Khajavi K, Comair Y G, Wyllie E, Palmer J, Morris H H, Hahn J F
Neurosurgery Service, Walter Reed Army Medical Center, Washington, DC, USA.
J Child Neurol. 1999 Jan;14(1):15-25. doi: 10.1177/088307389901400102.
Brain tumors are a common cause of seizures in children. Early surgical treatment can improve seizure outcome, but controversy exists regarding the most appropriate type of surgical intervention. Some studies suggest tumor resection alone is sufficient, while others recommend mapping and resection of the surrounding epileptogenic foci to optimize seizure outcome. To address this issue, we reviewed the charts of 34 pediatric patients aged 18 months to 20 years with medically intractable epilepsy and primary brain tumors. The average age at operation was 12.6 years, and patients had seizures for an average of 6.4 years. The majority of tumors were located in the temporal lobe. Seventeen patients, because of tumor location near an eloquent area, underwent extraoperative mapping using subdural electrode grids prior to definitive tumor resection. Fourteen of these patients had a gross total tumor resection, yet only two had a distinct zone of ictal onset identified and resected. The remaining 17 patients had tumors either in the nondominant hemisphere or far removed from speech-sensitive areas, and therefore did not undergo extraoperative subdural electroencephalograph mapping. Fourteen of these patients also had a gross total tumor resection, while none had intraoperative electrocorticography to guide the resection of additional nontumoral tissue. Overall, of the 28 patients treated with a gross total tumor resection, 24 (86%) are seizure free, while the other four are significantly improved. Of the six patients who had a subtotal tumor removal, five have persistent seizures. The mean follow-up was 3.6 years. We conclude that in children and adolescents, completeness of tumor resection is the most important factor in determining seizure outcome. The routine mapping and resection of epileptogenic foci might not be necessary in the majority of patients. As a corollary, the use of subdural electrode grids in pediatric patients with tumor-associated epilepsy should be limited to cases requiring extraoperative cortical stimulation for localization of nearby eloquent cortex.
脑肿瘤是儿童癫痫发作的常见原因。早期手术治疗可改善癫痫发作的预后，但对于最合适的手术干预类型仍存在争议。一些研究表明，仅肿瘤切除就足够了，而另一些研究则建议对周围致痫灶进行定位和切除，以优化癫痫发作的预后。为了解决这个问题，我们回顾了34例年龄在18个月至20岁之间、患有药物难治性癫痫和原发性脑肿瘤的儿科患者的病历。手术的平均年龄为12.6岁，患者癫痫发作的平均时间为6.4年。大多数肿瘤位于颞叶。17例患者由于肿瘤位于功能区附近，在进行确定性肿瘤切除之前，使用硬膜下电极栅进行了术中定位。其中14例患者进行了肿瘤全切，但只有2例确定并切除了明确的发作起始区。其余17例患者的肿瘤位于非优势半球或远离语言敏感区，因此未进行术中硬膜下脑电图定位。这17例患者中的14例也进行了肿瘤全切，而无一例进行术中皮质脑电图检查以指导切除额外的非肿瘤组织。总体而言，在28例接受肿瘤全切的患者中，24例（86%）无癫痫发作，另外4例有明显改善。在6例次全切除的患者中，5例仍有持续性癫痫发作。平均随访时间为3.6年。我们得出结论，在儿童和青少年中，肿瘤切除的完整性是决定癫痫发作预后的最重要因素。对于大多数患者来说，常规的致痫灶定位和切除可能没有必要。作为一个推论，对于患有肿瘤相关性癫痫的儿科患者，硬膜下电极栅的使用应仅限于需要术中皮质刺激以定位附近功能区皮质的病例。
