本文選題：神經膠質瘤　切入點：癲癇　出處：《大連醫(yī)科大學》2014年碩士論文　論文類型：學位論文

【摘要】：目的：總結合并癲癇的幕上膠質瘤開顱手術的經驗與治療結果；提供術前癲癇灶定位方法；探討顱內幕上膠質瘤合并癲癇的發(fā)病機理及致癇因素；討論以癲癇為首發(fā)癥狀的膠質瘤手術治療效果，為患者提供一個有效的治療方案。 方法：通過隨訪2008年3月～2010年3月經手術治療合并癲癇的幕上膠質瘤患者160例（病理證實）,分析其臨床資料，采用SPSS統(tǒng)計軟件，對并發(fā)癲癇的有統(tǒng)計學意義的篩選變量進行Logistic多元回歸分析。分析年齡、性別、主要癥狀、病程、癲癇病史、陽性體征、病變部位、采取手術入路、術中血管損傷、皮質牽拉、術后腦組織水腫、病理結果、病變復發(fā)、放射治療、術中皮層是否電灼和腫瘤切除程度等可能的影響因素為自變量，癲癇發(fā)作為因變量。術前除常規(guī)行頭顱CT及MRI檢查，還進行了常規(guī)腦電圖檢查及長程同步視頻腦電圖檢查。分析腫瘤切除程度，術中處理致癇灶的方式、方法對癲癇控制程度及預后的影響。癲癇預后按Engel分類標準進行術后療效評價：I級96例：癲癇發(fā)作消失，除外術后早期的癲癇發(fā)作；II級36例：癲癇發(fā)作極少或幾乎消失；Ⅲ級16例：值得的改善（癲癇頻率減少90%）；Ⅳ級12例：改善不明顯。 結果：腫瘤全切除128例中有96例（81%）在術中皮層腦電圖（ECoG）監(jiān)測下手術切除，癲癇完全消失；而不完全切除的32例中僅有8例（54%）癲癇發(fā)作完全消失。術中腫瘤切除的程度與預后癲癇發(fā)作有統(tǒng)計學意義（P=0.040）；術前每天癲癇發(fā)作＜1次者為86%（91/128），，而每天都發(fā)作≥1次者為56%（17/32），癲癇發(fā)作頻率與癲癇預后有統(tǒng)計學意義（P=0.048）；單純腫瘤切除的56例中術后未發(fā)生癲癇38例（54%），而腫瘤切除加MST的90例中有72例術后癲癇消失（82%）。將腫瘤全切和次全切術中是否處理致癇灶分為兩組，針對癲癇控制滿意率進行比較，差異有統(tǒng)計學意義（P0.05）。單純腫瘤切除，全切與次全切預后癲癇控制滿意率比較，差異有統(tǒng)計學意義（P0.01）。而在術中均處理致癇灶情況下，將腫瘤全切和次全切與部分切除者進行癲癇控制滿意率比較，差異無統(tǒng)計學意義（P＞0.05，見表4）。 結論：開顱手術是治療膠質瘤合并癲癇的一種有效方法，術前致癇灶的準確定位是治療關鍵。術前詳細詢問癲癇患者的病史，分析伴隨的臨床癥狀，進行全面系統(tǒng)的體格檢查，以及影像學（CT、MRI等）和實驗室檢查，明確病因診斷對臨床治療起到積極作用。并發(fā)癲癇的膠質瘤患者，切除病灶和控制癲癇同等重要。對于手術治療合并癲癇的膠質瘤患者，要求術中全切腫瘤，同時根據(jù)術中皮質腦電監(jiān)測（ECOG）徹底處理致癇灶。術前致癇灶的準確定位、選擇合適的手術入路和手術方法；術中進行病灶及致癇灶的徹底處理是獲得理想預后的有效途徑。術前癲癇病史長短、癲癇發(fā)作的頻次、腫瘤大小、瘤周腦組織水腫程度，術中手術入路、腫瘤切除程度和皮層是否電灼及術后病理級別、腦組織水腫、腫瘤復發(fā)等因素與癲癇發(fā)作密切相關，對患者預后生活質量有直接影響。術后癲癇發(fā)作對患者的神經功能康復和日常生活質量都有很大影響。另外借助心理醫(yī)生的健康指導教育可以改善患者術后的焦慮、抑郁等情緒，促進身心健康，進而提高生活質量。
[Abstract]:Objective: To summarize the epileptic supratemtorium glioma craniotomy experience and treatment results; provide preoperative localization of epileptic foci; of supratentorial gliomas with the pathogenesis of epilepsy and epileptogenic factors; to discuss the effect of surgical treatment for glioma epilepsy symptoms, provide an effective treatment regimen for patients.
Methods: through follow-up from March 2008 to 2010 3 menstrual surgical treatment of epilepsy with supratentorial gliomas were 160 cases (Pathology), analysis of the clinical data, using SPSS statistical software, screening variables on epilepsy have statistical significance in the multivariate Logistic regression analysis. The analysis of age, gender, course of disease, the main symptoms of epilepsy the history, positive signs, lesion, surgical approach, vascular injury, cortical stretch, brain edema, pathological results, disease recurrence, radiotherapy, intraoperative cortical electrocautery and whether the factors affect the tumor resection extent possible as independent variables, epilepsy as the dependent variable. In addition to the preoperative routine head CT and MRI examination, also conducted a routine EEG examination and long-range synchronization of video EEG analysis. The extent of tumor resection, intraoperative treatment of epileptogenic foci, method of seizure control extent and prognosis Effect of prognosis of the epilepsy surgery. According to Engel criteria for evaluating the effect of 96 cases of I grade: seizures disappeared, except for early postoperative seizure; 36 cases of grade II: seizures little or almost disappeared; 16 cases of grade III: worthwhile improvement (90% reduction of seizure frequency) 12 cases; grade IV: improve is not obvious.
Results: total resection in 128 cases, 96 cases (81%) in the intraoperative electrocorticography (ECoG) monitoring in surgical resection, epilepsy completely disappeared; without complete resection in 32 cases, only 8 cases (54%) seizures disappeared. Intraoperative epilepsy seizure degree and prognosis of tumor resection was statistically significant (P=0.040); preoperative seizures < 1 times every day for 86% (91/128), and every day more than 1 times for 56% episodes (17/32), the frequency of epileptic seizures and seizure outcomes were statistically significant (P=0.048); 38 cases of epilepsy occurred in 56 cases, simple tumor resection after operation (54%), and tumor resection plus MST 90 cases in 72 cases of postoperative epilepsy disappeared (82%). The total resection and subtotal resection of the tumor is treatment of the epileptogenic foci were divided into two groups according to seizure control satisfaction rate were compared, the difference was statistically significant (P0.05). Simple tumor resection, total resection and subtotal prognosis satisfactory seizure control rate The difference was statistically significant (P0.01). However, there was no statistically significant difference in the satisfaction rate of epileptic control between total resection and subtotal resection and partial resection for all epileptogenic foci. (P > 0.05, see Table 4).
Conclusion: craniotomy is an effective method for treatment of gliomas with epilepsy, accurate preoperative localization of epileptogenic foci is the key point of the treatment. The preoperative epilepsy patients asked in detail about the history, analysis of the clinical symptoms associated with, to conduct a comprehensive physical examination system and imaging (CT, MRI) and laboratory examination, clear etiological diagnosis of positive effect on the clinical treatment of glioma. Patients with epilepsy, resection of the lesion and control of epilepsy are equally important. For glioma surgical treatment of patients with epilepsy, requiring complete tumor resection, and according to the intraoperative monitoring of cortical electroencephalogram (ECOG) a thorough treatment of the epileptogenic focus. Accurate preoperative localization by the epileptogenic focus, select the appropriate surgical approach and surgical methods; thorough treatment of lesion and the epileptogenic foci in operation is an effective way to obtain ideal prognosis. Preoperative epilepsy duration, seizure frequency, tumor size, tumor Peripheral brain tissue edema, intraoperative surgical approach, the extent of tumor resection and whether cortical electrocautery and postoperative pathological grade, brain edema, tumor recurrence and factors of epilepsy are closely related, have a direct impact on the quality of life. The prognosis of patients with postoperative seizures have great influence on neural functional recovery of patients and the quality of daily life. The health guidance education by means of psychological doctor can improve the postoperative patients with anxiety, depression, and promote physical and mental health, and to improve the quality of life.

【學位授予單位】：大連醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R739.41

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