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1、Temporal plus epilepsy ( TPE )周健周健周健周健神神神神经经经经外科外科外科外科 首都医科大学首都医科大学首都医科大学首都医科大学 三博三博三博三博脑脑脑脑科医院科医院科医院科医院 中国中国中国中国. . 北京北京北京北京2016.52016.5颞叶癫痫的手术疗效颞叶癫痫的手术疗效l lOf 168 patients included, 108 (63.7%) underwent stereoelectroencephalography, Of 168 patients included, 108 (63.7%) underwent stereoelectroenc
2、ephalography, 131 (78%) had hippocampal sclerosis, 149 suffered from unilateral temporal 131 (78%) had hippocampal sclerosis, 149 suffered from unilateral temporal lobe epilepsy (88.7%), one from bitemporal epilepsy (0.6%) and 18 (10.7%) from lobe epilepsy (88.7%), one from bitemporal epilepsy (0.6%
3、) and 18 (10.7%) from temporal plus epilepsy. The probability of Engel class I outcome at 10 years of temporal plus epilepsy. The probability of Engel class I outcome at 10 years of follow-up was 67.3% (95% CI: 63.471.2) for the entire cohort, 74.5% (95% CI: follow-up was 67.3% (95% CI: 63.471.2) fo
4、r the entire cohort, 74.5% (95% CI: 70.678.4) for unilateral temporal lobe epilepsy, and 14.8% (95% CI: 5.923.7) for 70.678.4) for unilateral temporal lobe epilepsy, and 14.8% (95% CI: 5.923.7) for temporal plus epilepsy.temporal plus epilepsy.l lMultivariate analyses demonstrated four predictors of
5、 seizure relapse: Multivariate analyses demonstrated four predictors of seizure relapse: temporal plus epilepsy temporal plus epilepsy (P0.001), (P0.001), postoperative hippocampal remnant (P = 0.001), postoperative hippocampal remnant (P = 0.001), past history of traumatic or infectious brain insul
6、t (P = 0.022), past history of traumatic or infectious brain insult (P = 0.022), secondary generalized tonic-clonic seizures (P = 0.023). secondary generalized tonic-clonic seizures (P = 0.023).颞叶附加癫痫的简介颞叶附加癫痫的简介 The term of temporal plus (Tt) epilepsies has recently been suggested The term of tempo
7、ral plus (Tt) epilepsies has recently been suggested (Ryvlin and Kahane, 2005) to describe specific forms of seizures of (Ryvlin and Kahane, 2005) to describe specific forms of seizures of multilobar origin which are characterized by the involvement of a complex multilobar origin which are character
8、ized by the involvement of a complex epileptogenic network including the temporal lobe epileptogenic network including the temporal lobe andand the closed the closed neighboured structures, such as the orbito-frontal cortex, the insula, the neighboured structures, such as the orbito-frontal cortex,
9、the insula, the frontal and parietal operculum and the temporoparietooccipital junction.frontal and parietal operculum and the temporoparietooccipital junction.l lIn a depth EEG study aiming at verifying the role of the perisylvian cortex In a depth EEG study aiming at verifying the role of the peri
10、sylvian cortex in seizures involving the temporal lobe, Kahane et al. (2001) showed that six in seizures involving the temporal lobe, Kahane et al. (2001) showed that six of the seven patients in whom seizures arose from temporal and of the seven patients in whom seizures arose from temporal and sup
11、rasylvian opercular cortices, and in whom an adequate temporo-suprasylvian opercular cortices, and in whom an adequate temporo-perisylvian resection could be achieved, were totally seizure-free after perisylvian resection could be achieved, were totally seizure-free after surgery.surgery.l lTemporal
12、 lobe surgery alone was unsuccessful in the two temporo-Temporal lobe surgery alone was unsuccessful in the two temporo-insular cases of Isnard et al. (2004), since it allowed them to suppress insular cases of Isnard et al. (2004), since it allowed them to suppress the seizures of temporal lobe orig
13、in, but not those which arose from the seizures of temporal lobe origin, but not those which arose from the insula.the insula.l lMoreover, anterior temporal resection did not benefit the patients with Moreover, anterior temporal resection did not benefit the patients with ictal temporo-parietal symp
14、toms (reported by Aghakhani et al., 2004)ictal temporo-parietal symptoms (reported by Aghakhani et al., 2004)l lTemporal lobectomy failed to control seizures in four of the six Temporal lobectomy failed to control seizures in four of the six patients with posterior basal temporal ictal onset, report
15、ed patients with posterior basal temporal ictal onset, reported by Prasad et by Prasad et al. (2003)al. (2003)癫痫外科的术前评估癫痫外科的术前评估Phase IHistory, Physical ,VEEG Monitoring Neuropsychology testing, Imaging ( CT,MRI, PET, SPECT, MRS, fMR)Phase IIIntracarotid Amytal Test ( WADA )Phase IIIIntracranial Mon
16、itoring with a combination of depth, Strip, and Grid Electrodes癫痫外科的术前评估癫痫外科的术前评估Case discussionl lYuan Ml lFemale,26yrsl lR-handed病例特点病例特点辅助检查辅助检查 头皮脑电图头皮脑电图 头颅头颅MRIMRI 头头PETPET 神经心理评估神经心理评估颅内电极置入颅内电极置入病例特点病例特点女性，女性，女性，女性，26262626岁，右利手，病史岁，右利手，病史岁，右利手，病史岁，右利手，病史14141414年年年年现病史：现病史：现病史：现病史： 12121212
17、岁首次发作，主要表现为：岁首次发作，主要表现为：岁首次发作，主要表现为：岁首次发作，主要表现为：GTCSGTCSGTCSGTCS，持续约，持续约，持续约，持续约1-2min1-2min1-2min1-2min缓解，此缓解，此缓解，此缓解，此后一周内出现后一周内出现后一周内出现后一周内出现2 2 2 2次类似症状，服用丙戊酸钠后次类似症状，服用丙戊酸钠后次类似症状，服用丙戊酸钠后次类似症状，服用丙戊酸钠后2 2 2 2年无发作；年无发作；年无发作；年无发作；目前发作类型：精神先兆（似曾相识感）目前发作类型：精神先兆（似曾相识感）目前发作类型：精神先兆（似曾相识感）目前发作类型：精神先兆（似曾相识
18、感）言语自动言语自动言语自动言语自动自动运动（吞咽、自动运动（吞咽、自动运动（吞咽、自动运动（吞咽、双手摸索）双手摸索）双手摸索）双手摸索）GTCSGTCSGTCSGTCS，发作后不能回忆发作过程，发作后不能回忆发作过程，发作后不能回忆发作过程，发作后不能回忆发作过程治疗：丙戊酸钠、拉莫三嗪治疗：丙戊酸钠、拉莫三嗪治疗：丙戊酸钠、拉莫三嗪治疗：丙戊酸钠、拉莫三嗪个人史：母孕期正常，足月顺产，无生后缺氧窒息史；生长发育正常个人史：母孕期正常，足月顺产，无生后缺氧窒息史；生长发育正常个人史：母孕期正常，足月顺产，无生后缺氧窒息史；生长发育正常个人史：母孕期正常，足月顺产，无生后缺氧窒息史；生长发育
19、正常家族史：否认类似家族史家族史：否认类似家族史家族史：否认类似家族史家族史：否认类似家族史 Scalp EEG BGa -Yuan MScalp EEG SZ -Yuan MScalp EEG SZ continued-Yuan MScalp EEG SZ continued-Yuan MScalp EEG SZ continued-Yuan MScalp EEG SZ continued-Yuan MScalp EEG SZ continued-Yuan M 头皮脑电图头皮脑电图间歇期：未见典型癫痫样放电间歇期：未见典型癫痫样放电间歇期：未见典型癫痫样放电间歇期：未见典型癫痫样放电发作期：
20、发作期：发作期：发作期：1.1.1.1.临床：全身动作减少临床：全身动作减少临床：全身动作减少临床：全身动作减少自动运动自动运动自动运动自动运动 植物神经症状植物神经症状植物神经症状植物神经症状复杂运动复杂运动复杂运动复杂运动 2.EEG2.EEG2.EEG2.EEG：发作型，弥漫性，左侧前头部：发作型，弥漫性，左侧前头部：发作型，弥漫性，左侧前头部：发作型，弥漫性，左侧前头部 辅助检查辅助检查 头皮脑电图头皮脑电图 头颅头颅MRIMRI 头头PETPET 神经心理评估神经心理评估辅助检查辅助检查 头皮脑电图头皮脑电图 头颅头颅MRIMRI 头头PETPET 神经心理评估神经心理评估AFBJC
21、DELM左侧半球左侧半球左侧半球左侧半球：A 颞中回-杏仁核（16）B 颞中回-海马头（16）C 颞中回中部-海马旁回（16）D 颞中回后部-海马后部（16）E 颞上回-第2岛长回（12）F 颞极（12）J 额中回-第2-3岛短回、第1岛长回（斜视16）L 角回-扣带回（16）M 颞中回后部颞枕交界-颞底-海马头下方（斜插16）N 额上回-扣带回-额底内侧面（斜插16）右侧半球右侧半球B 颞中回-海马头（16）LN左侧半球左侧半球左侧半球左侧半球：A 颞中回-杏仁核（16）B 颞中回-海马头（16）C 颞中回中部-海马旁回（16）D 颞中回后部-海马后部（16）E 颞上回-第2岛长回（12）F
22、 颞极（12）J 额中回-第2-3岛短回、第1岛长回（斜视16）L 角回-扣带回（16）M 颞中回后部颞枕交界-颞底-海马头下方（斜插16）N 额上回-扣带回-额底内侧面（斜插16）右侧半球右侧半球B 颞中回-海马头（16）SEEG SZ onset-Yuan M临床：临床：精神先兆（精神先兆（1/5）自动运动自动运动植物神经症状植物神经症状复杂运动（复杂运动（1/5）LOCEEG：N1-2电极接触点低波幅快活动电极接触点低波幅快活动低波幅高频放电，平均低波幅高频放电，平均13.6s后扩散至后扩散至F(4-6)电极接触点电极接触点2-6s后后M（4-6）电极接触点）电极接触点 4-7s后后C(3-5)， F(1-2),J(2-3)电极接触点，平均电极接触点，平均4s后放电扩散至后放电扩散至B(2-4)电极接触点出现临床症电极接触点出现临床症状；状；脑电图起始平均脑电图起始平均32.2s后出现临床症状；后出现临床症状；NN2N2N1Seizure onset at N1-2 谢谢！谢谢！欢迎到三博做客！欢迎到三博做客！ 刚才的发言，如刚才的发言，如有不当之处请多指有不当之处请多指正。谢谢大家！正。谢谢大家！282021/8/22
