Department of Neurosurgery - Epilepsy surgery, Evangelisches Klinikum Bethel, Bielefeld, Germany.
Epilepsy Center Bethel, Bielefeld, Germany.
Epilepsia. 2019 Sep;60(9):1973-1983. doi: 10.1111/epi.16318. Epub 2019 Aug 29.
It has been suggested that multilobar epilepsies caused by lesions restricted to the posterior cerebral quadrant (ie, the parietal, temporal, and occipital lobes) can be treated successfully by a procedure termed posterior disconnection. The objective of the present paper was to identify determinants of the epileptological outcome following posterior disconnection surgery.
The authors retrospectively analyzed a series of 29 consecutive patients undergoing posterior disconnection surgery between 2005 and 2017 for the treatment of refractory posterior quadrantic epilepsy. Specifically, all presurgical and postoperative magnetic resonance (MR) studies were reviewed to identify cases with an incomplete disconnection, or the presence of a more widespread pathology involving the whole hemisphere rather than only its posterior quadrant. In addition, we reevaluated all presurgical video-electroencephalography (EEG) reports.
Seizure-free (International League Against Epilepsy [ILAE] 1) after surgery were 3/3 patients with EEG findings restricted to the posterior quadrant, 0/7 patients who had propagation of epileptic activity to the contralateral frontal lobe, and 11/19 (57.9%) who showed propagation to ipsilateral frontal and/or contralateral posterior. Eleven of 13 (84.6%) patients with purely posterior quadrantic magnetic resonance imaging (MRI) findings (as retrospectively diagnosed by neuroimaging) vs 3/16 (18.8%) cases with additional subtle abnormalities outside the posterior quadrant became seizure-free (P = .001). Eleven of 16 (68.8%) patients with complete disconnections were seizure-free vs only 3/13 (23.0%) cases with leftover temporal lobe tissue with contact to the insula (P = .025, both Fisher's exact test).
A posterior disconnection is a technically demanding but very effective operation for posterior quadrantic epilepsy. Good epileptologic outcomes require not only that the epileptogenic lesion does not extend beyond the confines of the disconnected cerebral volume but also the absence of subtle MRI abnormalities, more widespread than the clear-cut lesion of the posterior quadrant. Hemispheric or contralateral (particularly frontal) propagation of the epileptic activity may also indicate the presence of a hemispheric rather than posterior quadrantic pathology.
据报道，由局限于后颅窝区域（即顶叶、颞叶和枕叶）的病变引起的多脑叶癫痫可以通过一种称为后切断术的方法成功治疗。本研究的目的是确定后切断术治疗难治性后颅窝癫痫的癫痫学结果的决定因素。
作者回顾性分析了 2005 年至 2017 年间 29 例连续接受后切断术治疗难治性后颅窝癫痫的患者。具体来说，所有术前和术后磁共振（MR）研究均进行了回顾性分析，以确定存在不完全切断或更广泛的病变，该病变不仅累及整个半球，而且累及后颅窝以外的区域。此外，我们重新评估了所有术前视频脑电图（EEG）报告。
术后无癫痫发作（国际抗癫痫联盟[ILAE]1 级）的患者包括：3/3 例 EEG 结果仅局限于后颅窝的患者、0/7 例癫痫活动向对侧额叶传播的患者和 11/19（57.9%）例显示同侧额叶和/或对侧后颅窝传播的患者。13 例（84.6%）单纯后颅窝磁共振成像（MRI）发现（由神经影像学回顾性诊断）的患者中有 11 例无癫痫发作，而 16 例（18.8%）MRI 发现除后颅窝外有轻微异常的患者中有 3 例无癫痫发作（P=.001）。16 例（68.8%）完全切断的患者中有 11 例无癫痫发作，而仅 13 例（23.0%）仍有与岛叶接触的颞叶组织的患者中有 3 例无癫痫发作（P=.025，均为 Fisher 精确检验）。
后切断术是一种技术要求很高但非常有效的后颅窝癫痫治疗方法。良好的癫痫学结果不仅需要致痫病变不超出切断的脑容量范围，还需要不存在比明确的后颅窝病变更广泛的轻微 MRI 异常。癫痫活动的半球性或对侧（特别是额叶）传播也可能表明存在半球性而不是后颅窝性病变。
