How to establish causality in epilepsy surgery.
How to establish causality in epilepsy surgery.
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DOI：
10.1016/j.braindev.2013.04.004
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发表时间：
2013-09
影响因子：
1.7
通讯作者：
Juhasz, Csaba
中科院分区：
文献类型：
--
作者：
Asano, Eishi;Brown, Erik C.;Juhasz, Csaba
关键词：
电临床或神经影像数据中的焦点常常促使癫痫学家考虑对药物无法控制的癫痫发作患者进行癫痫手术，但并非所有的焦点发现都与癫痫发作的发生有因果关系。在希尔标准的帮助下，我们讨论了如何在癫痫术前评估的背景下建立因果关系。脑电图的优势包括能够确定大脑活动和临床事件之间的时间关系；因此，头皮视频脑电图对于评估大多数手术候选者是必要的。相关发作放电的存在可以确认特定发作的癫痫性质以及观察到的神经影像异常是否与癫痫发作有因果关系。相反，人们应该意识到头皮脑电图的空间分辨率有限，有时比癫痫发作区产生的原位放电更主要地表现出传播性癫痫样放电。当无创术前评估（包括解剖和功能神经影像学）无法确定假定的致痫区和语言皮质之间的边界时，可使用术中或术外皮质电图（ECoG）。回顾性和前瞻性研究报告称，完全切除 ECoG 上的癫痫发作区与更好的癫痫结果相关，但并非所有患者在此类切除手术后都不再癫痫发作。一些回顾性研究表明，切除在发作间期或发作期 ECoG 上显示 >80 Hz 高频振荡 (HFO) 的部位与更好的癫痫发作结果相关。其他人报告说，功能重要的区域可能在休息以及感觉运动和认知任务期间产生具有生理性质的 HFO。据报道，切除显示与任务相关的 HFO 增强的部位确实会导致手术后功能丧失。因此，一些但不是所有显示发作间期 HFO 的位点与癫痫发作有因果关系。此外，有证据表明，一些与任务相关的 HFO 可以被先前发生的发作间期峰值暂时抑制。评估发作间期 HFO 的重要性时，应考虑语言皮质、癫痫发作区和皮质病变。视频脑电图和 ECoG 通常提供有用但仍然有限的信息来确定术前评估中的因果关系。成功的管理最终需要对多种方式获得的数据进行全面评估。
Focality in electro-clinical or neuroimaging data often motivates epileptologists to consider epilepsy surgery in patients with medically-uncontrolled seizures, while not all focal findings are causally associated with the generation of epileptic seizures. With the help of Hill's criteria, we have discussed how to establish causality in the context of the presurgical evaluation of epilepsy. The strengths of EEG include the ability to determine the temporal relationship between cerebral activities and clinical events; thus, scalp video-EEG is necessary in the evaluation of the majority of surgical candidates. The presence of associated ictal discharges can confirm the epileptic nature of a particular spell and whether an observed neuroimaging abnormality is causally associated with the epileptic seizure. Conversely, one should be aware that scalp EEG has a limited spatial resolution and sometimes exhibits propagated epileptiform discharges more predominantly than in situ discharges generated at the seizure-onset zone. Intraoperative or extraoperative electrocorticography (ECoG) is utilized when noninvasive presurgical evaluation, including anatomical and functional neuroimaging, fails to determine the margin between the presumed epileptogenic zone and eloquent cortex. Retrospective as well as prospective studies have reported that complete resection of the seizure-onset zone on ECoG was associated with a better seizure outcome, but not all patients became seizure-free following such resective surgery. Some retrospective studies suggested that resection of sites showing high-frequency oscillations (HFOs) at >80 Hz on interictal or ictal ECoG was associated with a better seizure outcome. Others reported that functionally-important areas may generate HFOs of a physiological nature during rest as well as sensorimotor and cognitive tasks. Resection of sites showing task-related augmentation of HFOs has been reported to indeed result in functional loss following surgery. Thus, some but not all sites showing interictal HFOs are causally associated with seizure generation. Furthermore, evidence suggests that some task-related HFOs can be transiently suppressed by the prior occurrence of interictal spikes. The significance of interictal HFOs should be assessed by taking into account the eloquent cortex, seizure-onset zone, and cortical lesions. Video-EEG and ECoG generally provide useful but still limited information to establish causality in presurgical evaluation. A comprehensive assessment of data derived from multiple modalities is ultimately required for successful management.
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