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迷走神经刺激术联合多种手术方式治疗儿童难治性癫痫2例

2019-05-13 谭泊静 李云林 马康平 立体定向和功能性神经外科杂志

儿童难治性癫痫多种治疗方式疗效差,是临床工作中的难题。国内应用VNS治疗儿童难治性癫痫时间较短,相关文献少,VNS联合多种手术方式治疗儿童难治性癫痫的文献更是鲜见报道。现将首都儿科研究所附属儿童医院神经外科应用VNS联合多种术式治疗儿童难治性癫痫2例的临床经验及术后1年随访资料,报道如下。

儿童难治性癫痫多种治疗方式疗效差,是临床工作中的难题。国内应用VNS治疗儿童难治性癫痫时间较短,相关文献少,VNS联合多种手术方式治疗儿童难治性癫痫的文献更是鲜见报道。现将首都儿科研究所附属儿童医院神经外科应用VNS联合多种术式治疗儿童难治性癫痫2例的临床经验及术后1年随访资料,报道如下。
 
1.资料与方法
 
1)一般资料 
 
首都儿科研究所附属儿童医院神经外科于2016年11月~2017年6月应用VNS联合多种术式治疗儿童难治性癫痫2例,术后随访至少1年,其中男2例,年龄7岁4月~8岁2月,平均7.6岁。
 
病例1,男,7岁4月,起病年龄4岁,病程3年,存在产后缺氧史,发育落后于同龄儿童,发作形式为强直发作,痉挛发作,肌阵挛发作,失张力发作,每天发作数十次,曾口服6种抗癫痫药物,疗效欠佳。
 
病例2,男,8岁2月,起病年龄1岁,病程7年,存在产后缺氧史,智力运动发育明显落后于同龄儿童,发作形式为强直发作,全面强直阵挛发作,每天发作十余次,曾经在当地最多时服用7种抗癫痫药物,疗效欠佳。
 
2)辅助检查 
 
①影像学检查 
 
均行3.0T MRI薄层扫描,层厚1mm,无间距。病例1头MRI提示双侧额颞顶异常信号,考虑为软化灶;病例2头MRI提示双枕叶异常信号,考虑软化灶伴胶质细胞增生可能性大。
 
②脑电图检查 
 
均行视频脑电图(VEEG)监测至少3 次有效癫痫发作,病例1VEEG及皮层脑电图提示,双额、中央、顶区大量散在或连续性棘波,棘慢波,多棘慢波异常放电,右额、中央、顶为著,有时可波及全导。病例2VEEG 提示双侧枕颞区大量高波幅棘满波发放,以左枕颞为著,有时可波及全导。
 
③PET检查 
 
病例1发作间期PET提示双额叶代谢欠均匀;病例2发作间期PET提示双侧枕叶代谢明显减低。
 
3)手术方法 
 
病例1,2015年9月行胼胝体一期全段切开+右额叶癫痫灶切除术,术后病理回报为软化灶,2016年11月,行VNS手术。病例2,男,8岁2月,2015年9月行胼胝体后端切开+左枕叶癫痫灶切除术,术后病理回报为软化灶伴胶质细胞增生,2017年1月行VNS手术,2017年6月行胼胝体全段切开术。
 
4)术后程控方案 
 
VNS术后两周开机,开机参数,电流输出幅度为0.2mA,频率30Hz,脉宽250ms,刺激时间30s,间歇时间5mins,0.3mA步进,频率30Hz,脉宽250ms,刺激时间30s,间歇时间5mins。病例1最后程控参数为0.2mA,频率30Hz,脉宽500ms,刺激时间30s,间歇时间5mins;病例2最后程控参数为0.8mA,频率30Hz,脉宽250ms,刺激时间30s,间歇时间5mins。
 
5)评价方法 
 
VNS术后随访至少1年,术前一个月详细记录患儿发作频率等资料以便制定基线,发作次数较术前基线水平减少>50%为有效,评定标准为McHugh分级(见表1)。
 


2.结果
 
病例1于2015年10月行胼胝体一期全段切开+右额叶癫痫灶切除术后发作较术前减少约50%,术后半年发作逐渐增多,术后1年发作接近术前,于2016年11月,行VNS手术,术后发作逐渐减少,2017年10月(VNS术后10个月)至今无发作。
 
病例2于2015年12月行胼胝体后端切开+左枕叶癫痫灶切除术,术后发作较术前减少约40%,术后半年发作逐渐增多,术后1年发作同术前,2017年1月行VNS手术,术后发作较术前减少约30%,发作形式改变为跌倒发作,2017年6月行胼胝体全段切开术,2017年12月(VNS术后11个月)至今无发作。

原始出处

谭泊静,李云林,马康平,陈倩,陈述花,易林华,秦广彪.迷走神经刺激术联合多种手术方式治疗儿童难治性癫痫(附2例报道)[J].立体定向和功能性神经外科杂志,2018(03):151-153+161.

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    2019-05-15 freve
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