The Surgical Treatment For Temporal Lobe Epilepsy

OBJECTIVE:To discuss the influence of post-operative effectiveness by integrated positioning measure preoperative and the operative method.METHODS:Cases selection criteria:The patient who took 2-4 kinds of normal antiepileptic medicine with more than 2 years therapy,with times of antiepileptic medicine system adjustment,but still with several attack monthly,which seriously affect the patient daily life;the clinical manifestations and scalp dynamic electroencephalogram suggest that it is a temporal lobe epilepsy,accompanied or not accompanied with imaging positive findings.Total 86 patient were treated with temporal lobe epilepsy in our department during 2010-2014,who accord with the afore-mentioned conditions;the age of them are 19-48,average 32.6± 2.3;51 male,female 35;with 2-16 years history of epilepsy,average history is 6.4± 1.7 years.In all cases,a normal scalp electrode 128 channels prolonged video EEG monitoring were implemented,and with a routine of sphenoid bone electrodes,monitoring for 1-7 days,average 3.5 days.All patients are required with 1-3 times episode electroencephalogram(EEG)recorded.Sleep deprivation method is to stop using antiepileptic medicine,24 hours of sleep-depriving,prohibition of medicine and excitatory materials such as coffee,tea.In a channels prolonged video-electroencephalographic(VEEG)analysis,use a the 10-20 system electrode international standard methods,including sleep and waking states;while the routine accept the eyes close and open,flash stimulation,hyperventilation,sphenoid electrode hyperventilation and sphenoid bone tracings.Episodes graphics are analyzed respectively by 1 nerve electrophysiology and 2 neurosurgeon doctors.he classification of the initial attack:according to the classification of all initial attack of EEG records,we have a final classification:can be localization(local focus or locality);can be lateralization(one side);allgemeine(allgemeine or non-side);cant be lateralization.Of which,it is considered the unilateral the attacking for those begin with allgemeine,and finally changed to unilateral;while the localization attack,was that begin with local focus or the locality and transient to one unilateral attack;in the attack which capable of cognizance position,at least 50%of which is localization in the same area.All patients had a conventional brain MRI scans,long axis of the hippocampus coronal and sagittal thin layer scanning,including T1WI,T2WI,FLAIR,MRS of hippocampus.Not all the cases scanned with PET-CT,the scanning objects include:MRI negative,the uncertainty result of MRI and EEG and other cases.In all the cases,a PET-CT examination during the attack period preoperative was taken.CT scan parameters is:tube current 150 MA,tube voltage 120 kv,4.25 mm thick layer;18F deoxyglucose(18 F-FDG)intravenous;scan with audio-visual closed,staying in bed for 45 to 60 min later.Analysis the results of PET-CT brain metabolic imaging with visual inspection and semi-quantitative analysis.With visual,abnormal is where the two or above tow layer with the distinct abnormal metabolism.In all cases of surgery,perform a cortex electrode during operation,and deep electrode EEG monitoring,combination with preoperative evaluation data,to determine the specific type of surgical resection.For the electrodes placement in routine the cortex electrode is placed on the surface and bottom of temporal lobe,and frontal lobe;while the deep electrode is placed on the hippocampus and amygdala.For the surgery,preoperative the antiepileptic medicine is discontinued,endotracheal intubation and general anesthesia.Enlarge the incision on the forehead and temple near the midline.f Upon the cerebral duramater cut,monitor with streak cortex electrode and deep electrode.After separate the lateral fissure,place the cortex electrodes on the forehead,temporal lobe and insular of lateral fissure,for further definitude the source of abnormality discharge.With a comprehensive analysis on the situation of positioning,have a preoperative assess and intra-operative EEG monitoring,to choose an individualization resection type.In the cases accord with the mesial temporal lobe epilepsy,first selective resection of hippocampus and amygdala;after excision,if there is still epileptic discharge on lateral cortex,take a anterior temporal lobectomy with a excision extension on dominant hemisphere side 4-5 cm away from the temporal pole,and non-dominant hemisphere from the 5-6 cm to temporal pole.For the patient who was diagnosed as temporal neocortex,take a resection of focus temporal and cortex epileptogenic focus,or anterior temporal lobectomy.For the mixed type epilepsy,if the focus on the excision extension of the anterior temporal lobe,take a anterior temporal lobectomy;for the abnormal discharges focus,outside of the excision extension which interspersed or on the functional area,,take a crosscut or the across grain scorching hot.After operation,send the focus,hippocampus,amygdala and suspicious tissue marked respectively for pathological examination.Within 2 years after a surgery,take a routine 1 to 2 kinds of antiepileptic medicine,and a regular follow-up review for EEG and blood of after taking antiepileptic medicine etc.The patients were followed up at least half a year.RESULTS:In all cases,totally 78 took a surgical operation,8 without surgery;the reasons is 6 patient with difference opinions preoperative,without reaching an agreement on the location of the epileptogenic focus or the sides,so no exact operation opinions given;while the other 2 patient whose families couldn't bear the risk of surgery,they gave up.During the interictal,29 cases were recorded with spike and ware wave,amount to 33.8%of all cases;The main clinical during the attacking stage shows with sharp wave,spike wave,sharp slow wave,spine slow wave,episodes.During attacking stage,67 cases with a abnormal discharge on the unilateral,19 cases with abnormal discharge bilateral,of which,11 were the unilateral mainly.On the whole,for preoperative VEEG cases can be positioned,the significant percentage of surgical treatment is 89.2%.In all cases,MRI and MRS are taken on the brain and the hippocampus,where 75 cases were found abnormal,11 without of exact abnormal area finding.On the whole,for preoperative MRI positive cases,the significant percentage of surgical treatment is 92.2%while 71.4%fort the MRI-negative cases,and the significant difference between the two statistics also confirms the correlation relationship between positive findings of MRI and surgery effect.31 cases are taken on PET-CT,95.6%of all 23 cases positive PET-CT results have good operative effect.All patients were performed on with a cortex and monitored with deep electrode.The focus area localized with video EEG preoperative,and intraoperative with a cortex electrode and deep electrode,all can detect the interspersed or intense discharge.After excision of focus,57 cases in which the epileptiform discharge disappeared with an electrode monitoring intraoperative;still 21 cases with interspersed epileptiform discharge;by enlarge of excision extension or treatment with cortex thermocoagulation on the discharge focus,18 cases in which the epileptiform discharge disappeared,where part of the which focuses adjacent or on the functional area,and finally in 3 cases there are still few epileptiform discharges can be seen.Anterior temporal lobectomy is the most common operative procedtures,accouted for 38 cases.In this group,94.7%of all 38 cases have good operative effect.The other operative procedures include Anterior temporal lobectomy + cortex thermocoagulation,The resection of simple temporal lobe cortex and epileptic foci,Selectivity resection of hippocampus and amygdala,Expand anterior temporal lobectomy,Expand anterior temporal lobectomy + cortex thermocoagulation and so on.The most common pathological diagnosis is hippocampal sclerosis,accounted for 59.0%,which is in line with the MRI results,the significant efficacy of these patients after surgery is 91.3%;other pathological diagnosis including cortical dysplasia,gliosis with low-grade gliomas,vascular malformations,ectopic gray matter,brain softening,arachnoid cyst,and other normal tissues.Those pathological diagnosis of temporal lobe tissue with substantively changes have better effect.There are significantly differences on postoperative efficacy between simple temporal cortex dysplasia and other pathological changes.Comprehensively,significantly postoperative good efficacy is 96.6%when the lesion on VEEG,MRI,PET-CT were consistent,but incompletely consistent by 63.2%.There were significant differences between them.CONCLUSIONS:1.Preoperative location:long term video-EEG and MRI are the most important check methods,are the foundation and basis of the surgical treatment of temporal lobe epilepsy.MRS can improve diagnosis rate of hippocampal sclerosis while PET-CT can improve sensitivity of the epileptogenic,both of which can improve the efficacy of surgery.2.The selection of surgical methods:Intraoperative cortex and deep electrodes monitoring are the most important,for medial temporal lobe epilepsy,we should not simply remove the medial temporal lobe limbic system,but should also remove the temporal cortex,and the evidence for simple removal of the medial temporal lobe limbic system is insufficient.For focal epilepsy,in addition to the resection of the lesion,we should also remove the abnormal discharge tissues,and also to prevent the functional areas.3.The consistency of a variety of integrated positioning means is the most important,as the consistency of Long-term video EEG,MRI,PET=CT will produce a high cure rate.4.For drug refractory temporal lobe epilepsy,the good curative results can be acquired to conduct surgery for selective cases.