Lesko Robert, Benova Barbora, Jezdik Petr, Liby Petr, Jahodova Alena, Kudr Martin, Tichy Michal, Zamecnik Josef, Krsek Pavel
Departments of1Neurosurgery.
2Paediatric Neurology, and.
J Neurosurg Pediatr. 2020 Jul 31;26(5):533-542. doi: 10.3171/2020.4.PEDS20198. Print 2020 Nov 1.
In this study, the authors aimed to determine 1) whether the use of intraoperative electrocorticography (ECoG) affects outcomes and complication rates of children undergoing resective epilepsy surgery; 2) which patient- and epilepsy-related variables might influence ECoG-based surgical strategy; and 3) what the predictors of epilepsy surgery outcomes are.
Over a period of 12 years, data were collected on pediatric patients who underwent tailored brain resections in the Motol Epilepsy Center. In patients in whom an abnormal ECoG pattern (e.g., spiking, suppression burst, or recruiting rhythm) was not observed beyond presurgically planned resection margins, the authors did not modify the surgical plan (group A). In those with significant abnormal ECoG findings beyond resection margins, the authors either did (group B) or did not (group C) modify the surgical plan, depending on the proximity of the eloquent cortex or potential extent of resection. Using Fisher's exact test and the chi-square test, the 3 groups were compared in relation to epilepsy surgery outcomes and complication rate. Next, multivariate models were constructed to identify variables associated with each of the groups and with epilepsy surgery outcomes.
Patients in group C achieved significantly lower rates of seizure freedom compared to groups A (OR 30.3, p < 0.001) and B (OR 35.2, p < 0.001); groups A and B did not significantly differ (p = 0.78). Patients in whom the surgical plan was modified suffered from more frequent complications (B vs A+C, OR 3.8, p = 0.01), but these were mostly minor (duration < 3 months; B vs A+C, p = 0.008). In all cases, tissue samples from extended resections were positive for the presence of the original pathology. Patients with intended modification of the surgical plan (groups B+C) suffered more often from daily seizures, had a higher age at first seizure, had intellectual disability, and were regarded as MR-negative (p < 0.001). Unfavorable surgical outcome (Engel class II-IV) was associated with focal cortical dysplasia, incomplete resection based on MRI and/or ECoG findings, negative MRI finding, and inability to modify the surgical plan when indicated.
Intraoperative ECoG serves as a reliable tool to guide resection and may inform the prognosis for seizure freedom in pediatric patients undergoing epilepsy surgery. ECoG-based modification of the surgical plan is associated with a higher rate of minor complications. Children in whom ECoG-based modification of the surgical plan is indicated but not feasible achieve significantly worse surgical outcomes.
在本研究中，作者旨在确定：1）术中皮质脑电图（ECoG）的使用是否会影响接受切除性癫痫手术的儿童的手术结果和并发症发生率；2）哪些患者及癫痫相关变量可能影响基于ECoG的手术策略；3）癫痫手术结果的预测因素是什么。
在12年的时间里，收集了在Motol癫痫中心接受定制脑切除术的儿科患者的数据。对于术前计划切除边缘以外未观察到异常ECoG模式（如棘波、抑制爆发或募集节律）的患者，作者未修改手术计划（A组）。对于切除边缘以外有明显异常ECoG发现的患者，作者根据明确皮质的接近程度或潜在切除范围，要么修改手术计划（B组），要么不修改手术计划（C组）。使用Fisher精确检验和卡方检验，比较三组患者的癫痫手术结果和并发症发生率。接下来，构建多变量模型以识别与每组以及癫痫手术结果相关的变量。
与A组（比值比30.3，p<0.001）和B组（比值比35.2，p<0.001）相比，C组患者实现无癫痫发作的比例显著更低；A组和B组之间无显著差异（p=0.78）。手术计划被修改的患者出现并发症的频率更高（B组与A+C组相比，比值比3.8，p=0.01），但大多为轻微并发症（持续时间<3个月；B组与A+C组相比，p=0.008）。在所有病例中，扩大切除的组织样本原发病理检查均呈阳性。手术计划有意修改的患者（B+C组）每日发作更频繁，首次发作时年龄更大，有智力残疾，且被视为MRI阴性（p<0.001）。不良手术结果（Engel II-IV级）与局灶性皮质发育不良、基于MRI和/或ECoG结果的不完全切除、MRI阴性结果以及需要修改手术计划时无法修改有关。
术中ECoG是指导切除的可靠工具，可为接受癫痫手术的儿科患者的无癫痫发作预后提供参考。基于ECoG修改手术计划与较高的轻微并发症发生率相关。基于ECoG提示但不可行修改手术计划的儿童手术结果明显更差。
