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1、LiuZonghui,YuXin,ZhaoQuanjun,etalLiuZonghui,YuXin,ZhaoQuanjun,etal. .Neurosurgical Center of Chinese PLANeurosurgical Center of Chinese PLADepartment of Neurosurgery, Navy General HospitalDepartment of Neurosurgery, Navy General HospitalBeijing (100037) CHINABeijing (100037) CHINACombined Operations
2、 With Combined Operations With MST in the Treatment of MST in the Treatment of Intractable EpilepsyIntractable EpilepsyBackground In recent years, operations havebeenthemajorprocedurefortreatmentofmedicallyintractableepilepsy.Removal of epileptogenic lesions wasbelieved to be a best approach forseiz
3、urecontrol. Background But when functional area or theextensive of hemisphere were involvedbytheepileptogenicfocus,theoutcomewill be affected by the residue lesion,which lies unresectable cortex, such asprecentral gyrus, postcentral gyrus,Brocasarea,Wernichesarea,etc.Background Combined operations w
4、ith MSTcanreducetheoccurrenceofsynchronizedcelldischargeandmaynotimpairthemajorfunctionalcapacityofcortexbypreservingverticallyorientedfibers.Material and MethodClinicalmaterialThe combined operations with MST havebeen applied in 130 patients who sufferedfrom medically intractable epilepsy fromJanua
5、ry1996toJanuary2001.Male98andfemale32Age:10-55(mean30.7)years.Initialattack:2-40(mean17.2)years.Durationofillness:3-48(mean9)years.Material and MethodProbablecausen%Birthinjury2519.23Headtrauma2015.39Postfever1713.08Postencephalomeningitis2015.39Hemiencephalodysplasia2216.91Unclear2620.00Total130100
6、Table1.Material and MethodTable2.Seizuretypesn%Jacksonattack1713.08Generalizedseizures3728.47Simplepartialseizures2015.40Complexpartialseizures129.26Absenceseizures3224.53Unclassifiedepilepsyseizures129.26Total130100Material and MethodTable3.FocusLocationn%Lefthemispheres6146.92Righthemispheres6953.
7、08Total130100Material and MethodAccording to the preoperative EEG,SPECT or PET, CT and MRI locatingmeasures combined with ECoG detectionduring operation, the epileptogenic focuswasdefined.Surgical TechniqueAllpatientswereexaminedbyECoGto map the epileptogenic lesions duringoperation.Focusfarfromfunc
8、tionalareasuchasinanteriorfrontalortemporalcanberesectedbymassive.MSTwasperformed only when the lesion lay in ornearfunctionalarea,thehorizontalfiberscould be resected without causing seriousdisability.Examied of ECOG Found of cortical Surgical TechniqueWedesignedthetransector.Thetipofthishookwasbal
9、lwith0.4mmdiameterthatwasverysmoothsoastonottoimpairthepiamater.Surgical TechniqueFirstlywemadeasmallholewithaNo11 blade in an area, then put in thetransector through the hole and sweptforwardtoreachthecontralateraledge.Method of Subpial transectionThe depth of transection(4mm) The depth of transect
10、ion(4mm) The horizontal and vertically fibers The horizontal and vertically fibers Surgical TechniqueLet the smooth tip of ball of thetransectorshowedunderpiamater,thendrawit back under visual to transect the cortexwithoutpenetratingthepiamater.Surgical TechniqueThedepthoftransectionwas4mm.Thenexttr
11、ansectionwasmadeparalleland5mmaparttolastonetheoperationwasendedtillthesharpwavewasnolongerfoundwithECoG.Paralled transection stripParalled transection strip (fire wall) (fire wall) Surgical TechniqueCombinationofoperationsisdescribedasfollows:Resectionofthediffuselesionsofthehemisphere+MST21cases(l
12、eft12andright9,16.15%)Theant-temporal-lebectomyoramygdalohippocampectomy+MST29cases(left14andright15,22.30%)The resection of bifrontal multifocal + MST+anterior2/3corpuscallosotomy30cases(left14andright16,23.08%)Thecorticalandlesionresection+MST50cases(left21andright29,38.46%)ResultsShort-termeffect
13、ivecontrolofseizureshad been obtained in all 130 patientspostoperatively. Thereisnooperativedeathandseverecomplication.ResultsThefollow-upperiodswerefrom1-6(mean4.7)yearsin120patients:78patients(60%)wereseizures-free;37 patients (28.46%) had a 75% significant reduction (seizurefrequencyoroneseizurep
14、eryear);12 patients (9.33%) had a 50% reduction or a change fromseveretypetomoderatetype.3patients(2.31%)hadpoorresultthathadgeneralizedseizuresin2yearspostoperatively.Theeffectiveratewas97.69%andsignificanteffectiveratewas88.46%.Discussion: (1) Patients selectionThemostcurrentlyexaminationnowadays
15、is one that aims at checking thepresence and location of structural brainlesions(CT,MRI,MRAorDSA);detectionoftumors,AVMsandcorticaldysplasiaabnormalityetc.Discussion: (1) Patients selectionThestudyofthesourceofinformationcomesfromtheanalysisofthefrequencyandofthecompleteclinicalpatternoftheseizurean
16、dfirstovertseizuremanifestationsuccessiveseizurefeaturepostseizurestatus.Discussion: (1) Patients selectionThecarefulpatientsselection,strongconformingdatetoclinicalEEGneuropsychological MRI, judicious use ofECoGandwide-exposurecraniotomyresult in the best outcome for seizurecontrol.Discussion: (2)
17、Operation ThestudyoftheECoGremainsoneofthemostimportantmeansofunderstandingthespatialarrangementoftheepileptogenicprocess.Discussion: (2) Operation Incasesinvolvingcorticallesions,theresection must be planned to encompassnot only the lesion but surroundingepiletogenicactivity.The lesions and noze of
18、 epileptogenicThe lesions and noze of epileptogenicThe organic epilepsyDiscussion: (2) Operation Thefinalindicationforsurgeryaswellasthechoiceofthemostappropriatesurgerymodalitydevicesfromtheconvergenceoftheresultsoftheinvestigationdescribedabove.Discussion: (2) Operation TheECoGcanmorepreciselymapt
19、hecorticalregionsinvolvedinseizuregenerationandspread.TheECoGismostusefulwhileoperationonabrainthatlacksanyevidenceof a structural or functional lesion mostcommonlyduringepilepsysurgery.Limbic cortexLimbic cortexAnatomy of hippocampusBlood supply of hippocampusBlood supply of hippocampusDiscussion:
20、(2) Operation Human transactions are performed5mm apart, since cortical islands less than5mm in width are unable to sustain anepileptogenicdischarge.Thehorizontalfiberswereseentobedisruptionwithoutdamagetoneuronal cell bodies or vertically orientedfibers.(F. Morrell, 1989)Discussion: (2) Operation T
21、hemaindifficultyfromthisprocedureliesinthe“blindness”ofthetransection.Thesurgeon must use a supersensitive touch inperforming the transection in order topreventdamagetounderlyingcorticalvessels.(G. Rossi, 1996)Discussion: (2) Operation Paralled transection “ stripe” areevidenceofsubpialcapillaryrupt
22、ure.Thesearetypicalseenacrossthecortexandprovidehorizontallandmarksforplanningthedistance to the next transection. They mayfunctionasa“firewall”ofgliosis,preventingepileptiformactivity.(J.D. Gross, 1998)Discussion: (2) Operation Thrombin-soakedmicrospongesmaybeused topically to diminish stripe oozin
23、g.Interestingly,priorradiationtherapypreventedthetransectionstripesfrombecomingdarkorbloody.(O. Devinsky, 1994)ConclusionTheresultsindicatetheMSTcombinedwith epileptogenic focus resection; selectiveresectionoftemporalbasalpartofincisionofcorpuscallosumetccanimprovethechanceforcompleteseizurecontrolbutprotectmoreneuron from damage during operation aswell.ConclusionThuscombinationofthesesurgicaloperations is an effective and safeapproach of the surgical treatment forintractableepilepsy.Thank You
