利用磁共振引导的激光间质热疗胼胝体切开术侧定癫痫灶,以便采用分期手术方法

Kabir Sheikh, Derryl Miller, Robert Blake, Lisa Smith, Susan Conrad, Deborah Sokol, M. Obeid, Rupa Radhakrishnan, Anna Schultheis, Jeffrey Raskin
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摘要

新发难治性癫痫(NORSE)是一种病因复杂的疾病,发病率和死亡率都很高。NORSE 通常对药物治疗无效,因此需要进行癫痫手术治疗。由于大多数 NORSE 病例的病因难以捉摸,因此手术评估极具挑战性,尤其是致痫区(EZ)不易侧位时,额叶癫痫发作就会出现这种情况。由于通过胼胝体的共神经连接产生的双侧同步性和头皮脑电图(EEG)的低时空分辨率,额叶 EZ 的侧位可能具有挑战性。我们报告了一名患有 NORSE 的儿科患者,她表现为局灶性意识障碍发作,并聚集成超级难治性癫痫状态(SRSE)。她在服用治疗剂量的抗癫痫药物、滴注麻醉剂、使用甲基强的松龙进行免疫调节、静脉注射免疫球蛋白和阿纳金雷以及生酮饮食失败后,需要进行手术干预来治疗癫痫发作。尽管她的症状是局灶性的,但在头皮脑电图和第二阶段立体脑电图(sEEG)上,癫痫发作的侧位并不明显。我们采用多级手术方法进行了前磁共振引导激光间质热疗胼胝体切开术(MRgLITT CC),成功地将 EZ 侧向化,重新植入 sEEG 电极后出现了左侧化发作模式。我们的病例表明,微创 MRgLITT CC 可成功用于额叶癫痫的 EZ 侧向化,对于 NORSE 伴 SRSE 患者,应考虑进行癫痫手术。我们还证明,激光间质热疗(LITT)虽然并不总能使患者摆脱癫痫发作,但却能充分破坏网络以中止癫痫状态,从而改善癫痫发作。
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Using magnetic resonance-guided laser interstitial thermal therapy corpus callosotomy to lateralize a seizure focus for staged surgical approach
New onset refractory status epilepticus (NORSE) is an etiologically heterogeneous condition that is associated with high morbidity and mortality. NORSE is often refractory to medical management prompting a workup for epilepsy surgery. Because NORSE remains etiologically elusive in most cases, surgical evaluations are challenging, especially when the epileptogenic zone (EZ) is not easy to lateralize as can be seen in frontal lobe seizures. Lateralizing a frontal lobe EZ may be challenging due to bilateral synchrony from commissural connections through the corpus callosum and low spatiotemporal resolution of the scalp electroencephalography (EEG). We report a pediatric patient with NORSE presenting with focal impaired awareness seizures clustering into super refractory status epilepticus (SRSE). She required surgical intervention for the treatment of her seizures after failing therapeutic doses of antiseizure medications, anesthetic drips, immunomodulation with methylprednisolone, intravenous immunoglobulin and anakinra, and the ketogenic diet. Despite her semiology being focal, the seizures were not well lateralized on scalp EEG and during phase 2 stereo-EEG (sEEG). Anterior magnetic resonance-guided laser interstitial thermal therapy corpus callosotomy (MRgLITT CC) was performed in a multistage surgical approach to successfully lateralize the EZ with a left-lateralized ictal pattern seen after reimplantation of sEEG electrodes. Our case suggests that minimally invasive MRgLITT CC can be successfully used to lateralize an EZ in frontal lobe epilepsy and that epilepsy surgery should be considered in patients with NORSE with SRSE. We also demonstrate that laser interstitial thermal therapy (LITT), while not always resulting in seizure freedom, can sufficiently disrupt a network to abort status epilepticus and lead to seizure improvements.
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