Combination Of Co-SEP, Co-MEP, ECoG And Awake Craniotomy Used In The Surgery Of Secondary Epilepsy Of Central Areal Lesions

Objective To evaluate the value of cortical sensory evoked potentials (Co-SEP) and motor evoked potentials(Co-MEP)combined with the electrocorticogram (ECoG) and awake craniotomy in epilepsy surgery with the epileptogenic focus in central area.Method 30 cases of epilepsy by symptomatology, neuroimaging, electrophysiological examination comprehensive assessment before surgery,the patients who received PET-CT examination in 22 cases,accepted the EEG examination in 17 cases, fMRI in 9 cases, clear epileptogenic focus and/or epileptogenic lension in the district and adjacent parts, In the left side in 13 cases, right 16, and 1 case of bilateral. Application of intraoperative tracheal intubation and intravenous anesthesia, large trauma craniotomy, according to the preoperative findings determing the approximate location of the central sulcus,as far as possibal to place the banded electrode Perpendicular to the central sulcus,the angle between the central sulcus and the electrode at least greater than 45°,through the Co-SEP of the N20-p25 and P22-N33 of the phase inverted to determine the location of the central sulcus.Subsequently, adjust the position of the electrode strip to the central gyrus, the stimulus intensity starting from 2 mA,and with 1mA increments,the maximum not more than 25mA,unit it leads to well-differentiated Co-MEP waveform,then used the number paper marked the position of which can led to the Co-MEP. There are three patients who were treated with laryngeal mark, and intravenous anesthesia., positioning the motor speech area,sensory language area,the language area will be marked. Then spread on the cortical surface of the electrode sheet to record unusual epileptic discharge areas, avoid the sensory areas,motor areas and the language areas which localization through the use of Co-SEP, Co-MEP and intraoperative language testing, then removal the epileptic foci and the epileptogenic lesions, if the foci or lesiongs in the functional area, If not, we can choose MST or bipolar coagulation technique, the process was repeated until the spikes disappeared or significantly decreased.The results were observed for 6～12 months after the surgery. Observation including reservations of the neurological function, the improvement in seizures, and completeness of tumor resection and the tumor recurrence. Results Complete resection of eppileptogenic lesions in 12 cases,15 cases of partial resection,no resection in 3 cases. All patients with epileptic foci involving both the central area, removal of areas outside the central part, where lesion in the dominant hemisphere, a total of 3 cases of the language areas. Located in the central area and language areas of the epileptogenic zone, under the MST and cortical bipolar coagulation technique.30 patients were followed up for 6 to 18 month, according to Engel seizure control efficacy standards:17 cases reached toⅠlevel; 7 reached toⅡlevel; 3 reached toⅢlevel; and 3 reached toⅣlevel The 3 patients who received awake craniotomy,1 cases occurred symptoms of partial motor aphasia in the third day of postoperative, and 2 cases showed sensory aphasia at the after day of the postoperative, and through enhance dehydration and neurotrophic treatment, the symptoms were recovery after 1 week of the operation In The other patients,1 cases showed contralateral limb muscle strength decline in the 5 days after operation,1 of urinary incontinence and spiritual apathy in a week after surgery, both the cases were symptoms eased after dehydrated and neurotrophic drugs were used, and after three months of review, the symptoms disappeared. All patients had no permanent motor dysfunction. In glioma patients underwent rountine postoperative radiotherapy and chemotherapy,and reviewed the MRI after 6 months of the surgery, the patients who received total resection did not show tumor recurrence, subtotal in two cases with glioblastoma, appeared seizures at 8 months and 10 months after surgery respectively, review the MRI,tumor recurrence,and the patients underwent secondary surgery, and there is no significant imaging changes in the remaining patients.Conclusion the application of Intraoperative monitor of Co-SEP, Co-MEP combined the ECoG and evoked craniotomy in epilepsy surgery, Can effectively guide the epilepsy surgery in the brain central area,avoid injury the important brain function, while the maximum remove of the lesions.