Maslarova Anna, Zhao Yining, Rösch Julie, Dörfler Arnd, Coras Roland, Blümcke Ingmar, Lang Johannes, Schmidt Manuel, Hamer Hajo M, Reindl Caroline, Welte Tamara M, Rampp Stefan, Rössler Karl, Buchfelder Michael, Brandner Sebastian
Department of Neurosurgery, Erlangen University Hospital, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
Clin Neurol Neurosurg. 2023 Mar;226:107603. doi: 10.1016/j.clineuro.2023.107603. Epub 2023 Jan 18.
MRI-negative drug-resistant epilepsy presents a challenge when it comes to surgical planning, and surgical outcome is worse than in cases with an identified lesion. Although increasing implementation of more powerful MRI scanners and artificial intelligence has led to the detection of previously unrecognizable lesions, in some cases even postoperative pathological evaluation of electrographically epileptogenic zones shows no structural alterations. While in temporal lobe epilepsy a standardized resection approach can usually be performed, the surgical management of extra-temporal lesions is always individual. Here we present a strategy for treating patients with extra-temporal MRI-negative epilepsy focus and report our histological findings and patient outcome.
Patients undergoing epilepsy surgery in the Department of Neurosurgery at the University Hospital Erlangen between 2012 and 2020 were included in the study. Inclusion criteria were: (1) failure to identify a structural lesion on preoperative high-resolution 3 Tesla MRI with a standardized epilepsy protocol and (2) preoperative intracranial EEG (iEEG) diagnostics.
We identified 8 patients corresponding to the inclusion criteria. Second look MRI analysis by an experienced neuroradiologist including the most recent analysis algorithm utilized in our clinic revealed a possible lesion in two patients. One of the patients with a clear focal cortical dysplasia (FCD) finding on a second look was excluded from further analysis. Of the other 7 patients, in one patient iEEG was performed with subdural electrodes, whereas the other 6 were evaluated with depth electrodes. MEG was performed preoperatively in all but one patient. An MEG focus was implemented in resection planning in 3 patients. FDG PET was performed in all, but only implemented in one patient. Histopathological evaluation revealed one non-lesional case, 4 cases of FCD and 2 cases with mild developmental malformation. All patients were free from permanent neurological deficits and presented with Engel 1A or 1B outcome on the last follow-up.
We demonstrate that extra-temporal MRI-negative epilepsy can be treated successfully provided an extensive preoperative planning is performed. The most important diagnostic was stereo-EEG, whereas additional data from MEG was helpful and FDG PET was rarely useful in our cohort.
对于MRI阴性的耐药性癫痫，手术规划面临挑战，且手术结果比有明确病灶的病例更差。尽管功能更强大的MRI扫描仪和人工智能的应用日益增多，已使一些先前无法识别的病灶得以发现，但在某些情况下，即使对脑电图癫痫源区进行术后病理评估，也未发现结构改变。在颞叶癫痫中，通常可采用标准化的切除方法，而颞叶外病灶的手术管理则总是因人而异。在此，我们介绍一种治疗颞叶外MRI阴性癫痫灶患者的策略，并报告我们的组织学发现和患者预后。
纳入2012年至2020年在埃尔朗根大学医院神经外科接受癫痫手术的患者。纳入标准为：（1）术前采用标准化癫痫方案的高分辨率3特斯拉MRI未发现结构病灶；（2）术前进行颅内脑电图（iEEG）诊断。
我们确定了8例符合纳入标准的患者。一位经验丰富的神经放射科医生进行的二次MRI分析，包括我们诊所使用的最新分析算法，在两名患者中发现了可能的病灶。其中一名在二次检查时发现明确局灶性皮质发育不良（FCD）的患者被排除在进一步分析之外。在其他7名患者中，一名患者使用硬膜下电极进行了iEEG检查，而其他6名患者使用深度电极进行了评估。除一名患者外，所有患者术前均进行了脑磁图（MEG）检查。3名患者在切除规划中采用了MEG定位。所有患者均进行了氟代脱氧葡萄糖正电子发射断层扫描（FDG PET），但仅在一名患者中应用于手术规划。组织病理学评估显示1例无病灶病例、4例FCD病例和2例轻度发育畸形病例。所有患者均无永久性神经功能缺损，最后一次随访时Engel分级为1A或1B级。
我们证明，只要进行广泛的术前规划，颞叶外MRI阴性癫痫可以成功治疗。最重要的诊断方法是立体脑电图，而MEG的额外数据有帮助，FDG PET在我们的队列中很少有用。
