Neurology:综合多研究,MRI诊断局灶性皮质发育不良难治性癫痫术后优良预后率达70%

2022-01-16 Naomi MedSci原创

有研究者对现有文献进行了系统的回顾和荟萃分析,以确定MRI检测的FCD手术后癫痫发作预后良好的比率和预测因素。 70%的具有FCD MRI特征的难治性癫痫患者在切除手术后可获得良好的癫痫发作结果。

      局灶性皮质发育不良(FCD)包括一系列皮质发育的局灶性畸形,特征是皮质层叠紊乱,伴或不伴有异常细胞类型。虽然FCD的确诊依赖于组织病理学(在某些情况下,还包括遗传学),但实际上诊断始于磁共振成像(MRI),作为耐药癫痫患者术前评估的一部分。FCD的特征性MRI特征包括局灶性皮质增厚、脑回和脑沟模式异常、皱褶大小改变、皮质和皮质下信号异常、灰白质交界处模糊,以及从皮质延伸到脑室的漏斗状高T2/FLAIR信号(跨地幔征)。值得注意的是,这些特征可能是微妙或完全无法识别,即使经过专家审查,21-58%的FCD病变在MRI上也无法识别。

      FCD是耐药癫痫的一个重要原因,也是癫痫手术的第三个最常见的适应症,仅次于海马硬化症和肿瘤。然而,与其他病理相比,FCD被报道与较差的手术后癫痫结果有关。在接受FCD相关耐药癫痫手术的患者中,那些变得“无致残性癫痫发作”(Engel I级结果)的比例差别很大。从8.3%到86.4%不等。对这类研究的荟萃分析发现,Engel I级预后的总体比率为55.8%±16.2%。

       然而,FCD手术系列通常建立在FCD的组织病理学诊断的基础上,因此包括MRI检测到的FCD患者和MRI未检测到的FCD患者(MRI阴性病例)的混合队列。虽然基于组织学的术后预测可能是有用的,但在常规的临床工作流程中,手术患者的选择是基于术前的结果,包括MRI。关于接受MRI检测的FCD手术患者癫痫发作结果的研究缺乏全面的评估和分析,这一努力可以为临床医生提供关键数据,用于对正在接受癫痫手术的MRI检测到的FCD患者进行常规咨询。为了解决这一认识差距,有研究者对现有文献进行了系统的回顾和荟萃分析,以确定MRI检测的FCD手术后癫痫发作预后良好的比率和预测因素。拟解决问题包括以下几点:

(Ⅰ)确定MRI检测到的FCD相关的难治性癫痫手术后预后良好的总体比率(主要目标);

(Ⅱ)确定此类手术后良好发作结果的预测因素;

(Ⅲ)确定研究质量对报告的术后预后良好的任何影响。

      研究者根据PRISMA指南设计了我们的研究方案,并在Prospero注册了该方案。检索MEDLINE、EMBASE和科学网,查找≥检测到的耐药癫痫切除术后12个月患者的随访研究。随机效应荟萃分析用于计算获得良好结果(定义为Engel I级、ILAE 1-2级或“无癫痫”状态)的患者的比例。用Meta回归分析异质性的来源。

  • 搜索发现了3745条参考文献。其中,35项研究(共1353名患者)包括在内。
  • 大多数研究(89%)在术后24个月跟踪观察患者术后优良预后率为70%(95%CI:64~75)。
  • 研究间有很高的异质性。
  • 良好的预后与病变完全切除[风险比RR=2.42(95%CI:1.55~3.76,p<0.001)]和病变部位在颞叶[RR=1.38(95%CI:1.07~1.79,p=0.013)]有关,但与病变范围、颅内脑电图使用或FCD组织学类型无关。
  • 同一研究中包括的FCD组织类型的数量占观察到的异质性的7.6%。

      70%的具有FCD MRI特征的难治性癫痫患者在切除手术后可获得良好的癫痫发作结果。该发现可纳入常规术前咨询,并强调在安全和可行的情况下完全切除MRI检测到的FCD的重要性。

文献来源:Willard, Anna et al. “Seizure Outcome After Surgery for MRI-Diagnosed Focal Cortical Dysplasia: A Systematic Review and Meta-analysis.” Neurology, 10.1212/WNL.0000000000013066. 10 Dec. 2021, doi:10.1212/WNL.0000000000013066

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    2022-12-03 yinhl1978
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    2022-01-26 ms7000000113042242

    学了,非常棒的文章

    0

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    2022-01-18 neurowu
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    2022-01-18 freve
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