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目的评价综合应用多种定位技术治疗功能区皮层下小病灶相关性癫痫的手术方法及效果。方法 58例功能区皮层下小病灶引起的癫痫患者,在立体定向仪导向下,开放直视手术切除病灶,术中皮层脑电图(ECoG)监测定位致痫灶,术中神经电生理监测(IOM)判断致痫区的功能以及二者的重叠程度,辅助以麻醉唤醒定位语言区、实时超声检查病变切除程度,根据监测结果分别采取致痫灶切除术、多处软膜下横切术(MST)或皮层低功率电凝热灼术妥善处理致痫灶。结果病灶全部切除52例,少量残留6例。病灶区域ECoG监测除波幅略有降低外无明显异常13例,行占位病灶切除术;ECoG明显异常,在非主要功能区8例,行占位病灶+周边致痫皮层切除术;ECoG明显异常而又在主要功能区37例,行占位病灶+功能区致痫皮层多处软膜下横切术(MST)或低功率电凝热灼术。ECoG监测发现痫样放电消失、基本节律大致恢复正常29例,仍残留少量棘波13例,残存较多棘波且基本节律轻到中度异常16例。随访1～5年,EngelⅠ级46例,EngelⅡ级8例,EngelⅢ级4例,总有效率100%。出现暂时性轻偏瘫17例,暂时性失语8例,无严重永久性并发症。结论综合应用立体定向引导、术中IOM、ECoG、麻醉唤醒及实时超声定位治疗功能区小病灶相关性癫痫,能够精准定位并切除病灶及处理致痫灶,避免损伤功能区,是一种微创、安全、有效的手术方法。
Objective To evaluate the surgical method and effect of comprehensive application of multiple localization techniques in the treatment of epilepsy associated with small lesions in the functional area. Methods Fifty-eight patients with epilepsy caused by small lesions in the functional area under the guidance of stereotactic instrument were treated with open surgery, epileptogenic zone was monitored by ECoG, and electrophysiological monitoring IOM) to determine the function of epileptogenic zone as well as the degree of overlap between the two, assisted with awakening language positioning anesthesia, real-time ultrasound examination lesion degree, respectively, according to the results of the epileptogenic resection, multiple subdural transection MST) or cortical low-power electrocoagulation and cautery for proper treatment of epileptogenic lesions. Results All lesions were excised in 52 cases, with a small amount of residual in 6 cases. ECoG in the lesion area showed no significant abnormalities except for slight decrease in amplitude. Thirteen patients underwent focal lesion resection; ECoG was significantly abnormal; there were 8 cases in non-major functional areas, However, in 37 cases in the main functional area, epidural cortex transection submucous transverse transection (MST) or low-power electrocauteric cautery were performed in the lesions + functional areas. ECoG monitoring found that disappearance of epileptiform discharges, the basic rhythm returned to normal in 29 cases, there are still a small number of spikes in 13 cases, remaining more spikes and mild to moderate essential rhythm in 16 cases. Followed up for 1 to 5 years, Engel Ⅰ 46 cases, Engel Ⅱ 8 cases, Engel Ⅲ 4 cases, the total efficiency of 100%. 17 cases of transient mild hemiplegia, temporary aphasia in 8 cases, no serious permanent complications. Conclusion Stereotactic guidance, intraoperative IOM, ECoG, anesthesia arousal and real-time ultrasound in the treatment of small lesions associated with functional epilepsy can accurately locate and excise the lesion and treat the epileptogenic zone without damaging the functional area. It is a minimally invasive , Safe and effective surgical methods.