海马硬化合并颞叶新皮质病变颞叶癫痫的手术疗效及其预后因素分析

Analysis of surgical efficacy and prognostic factors in temporal lobe epilepsy patients with hippocampal sclerosis and temporal lobe neocortical lesions

目的探讨海马硬化合并题叶新皮质病变题叶癫痫(TLE)患者的手术疗效及其预后影响因素。方法回顾性收集2014年1月至2018年4月中南大学湘雅医院神经外科接受前题叶切除手术治疗海马硬化合并叶新皮质病变的62例TLE患者的临床资料。术后3个月及每年通过门诊或电话方式对患者进行随访,根据国际抗癫痫联盟(ILAE)癫痫预后标准进行手术疗效分级,并分为疗效满意组(满意组)和疗效不满意组(不满意组),采用单因素和多因素logistic回归分析法评估可能影响手术疗效的因素;将单因素分析中P<0.05的变量纳入多因素logistic回归模型中分析,以确定术后疗效不满意的危险因素。根据术后病理学类型,分为局灶性皮质发育不良(FCD)Ⅲa组(海马硬化合并题叶新皮质FCDⅠ型)和双重病理组(存在海马硬化合并其他病理学改变),分析不同病理学类型患者的临床特征及手术疗效的差异。结果术后经病理学证实,62例患者中,43例(69.35%)为FCDⅢa型;19例(30.65%)为双重病理。62例患者的手术均顺利完成,6例(9.68%)患者出现术后并发症。术后3个月50例(80.65%)患者为癫痫无发作或先兆发作;12例(19.35%)患者术后仍有癫痫发作。62例患者均获得临床随访,随访时间为(3.37±0.94)年,至末次随访,49例(79.00%)患者术后无癫痫发作或先兆发作,其中ILAE1级46例,2级3例;13例(21.00%)患者术后仍有癫痫发作,其中ILAE3级3例、4级6例、5级3例、6级1例。单因素分析结果显示,术后满意组与不满意组患者的手术年龄、病变侧别、发作间期癫痫样放电(IEDs)的差异均有统计学意义(均P<0.05);而性别、癫痫病程、起病年龄等差异均无统计学意义(均P>0.05)。多因素分析结果显示,双侧IEDs是影响术后疗效不满意的危险因素(OR=8.57,95%CI:1.62~45.40,P=0.012)。与双重病理组比较,FCDⅢa组患者的手术年龄较大、病程较长,差异均有统计学意义(均P<0.05);但两组患者手术疗效的差异无统计学意义(P>0.05)。结论手术切除是治疗海马硬化合并叶新皮质病变TLE患者的有效方式,双侧IEDs是手术疗效不佳的危险因素。尽管FCDⅢa型与双重病理的患者在临床特征上有差异,但两组患者的手术疗效类似。

Objective To explore the surgical efficacy and prognostic factors in temporal lobe epilepsy(TLE)patients with hippocampal sclerosis combined with temporal lobe neocortical lesions.Methods The clinical data of 62 TLE patients who underwent anterior temporal lobe resection for hippocampal sclerosis combined with temporal lobe neocortical lesions at the Department of Neurosurgery,Xiangya Hospital,Central South University from January 2014 to April 2018 were retrospectively collected.Patients were followed up 3 months after surgery and every year by outpatient or telephone interviews.The surgical efficacy was graded according to the International League Against Epilepsy(ILAE)epilepsy surgery outcome standards and divided into a favored outcome group(favored group)and an unfavored outcome group(unfavored group).Univariate and multivariate logistic regression analyses were used to evaluate factors that may affect the surgical efficacy.Variables with P<0.05 in the univariate analysis were included in multivariate analysis to determine the risk factors for unfavored postoperative outcome.According to the postoperative pathology type,the patients were divided into focal cortical dysplasia(FCD)Ⅲa(hippocampal sclerosis combined with temporal lobe neocortex FCD type Ⅰ)group and dual pathology(hippocampal sclerosis combined with other pathological lesions)group.The differences in clinical characteristics and surgical efficacy of patients with different pathology types were analyzed.Results Postoperative pathology confirmed that 43 patients(69.35%)had FCD type Ⅲa;19 patients(30.65%)had dual pathology.The operations of 62 patients were successfully completed,and 6 patients(9.68%)experienced postoperative complications,including 1 case of intracranial hemorrhage,1 case of subarachnoid hemorrhage,1 case of intracranial infection,1 case of mild hemiplegia,1 case of mania,and 1 case of persistent mild aphasia.At 3 months post surgery,50 patients(80.65%)had no seizures or had aura of epilepsy;12 patients(19.35%)still had epileptic seizures after surgery.All 62 patients received clinical follow-up,and the follow-up time was 3.37±0.94 years.By the last follow-up,49 patients(79.00%)had no epileptic seizures after surgery,including 46 patients with ILAE grade 1 outcome and 3 patients with grade 2 outcome;13 patients still had epileptic seizures after surgery,including 3 cases of ILAE grade 3,6 cases of grade 4,3 cases of grade 5,and 1 case of grade 6.The results of univariate analysis showed that the differences in age at surgery,side of the lesion,and interictal epileptiform discharges(IEDs)between the postoperative favored outcome group and unfavored outcome group were statistically significant(all P<0.05);while there were no statistically significant differences in gender,disease course or age of onset(all P>0.05).Multivariate analysis results showed that existence of bilateral IEDs was a risk factor for unfavored postoperative outcome(OR=8.57,95%CI:1.62-45.40,P=0.012).Compared with the dual pathology group,the patients in the FCDⅢa group were older at surgery and had a longer course of disease,and the differences were statistically significant(both P<0.05).However,there was no statistically significant difference in the postoperative efficacy between the two groups(P>0.05).Conclusions Surgical resection is an effective way to treat TLE patients with hippocampal sclerosis and temporal lobe neocortex lesions.Existence of bilateral IEDs is a risk factor for poor surgical efficacy.Although there are differences in clinical characteristics between patients with FCD type Ⅲa and dual pathology,the surgical outcomes are similar between the two groups.