Hartlieb Till, Kudernatsch Manfred, Staudt Martin
Fachzentrum für pädiatrische Neurologie, Neuro-Rehabilitation und Epileptologie, Schön Klinik Vogtareuth, Krankenhausstr. 20, 83569, Vogtareuth, Deutschland.
Institut für Rehabilitation, Transition und Palliation von neurologisch kranken Kindern, Paracelsus Medizinische Privatuniversität Salzburg, Salzburg, Österreich.
Nervenarzt. 2022 Feb;93(2):142-150. doi: 10.1007/s00115-021-01219-5. Epub 2021 Oct 31.
Hemispherotomies represent a major part of surgical interventions for epilepsy in childhood (16-21%). The anatomical resection has been replaced by minimally invasive disconnection techniques with lower perioperative mortality and fewer postoperative complications. Today the procedure is not only carried out from the lateral aspect via the Sylvian fissure/insula but also via a vertical parasagittal approach. Depending on the publication, hemispherotomy leads to freedom from postoperative seizures in 60-90% of patients. Despite changes in the surgical technique, disturbances of the cerebrospinal fluid circulation continue to be the main complication in 5-15% of cases. Hemispheric epileptogenic lesions usually lead to early onset and difficult to treat epilepsy in childhood. These epilepsies are characterized by a high frequency of seizures and propagation of epileptic discharges to the healthy hemisphere. The aim of a hemispherotomy is, in addition to postoperative freedom from seizures, the complete disconnection of the affected hemisphere. When deciding on a hemispherotomy, the expected functional consequences play a major role in addition to epileptological aspects. In the case of deficits already present preoperatively (hemianopia, hemiparesis) or reorganization of functions in the contralesional hemisphere (language), no new deficits are to be expected from the operation. In terms of cognition, a hemispherotomy can improve function by releasing the neuroplastic potential of the healthy hemisphere. In order to keep the negative and often irreversible effects of epilepsy as low as possible and to be able to use as much potential for neuroplasticity of the healthy hemisphere as possible, surgery should be considered as early as possible.
大脑半球切除术是儿童癫痫外科治疗的重要组成部分（占16%-21%）。解剖性切除术已被微创离断技术所取代，后者围手术期死亡率更低，术后并发症更少。如今，该手术不仅可通过外侧经外侧裂/岛叶进行，还可通过垂直矢旁入路进行。根据不同的文献报道，大脑半球切除术可使60%-90%的患者术后无癫痫发作。尽管手术技术有所改变，但脑脊液循环障碍仍是5%-15%病例中的主要并发症。半球性致痫病灶通常导致儿童期癫痫早发且难以治疗。这些癫痫的特点是发作频率高，癫痫放电向健康半球扩散。大脑半球切除术的目的除了使患者术后无癫痫发作外，还包括完全离断患侧半球。在决定是否进行大脑半球切除术时，除了癫痫学方面的因素外，预期的功能后果也起着重要作用。对于术前已存在的缺陷（偏盲、偏瘫）或对侧半球功能重组（语言）的情况，手术预计不会产生新的缺陷。在认知方面，大脑半球切除术可通过释放健康半球的神经可塑性潜能来改善功能。为了尽可能降低癫痫的负面且往往不可逆的影响，并尽可能利用健康半球的神经可塑性潜能，应尽早考虑手术。
