Association of Seizure Spread With Surgical Failure in Epilepsy
Association of Seizure Spread With Surgical Failure in Epilepsy
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DOI：
10.1001/jamaneurol.2018.4316
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发表时间：
2019-04-01
期刊：
影响因子：
29
通讯作者：
Spencer, Dennis D.
中科院分区：
文献类型：
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作者：
Andrews, John P.;Gummadavelli, Abhijeet;Spencer, Dennis D.
重要性：在接受手术治疗耐药颞叶癫痫（TLE）的患者中，癫痫发作复发的患者多达一半。了解为什么TLE对某些患者的手术有抵抗性，可能会揭示癫痫发生网络，并指导新的治疗方法来改善结果。目的探讨手术难治性TLE的特点。设计、环境和参与者回顾性分析了一家综合性癫痫中心2000年1月1日至2015年12月31日期间由一名外科医生行标准颞前内侧切除术的131例患者的医疗记录。13例患者因随访时间少于1年而被排除。确定了癫痫复发风险最高的患者。颅内脑电图（iEEG）分析生成三维发作扩散表征和量化快速发作扩散。2017年6月对癫痫发作结局和随访数据进行最终分析。对所有患者手术后的Engel级癫痫发作结果进行评估，将癫痫复发定义为Engel II级或以上。视觉分析新皮质网格/条带和深度电极的颅内记录，以判断癫痫的扩散。Fast 3功率被投射到患者脑磁共振成像扫描的重建上，以可视化扩散模式，并被量化以比较切缘内和切缘外的功率。结果118例患者随访1年及以上（平均[SD]， 6.5[4.6]年），女性66例（55.9%），男性52例（44.1%）（中位年龄39岁[范围4-66岁）)。术后第10年及以后持续Engel I级癫痫发作自由的累积概率为65.6%，第1至3年复发的概率为92%。多变量统计分析发现，选择iEEG研究是癫痫复发最可靠的预测因素，混合效应模型估计iEEG队列的Engel评分平均（SD）为1.1(0.33)（P = .001）。在有iEEG结果的患者中，小于10秒的快速发作扩散与复发相关（风险比5.99;95% CI, 1.7-21.1; P < 0.01）。在癫痫发作的前10秒，癫痫复发患者的颞外侧皮层切除缘外的快速β能量活动明显高于非癫痫发作患者（平均[SEM]， 1375% [16.8%] vs 93.4% [4.6%]; P < 0.05）。结论与意义癫痫快速扩散至颞前内侧切除缘外是导致耐药TLE手术失败的重要原因。通过研究早期扩散区域作为切除或神经调节的候选者，可以改善癫痫手术后的癫痫控制。
IMPORTANCE Seizures recur in as many as half of patients who undergo surgery for drug-resistant temporal lobe epilepsy (TLE). Understanding why TLE is resistant to surgery in some patients may reveal insights into epileptogenic networks and direct new therapies to improve outcomes.OBJECTIVE To characterize features of surgically refractory TLE.DESIGN, SETTING, AND PARTICIPANTS Medical records from a comprehensive epilepsy center were retrospectively reviewed for 131 patients who received a standard anteromedial temporal resection by a single surgeon from January 1, 2000, to December 31, 2015. Thirteen patients were excluded for having less than 1year of follow-up. Patients at the highest risk for seizure recurrence were identified. Intracranial electroencephalogram (iEEG) analyses generated 3-dimensional seizure spread representations and quantified rapid seizure spread. The final analyses of seizure outcome and follow-up data were performed in June 2017.MAIN OUTCOMES AND MEASURES The Engel class seizure outcome following surgery was evaluated for all patients, defining seizure recurrence as Engel class II or greater. Intracranial recordings of neocortical grids/strips and depth electrodes were analyzed visually for seizure spread. Fast 3 power was projected onto reconstructions of patients' brain magnetic resonance imaging scans to visualize spread patterns and was quantified to compare power within vs outside resective margins.RESULTS Of 118 patients with 1 year of follow-up or more (mean [SD], 6.5 [4.6] years), 66 (55.9%) were women and 52 (44.1%) were men (median age, 39 years [range, 4-66 years)). The cumulative probability of continuous Engel class I seizure freedom since surgery at postoperative year 10 and afterward was 65.6%, with 92% of recurrences in years 1 to 3. Multi variable statistical analyses found that the selection for iEEG study was the most reliable predictor of seizure recurrence, with a mixed-effects model estimating that the Engel score in the iEEG cohort was higher by a mean (SD) of 1.1(0.33) (P = .001). In patients with iEEG results, rapid seizure spread in less than 10 seconds was associated with recurrence (hazard ratio, 5.99; 95% CI, 1.7-21.1; P < .01). In the first 10 seconds of seizures, fast beta power activity outside the resective margins in the lateral temporal cortex was significantly greater in patients whose seizures recurred compared with patients who were seizure-free (mean [SEM], 1375% [16.8%] vs 93.4% [4.6%]; P < .05).CONCLUSIONS AND SIGNIFICANCE Rapid seizure spread outside anteromedial temporal resection resective margins plays a significant role in the surgical failure of drug-resistant TLE. Seizure control after epilepsy surgery might be improved by investigating areas of early spread as candidates for resection or neuromodulation.