癫痫 .ppt

LiuZonghui,YuXin,ZhaoQuanjun,etal.NeurosurgicalCenterofChinesePLADepartmentofNeurosurgery,NavyGeneralHospitalBeijing(100037)CHINA,CombinedOperationsWithMSTintheTreatmentofIntractableEpilepsy,Background,Inrecentyears,operationshavebeenthemajorprocedurefortreatmentofmedicallyintractableepilepsy.Removalofepileptogeniclesionswasbelievedtobeabestapproachforseizurecontrol.,Background,Butwhenfunctionalareaortheextensiveofhemispherewereinvolvedbytheepileptogenicfocus,theoutcomewillbeaffectedbytheresiduelesion,whichliesunresectablecortex,suchasprecentralgyrus,postcentralgyrus,Brocasarea,Wernichesarea,etc.,Background,CombinedoperationswithMSTcanreducetheoccurrenceofsynchronizedcelldischargeandmaynotimpairthemajorfunctionalcapacityofcortexbypreservingverticallyorientedfibers.,MaterialandMethod,ClinicalmaterialThecombinedoperationswithMSThavebeenappliedin130patientswhosufferedfrommedicallyintractableepilepsyfromJanuary2019toJanuary2019.Male98andfemale32Age:10-55(mean30.7)years.Initialattack:2-40(mean17.2)years.Durationofillness:3-48(mean9)years.,MaterialandMethod,Table1.,MaterialandMethod,Table2.,MaterialandMethod,Table3.,MaterialandMethod,AccordingtothepreoperativeEEG,SPECTorPET,CTandMRIlocatingmeasurescombinedwithECoGdetectionduringoperation,theepileptogenicfocuswasdefined.,SurgicalTechnique,AllpatientswereexaminedbyECoGtomaptheepileptogeniclesionsduringoperation.Focusfarfromfunctionalareasuchasinanteriorfrontalortemporalcanberesectedbymassive.MSTwasperformedonlywhenthelesionlayinornearfunctionalarea,thehorizontalfiberscouldberesectedwithoutcausingseriousdisability.,ExamiedofECOG,Foundofcortical,SurgicalTechnique,Wedesignedthetransector.Thetipofthishookwasballwith0.4mmdiameterthatwasverysmoothsoastonottoimpairthepiamater.,SurgicalTechnique,FirstlywemadeasmallholewithaNo11bladeinanarea,thenputinthetransectorthroughtheholeandsweptforwardtoreachthecontralateraledge.,MethodofSubpialtransection,Thedepthoftransection(4mm),Thehorizontalandverticallyfibers,SurgicalTechnique,Letthesmoothtipofballofthetransectorshowedunderpiamater,thendrawitbackundervisualtotransectthecortexwithoutpenetratingthepiamater.,SurgicalTechnique,Thedepthoftransectionwas4mm.Thenexttransectionwasmadeparalleland5mmaparttolastonetheoperationwasendedtillthesharpwavewasnolongerfoundwithECoG.,Paralledtransectionstrip(firewall),SurgicalTechnique,Combinationofoperationsisdescribedasfollows:Resectionofthediffuselesionsofthehemisphere+MST21cases(left12andright9,16.15%)Theant-temporal-lebectomyoramygdalohippocampectomy+MST29cases(left14andright15,22.30%)Theresectionofbifrontalmultifocal+MST+anterior2/3corpuscallosotomy30cases(left14andright16,23.08%)Thecorticalandlesionresection+MST50cases(left21andright29,38.46%),Results,Short-termeffectivecontrolofseizureshadbeenobtainedinall130patientspostoperatively.Thereisnooperativedeathandseverecomplication.,Results,Thefollow-upperiodswerefrom1-6(mean4.7)yearsin120patients:78patients(60%)wereseizures-free;37patients(28.46%)hada75%significantreduction(seizurefrequencyoroneseizureperyear);12patients(9.33%)hada50%reductionorachangefromseveretypetomoderatetype.3patients(2.31%)hadpoorresultthathadgeneralizedseizuresin2yearspostoperatively.Theeffectiveratewas97.69%andsignificanteffectiveratewas88.46%.,Discussion:(1)Patientsselection,Themostcurrentlyexaminationnowadaysisonethataimsatcheckingthepresenceandlocationofstructuralbrainlesions(CT,MRI,MRAorDSA);detectionoftumors,AVMsandcorticaldysplasiaabnormalityetc.,Discussion:(1)Patientsselection,Thestudyofthesourceofinformationcomesfromtheanalysisofthefrequencyandofthecompleteclinicalpatternoftheseizureandfirstovertseizuremanifestationsuccessiveseizurefeaturepostseizurestatus.,Discussion:(1)Patientsselection,Thecarefulpatientsselection,strongconformingdatetoclinicalEEGneuropsychologicalMRI,judicioususeofECoGandwide-exposurecraniotomyresultinthebestoutcomeforseizurecontrol.,Discussion:(2)Operation,ThestudyoftheECoGremainsoneofthemostimportantmeansofunderstandingthespatialarrangementoftheepileptogenicprocess.,Discussion:(2)Operation,Incasesinvolvingcorticallesions,theresectionmustbeplannedtoencompassnotonlythelesionbutsurroundingepiletogenicactivity.,Thelesionsandnozeofepileptogenic,Theorganicepilepsy,Discussion:(2)Operation,Thefinalindicationforsurgeryaswellasthechoiceofthemostappropriatesurgerymodalitydevicesfromtheconvergenceoftheresultsoftheinvestigationdescribedabove.,Discussion:(2)Operation,TheECoGcanmorepreciselymapthecorticalregionsinvolvedinseizuregenerationandspread.TheECoGismostusefulwhileoperationonabrainthatlacksanyevidenceofastructuralorfunctionallesionmostcommonlyduringepilepsysurgery.,Limbiccortex,Anatomyofhippocampus,Bloodsupplyofhippocampus,Discussion:(2)Operation,Humantransactionsareperformed5mmapart,sincecorticalislandslessthan5mminwidthareunabletosustainanepileptogenicdischarge.Thehorizontalfiberswereseentobedisruptionwithoutdamagetoneuronalcellbodiesorverticallyorientedfibers.(F.Morrell,1989),Discussion:(2)Operation,Themaindifficultyfromthisprocedureliesinthe“blindness”ofthetransection.Thesurgeonmustuseasupersensitivetouchinperformingthetransectioninordertopreventdamagetounderlyingcorticalvessels.(G.Rossi,2019),Discussion:(2)Operation,Paralledtransection“stripe”areevidenceofsubpialcapillaryrupture.Thesearetypicalseenacrossthecortexandprovidehorizontallandmarksforplanningthedistancetothenexttransection.Theymayfunctionasa“firewall”ofgliosis,preventingepileptifo