从侧方入路到垂直入路大脑半球切开术的临床实践

Clinical practice of hemispherotomy from lateral approach to vertical approach

目的探讨垂直入路的大脑半球切开术治疗药物难治性半球性癫疒间的技术优势。方法回顾性分析18例药物难治性半球性癫疒间病人(共22例次手术)的临床资料,均采用大脑半球切开手术。根据手术方式分为侧方入路组(n=13)和垂直入路组(n=9)。侧方入路组采用功能性大脑半球切除3例,环岛叶大脑半球切开10例;垂直入路组均采用经胼胝体-基底核的半球间垂直性大脑半球切开。结果两组病人手术时年龄、体质量无明显差异(P>0.05);垂直入路组的术中输血量、手术时间明显少于侧方入路组(P <0.05)。侧方入路组4例因离断不完全而致术后癫疒间复发,采用垂直入路行二次手术;垂直入路组术后均无发作。侧方入路组术后出现颅内感染2例,交通性脑积水1例;垂直入路组术后出现尿崩症2例。结论垂直入路较侧方入路的大脑半球切开手术优势明显,手术创伤较小,出血少,时间短,疗效预期更佳。垂直入路术后出现尿崩症,与开放第三脑室处理前联合相关。

Objective To explore the technical advantages of hemispherotomy for drug refractory hemispheric epilepsy via vertical approach.Methods Clinical data of 18 patients with drug refractory hemispheric epilepsy who received 22 times of hemispherotomy were analyzed retrospectively.The patients were divided into lateral approach group(n=13)and vertical approach group(n=9)according to the surgical method.The functional hemispherectomy was performed on 3 patients and peri-insular hemispherotomy on10 in lateral approach group.The transcallosal-basal ganglia interhemispheric vertical hemispherotomy was performed on 9 patients in vertical approach group.Results There was no difference in age and body weight between the two groups(P>0.05).The intraoperative blood transfusion and surgical time was less in vertical approach group than lateral approach group(P<0.05).The recurrence of epilepsy occurred in 4 patients of lateral approach group because of incomplete disconnection,who received second surgery via vertical approach.No seizure occurred in vertical approach group.The intracranial infection occurred in 2 patients and hydrocephalus in 1 of the lateral approach group.However,the diabetes insipidus occurred in 2 patients of the vertical approach group.Conclusions Compared with lateral approach,the hemispherotomy via vertical approach has more advantages such as less injury,less bleeding and shorter surgery time,thus could achieve better effect.Diabetes insipidus after the vertical approach surgery is related with the operation of the third ventricle opening resulting in the anterior commissure disconnection.