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1、Liu Zonghui,Yu Xin,Zhao Quanjun,et al.Neurosurgical Center of Chinese PLADepartment of Neurosurgery,Navy General HospitalBeijing(100037)CHINA,Combined Operations With MST in the Treatment of Intractable Epilepsy,Background,In recent years,operations have been the major procedure for treatment of med
2、ically intractable epilepsy.Removal of epileptogenic lesions was believed to be a best approach for seizure control.,Background,But when functional area or the extensive of hemisphere were involved by the epileptogenic focus,the outcome will be affected by the residue lesion,which lies unresectable
3、cortex,such as precentral gyrus,postcentral gyrus,Brocas area,Werniches area,etc.,Background,Combined operations with MST can reduce the occurrence of synchronized cell discharge and may not impair the major functional capacity of cortex by preserving vertically oriented fibers.,Material and Method,
4、Clinical materialThe combined operations with MST have been applied in 130 patients who suffered from medically intractable epilepsy from January 1996 to January 2001.Male 98 and female 32Age:10-55(mean 30.7)years.Initial attack:2-40(mean 17.2)years.Duration of illness:3-48(mean 9)years.,Material an
5、d Method,Table 1.,Material and Method,Table 2.,Material and Method,Table 3.,Material and Method,According to the preoperative EEG,SPECT or PET,CT and MRI locating measures combined with ECoG detection during operation,the epileptogenic focus was defined.,Surgical Technique,All patients were examined
6、 by ECoG to map the epileptogenic lesions during operation.Focus far from functional area such as in anterior frontal or temporal can be resected by massive.MST was performed only when the lesion lay in or near functional area,the horizontal fibers could be resected without causing serious disabilit
7、y.,Examied of ECOG,Found of cortical,Surgical Technique,We designed the transector.The tip of this hook was ball with 0.4 mm diameter that was very smooth so as to not to impair the piamater.,Surgical Technique,Firstly we made a small hole with a No11 blade in an area,then put in the transector thro
8、ugh the hole and swept forward to reach the contralateral edge.,Method of Subpial transection,The depth of transection(4mm),The horizontal and vertically fibers,Surgical Technique,Let the smooth tip of ball of the transector showed under piamater,then draw it back under visual to transect the cortex
9、 without penetrating the piamater.,Surgical Technique,The depth of transection was 4mm.The next transection was made parallel and 5mm apart to last one the operation was ended till the sharp wave was no longer found with ECoG.,Paralled transection strip(fire wall),Surgical Technique,Combination of o
10、perations is described as follows:Resection of the diffuse lesions of the hemisphere+MST 21 cases(left 12 and right 9,16.15%)The ant-temporal-lebectomy or amygdalohippocampectomy+MST 29cases(left 14 and right 15,22.30%)The resection of bifrontal multifocal+MST+anterior 2/3 corpus callosotomy30 cases
11、(left 14 and right 16,23.08%)The cortical and lesion resection+MST50 cases(left 21 and right 29,38.46%),Results,Short-term effective control of seizures had been obtained in all 130 patients postoperatively.There is no operative death and severe complication.,Results,The follow-up periods were from
12、1-6(mean 4.7)years in 120 patients:78 patients(60%)were seizures-free;37 patients(28.46%)had a 75%significant reduction(seizure frequency or one seizure per year);12 patients(9.33%)had a 50%reduction or a change from severe type to moderate type.3 patients(2.31%)had poor result that had generalized
13、seizures in 2 years postoperatively.The effective rate was 97.69%and significant effective rate was 88.46%.,Discussion:(1)Patients selection,The most currently examination nowadays is one that aims at checking the presence and location of structural brain lesions(CT,MRI,MRA or DSA);detection of tumo
14、rs,AVMs and cortical dysplasia abnormality etc.,Discussion:(1)Patients selection,The study of the source of information comes from the analysis of the frequency and of the complete clinical pattern of the seizure and first overt seizure manifestation successive seizure feature post seizure status.,D
15、iscussion:(1)Patients selection,The careful patients selection,strong conforming date to clinical EEG neuropsychological MRI,judicious use of ECoG and wide-exposure craniotomy result in the best outcome for seizure control.,Discussion:(2)Operation,The study of the ECoG remains one of the most import
16、ant means of understanding the spatial arrangement of the epileptogenic process.,Discussion:(2)Operation,In cases involving cortical lesions,the resection must be planned to encompass not only the lesion but surrounding epiletogenic activity.,The lesions and noze of epileptogenic,The organic epileps
17、y,Discussion:(2)Operation,The final indication for surgery as well as the choice of the most appropriate surgery modality devices from the convergence of the results of the investigation described above.,Discussion:(2)Operation,The ECoG can more precisely map the cortical regions involved in seizure
18、 generation and spread.The ECoG is most useful while operation on a brain that lacks any evidence of a structural or functional lesion most commonly during epilepsy surgery.,Limbic cortex,Anatomy of hippocampus,Blood supply of hippocampus,Discussion:(2)Operation,Human transactions are performed 5mm
19、apart,since cortical islands less than 5mm in width are unable to sustain an epileptogenic discharge.The horizontal fibers were seen to be disruption without damage to neuronal cell bodies or vertically oriented fibers.(F.Morrell,1989),Discussion:(2)Operation,The main difficulty from this procedure
20、lies in the“blindness”of the transection.The surgeon must use a supersensitive touch in performing the transection in order to prevent damage to underlying cortical vessels.(G.Rossi,1996),Discussion:(2)Operation,Paralled transection“stripe”are evidence of subpial capillary rupture.These are typical
21、seen across the cortex and provide horizontal landmarks for planning the distance to the next transection.They may function as a“fire wall”of gliosis,preventing epileptiform activity.(J.D.Gross,1998),Discussion:(2)Operation,Thrombin-soaked microsponges may be used topically to diminish stripe oozing
22、.Interestingly,prior radiation therapy prevented the transection stripes from becoming dark or bloody.(O.Devinsky,1994),Conclusion,The results indicate the MST combined with epileptogenic focus resection;selective resection of temporal basal part of incision of corpus callosum etc can improve the chance for complete seizure control but protect more neuron from damage during operation as well.,Conclusion,Thus combination of these surgical operations is an effective and safe approach of the surgical treatment for intractable epilepsy.,Thank You,
