Epilepsy Center/Neurological Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.
Epilepsia. 2012 Jan;53(1):44-50. doi: 10.1111/j.1528-1167.2011.03274.x. Epub 2011 Sep 28.
Outcomes following unilobar surgeries for refractory epilepsy have been well described. However, little is known about long-term seizure outcomes following multilobar resections. The aim of the current study was to identify long-term seizure control and predictors of seizure recurrence in this patient population.
Records of patients who underwent multilobar epilepsy surgery at the Cleveland Clinic between 1994 and 2010 were retrospectively reviewed. A postoperative follow-up of at least 6 months was required. Patients were classified as seizure free if they achieved an Engel class I at last follow-up. Long-term chances of seizure freedom were illustrated using a survival analysis, and predictors of recurrence were identified using Cox proportional hazard modeling.
Sixty-three patients with medically intractable epilepsy underwent multilobar surgical resections during the study period (mean follow-up of 4.6 years). Predominant resection types included extended occipital (temporoparietooccipital, parietooccipital, temporooccipital: 57%), frontotemporal (21%), and temporoparietal (17%). Mean age at surgery was 21.4 years and mean age at seizure onset was 10.1 years. Fifty-six percent of the patients underwent extraoperative invasive electroencephalography (EEG) evaluations. At 6 postoperative months, 71% (95% confidence interval (CI) 65-77) were seizure-free (SF), 64% (CI 58-70) were SF at 1 year, 52% (CI 46-59) were SF at 5 years, and 41% (CI 32-50) remained SF at 10 years. Forty-one patients had at least one breakthrough seizure after surgery (median timing of recurrence 6.1 months), with an Engel class 1 achieved again by last follow-up in 12 of these 41 cases. Nine patients required a reoperation. Patients who underwent extended occipital/posterior quadrant resections had more favorable outcomes as compared to the other groups. With multivariate analysis, the type of resection (p = 0.03), preoperative auras (p = 0.03), an incomplete resection (0.03), and the presence of postoperative spikes (p = 0.0003) correlated with seizure recurrence. The risk of seizure recurrence for an incomplete resection was 2.3 (CI 1.53-3.36), preoperative aura 2.3 (CI 1.34-3.87), and postoperative spikes on surface EEG 2.5 (CI 1.29-4.71).
A favorable outcome can be achieved in 41% of patients undergoing multilobar resections for epilepsy surgery at 10 years of follow-up. Close to one-third of patients who have breakthrough seizures after surgery are able to regain seizure freedom by last follow-up. Predictors of recurrence include resection type (frontotemporal and parietotemporal resections did worse), presence of preoperative aura, an incomplete surgical resection, and the presence of postoperative interictal discharges on EEG.
针对难治性癫痫的单叶手术的结果已有详尽描述。然而，对于多叶切除术后的长期癫痫发作结果，人们知之甚少。本研究旨在确定该患者群体的长期癫痫控制和复发预测因素。
回顾了克利夫兰诊所 1994 年至 2010 年间接受多叶癫痫手术的患者的记录。需要至少 6 个月的术后随访。如果患者在最后一次随访时达到 Engel Ⅰ级，则被认为无癫痫发作。使用生存分析来展示长期无癫痫发作的机会，使用 Cox 比例风险建模来确定复发的预测因素。
在研究期间，63 名患有药物难治性癫痫的患者接受了多叶手术切除（平均随访 4.6 年）。主要的切除类型包括扩展的枕叶（颞顶枕叶、枕顶叶、颞枕叶：57%）、额颞叶（21%）和颞顶叶（17%）。手术时的平均年龄为 21.4 岁，癫痫发作的平均年龄为 10.1 岁。56%的患者接受了手术外的侵入性脑电图（EEG）评估。术后 6 个月时，71%（95%置信区间[CI]为 65-77）的患者无癫痫发作（SF），1 年时 64%（CI 为 58-70）SF，5 年时 52%（CI 为 46-59）SF，10 年时 41%（CI 为 32-50）SF。41 例患者在手术后至少有一次发作（复发的中位时间为 6.1 个月），其中 12 例在最后一次随访时再次达到 Engel Ⅰ级。9 例患者需要再次手术。与其他组相比，接受扩展的枕叶/后象限切除术的患者有更好的结果。多变量分析显示，切除术类型（p=0.03）、术前先兆（p=0.03）、不完全切除（p=0.03）和术后棘波（p=0.0003）与癫痫复发相关。不完全切除的癫痫复发风险为 2.3（CI 为 1.53-3.36），术前先兆为 2.3（CI 为 1.34-3.87），术后表面 EEG 上的棘波为 2.5（CI 为 1.29-4.71）。
在 10 年的随访中，接受多叶切除术的癫痫患者中有 41%可以获得良好的结果。近三分之一在手术后出现发作突破的患者在最后一次随访时能够再次无癫痫发作。复发的预测因素包括切除术类型（额颞叶和顶颞叶切除术效果较差）、术前先兆、手术不完全切除和 EEG 上的术后间发性放电。
