Surgical Management Of Non-lesional Epilepsy In Children

Objective:Non-lesional epilepsy(NLE) is a kind of clinic syndrom(?) of nervous system.This type of epilepsy can not be found the clear focus or the brain structural changes by neuroimaging examinations(MRI/CT) which present difficult treatment decisions in resective epilepsy,surgery.Furthermore, children's cognitive function may be overall damaged after seizures.It is difficult to change other medicines to control seizures when two or three antiepileptic drugs were no effect.Therefore,operation is the best option.This study attempts to explore the identification ofthe localization of epilepsy and strategy of surgical treatment combined application of video-electronencephalogram(VEEG),function MRI(fMRI)and single-photon emission tomography(SPECT).Methods:A total of 21 children patients With NLE who confirmed by EEG,CT and MRI were enrolled fromFebruary 2005 to February 2007.All of the patients were in the situation offrequent seizures affected the study and life after using antiepileptic drugs systematically more than 2 years.21 cases were identified thelocalization of epilepsy focicombined application of VEEG,fMRI and SPECT before operation and precise positioning used cortex electrodes EEG during operation.According to the different clinical attack types and the location of epilepsy,the cases dividel into 5 groups:microscopic epilepsy foci resection group(A group,8 cases)multiple subpial transaction(MSTs) or Low-power thermal electrocoagulationgroup(B group,3 cases),combining microscopic epilepsy foci resection and MSTs group (C group,4 cases) and combining microscopic epilepsy loci resection and anterior temporal lobectomy group(D group,6 cases).According to the Engle standard of the curative effect,we analyzed the relationship among location of epilepsy foci,modus operandi and surgical results.At the same time,20 school-age children of physical health,mentalnormal and intelligence well were chosen as the control group All the subjects were tested by the event-related potentials(ERPS) and the pupil rating sale screening for learing disabilities (PRS).The results were statistical analysis Results:1.The location of epilepsy: A.the positive rate of the epilepsy foci location using EEG,fMRI and SPECT. The rate of the identification of the seizure side and localization of epilepy foci during the inter-attack period:66.67%(14/21)/95.24%(20/21),80.95%(17/21) /76.19%(16/21) and 85.71%(18/21)/80.95%(17/21).The rate of the identification of the seizure side and localization of epilepsy foci during the attack period:85.71%(18/21)/90.48%(19/21),71.43%(15/21)/61.90% (13/21) and 76.19%(16/21)/66.67%(14/21).B.12 cases are positive by pre-operation examination of EEG,fMRI and PET.10 cases are onsistent with the localization of epilepsy foci.There are 7 cases of Engle gradeⅠand 3 cases of Engle gradeⅡafter operation.In the remaining cases,1 case is Engle gradeⅡand 1 case is Engle gradeⅢ.Only two positive among EEG,Fmri and SPECT are 7 cases.Both consistent are 5 cases.There are 4 cases of EnglegradeⅠand 1 cases of Engle gradeⅡafter operation.In the remaining cases,1 case is Engle gradeⅡand 1 case is Engle gradeⅢ.There are 1 cases of Engle gradeⅢand 1 cases of Engle gradeⅣafter operation in the group which only one factor is positive.2.All the cases are positive during the operation when confirmed the localization of epilepsy foci and identification of the seizure range by the cortex electrodes EEG.The location and range is similar compared with pre-operation.3.The relationship between modus operandi and Surgical results: among 4 groups,the Engle gradeⅠis 6/0/2/5,gradeⅡis 1/1/1/1,gradeⅢis 1/1/1/0 and gradeⅣis 0/1/0/0.4Indicators of cognitive function before and after surgery:A.the results of ERPS:Latency and amplitude of P300 are 352.19±43.42ms/11.75±3.94μV(pre-operation group),310.16±21.12/ 11.98±3.62μV(post-operation group) and 312.16±25.43/12.96±3.4μV (control group).Comparison of the two groups(pre-operation group vs. post-operation group and pre-operation group vs.control group)showed that there is a significant difference(P＜10.05).And,there is no statistically difference between post-operation group and control group.Furthermore,there is no statistically difference of amplitude among 3 groups.B.the results of PRS.The score before operation is 72.16±14.38(total score),27.01±5.33(language score) and 45.42±9.46(non-language score).The score after operation is 88.16±9.83 (total score),31.12±4.17(language score) and 50.16±6.42(non-language score). The score of control group is 90.42±10.16(total score),33.42±4.70(language score) and 56.06±6.84(non-language score).All scores of pre-operation group were significantly lower than the control group.But,there is no statistically difference between post-operation group and control group.C.The relationship (r) between the latency of P300 and the results of PRS is-0.395,-0.266 and -0.427.On the other hand,he relationship(r) between the amplitude of P300 and the results of PRS is 0.242,0.236 and 0.213.There is a significant negative correlation between the latency of P300 and the results of PRS in preoperation group.And,there is no statistically difference betweenthe amplitude of P300 and the results of PRS.5 Surgical results:There is no intracranial hemorrhage and infection after operation.Only 1 patients suffered transient hemiplegia after operation and recovered in 10 days.According to Engle scale,the results after follow-up for one year are 13 cases of I grade(61.90%),4 cases ofⅡgrade (19.04%),3 cases of grade(14.29%) and 1 cases ofⅣgrade(4.76%).There are no new neurological deficits results from operation.Conclusion:1.It is found that EEG during the attack period and SPECT during theInter-attack period had the highest positive raterespectively.EEG during the attack period and SPECT during the Inter-attack period should be used as the first choice for the location of epilepsy foci.Functional localization may carry out bycombined application of VEEG,fMRI and SPECT.Operation on this kind of epilepsy can often achieve better effects if three consistent 2.The surgical results(Engle grade) may be good which surgical decision combined pre-operation location and region of which distributed 3.Cognitive dysfunction usually occurs in the children with NLE before operation.But,operation can significant improve the cognitive dysfunction.4.Significant positive correlation was observed between surgical results and the improvement of cognitive dysf(?)ction.5.It is an effective way to select appropriate surgical methods to NLE based on epileptic focus located by EEG,f MRI,and SPECT andclinical characteristics.