Operative posterior disconnection in epilepsy surgery: Experience with 29 patients
Operative posterior disconnection in epilepsy surgery: Experience with 29 patients
复制标题
DOI：
10.1111/epi.16318
复制
发表时间：
2019-08-29
期刊：
影响因子：
5.6
通讯作者：
Bien, Christian G.
中科院分区：
文献类型：
--
作者：
Kalbhenn, Thilo;Cloppenborg, Thomas;Bien, Christian G.
目的有研究表明，由局限于大脑后象限（即顶叶、颞叶和枕叶）的病变引起的多叶癫痫可以通过后脑断开术成功治疗。本文的目的是确定后路断开手术后癫痫预后的决定因素。方法回顾性分析2005年至2017年连续29例后路断开手术治疗难治性后象限癫痫的患者。具体地说，我们回顾了所有术前和术后磁共振（MR）研究，以确定不完全断开的病例，或者涉及整个半球而不仅仅是后象限的更广泛的病理存在。此外，我们重新评估了所有手术前视频脑电图（EEG）报告。结果术后无癫痫发作（国际抗癫痫联盟[ILAE] 1） 3/3患者脑电图表现局限于后象限，0/7患者脑电图表现向对侧额叶传播，11/19（57.9%）患者脑电图表现向同侧额叶和/或对侧后叶传播。13例单纯后象限磁共振成像（MRI）发现（通过神经影像学回顾性诊断）的患者中有11例（84.6%）无癫痫发作，而后象限外附加细微异常的患者中有3/16例（18.8%）无癫痫发作（P = 0.001）。16例完全断开的患者中有11例（68.8%）没有癫痫发作，而只有3/13例（23.0%）颞叶组织与岛岛接触（P = 0.025，均为Fisher精确检验）。后路断开术是治疗后象限癫痫的一种技术要求高但非常有效的手术。良好的癫痫预后不仅要求癫痫性病变不超出断开的脑容量范围，而且要求没有细微的MRI异常，这些异常比清晰的后象限病变更广泛。癫痫活动的半球或对侧（特别是额叶）传播也可能表明存在半球病理学而不是后象限病理学。
Objective It has been suggested that multilobar epilepsies caused by lesions restricted to the posterior cerebral quadrant (ie, the parietal, temporal, and occipital lobes) can be treated successfully by a procedure termed posterior disconnection. The objective of the present paper was to identify determinants of the epileptological outcome following posterior disconnection surgery. Methods The authors retrospectively analyzed a series of 29 consecutive patients undergoing posterior disconnection surgery between 2005 and 2017 for the treatment of refractory posterior quadrantic epilepsy. Specifically, all presurgical and postoperative magnetic resonance (MR) studies were reviewed to identify cases with an incomplete disconnection, or the presence of a more widespread pathology involving the whole hemisphere rather than only its posterior quadrant. In addition, we reevaluated all presurgical video-electroencephalography (EEG) reports. Results Seizure-free (International League Against Epilepsy [ILAE] 1) after surgery were 3/3 patients with EEG findings restricted to the posterior quadrant, 0/7 patients who had propagation of epileptic activity to the contralateral frontal lobe, and 11/19 (57.9%) who showed propagation to ipsilateral frontal and/or contralateral posterior. Eleven of 13 (84.6%) patients with purely posterior quadrantic magnetic resonance imaging (MRI) findings (as retrospectively diagnosed by neuroimaging) vs 3/16 (18.8%) cases with additional subtle abnormalities outside the posterior quadrant became seizure-free (P = .001). Eleven of 16 (68.8%) patients with complete disconnections were seizure-free vs only 3/13 (23.0%) cases with leftover temporal lobe tissue with contact to the insula (P = .025, both Fisher's exact test). Significance A posterior disconnection is a technically demanding but very effective operation for posterior quadrantic epilepsy. Good epileptologic outcomes require not only that the epileptogenic lesion does not extend beyond the confines of the disconnected cerebral volume but also the absence of subtle MRI abnormalities, more widespread than the clear-cut lesion of the posterior quadrant. Hemispheric or contralateral (particularly frontal) propagation of the epileptic activity may also indicate the presence of a hemispheric rather than posterior quadrantic pathology.