双侧非对称强直发作的症状学特点及临床应用价值

Semiological characteristics and clinical application value of bilateral asymmetrical tonic seizures

目的阐明广义双侧非对称强直发作(BATS)三种亚型的症状学特点,总结该组症状学在发作起始区(SOZ)定侧及定位中的临床应用价值,并分析其与不对称强直性肢体姿势(ATLP)的差异。方法回顾2011年9月至2018年5月于首都医科大学三博脑科医院行立体定向电极植入的385例患者,只要监测中记录到1次癫痫临床发作表现为BATS或ATLP,便归入对应组别。采用Engel′s分级标准评价手术预后,随访时间不少于6个月。癫痫发作描述根据Lüders发作症状学分类,用箭头将发作症状按照发生的时间先后顺序依次连接。结果BATS经典型和双侧近端强直在是否能"作为独立发作""作为发作起始及结束""伴有偏转"及"全身强直阵挛发作"等方面均差异无统计学意义(均P>0.05)。广义BATS和ATLP相比,除是否能"作为独立发作"和"出现于偏转之前"两个特征外(P值分别为1.000和0.068),余差异均有统计学意义(均P<0.05)。BATS经典型和第2运动区癫痫对SOZ的定侧价值高达100.0%。广义BATS患者SOZ分布脑区较广泛,但罕见于额眶回、额极、内侧颞叶;双侧近端强直在辅助感觉运动区及临近区域的出现率与其他脑区相比,差异未达统计学意义,但有低的趋势[分别为0/8、40.0%(18/45),χ^2=3.226,P=0.072]。BATS与ATLP相比,对SOZ定侧价值更高[分别为84.9%(45/53)、57.1%(24/42),χ^2=9.086,P=0.003],且起源于内侧颞叶较少[分别为3.8%(2/53)、23.8%(10/42),χ^2=8.523,P=0.004]。结论与ATLP明显不同,广义BATS发作以上肢近端肌肉强直为核心特征,且在SOZ定侧和定位方面均具有较高的临床应用价值。

Objective To illustrate the semiological characteristics of the three sub-types within the broad bilateral asymmetric tonic seizures (BATS), summarize their predictive values on lateralization and localization of seizure onset zone (SOZ), and analyze the difference between BATS and asymmetrical tonic limb posturing (ATLP). Methods A retrospective review of 385 patients who underwent stereotactic electrode implantation in the Sanbo Brain Hospital, Capital Medical University from September 2011 to May 2018 was performed. As long as there was a clinical epileptic seizure in the presence of BATS or ATLP, the patients were classified into the corresponding groups. Postoperative prognosis was assessed using Engel′s grading criteria for a follow-up of no less than six months. Seizure descriptions were based on the classification of epileptic seizures introduced by Lüders, which used arrows to connect the symptoms in chronological order. Results There was no statistically significant difference between the classic BATS and bilateral proximal tonic seizure in terms of whether it could be an independent seizure, as the onset and end of the seizure, with version and generalized tonic-clonic seizure (P>0.05). Compared with the ATLP, except for whether it could be an independent seizure (P=1.000) and onset before versive seizure (P=0.068), the BATS showed significantly different semiological features (P<0.05). The classic BATS and secondary motor area epilepsy had a 100.0% predictive accuracy on the lateralization of SOZ. In the patients with broad BATS, the SOZ distribution was more extensive, but it was rare in the orbitofrontal gyrus, frontal pole and mesial temporal lobe. Compared with the bilateral proximal tonic seizures from the other regions, those originated from supplementary somatosensory motor area and its adjacent areas were rare and showed no statistically significant difference (0/8 vs 40.0%(18/45),χ^2=3.226, P=0.072) but a low trend. The predictive value of BATS on lateralization of SOZ was higher than that of ATLP (84.9%(45/53) vs 57.1%(24/42),χ^2=9.086, P=0.003), and BATS was less originated from temporal lobe than ATLP (3.8%(2/53) vs 23.8%(10/42),χ^2=8.523, P=0.004). Conclusion Different from ATLP, the broad BATS are characterized by tonic proximal upper limb posturing, and have a higher predictive value on lateralization and localization of SOZ.