significantly. Conclusion: Complicated structural and functional organization of parietal lobe leads to the significant variation of semiology of parietal epilepsy. Cluster and correlation analysis of semiological components and involvement of cortical regions in ictal SEEG contributes to the identification of the semiological localization value of parietal lobe epilepsy.