引用本文： 中国抗癫痫协会癫痫中心规范化建设工作委员会. 癫痫外科治疗术前评估规范（草案）. 癫痫杂志, 2020, 6(4): 273-295. doi: 10.7507/2096-0247.20200047 复制
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1 癫痫外科治疗术前评估的意义
DIANXIANSHIYIZHONGNAOBUMANXINGJIBING。DIANXIANDEZHILIAOSHIYIGEZHANGQI、XITONGDEGONGCHENG，XUYAOYOUSHENJINGNEIWAIKE、ERKE、SHENJINGYINGXIANG、SHENJINGXINLI、SHENJINGKANGFUDENGDUOXUEKEGONGTONGCANYU。DIANXIANWAIKESHOUSHUSHIZHILIAOHUANJIEZHONGDE“ZHONGYAOYIHUAN”ERFEI“ZUIHOUYIHUAN”；WAIKESHOUSHUDEMUDESHI“JIANQINGHUOXIAOCHUDIANXIANFAZUO，ZUIZHONGTIGAOHUANZHESHENGHUOZHILIANGBINGHUIGUISHEHUI”，ERFEIDANCHUNDE“JIANSHAODIANXIANFAZUO”。
GENJUSHIJIEWEISHENGZUZHIDETONGJI,WOGUOXIANYOUDIANXIANHUANZHEYUE 1 000 WAN,QIZHONGYAOWUNANZHIXINGDIANXIANYUE 200～300 WAN。GENJUZHONGGUOKANGDIANXIANXIEHUI（CAAE）DUIQUANGUODIANXIANSHOUSHULIANGDETONGJI，JINJINIANWOGUODEDIANXIANSHOUSHULIANGYUE 3 500～4 000 LI/NIAN。YOUCIKEJIANDIANXIANWAIKEDEZHILIAOQUEKOUFEICHANGDA。
癫痫外科手术涉及到手术适应证、基于多学科（神经内外科、儿科、神经影像、神经康复等）的综合术前评估、手术方式及手术效果等多个方面[1, 2]。下面逐一阐述。
1.1 手术适应证
原则上讲，若患者经过规范的抗癫痫药物（AEDs）治疗，仍未达到癫痫发作的有效控制，并已经影响患者的生活质量，同时患者和家属有手术治疗意愿，患者能耐受手术并能在围手术期很好地配合，就可以考虑进行术前评估。术前评估要综合考虑患者的癫痫及发作类型、电生理及影像学所见、病因及病理特征等因素（表 1）。
表1
癫痫外科手术适应证
XUANZESHUQIANPINGGUHUANZHESHI，YINGZUNXUNGETIHUAYUANZE：① YAOWUZHILIAOGUANCHASHIJIAN：YONGLIANGZHONGYISHANG AEDs、GUANCHALIANGNIANYIRANYOUDIANXIANFAZUODEHUANZHEWEIYAOWUNANZHIXINGDIANXIAN，CIBIAOZHUNSHIYONGYUDADUOSHUHUANZHE。DANDUILUNEIZHONGLIUXINGBINGBIAN、KUAISUJINZHANDE Rasmussen NAOYAN、YINGYOUERNANZHIXINGDIANXIANHUODIANXIANXINGNAOBINGDENGQINGKUANG，YIZAOQICAIQUSHOUSHUZHILIAO；② MOUXIETESHUDIANSHENGLITEZHENG：YOUQIZAIHUANER，MOUXIETESHUBUWEIJUZAOQIYUAN（RUNAOYENEICEMIAN）DEDIANXIAN，XIANXINGFANGDIANKEYICHENGXIANMIMANXING、DUOZAOXINGSHENZHIQUANMIANXING（TONGCHANGSHIYOUYUYICHANGFANGDIANDEKUAISUCHUANBOSUOZHI），ZHEIZHONGQINGKUANGJINGGUOZIXIPINGGU，KENENGBINGFEISHIJUEDUISHOUSHUJINJI；③ SHOUSHUNIANLING：ZHENDUIERTONGNANZHIXINGDIANXIAN，MINGQUEDIANXIANZAOHOUYINGJINZAOSHOUSHU，YIMIANFANFUDIANXIANFAZUOYINGXIANGSHENJINGXITONGFAYU，ERTONGDANAOJUYOUJIAOHAODEGONGNENGKESUXING，SHOUSHUSHIYINGZHENGDEXUANZEYAOXIANGDUIJIJI。ZHENDUILAONIANDIANXIANHUANZHE，JINGUANYOUGEANBAODAO，ZONGTISHANG 60 SUIYISHANGJIESHOUSHOUSHUDEBINGLIRENGPIANSHAO；④ RENZHIGONGNENG；DUICHENGNIANHUANZHE，RENZHIGONGNENGDIXIATISHICUNZAIMISANXINGNAOGONGNENGYICHANG，SHOUSHUYAOXIANGDUIJINSHEN；DUIHUANER，JUZAOXINGBINGBIANKEYIDAOZHIMIMANXINGNAOGONGNENGZHANGAI，ERSHOUSHUZHILIAOKENENGYOUZHUYUGAISHANRENZHIGONGNENG。
1.2 手术方式的选择
DIANXIANDESHOUSHUFANGSHIBAOKUOQIECHUXINGSHOUSHU、GUXIXINGSHOUSHU、LITIDINGXIANGHUISUNSHUJISHENJINGDIAOKONGSHOUSHU。① QIECHUXINGSHOUSHU：KAIZHANZUIDUOYESHIZUICHENGSHUDESHOUSHUFANGSHI，SHITONGGUOQIECHUDIANXIANYUANQUHEFAZUOQISHIQULAIJINKENENGDADAOHUANZHESHUHOUWUFAZUODEMUDE；QIECHUXINGSHOUSHUBAOKUO“BINGZAOXINGDIANXIAN”HECIGONGZHENCHENGXIANG（MRI）YINXINGDEJUZAOXINGDIANXIAN，RUNAOPIZHIDIANXIANZAOQIECHUSHU、QIANNIEYEQIECHUSHU、XUANZEXINGXINGRENHE-HAIMAQIECHUSHU、DANAOBANQIUQIECHUSHUDENG；② GUXIXINGSHOUSHU：CILEISHOUSHUZHIZAIZUDUANDIANXIANFANGDIANDECHUANBOTONGLUYIDADAOJIANQINGFAZUODEMUDE，TONGCHANGNANYIWANQUANXIAOCHUFAZUO；CHANGYONGSHUSHIBAOKUOPIANZHITIQIEKAISHU、DUOCHURUANNAOMOXIAHENGXINGXIANWEIQIEDUANSHUDENG；③ JUBUHUISUNSHOUSHU：YUNYONGLITIDINGXIANGJISHU，JINGQUEHUISUNNAOSHENBUDEJIEGOU，LIRUNAOSHENBUWEIXIAOBINGZAO、XINGRENHE、HAIMADENG；LITIDINGXIANGFANGSHEWAIKE，RU γ-DAO、X-DAOYESHUYUCILEISHOUSHU；④ SHENJINGDIAOKONGSHOUSHU：TONGGUODIANHUOCICIJIGAIBIANSHENJINGXITONGGONGNENGERHUODEZHILIAOXIAOGUO，ZHUYAOBAOKUOMIZOUSHENJINGDIANCIJI、NAOSHENBUTESHUHETUANDIANCIJI、BIHUANSHISHENJINGCIJISHUDENG。
1.3 术前评估与手术治疗方案选择
药物难治性癫痫患者能否手术、实施何种手术，取决于由多学科组成的综合评估团队的评估结果。只有综合患者癫痫发作的临床表现（症状学）和各种客观检查资料，才能对可能的癫痫灶有一个全面的“理解和认识”。由于癫痫灶是一个理论性的概念，目前缺乏定位的金标准，故在实际临床工作中，多数学者采用下述的癫痫灶相关概念来最终定位可能的癫痫灶（表 2）。
表2
癫痫灶等相关概念及检查技术
JINNIANLAI，GUONEIWAIXUEZHEJIADALEDUINAOWANGLUO、DIANXIANWANGLUODEJICHUHELINCHUANGYANJIU。CONGJIEPOU-DIAN-LINCHUANGDE“SANWEIYITI”JIAODUQULITIDINGWEIKENENGDEDIANXIANZAO。SUIZHEXIANDAIKEXUEJISHUDEFAZHANHEPINGGUSHOUDUANDEJINYIBUCHENGSHU，DINGWEIDIANXIANZAOHUIBIANDEYUELAIYUEJINGQUE。
SHOUSHUFANGSHIDEXUANZEQUJUEYUDUIDIANXIANZAODERENSHIHELIJIECHENGDU。LILUNSHANGJIANG，DIANXIANZAODINGWEIDEYUEJINGZHUN，DUIDIANXIANZAODEGONGNENGRENSHIYUEQUANMIAN，SHISHIDIANXIANZAOQIECHUXINGSHOUSHUDEKENENGXINGYUEDA；FOUZE，RUOBUNENGJINGQUEDINGWEIHUOSHOUSHUHUIDAILAIYANZHONGDESHENJINGGONGNENGQUESUN，ZEYINGCAIQUGUXIXINGSHOUSHUHUODIAOZHENGYAOWUZHILIAO。
1.4 手术后效果
JIYUZONGHEPINGGUJICHUSHANGDEWAIKESHOUSHU，QISHUHOUXIAOGUOSHOUZHUDUOYINSUDEYINGXIANG，YUKENENGDEZHIXIANBINGLI、HUANZHEBINGCHENG、ZHILIAOSHIJI、NIANLINGJISHUZHEDECAOZUOJISHUDENGYOUGUAN。
克利夫兰癫痫中心对 136 例儿童和青少年癫痫患者进行外科治疗，各年龄段癫痫发作完全控制率分别是 69%（13～20 岁）、68%（7～12 岁）、75%（3～6 岁）、60%（3 岁以下），说明癫痫患儿的手术疗效至少与成年癫痫患者相当[1]。
就颞叶癫痫而言，2001 年 Weibe 等[2]在《新英格兰杂志》发表了第一篇关于成年人颞叶癫痫手术与药物治疗的前瞻性对照研究：1 年内手术组无发作率为 58%，药物组为 8%，二者具有统计学差异；生活质量的比较显示药物组低于手术组，但无统计学差异。Engel 等[3]于 2012 年发表了经过 2 年的随访结果，手术组无发作率为 73%，而药物组为 0，有统计学差异。瑞典的 Edelvik 教授等[4]随访了 5 年以上的颞叶癫痫手术后情况，无发作率在 40%～66%，术后停药率约为 20%，术后无发作者停药率为 43%～86%。
Ansari 等[5]研究发现，非颞叶癫痫术后 5 年无发作率为 14.7%～68%。局灶性皮质发育不良（Focal cortical dysplasia，FCD）-I 型和癫痫灶切除不完全是癫痫再发作的独立影响因素。Althausen 等[6]经过近 10 年随访大脑半球切除术的效果，75%（45/61）的患者无癫痫发作，且 80% 的无发作者已停用 AEDs。同时，在切除性手术中大脑半球切除术后患者的认知和生活质量改善非常明显，长期随访显示 28% 的患者 IQ 提高，85% 的患者至少 1 项认知水平改善，57% 的患者行为障碍减轻。Malik 等[7]随访了 11 例婴儿早期肌阵挛脑病的患儿，经切除性手术治疗后 Engel I 级 7 例、Engel Ⅱ 级 4 例，发育水平接近正常。而同期 15 例未手术的患儿半数死亡，生存的患者均存在显著的发育迟滞。Lancman 等[8]Meta 分析显示：胼胝体切开术对失张力发作的控制优于迷走神经刺激术，其他癫痫发作类型二者间无统计学差异。一项有关脑深部电刺激治疗癫痫的多中心双盲随机对照研究显示了双侧丘脑前核刺激治疗癫痫的有效性。3 个月双盲期结束时刺激组较对照组癫痫发作明显减少（40.4% vs.14.5%，P = 0.002），术后 2 年癫痫发作减少中位数达到 56%，54% 的患者有效[9]。
ZONGZHI，ZAIJINGZHUNDINGWEIDIANXIANZAODEJICHUSHANG，DIANXIANSHOUSHUZHILIAOJUZAOXINGDIANXIANLIAOXIAOKENDING，ZHILIAOBINGZAOXINGQUANMIANXINGDIANXIANYEYOUJIAOHAODEXIAOGUO。
2 癫痫灶和癫痫网络
2.1 癫痫发作分类
DIANXIANDEFAZUOFENLEI，JINGDIANDESHIGUOJIKANGDIANXIANLIANMENG（ILAE）YU 1981 NIANZHUYAOCANZHAONAODIANTU（EEG）JIEGUOHELINCHUANGBIAOXIANTICHUDEFANGAN。GENJUFAZUOSHIYOUWUYISHISANGSHIJIANGBUFENXINGFAZUOQUFENDANCHUNBUFENXING、FUZABUFENXING，QIZHONGYINGYONGDE“BUFENXING”SHUYUZAI 2000 NIANHOUDEXIUDINGZHONGGENGGAIWEI“JUZAOXING”，YIBIMIANYINQILINCHUANGQIYI。ILAE GAODUCHOUXIANGHEGAIKUOHUADEFENLEIDUILINCHUANGYAOWUZHILIAODEXUANZEYOUZHONGYAOJIAZHI，DANYOUYUQUEFADUIFAZUOZHENGZHUANGXIZHIDEMIAOSHUYIJIDUIFAZUOYANBIANDEFANYING，DUILIJIEFAZUOZHENGZHUANGYUGONGNENGJIEPOUDEXIANGGUANXINGHEFAZUOZHENGZHUANGDEDINGWEIJIAZHIYOUXIAN。
2017 年，ILAE 对癫痫发作分类做了较大变动，体现在局灶性发作分类中，注重了发作症状的特征，有助于理解发作症状所涉及的神经网络（图 1）。
图1
2017 年国际抗癫痫联盟癫痫发作分类建议
DIANXIANFAZUODEFENLEISUIZHERENMENRENSHIDESHENRUZAIBUDUANWANSHANZHIZHONG。YOUYUNANZHIXINGJUZAOXINGDIANXIANSHOUSHUZHILIAOZAIJIN 20 YUNIANDEGUANGFANKAIZHAN，DUIDIANXIANFAZUOFENLEIDEDINGWEIYIYITICHULEGENGGAODEYAOQIU。XIANJIEDUAN ILAE TICHUDEJUZAOXINGFAZUOFENLEIFANGAN，JINGUANYINRULEWANGLUOGAINIAN，DANDUIYUYUFAZUOZHENGZHUANGDEGONGNENGJIEPOUJIEGOUDEXIANGGUANXINGLIANXIRENGRANYOUXIAN。KEYIGENJUFAZUOZHENGZHUANGTEZHENGHEXIJIEJINXINGDEFAZUOZHENGZHUANGXUEFENLEI，CHANGSHIYINGYONGYUSHUQIANPINGGU，DANSHIJIANYUDIANXIANFAZUOZHENGZHUANGXUEDEFUZABIAOXIAN，MUQIANRENGQUEFATONGYIBINGQIEJUYOUPUBIANYINGYONGJIAZHIDEFAZUOZHENGZHUANGXUEFENLEITIXI，SHIJIANZHONGYINGGAIZHUZHONGGETIHUAPINGGUYUANZE。
2.2 癫痫源理论
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ZAIJINGDIANDEDIANXIANYUANLILUNTIXIZHONG，DIANXIANZAOSHIZHISHIXIANSHUHOUWUFAZUOSUOXUYAOQIECHUDEZUISHAONAOZUZHI。DUIYUBUTONGDEDIANXIANYUANQUYUXIANGGUANGAINIAN，JINGDIANDEDIANXIANYUANLILUNTIXIMIAOSHULEGEZIXIANGDUIDULIDEGONGNENGTEZHENGHEXIANGYINGDEDINGWEISHOUDUAN，TONGSHIBINGWEILINCHUANGSHOUSHUCAOZUOTICHULEXIANGYINGDEJIANYI。
ZAILINCHUANGSHIJIANZHONG，YOUYUDIANXIANYUANJINWEILILUNXINGGAINIAN，MUQIANQUEFADINGWEIDEJINBIAOZHUN。LINCHUANGTONGGUOBUTONGJIAODULAIDINGWEIDIANXIANYUANXIANGGUANQUYU，ZUIZHONGTUIDAODIANXIANYUANDEDINGWEIJIASHE，QIANGDIAOGETIHUADEYUANZE，ZAIJINKENENGBAOHUGONGNENGPIZHIDEQINGKUANGXIA，YIJIEGOUXINGDIANXIANBINGLIZAOHEDIANXIANFAZUOQIYUANQUZUOWEISHOUSHUSHOUYAOQIECHUDENAOZUZHIJUYOUHELIXING。
2.3 癫痫脑网络
XIANDAIYINGXIANGXUEHESHENJINGDIANSHENGLIDENGJISHUYIJIJICHUSHENJINGKEXUEYANJIUDEJINZHANTISHIDIANXIANSHINAOWANGLUOXINGJIBING。MUQIANDEGUANNIANQINGXIANGYUJUZAOXINGDIANXIANFAZUOSHEJILEPIZHI-PIZHIJIANWANGLUOYIJIPIZHI-PIZHIXIAWANGLUO，ERBUJINJINSHIDANDUDEDIANXIANYUAN。DIANXIANWANGLUODEGAINIANYETIXIANZAI 2017 NIAN ILAE XINTICHUDEDIANXIANFAZUOFENLEIFANGANZHONG。
CONGTULUNDEJIAODUFENXI，GOUJIANDIANXIANWANGLUOXUYAOLIANGGEHEXINYAOSU：WANGLUODEJIEDIANHEWANGLUODEBIANXIAN。DIANXIANFAZUOZHONGSUOSHEJIDEBUTONGJIEPOUJIEGOU，KEYIBEIRENWEISHIWANGLUODEJIEDIAN，ERBUTONGJIEPOUJIEGOUZHIJIANDELIANXIQIANGDU，JIJIEDIANZHIJIANLIANXIDEMIQIECHENGDUWEIWANGLUODEBIANXIAN，DIANXIANWANGLUOGENGQIANGDIAOLEGONGNENGXINGLIANXI。
2.3.1 脑皮质的功能解剖与癫痫网络
2.3.1.1 从功能解剖的角度认识癫痫网络
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2.3.1.2 从脑解剖连接的角度理解癫痫网络
MUQIANYINGYONGDEMISANZHANGLIANGCHENGXIANGJISHUNENGGOUHENHAODEZAITIGUANCHARENLEIDEBAIZHICHUANDAOTONGLU，LIRU，GOUSHULIANJIELENIEYEQIANBUHEKUANGEHUI，SHIXINGCHENGQIANBIANYUANXITONGBINGSHEJIQINGGANDEZHONGYAOJIEPOUJICHU。WEIYUFUCEDEXIAZONGSHULIANJIELEZHENYESHIJUEQUHENIEYENEICEHAIMAYIJIXINGRENHE，SHEJILESHIJUEGANZHI、MIANKONGSHIBIEDENGGONGNENG。ERLIANJIEWAICELIEZHOUWEIPIZHIBAOKUONIEYE、DINGYEHEEGAIDEGONGZHUANGSHUZAIYOUSHIBANQIUZHUYAOSHEJILEYUYANJIAGONG，ZAIFEIYOUSHIBANQIUZESHEJILESHIKONGJIANXINXIJIAGONGDENG。
DIANXIANFAZUOZHENGZHUANGFUZA，TISHIDIANXIANFAZUODECHUANBOWANGLUOFUZA。ZHENDUIHUANZHEGETI，RUQIFAZUOZHENGZHUANGXIANGDUIKEBAN，ZAIFAZUOJINCHENGZHONG，FAZUOZHENGZHUANGHETIZHENGDECHUXIANSHUNXUJUYOUYIZHIXING，TISHIDIANXIANFAZUOCHUANBOCUNZAIYOUXIANCHUANBOTONGLU，ERNAOJIEPOULIANJIEDUIYULIJIEZHENGZHUANGXUEDEYANBIANJUYOUJIJIDEYIYI。
2.3.1.3 从特异性功能环路深化对癫痫网络的认识
DANAOSHEJILEFUZADEGONGNENG，BAOKUOYUNDONG、QUTIGANJUE、ZIZHUSHENJING、YUYAN、JIYI、QINGGANDENG，TONGSHIYESHEJILEBUTONGDESHENJINGGONGNENGWANGLUO。LIRU，YUNDONGGONGNENGWANGLUOZHUYAOSHEJILEFUZHUYUNDONGQU、YUNDONGQIANQU、ZHONGYANGQIANHUIDENGJIEGOU，GONGTONGWANCHENGYUNDONGDEJIHUA、ZHIXINGYIJIJIANCEXIUSHIDENG；YOUXINGRENHE、QIANDAO、KUANGEHUI、QIUNAOQIANBU、QIANKOUDAIHUIZUCHENGLEQIANBIANYUANXITONG，ZHUDAOQINGGANGONGNENG；ERYOUHAIMA、HAIMAXIATUO、NEIXIUPIZHI、PANGXIUPIZHI、HAIMAPANGHUI、YABUPIZHI、HOUKOUDAIHUIDENGZUCHENGDEHOUBIANYUANXITONG，GOUCHENGLEWANCHENGMIAOSHUXINGJIYIHEKONGJIANJIYIGONGNENGDEZHUTI。TONGSHI，ZAITEYIXINGSHENJINGHUANLUZHONG，XUYAOSHUXIXINXIDELIUXIANG，LIRU，JINGDIANDESHIJUEXINXIYOUCHUJISHIJUEPIZHITONGGUOBEICEHUANLUCHUANDAO，ZHUYAOSHIBIEXIANGGUANKONGJIANDINGWEIDESHIJUEXINXI，ERFUCEHUANLUGENGDUODISHEJILESHIJUEXINXIDENEIRONG。
DIANXIANFAZUOZHENGZHUANGSHINAOGONGNENGYICHANGDEFANYING，DUIYUTEYIXINGNAOGONGNENGWANGLUODERENSHIWEIDINGWEIDIANXIANQIYUANHESHEJIDEWANGLUOTIGONGLESILU。LIRUKONGJU、FENNU、KUQI、YUYUEGANDENGFAZUOBIAOXIAN，WANGWANGTISHIQIYUANHUOZHELEIJILEQINGGANHUANLUZHONGDEBUTONGJIEGOU，EREXIN、OUTU、LIUXIAN、WEICHANGDAOYIJIKOUYANZIDONGZHENGDENGZHENGZHUANG，ZETISHILENIEJI、XINGRENHEYIJIQIANDAOYEWEIZHUDEZIZHUSHENJINGGONGNENGWANGLUOSHOULEI，TEBIESHIQIANDAOYEDEQIYUANHUOYICHANGHUODONGBOJIDAOLECIQUYU；TONGSHI，XINGRENHEYIJIQIANDAOYESHISHEJIFAZUOXINGXINLVGAIBIANDEGUANJIANJIEGOU，ZUOCEBANQIUSHIFUJIAOGANSHENJINGDIAOJIEZHANYOUSHI，XINLVJIANMAN（<50 CI/min）、XINLVBUQISHENZHIXINBOTINGZHI（R-R JIANQI>3s）DENGBIAOXIANZEDUOYUZUOCEXIANGGUAN；YOUCESHIJIAOGANSHENJINGDIAOJIEZHANYOUSHI，LINCHUANGCHANGJIANDEXINDONGJIASUBIAOXIAN（>120 CI/min）WANGWANGDINGWEIZAIYOUCE。XUYAOQIANGDIAODESHI，JINGUANTEYIXINGNAOGONGNENGWANGLUOYOUZHUYUTISHIDIANXIANWANGLUO，DANSHIDIANXIANFAZUOKENENGSHIYIDUOFANGXIANGBINGXINGHE/HUOXUGUANDEFANGSHICHUANBO，WANGWANGKEYILEIJIDUOGEGONGNENGWANGLUO，SUOYIDUIYUFAZUOZHENGZHUANGDERENSHIXUYAOZAISHIJIANJINCHENGZHONGQUANMIANKAOLVFAZUOZHENGZHUANG，BUTONGFAZUOZHENGZHUANGCHUXIANDEZAOWANCIXUDUIYUZHENGZHUANGQIYUANDEJIESHIZHIGUANZHONGYAO；YOUYUFAZUOZHENGZHUANGYEWANGWANGSHIBUTONGGONGNENGJIEGOUXIANGHUZUOYONGDEJIEGUO，BUTONGFAZUOZHENGZHUANGTONGSHICHUXIANDEXIANXIANG，DUIYUFAZUOQIYUANDETISHIWANGWANGJUYOUTEZHENGXING。
2.3.2 电生理技术刻画动态癫痫网络
JIANYUDIANXIANFAZUOSHIDONGTAIDESHIKONGJINZHANGUOCHENG，GUANZHUFAZUOXINGFANGDIANDEHUODONGGUILV，KEWEIJIESHIDIANXIANWANGLUOTIGONGYOUJIAZHIDEZILIAO。
LINCHUANGSHANG EEG DEYUEDUWANGWANGJIYUMUCE，KEHUODEDIANXIANXINGFANGDIANQIYUANHECHUANBODEZONGTIDEDINGXINGJIELUN，JIBUTONGBUWEIZHIJIANDETONGBUXINGGUILV；JINYIBUYINGYONGBUTONGDEXIANXINGHUOZHEFEIXIANXINGJISUANFANGFANENGGOUDINGLIANGFANYINGDIANXIANFAZUOWANGLUOHUODONGDEGUILV。ZHIJIEPIZHIDIANCIJIKEYIMINGQUEJUTIKONGJIANJIEPOUJIEGOUDEGONGNENG，ERPIZHI-PIZHIJIANYOUFADIANWEINENGPINGJIAJIEPOUJIEGOUZHIJIANDEGONGNENGLIANXI，ZHIGUANBINGJUYOUFANGXIANGXINXI，WEILIJIEDIANXIANDEJIEPOU-DIAN-LINCHUANGFAZUOCHUANBOTIGONGLEXINSHIJIAO。
XIANGDUIYUTOUPI EEG，LUNEI EEG TIGONGLEGAOKONGJIANFENBIANLV、GAOSHIJIANFENBIANLVDENAODIANXINHAO，WEIRENSHIDIANXIANWANGLUOTIGONGLEXINDESHOUDUAN。QIZHONG，PIZHI EEG NENGGOUXIANSHIFAZUOXINGFANGDIANZAIPIZHIBIAOMIANDEWANGLUOCHUANBOGUILV，TONGGUOLITIDINGXIANGSHOUDUANZHIZHIRUSHENBUDIANJIDELITINAODIANTUJISHUNENGGOUTONGSHIJILUYINGMOXIADIANJIBUNENGHUODEDEXINXI，KEYIZHIRUXINGRENHE、HAIMA、DAOYEYIJINEICEEYEDENGJIEGOU。Bancaud HE Talairach ZAIBANGESHIJIQIANTICHULELITIDINGXIANGNAODIANTUDEYUANLI，GUANZHUDIANXIANFAZUOZHENGZHUANGDEJIEPOU-DIAN-LINCHUANGXIANGGUANXING，TONGGUOMIAOSHUDIANXIANXINGFANGDIANDESHIJIANHEKONGJIANDESANWEIDONGTAIGUOCHENG，KEYITUIYANDIANXIANFAZUODEQIYUANHECHUANBODELITIWANGLUO。
DIANXIANYUANHEDIANXIANWANGLUODELILUNHEGUANNIANJUNZAIFAZHANGUOCHENGZHIZHONG，WEIZHENGTILIJIEDIANXIANFAZUOZHENGZHUANGYANBIANTIGONGLEKUANGJIA。
3 癫痫术前评估的方法
3.1 癫痫发作症候学
DIANXIANFAZUOZHENGZHUANGYIZHISHIDIANXIANFAZUOHEDIANXIANZONGHEZHENGFENLEIDEZHONGYAOYIJUZHIYI。DIANXIANFAZUOZHENGZHUANGDEMIAOSHUJIBENLAIZIYUHUANZHEHUOMUJIZHETIGONGDUIFAZUODEXIANGXIMIAOSHUHE/HUOVEEGJILUDAODEFAZUOLUXIANG。RENMENDUIDIANXIANDERENSHIZAI ILAE DUIDIANXIANFAZUOFENLEIBIAOZHUNDEBUDUANXIUGAIZHONGDEDAOLEHENHAODETIXIAN。2017 NIAN ILAE TICHUDEXINDIANXIANFAZUOFENLEISHIJIYU 1981 NIANDIANXIANFAZUOFENLEIBIAOZHUNHE 2010 NIANDIANXIANFAZUOFENLEIJIANYI，BINGJIEHELINCHUANGYISHENGDEYIJIANERJINXINGDEYICIBIJIAODADEGEXIN。XINDEDIANXIANFAZUOFENLEIYIJIANZHONGGENGZHONGSHIGENJUFAZUOZHENGZHUANGJIFAZUOZHENGZHUANGYANBIANJINXINGFENLEI，QIANGDIAOLINCHUANGFAZUOBIAOXIANZAIDIANXIANFAZUOFENLEIZHONGDEZUOYONG。2017 NIAN ILAE DIANXIANFAZUOFENLEIZHONGQIANGDIAOLEJUZAOXINGQIYUANDEGELEIFAZUO，YOUZHUYULIJIEFAZUOZHENGZHUANGWANGLUO。ERJUZAOXINGXINGQIYUANDEFAZUOSHIYAOWUNANZHIXINGDIANXIANXUANZEWAIKESHOUSHUDEZUICHANGJIANDEFAZUOLEIXING。
DIANXIANSHUQIANPINGGUSHIDUIDIANXIANFAZUOXIANGGUANDEJIEPOU-DIAN-LINCHUANGZILIAOJINXINGZONGHEFENXIPANDINGDIANXIANZAODEGUOCHENG，QIZHONGLINCHUANGFAZUOZHENGZHUANGSHIDIANXIANSHUQIANPINGGUDESANZUZHIYI，QIZHONGYAOXINGBUYANERYU。
ZAIDIANXIANZAODINGWEIGUOCHENGZHONG，DIANXIANFAZUOZHENGZHUANGKEYIBANGZHUDIANXIANZAODINGCEHEDINGWEI，HAIKEYIYOUZHUYULIJIEDIANXIANYICHANGHUODONGZAINAONEIDEYANBIANGUOCHENG。ZONGHEFENXICAINENGCHONGFENTIXIANFAZUOZHENGZHUANGDEDIANXIANZAODINGWEIJIAZHI。ZHEISHIYINWEIFAZUOZHENGZHUANGQUHEDIANXIANZAOBUYIDINGYIZHI，RENHEJIHUOFAZUOZHENGZHUANGQUDEDIANHUODONGJUNKENENGSHIGAIQUCHANSHENGHUOBIAODAXIANGYINGZHENGZHUANG。SUOYIGENJUFAZUOZHENGZHUANGPANDINGDEFAZUOZHENGZHUANGQUKENENGHEDIANXIANZAOYIZHIHUOJIEJIN，YEKENENGSHIYUANGEDIANXIANZAO。TONGYIFAZUOZHENGZHUANGKEYOUBUTONGDIANXIANZAOYINQI，BUTONGDIANXIANZAOKEYINQITONGYIFAZUOZHENGZHUANG，LIRU，GUODUYUNDONGFAZUOBIAOXIANKEJIANYUEKUANGHUI、FUZHUGANJUEYUNDONGQU、KOUDAIHUI、NIEJI、DAOYE、DINGYE、ZHENYEDENGBUTONGBUWEIDEDIANXIANZAOYINQIDEFAZUOZHONG。ERQIYUEKUANGHUIDEFAZUO，ZAIKUOSANZHIZHENGZHUANGQIYUANQUZHIQIANWUZHENGZHUANG，CIHOUKEYINKUOSANDAOBUTONGDEFAZUOZHENGZHUANGQUERCHUXIANBUTONGZHENGZHUANG：① DANGXIANXINGDIANHUODONGLEIJICHUJIYUNDONGQUSHI，KEYINQIZHENLUANXINGFAZUO；② DANGFUZHUGANJUEYUNDONGQUBEIJIHUOSHI，KECHUXIANFEIDUICHENGXINGQIANGZHIHUOGUODUYUNDONGXINGFAZUO。
发作症状学的定侧定位价值见表 3。随着医学特别是癫痫相关科学的发展，人们对癫痫发作症状及其在癫痫灶定位中的价值的认识会进一步加深。
表3
癫痫发作症状的定侧价值（定侧价值>75%）
3.2 癫痫术前评估影像学
DIANXIANSHUQIANPINGGUYESHIYOUGUANDIANXIANFAZUODEJIEPOU-DIAN-LINCHUANGDEPINGGUGUOCHENG，QIZHONGJIEPOUXUEFANGMIANDEPINGGUSHITONGGUODUOZHONGYINGXIANGXUESHOUDUANSHIXIANDE。BAOKUOJIEGOUYINGXIANGXUE、GONGNENGYINGXIANGXUE、HEYIXUEDENGDUOZHONGJISHU，ERYINGXIANGXUEHOUCHULIJISHUDEJIANLIWEIDIANXIANZAODEDINGWEITIGONGLEJIDADEBIANLI。
3.2.1 结构影像学
在难治性癫痫的术前评估中，脑结构影像学极为重要。结构影像学主要包括计算机断层成像（CT）或MRI，可明确脑内有无结构性病变，确定病灶部位和范围[10]。但要注意：结构影像学上显示的脑内病变并不一定是癫痫灶，它与癫痫灶的关系：① 与癫痫灶基本一致；② 癫痫灶在病变周围，例如脑软化灶；③ 癫痫灶与病变无关；虽然局部脑结构影像改变并不一定是癫痫灶，但二者之间常有密切联系，根据结构影像学定位癫痫灶的可靠性可达到 70% 以上[11-13]。
3.2.1.1 头部计算机断层扫描
TOUBU CT YOUZHUYUXIANSHIHANYOUGAIHUA、CHUXUEDENGBINGBIAN。DUIYULINCHUANGHUAIYIYOUGAIHUAHUOCHUXUEXINGBINGBIANDEHUANZHE（RUJIEJIEXINGYINGHUA、KENENGHANYOUGAIHUADEZHANWEIXINGBINGBIAN、CHUXUEDENG），JIANYIJINXINGTOUBU CT SAOMIAO。
3.2.1.2 头部磁共振
ZAIDIANXIANSHUQIANPINGGUZHONG，JIANYIXUANYONGCHANGQIANG 1.5T JIYISHANG，CHANGGUI MRI XULIEBAOKUO T1 JIAQUANCHENGXIANG（T1-weighted images，T1WI，GUANZHUANGWEI、ZHOUWEI、SHIZHUANGWEI）、T2 JIAQUANCHENGXIANG（T2-weighted images，T2WI，GUANZHUANGWEI、ZHOUWEI）、YETISHUAIJIANFANZHUANHUIFU（Fluid-attenuation inversion recovery，FLAIR）CHENGXIANG（GUANZHUANGWEI、ZHOUWEI、SHIZHUANGWEI）DENG，CENGHOU 1～3 mm，CENGJIANGE 0～1 mm。JIANYIXUANYONG OM XIANHUO AC-PC XIANWEISAOMIAODINGWEIXIAN。DUIYUTESHUDEXINGQUQUHUOJIEGOUKELINGHUODIAOZHENGSAOMIAOJIAODU，LIRUWEIXIANSHIHAIMA，KEXUANZECHUIZHIYUHAIMAZHANGZHOUDESAOMIAOXULIE（GUANZHUANGWEI），ERXUANZE FLAIR XULIEYOUZHUYUGENGHAODIFANYINGHAIMANEIBUJIEGOU，FAXIANQINGWEIDEHAIMABINGBIAN。
KEGENJUTIAOJIANXUANZECIMINGANJIAQUANCHENGXIANG，NENGGENGHAODIXIANSHIWEIXIAOXUEGUANJIXINGRUHAIMIANZHUANGXUEGUANLIUDAOZHIDEWEICHUXUEHEHANTIEXUEHUANGSUDECHENJI。
BOCENGDE T1 JIAQUANCIHUAQIANGDUYUBEITIDUHUIBOXULIE（Magnetization prepared rapid acquisition gradient echo，MPRAGE），NENGBICHUANTONG T1W CHENGXIANGFANGFAGENGWEIQINGXIDIXIANSHIPIZHIJIEGOUYICHANG，YOULIYU FCD DEJIANCHU。
3.2.1.3 高场强磁共振成像
高场强MRI有较高信噪比，从而具有更高的空间分辨率，揭示更微小的解剖结构细节，因此较传统 MRI 具有更高的病灶检出率；例如，3.0T MRI 在 1.5T MRI 阴性病例的病灶检出率为 65%[14]。7T MRI 在 3.0T MRI 阴性病例的病灶检出率为 29%[15]，尽管尚未在临床广泛应用。
3.2.1.4 影像后处理技术
MRI 后处理技术是一项对原始 MRI 数据进行调整重建再对比分析的方法，能够提高发现癫痫相关的结构异常的敏感度。高分辨 MRI 序列虽然能够检出相当数量的结构性病变，如海马硬化和 FCD IIb 型，但仍有高达 30% 的微小病变被漏诊[16]。MRI阴性患者术后无发作比例低，仅为38%左右[17]，所以建议术前评估中对影像学数据适当运用影像后处理技术。例如对于海马，可以进行海马体积测量和信号分析[18]，定量评价海马萎缩及信号改变的程度，发现轻微异常。
对于可疑 FCD，可应用基于体素的形态测量（Voxel-based morphometry，VBM），自动提取个体 T1W 的灰质和白质信息，并与正常对照数据库进行统计学比较，有助于发现微小皮质病灶。灰白质交界计算模型[19, 20]、皮质厚度定量测量、基于大脑形态学及一阶结构模型[21]、脑沟的形态学测量[22, 23]等后处理技术也逐步应用于新皮质微小病灶的检出，提高了病灶检出率。
YINGZHUYIDESHI，MRI HOUCHULIJISHUQIANQUEDAYANGBEN、QIANZHANXINGYANJIU，SHANGDAIJINYIBUFENXIQILINCHUANGYINGYONGJIAZHIHEZHENDUANXIAONENG。MRI HOUCHULIJISHUJINSHIJIEGOUSHANGDEFENXI，XUYAOJIEHEHUANZHEDEQITAJIEPOU-DIAN-LINCHUANGXINXI［BINGSHI、ZHENGZHUANGXUE、EEG、NAOCITU（Magnetoencephalography，MEG）、ZHENGDIANZIFASHEJISUANJIDUANCENGXIANXIANG（Positron emission tomography，PET）JIDANGUANGZIJISUANJIDUANCENGXIANXIANG（Single-photon emission computed tomography，SPECT）DENG］JINXINGZONGHEPANDUANCAIYOULINCHUANGYIYI。
3.2.2 功能影像学
3.2.2.1 功能磁共振成像
癫痫外科手术目的是最大限度的切除癫痫灶，同时最大程度的保留功能区。功能磁共振成像（fMRI） 是一种在活体进行的无创性功能成像技术，其成像原理是当大脑神经元放电活跃时，局部脑区的血流量增加，氧合血红蛋白增加，脱氧血红蛋白减少，两种血红蛋白的顺磁性不同，这种血氧水平变化引起的 MRI 信号变化，称之为血氧水平依赖（BOLD）的fMRI。它包括任务态和静息态 fMRI，前者可应用于运动区及语言区的定位，后者可用于癫痫灶定位[24]。
fMRI 技术的优点是空间分辨率高，有利于深部病灶的发现并确定手术范围，但是其时间分辨率低，因此临床将 EEG、fMRI 结合起来，能够了解并分析异常间期放电时血氧水平依赖的反应，对于癫痫灶的判定有一定价值[25, 26]。
3.2.2.2 正电子发射计算机断层显像
借助于正电子核素标记物，正电子发射计算机断层显像（PET） 可以无创、动态、定量评价活体组织或器官在生理状态及疾病过程中的功能状态。广泛应用的是 PET-CT 一体机，可同时获得 CT 解剖图像和 PET 功能代谢图像，两种图像优势互补，使医生在了解生物代谢信息的同时获得精准的解剖定位，从而对疾病做出全面、准确的判断。基于这种优势，目前 PET 检查已经广泛应用于癫痫灶的定位诊断中。在癫痫发作的发作期，病灶中大量神经元的同步放电，能量消耗增加，导致局部血流和葡萄糖代谢增多，呈高代谢；而在癫痫发作间期，癫痫灶由于存在海马或大脑皮质萎缩、神经元减少，局部血流和葡萄糖代谢减低，一般呈低代谢。利用18F 标记的脱氧葡萄糖（fluoro deoxy glucose，FDG）作为示踪剂，发现组织对示踪剂摄取能力的不同可直观的提示癫痫灶。
YOUYU CT TUXIANGFENBIANLVDI，JINNIANLAI，ZAI PET-CT JICHUSHANGFAZHANQILAIDE PET-MRI，SHIJIANG PET DEFENZICHENGXIANGGONGNENGYU MRI DESANWEICHENGXIANGGONGNENGJIEHEQILAIDEYIZHONGXINJISHU，JUYOULINGMINDUGAO、JINGZHUNXINGHAODEYOUDIAN，BINGQIEDUIRENTIDEFANGSHEXINGSUNSHANGKEYIDAFUDUJIANDI，DUIYUDIANXIANZAODEJINGQUEDINGWEI，YOUZHEQITAYINGXIANGSHEBEIWUKEBINIDEYOUSHI，SHIXIANJIEPOUHEDAIXIEXINXIDEHUXIANGBUCHONG、CANKAOHEYINZHENG，TIGAODIANXIANZAOJIANCEDETEYIXINGHEMINGANDU。
作为功能成像性技术，PET 具有对代谢异常区显示的敏感性高，但特异性低的特点，在癫痫术前评估中，所显示的代谢异常区常大于甚至远远多于癫痫灶，即假阳性率较高，需要结合其他临床资料（解剖-电-临床）综合分析。但在癫痫灶的评估中起着非常重要的作用，不仅为解剖-电-临床提示的癫痫灶提供进一步证据，对结构影像学“阴性”的症状性局灶性癫痫患者癫痫灶的评估更为重要，PET 可能会提示局灶性代谢异常，为下一步癫痫灶定位或为进一步颅内电极植入方案的制定提供重要依据[27]。
YUNYONGHOUCHULIJISHUJIANG PET HEJIEGOUYINGXIANGXUETUXIANGZILIAOJINXINGRONGHEZHONGJIAN，JIANGJINYIBUTIGAOBINGBIANDEJIANCHALV。
3.2.2.3 单光子计算机断层显像
发作期SPECT 可以提供脑血流的信息，常应用的示踪剂包括99mTc 标记的六甲基丙二胺肟或双半胱乙酯，由于体外稳定性差异，后者更适用于癫痫患者。发作期单光子计算机断层显像减影与 MRI 融合成像术（Subtraction ictal single-photon emission computed tomography coregistered to MRI，SISCOM）处理过程主要包括：SPECT 发作期与发作间期影像配准、密度归一化、减影、SPECT 减影图像与 MRI 配准融合。发作期注射示踪剂的时间影响 SISCOM 结果的准确性，一般认为注射时间控制在癫痫发作的前 20 s 内。通常认为癫痫发作开始后注射时间越早，发作期 SPECT 定位价值越高，因此对于有先兆的患者，更容易获得准确结果[28]。
3.3 癫痫术前评估生理学
3.3.1 脑电图学
EEG JIANCHADUIDIANXIANZAODEPINGGUHESHOUSHUBINGRENDEXUANZEZHIGUANZHONGYAO。FAZUOQIJIFAZUOJIANQI EEG DEFENXI，NENGTIGONGDINGCEHUODINGWEIXINXI，PANDUANDIANXIANZAODEFANWEI，NENGGOUBANGZHUQUEDINGJIEGOUXINGBINGBIANSHIFOUJUYOUZHIXIANXING，HUOZHEBANGZHUQUERENDUOGEBINGZAOZHONGJUYOUZHIXIANXINGDEBINGZAO，YIJIPANDUANSHIDANYIFAZUOQIYUANHAISHIDUOZAOQIYUAN。
3.3.1.1 头皮脑电图
a. FAZUOJIANQIDIANXIANYANGYICHANGFANGDIAN
FAZUOJIANQIJILUJUYOUYIDINGDEDINGWEIJIAZHI。FAZUOJIANQICHUXIANHENGDINGDE、JUZAOXINGDEMANBOHUOZHEDIANYAYIZHI，ZETISHIJUBUJIEGOUYICHANGHUOZHEGONGNENGZHANGAI。HENGDINGYUMOUYIQUYUDECHIXUXINGHUOZHEFANFUDEJI/JIANBOJIELV、DUOJI/JIANBODUIYUDIANXIANZAOJUYOUTISHIJIAZHI。TEBIESHI，MOUXIEFAZUOJIANQIDEDIANXIANYANGFANGDIANMOSHIYUFAYUXINGBINGLIGAIBIAN［RUJUZAOXINGPIZHIFAYUBULIANG（FCD）、FAYUXINGZHONGLIUDENG］YOUGUAN，JUYOUJIAOGAODEDINGWEIJIAZHI。FAZUOJIANQIFANGDIANRUGUOCHAOCHULEDIANXIANZAODEFANWEIHUOZHECHUXIANZAIDUICEDOUKENENGYINGXIANGSHOUSHUYUHOU。JUZAOXINGDIANXIANHUANZHECHULEJUZAOXINGDEFANGDIAN，RUTONGSHICHUXIANGUANGFANXINGFANGDIAN，ZEDINGWEIJIAZHIJIAOXIAO。BUFENHUANZHE，YOUQISHINIEYEWAIDIANXIAN，RUGUOFAZUOJIANQIFANGDIANHENGDINGDECHUXIANYUYIGEQUYU，ZEKENENGBIFAZUOQIDE EEG GENGYOUDINGWEIJIAZHI。
b. FAZUOQINAODIANTU
FAZUOQI EEG JILUSHISHUQIANPINGGUDEYIGEZHONGYAONEIRONG，YOUQIDUIYUKENENGJINXINGQIECHUXINGSHOUSHUZHILIAODEJUZAOXINGDIANXIANDEDIANXIANZAODINGWEIJUYOUJIAODADEJIAZHI。
FAZUOQI EEG FENXIDEZHONGYAONEIRONGSHIPANDUANFAZUOZHENGZHUANGZHIQIAN EEG BIANHUADEQISHIQUYU，DUIDINGWEIZHIGUANZHONGYAO。JUZAOXINGFAZUODEFAZUOQI EEG DEFENBUYOUJIZHONGXINGSHI：① JUZAOXING：ZHIFAZUOKAISHIDEFANGDIANYINGXIANGDAOJISHAOSHUTOUPIDIANJI；② NAOQUXING：SHEJIYIDINGFANWEINAOQU，TOUPI EEG XIANSHISHEJIXIANGLINSHUGEDAOLIANDEJIELVXINGFANGDIAN；③ YICEXING：FAZUOQIFANGDIANLEIJIYICEBANQIU，NANYIJINYIBUJINGXIDINGWEI；④ FEIYICEXING：FAZUOQIFANGDIANQIYUANYULIANGCEBANQIUDEMOUYIJUBUQUYU，TOUPIDIANJISHUANGCEDIANYADAZHIXIANGDENG。
JUZAOXINGFAZUODETOUPI EEG YOUDUOZHONGXINGSHIDEFAZUOQISHIMOSHI，BAOKUO：① FAZUOJIANQIFANGDIANDETURANXIAOSHI，HUOYOULINGYIZHONGWANQUANBUTONGDEJIELVXINGHUODONGSUOQUDAI；② TURANDEGUANGFANXING、YICEXINGHUOZHENAOQUXINGDEDIANYIZHI；③ YUFAZUOJIANQIBUTONGDEJIELVXINGHUODONG（KEWEI α、β、θ、δ DENGBUTONGPINDUAN），BINGQIEYOUPINLV、BOFUHEFANWEIDEYANBIAN，DUOSHUBIAOXIANWEIPINLVZHUJIANJIANMAN，BOFUZHUJIANZENGGAO，FANWEIZHUJIANKUODA，ZHIZHIFAZUOZHONGZHI；XINGTAIXIANGTONG、WUMINGXIANYANBIANDEFAZUOQIFANGDIANMOSHIZAIJUZAOXINGDIANXIANZHONGBIJIAOSHAOJIAN，ZHUYAOJIANYUQUANMIANXINGFAZUO，RUSHISHENFAZUODENG；④ ZAIFAZUOQISHIJIEDUAN，ZAIDIANYIZHIDEBEIJINGXIACHUXIANJUZAOXINGDEDIBOFUKUAIHUODONG，YIWEIZHEGAIJILUDIANJILINJINDIANXIANZAO，JUYOUJIAOGAODEDINGWEIJIAZHI，ERQIEYULIANGHAODESHOUSHUYUHOUXIANGGUAN。DUIYUMOUGETEDINGDEHUANZHE，RUGUOWEIDANYIDIANXIANZAO，ZEFAZUOQI EEG DEMOSHITONGCHANGSHIYIZHIDE。RUGUOFAZUOQI EEG JUYOUMINGXIANDEDUOBIANXING，ZEYINGKAOLVDAODIANXIANZAOFANWEIXIANGDUIJIAODAHUOZHEDUOGEDIANXIANZAODEKENENG。
ZAITOUPI EEG ZHONG，LINCHUANGZHENGZHUANGZAOYUFAZUOQI EEG DEBIANHUA，QIFANYINGDECHANGCHANGSHIFANGDIANGUANGFANCHUANDAODEJIEGUO，XUZIXIFENXIZHENGZHUANGXUEHE EEG QISHIDEGUANXI，JINSHENDEJIESHITOUPI EEG DEDINGWEIYIYI。JUZAOQIYUANDEFAZUOQIMOSHIZHUYAOJIANYUNEICENIEYEDIANXIAN、EYEBEIWAICEDIANXIAN，YICEXINGQIYUANDEFAZUOQIMOSHIZHUYAOJIANYUXINPICENGNIEYEDIANXIAN，ERGUANGFANXINGDEFAZUOMOSHIZHUYAOJIANYUEYENEICEDIANXIAN，DINGYEHEZHENYEFAZUODEFAZUOQI EEG FANYINGDEWANGWANGSHICHUANDAO，SUOYIMOSHIDUOYANG，KENENGZAOCHENGWUPAN。YOUXIEFAZUORUGUODUYUNDONGXINGFAZUOCHANSHENGDEDALIANGDONGZUOWEICHAKENENGSHI EEG BEIYANGAI，DINGWEIKUNNAN。TOUPI EEG DEFAZUOQIJILUDUINEICENIEYEDIANXIANHEBEIWAICEEYEDIANXIANDEDINGWEIZUIYOUYIYI。ERDUIYUEYENEICEMIAN、EYEDIMIAN（KUANGEHUI）、DAOYEQIYUANDEFAZUOZEDINGWEIKUNNAN。LINGWAI，YINGER、ERTONG、QINGSHAONIANYOUYUXIANTIANXINGHUOZHEZAOQIHUODEXINGJUZAOXINGHUOZHEBANQIUXINGZHIXIANXINGBINGBIANSUOZHINANZHIXINGDIANXIAN，KEYIYOUGAOFENGSHILV、QUANMIANXINGDEJIMANZONGHEBOHUOZHEQITAXINGSHIDEQUANMIANXINGFANGDIANMOSHI，HENSHAOHUOZHEMEIYOUJUZAOXINGDETEZHENG，DANSHIZHEIXIEERTONGRENGRANSHIDIANXIANSHOUSHUDESHIYINGZHENGHUANZHE。
ZAITOUPI EEG ZHONG，YOUYIBUFENJUZAOXINGFAZUOMEIYOUMINGXIANDEFAZUOQI EEG BIANHUA，YOUQIZAIJUZAOXINGGANJUEXINGFAZUOZHONGGENGWEICHANGJIAN，ZHEIYEFANYINGLETOUPI EEG DINGWEIFEICHANGJUXIANQIYUANDIANXIANFAZUODEKUNNAN。
YIBANLAIYAN，FAZUOQI EEG MOSHIYUFAZUOQIYUANBUWEIZHIJIANQUEFABIRANDELIANXI，JIYIZHONGMOSHIKEJIANYUBUTONGBUWEIQIYUAN、BUTONGLEIXINGDEFAZUO，ERTONGYIQISHIBUWEI、TONGYIZHONGFAZUOLEIXINGYEKEYIYOUBUTONGDEFAZUOQI EEG MOSHI。YINCIBUNENGGULIDEYIKAOFAZUOQI EEG DINGWEI，YINGJIEHEZHENGZHUANGXUE、YINGXIANGXUEDENGQITAZHENGJUZUOCHUPANDUAN，BIYAOSHIXULUNEIDIANJIJIANCHA。
3.3.1.2 颅内脑电图
TONGGUOWUCHUANGXINGPINGGU，RUGUOFAZUOZHENGZHUANGXUE、TOUPI EEG YIJIYINGXIANGXUEJIEGUOSANZHEBUYIZHIHUOZHEXIANGHUMAODUN，DIANXIANZAOWEINENGMINGQUE；DIANXIANZAOLINJINHUOZHEWEIYUZHONGYAOGONGNENGQU，HUOZHEYINGXIANGXUEJIANCHAWUYICHANGFAXIAN，WUFAQUEDINGQIECHUFANWEI，ZEXUYAOLUNEIDIANJIZHIRU，TONGGUOLUNEI EEG JINYIBUMINGQUEDIANXIANZAODEWEIZHI、FANWEIYIJIYUGONGNENGQUDEGUANXI。
LUNEIDIANJIFENYINGMOXIADIANJIHESHENBUDIANJILIANGZHONG。JIYUWUCHUANGXINGPINGGUJIEDUANDEXINXI，QUEDINGDIANJIZHIRUDEFANWEI。TONGGUOLUNEI EEG FAZUOJIANQIHEFAZUOQIJILU，KEYIXIANGDUIZHUNQUEDIDINGWEIJIREQUJIDIANXIANZAOFANWEI，TONGSHIKEYITONGGUODIANCIJIQUEDINGGONGNENGQU，MINGQUEDIANXIANZAOYUGONGNENGQUDEGUANXI。YINGMOXIAPIANZHUANGDIANJIXUYAOKAILUSHOUSHUZHIRU，SHIHEDIANXIANZAOWEIYUPICENGBIAOQIANBUWEIDEHUANZHE，ZAIDIANCIJIDINGWEIGONGNENGQUFANGMIANYOUYIDINGYOUSHI。SHENBUDIANJISHIYONGYUDIANXIANZAOWEIYUHAIMA、DAOYE、HUIZHIYIWEI、XIAQIUNAOCUOGOULIUDENGSHENBUDIANXIANZAO。LITIDINGXIANGNAODIANTU（SEEG）JUYOUKEFUGAISHENBUJIBANQIUNEICEMIANJIEGOU、KESHUANGCEZHIRUDENGYOUSHI。MUQIANLINCHUANGYINGYONGYUELAIYUEDUO。
LUNEIDIANJI EEG DEFAZUOJIANQIGAOPINZHENDANGYUDIANXIANZAOYOUMIQIEGUANXI，KEZUOWEIDINGWEIDIANXIANZAODEZHONGYAODIANSHENGLICANSHU。JINGUANDUIYULUNEI EEG FAZUOXINGFANGDIANDEQIYUANMOSHIYOUBUTONGDEMIAOSHU，MUQIANRENWEIZAIDIPINLV/ZHILIUDIANPIAOYISHANGCHUXIANDEJUZAOXINGDEDIBOFUKUAIHUODONGTONGSHIJUYOUFAZUOQIANFANGDIANQISHIDELUNEI EEG FAZUOQIMOSHIJUYOUBIJIAOKEKAODEDINGWEIJIAZHI。XUYAOZHUYIDESHILUNEIDIANJIDEZHIRUMOSHIJIFANWEISHIJIYUWUCHUANGXINGPINGGUJIEDUANXINGCHENGDEGUANYUDIANXIANZAODEJIASHE，RUGUOJIASHECUOWU，ZEDIANJIZHIRUKENENGBUQUANMIAN，CONGERZAOCHENGLUNEIDIANJIDEJIELUNBUKEKAO。
3.3.2 脑磁图
MEG SHIYIXIANGDUIRENTIWUCHUANGDENAOGONGNENGJIANCHAJISHU，TONGGUOGAODULINGMINDECHAODAOLIANGZIGANSHEYISHISHIJIANCENAOBUCICHANGXINHAODEBIANHUA，DUIDIANXIANHUANZHEFAZUOJIANQIYICHANGFANGDIANDEDINGWEIFEICHANGYOUBANGZHU。XIANDAI MEG SHEBEIJUYOUSHANGBAIGETANCETONGDAO，KEFUGAIZHENGGENAOBU，DUIDANAOCICHANGXINHAOJINXINGQUANFANGWEIJIANCE。JIANGJILUDAODECIXINHAOTONGGUOQIADANGDESHUXUEMOXING，JISUANCHUQIWEIZHI、QIANGDUHEFANGXIANG，BINGYUQITOUBU MRI YINGXIANGRONGHECHULI，JICIYUANXINGCHENGXIANG，KEDINGWEIDIANXIANZAO。
EEG HE MEG SUIRANDOUSHIJIYUSHENJINGDIANSHENGLIDEJIANCHAJISHU，DANSHIGEZIYOUBUTONGDETEDIAN。DANAOWAIZHOUNAOJIYE、LUGU、TOUPIDENGZUZHIJUYOUBUTONGDEDAODIANLV，HUIDUINAODIANHUODONGDEKUOBUCHANSHENGMINGXIANYINGXIANG，YINCILIYONGNAODIANXINHAOJINXINGYUANDINGWEI，QIZHUNQUEXINGJIANGSHOUDAOYINGXIANG。CICHANGZAINAO、NAOJIYE、LUGUHETOUPIDENGJIEZHIZHONGDECHUANTOULVJIHUBUSHOUYINGXIANG，SUOYILIYONGCIXINHAOJINXINGYUANDINGWEIJIUXIANGDUIZHUNQUEDEDUO。MEG JUYOUHAOMIAOJIDESHIJIANFENBIANLVHEHAOMIJIDEKONGJIANFENBIANLV，NENGGOUSHISHI、JINGZHUNDIFANYINGBUTONGNAOQUDEGONGNENGBIANHUA。
EEG ZHUYAOJIANCEJINGXIANGCHUIZHIYUDIANJIDEDIANLIU，FANYINGDESHINAOHUINEICHUIZHIPAILIEDEZHUITIXIBAOCHANSHENGDEXIBAOWAIDIANLIU；MEG ZHINENGJIANCEDAOYUCHUANGANXIANQUANXIANGHUCHUIZHIDECILIXIAN，YINCIJILUDESHINAOGOUNEIZHUITIXIBAODEXIBAONEIDIANLIUCHANSHENGDECICHANG，FANYINGLEPICENGQIEXIANFANGXIANGPAILIEDEZHUITIXIBAODEHUODONGQINGKUANG。LINGWAI，YOUYUCICHANGQIANGDUSUIZHEJIANCEXIANQUANYUXINHAOYUANZHIJIANJULIDEZENGDAERJIANXIAO，MEG HENNANJIANCEDAODANAOSHENBUDESHENJINGHUODONG；ER EEG YOUYURENTIJIEZHICHUANDAOXINGDEBUTONG，YOUKENENGJILUDAOLAIZIDANAOSHENBUDERONGJICHUANDAODIANLIU。YINCI，EEG HE MEG SHICONGLIANGGEBUTONGFANGMIANFANYINGSHENJINGXIBAODIANLIUDEHUODONGQINGKUANG，JUYOUXIANGHUBUCHONGDEZUOYONG，BUNENGXIANGHUTIDAI。
MEG TONGGUOYUANFENXIDUIDIANXIANZAOJINXINGDINGWEI，MUQIANSHIYONGZUIGUANGFANDEYUANFENXIFANGFASHIDENGJIADIANLIUOUJIZIMOXING。MEG DUIYU FCD SUOZHIDENANZHIXINGDIANXIANJUYOUHENHAODEDINGWEIJIAZHI，YOUQISHIYOUZHUYUQUEDING MRI WEIFAXIANDEXIAO FCD BINGZAO。MEG DUIYUDANAOBIAOQIANPICENGDEXINHAOBIJIAOMINGAN，ERDUIYUNEICENIEYEDENGSHENBUJIEGOUYICHANGHUODONGDEJIANCHULVZEXIANGDUIJIAODI，ZAIZHEIYIFANGMIANYOUSHIFANERBUJI EEG DINGWEIMINGQUE。DANGTOUPI EEG XIANSHIWEIZHONGXIANBUWEIHUOSHUANGCEYICHANGFANGDIAN，ZUOYOUCEBIENANYIQUEDINGSHI，MEG KENENGDUIDINGCEJIDINGWEIYOUSUOBANGZHU。MEG OUJIZIDEFENBUTEZHENGYEKEYIWEIQUEDING SEEG FANGANYIJISHOUSHUYUHOUTIGONGHENDUOYOUYONGDEZHIDAO。DANG MEG OUJIZIFENBUJIZHONGBINGQIEFANGXIANGWENDINGSHI，SHOUSHUYUHOUJIAOHAO，ERDANGOUJIZIBIJIAOFENSANSHI，YIBANSHOUSHUYUHOUBUJIA。YOUYANJIUFAXIAN，OUJIZIJIZHONGFENBUDEBUWEIBEIWANQUANQIECHUDEHUANZHE，QISHUHOUWUFAZUODEGAILVYAOGAOYUBUFENQIECHUHUOWEIBEIQIECHUDEHUANZHE。MEG HAIKEYONGYUDINGWEIPIZHIGONGNENGQU，TONGGUOTIGAN、SHIJUE、TINGJUEJIYUYANYOUFACICHANGQUEDINGXIANGYINGDEGONGNENGQU，WEIDIANXIANSHOUSHUPINGGUTIGONGBANGZHU。
SUIRAN MEG JUYOUSHANGSHUYOUDIAN，DANSHIMUQIANRENGCUNZAIYOUYIDINGJUXIANXING。YOUYUJIANCHASHIJIANJIAODUAN，MEG JIANCEDAOHUANZHEFAZUODEJILVBUGAO；JISHIOUERJIANCEDAODIANXIANFAZUO，FAZUOSHIDEYUNDONGWEICHAYEHUIGANRAO MEG CIYUANDINGWEIDEZHUNQUEXING，GU MEG TANCEDEDUOSHIFAZUOJIANQIYICHANGCIXINHAO，DUIDIANXIANZAODEDINGWEIZUOYONGYOUXIAN。YINCI，XUJIEHEHUANZHEDELINCHUANGBIAOXIANYIJIQITANAOGONGNENGJIANCHAFANGFAJINXINGZONGHEPINGGU。
3.3.3 感觉和运动诱发电位
3.3.3.1 运动诱发电位
DIANXIANWAIKESHOUSHUYAOQIUZAICHEDIQIECHUDIANXIANZAODETONGSHI，ZUIDAXIANDUDIBAOLIUHUANZHEDEDANAOZHONGYAOGONGNENGQU。YINCI，YICEBANQIUBINGBIANBANNANZHIXINGDIANXIANHUANZHESHOUSHUQIANZHUNQUE、KEGUANPINGGUBINGBIANBANQIUDEYUNDONGGONGNENGZHIGUANZHONGYAO。YUNDONGYOUFADIANWEI（Motorevoked potential，MEP） SHIZHIJINGLUCIJIYUNDONGPIZHIZAIDUICEBAJIJILUDAODEJIROUYUNDONGFUHEDIANWEI，CONGERJIANCHAYUNDONGSHENJINGCONGPIZHIDAOJIROUCHUANDAOTONGLUDEZHENGTIWANZHENGXING。GENJUCIJIDEFANGSHIFENWEIDIANCIJI MEP HECICIJI MEP。JINGLUCICIJI（Transcranial magnetic stimulation，TMS）JUYOUCHUANTOUXINGQIANG、WUMINGXIANTENGTONGGAN、CAOZUOJIANBIANDENGYOUSHI，MUQIANLINCHUANGYINGYONGGENGWEIGUANGFAN。
由于大脑皮质具有一定的可塑性，一侧半球病变对功能的影响在一定程度上可被其他部位代偿，比如对侧运动中枢。因此，在评价半球运动功能时，采用一侧皮层刺激，双侧拇短展肌记录的方法。嘱受试者取坐位、全身肌肉放松、闭目，“8”字线圈平面与头皮切面相贴并保持平行，线圈手柄均朝向枕侧。线圈与受试者矢状线成 45°角。单脉冲 TMS 点刺激，输出强度为 70%～100%。刺激部位为拇短展肌皮质运动区相对应的头皮点，一般在按照国际脑电图 10-20 安装系统 Cz 点前 2 cm 再旁开 2 cm 处附近。用氯化银材质的盘状电极置于双侧拇短展肌的皮肤表面，用双极导联记录，两电极相距 2 cm，记录电极置于近端，地线置于手心。刺激同一个部位，至少记录 3～5 次，以观察其重复性（图 2）。
图2
运动诱发电位
ZUOTU：GONGNENGWANQUANDAICHANGHUANZHEDEYUNDONGYOUFADIANWEI；CIJIFEIBINGZAOCEMUDUANZHANJI（APB）DEPIZHIYUNDONGQU，SHUANGCEMUDUANZHANJIJUNKEJILUDAO MEP；CIJIBINGZAOCEMUDUANZHANJIDEPIZHIYUNDONGQU，SHUANGCEMUDUANZHANJIJUNBUNENGJILUDAO MEP；ZHONGTU：GONGNENGBUNENGDAICHANGHUANZHEDEYUNDONGYOUFADIANWEI；WULUNCIJIFEIBINGZAOCEHUOBINGZAOCEMUDUANZHANJIDEPIZHIYUNDONGQU，JINZAIDUICEMUDUANZHANJIKEJILUDAO MEP，TONGCEBUNENGJILUDAO MEP；YOUTU：GONGNENGBUFENDAICHANGHUANZHEDEYUNDONGYOUFADIANWEI：CIJIFEIBINGZAOCEMUDUANZHANJIDEPIZHIYUNDONGQU，SHUANGCEMUDUANZHANJIJUNKEJILUDAO MEP；CIJIBINGZAOCEMUDUANZHANJIDEPIZHIYUNDONGQU，DUICEMUDUANZHANJIYEKEJILUDAO MEP
术前 MEP 结果对手术的指导意义：对于病灶侧半球运动功能完全代偿的患者，行患侧半球切除术后对侧肢体无运动功能损害加重。对于病灶侧半球运动功能部分代偿的患者，病灶侧半球切除术后对侧肢体运动功能损害加重，经康复治疗 3 个月后可部分恢复。对于病灶侧半球运动功能不能代偿的患者结合其他检查结果，认为术后发生对侧肢体运动功能损害的可能性很大时，建议行改良大脑半球切除术[29, 30]。TMS-MEP 能够客观评估双侧半球的运动功能，是一种有效、可靠且无创的评估手段。
3.3.3.2 感觉诱发电位
在癫痫外科治疗中，确定中央沟的位置对于保护功能区具有一定帮助，除了皮层电刺激、fMRI 和 MEG 外，应用颅内电极或硬膜外电极进行感觉诱发电位检查也能够进行中央区的确定[31]。选取对侧上肢进行正中神经电刺激，在埋置电极侧的大脑半球中央区可记录到体感诱发电位，且由于中央前、后回皮质产生的偶极现象，在中央后回记录到 N20/P25 复合波形，并以记录到的 N20/P20 峰值时刻点数据进行平面二维诱发电位地形图绘制，可直观显示这种极性翻转，在中央前回记录到与之极性相反的 P20/N25 复合波形，这种横跨中央沟的波形位相倒置，是应用感觉诱发电位识别中央区的可靠标志[32]，见图 3。此外，应用感觉诱发电位检查，还可进行次级躯体感觉区的识别[32]。
图3
硬膜外埋置电极记录到的诱发电位地形图（左）和诱发电位图（右）
ZUOTUZHONGSHUZIBIAOSHIYOUFADIANWEIQIANFUQI，DUIYINGYOUTUSITIAOHONGXIANSUOZAIDESHIJIANDIAN；YOUFADIANWEIDIXINGTUKEJIANYOUFABOXINGJIXINGWEIXIANGFANZHUANDEDIANJISUOZAIQU，YOUFADIANWEITUKEJIANYOUFABOXINGWEIXIANGFANZHUAN
3.3.4 重复经颅磁刺激
GENJUFALADIYUANLI，DIANRONGDUIXIANQUANFANGDIANCHANSHENGMAICHONGDIANLIU，MAICHONGDIANLIUJIKECHANSHENGSHUNBIANCICHANG，CICHANGMAICHONGWUCHUANGERQIEJIHUWUSHUAIJIANDICHUANGUOLUGU，ZAINAOZUZHINEIYOUFACHUGANYINGDIANLIUSHISHENJINGXIBAODEXINGFENXINGFASHENGGAIBIAN，CIWEI TMS。ZHONGFUJINGLUCICIJI（rTMS）SHITONGGUOGAOPINHUODIPINLIANXUZHONGFUCIJICONGERDADAOXINGFENHUOYIZHIJUBUDANAOPIZHIGONGNENGDEMUDE。rTMS KEYIXUNIDI“SUNHUI”DANAOJUBUGONGNENGCONGERWUCHUANGDETANSUONAOGONGNENG。
语言功能是重要的脑功能，语言优势半球是指语言功能区明显偏向于某一侧的大脑半球。右利手者中，语言优势半球和利手的皮质运动区域都在左半球的一致率在 95%～98% 之间，而左利手者，语言功能呈现出较为复杂的混合偏侧。癫痫手术前用无创方法定位语言功能区是未来趋势，rTMS 可以对语言皮质区产生瞬间的可逆性干扰从而无创定位语言功能区[33]。因此，利用高频、阈上强度的 rTMS 刺激语言功能区，干扰言语输出，直至言语中断，可对大脑语言优势半球进行定位[34, 35]。
将磁刺激 8 字线圈置于双侧头皮外侧裂附近区域的语言功能区，指令患者读数，其间以 20 Hz 频率、最大输出的 80% 刺激强度分别进行单侧重复磁刺激 3～5s，观察是否存在语言中断或音调改变，若存在语言中断或音调改变则提示刺激位置为语言功能区。刺激同一个部位，至少观察两次以上以确定其重复性。重复经颅磁刺激定位语言功能区的可靠性与阿米妥颈内动脉注射试验（Wada 试验）的符合率达到了 95%[36]，具有无创伤、可重复刺激、可检测不同的言语任务、风险小、操作简便、患者可能不需住院等许多优点，但儿童或智力障碍的癫痫患者不能配合这种无创检查。
3.3.5 皮层电刺激
皮层电刺激定位大脑功能区是皮层功能定位的金标准，可以在术中实施，也可以应用硬膜下或者深部电极记录发作期颅内电极 EEG 后实施。与术中皮层电刺激相比，后者可以有更充分的时间，患者可以更好的配合，是皮层功能定位的首选方法[37]。当癫痫灶邻近或位于感觉、运动及语言区时，为避免手术切除癫痫灶时损伤皮层功能，均需行皮层电刺激进行功能定位。埋置颅内电极的患者，监测到 3 次及以上惯常发作后可以进行皮层电刺激定位功能区。电刺激时优先刺激远离颅内电极 EEG 发作起始区的部位，以免刺激时引起发作。在进行皮层电刺激时，如果刺激强度过高，可能会诱发癫痫发作；如果刺激强度不足，则不能刺激出功能反应。因此，要逐渐增加刺激强度，避免增加过快导致癫痫发作。患者病程越长，皮层的兴奋性越高，出现后放电的阈值越低，此时刺激强度更应缓慢增加，待后放电消失后再进行下一次刺激。
最常用的刺激参数为频率 50 Hz 或 60 Hz，脉宽 200～300 μs，刺激强度 1～12 mA，每串刺激持续时间 2～5s，每次刺激间隔 10～20s[38]。选用相邻电极为参考电极。成人刺激强度最大增加到 10 mA；儿童皮层发育未成熟，对电刺激的反应阈值可能会更高，因此刺激强度可以最大增加到 12 mA。术中进行皮层电刺激时，由于是在麻醉状态下进行，刺激强度可以增加到 20 mA。通常感觉阈值和运动阈值较低，后放电阈值高于感觉和运动反应阈值。如刺激强度<5 mA 即出现感觉、运动反应，则阳性反应较为可靠。
语言的功能定位相对较为复杂，因此要联合应用多种语言任务来进行综合定位。基本的语言任务包括自发语言、言语理解和命名；附加的语言任务包括复述、阅读和书写[39]。在进行皮层电刺激时，先进行基本语言任务测试，再进行附加任务测试。如果出现语言停顿、命名错误或命名障碍，而无后放电现象出现，则语言定位可靠；如果出现语言的流利性降低、言语错乱和语调改变，则术中还需再次进行语言功能确认。值得注意的是，出现语言紊乱时要仔细甄别是由于刺激引起了舌/喉肌痉挛还是刺激到真正的语言运动中枢，此时可以嘱患者张口，刺激时观察患者舌肌有无回缩。
PICENGDIANCIJISHICHULEMINGQUEGANJUE、YUNDONGJIYUYANGONGNENGZHIWAI，HUANZHECHUXIANDEGEZHONGXINGXINGSESEDEGANJUEHEZHENGZHUANGJUNYINGYINQIGAODUZHONGSHI。ZUIWEIZHONGYAODESHIJIAODIQIANGDUDEDIANLIUQIANGDUCIJISHICHUXIANFAZUOZHENGZHUANGDEDIANJIDIAN，ZHEIXIEGUANJIANDEDIANJIDIANRUGUOYULUNEIDIANJIJILUDAODEFAZUOQISHIQUBUYIZHI，YINGZONGHEKAOLVPANDUANSHUZHONGSHIFOUXUYAOYIBINGQIECHU。DIANCIJICHUXIANFAZUOXIANZHAODEBUWEI，YULUNEIDIANJIEEGFAZUOQISHIQUYIZHI，KEYIRENWEIXIANZHAODINGWEIJIAZHIKEKAO；RUBUYIZHI，ZEZONGHEQITAJIANCHAJIEGUO，BIANBIECIJIYINCHUDEXIANZHAOYUFAZUODEGUANXI。
3.3.6 Wada 试验
ZAIDIANXIANSHUQIANPINGGUZHONG，YUYAN、JIYI、YUNDONGGONGNENGQUDEDINGWEIJUYOUZHONGYAOYIYI，TEBIESHIDIANXIANZAOWEIYUGONGNENGQUFUJINSHI，KEYONG Wada SHIYANLAIQUEDINGYOUSHICEBANQIU。
Wada 试验，又名颈内动脉异戊巴比妥试验，由 Wada 博士（1949 年）提出并用于临床，是术前神经生理学评估必不可少的一部分[40]。Wada 试验需要在药物注射前开始 EEG 记录，经股动脉插入导管至一侧颈内动脉行脑血管造影，继之将异戊巴比妥钠或其他短效麻醉药如丙泊酚[41]通过导管分别注入到大脑半球的脑血管中，通常先麻醉患侧半球，注射侧大脑半球被引入暂时性的休眠状态后测试半球语言、记忆和运动等功能，休息 20～45 min 后开始对侧大脑半球脑血管造影并注射麻醉药，判断语言、记忆功能的优势半球，评估运动功能，从而预测手术对半球的影响[42]。因国内缺乏异戊巴比妥，近年来，应用丙泊酚作为替代进行 Wada 试验，取得了满意的效果。
Wada 试验可用于术前语言优势半球定侧、颞叶切除术后患者的记忆功能预测、癫痫灶定侧、预测术后发作缓解等。若患者为左利手或其家族成员有左利手史，有早期左侧半球损害，神经心理学测验结果和头皮EEG监测结果不符，双侧 EEG 均不正常，或行神经心理学测验双侧记忆都有损伤可行 Wada 试验[43]。
麻醉药物的注射可引起不良反应，包括眼痛、颤抖、面部扭曲、流泪、发笑和情感淡漠，意识错乱、不随意运动或头眼偏转，肌张力增高，伴有抽搐和节律性运动等[44]。无创性方法如 fMRI、MEG、PET 和 TMS 等评估手段也可确定优势半球，但目前还没有一种方法能够完全替代 Wada 试验，其被认为是确定记忆和语言优势半球的金标准。
3.4 癫痫术前评估心理学
3.4.1 神经心理评估的目的及作用
神经心理评估是癫痫临床诊疗中的一项重要内容，药物治疗效果好及药物难治性癫痫患者均应进行评估。神经心理评估的目的在于：① 完善癫痫患者认知及行为障碍的共病诊断；② 评估患者的精神、行为状况对其生活质量、家庭及社会的影响，并做合理的解释；③ 为针对性的心理行为干预提供基线依据；④ 监测癫痫发作、各种治疗（包括药物治疗、各种手术治疗及调整治疗方案）前后对患者认知、情绪等行为的影响[45, 46]。
DIANXIANSHUQIANPINGGUZHONGSHENJINGXINLIPINGGUDEMUDEBAOKUO：① PINGGUYUYAN、JIYIDENGZHONGYAORENZHIGONGNENGDEYOUSHICEBIE；② XIEZHUDIANXIANZAOJIGONGNENGSHOUSUNNAOQUDEDINGCEJIDINGWEI；③ YUCEDIANXIANSHOUSHUDUIHUANZHENAOGONGNENGSUNHAIDEQIANZAIFENGXIAN，WEISHUHOUGONGNENGYUHOUPINGGUTIGONGYIJU；④ WEISHOUSHUHOULIAOXIAOPINGGUTIGONGJIXIANCANKAO。
3.4.2 临床神经心理测试专业人员
LINCHUANGSHENJINGXINLICESHIXUYAOYOUZHUANMENJINGGUOXITONGPEIXUNDESHENJINGXINLIYISHIJIXINLICELIANGSHIZHIXING，SHENJINGXINLIYISHIXUJUBEIYIXIATIAOJIAN：① JINGGUOLINCHUANGSHENJINGXINLIXUEDEZHUANYEXUNLIAN，BINGXUYAOJINGYANFENGFUDEXINLICELIANGSHIXIEZHU；② ZHANGWONAO-RENZHI-XINGWEIXUELILUN，SHUZHINAODEJIEPOUHEGONGNENG、RENZHIXINLIXUEJIYOUGUANJIBINGDEXIANGGUANZHISHI；③ ZHANGWOBIAOZHUNDESHENJINGXINLIJIXINGWEICESHIFANGFA，BINGNENGDUICESHIJIEGUOJIEHELINCHUANGJINXINGJIEDU；④ DIANXIANXIANGGUANDELINCHUANGSHENJINGXINLICESHIZHUANYERENYUANSHANGXUJUBEIDIANXIANYOUGUANDEZHUANYEZHISHI。
3.4.3 癫痫术前神经心理评估时机及禁忌症
DIANXIANSHUQIANSHENJINGXINLIPINGGUSHIJI：① RUGUOQINGKUANGYUNXU，JIANYIDUISUOYOUSHOUCICHUXIANDIANXIANFAZUOHUANZHEJUNJINXINGRENZHIHUOXINGWEIKUNNANDECHANGGUISHAICHA，JIANYIDECHANGGUISHAICHATIGONGLEYIZHONGGAOXIAOQIEJINGJIDEFANGFA，KESHAIXUANCHUXUYAOGENGWEIXIANGXI（HEANGGUIDE）SHENJINGXINLIXUEPINGGUDEHUANZHE；② DANGHUANZHEJUYOUJUZAOXINGRENZHIZHANGAIZHENGZHUANGHUOTIZHENGSHI，SHENJINGXINLIPINGGUKEXIEZHUTIGONGYOUGUANZONGHEZHENG、BINGBIANDINGWEIHUOFAZUOXIANGGUANSHENJINGWANGLUODEPICENGDINGWEIXINXI；③ DANGHUAIYIHUANZHECUNZAISHENJINGFAYUCHIZHI、XINGWEIHUOXUEXIKUNNANHUORENZHIXIAJIANGSHI，DONGTAISHENJINGXINLIPINGGUKEWEIZHENGQUEDEZHILIAO、ZHIYEDEXUANZEHESHEQUHUOSHEHUIDEZHICHITIGONGYIJU；④ DANGXUYAOPINGGUJIBINGHEZHILIAODEYINGXIANGSHIYINGJINXINGSHENJINGXINLIPINGGU。
XIANGDUIJINJIZHENG：① JIN 6 GEYUEZHINEICENGJINGJIESHOUPINGGUDEHUANZHE，BUYIZAICIPINGGU，YINCUNZAIXUEXIXIAOYING，KENENGDAOZHIPINGGUJIEGUOJIAOSHIJIJIEGUOHAO，YOUQISHIZHUYILI、JIYILI、JINGSHENYUNDONGSUDUJIZHIXINGGONGNENGDENG；② DIANXIANCHIXUZHUANGTAIHUOQITAYANZHONGYINGJIBINGLIZHUANGTAIHOU，YISHIWEIWANQUANHUIFUZHE，PINGGUJIEGUOBUKEKAO。
3.4.4 癫痫儿童的神经心理评估注意事项
DIANXIANHUANERYOUYUSHOUBINGYINXUE（FCD ZHEDUOJIAN）、NAOSHENJINGSUOCHUFAYUJIEDUANJIHUANJINGSHEHUIDENGDUOGEYINSUDEYINGXIANG，CHENGRENDIANXIANWAIKEXIANGGUANDERENZHIXINGWEIYUHOUDEYANJIUJIEGUOBUSHIYUHUANER。JUTITIXIANZAIYIXIAFANGMIAN：① BUTONGNIANLINGDUANXUANZEBUTONGMINGANDUDESHENJINGFAYUPINGGUGONGJU，LIRUYUYANCESHIRENWUDEYUFA、CIHUIDENGXUJIEHEBUTONGNIANLINGHUANERDEJIAOYUBEIJING，JINZUOJIANDANYUYANCESHIRUZHAOCIRENWUJIYUYANLIUCHANGXINGCESHIDEJIEGUOBUZUYIJINXINGDIANXIANSHUQIANDIANXIANZAODINGCEJISHUHOUYUYANYUHOUPANDUAN；② XUANZEYOUXINLIXUEYANJIUBEIJINGJIERTONGCHANGMODEXINXIAODUJIAOHAODEGONGRENDEXINLICELIANGGONGJU，QIPINGGUJIEGUOCAIJUBEILINCHUANGYIYI。
3.4.5 评估方法
采用量表或者心理任务测试的方法，经过 6～8 h 的评估及行为观察，全面评估患者各项认知功能及行为状态。癫痫中心所采用的主要认知功能筛查组套见表 4。
表4
主要认知功能及其心理学测试内容
3.4.5.1 智商测试
WEISHILIANGBIAO，FANYINGZHENGTIZHILISHUIPING，DANSHIBUNENGTIGONGDIANXIANZAODEDINGCEJIDINGWEIXINXI。YOUYUWANZHENGBANWEISHICESHIXUYAO 2 h，DUOSHUZHONGXINCAIYONGJIANHUABAN，ZHENGTAOLIANGBIAOKEFENGEWEIXUDUOBUTONGGONGNENGDEFENLIANGBIAO，LIRUYUYANZHISHANG、JIYILIANGBIAODENG，KEGENJUHUANZHEDEBUTONGQINGKUANGXUANZEBUTONGGONGNENGDEFENLIANGBIAO。JIESHENGDESHIJIANKEJINXINGGENGWEIXIANGJINDEJUYOUDINGWEI、DINGCEYIYIDESHENJINGXINLICESHI。
3.4.5.2 认知任务测试及神经心理评估
前者为限时任务测试，成绩按照测验反应的时间及测验结果正确率双维度计算，可作为首选，适用于智力水平正常，测试配合好，结果可靠的癫痫患者；后者为不限时的任务测试，成绩按照答对题目的数量计算，适用于一般智力差，配合度差的患者。测试任务选择责任脑区有明确偏侧化及脑区定位的任务。常用的认知测试项目和任务及其提示功能受损区的定侧、定位价值见表 5。
表5
常用的认知测试任务
4 癫痫术前评估的原则
4.1 多种评估技术的递进选用和分阶段评估
DIANXIANSHUQIANPINGGUGONGZUOMUDESHIYINGYONGDUOZHONGSHOUDUANJINGZHUNDINGWEIDIANXIANZAOYIJIGONGNENGQU，DADAOZUIHAODESHOUSHUZHILIAOXIAOGUOHEZUISHAODEGONGNENGSUNSHANG。MUQIANZAILINCHUANGGONGZUOZHONG，YOUYUDIANXIANZAOJINWEILILUNXINGGAINIAN，TONGGUOYUNYONGBUTONGFANGFALAIDINGWEIDIANXIANZAOXIANGGUANQUYU，ZUIZHONGDINGWEIDIANXIANZAO，TONGSHIPINGJIADIANXIANWANGLUO。YIBANCHENGXUWEIZAIXIZHIDEFAZUOZHENGZHUANGXUEGUANCHAHEFENXIJICHUSHANG，ZONGHEYINGYONGNAODIANSHENGLI、JIEGOUYINGXIANGXUEHEGONGNENGYINGXIANGXUEDENGSHOUDUANCONGBUTONGDEJIAODUJINXINGPINGGU，ZUIHOUJINXINGZONGHEKAOLV。
总体而言，术前评估中，应遵循临床症候-电生理-脑解剖结构相吻合的理论，合理选择有关检查手段。各种检查技术对于癫痫灶定位的贡献度是有差别的（表 6），一些技术定位可靠性较高，另一些技术定位灵敏性较高，应该综合分析这些技术结果之间的关系，在定位过程中当信息相互矛盾时，要遵循两个基本原则。首先，可靠性低的结果应该让位于可靠性高的检查结果；一般来讲，结构影像与临床发作症状以及发作间期和发作期头皮 EEG 定位结果一致时是可靠的。三者检查结果不一致时，根据情况需要采用颅内电极进行 EEG 长时间描记，获取发作期的 EEG 进行定位。其次，分析脑电和症候学信息时应该遵循时间先后顺序的原则，也就是发作过程中时间越早的信息提示的部位越可靠。
表6
各种定位技术的相对可靠性与敏感性
当无法获得全部可靠信息时，或重要信息之间相互矛盾无法解释清楚癫痫发作过程时，应该制定埋置颅内电极的方案（表 7），利用颅内电极 EEG（包括硬膜下电极 EEG 以及 SEEG）获得的信息进一步定位癫痫灶。需要注意的是，与其说颅内电极是探测性检查手段，不如说是验证手段更为合适。无论哪种颅内电极的置入都应基于明确的理论假设基础。
表7
多种定位技术的综合选用原则以及颅内电极埋置的选择
4.2 癫痫灶与癫痫网络推理
DIANXIANZAODINGWEISHIYIGEZONGHEFENXIDEGUOCHENG，HENDUOBINGLIWUFAHUOQUDINGWEIQUANBUXINXI，YINGGAILIYONGNAOJIEPOU、SHENJINGSHENGLIHENAOWANGLUOZHISHIJIESHIMEIYICIDIANXIANFAZUODESHENJINGHUODONGGUOCHENG，LUOJITUILISHISHIFENBIYAODE，DIANXIANZHONGXINDESHENJINGNEI、WAIKEYISHIJINXINGZONGHETAOLUN，ZHIDINGSHOUSHUFANGAN。
SUIZHEDIANXIANBINGLISHENGLIYANJIUDESHENRU，TEBIESHIZAI SEEG GUANGFANYINGYONGGUOCHENGZHONG，ZHUJIANRENSHIDAOCANYUMOUCIDIANXIANFAZUODENAOQUWANGWANGBINGBUJUXIANZAIYIGETEDINGDENAOQU，YOUSHIHUIBOJIDUOGEXIANGJUJIAOYUANDEBUTONGNAOQU，ZHEIXIEQUYUXIANGHUYINGXIANGCUDONG、JIAOTIJIHUO、BICIHUWEIYINGUO，HENDUOSHIHOUWUFAQUFENNAGEQUYUSHIZHENZHENGDEDIANXIANZAO，GUCIYINRULEYIGEDIANXIANWANGLUODEGAINIANLAIQUEDINGZHONGYAODEDIANXIANNAOQU。ZAISHIJIANZHONGYINGGAIGENJUSHANGSHUJIANCHAFANGFAHUODEDEZHENGJU，ZONGHEFENXIMINGQUEBUTONGNAOQUCANYUDIANXIANFAZUODEMIQIECHENGDU、FENXIZHEIXIEQUYUJIHUODESHUNXU，QUEDINGDIANXIANWANGLUO，YONGYUZHIDAOSHOUSHUQIECHUDIANXIANNAOQUFANGANDEZHIDING。
4.3 划分癫痫灶与脑功能区边界
DIANXIANSHUQIANPINGGUZHONGLINGYIXIANGZHONGYAODERENWUSHIJINXINGZHONGYAODENAOGONGNENGQUDINGWEI，ZHEIBAOKUOYUNDONGQU，TEBIESHIZHITIYUNDONGGONGNENGQU、QUTIGANJUEGONGNENGQU、YUYANGONGNENGQUDENGZHONGYAONAOGONGNENGQUDEBIANJIEHUAFEN。JIBENYUANZESHIMINGQUEDIANXIANZAOQUDEBIANJIEYUZHONGYAOGONGNENGQUDEBIANJIE，RUGUOLIANGGEPICENGQUYUXIANGHUFENLI，ZEKEYIANQUANQIECHUDIANXIANZAO；RUOLIANGGEQUYUWANQUANZHONGDIE，ZEBUSHIHEJINXINGDIANXIANZAODEQIECHUZHILIAO，FANGZHISHOUSHUZAOCHENGNAOGONGNENGZHANGAI；RUOLIANGGEQUYUBUFENZHONGDIE，ZEYINGGENJUQINGKUANGPANDINGLIANGZHEZHIBIANJIEHEZHONGDIEFANWEI，SHIDANGQIECHUDIANXIANZAO，YIQUEBAOBUDAOZHIZHONGYAONAOGONGNENGZHANGAIWEIYUANZE。
NAOGONGNENGQUSHIFOUBAOLIUYEYAOGENJUHUANZHEDEJUTIQINGKUANGLAIJUEDING。WEILEWANQUANKONGZHIDIANXIANFAZUO，SHOUSHUDAOZHIBUFENQUTIGANJUEGONGNENGZHANGAIDUIYIXIEHUANZHESHIKEYIJIESHOUDE。CIWAI，SUIRANSHIYUNDONGGONGNENGQU，DANCETOUMIANBUYUNDONGGONGNENGQUQIECHUBINGBUHUIJIHUANZHEDAILAIJIAODADESHENGHUOZHANGAI，WEILEDACHENGWANQUANWUFAZUODEXIAOGUOYOUSHIKEYIJINXINGTOUMIANBUYUNDONGPICENGGONGNENGQUDIANXIANZAODEQIECHU。QUEDINGQUTIGANJUE、YUNDONGGONGNENGQUDEJISHUBAOKUOTIGANYOUFADIANWEIJIANCHA、YUNDONGYOUFADIANWEIJIANCHA、MEG、fMRI DENG，QIJIEGUOYUPICENGDIANCIJIJIEGUOBIJIAOWENHE；ERNAOGONGNENGCHENGXIANGQUEDINGYUYANGONGNENGQUDEFANWEIYAOYUANYUANDAYUPICENGDIANCIJIJISHUSUOQUEDINGDEYUYANGONGNENGQUYU，HOUZHEQUEDINGDEQUYUSHIBIBUKESHAODEJIBENYUYANPICENGQUYU，SUNHAIHOURONGYIDAOZHIYUYANGONGNENGZHANGAI，YINGYONGSHIYAOZHUYI。
4.4 信息矛盾处理
DUIYUXINXIBUWANZHENG、XINXIXIANGHUMAODUNDEDIANXIANHUANZHEKEYIMAIZHILUNEIDIANJI，ZHANGQIJIANCEDANAODEDIANHUODONG，DANYAOZHUYIYIXIAJIDIAN，SHOUXIANYAODUIDIANXIANHUANZHEQUANBUXINXIJINXINGZONGHEFENXI，TICHUYIZHONGHUOLIANGZHONGHELIDEDIANXIANFAZUOSHENJINGHUODONGKUOBUNAOWANGLUOJIASHE，ZHENDUIKENENGSHEJIDENAOQUYOUMUDESHEJILUNEIDIANJIMAIZHIFANGAN，YIJIESHIDIANXIANFAZUOSHENJINGHUODONGDEGUOCHENG，MIBUQITADINGWEIXINXIDEBUZU。QICI，LUNEIDIANJI EEG DEYOUSHIZAIYUKEYIZHAODAODIANXIANFAZUOZUIWEICHUSHIDEYICHANGDIANHUODONGBUWEI，HENXIANRANSHIJIANYOUXIANXINGYUANZEYINGGAISHOUDAOCHONGFENDEZHONGSHI，YEJIUSHIDUOKONGJIANBUWEIDELUNEIDIANJIDIANHUODONGXINXIYIJIZHENGHOUXUEXINXIDEBIDUISHIFENZHONGYAO，ZUIZAOCHUXIANYICHANGHUODONGQIEZAOYUZUIXIANYIGEZHENGHOUDEYICHANGJIELVCHUXIANBUWEIZUIYOUJIAZHI，ZUIKAOJINZHENZHENGDEDIANXIANZAO。ZAIZE，ZHONGSHISHENBUPICENGJIEGOUCANYUDIANXIANFAZUOGUOCHENGDEKENENGXING，LIJIEDAOYE、EYEDIMIANJIEGOUJIZHONGXIANJIEGOURUENEICEYIJIDINGNEICEJIEGOUZAIDIANXIANFAZUOGUOCHENGZHONGDEZUOYONG。ZUIHOU，CHONGFENLIYONGPICENGDIANCIJIJISHUSUOTISHIDEXINXIBANGZHUDINGWEI，LUNEIDIANJITEBIESHINAOSHENBUDIANJIDIANCIJIKEYIYOUFACHUHOUFANGDIANHUOZHEDIANXIANFAZUO，JIEHECISHIDE EEG BIANHUATEDIAN，BIDUIYUGUANCHANGFAZUODEXIANGSIXING，KEYIHENHAODEHUIZHICHUDIANXIANFAZUONAOWANGLUOLIANLUOTU，YOUZHUYUDIANXIANZAODINGWEI。
5 癫痫术前评估的参考策略
SHUQIANPINGGUDEZHILIANGJUEDINGSHOUSHUZHILIAODEXIAOGUO，JINGUANSHUQIANPINGGUJISHUYUELAIYUEDUO，WEIDIANXIANZAODEDINGWEITIGONGLEJIDADEFANGBIAN，DANMUQIANSHUQIANPINGGUYIRANSHIYIXIANGJIWEIFANZADEXITONGGONGZUO，ZHEIMEDUOSHOUDUANJIAZHIRUHE，RUHEPINGJIAQIMINGANXING、KEKAOXING，ZHEIXIEPINGGUSHOUDUANRUHEXUGUANYINGYONG，YIBIANZUIDACHENGDUJIEYUEYILIAOZIYUAN、JIANSHAOGONGZUOLIANG；LINGWAI，DANGJIANCHAJIEGUOHUXIANGMAODUNSHI，RUHEQUANHENGLIBI、ZHAOCHUGONGXING、QUWEICUNZHEN，QUEDINGZHENZHENGDEDIANXIANZAO；ZAIWUJIKESHI、CHOUCHUBUQIAN、BUZHISUOCUOSHIRUHETUPOCHUANTONG、ZHAODAOXIANSUO、SHUNTENGMOGUA、SHIXIANDINGWEI；RUHELIYONGYOUCHUANGDEJIANCHASHOUDUAN，MINGQUEZHIDIANZAO。YIXIAJIZHONGJIBENCELVE，KEYIJIEJIAN。
5.1 半球巨大病灶患者定位策略
YINGXIANGXUEJIANCHADUIYUDINGWEIDIANXIANZAOZHIGUANZHONGYAO，JIEGOUYINGXIANGXUEJIANCHAZHUYAOSHINAOBU CT HE MRI DEJIANCHAJIEGUOFEICHANGZHIGUAN，BIANYULINCHUANGLIJIEDIANXIANZAO。RUGUOLINCHUANGSHANGFAXIANYICEBANQIUDEJUDAJIEGOUXINGBINGZAO，SHOUXIANKAOLVBINGZAOYUDIANXIANDEGUANXI，PINGGUSHIZHUYISANDIAN。SHOUXIAN，DIANXIANFAZUODEZHENGZHUANGSHIFOUTISHIYUBINGZAOCEBIEWENHE，BAOKUOJIZHENLUAN、JINGLUAN、QIANGZHI、QUTIGANJUEXIANZHAO、SHIJUEXIANZHAODENG。QICI，TOUPI EEG JIANQIFANGDIANHEFAZUOQIYICHANGJIELVCHUXIANZAIBINGZAOCE，ZEGENGJIAZHICHIBINGZAOCEDIANXIANZAODINGWEI；RUGUOFANGDIANCHUXIANZAISHUANGCEHUOLIANGCEJIELVJIBENDUICHENG，BUNENGFOUDINGDIANXIANZAOWEIYUBINGZAOCE，BUFANGAIBANQIUQIECHUHUOLIDUANSHOUSHUDESHISHI。ZAIZE，JIDUANSHAOJIANDEQINGKUANGSHIDIANXIANFAZUODEZHENGZHUANGBIAOXIANZAIBINGZAOTONGCE，CIZHONGQINGKUANGXIAYOULIANGZHONGKENENGXING，DIANXIANZAOKENENGWEIYUBINGZAOCEBANQIUHUODUICEBANQIU，KEYIGENJUQITAXINXIJIAYIPANDUAN。
5.2 孤立性结构病灶患者定位策略
YINGXIANGFAXIANDEGULIXINGJIEGOUBINGZAOSHIZUIZHONGYAODEDINGWEIXINXIZHIYI，ZHENGZHUANGXUEKEYIJIESHIBINGZAOYUDIANXIANFAZUOZHENGZHUANGDEGUANXI，ZEJIYUBINGZAODINGWEI。RUGUO EEG FAZUOJIANQI、FAZUOQIXINXIYUBINGZAOWENHE，GENGJIAZHICHIYINGXIANGBINGZAODINGWEIDEJIEGUO；RUGUO EEG FAZUOJIANQI、FAZUOQIXINXIYUBINGZAOBUWENHE，BINGBUNENGFOUDINGYINGXIANGBINGZAODINGWEIDEJIAZHI。RUGUOZHENGZHUANGXUEXINXIBUNENGTIGONGDINGWEIJIAZHI，ER EEG、MEG XINXIYUBINGZAOXINXIWENHE，YINGXIANGBINGZAOYIRANFEICHANGYOUDINGWEIJIAZHI。ZUIXINDE VBM JIEGOUYINGXIANGFENXIJISHUTISHIDEWEIXIAOJIEGOUGAIBIANYEYOUYIDINGDEDINGWEIJIAZHI，ZHIDETUIGUANGYINGYONG。
5.3 结构影像检查阴性患者的脑电图、脑磁图应用策略
GAODUTONGBUHUADEDANAOSHENJINGYUANYICHANGFANGDIANKEYIBEI EEG HE MEG CAIJIDAO，QISUOTISHIDEFANGDIANKONGJIANBUWEISHUYUDANAOYICHANGXINGFENDEQUYU，YICHANGFANGDIANQUYUZAIDINGWEIGUOCHENGZHONGYOUMINGQUETISHIYIYI。YINGYONGSHIZHUYIYIXIAJIDIAN：SHOUXIAN，FAXIANDUOGEYICHANGFANGDIANQUYU，BUYINGJINJINGENJUJIANQIDEFANGDIANBUWEIDINGWEIDIANXIANZAO。QICI，ZAIFENXIFAZUOQINAODIANXINXISHIYINGZUNXUNSHIJIANSHUNXUYUANZE，YUEZAOCHUXIANYICHANGHUODONGDEBUWEIYUEKAOJINDIANXIANZAO。ZAIZE，YINGGAIYUZHENGZHUANGXUEBIJIAO，ZIXITONGBUYUEDULUXIANG EEG，BIDUILIANGZHEZHIJIANDUOGESHIJIANDEFASHENGSHUNXU，ZHENGZHUANGXUETEZHENGYUNAODIANXUETEZHENGSUOTISHIDEPICENGQUYUKENENGBICIJIAOHUCHENGXIAN，PINGGUSHIYINGGAICHONGFENKAOLVDAODIANXIANSHENJINGHUODONGKUOBUDEDONGTAIGUOCHENG，HUIZHIWANZHENGDEDIANXIANFAZUOPICENGKUOBUDONGTAIWANGLUOTU。
5.4 结构影像阴性患者的症候学线索逆向追踪策略
JIEGOUYINGXIANGXUEYINXINGDEHUANZHEZHENGHOUXUEDESHENRUFENXISHIFENZHONGYAO，ZHUYILIANGFANGMIANDEXIANSUO：SHOUXIAN，SHENRULEJIEHUANZHEFAZUODEXIANZHAO，XIANZHAOKEYITIGONGYOUDINGWEIYIYIDEXINXI。QICI，DIANXIANFAZUODECHUSHIYUNDONGZHENGZHUANGDEBUWEIKEYITISHIDIANXIANZAO。TANTAOZHENGHOUXUEDINGWEISHIYINGGAIZUNXUNNIXIANGZHUIZONGYUANLI，YEJIUSHIZAIQUEDINGHEXINZHENGHOUDEQINGKUANGXIAJINKENENGXIANGFAZUOZAOQIZHENGZHUANGJINXINGZHUIZONG，YUEZAOQIDEFAZUOZHENGZHUANGSUOTISHIDEPICENGQUYUYUEKAOJINDIANXIANZAO。
5.5 结构影像学阴性患者的脑功能检查策略
DUIYUJIEGOUYINGXIANGXUEJIANCHAYINXINGDEHUANZHE，SISCOM JIEGUOHUOZHE PET FAXIANDEDANAOPICENGJUBUDIDAIXIEQUYOUZHONGYAODINGWEIYIYI，RUGUODIANXIANFAZUOZHENGZHUANGTISHIWEINIEYEDIANXIANHUANZHE，PET DIDAIXIEQUWEIYUYICENIEYE，ZEDINGCEYIYIZHONGDA。PET-MRI RONGHEJISHUFAXIANDEPICENGJUZAODIDAIXIEQUYU MEG CIYUANCHENGXIANGHUOZHE VBM TISHIBUWEIXIANGWENHEZEJIAOKEKAO。NAOGONGNENGCHENGXIANGTISHIDEYICHANGNAOQUYINGGAIZAINENGLIANGHAOJIESHIZHENGHOUXUEXIANXIANGDEFASHENGGUOCHENGSHICAIYOUDINGWEIYIYI。
5.6 颞叶癫痫患者术前评估策略
颞叶癫痫是药物难治性癫痫中最常见的类型，手术疗效优于药物治疗[2]。合理的术前评估、彻底切除癫痫灶、最大限度保留功能区是颞叶癫痫手术成功的关键。
5.6.1 颞叶的功能解剖
NIEYEWEIYUWAICELIEDEXIAFANG，DINGZHENLIEHEZHENQIANQIEJIDEQIANFANG，YIWAICELIEYUEDINGYEFENJIE，HOUMIANYUZHENYEXIANGLIN。NIEYEQIANDUANWEINIEJI，WAICEMIANYOUYUWAICELIEPINGXINGDENIESHANGGOUYIJIDIMIANDENIEXIAGOU，LIANGGOUJIANGNIEYEWAICEFENWEINIESHANGHUI、 NIEZHONGHUI、NIEXIAHUI，NIESHANGHUIDEYIBUFENYANRUWAICELIEZHONG，WEINIEHENGHUI。NIEYEDEZHUYAOGONGNENGQUBAOKUO：① GANJUEYUYANZHONGSHUQU：WEIYUYOUSHIBANQIUNIESHANGHUIHOUBU；② TINGJUEZHONGSHU：WEIYUNIESHANGHUIZHONGBUJINIEHENGHUI；③ XIUJUEZHONGSHU：WEIYUGOUHUIHAIMAHUIQIANBU，JIESHOUSHUANGCEXIUJUEXIANWEIDECHUANRU；④ NIEYEQIANBU：YUJIYILIANXIANGHEBIJIAODENGGAOJISHENJINGHUODONGYOUGUAN；⑤ NIEYENEICEMIAN：CIQUYUSHUYUBIANYUANXITONG，HAIMASHIQIZHONGDEZHONGYAOJIEGOU，YUJIYI、JINGSHEN、XINGWEI、NEIZANGGONGNENGYOUGUAN。
5.6.2 颞叶癫痫的病因、分类与发作特征
常见病因包括海马硬化、发育性肿瘤、FCD、海绵状血管畸形、软化灶等，部分患者有儿童期热性惊厥史或早期脑损伤，包括外伤、感染或缺血缺氧性脑损伤等，可引起海马硬化。颞叶癫痫分类方法多样，传统上分为内侧颞叶癫痫和外侧颞叶癫痫[48]，近年来有学者将其分为颞叶内侧型、外侧型、颞极型、内外侧型和颞叶附加癫痫，少数患者为双侧颞叶癫痫[49]。
NIEYEDIANXIANFAZUODETEZHENGXINGBIAOXIANWEI：① BUBANYISHIZHANGAIDEJUZAOXINGFAZUO：DANCHUNBUFENXINGFAZUOBIAOXIANWEIZIZHUSHENJINGZHENGZHUANGHE/HUOJINGSHENZHENGZHUANGYIJIMOUXIEGANJUEXIANXIANG（RUHUANXIU、FUBUSHANGSHENGGAN、SICENGXIANGSHIGANDENG）；② BANYISHIZHANGAIDEJUZAOXINGFAZUO：WANGWANGYIYUNDONGTINGZHIKAISHI，SUIZHICHUXIANYISHIZHANGAI，BANSUICHUXIANDIANXINGDEKOU-XIAOHUADAOZIDONGZHENG，YEJINGCHANGSUIZHIFASHENGQITAZIDONGZHENG，CHIXUSHIJIANCHANG>1 min，FAZUOHOUCHANGYOUYISHIHUNZHUO、YIWANG，HUIFUGUOCHENGSHIZHUJIANDE。
5.6.3 一期非侵入性评估
5.6.3.1 视频脑电图
TOUPIEEGDETEZHENGKEBIAOXIANWEIBEIJINGHUODONGQINGDUHUOXIANZHUDEBUDUICHENG；NIEQIANBUHUONIEHOUBUJIBO、JIANBOHUOMANBO，DANCEHUOSHUANGCETONGBU，YEKEYIBUTONGBU；YICHANGHUODONGKENENGBUJUXIANYUNIEQU。DIEGUDIANJICAIJIEEGYOUZHONGYAOJIAZHI。BIXUTONGSHIJILUFAZUOJIANQIHEFAZUOQIDEEEG。
5.6.3.2 磁共振
XUZHISHAOBAOKUOQUANTOUWUJIANDUAN 3 mm CENGHOUDE T1、T2、T2-FLAIR XIANG，GUANZHUANGWEICAIYONGCHUIZHIYUHAIMAZHANGZHOUDEXIEGUANZHUANGWEISAOMIAO，3D-T1 DUIYUYINGXIANGHOUCHULIZHIGUANZHONGYAO。
5.6.3.3 正电子发射计算机断层显像
发作间期18F-FDG PET 扫描对颞叶癫痫有很大价值。发作间期，一侧颞叶低代谢有重要定位意义。需要注意的颞叶癫痫发作间期低代谢的范围往往大于癫痫灶的范围，需仔细甄别。
5.6.3.4 单光子计算机断层显像
NIEYEDIANXIANFAZUOQIDIANXIANZAOBIAOXIANWEIGAOGUANZHU，FAZUOJIANQIBIAOXIANWEIDIGUANZHU。
5.6.3.5 脑磁图
KEYIFAXIANDIANXIANYICHANGHUODONGDIANLIUYUANWEIYUYICENIEYEJIEGOU，SHUANGCENIEYEJIEGOUJUNKEJIANCEDAOFANGDIANDIANLIUYUANSHI，ZHUYIJIEHEQITAXINXIFENXIPANDUAN。
5.6.3.6 神经心理学评估
NIEYEDIANXIANHUANZHEDESHENJINGXINLIXUEPINGGUTEBIEZHONGYAO，YINGGAIZUOWEICHANGGUIJIANCHA，NEIRONGBAOKUOZHILI、ZHUYILI、YUNDONG、GANJUE、YUYAN、JIYI、SHIKONGJIANNENGLI、ZHIXINGGONGNENGDENG。YOUSHIBANQIUCENIEQIANYEQIECHUSHUYIYINQIHUANZHEJIYIGONGNENGDEJIANTUI，GUXUZAISHUQIANMINGQUEYOUSHIBANQIUBINGDUIJIYILICHONGFENPINGGU，CONGERZHIDAOSHOUSHUCELVE。
5.6.4 二期侵入性评估
5.6.4.1 颅内脑电图
由于颞叶癫痫的放电常来自于颞叶内侧、底面等深部结构，目前 SEEG 在颞叶癫痫中应用较为广泛。对于症状学、EEG不典型、结构影像学阴性或不同检查结果互相矛盾的情况，应考虑到假性颞叶癫痫或颞叶附加癫痫的可能，应利用颅内EEG进一步明确癫痫灶范围以及功能区范围[50]。
5.6.4.2 Wada 试验
GUANGFANYONGYUYUYAN、JIYI、YUNDONGGONGNENGDESHUQIANPINGGU，SHIMUQIANQUEDINGYANYU、JIYIYOUSHICEDEJINBIAOZHUN。
5.6.5 颞叶癫痫患者术前评估策略流程图
颞叶癫痫患者的术前评估策略流程详见图 4。
图4
颞叶癫痫患者术前评估策略流程图
5.7 岛叶癫痫患者术前评估策略
岛叶癫痫术前评估定位困难。岛叶-岛盖区癫痫是指颅内电极确认的岛叶-岛盖区起源放电引发的癫痫或存在岛叶病灶及其关联性发作症状的癫痫[51, 52]。
5.7.1 岛叶的功能解剖
岛叶位于外侧裂内血管墙的深面，经前、下、上环岛沟与额、颞、顶叶相隔，岛中央沟将岛叶分为岛前小叶、岛后小叶两部分，岛前小叶分为 3 个岛短回，岛后小叶分为 2 个岛长回。岛盖是指位于环岛沟投影到脑表面外侧裂内外的灰质，包括额眶岛盖、额顶岛盖、颞叶岛盖。岛叶深部的白质纤维是极外囊及外囊。岛叶相关长纤维束主要有钩束、弓状束、额枕下束、颞干和视辐射。岛叶后上部皮质深方为壳核、苍白球，直接与锥体束相邻，是手术的危险区。Kurth 等[53]在岛叶 fMRI 研究 Meta 分析中将岛叶分为 4 个功能区：岛极周围的社交-情绪区、前岛短回背侧及中岛短回的认知区、中岛短回的嗅味觉区、后岛短回-后岛长回上部的感觉运动区。
5.7.2 岛叶-岛盖区的癫痫灶定位
5.7.2.1 症状学
岛叶的功能连接非常复杂，岛叶及岛叶周围皮质产生的癫痫发作的症状学特点也很复杂，可以概括为以下几类[54, 55]：① 躯体感觉症状，多表现为分布于皮肤局限区域（口周、面部、手、上肢），或广泛区域的一种无痛的麻刺感、过电感或温热感，其他的躯体感觉还包括发紧感、颤动感及跳动感等；② 内脏感觉，主要表现为咽喉部紧缩感、恶心、胃气上升感、胸部紧缩感等，严重时可表现为呼吸困难、窒息；③ 口咽运动症状，主要与口咽部运动相关，如咀嚼、咂嘴、吞咽等，并与发作性呕吐有关；④ 躯体运动症状，例如过度运动症状，或者不对称强直、自动症等运动症状；⑤ 特殊感觉，包括特殊的味觉、听觉症状，以及前庭觉症状，如旋转，漂浮感，坠落感及头昏等；⑥ 意识清醒状态下的语言功能障碍；⑦ 植物神经症状，主要是指发作时心率变化（心率过快、过慢、心脏停博）、皮肤改变（苍白、潮红、汗毛竖立）等。这些先兆和发作期症状，可以支持或提示发作时岛叶-岛盖受累。
5.7.2.2 影像学
GAOFENBIANLVDE MRI SHIDAOYEDIANXIANDINGWEIZHENDUANDEZHONGYAOYIJU，TONGGUO MRI XIANSHIDEDAOYEQUYUBINGZAOCHANGKEZHENDUANDAOYEDIANXIAN。DANSHI，YOUYUDAOYEJIDAOGAIQUYUPICENGZHOUZHEDUO，JIAOXIAODE FCD HENNANQUEREN。PET JIANCHADUIYUTISHIDAOYE-DAOGAIDIANXIANJUYOUYIDINGDEZUOYONG，YOUQISHIYU MRI JINXINGRONGHEZHIHOU，CHANGKEFAXIANJUBUPICENGDEDIDAIXIEQU。FAZUOQI SPECT YEDUIDAOYE-DAOGAIQUDIANXIANYOUMINGQUEDEDINGWEIJIAZHI。VBM DUIBUFENDAOYE-DAOGAIQUDIANXIANJUYOUYIDINGDEDINGWEITISHIZUOYONG。
5.7.2.3 脑电图
DAOYEDIANXIANDETOUPI EEG BUJUTEYIXING，KEYIXIANSHIEYE、NIEYE、ZHONGYANGDINGQUDEJUXIANXINGYICHANGFANGDIAN，YEKEYISHIGUANGFANDEYICHANGDIANHUODONG，HUOJILUBUDAOMINGXIANDEYICHANGFANGDIAN。YOUSHI，JUBUDE、YICEDEMANBOHUODONGHUOMEIYOUJILUDAOMINGXIANDEYICHANGFANGDIANBENSHENJIUKENENGBEIKANZUOSHIDAOYEDIANXIANDETEZHENGXING EEG GAIBIAN。YOUXIEDIANXIANZAOLEIJIDAOGAIJIZHOUWEIPICENGDEHUANZHE，KEYIZAIE、NIE、DINGYEQUJILUDAOJUZAOXINGJIANBOHUODONG。ZONGTIERYAN，WULUNFAZUOJIANQIHUOFAZUOQITOUPI EEG，DINGWEIDAOYEDIANXIANDOUHENKUNNAN。
5.7.2.4 脑磁图
YUTOUPI EEG XIANGBI，MEG ZAIDINGWEIDAOYEDIANXIANFANGMIAN，JUYOUXIANZHUYOUSHI，MEG DUIYUCELIANGWEIYUDANAOGOULIENEINAOPICENGDEYICHANGFANGDIANGENGJIAMINGAN。DUIYUDAOYEDIANXIAN，YOUQISHIZAICELIENEIZHEFANDEDAOGAIPICENGDEYICHANGFANGDIAN，MEG JIANCHAJIAOWEIMINGAN。DUI MRI YINXINGBIAOXIANDEBINGLI，KEYITIGONGEWAIDEDINGWEIXINXI。
5.7.2.5 颅内电极记录
DAOYE-DAOGAIQUDIANXIANCHANGCHANGXUYAOYINGYONGLUNEIDIANJIJILUCAIDEYIMINGQUEZHENDUAN。YOUYUDAOYEDETESHUJIEPOUWEIZHI，JISHIYINGYONGYINGMOXIAPICENGDIANJIYEKENENGBUNENGMINGQUEDINGWEIDAOYE-DAOGAIQUDIANXIAN。CHANGXUYAOLIANHEYINGYONGSHENBUDIANJI，HUOJIANGWAICELIEFENKAI，ZAIDAOYEHEDAOGAIQUPICENGFANGZHIPICENGDIANJI。SEEG FEICHANGYOUZHUYUDINGWEIDAOYE-DAOGAIQUDIANXIAN。ZHIDEZHUYIDESHI，SEEG DIANJICAIJIDEFANWEIHENJUXIAN，QIEGAIBUFENXUEGUANSHIFENFENGFU，ZAISHEJI SEEG DIANJIZHIRUWEIZHIHEFANGSHISHI，XUZONGHEFENXIDIANJIZHIRUDEBADIANBUWEI、ZHIRUFANGSHIHELUJING，YIJIYINGYONGDIANJIDESHULIANG。
5.8 额叶癫痫患者术前评估策略
5.8.1 额叶的功能解剖
额叶是大脑最大一个脑叶，主要包括了中央运动区的 Broadmann 4 区和运动前区（6 区），额叶背侧的额眼区（8 区）、前额背外侧皮层（9 区）、额极区（10 区）和额眶回（11、12 区）、前扣带回（24、25、32、33 区）、中央下区（43 区）、Broca 区（44、45 区）、背外侧前额叶（46 区）和前额下回（47 区）。见图 5。
图5
额叶皮层的 Broadmann 分区
5.8.2 额叶的癫痫灶定位
5.8.2.1 症状学
额叶癫痫临床特点包括：夜间或睡眠中多发，发作时间短、频率高，且有丛集性发作，发作后意识恢复快，症状刻板，运动幅度大，可有对侧头眼偏转，不对称强直等特点。这些症状特点对癫痫灶的定位与定侧有一定的提示作用，但特异性较差，比如过度运动多见于额叶，也可以见于颞叶、岛叶等部位。头眼偏转同样可以见于额叶、颞叶、枕叶等脑区，还可以见于对侧或同侧半球。对症状学的全程顺序分析可能提供更多的定位、定侧信息[56]。
5.8.2.2 影像学
MRI SHIFOUKEYIFAXIANBINGZAOYUEYEDIANXIANSHUHOUXIAOGUOYOUMINGQUEXIANGGUANXING，SUOYIGAOCHANGQIANG（3.0T HUO 7.0T）MRI DEBOCENGDUOXULIEDESAOMIAO，TEBIESHI 3D-FLAIR、3D-T1 MPRAGE HEBAIHUIZHIJIEXIANZENGQIANGSAOMIAOFEICHANGZHONGYAO，KEYIFAXIANYIXIENAOPIZHIFAYUBULIANGXINGBINGBIAN。DUIYUBANSUIYINEIDEERTONG T2 BOCENGSAOMIAOJIAO FLAIR GENGRONGYIFAXIANBINGBIAN，ER 6～18 GEYUEDEHUANZHEWULUNSHI FLAIR HAISHI T2 XULIEDOUKENENGNANYIFAXIANBINGBIAN，SUOYIDUIYU MRI YINXINGDEEYEDIANXIANHUANERYAODUOCIJIANCHA MRI，YIQIFAXIANBINGZAO。VBM DENGYINGXIANGHOUCHULIKENENGBANGZHUFAXIAN MRI YICHANG。MRI YINXINGDEDIANXIANHUANZHEKEYIJINXING MRI-PET RONGHE、SISCOM HUO EEG-fMRI JIANCHA，BANGZHUDINGWEIEYEDIANXIANZAO。
5.8.2.3 脑电图和脑磁图
额叶内侧面、额叶底面相关的癫痫样放电应用常规头皮 EEG 监测困难，发作期 EEG 多伴明显的动作伪差，难以发现异常放电。而且额叶癫痫双侧传导甚至快于同侧半球内的传导，所以 EEG 上经常表现为双侧的异常放电。除了背外侧额叶癫痫外，EEG 对额叶癫痫定位困难，应用密集电极的 EEG 可以提高额叶癫痫的定侧及定位价值。发作间期 MEG 对额叶癫痫的定位有一定的帮助，MEG 源定位脑区为单灶且手术全切除者预后良好[57]。
5.8.2.4 颅内电极记录
LUNEIDIANJI EEG SHIEYEDIANXIANSHUQIANPINGGUZHONGDEZHONGYAOGONGJU，MRI YINXINGEYEDIANXIAN、GUANGFANXING MRI YICHANGDEEYEDIANXIAN、LEIJIHUOLINJINYUNDONGQUHEYOUSHICELEIJIYUYANQUDEEYEDIANXIANDOUYINGDANGKAOLVJINXINGLUNEIDIANJI EEG JIANCHA。DUIYUEYEDIANXIANHEBINGLUNEIJUXIANXINGFEIPIZHIFAYUBULIANGDEBINGZAO（RUHAIMIANZHUANGXUEGUANLIU、NAONANGCHONG、GAIHUAZAO、ZHONGLIU、JIEJIEXINGYINGHUAZHENGDEPICENGJIEJIE），QIEDIANXIANZHENGZHUANGXUEKEYIYONGBINGZAOJIESHISHI，HUO MRI YANGXINGHEBINGJINXINGXINGRENZHISUNHAIHEPINFANDIANXIANFAZUODEYINGYOUEREYEDIANXIAN，WULUNSHIFOULEIJIGONGNENGQU，JIANYIGENJU MRI HE PET DENGJIEGUOJINXINGYIQIQIECHUSHOUSHU，BUTUIJIANLUNEIDIANJIMAIZANG。XUYAOZHIRULUNEIDIANJIDINGWEIZHE，YINGDANGFUGAI MRI YANGXINGQUYU、FAZUOJIANQI EEG ZHUYAOXIANXINGFANGDIANQUYU、FAZUOQI EEG KEYIQIYUANQUYUHE PET、MEG、SISCOM JIANCHATISHIDEKENENGYICHANGQUYU，LINJINGONGNENGQUZHEHAIYINGDANGBAOKUOGONGNENGQU。LINGWAI，YOUYUEYEDIANXIANZAIZHENGZHUANGXUEHUODIANSHENGLISHANGKENENGYUDAOYE、NIEYEHEDINGYEJIANYOUZHONGDIE，SUOYICHANGGENJUWUCHUANGJIANCHAPINGGUJIEGUO，LUNEIDIANJIZHIRUSHIXUYAOXUANZEXINGFUGAISHANGSHUBUFENHUOQUANBUQUYU。DUIYUKAOLVDIANXIANZAOWEIYUEYENEICE、KOUDAIHUI、EKUANGHUI、SHUANGEYE、DAOYEZHEYOUXIANKAOLV SEEG DEFANGSHI，KEYIJIANSHAOCHUANGSHANGHETIGAODIANJIZHIRUZHUNQUEXING。DUIYUBINGZAOHUODIANXIANZAOZHUYAOLEIJIYUNDONGQUHEYOUSHICEYUYANQU，LUNEIDIANJIMAIZANGDEMUDECHULEQUEDINGDIANXIANZAO，GENGZHUYAOSHIWANCHENGGONGNENGQUDINGWEI，YINGDANGYOUXIANKAOLVYINGMOXIADIANJI（HUOJIEHENAOSHENBUDIANJI）EEG。
5.8.2.5 神经心理检查
SHENJINGXINLIJIANCHADUISHUQIANDINGWEIHEDINGCEDIANXIANZAOYOUYIDINGBANGZHU，GENGZHONGYAODEYONGYUSHUQIANYUSHUHOUDUIBIZONGHEPINGJIASHOUSHUXIAOGUO。
5.8.2.6 额叶各部分起源特点
BUTONGFAZUOZHENGZHUANGBIAOXIANKEYITISHIDIANXIANFAZUOQIYUANYUEYEDEBUTONGNAOQU。ZHONGYANGQUDIANXIANLINCHUANGSHANGZHUYAOBIAOXIANWEIYIDUICEYUNDONGZHENGZHUANGWEIZHUDEDUICEZHITIDEQIANGZHI、ZAOQIHUOWANQIZHENLUAN、DANCHUNYUNDONGZHENGZHUANG、BUDUICHENGQIANGZHIZISHI、KOUJIAOPIANXIE，YEKEYIBANYOUQUANMIANQIANGZHIZHENLUANFAZUO、QUTIGANJUEXIANZHAODENG。BA4 QUDEEYEDIANXIANYUHOUDEZHUYAOYINSUSHICUNZAI MRI BINGLIYICHANG，BENQUSHUQIANPINGGUDEZHONGDIANZAIYUYANGEDEZHENGZHUANGXUEFENXIHEGAOCHANGQIANG（3.0T HUO 7.0T）MRI DEBOCENGDUOXULIEDESAOMIAO，TEBIESHI FLAIR HEBAIHUIZHIJIEXIANZENGQIANGSAOMIAO，LINGWAI PET-MRI DERONGHEDUIFAXIANBINGZAOYEYOUJIAODAYIYI。DUIYUWUBINGLIZAOQIEKAOLVWEIYU BA4 QUDEDIANXIANJINXINGLUNEIDIANJIMAIZHIYUQIECHUXINGSHOUSHUZHILIAOXUSHENZHONG。
FUZHUYUNDONGQUFAZUOLINCHUANGSHANGZHUYAOBIAOXIANWEIBUDUICHENGDEQIANGZHIXINGZISHI，CHIXUSHIJIANJIAODUAN，KEYIBUBANYOUYISHISANGSHI。RUYICEZHITIQUQU，DUICEZHITISHENZHI，ZETISHIDIANXIANZAOWEIYUQUQUZHITICE。
前扣带回主要与导水管周灰质、伏隔核、杏仁核、前岛叶有密切的纤维联系，参与情感和自主神经功能，前扣带回癫痫常见的症状包括过度运动 I 型、恐惧、发笑、发作性噘嘴，但也可有痉挛发作等特殊形式，其癫痫发作症状多样，缺乏特异性，单纯依靠症状学定位非常困难。单纯局限于扣带回的癫痫 EEG 定位、定侧意义较小，对于同时累有额叶其它部位的扣带回癫痫 EEG 有 2/3 有一定定侧或定位的意义。怀疑扣带回癫痫的 MRI 阴性或广泛 MRI 异常的患者应当进行颅内电极植入的评估[58]，但由于上引流静脉及矢状窦粘连等原因，颅内硬膜下电极在中线扣带回及额顶叶背外侧皮层位置准确植入存在一定的风险，深部电极特别是 SEEG 成为扣带回癫痫灶定位的良好手段，考虑为扣带回癫痫时，SEEG 埋藏中至少应当 4 个电极覆盖前、前中、后中和后扣带回。
背外侧额叶癫痫可以有对称性轴性强直、撇嘴、简单的姿势性运动、发声等癫痫发作症状，但复杂的姿势性运动和固定的面部表情等很少出现。累及辅助运动区时会有不对称性强直、累及额眼区时会出现头眼偏斜，其类型多为先有短暂的向同侧偏，然后有较长时间的头眼向对侧偏斜。EEG 有较高的定侧和定位意义，但额叶癫痫向额叶外及对侧传导较快，所以放电范围多较广泛。MRI 检查及 MRI-PET 融合与其它部位额叶癫痫一样非常重要。MRI 阴性者应当进行颅内电极检查，需要进行功能区定位时可行硬膜下电极埋置[59]。
额极与额眶回癫痫临床上主要表现为恐惧等情绪和过度运动自动症、复杂的姿势性运动和固定的面部表情等。发作间期常规 EEG 定位与定侧癫痫灶困难。发作期多为运动伪差。MRI 阴性者应当进行 MRI-PET 融合检查，仍无明显病灶时，可行影像后处理、MEG、SEEG 电极的埋藏检查等[60]。额叶癫痫术前评估的检查策略见表 8。
表8
额叶癫痫术前评估的检查策略
5.9 顶枕叶癫痫（后皮层癫痫）患者术前评估策略
后皮层癫痫是指发作起始于枕叶、顶叶或后颞叶区域，或是其中 2 个或 3 个脑叶交界区的癫痫总称，是相对于常见的额叶癫痫和颞叶癫痫而言的。这 3 个脑叶并无明确的解剖学分界线，其划分是根据一些解剖学标记而设定的人为界限，此区的癫痫灶可能较大，跨越了人为的界限，在进行手术治疗时，也难以局限于人为界定的枕叶顶叶中，因此有时无法确切认定某例患者是枕叶癫痫、顶叶癫痫或是颞叶后部起源的癫痫[61]。Blume 等[62]在文章中也提到更愿意使用“后皮层癫痫”这一词，而不再勉强区分枕叶癫痫，顶叶癫痫或颞叶后癫痫。本规范也将起源于此区域的癫痫发作作为一组综合征进行讨论。
5.9.1 后皮层的功能解剖与传导路径
LEJIEHOUPICENGDIANXIANDELINCHUANGBIAOXIAN，HENZHONGYAODEYIDIANSHIYAOMINGQUEHOUPICENGQIYUANFAZUODECHUANBOKUOBUTEDIAN，JICHANGCHANGSHIXIANGQIANTOUBUKUOSAN。NIEYEXINPICENGJUYOUDALIANGDELIANLUOXIANWEILIANXINIEYEDEGEBUFEN，BINGLIANXINIEYEYUQITANAOYE，ZAI Broadmann 18、19 QUYU 37 QUZHIJIANYOUZHISHIQUDELIANLUOXIANWEI，ZAI Broadmann 7、40 QUYU 22 QUZHIJIANYOUZHIDINGYEDELIANLUOXIANWEI。ZHEIXIEDOUKENENGBAOKUOZAINIEYE、DINGYE、ZHENYEGANJUEYUNDONGQUZHIJIANDEFUZALIANJIEZHONG，PICENGDIANCIJIYANJIUYEZHENGSHINIEYEHOUBUQUYUYUQUTIHUODONGYOUGUAN，BINGYUTINGJUEHUOSHIJUEXINGSHIDEYUYANJIAOLIUYOUGUAN。WEIYUNIEHOUZHENQUDEFAZUOQIXIANXINGDIANHUODONGKEYITONGGUOBEICETONGLUKUOBUZHIZHONGYANGQU、EHOUHUOFUZHUYUNDONGQU，CHANSHENGXIANGYINGDELINCHUANGZHENGZHUANG；YEKEYITONGGUOFUCETONGLUKUOBUZHINIEYENEICEHUONIEYEPICENG，CHANSHENGNIEYEDIANXIANDEFAZUOZHENGZHUANG；HAIKENENGTONGGUOZHOUWEIPICENGDEKUOBU，CHANSHENGDINGYE、NIEHOU、DAOYE、ZHONGYANGQUPICENGDELINCHUANGFAZUOZHENGZHUANG。LIRU，JINGCELIEXIABUDEKUOSANKENENGJINBIAOXIANWEIBANZIDONGZHENG、XIONGMENBUSHI、KONGJUYIJISICENGXIANGSHIGANDENGLEISIQIYUANYUNIEYENEICEJIEGOUDEFUZABUFENXINGFAZUO。ERJINGCELIESHANGXIANGZHONGYANGQUKUOSANDEFAZUOKEYIYINQIBANYOUMINGXIANYUNDONG、GANJUEZHENGZHUANGHETIZHENGDEBUFENXINGFAZUO，KUOSANZHIFUZHUYUNDONGQUSHIKECHANSHENGYICHANGDEZISHI。
5.9.2 后皮层癫痫灶定位评估
HOUPICENGDIANXIANDEDIANXIANZAODINGWEIYETONGYANGYILAILINCHUANGZHENGZHUANGXUE、SHENJINGYINGXIANGXUE、FAZUOJIANQIHEFAZUOQI EEG DENGJIANCHASUOTIGONGDEDINGWEIYIJU。YOUYUSHEJINIEHOU、DINGYE、ZHENYE 3 GENAOQU，LINCHUANGFAZUODEBIAOXIANGENGJIAFUZA，YINCI，CHONGFENLEJIEQIYUANYUHOUPICENGDIANXIANFAZUODELINCHUANGTEDIANSHIFEICHANGZHONGYAODE。XIANGXIDEXUNWENHUANZHEBINGSHI，BAOKUOXIANZHAO、QISHIZHENGZHUANGHEZHENGZHUANGYANBIANGUOCHENG、FAZUOHOUDESHENJINGGONGNENGQUESHIQINGKUANG，YIJIBUTONGNIANLINGSHIQIDEZHENGZHUANGBIANHUADENGDENG，CHANGCHANGKEYITISHIDIANXIANZAOWEIYUHOUPICENG。
5.9.2.1 症状学
视觉先兆被认为可以强烈提示枕叶发作，视幻觉是在缺乏外界刺激的情况下出现的主观体验性的图形。在询问病史时，需要明确发作期视幻觉的颜色、形状、大小、位置、是否运动、持续时间、发作频率，以及是否有相关进展症状。简单的视幻觉，常常为几何图形、光点、直线等，上述这些症状往往起源于初级视觉皮层。复杂的视幻觉，包括物体、人物、风景等复杂图形或者图像。视错觉是对于真实影像的误解和错觉，比如视物显小、视物显大等。复杂的视幻觉和视错觉，主要在癫痫发作进展时出现，这些症状可以是癫痫发作的首发症状，但通常在简单视幻觉之后出现，上述症状可能累及到枕-顶或枕-颞交界区。其他常见的枕叶发作症状包括发作性快速眨眼、眼睑痉挛、双眼强直性偏转以及视像残留等。比较有意思的是双眼强直性偏转，即双侧眼球运动可分为两种，一种为平稳追踪运动，为持续性缓慢眼球运动，往往是同向运动，即定位信息在同侧，被认为与颞后枕交界处的中颞/颞上内侧（MT/MST）区相关；另一种与之相对应的眼球运动叫扫视运动，为快速的眼球运动，既有同向运动，又有反向运动[63, 64]。颞叶后部与枕叶交界的新皮层发作有时不仅出现视觉先兆，还可以出现失语等其他症状。明确的躯体基本感觉异常与顶叶感觉皮质间有很强的定位关系，可作为顶叶尤其是累及中央后回的癫痫灶的重要证据。但是，一些与顶叶发作有关的其他症状相对少见且定位比较困难，包括：双侧感觉异常、体像障碍、躯体失认、眩晕等[65]。部分患者的癫痫灶范围较大，可能同时累及颞后、顶叶、枕叶中的 2 个或 3 个部位。因此，临床所见的癫痫发作起始症状中可能混杂有后皮层不同脑叶的症状特点。
5.9.2.2 影像学
SHENJINGYINGXIANGXUEJIANCHAZAIHOUPICENGDIANXIANDEDINGWEIZHONGJUYOUFEICHANGZHONGYAODEZUOYONG，YOUQISHI MRI XIANSHIBINGZAOCHANGQIANGLIETISHIDIANXIANZAODEWEIZHI。FCD、RUANHUAZAO、DUOXIAONAOHUIJIXING、ZHONGLIUDENGSHICHANGJIANDEYINGXIANGXUEGAIBIAN，SHOUSHUYECHANGXUYAOQIECHUZHEIXIEBINGBIAN。DUIYU MRI YINXINGBIAOXIANDEHUANZHE，DIANXIANZAODINGWEICHANGCHANGSHIFENKUNNAN，XUYAOZIXIFENXIFAZUOZHENGZHUANGXUEBIAOXIAN，YOUQISHIXIANZHAOBIAOXIAN，JINXINGDINGWEIFENXI。XUYAOTEBIEQIANGDIAODESHI，HOUPICENGDIANXIANFAZUOQIZHENGZHUANGKENENGSHIYOUYUFANGDIANKUOBUZHIEYEHUONIEYEHOUCHUXIANDE，HENRONGYIWUDAOWEIEYE、NIEYEDIANXIAN。QITAYINGXIANGXUEJIANCHA，RU PET、SPECT、MEG DENGJIANCHADUIHOUPICENGDIANXIANZAODEDINGWEIYEJUYOUZHONGYAOTISHIZUOYONG，CHANGZUOWEI MRI JIEGUODEYOUYIBUCHONG，ERDUIYU MRI YINXINGDEHUANZHE，ZHEIXIEFUZHUJIANCHADEYANGXINGFAXIANKENENGSHIDIANXIANZAODINGWEIDEZHONGYAOTISHI。YINGYONG VBM HEQITAYINGXIANGHOUCHULIFENXIFANGFASUODEDEYANGXINGFAXIANYEKENENGDUIDIANXIANZAODINGWEIJUYOUTISHIZUOYONG。
5.9.2.3 颅内电极定位
YOUYUHOUPICENGDIANXIANZAODINGWEIKUNNAN，SHOUSHUQIECHUFANWEIBUYIQUEDING，YOUSHEJIYUNDONG、GANJUE、YUYAN、SHIJUE、RENZHIDENGZHONGYAOGONGNENGQU，YINCI，SHOUSHUZHILIAOSHIYIXIANGTIAOZHAN。ZAIFEIJUXIAN MRI BINGZAOXIANGGUANHOUPICENGDIANXIANDESHUQIANPINGGUZHONG，YINGYONGLUNEIDIANJIJILUCHANGCHANGSHIBIXUDESHOUDUAN。KEYIYONGLAIQUEDINGFAZUOQISHIDECEBIE、DIANXIANZAODEWEIZHIHEFANWEI，ZHIDINGSHIYIDESHOUSHUQIECHUJIHUA。DANGDIANXIANZAOWEIYUYUNDONG、GANJUE、YUYANDENGZHONGYAOGONGNENGQUFUJINSHI，HAIXUYAOLIYONGLUNEIDIANJIJINXINGPICENGDIANCIJIZHITU，DINGWEIGONGNENGQUDEJINGQUEWEIZHI。GEXIANGSHUQIANPINGGUSHOUDUANDEDAODEXINXIKEYIZUOWEILUNEIDIANJIZHIRUFANGANDEYIJU，BINGYICIXUANZEYINGYONGYINGMOXIAPICENGDIANJIHUO SEEG DIANJI。
5.10 幼小儿童患者术前评估策略
ILAE XIASHUDIANXIANWAIKEZUWEIHUIYU 1998 NIANCHENGLIERTONGDIANXIANWAIKEFENHUI，ZHESHOUZHIDINGTUIJIANERTONGDIANXIANHUANZHESHOUSHUZHILIAODESHIYINGZHENGBINGTANTAOHETUIGUANGZHENGGUIDESHUQIANPINGGUFANGFA。KEJIANERTONGDIANXIANWAIKEYUCHENGRENZHIJIANDEJUDACHABIE。
5.10.1 儿童难治性癫痫术前评估与成人之间的主要区别及特点
SHOUSHUMUDEBUTONG，YINERXUANZESHOUSHUDESHIYINGZHENGJISHIJIBUTONG：CHENGRENNANZHIXINGDIANXIANSHOUSHUZHILIAODEZHUYAOMUDESHISHIHUANZHEFAZUOXIAOSHICONGERNENGZHONGXINRONGRUSHEHUI，DULISHENGHUO、JIEHUN、JIUYE。ERERTONGSHOUSHUDEZHUYAOMUDEZAIYUXIAOCHUFAZUO，SHIHUANERSHENJINGXITONGJIRENZHIDENGFAYUGUOCHENGBUSHOUPINFANFAZUODEYINGXIANG，CONGERKEYIZHONGXINZOUSHANGZHENGCHANGDEFAYUZHENGGUI。DUIYUSHIHESHOUSHUDEHUANZHEYINGJINZAOSHOUSHUZHILIAO。
DILINGDIANXIANHUANERWAIKESHOUSHUFENGXIANGAO，SHOUSHUSHIJIYINGZIXIQUANHENG：SUIRANSHOUSHUZHILIAOYUEZAOYUEJISHIYUEHAO，DANZAOQIDIANXIANSHOUSHU，TEBIESHIZAIYINGYOUERQI，NAOWAIKESHOUSHUYAOCHENGDANGENGDADEFENGXIAN。JIANYICILEISHOUSHUYINGZAIJIBIEZUIGAODEDIANXIANZHONGXINNEIYOUSHENJINGNEIKEJISHENJINGWAIKEYISHENGGONGTONGPINGGUKAIZHAN。
DIANXIANHUANERSHUHOUDEKANGFUNENGLIQIANG。YOUYUERTONGSHENJINGXITONGJUYOUHENQIANGDEKESUXING，YUCHENGRENDIANXIANSHUHOUDEHUIFUNENGLIJIERANBUTONG，JUYOUHENDADEYOUSHI。ZAISHUQIANPINGGUSHI，YINGGENJUHUANERDENIANLINGJINSHENKAOLVGONGNENGSANGSHIYUFAZUOYUHOUDEGUANXI，ZHIDINGHELIDESHOUSHUJIHUA。
5.10.2 儿童难治性癫痫术前评估的主要内容
5.10.2.1 癫痫病因的判断
儿童难治性癫痫的主要致病因素很多，且有些仅在儿童期间才出现。针对患儿，虽然都是难治性局灶性癫痫，病因不同预后会非常不同。例如 Dravet 综合征的患儿，虽然发作起始非常局限，但切除性手术的预后非常不好。另一方面，如果癫痫为年龄相关的综合征，即使发作难以控制，也绝对不是手术的适应证。因此，明确患儿所患癫痫的病因及远期预后对于评估患儿能否手术至关重要[66]。
5.10.2.2 难治性癫痫的诊断
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5.10.2.3 儿童癫痫外科术前评估主要检查手段
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WENZHANGGONGXIANFENBU（PAIMINGANXINGSHIPINYIN）
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1 癫痫外科治疗术前评估的意义
DIANXIANSHIYIZHONGNAOBUMANXINGJIBING。DIANXIANDEZHILIAOSHIYIGEZHANGQI、XITONGDEGONGCHENG，XUYAOYOUSHENJINGNEIWAIKE、ERKE、SHENJINGYINGXIANG、SHENJINGXINLI、SHENJINGKANGFUDENGDUOXUEKEGONGTONGCANYU。DIANXIANWAIKESHOUSHUSHIZHILIAOHUANJIEZHONGDE“ZHONGYAOYIHUAN”ERFEI“ZUIHOUYIHUAN”；WAIKESHOUSHUDEMUDESHI“JIANQINGHUOXIAOCHUDIANXIANFAZUO，ZUIZHONGTIGAOHUANZHESHENGHUOZHILIANGBINGHUIGUISHEHUI”，ERFEIDANCHUNDE“JIANSHAODIANXIANFAZUO”。
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癫痫外科手术涉及到手术适应证、基于多学科（神经内外科、儿科、神经影像、神经康复等）的综合术前评估、手术方式及手术效果等多个方面[1, 2]。下面逐一阐述。
1.1 手术适应证
原则上讲，若患者经过规范的抗癫痫药物（AEDs）治疗，仍未达到癫痫发作的有效控制，并已经影响患者的生活质量，同时患者和家属有手术治疗意愿，患者能耐受手术并能在围手术期很好地配合，就可以考虑进行术前评估。术前评估要综合考虑患者的癫痫及发作类型、电生理及影像学所见、病因及病理特征等因素（表 1）。
表1
癫痫外科手术适应证
XUANZESHUQIANPINGGUHUANZHESHI，YINGZUNXUNGETIHUAYUANZE：① YAOWUZHILIAOGUANCHASHIJIAN：YONGLIANGZHONGYISHANG AEDs、GUANCHALIANGNIANYIRANYOUDIANXIANFAZUODEHUANZHEWEIYAOWUNANZHIXINGDIANXIAN，CIBIAOZHUNSHIYONGYUDADUOSHUHUANZHE。DANDUILUNEIZHONGLIUXINGBINGBIAN、KUAISUJINZHANDE Rasmussen NAOYAN、YINGYOUERNANZHIXINGDIANXIANHUODIANXIANXINGNAOBINGDENGQINGKUANG，YIZAOQICAIQUSHOUSHUZHILIAO；② MOUXIETESHUDIANSHENGLITEZHENG：YOUQIZAIHUANER，MOUXIETESHUBUWEIJUZAOQIYUAN（RUNAOYENEICEMIAN）DEDIANXIAN，XIANXINGFANGDIANKEYICHENGXIANMIMANXING、DUOZAOXINGSHENZHIQUANMIANXING（TONGCHANGSHIYOUYUYICHANGFANGDIANDEKUAISUCHUANBOSUOZHI），ZHEIZHONGQINGKUANGJINGGUOZIXIPINGGU，KENENGBINGFEISHIJUEDUISHOUSHUJINJI；③ SHOUSHUNIANLING：ZHENDUIERTONGNANZHIXINGDIANXIAN，MINGQUEDIANXIANZAOHOUYINGJINZAOSHOUSHU，YIMIANFANFUDIANXIANFAZUOYINGXIANGSHENJINGXITONGFAYU，ERTONGDANAOJUYOUJIAOHAODEGONGNENGKESUXING，SHOUSHUSHIYINGZHENGDEXUANZEYAOXIANGDUIJIJI。ZHENDUILAONIANDIANXIANHUANZHE，JINGUANYOUGEANBAODAO，ZONGTISHANG 60 SUIYISHANGJIESHOUSHOUSHUDEBINGLIRENGPIANSHAO；④ RENZHIGONGNENG；DUICHENGNIANHUANZHE，RENZHIGONGNENGDIXIATISHICUNZAIMISANXINGNAOGONGNENGYICHANG，SHOUSHUYAOXIANGDUIJINSHEN；DUIHUANER，JUZAOXINGBINGBIANKEYIDAOZHIMIMANXINGNAOGONGNENGZHANGAI，ERSHOUSHUZHILIAOKENENGYOUZHUYUGAISHANRENZHIGONGNENG。
1.2 手术方式的选择
DIANXIANDESHOUSHUFANGSHIBAOKUOQIECHUXINGSHOUSHU、GUXIXINGSHOUSHU、LITIDINGXIANGHUISUNSHUJISHENJINGDIAOKONGSHOUSHU。① QIECHUXINGSHOUSHU：KAIZHANZUIDUOYESHIZUICHENGSHUDESHOUSHUFANGSHI，SHITONGGUOQIECHUDIANXIANYUANQUHEFAZUOQISHIQULAIJINKENENGDADAOHUANZHESHUHOUWUFAZUODEMUDE；QIECHUXINGSHOUSHUBAOKUO“BINGZAOXINGDIANXIAN”HECIGONGZHENCHENGXIANG（MRI）YINXINGDEJUZAOXINGDIANXIAN，RUNAOPIZHIDIANXIANZAOQIECHUSHU、QIANNIEYEQIECHUSHU、XUANZEXINGXINGRENHE-HAIMAQIECHUSHU、DANAOBANQIUQIECHUSHUDENG；② GUXIXINGSHOUSHU：CILEISHOUSHUZHIZAIZUDUANDIANXIANFANGDIANDECHUANBOTONGLUYIDADAOJIANQINGFAZUODEMUDE，TONGCHANGNANYIWANQUANXIAOCHUFAZUO；CHANGYONGSHUSHIBAOKUOPIANZHITIQIEKAISHU、DUOCHURUANNAOMOXIAHENGXINGXIANWEIQIEDUANSHUDENG；③ JUBUHUISUNSHOUSHU：YUNYONGLITIDINGXIANGJISHU，JINGQUEHUISUNNAOSHENBUDEJIEGOU，LIRUNAOSHENBUWEIXIAOBINGZAO、XINGRENHE、HAIMADENG；LITIDINGXIANGFANGSHEWAIKE，RU γ-DAO、X-DAOYESHUYUCILEISHOUSHU；④ SHENJINGDIAOKONGSHOUSHU：TONGGUODIANHUOCICIJIGAIBIANSHENJINGXITONGGONGNENGERHUODEZHILIAOXIAOGUO，ZHUYAOBAOKUOMIZOUSHENJINGDIANCIJI、NAOSHENBUTESHUHETUANDIANCIJI、BIHUANSHISHENJINGCIJISHUDENG。
1.3 术前评估与手术治疗方案选择
药物难治性癫痫患者能否手术、实施何种手术，取决于由多学科组成的综合评估团队的评估结果。只有综合患者癫痫发作的临床表现（症状学）和各种客观检查资料，才能对可能的癫痫灶有一个全面的“理解和认识”。由于癫痫灶是一个理论性的概念，目前缺乏定位的金标准，故在实际临床工作中，多数学者采用下述的癫痫灶相关概念来最终定位可能的癫痫灶（表 2）。
表2
癫痫灶等相关概念及检查技术
JINNIANLAI，GUONEIWAIXUEZHEJIADALEDUINAOWANGLUO、DIANXIANWANGLUODEJICHUHELINCHUANGYANJIU。CONGJIEPOU-DIAN-LINCHUANGDE“SANWEIYITI”JIAODUQULITIDINGWEIKENENGDEDIANXIANZAO。SUIZHEXIANDAIKEXUEJISHUDEFAZHANHEPINGGUSHOUDUANDEJINYIBUCHENGSHU，DINGWEIDIANXIANZAOHUIBIANDEYUELAIYUEJINGQUE。
SHOUSHUFANGSHIDEXUANZEQUJUEYUDUIDIANXIANZAODERENSHIHELIJIECHENGDU。LILUNSHANGJIANG，DIANXIANZAODINGWEIDEYUEJINGZHUN，DUIDIANXIANZAODEGONGNENGRENSHIYUEQUANMIAN，SHISHIDIANXIANZAOQIECHUXINGSHOUSHUDEKENENGXINGYUEDA；FOUZE，RUOBUNENGJINGQUEDINGWEIHUOSHOUSHUHUIDAILAIYANZHONGDESHENJINGGONGNENGQUESUN，ZEYINGCAIQUGUXIXINGSHOUSHUHUODIAOZHENGYAOWUZHILIAO。
1.4 手术后效果
JIYUZONGHEPINGGUJICHUSHANGDEWAIKESHOUSHU，QISHUHOUXIAOGUOSHOUZHUDUOYINSUDEYINGXIANG，YUKENENGDEZHIXIANBINGLI、HUANZHEBINGCHENG、ZHILIAOSHIJI、NIANLINGJISHUZHEDECAOZUOJISHUDENGYOUGUAN。
克利夫兰癫痫中心对 136 例儿童和青少年癫痫患者进行外科治疗，各年龄段癫痫发作完全控制率分别是 69%（13～20 岁）、68%（7～12 岁）、75%（3～6 岁）、60%（3 岁以下），说明癫痫患儿的手术疗效至少与成年癫痫患者相当[1]。
就颞叶癫痫而言，2001 年 Weibe 等[2]在《新英格兰杂志》发表了第一篇关于成年人颞叶癫痫手术与药物治疗的前瞻性对照研究：1 年内手术组无发作率为 58%，药物组为 8%，二者具有统计学差异；生活质量的比较显示药物组低于手术组，但无统计学差异。Engel 等[3]于 2012 年发表了经过 2 年的随访结果，手术组无发作率为 73%，而药物组为 0，有统计学差异。瑞典的 Edelvik 教授等[4]随访了 5 年以上的颞叶癫痫手术后情况，无发作率在 40%～66%，术后停药率约为 20%，术后无发作者停药率为 43%～86%。
Ansari 等[5]研究发现，非颞叶癫痫术后 5 年无发作率为 14.7%～68%。局灶性皮质发育不良（Focal cortical dysplasia，FCD）-I 型和癫痫灶切除不完全是癫痫再发作的独立影响因素。Althausen 等[6]经过近 10 年随访大脑半球切除术的效果，75%（45/61）的患者无癫痫发作，且 80% 的无发作者已停用 AEDs。同时，在切除性手术中大脑半球切除术后患者的认知和生活质量改善非常明显，长期随访显示 28% 的患者 IQ 提高，85% 的患者至少 1 项认知水平改善，57% 的患者行为障碍减轻。Malik 等[7]随访了 11 例婴儿早期肌阵挛脑病的患儿，经切除性手术治疗后 Engel I 级 7 例、Engel Ⅱ 级 4 例，发育水平接近正常。而同期 15 例未手术的患儿半数死亡，生存的患者均存在显著的发育迟滞。Lancman 等[8]Meta 分析显示：胼胝体切开术对失张力发作的控制优于迷走神经刺激术，其他癫痫发作类型二者间无统计学差异。一项有关脑深部电刺激治疗癫痫的多中心双盲随机对照研究显示了双侧丘脑前核刺激治疗癫痫的有效性。3 个月双盲期结束时刺激组较对照组癫痫发作明显减少（40.4% vs.14.5%，P = 0.002），术后 2 年癫痫发作减少中位数达到 56%，54% 的患者有效[9]。
ZONGZHI，ZAIJINGZHUNDINGWEIDIANXIANZAODEJICHUSHANG，DIANXIANSHOUSHUZHILIAOJUZAOXINGDIANXIANLIAOXIAOKENDING，ZHILIAOBINGZAOXINGQUANMIANXINGDIANXIANYEYOUJIAOHAODEXIAOGUO。
2 癫痫灶和癫痫网络
2.1 癫痫发作分类
DIANXIANDEFAZUOFENLEI，JINGDIANDESHIGUOJIKANGDIANXIANLIANMENG（ILAE）YU 1981 NIANZHUYAOCANZHAONAODIANTU（EEG）JIEGUOHELINCHUANGBIAOXIANTICHUDEFANGAN。GENJUFAZUOSHIYOUWUYISHISANGSHIJIANGBUFENXINGFAZUOQUFENDANCHUNBUFENXING、FUZABUFENXING，QIZHONGYINGYONGDE“BUFENXING”SHUYUZAI 2000 NIANHOUDEXIUDINGZHONGGENGGAIWEI“JUZAOXING”，YIBIMIANYINQILINCHUANGQIYI。ILAE GAODUCHOUXIANGHEGAIKUOHUADEFENLEIDUILINCHUANGYAOWUZHILIAODEXUANZEYOUZHONGYAOJIAZHI，DANYOUYUQUEFADUIFAZUOZHENGZHUANGXIZHIDEMIAOSHUYIJIDUIFAZUOYANBIANDEFANYING，DUILIJIEFAZUOZHENGZHUANGYUGONGNENGJIEPOUDEXIANGGUANXINGHEFAZUOZHENGZHUANGDEDINGWEIJIAZHIYOUXIAN。
2017 年，ILAE 对癫痫发作分类做了较大变动，体现在局灶性发作分类中，注重了发作症状的特征，有助于理解发作症状所涉及的神经网络（图 1）。
图1
2017 年国际抗癫痫联盟癫痫发作分类建议
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2.2 癫痫源理论
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2.3 癫痫脑网络
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2.3.1 脑皮质的功能解剖与癫痫网络
2.3.1.1 从功能解剖的角度认识癫痫网络
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2.3.1.2 从脑解剖连接的角度理解癫痫网络
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2.3.1.3 从特异性功能环路深化对癫痫网络的认识
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2.3.2 电生理技术刻画动态癫痫网络
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3 癫痫术前评估的方法
3.1 癫痫发作症候学
DIANXIANFAZUOZHENGZHUANGYIZHISHIDIANXIANFAZUOHEDIANXIANZONGHEZHENGFENLEIDEZHONGYAOYIJUZHIYI。DIANXIANFAZUOZHENGZHUANGDEMIAOSHUJIBENLAIZIYUHUANZHEHUOMUJIZHETIGONGDUIFAZUODEXIANGXIMIAOSHUHE/HUOVEEGJILUDAODEFAZUOLUXIANG。RENMENDUIDIANXIANDERENSHIZAI ILAE DUIDIANXIANFAZUOFENLEIBIAOZHUNDEBUDUANXIUGAIZHONGDEDAOLEHENHAODETIXIAN。2017 NIAN ILAE TICHUDEXINDIANXIANFAZUOFENLEISHIJIYU 1981 NIANDIANXIANFAZUOFENLEIBIAOZHUNHE 2010 NIANDIANXIANFAZUOFENLEIJIANYI，BINGJIEHELINCHUANGYISHENGDEYIJIANERJINXINGDEYICIBIJIAODADEGEXIN。XINDEDIANXIANFAZUOFENLEIYIJIANZHONGGENGZHONGSHIGENJUFAZUOZHENGZHUANGJIFAZUOZHENGZHUANGYANBIANJINXINGFENLEI，QIANGDIAOLINCHUANGFAZUOBIAOXIANZAIDIANXIANFAZUOFENLEIZHONGDEZUOYONG。2017 NIAN ILAE DIANXIANFAZUOFENLEIZHONGQIANGDIAOLEJUZAOXINGQIYUANDEGELEIFAZUO，YOUZHUYULIJIEFAZUOZHENGZHUANGWANGLUO。ERJUZAOXINGXINGQIYUANDEFAZUOSHIYAOWUNANZHIXINGDIANXIANXUANZEWAIKESHOUSHUDEZUICHANGJIANDEFAZUOLEIXING。
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ZAIDIANXIANZAODINGWEIGUOCHENGZHONG，DIANXIANFAZUOZHENGZHUANGKEYIBANGZHUDIANXIANZAODINGCEHEDINGWEI，HAIKEYIYOUZHUYULIJIEDIANXIANYICHANGHUODONGZAINAONEIDEYANBIANGUOCHENG。ZONGHEFENXICAINENGCHONGFENTIXIANFAZUOZHENGZHUANGDEDIANXIANZAODINGWEIJIAZHI。ZHEISHIYINWEIFAZUOZHENGZHUANGQUHEDIANXIANZAOBUYIDINGYIZHI，RENHEJIHUOFAZUOZHENGZHUANGQUDEDIANHUODONGJUNKENENGSHIGAIQUCHANSHENGHUOBIAODAXIANGYINGZHENGZHUANG。SUOYIGENJUFAZUOZHENGZHUANGPANDINGDEFAZUOZHENGZHUANGQUKENENGHEDIANXIANZAOYIZHIHUOJIEJIN，YEKENENGSHIYUANGEDIANXIANZAO。TONGYIFAZUOZHENGZHUANGKEYOUBUTONGDIANXIANZAOYINQI，BUTONGDIANXIANZAOKEYINQITONGYIFAZUOZHENGZHUANG，LIRU，GUODUYUNDONGFAZUOBIAOXIANKEJIANYUEKUANGHUI、FUZHUGANJUEYUNDONGQU、KOUDAIHUI、NIEJI、DAOYE、DINGYE、ZHENYEDENGBUTONGBUWEIDEDIANXIANZAOYINQIDEFAZUOZHONG。ERQIYUEKUANGHUIDEFAZUO，ZAIKUOSANZHIZHENGZHUANGQIYUANQUZHIQIANWUZHENGZHUANG，CIHOUKEYINKUOSANDAOBUTONGDEFAZUOZHENGZHUANGQUERCHUXIANBUTONGZHENGZHUANG：① DANGXIANXINGDIANHUODONGLEIJICHUJIYUNDONGQUSHI，KEYINQIZHENLUANXINGFAZUO；② DANGFUZHUGANJUEYUNDONGQUBEIJIHUOSHI，KECHUXIANFEIDUICHENGXINGQIANGZHIHUOGUODUYUNDONGXINGFAZUO。
发作症状学的定侧定位价值见表 3。随着医学特别是癫痫相关科学的发展，人们对癫痫发作症状及其在癫痫灶定位中的价值的认识会进一步加深。
表3
癫痫发作症状的定侧价值（定侧价值>75%）
3.2 癫痫术前评估影像学
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3.2.1 结构影像学
在难治性癫痫的术前评估中，脑结构影像学极为重要。结构影像学主要包括计算机断层成像（CT）或MRI，可明确脑内有无结构性病变，确定病灶部位和范围[10]。但要注意：结构影像学上显示的脑内病变并不一定是癫痫灶，它与癫痫灶的关系：① 与癫痫灶基本一致；② 癫痫灶在病变周围，例如脑软化灶；③ 癫痫灶与病变无关；虽然局部脑结构影像改变并不一定是癫痫灶，但二者之间常有密切联系，根据结构影像学定位癫痫灶的可靠性可达到 70% 以上[11-13]。
3.2.1.1 头部计算机断层扫描
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3.2.1.2 头部磁共振
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KEGENJUTIAOJIANXUANZECIMINGANJIAQUANCHENGXIANG，NENGGENGHAODIXIANSHIWEIXIAOXUEGUANJIXINGRUHAIMIANZHUANGXUEGUANLIUDAOZHIDEWEICHUXUEHEHANTIEXUEHUANGSUDECHENJI。
BOCENGDE T1 JIAQUANCIHUAQIANGDUYUBEITIDUHUIBOXULIE（Magnetization prepared rapid acquisition gradient echo，MPRAGE），NENGBICHUANTONG T1W CHENGXIANGFANGFAGENGWEIQINGXIDIXIANSHIPIZHIJIEGOUYICHANG，YOULIYU FCD DEJIANCHU。
3.2.1.3 高场强磁共振成像
高场强MRI有较高信噪比，从而具有更高的空间分辨率，揭示更微小的解剖结构细节，因此较传统 MRI 具有更高的病灶检出率；例如，3.0T MRI 在 1.5T MRI 阴性病例的病灶检出率为 65%[14]。7T MRI 在 3.0T MRI 阴性病例的病灶检出率为 29%[15]，尽管尚未在临床广泛应用。
3.2.1.4 影像后处理技术
MRI 后处理技术是一项对原始 MRI 数据进行调整重建再对比分析的方法，能够提高发现癫痫相关的结构异常的敏感度。高分辨 MRI 序列虽然能够检出相当数量的结构性病变，如海马硬化和 FCD IIb 型，但仍有高达 30% 的微小病变被漏诊[16]。MRI阴性患者术后无发作比例低，仅为38%左右[17]，所以建议术前评估中对影像学数据适当运用影像后处理技术。例如对于海马，可以进行海马体积测量和信号分析[18]，定量评价海马萎缩及信号改变的程度，发现轻微异常。
对于可疑 FCD，可应用基于体素的形态测量（Voxel-based morphometry，VBM），自动提取个体 T1W 的灰质和白质信息，并与正常对照数据库进行统计学比较，有助于发现微小皮质病灶。灰白质交界计算模型[19, 20]、皮质厚度定量测量、基于大脑形态学及一阶结构模型[21]、脑沟的形态学测量[22, 23]等后处理技术也逐步应用于新皮质微小病灶的检出，提高了病灶检出率。
YINGZHUYIDESHI，MRI HOUCHULIJISHUQIANQUEDAYANGBEN、QIANZHANXINGYANJIU，SHANGDAIJINYIBUFENXIQILINCHUANGYINGYONGJIAZHIHEZHENDUANXIAONENG。MRI HOUCHULIJISHUJINSHIJIEGOUSHANGDEFENXI，XUYAOJIEHEHUANZHEDEQITAJIEPOU-DIAN-LINCHUANGXINXI［BINGSHI、ZHENGZHUANGXUE、EEG、NAOCITU（Magnetoencephalography，MEG）、ZHENGDIANZIFASHEJISUANJIDUANCENGXIANXIANG（Positron emission tomography，PET）JIDANGUANGZIJISUANJIDUANCENGXIANXIANG（Single-photon emission computed tomography，SPECT）DENG］JINXINGZONGHEPANDUANCAIYOULINCHUANGYIYI。
3.2.2 功能影像学
3.2.2.1 功能磁共振成像
癫痫外科手术目的是最大限度的切除癫痫灶，同时最大程度的保留功能区。功能磁共振成像（fMRI） 是一种在活体进行的无创性功能成像技术，其成像原理是当大脑神经元放电活跃时，局部脑区的血流量增加，氧合血红蛋白增加，脱氧血红蛋白减少，两种血红蛋白的顺磁性不同，这种血氧水平变化引起的 MRI 信号变化，称之为血氧水平依赖（BOLD）的fMRI。它包括任务态和静息态 fMRI，前者可应用于运动区及语言区的定位，后者可用于癫痫灶定位[24]。
fMRI 技术的优点是空间分辨率高，有利于深部病灶的发现并确定手术范围，但是其时间分辨率低，因此临床将 EEG、fMRI 结合起来，能够了解并分析异常间期放电时血氧水平依赖的反应，对于癫痫灶的判定有一定价值[25, 26]。
3.2.2.2 正电子发射计算机断层显像
借助于正电子核素标记物，正电子发射计算机断层显像（PET） 可以无创、动态、定量评价活体组织或器官在生理状态及疾病过程中的功能状态。广泛应用的是 PET-CT 一体机，可同时获得 CT 解剖图像和 PET 功能代谢图像，两种图像优势互补，使医生在了解生物代谢信息的同时获得精准的解剖定位，从而对疾病做出全面、准确的判断。基于这种优势，目前 PET 检查已经广泛应用于癫痫灶的定位诊断中。在癫痫发作的发作期，病灶中大量神经元的同步放电，能量消耗增加，导致局部血流和葡萄糖代谢增多，呈高代谢；而在癫痫发作间期，癫痫灶由于存在海马或大脑皮质萎缩、神经元减少，局部血流和葡萄糖代谢减低，一般呈低代谢。利用18F 标记的脱氧葡萄糖（fluoro deoxy glucose，FDG）作为示踪剂，发现组织对示踪剂摄取能力的不同可直观的提示癫痫灶。
YOUYU CT TUXIANGFENBIANLVDI，JINNIANLAI，ZAI PET-CT JICHUSHANGFAZHANQILAIDE PET-MRI，SHIJIANG PET DEFENZICHENGXIANGGONGNENGYU MRI DESANWEICHENGXIANGGONGNENGJIEHEQILAIDEYIZHONGXINJISHU，JUYOULINGMINDUGAO、JINGZHUNXINGHAODEYOUDIAN，BINGQIEDUIRENTIDEFANGSHEXINGSUNSHANGKEYIDAFUDUJIANDI，DUIYUDIANXIANZAODEJINGQUEDINGWEI，YOUZHEQITAYINGXIANGSHEBEIWUKEBINIDEYOUSHI，SHIXIANJIEPOUHEDAIXIEXINXIDEHUXIANGBUCHONG、CANKAOHEYINZHENG，TIGAODIANXIANZAOJIANCEDETEYIXINGHEMINGANDU。
作为功能成像性技术，PET 具有对代谢异常区显示的敏感性高，但特异性低的特点，在癫痫术前评估中，所显示的代谢异常区常大于甚至远远多于癫痫灶，即假阳性率较高，需要结合其他临床资料（解剖-电-临床）综合分析。但在癫痫灶的评估中起着非常重要的作用，不仅为解剖-电-临床提示的癫痫灶提供进一步证据，对结构影像学“阴性”的症状性局灶性癫痫患者癫痫灶的评估更为重要，PET 可能会提示局灶性代谢异常，为下一步癫痫灶定位或为进一步颅内电极植入方案的制定提供重要依据[27]。
YUNYONGHOUCHULIJISHUJIANG PET HEJIEGOUYINGXIANGXUETUXIANGZILIAOJINXINGRONGHEZHONGJIAN，JIANGJINYIBUTIGAOBINGBIANDEJIANCHALV。
3.2.2.3 单光子计算机断层显像
发作期SPECT 可以提供脑血流的信息，常应用的示踪剂包括99mTc 标记的六甲基丙二胺肟或双半胱乙酯，由于体外稳定性差异，后者更适用于癫痫患者。发作期单光子计算机断层显像减影与 MRI 融合成像术（Subtraction ictal single-photon emission computed tomography coregistered to MRI，SISCOM）处理过程主要包括：SPECT 发作期与发作间期影像配准、密度归一化、减影、SPECT 减影图像与 MRI 配准融合。发作期注射示踪剂的时间影响 SISCOM 结果的准确性，一般认为注射时间控制在癫痫发作的前 20 s 内。通常认为癫痫发作开始后注射时间越早，发作期 SPECT 定位价值越高，因此对于有先兆的患者，更容易获得准确结果[28]。
3.3 癫痫术前评估生理学
3.3.1 脑电图学
EEG JIANCHADUIDIANXIANZAODEPINGGUHESHOUSHUBINGRENDEXUANZEZHIGUANZHONGYAO。FAZUOQIJIFAZUOJIANQI EEG DEFENXI，NENGTIGONGDINGCEHUODINGWEIXINXI，PANDUANDIANXIANZAODEFANWEI，NENGGOUBANGZHUQUEDINGJIEGOUXINGBINGBIANSHIFOUJUYOUZHIXIANXING，HUOZHEBANGZHUQUERENDUOGEBINGZAOZHONGJUYOUZHIXIANXINGDEBINGZAO，YIJIPANDUANSHIDANYIFAZUOQIYUANHAISHIDUOZAOQIYUAN。
3.3.1.1 头皮脑电图
a. FAZUOJIANQIDIANXIANYANGYICHANGFANGDIAN
FAZUOJIANQIJILUJUYOUYIDINGDEDINGWEIJIAZHI。FAZUOJIANQICHUXIANHENGDINGDE、JUZAOXINGDEMANBOHUOZHEDIANYAYIZHI，ZETISHIJUBUJIEGOUYICHANGHUOZHEGONGNENGZHANGAI。HENGDINGYUMOUYIQUYUDECHIXUXINGHUOZHEFANFUDEJI/JIANBOJIELV、DUOJI/JIANBODUIYUDIANXIANZAOJUYOUTISHIJIAZHI。TEBIESHI，MOUXIEFAZUOJIANQIDEDIANXIANYANGFANGDIANMOSHIYUFAYUXINGBINGLIGAIBIAN［RUJUZAOXINGPIZHIFAYUBULIANG（FCD）、FAYUXINGZHONGLIUDENG］YOUGUAN，JUYOUJIAOGAODEDINGWEIJIAZHI。FAZUOJIANQIFANGDIANRUGUOCHAOCHULEDIANXIANZAODEFANWEIHUOZHECHUXIANZAIDUICEDOUKENENGYINGXIANGSHOUSHUYUHOU。JUZAOXINGDIANXIANHUANZHECHULEJUZAOXINGDEFANGDIAN，RUTONGSHICHUXIANGUANGFANXINGFANGDIAN，ZEDINGWEIJIAZHIJIAOXIAO。BUFENHUANZHE，YOUQISHINIEYEWAIDIANXIAN，RUGUOFAZUOJIANQIFANGDIANHENGDINGDECHUXIANYUYIGEQUYU，ZEKENENGBIFAZUOQIDE EEG GENGYOUDINGWEIJIAZHI。
b. FAZUOQINAODIANTU
FAZUOQI EEG JILUSHISHUQIANPINGGUDEYIGEZHONGYAONEIRONG，YOUQIDUIYUKENENGJINXINGQIECHUXINGSHOUSHUZHILIAODEJUZAOXINGDIANXIANDEDIANXIANZAODINGWEIJUYOUJIAODADEJIAZHI。
FAZUOQI EEG FENXIDEZHONGYAONEIRONGSHIPANDUANFAZUOZHENGZHUANGZHIQIAN EEG BIANHUADEQISHIQUYU，DUIDINGWEIZHIGUANZHONGYAO。JUZAOXINGFAZUODEFAZUOQI EEG DEFENBUYOUJIZHONGXINGSHI：① JUZAOXING：ZHIFAZUOKAISHIDEFANGDIANYINGXIANGDAOJISHAOSHUTOUPIDIANJI；② NAOQUXING：SHEJIYIDINGFANWEINAOQU，TOUPI EEG XIANSHISHEJIXIANGLINSHUGEDAOLIANDEJIELVXINGFANGDIAN；③ YICEXING：FAZUOQIFANGDIANLEIJIYICEBANQIU，NANYIJINYIBUJINGXIDINGWEI；④ FEIYICEXING：FAZUOQIFANGDIANQIYUANYULIANGCEBANQIUDEMOUYIJUBUQUYU，TOUPIDIANJISHUANGCEDIANYADAZHIXIANGDENG。
JUZAOXINGFAZUODETOUPI EEG YOUDUOZHONGXINGSHIDEFAZUOQISHIMOSHI，BAOKUO：① FAZUOJIANQIFANGDIANDETURANXIAOSHI，HUOYOULINGYIZHONGWANQUANBUTONGDEJIELVXINGHUODONGSUOQUDAI；② TURANDEGUANGFANXING、YICEXINGHUOZHENAOQUXINGDEDIANYIZHI；③ YUFAZUOJIANQIBUTONGDEJIELVXINGHUODONG（KEWEI α、β、θ、δ DENGBUTONGPINDUAN），BINGQIEYOUPINLV、BOFUHEFANWEIDEYANBIAN，DUOSHUBIAOXIANWEIPINLVZHUJIANJIANMAN，BOFUZHUJIANZENGGAO，FANWEIZHUJIANKUODA，ZHIZHIFAZUOZHONGZHI；XINGTAIXIANGTONG、WUMINGXIANYANBIANDEFAZUOQIFANGDIANMOSHIZAIJUZAOXINGDIANXIANZHONGBIJIAOSHAOJIAN，ZHUYAOJIANYUQUANMIANXINGFAZUO，RUSHISHENFAZUODENG；④ ZAIFAZUOQISHIJIEDUAN，ZAIDIANYIZHIDEBEIJINGXIACHUXIANJUZAOXINGDEDIBOFUKUAIHUODONG，YIWEIZHEGAIJILUDIANJILINJINDIANXIANZAO，JUYOUJIAOGAODEDINGWEIJIAZHI，ERQIEYULIANGHAODESHOUSHUYUHOUXIANGGUAN。DUIYUMOUGETEDINGDEHUANZHE，RUGUOWEIDANYIDIANXIANZAO，ZEFAZUOQI EEG DEMOSHITONGCHANGSHIYIZHIDE。RUGUOFAZUOQI EEG JUYOUMINGXIANDEDUOBIANXING，ZEYINGKAOLVDAODIANXIANZAOFANWEIXIANGDUIJIAODAHUOZHEDUOGEDIANXIANZAODEKENENG。
ZAITOUPI EEG ZHONG，LINCHUANGZHENGZHUANGZAOYUFAZUOQI EEG DEBIANHUA，QIFANYINGDECHANGCHANGSHIFANGDIANGUANGFANCHUANDAODEJIEGUO，XUZIXIFENXIZHENGZHUANGXUEHE EEG QISHIDEGUANXI，JINSHENDEJIESHITOUPI EEG DEDINGWEIYIYI。JUZAOQIYUANDEFAZUOQIMOSHIZHUYAOJIANYUNEICENIEYEDIANXIAN、EYEBEIWAICEDIANXIAN，YICEXINGQIYUANDEFAZUOQIMOSHIZHUYAOJIANYUXINPICENGNIEYEDIANXIAN，ERGUANGFANXINGDEFAZUOMOSHIZHUYAOJIANYUEYENEICEDIANXIAN，DINGYEHEZHENYEFAZUODEFAZUOQI EEG FANYINGDEWANGWANGSHICHUANDAO，SUOYIMOSHIDUOYANG，KENENGZAOCHENGWUPAN。YOUXIEFAZUORUGUODUYUNDONGXINGFAZUOCHANSHENGDEDALIANGDONGZUOWEICHAKENENGSHI EEG BEIYANGAI，DINGWEIKUNNAN。TOUPI EEG DEFAZUOQIJILUDUINEICENIEYEDIANXIANHEBEIWAICEEYEDIANXIANDEDINGWEIZUIYOUYIYI。ERDUIYUEYENEICEMIAN、EYEDIMIAN（KUANGEHUI）、DAOYEQIYUANDEFAZUOZEDINGWEIKUNNAN。LINGWAI，YINGER、ERTONG、QINGSHAONIANYOUYUXIANTIANXINGHUOZHEZAOQIHUODEXINGJUZAOXINGHUOZHEBANQIUXINGZHIXIANXINGBINGBIANSUOZHINANZHIXINGDIANXIAN，KEYIYOUGAOFENGSHILV、QUANMIANXINGDEJIMANZONGHEBOHUOZHEQITAXINGSHIDEQUANMIANXINGFANGDIANMOSHI，HENSHAOHUOZHEMEIYOUJUZAOXINGDETEZHENG，DANSHIZHEIXIEERTONGRENGRANSHIDIANXIANSHOUSHUDESHIYINGZHENGHUANZHE。
ZAITOUPI EEG ZHONG，YOUYIBUFENJUZAOXINGFAZUOMEIYOUMINGXIANDEFAZUOQI EEG BIANHUA，YOUQIZAIJUZAOXINGGANJUEXINGFAZUOZHONGGENGWEICHANGJIAN，ZHEIYEFANYINGLETOUPI EEG DINGWEIFEICHANGJUXIANQIYUANDIANXIANFAZUODEKUNNAN。
YIBANLAIYAN，FAZUOQI EEG MOSHIYUFAZUOQIYUANBUWEIZHIJIANQUEFABIRANDELIANXI，JIYIZHONGMOSHIKEJIANYUBUTONGBUWEIQIYUAN、BUTONGLEIXINGDEFAZUO，ERTONGYIQISHIBUWEI、TONGYIZHONGFAZUOLEIXINGYEKEYIYOUBUTONGDEFAZUOQI EEG MOSHI。YINCIBUNENGGULIDEYIKAOFAZUOQI EEG DINGWEI，YINGJIEHEZHENGZHUANGXUE、YINGXIANGXUEDENGQITAZHENGJUZUOCHUPANDUAN，BIYAOSHIXULUNEIDIANJIJIANCHA。
3.3.1.2 颅内脑电图
TONGGUOWUCHUANGXINGPINGGU，RUGUOFAZUOZHENGZHUANGXUE、TOUPI EEG YIJIYINGXIANGXUEJIEGUOSANZHEBUYIZHIHUOZHEXIANGHUMAODUN，DIANXIANZAOWEINENGMINGQUE；DIANXIANZAOLINJINHUOZHEWEIYUZHONGYAOGONGNENGQU，HUOZHEYINGXIANGXUEJIANCHAWUYICHANGFAXIAN，WUFAQUEDINGQIECHUFANWEI，ZEXUYAOLUNEIDIANJIZHIRU，TONGGUOLUNEI EEG JINYIBUMINGQUEDIANXIANZAODEWEIZHI、FANWEIYIJIYUGONGNENGQUDEGUANXI。
LUNEIDIANJIFENYINGMOXIADIANJIHESHENBUDIANJILIANGZHONG。JIYUWUCHUANGXINGPINGGUJIEDUANDEXINXI，QUEDINGDIANJIZHIRUDEFANWEI。TONGGUOLUNEI EEG FAZUOJIANQIHEFAZUOQIJILU，KEYIXIANGDUIZHUNQUEDIDINGWEIJIREQUJIDIANXIANZAOFANWEI，TONGSHIKEYITONGGUODIANCIJIQUEDINGGONGNENGQU，MINGQUEDIANXIANZAOYUGONGNENGQUDEGUANXI。YINGMOXIAPIANZHUANGDIANJIXUYAOKAILUSHOUSHUZHIRU，SHIHEDIANXIANZAOWEIYUPICENGBIAOQIANBUWEIDEHUANZHE，ZAIDIANCIJIDINGWEIGONGNENGQUFANGMIANYOUYIDINGYOUSHI。SHENBUDIANJISHIYONGYUDIANXIANZAOWEIYUHAIMA、DAOYE、HUIZHIYIWEI、XIAQIUNAOCUOGOULIUDENGSHENBUDIANXIANZAO。LITIDINGXIANGNAODIANTU（SEEG）JUYOUKEFUGAISHENBUJIBANQIUNEICEMIANJIEGOU、KESHUANGCEZHIRUDENGYOUSHI。MUQIANLINCHUANGYINGYONGYUELAIYUEDUO。
LUNEIDIANJI EEG DEFAZUOJIANQIGAOPINZHENDANGYUDIANXIANZAOYOUMIQIEGUANXI，KEZUOWEIDINGWEIDIANXIANZAODEZHONGYAODIANSHENGLICANSHU。JINGUANDUIYULUNEI EEG FAZUOXINGFANGDIANDEQIYUANMOSHIYOUBUTONGDEMIAOSHU，MUQIANRENWEIZAIDIPINLV/ZHILIUDIANPIAOYISHANGCHUXIANDEJUZAOXINGDEDIBOFUKUAIHUODONGTONGSHIJUYOUFAZUOQIANFANGDIANQISHIDELUNEI EEG FAZUOQIMOSHIJUYOUBIJIAOKEKAODEDINGWEIJIAZHI。XUYAOZHUYIDESHILUNEIDIANJIDEZHIRUMOSHIJIFANWEISHIJIYUWUCHUANGXINGPINGGUJIEDUANXINGCHENGDEGUANYUDIANXIANZAODEJIASHE，RUGUOJIASHECUOWU，ZEDIANJIZHIRUKENENGBUQUANMIAN，CONGERZAOCHENGLUNEIDIANJIDEJIELUNBUKEKAO。
3.3.2 脑磁图
MEG SHIYIXIANGDUIRENTIWUCHUANGDENAOGONGNENGJIANCHAJISHU，TONGGUOGAODULINGMINDECHAODAOLIANGZIGANSHEYISHISHIJIANCENAOBUCICHANGXINHAODEBIANHUA，DUIDIANXIANHUANZHEFAZUOJIANQIYICHANGFANGDIANDEDINGWEIFEICHANGYOUBANGZHU。XIANDAI MEG SHEBEIJUYOUSHANGBAIGETANCETONGDAO，KEFUGAIZHENGGENAOBU，DUIDANAOCICHANGXINHAOJINXINGQUANFANGWEIJIANCE。JIANGJILUDAODECIXINHAOTONGGUOQIADANGDESHUXUEMOXING，JISUANCHUQIWEIZHI、QIANGDUHEFANGXIANG，BINGYUQITOUBU MRI YINGXIANGRONGHECHULI，JICIYUANXINGCHENGXIANG，KEDINGWEIDIANXIANZAO。
EEG HE MEG SUIRANDOUSHIJIYUSHENJINGDIANSHENGLIDEJIANCHAJISHU，DANSHIGEZIYOUBUTONGDETEDIAN。DANAOWAIZHOUNAOJIYE、LUGU、TOUPIDENGZUZHIJUYOUBUTONGDEDAODIANLV，HUIDUINAODIANHUODONGDEKUOBUCHANSHENGMINGXIANYINGXIANG，YINCILIYONGNAODIANXINHAOJINXINGYUANDINGWEI，QIZHUNQUEXINGJIANGSHOUDAOYINGXIANG。CICHANGZAINAO、NAOJIYE、LUGUHETOUPIDENGJIEZHIZHONGDECHUANTOULVJIHUBUSHOUYINGXIANG，SUOYILIYONGCIXINHAOJINXINGYUANDINGWEIJIUXIANGDUIZHUNQUEDEDUO。MEG JUYOUHAOMIAOJIDESHIJIANFENBIANLVHEHAOMIJIDEKONGJIANFENBIANLV，NENGGOUSHISHI、JINGZHUNDIFANYINGBUTONGNAOQUDEGONGNENGBIANHUA。
EEG ZHUYAOJIANCEJINGXIANGCHUIZHIYUDIANJIDEDIANLIU，FANYINGDESHINAOHUINEICHUIZHIPAILIEDEZHUITIXIBAOCHANSHENGDEXIBAOWAIDIANLIU；MEG ZHINENGJIANCEDAOYUCHUANGANXIANQUANXIANGHUCHUIZHIDECILIXIAN，YINCIJILUDESHINAOGOUNEIZHUITIXIBAODEXIBAONEIDIANLIUCHANSHENGDECICHANG，FANYINGLEPICENGQIEXIANFANGXIANGPAILIEDEZHUITIXIBAODEHUODONGQINGKUANG。LINGWAI，YOUYUCICHANGQIANGDUSUIZHEJIANCEXIANQUANYUXINHAOYUANZHIJIANJULIDEZENGDAERJIANXIAO，MEG HENNANJIANCEDAODANAOSHENBUDESHENJINGHUODONG；ER EEG YOUYURENTIJIEZHICHUANDAOXINGDEBUTONG，YOUKENENGJILUDAOLAIZIDANAOSHENBUDERONGJICHUANDAODIANLIU。YINCI，EEG HE MEG SHICONGLIANGGEBUTONGFANGMIANFANYINGSHENJINGXIBAODIANLIUDEHUODONGQINGKUANG，JUYOUXIANGHUBUCHONGDEZUOYONG，BUNENGXIANGHUTIDAI。
MEG TONGGUOYUANFENXIDUIDIANXIANZAOJINXINGDINGWEI，MUQIANSHIYONGZUIGUANGFANDEYUANFENXIFANGFASHIDENGJIADIANLIUOUJIZIMOXING。MEG DUIYU FCD SUOZHIDENANZHIXINGDIANXIANJUYOUHENHAODEDINGWEIJIAZHI，YOUQISHIYOUZHUYUQUEDING MRI WEIFAXIANDEXIAO FCD BINGZAO。MEG DUIYUDANAOBIAOQIANPICENGDEXINHAOBIJIAOMINGAN，ERDUIYUNEICENIEYEDENGSHENBUJIEGOUYICHANGHUODONGDEJIANCHULVZEXIANGDUIJIAODI，ZAIZHEIYIFANGMIANYOUSHIFANERBUJI EEG DINGWEIMINGQUE。DANGTOUPI EEG XIANSHIWEIZHONGXIANBUWEIHUOSHUANGCEYICHANGFANGDIAN，ZUOYOUCEBIENANYIQUEDINGSHI，MEG KENENGDUIDINGCEJIDINGWEIYOUSUOBANGZHU。MEG OUJIZIDEFENBUTEZHENGYEKEYIWEIQUEDING SEEG FANGANYIJISHOUSHUYUHOUTIGONGHENDUOYOUYONGDEZHIDAO。DANG MEG OUJIZIFENBUJIZHONGBINGQIEFANGXIANGWENDINGSHI，SHOUSHUYUHOUJIAOHAO，ERDANGOUJIZIBIJIAOFENSANSHI，YIBANSHOUSHUYUHOUBUJIA。YOUYANJIUFAXIAN，OUJIZIJIZHONGFENBUDEBUWEIBEIWANQUANQIECHUDEHUANZHE，QISHUHOUWUFAZUODEGAILVYAOGAOYUBUFENQIECHUHUOWEIBEIQIECHUDEHUANZHE。MEG HAIKEYONGYUDINGWEIPIZHIGONGNENGQU，TONGGUOTIGAN、SHIJUE、TINGJUEJIYUYANYOUFACICHANGQUEDINGXIANGYINGDEGONGNENGQU，WEIDIANXIANSHOUSHUPINGGUTIGONGBANGZHU。
SUIRAN MEG JUYOUSHANGSHUYOUDIAN，DANSHIMUQIANRENGCUNZAIYOUYIDINGJUXIANXING。YOUYUJIANCHASHIJIANJIAODUAN，MEG JIANCEDAOHUANZHEFAZUODEJILVBUGAO；JISHIOUERJIANCEDAODIANXIANFAZUO，FAZUOSHIDEYUNDONGWEICHAYEHUIGANRAO MEG CIYUANDINGWEIDEZHUNQUEXING，GU MEG TANCEDEDUOSHIFAZUOJIANQIYICHANGCIXINHAO，DUIDIANXIANZAODEDINGWEIZUOYONGYOUXIAN。YINCI，XUJIEHEHUANZHEDELINCHUANGBIAOXIANYIJIQITANAOGONGNENGJIANCHAFANGFAJINXINGZONGHEPINGGU。
3.3.3 感觉和运动诱发电位
3.3.3.1 运动诱发电位
DIANXIANWAIKESHOUSHUYAOQIUZAICHEDIQIECHUDIANXIANZAODETONGSHI，ZUIDAXIANDUDIBAOLIUHUANZHEDEDANAOZHONGYAOGONGNENGQU。YINCI，YICEBANQIUBINGBIANBANNANZHIXINGDIANXIANHUANZHESHOUSHUQIANZHUNQUE、KEGUANPINGGUBINGBIANBANQIUDEYUNDONGGONGNENGZHIGUANZHONGYAO。YUNDONGYOUFADIANWEI（Motorevoked potential，MEP） SHIZHIJINGLUCIJIYUNDONGPIZHIZAIDUICEBAJIJILUDAODEJIROUYUNDONGFUHEDIANWEI，CONGERJIANCHAYUNDONGSHENJINGCONGPIZHIDAOJIROUCHUANDAOTONGLUDEZHENGTIWANZHENGXING。GENJUCIJIDEFANGSHIFENWEIDIANCIJI MEP HECICIJI MEP。JINGLUCICIJI（Transcranial magnetic stimulation，TMS）JUYOUCHUANTOUXINGQIANG、WUMINGXIANTENGTONGGAN、CAOZUOJIANBIANDENGYOUSHI，MUQIANLINCHUANGYINGYONGGENGWEIGUANGFAN。
由于大脑皮质具有一定的可塑性，一侧半球病变对功能的影响在一定程度上可被其他部位代偿，比如对侧运动中枢。因此，在评价半球运动功能时，采用一侧皮层刺激，双侧拇短展肌记录的方法。嘱受试者取坐位、全身肌肉放松、闭目，“8”字线圈平面与头皮切面相贴并保持平行，线圈手柄均朝向枕侧。线圈与受试者矢状线成 45°角。单脉冲 TMS 点刺激，输出强度为 70%～100%。刺激部位为拇短展肌皮质运动区相对应的头皮点，一般在按照国际脑电图 10-20 安装系统 Cz 点前 2 cm 再旁开 2 cm 处附近。用氯化银材质的盘状电极置于双侧拇短展肌的皮肤表面，用双极导联记录，两电极相距 2 cm，记录电极置于近端，地线置于手心。刺激同一个部位，至少记录 3～5 次，以观察其重复性（图 2）。
图2
运动诱发电位
ZUOTU：GONGNENGWANQUANDAICHANGHUANZHEDEYUNDONGYOUFADIANWEI；CIJIFEIBINGZAOCEMUDUANZHANJI（APB）DEPIZHIYUNDONGQU，SHUANGCEMUDUANZHANJIJUNKEJILUDAO MEP；CIJIBINGZAOCEMUDUANZHANJIDEPIZHIYUNDONGQU，SHUANGCEMUDUANZHANJIJUNBUNENGJILUDAO MEP；ZHONGTU：GONGNENGBUNENGDAICHANGHUANZHEDEYUNDONGYOUFADIANWEI；WULUNCIJIFEIBINGZAOCEHUOBINGZAOCEMUDUANZHANJIDEPIZHIYUNDONGQU，JINZAIDUICEMUDUANZHANJIKEJILUDAO MEP，TONGCEBUNENGJILUDAO MEP；YOUTU：GONGNENGBUFENDAICHANGHUANZHEDEYUNDONGYOUFADIANWEI：CIJIFEIBINGZAOCEMUDUANZHANJIDEPIZHIYUNDONGQU，SHUANGCEMUDUANZHANJIJUNKEJILUDAO MEP；CIJIBINGZAOCEMUDUANZHANJIDEPIZHIYUNDONGQU，DUICEMUDUANZHANJIYEKEJILUDAO MEP
术前 MEP 结果对手术的指导意义：对于病灶侧半球运动功能完全代偿的患者，行患侧半球切除术后对侧肢体无运动功能损害加重。对于病灶侧半球运动功能部分代偿的患者，病灶侧半球切除术后对侧肢体运动功能损害加重，经康复治疗 3 个月后可部分恢复。对于病灶侧半球运动功能不能代偿的患者结合其他检查结果，认为术后发生对侧肢体运动功能损害的可能性很大时，建议行改良大脑半球切除术[29, 30]。TMS-MEP 能够客观评估双侧半球的运动功能，是一种有效、可靠且无创的评估手段。
3.3.3.2 感觉诱发电位
在癫痫外科治疗中，确定中央沟的位置对于保护功能区具有一定帮助，除了皮层电刺激、fMRI 和 MEG 外，应用颅内电极或硬膜外电极进行感觉诱发电位检查也能够进行中央区的确定[31]。选取对侧上肢进行正中神经电刺激，在埋置电极侧的大脑半球中央区可记录到体感诱发电位，且由于中央前、后回皮质产生的偶极现象，在中央后回记录到 N20/P25 复合波形，并以记录到的 N20/P20 峰值时刻点数据进行平面二维诱发电位地形图绘制，可直观显示这种极性翻转，在中央前回记录到与之极性相反的 P20/N25 复合波形，这种横跨中央沟的波形位相倒置，是应用感觉诱发电位识别中央区的可靠标志[32]，见图 3。此外，应用感觉诱发电位检查，还可进行次级躯体感觉区的识别[32]。
图3
硬膜外埋置电极记录到的诱发电位地形图（左）和诱发电位图（右）
ZUOTUZHONGSHUZIBIAOSHIYOUFADIANWEIQIANFUQI，DUIYINGYOUTUSITIAOHONGXIANSUOZAIDESHIJIANDIAN；YOUFADIANWEIDIXINGTUKEJIANYOUFABOXINGJIXINGWEIXIANGFANZHUANDEDIANJISUOZAIQU，YOUFADIANWEITUKEJIANYOUFABOXINGWEIXIANGFANZHUAN
3.3.4 重复经颅磁刺激
GENJUFALADIYUANLI，DIANRONGDUIXIANQUANFANGDIANCHANSHENGMAICHONGDIANLIU，MAICHONGDIANLIUJIKECHANSHENGSHUNBIANCICHANG，CICHANGMAICHONGWUCHUANGERQIEJIHUWUSHUAIJIANDICHUANGUOLUGU，ZAINAOZUZHINEIYOUFACHUGANYINGDIANLIUSHISHENJINGXIBAODEXINGFENXINGFASHENGGAIBIAN，CIWEI TMS。ZHONGFUJINGLUCICIJI（rTMS）SHITONGGUOGAOPINHUODIPINLIANXUZHONGFUCIJICONGERDADAOXINGFENHUOYIZHIJUBUDANAOPIZHIGONGNENGDEMUDE。rTMS KEYIXUNIDI“SUNHUI”DANAOJUBUGONGNENGCONGERWUCHUANGDETANSUONAOGONGNENG。
语言功能是重要的脑功能，语言优势半球是指语言功能区明显偏向于某一侧的大脑半球。右利手者中，语言优势半球和利手的皮质运动区域都在左半球的一致率在 95%～98% 之间，而左利手者，语言功能呈现出较为复杂的混合偏侧。癫痫手术前用无创方法定位语言功能区是未来趋势，rTMS 可以对语言皮质区产生瞬间的可逆性干扰从而无创定位语言功能区[33]。因此，利用高频、阈上强度的 rTMS 刺激语言功能区，干扰言语输出，直至言语中断，可对大脑语言优势半球进行定位[34, 35]。
将磁刺激 8 字线圈置于双侧头皮外侧裂附近区域的语言功能区，指令患者读数，其间以 20 Hz 频率、最大输出的 80% 刺激强度分别进行单侧重复磁刺激 3～5s，观察是否存在语言中断或音调改变，若存在语言中断或音调改变则提示刺激位置为语言功能区。刺激同一个部位，至少观察两次以上以确定其重复性。重复经颅磁刺激定位语言功能区的可靠性与阿米妥颈内动脉注射试验（Wada 试验）的符合率达到了 95%[36]，具有无创伤、可重复刺激、可检测不同的言语任务、风险小、操作简便、患者可能不需住院等许多优点，但儿童或智力障碍的癫痫患者不能配合这种无创检查。
3.3.5 皮层电刺激
皮层电刺激定位大脑功能区是皮层功能定位的金标准，可以在术中实施，也可以应用硬膜下或者深部电极记录发作期颅内电极 EEG 后实施。与术中皮层电刺激相比，后者可以有更充分的时间，患者可以更好的配合，是皮层功能定位的首选方法[37]。当癫痫灶邻近或位于感觉、运动及语言区时，为避免手术切除癫痫灶时损伤皮层功能，均需行皮层电刺激进行功能定位。埋置颅内电极的患者，监测到 3 次及以上惯常发作后可以进行皮层电刺激定位功能区。电刺激时优先刺激远离颅内电极 EEG 发作起始区的部位，以免刺激时引起发作。在进行皮层电刺激时，如果刺激强度过高，可能会诱发癫痫发作；如果刺激强度不足，则不能刺激出功能反应。因此，要逐渐增加刺激强度，避免增加过快导致癫痫发作。患者病程越长，皮层的兴奋性越高，出现后放电的阈值越低，此时刺激强度更应缓慢增加，待后放电消失后再进行下一次刺激。
最常用的刺激参数为频率 50 Hz 或 60 Hz，脉宽 200～300 μs，刺激强度 1～12 mA，每串刺激持续时间 2～5s，每次刺激间隔 10～20s[38]。选用相邻电极为参考电极。成人刺激强度最大增加到 10 mA；儿童皮层发育未成熟，对电刺激的反应阈值可能会更高，因此刺激强度可以最大增加到 12 mA。术中进行皮层电刺激时，由于是在麻醉状态下进行，刺激强度可以增加到 20 mA。通常感觉阈值和运动阈值较低，后放电阈值高于感觉和运动反应阈值。如刺激强度<5 mA 即出现感觉、运动反应，则阳性反应较为可靠。
语言的功能定位相对较为复杂，因此要联合应用多种语言任务来进行综合定位。基本的语言任务包括自发语言、言语理解和命名；附加的语言任务包括复述、阅读和书写[39]。在进行皮层电刺激时，先进行基本语言任务测试，再进行附加任务测试。如果出现语言停顿、命名错误或命名障碍，而无后放电现象出现，则语言定位可靠；如果出现语言的流利性降低、言语错乱和语调改变，则术中还需再次进行语言功能确认。值得注意的是，出现语言紊乱时要仔细甄别是由于刺激引起了舌/喉肌痉挛还是刺激到真正的语言运动中枢，此时可以嘱患者张口，刺激时观察患者舌肌有无回缩。
PICENGDIANCIJISHICHULEMINGQUEGANJUE、YUNDONGJIYUYANGONGNENGZHIWAI，HUANZHECHUXIANDEGEZHONGXINGXINGSESEDEGANJUEHEZHENGZHUANGJUNYINGYINQIGAODUZHONGSHI。ZUIWEIZHONGYAODESHIJIAODIQIANGDUDEDIANLIUQIANGDUCIJISHICHUXIANFAZUOZHENGZHUANGDEDIANJIDIAN，ZHEIXIEGUANJIANDEDIANJIDIANRUGUOYULUNEIDIANJIJILUDAODEFAZUOQISHIQUBUYIZHI，YINGZONGHEKAOLVPANDUANSHUZHONGSHIFOUXUYAOYIBINGQIECHU。DIANCIJICHUXIANFAZUOXIANZHAODEBUWEI，YULUNEIDIANJIEEGFAZUOQISHIQUYIZHI，KEYIRENWEIXIANZHAODINGWEIJIAZHIKEKAO；RUBUYIZHI，ZEZONGHEQITAJIANCHAJIEGUO，BIANBIECIJIYINCHUDEXIANZHAOYUFAZUODEGUANXI。
3.3.6 Wada 试验
ZAIDIANXIANSHUQIANPINGGUZHONG，YUYAN、JIYI、YUNDONGGONGNENGQUDEDINGWEIJUYOUZHONGYAOYIYI，TEBIESHIDIANXIANZAOWEIYUGONGNENGQUFUJINSHI，KEYONG Wada SHIYANLAIQUEDINGYOUSHICEBANQIU。
Wada 试验，又名颈内动脉异戊巴比妥试验，由 Wada 博士（1949 年）提出并用于临床，是术前神经生理学评估必不可少的一部分[40]。Wada 试验需要在药物注射前开始 EEG 记录，经股动脉插入导管至一侧颈内动脉行脑血管造影，继之将异戊巴比妥钠或其他短效麻醉药如丙泊酚[41]通过导管分别注入到大脑半球的脑血管中，通常先麻醉患侧半球，注射侧大脑半球被引入暂时性的休眠状态后测试半球语言、记忆和运动等功能，休息 20～45 min 后开始对侧大脑半球脑血管造影并注射麻醉药，判断语言、记忆功能的优势半球，评估运动功能，从而预测手术对半球的影响[42]。因国内缺乏异戊巴比妥，近年来，应用丙泊酚作为替代进行 Wada 试验，取得了满意的效果。
Wada 试验可用于术前语言优势半球定侧、颞叶切除术后患者的记忆功能预测、癫痫灶定侧、预测术后发作缓解等。若患者为左利手或其家族成员有左利手史，有早期左侧半球损害，神经心理学测验结果和头皮EEG监测结果不符，双侧 EEG 均不正常，或行神经心理学测验双侧记忆都有损伤可行 Wada 试验[43]。
麻醉药物的注射可引起不良反应，包括眼痛、颤抖、面部扭曲、流泪、发笑和情感淡漠，意识错乱、不随意运动或头眼偏转，肌张力增高，伴有抽搐和节律性运动等[44]。无创性方法如 fMRI、MEG、PET 和 TMS 等评估手段也可确定优势半球，但目前还没有一种方法能够完全替代 Wada 试验，其被认为是确定记忆和语言优势半球的金标准。
3.4 癫痫术前评估心理学
3.4.1 神经心理评估的目的及作用
神经心理评估是癫痫临床诊疗中的一项重要内容，药物治疗效果好及药物难治性癫痫患者均应进行评估。神经心理评估的目的在于：① 完善癫痫患者认知及行为障碍的共病诊断；② 评估患者的精神、行为状况对其生活质量、家庭及社会的影响，并做合理的解释；③ 为针对性的心理行为干预提供基线依据；④ 监测癫痫发作、各种治疗（包括药物治疗、各种手术治疗及调整治疗方案）前后对患者认知、情绪等行为的影响[45, 46]。
DIANXIANSHUQIANPINGGUZHONGSHENJINGXINLIPINGGUDEMUDEBAOKUO：① PINGGUYUYAN、JIYIDENGZHONGYAORENZHIGONGNENGDEYOUSHICEBIE；② XIEZHUDIANXIANZAOJIGONGNENGSHOUSUNNAOQUDEDINGCEJIDINGWEI；③ YUCEDIANXIANSHOUSHUDUIHUANZHENAOGONGNENGSUNHAIDEQIANZAIFENGXIAN，WEISHUHOUGONGNENGYUHOUPINGGUTIGONGYIJU；④ WEISHOUSHUHOULIAOXIAOPINGGUTIGONGJIXIANCANKAO。
3.4.2 临床神经心理测试专业人员
LINCHUANGSHENJINGXINLICESHIXUYAOYOUZHUANMENJINGGUOXITONGPEIXUNDESHENJINGXINLIYISHIJIXINLICELIANGSHIZHIXING，SHENJINGXINLIYISHIXUJUBEIYIXIATIAOJIAN：① JINGGUOLINCHUANGSHENJINGXINLIXUEDEZHUANYEXUNLIAN，BINGXUYAOJINGYANFENGFUDEXINLICELIANGSHIXIEZHU；② ZHANGWONAO-RENZHI-XINGWEIXUELILUN，SHUZHINAODEJIEPOUHEGONGNENG、RENZHIXINLIXUEJIYOUGUANJIBINGDEXIANGGUANZHISHI；③ ZHANGWOBIAOZHUNDESHENJINGXINLIJIXINGWEICESHIFANGFA，BINGNENGDUICESHIJIEGUOJIEHELINCHUANGJINXINGJIEDU；④ DIANXIANXIANGGUANDELINCHUANGSHENJINGXINLICESHIZHUANYERENYUANSHANGXUJUBEIDIANXIANYOUGUANDEZHUANYEZHISHI。
3.4.3 癫痫术前神经心理评估时机及禁忌症
DIANXIANSHUQIANSHENJINGXINLIPINGGUSHIJI：① RUGUOQINGKUANGYUNXU，JIANYIDUISUOYOUSHOUCICHUXIANDIANXIANFAZUOHUANZHEJUNJINXINGRENZHIHUOXINGWEIKUNNANDECHANGGUISHAICHA，JIANYIDECHANGGUISHAICHATIGONGLEYIZHONGGAOXIAOQIEJINGJIDEFANGFA，KESHAIXUANCHUXUYAOGENGWEIXIANGXI（HEANGGUIDE）SHENJINGXINLIXUEPINGGUDEHUANZHE；② DANGHUANZHEJUYOUJUZAOXINGRENZHIZHANGAIZHENGZHUANGHUOTIZHENGSHI，SHENJINGXINLIPINGGUKEXIEZHUTIGONGYOUGUANZONGHEZHENG、BINGBIANDINGWEIHUOFAZUOXIANGGUANSHENJINGWANGLUODEPICENGDINGWEIXINXI；③ DANGHUAIYIHUANZHECUNZAISHENJINGFAYUCHIZHI、XINGWEIHUOXUEXIKUNNANHUORENZHIXIAJIANGSHI，DONGTAISHENJINGXINLIPINGGUKEWEIZHENGQUEDEZHILIAO、ZHIYEDEXUANZEHESHEQUHUOSHEHUIDEZHICHITIGONGYIJU；④ DANGXUYAOPINGGUJIBINGHEZHILIAODEYINGXIANGSHIYINGJINXINGSHENJINGXINLIPINGGU。
XIANGDUIJINJIZHENG：① JIN 6 GEYUEZHINEICENGJINGJIESHOUPINGGUDEHUANZHE，BUYIZAICIPINGGU，YINCUNZAIXUEXIXIAOYING，KENENGDAOZHIPINGGUJIEGUOJIAOSHIJIJIEGUOHAO，YOUQISHIZHUYILI、JIYILI、JINGSHENYUNDONGSUDUJIZHIXINGGONGNENGDENG；② DIANXIANCHIXUZHUANGTAIHUOQITAYANZHONGYINGJIBINGLIZHUANGTAIHOU，YISHIWEIWANQUANHUIFUZHE，PINGGUJIEGUOBUKEKAO。
3.4.4 癫痫儿童的神经心理评估注意事项
DIANXIANHUANERYOUYUSHOUBINGYINXUE（FCD ZHEDUOJIAN）、NAOSHENJINGSUOCHUFAYUJIEDUANJIHUANJINGSHEHUIDENGDUOGEYINSUDEYINGXIANG，CHENGRENDIANXIANWAIKEXIANGGUANDERENZHIXINGWEIYUHOUDEYANJIUJIEGUOBUSHIYUHUANER。JUTITIXIANZAIYIXIAFANGMIAN：① BUTONGNIANLINGDUANXUANZEBUTONGMINGANDUDESHENJINGFAYUPINGGUGONGJU，LIRUYUYANCESHIRENWUDEYUFA、CIHUIDENGXUJIEHEBUTONGNIANLINGHUANERDEJIAOYUBEIJING，JINZUOJIANDANYUYANCESHIRUZHAOCIRENWUJIYUYANLIUCHANGXINGCESHIDEJIEGUOBUZUYIJINXINGDIANXIANSHUQIANDIANXIANZAODINGCEJISHUHOUYUYANYUHOUPANDUAN；② XUANZEYOUXINLIXUEYANJIUBEIJINGJIERTONGCHANGMODEXINXIAODUJIAOHAODEGONGRENDEXINLICELIANGGONGJU，QIPINGGUJIEGUOCAIJUBEILINCHUANGYIYI。
3.4.5 评估方法
采用量表或者心理任务测试的方法，经过 6～8 h 的评估及行为观察，全面评估患者各项认知功能及行为状态。癫痫中心所采用的主要认知功能筛查组套见表 4。
表4
主要认知功能及其心理学测试内容
3.4.5.1 智商测试
WEISHILIANGBIAO，FANYINGZHENGTIZHILISHUIPING，DANSHIBUNENGTIGONGDIANXIANZAODEDINGCEJIDINGWEIXINXI。YOUYUWANZHENGBANWEISHICESHIXUYAO 2 h，DUOSHUZHONGXINCAIYONGJIANHUABAN，ZHENGTAOLIANGBIAOKEFENGEWEIXUDUOBUTONGGONGNENGDEFENLIANGBIAO，LIRUYUYANZHISHANG、JIYILIANGBIAODENG，KEGENJUHUANZHEDEBUTONGQINGKUANGXUANZEBUTONGGONGNENGDEFENLIANGBIAO。JIESHENGDESHIJIANKEJINXINGGENGWEIXIANGJINDEJUYOUDINGWEI、DINGCEYIYIDESHENJINGXINLICESHI。
3.4.5.2 认知任务测试及神经心理评估
前者为限时任务测试，成绩按照测验反应的时间及测验结果正确率双维度计算，可作为首选，适用于智力水平正常，测试配合好，结果可靠的癫痫患者；后者为不限时的任务测试，成绩按照答对题目的数量计算，适用于一般智力差，配合度差的患者。测试任务选择责任脑区有明确偏侧化及脑区定位的任务。常用的认知测试项目和任务及其提示功能受损区的定侧、定位价值见表 5。
表5
常用的认知测试任务
4 癫痫术前评估的原则
4.1 多种评估技术的递进选用和分阶段评估
DIANXIANSHUQIANPINGGUGONGZUOMUDESHIYINGYONGDUOZHONGSHOUDUANJINGZHUNDINGWEIDIANXIANZAOYIJIGONGNENGQU，DADAOZUIHAODESHOUSHUZHILIAOXIAOGUOHEZUISHAODEGONGNENGSUNSHANG。MUQIANZAILINCHUANGGONGZUOZHONG，YOUYUDIANXIANZAOJINWEILILUNXINGGAINIAN，TONGGUOYUNYONGBUTONGFANGFALAIDINGWEIDIANXIANZAOXIANGGUANQUYU，ZUIZHONGDINGWEIDIANXIANZAO，TONGSHIPINGJIADIANXIANWANGLUO。YIBANCHENGXUWEIZAIXIZHIDEFAZUOZHENGZHUANGXUEGUANCHAHEFENXIJICHUSHANG，ZONGHEYINGYONGNAODIANSHENGLI、JIEGOUYINGXIANGXUEHEGONGNENGYINGXIANGXUEDENGSHOUDUANCONGBUTONGDEJIAODUJINXINGPINGGU，ZUIHOUJINXINGZONGHEKAOLV。
总体而言，术前评估中，应遵循临床症候-电生理-脑解剖结构相吻合的理论，合理选择有关检查手段。各种检查技术对于癫痫灶定位的贡献度是有差别的（表 6），一些技术定位可靠性较高，另一些技术定位灵敏性较高，应该综合分析这些技术结果之间的关系，在定位过程中当信息相互矛盾时，要遵循两个基本原则。首先，可靠性低的结果应该让位于可靠性高的检查结果；一般来讲，结构影像与临床发作症状以及发作间期和发作期头皮 EEG 定位结果一致时是可靠的。三者检查结果不一致时，根据情况需要采用颅内电极进行 EEG 长时间描记，获取发作期的 EEG 进行定位。其次，分析脑电和症候学信息时应该遵循时间先后顺序的原则，也就是发作过程中时间越早的信息提示的部位越可靠。
表6
各种定位技术的相对可靠性与敏感性
当无法获得全部可靠信息时，或重要信息之间相互矛盾无法解释清楚癫痫发作过程时，应该制定埋置颅内电极的方案（表 7），利用颅内电极 EEG（包括硬膜下电极 EEG 以及 SEEG）获得的信息进一步定位癫痫灶。需要注意的是，与其说颅内电极是探测性检查手段，不如说是验证手段更为合适。无论哪种颅内电极的置入都应基于明确的理论假设基础。
表7
多种定位技术的综合选用原则以及颅内电极埋置的选择
4.2 癫痫灶与癫痫网络推理
DIANXIANZAODINGWEISHIYIGEZONGHEFENXIDEGUOCHENG，HENDUOBINGLIWUFAHUOQUDINGWEIQUANBUXINXI，YINGGAILIYONGNAOJIEPOU、SHENJINGSHENGLIHENAOWANGLUOZHISHIJIESHIMEIYICIDIANXIANFAZUODESHENJINGHUODONGGUOCHENG，LUOJITUILISHISHIFENBIYAODE，DIANXIANZHONGXINDESHENJINGNEI、WAIKEYISHIJINXINGZONGHETAOLUN，ZHIDINGSHOUSHUFANGAN。
SUIZHEDIANXIANBINGLISHENGLIYANJIUDESHENRU，TEBIESHIZAI SEEG GUANGFANYINGYONGGUOCHENGZHONG，ZHUJIANRENSHIDAOCANYUMOUCIDIANXIANFAZUODENAOQUWANGWANGBINGBUJUXIANZAIYIGETEDINGDENAOQU，YOUSHIHUIBOJIDUOGEXIANGJUJIAOYUANDEBUTONGNAOQU，ZHEIXIEQUYUXIANGHUYINGXIANGCUDONG、JIAOTIJIHUO、BICIHUWEIYINGUO，HENDUOSHIHOUWUFAQUFENNAGEQUYUSHIZHENZHENGDEDIANXIANZAO，GUCIYINRULEYIGEDIANXIANWANGLUODEGAINIANLAIQUEDINGZHONGYAODEDIANXIANNAOQU。ZAISHIJIANZHONGYINGGAIGENJUSHANGSHUJIANCHAFANGFAHUODEDEZHENGJU，ZONGHEFENXIMINGQUEBUTONGNAOQUCANYUDIANXIANFAZUODEMIQIECHENGDU、FENXIZHEIXIEQUYUJIHUODESHUNXU，QUEDINGDIANXIANWANGLUO，YONGYUZHIDAOSHOUSHUQIECHUDIANXIANNAOQUFANGANDEZHIDING。
4.3 划分癫痫灶与脑功能区边界
DIANXIANSHUQIANPINGGUZHONGLINGYIXIANGZHONGYAODERENWUSHIJINXINGZHONGYAODENAOGONGNENGQUDINGWEI，ZHEIBAOKUOYUNDONGQU，TEBIESHIZHITIYUNDONGGONGNENGQU、QUTIGANJUEGONGNENGQU、YUYANGONGNENGQUDENGZHONGYAONAOGONGNENGQUDEBIANJIEHUAFEN。JIBENYUANZESHIMINGQUEDIANXIANZAOQUDEBIANJIEYUZHONGYAOGONGNENGQUDEBIANJIE，RUGUOLIANGGEPICENGQUYUXIANGHUFENLI，ZEKEYIANQUANQIECHUDIANXIANZAO；RUOLIANGGEQUYUWANQUANZHONGDIE，ZEBUSHIHEJINXINGDIANXIANZAODEQIECHUZHILIAO，FANGZHISHOUSHUZAOCHENGNAOGONGNENGZHANGAI；RUOLIANGGEQUYUBUFENZHONGDIE，ZEYINGGENJUQINGKUANGPANDINGLIANGZHEZHIBIANJIEHEZHONGDIEFANWEI，SHIDANGQIECHUDIANXIANZAO，YIQUEBAOBUDAOZHIZHONGYAONAOGONGNENGZHANGAIWEIYUANZE。
NAOGONGNENGQUSHIFOUBAOLIUYEYAOGENJUHUANZHEDEJUTIQINGKUANGLAIJUEDING。WEILEWANQUANKONGZHIDIANXIANFAZUO，SHOUSHUDAOZHIBUFENQUTIGANJUEGONGNENGZHANGAIDUIYIXIEHUANZHESHIKEYIJIESHOUDE。CIWAI，SUIRANSHIYUNDONGGONGNENGQU，DANCETOUMIANBUYUNDONGGONGNENGQUQIECHUBINGBUHUIJIHUANZHEDAILAIJIAODADESHENGHUOZHANGAI，WEILEDACHENGWANQUANWUFAZUODEXIAOGUOYOUSHIKEYIJINXINGTOUMIANBUYUNDONGPICENGGONGNENGQUDIANXIANZAODEQIECHU。QUEDINGQUTIGANJUE、YUNDONGGONGNENGQUDEJISHUBAOKUOTIGANYOUFADIANWEIJIANCHA、YUNDONGYOUFADIANWEIJIANCHA、MEG、fMRI DENG，QIJIEGUOYUPICENGDIANCIJIJIEGUOBIJIAOWENHE；ERNAOGONGNENGCHENGXIANGQUEDINGYUYANGONGNENGQUDEFANWEIYAOYUANYUANDAYUPICENGDIANCIJIJISHUSUOQUEDINGDEYUYANGONGNENGQUYU，HOUZHEQUEDINGDEQUYUSHIBIBUKESHAODEJIBENYUYANPICENGQUYU，SUNHAIHOURONGYIDAOZHIYUYANGONGNENGZHANGAI，YINGYONGSHIYAOZHUYI。
4.4 信息矛盾处理
DUIYUXINXIBUWANZHENG、XINXIXIANGHUMAODUNDEDIANXIANHUANZHEKEYIMAIZHILUNEIDIANJI，ZHANGQIJIANCEDANAODEDIANHUODONG，DANYAOZHUYIYIXIAJIDIAN，SHOUXIANYAODUIDIANXIANHUANZHEQUANBUXINXIJINXINGZONGHEFENXI，TICHUYIZHONGHUOLIANGZHONGHELIDEDIANXIANFAZUOSHENJINGHUODONGKUOBUNAOWANGLUOJIASHE，ZHENDUIKENENGSHEJIDENAOQUYOUMUDESHEJILUNEIDIANJIMAIZHIFANGAN，YIJIESHIDIANXIANFAZUOSHENJINGHUODONGDEGUOCHENG，MIBUQITADINGWEIXINXIDEBUZU。QICI，LUNEIDIANJI EEG DEYOUSHIZAIYUKEYIZHAODAODIANXIANFAZUOZUIWEICHUSHIDEYICHANGDIANHUODONGBUWEI，HENXIANRANSHIJIANYOUXIANXINGYUANZEYINGGAISHOUDAOCHONGFENDEZHONGSHI，YEJIUSHIDUOKONGJIANBUWEIDELUNEIDIANJIDIANHUODONGXINXIYIJIZHENGHOUXUEXINXIDEBIDUISHIFENZHONGYAO，ZUIZAOCHUXIANYICHANGHUODONGQIEZAOYUZUIXIANYIGEZHENGHOUDEYICHANGJIELVCHUXIANBUWEIZUIYOUJIAZHI，ZUIKAOJINZHENZHENGDEDIANXIANZAO。ZAIZE，ZHONGSHISHENBUPICENGJIEGOUCANYUDIANXIANFAZUOGUOCHENGDEKENENGXING，LIJIEDAOYE、EYEDIMIANJIEGOUJIZHONGXIANJIEGOURUENEICEYIJIDINGNEICEJIEGOUZAIDIANXIANFAZUOGUOCHENGZHONGDEZUOYONG。ZUIHOU，CHONGFENLIYONGPICENGDIANCIJIJISHUSUOTISHIDEXINXIBANGZHUDINGWEI，LUNEIDIANJITEBIESHINAOSHENBUDIANJIDIANCIJIKEYIYOUFACHUHOUFANGDIANHUOZHEDIANXIANFAZUO，JIEHECISHIDE EEG BIANHUATEDIAN，BIDUIYUGUANCHANGFAZUODEXIANGSIXING，KEYIHENHAODEHUIZHICHUDIANXIANFAZUONAOWANGLUOLIANLUOTU，YOUZHUYUDIANXIANZAODINGWEI。
5 癫痫术前评估的参考策略
SHUQIANPINGGUDEZHILIANGJUEDINGSHOUSHUZHILIAODEXIAOGUO，JINGUANSHUQIANPINGGUJISHUYUELAIYUEDUO，WEIDIANXIANZAODEDINGWEITIGONGLEJIDADEFANGBIAN，DANMUQIANSHUQIANPINGGUYIRANSHIYIXIANGJIWEIFANZADEXITONGGONGZUO，ZHEIMEDUOSHOUDUANJIAZHIRUHE，RUHEPINGJIAQIMINGANXING、KEKAOXING，ZHEIXIEPINGGUSHOUDUANRUHEXUGUANYINGYONG，YIBIANZUIDACHENGDUJIEYUEYILIAOZIYUAN、JIANSHAOGONGZUOLIANG；LINGWAI，DANGJIANCHAJIEGUOHUXIANGMAODUNSHI，RUHEQUANHENGLIBI、ZHAOCHUGONGXING、QUWEICUNZHEN，QUEDINGZHENZHENGDEDIANXIANZAO；ZAIWUJIKESHI、CHOUCHUBUQIAN、BUZHISUOCUOSHIRUHETUPOCHUANTONG、ZHAODAOXIANSUO、SHUNTENGMOGUA、SHIXIANDINGWEI；RUHELIYONGYOUCHUANGDEJIANCHASHOUDUAN，MINGQUEZHIDIANZAO。YIXIAJIZHONGJIBENCELVE，KEYIJIEJIAN。
5.1 半球巨大病灶患者定位策略
YINGXIANGXUEJIANCHADUIYUDINGWEIDIANXIANZAOZHIGUANZHONGYAO，JIEGOUYINGXIANGXUEJIANCHAZHUYAOSHINAOBU CT HE MRI DEJIANCHAJIEGUOFEICHANGZHIGUAN，BIANYULINCHUANGLIJIEDIANXIANZAO。RUGUOLINCHUANGSHANGFAXIANYICEBANQIUDEJUDAJIEGOUXINGBINGZAO，SHOUXIANKAOLVBINGZAOYUDIANXIANDEGUANXI，PINGGUSHIZHUYISANDIAN。SHOUXIAN，DIANXIANFAZUODEZHENGZHUANGSHIFOUTISHIYUBINGZAOCEBIEWENHE，BAOKUOJIZHENLUAN、JINGLUAN、QIANGZHI、QUTIGANJUEXIANZHAO、SHIJUEXIANZHAODENG。QICI，TOUPI EEG JIANQIFANGDIANHEFAZUOQIYICHANGJIELVCHUXIANZAIBINGZAOCE，ZEGENGJIAZHICHIBINGZAOCEDIANXIANZAODINGWEI；RUGUOFANGDIANCHUXIANZAISHUANGCEHUOLIANGCEJIELVJIBENDUICHENG，BUNENGFOUDINGDIANXIANZAOWEIYUBINGZAOCE，BUFANGAIBANQIUQIECHUHUOLIDUANSHOUSHUDESHISHI。ZAIZE，JIDUANSHAOJIANDEQINGKUANGSHIDIANXIANFAZUODEZHENGZHUANGBIAOXIANZAIBINGZAOTONGCE，CIZHONGQINGKUANGXIAYOULIANGZHONGKENENGXING，DIANXIANZAOKENENGWEIYUBINGZAOCEBANQIUHUODUICEBANQIU，KEYIGENJUQITAXINXIJIAYIPANDUAN。
5.2 孤立性结构病灶患者定位策略
YINGXIANGFAXIANDEGULIXINGJIEGOUBINGZAOSHIZUIZHONGYAODEDINGWEIXINXIZHIYI，ZHENGZHUANGXUEKEYIJIESHIBINGZAOYUDIANXIANFAZUOZHENGZHUANGDEGUANXI，ZEJIYUBINGZAODINGWEI。RUGUO EEG FAZUOJIANQI、FAZUOQIXINXIYUBINGZAOWENHE，GENGJIAZHICHIYINGXIANGBINGZAODINGWEIDEJIEGUO；RUGUO EEG FAZUOJIANQI、FAZUOQIXINXIYUBINGZAOBUWENHE，BINGBUNENGFOUDINGYINGXIANGBINGZAODINGWEIDEJIAZHI。RUGUOZHENGZHUANGXUEXINXIBUNENGTIGONGDINGWEIJIAZHI，ER EEG、MEG XINXIYUBINGZAOXINXIWENHE，YINGXIANGBINGZAOYIRANFEICHANGYOUDINGWEIJIAZHI。ZUIXINDE VBM JIEGOUYINGXIANGFENXIJISHUTISHIDEWEIXIAOJIEGOUGAIBIANYEYOUYIDINGDEDINGWEIJIAZHI，ZHIDETUIGUANGYINGYONG。
5.3 结构影像检查阴性患者的脑电图、脑磁图应用策略
GAODUTONGBUHUADEDANAOSHENJINGYUANYICHANGFANGDIANKEYIBEI EEG HE MEG CAIJIDAO，QISUOTISHIDEFANGDIANKONGJIANBUWEISHUYUDANAOYICHANGXINGFENDEQUYU，YICHANGFANGDIANQUYUZAIDINGWEIGUOCHENGZHONGYOUMINGQUETISHIYIYI。YINGYONGSHIZHUYIYIXIAJIDIAN：SHOUXIAN，FAXIANDUOGEYICHANGFANGDIANQUYU，BUYINGJINJINGENJUJIANQIDEFANGDIANBUWEIDINGWEIDIANXIANZAO。QICI，ZAIFENXIFAZUOQINAODIANXINXISHIYINGZUNXUNSHIJIANSHUNXUYUANZE，YUEZAOCHUXIANYICHANGHUODONGDEBUWEIYUEKAOJINDIANXIANZAO。ZAIZE，YINGGAIYUZHENGZHUANGXUEBIJIAO，ZIXITONGBUYUEDULUXIANG EEG，BIDUILIANGZHEZHIJIANDUOGESHIJIANDEFASHENGSHUNXU，ZHENGZHUANGXUETEZHENGYUNAODIANXUETEZHENGSUOTISHIDEPICENGQUYUKENENGBICIJIAOHUCHENGXIAN，PINGGUSHIYINGGAICHONGFENKAOLVDAODIANXIANSHENJINGHUODONGKUOBUDEDONGTAIGUOCHENG，HUIZHIWANZHENGDEDIANXIANFAZUOPICENGKUOBUDONGTAIWANGLUOTU。
5.4 结构影像阴性患者的症候学线索逆向追踪策略
JIEGOUYINGXIANGXUEYINXINGDEHUANZHEZHENGHOUXUEDESHENRUFENXISHIFENZHONGYAO，ZHUYILIANGFANGMIANDEXIANSUO：SHOUXIAN，SHENRULEJIEHUANZHEFAZUODEXIANZHAO，XIANZHAOKEYITIGONGYOUDINGWEIYIYIDEXINXI。QICI，DIANXIANFAZUODECHUSHIYUNDONGZHENGZHUANGDEBUWEIKEYITISHIDIANXIANZAO。TANTAOZHENGHOUXUEDINGWEISHIYINGGAIZUNXUNNIXIANGZHUIZONGYUANLI，YEJIUSHIZAIQUEDINGHEXINZHENGHOUDEQINGKUANGXIAJINKENENGXIANGFAZUOZAOQIZHENGZHUANGJINXINGZHUIZONG，YUEZAOQIDEFAZUOZHENGZHUANGSUOTISHIDEPICENGQUYUYUEKAOJINDIANXIANZAO。
5.5 结构影像学阴性患者的脑功能检查策略
DUIYUJIEGOUYINGXIANGXUEJIANCHAYINXINGDEHUANZHE，SISCOM JIEGUOHUOZHE PET FAXIANDEDANAOPICENGJUBUDIDAIXIEQUYOUZHONGYAODINGWEIYIYI，RUGUODIANXIANFAZUOZHENGZHUANGTISHIWEINIEYEDIANXIANHUANZHE，PET DIDAIXIEQUWEIYUYICENIEYE，ZEDINGCEYIYIZHONGDA。PET-MRI RONGHEJISHUFAXIANDEPICENGJUZAODIDAIXIEQUYU MEG CIYUANCHENGXIANGHUOZHE VBM TISHIBUWEIXIANGWENHEZEJIAOKEKAO。NAOGONGNENGCHENGXIANGTISHIDEYICHANGNAOQUYINGGAIZAINENGLIANGHAOJIESHIZHENGHOUXUEXIANXIANGDEFASHENGGUOCHENGSHICAIYOUDINGWEIYIYI。
5.6 颞叶癫痫患者术前评估策略
颞叶癫痫是药物难治性癫痫中最常见的类型，手术疗效优于药物治疗[2]。合理的术前评估、彻底切除癫痫灶、最大限度保留功能区是颞叶癫痫手术成功的关键。
5.6.1 颞叶的功能解剖
NIEYEWEIYUWAICELIEDEXIAFANG，DINGZHENLIEHEZHENQIANQIEJIDEQIANFANG，YIWAICELIEYUEDINGYEFENJIE，HOUMIANYUZHENYEXIANGLIN。NIEYEQIANDUANWEINIEJI，WAICEMIANYOUYUWAICELIEPINGXINGDENIESHANGGOUYIJIDIMIANDENIEXIAGOU，LIANGGOUJIANGNIEYEWAICEFENWEINIESHANGHUI、 NIEZHONGHUI、NIEXIAHUI，NIESHANGHUIDEYIBUFENYANRUWAICELIEZHONG，WEINIEHENGHUI。NIEYEDEZHUYAOGONGNENGQUBAOKUO：① GANJUEYUYANZHONGSHUQU：WEIYUYOUSHIBANQIUNIESHANGHUIHOUBU；② TINGJUEZHONGSHU：WEIYUNIESHANGHUIZHONGBUJINIEHENGHUI；③ XIUJUEZHONGSHU：WEIYUGOUHUIHAIMAHUIQIANBU，JIESHOUSHUANGCEXIUJUEXIANWEIDECHUANRU；④ NIEYEQIANBU：YUJIYILIANXIANGHEBIJIAODENGGAOJISHENJINGHUODONGYOUGUAN；⑤ NIEYENEICEMIAN：CIQUYUSHUYUBIANYUANXITONG，HAIMASHIQIZHONGDEZHONGYAOJIEGOU，YUJIYI、JINGSHEN、XINGWEI、NEIZANGGONGNENGYOUGUAN。
5.6.2 颞叶癫痫的病因、分类与发作特征
常见病因包括海马硬化、发育性肿瘤、FCD、海绵状血管畸形、软化灶等，部分患者有儿童期热性惊厥史或早期脑损伤，包括外伤、感染或缺血缺氧性脑损伤等，可引起海马硬化。颞叶癫痫分类方法多样，传统上分为内侧颞叶癫痫和外侧颞叶癫痫[48]，近年来有学者将其分为颞叶内侧型、外侧型、颞极型、内外侧型和颞叶附加癫痫，少数患者为双侧颞叶癫痫[49]。
NIEYEDIANXIANFAZUODETEZHENGXINGBIAOXIANWEI：① BUBANYISHIZHANGAIDEJUZAOXINGFAZUO：DANCHUNBUFENXINGFAZUOBIAOXIANWEIZIZHUSHENJINGZHENGZHUANGHE/HUOJINGSHENZHENGZHUANGYIJIMOUXIEGANJUEXIANXIANG（RUHUANXIU、FUBUSHANGSHENGGAN、SICENGXIANGSHIGANDENG）；② BANYISHIZHANGAIDEJUZAOXINGFAZUO：WANGWANGYIYUNDONGTINGZHIKAISHI，SUIZHICHUXIANYISHIZHANGAI，BANSUICHUXIANDIANXINGDEKOU-XIAOHUADAOZIDONGZHENG，YEJINGCHANGSUIZHIFASHENGQITAZIDONGZHENG，CHIXUSHIJIANCHANG>1 min，FAZUOHOUCHANGYOUYISHIHUNZHUO、YIWANG，HUIFUGUOCHENGSHIZHUJIANDE。
5.6.3 一期非侵入性评估
5.6.3.1 视频脑电图
TOUPIEEGDETEZHENGKEBIAOXIANWEIBEIJINGHUODONGQINGDUHUOXIANZHUDEBUDUICHENG；NIEQIANBUHUONIEHOUBUJIBO、JIANBOHUOMANBO，DANCEHUOSHUANGCETONGBU，YEKEYIBUTONGBU；YICHANGHUODONGKENENGBUJUXIANYUNIEQU。DIEGUDIANJICAIJIEEGYOUZHONGYAOJIAZHI。BIXUTONGSHIJILUFAZUOJIANQIHEFAZUOQIDEEEG。
5.6.3.2 磁共振
XUZHISHAOBAOKUOQUANTOUWUJIANDUAN 3 mm CENGHOUDE T1、T2、T2-FLAIR XIANG，GUANZHUANGWEICAIYONGCHUIZHIYUHAIMAZHANGZHOUDEXIEGUANZHUANGWEISAOMIAO，3D-T1 DUIYUYINGXIANGHOUCHULIZHIGUANZHONGYAO。
5.6.3.3 正电子发射计算机断层显像
发作间期18F-FDG PET 扫描对颞叶癫痫有很大价值。发作间期，一侧颞叶低代谢有重要定位意义。需要注意的颞叶癫痫发作间期低代谢的范围往往大于癫痫灶的范围，需仔细甄别。
5.6.3.4 单光子计算机断层显像
NIEYEDIANXIANFAZUOQIDIANXIANZAOBIAOXIANWEIGAOGUANZHU，FAZUOJIANQIBIAOXIANWEIDIGUANZHU。
5.6.3.5 脑磁图
KEYIFAXIANDIANXIANYICHANGHUODONGDIANLIUYUANWEIYUYICENIEYEJIEGOU，SHUANGCENIEYEJIEGOUJUNKEJIANCEDAOFANGDIANDIANLIUYUANSHI，ZHUYIJIEHEQITAXINXIFENXIPANDUAN。
5.6.3.6 神经心理学评估
NIEYEDIANXIANHUANZHEDESHENJINGXINLIXUEPINGGUTEBIEZHONGYAO，YINGGAIZUOWEICHANGGUIJIANCHA，NEIRONGBAOKUOZHILI、ZHUYILI、YUNDONG、GANJUE、YUYAN、JIYI、SHIKONGJIANNENGLI、ZHIXINGGONGNENGDENG。YOUSHIBANQIUCENIEQIANYEQIECHUSHUYIYINQIHUANZHEJIYIGONGNENGDEJIANTUI，GUXUZAISHUQIANMINGQUEYOUSHIBANQIUBINGDUIJIYILICHONGFENPINGGU，CONGERZHIDAOSHOUSHUCELVE。
5.6.4 二期侵入性评估
5.6.4.1 颅内脑电图
由于颞叶癫痫的放电常来自于颞叶内侧、底面等深部结构，目前 SEEG 在颞叶癫痫中应用较为广泛。对于症状学、EEG不典型、结构影像学阴性或不同检查结果互相矛盾的情况，应考虑到假性颞叶癫痫或颞叶附加癫痫的可能，应利用颅内EEG进一步明确癫痫灶范围以及功能区范围[50]。
5.6.4.2 Wada 试验
GUANGFANYONGYUYUYAN、JIYI、YUNDONGGONGNENGDESHUQIANPINGGU，SHIMUQIANQUEDINGYANYU、JIYIYOUSHICEDEJINBIAOZHUN。
5.6.5 颞叶癫痫患者术前评估策略流程图
颞叶癫痫患者的术前评估策略流程详见图 4。
图4
颞叶癫痫患者术前评估策略流程图
5.7 岛叶癫痫患者术前评估策略
岛叶癫痫术前评估定位困难。岛叶-岛盖区癫痫是指颅内电极确认的岛叶-岛盖区起源放电引发的癫痫或存在岛叶病灶及其关联性发作症状的癫痫[51, 52]。
5.7.1 岛叶的功能解剖
岛叶位于外侧裂内血管墙的深面，经前、下、上环岛沟与额、颞、顶叶相隔，岛中央沟将岛叶分为岛前小叶、岛后小叶两部分，岛前小叶分为 3 个岛短回，岛后小叶分为 2 个岛长回。岛盖是指位于环岛沟投影到脑表面外侧裂内外的灰质，包括额眶岛盖、额顶岛盖、颞叶岛盖。岛叶深部的白质纤维是极外囊及外囊。岛叶相关长纤维束主要有钩束、弓状束、额枕下束、颞干和视辐射。岛叶后上部皮质深方为壳核、苍白球，直接与锥体束相邻，是手术的危险区。Kurth 等[53]在岛叶 fMRI 研究 Meta 分析中将岛叶分为 4 个功能区：岛极周围的社交-情绪区、前岛短回背侧及中岛短回的认知区、中岛短回的嗅味觉区、后岛短回-后岛长回上部的感觉运动区。
5.7.2 岛叶-岛盖区的癫痫灶定位
5.7.2.1 症状学
岛叶的功能连接非常复杂，岛叶及岛叶周围皮质产生的癫痫发作的症状学特点也很复杂，可以概括为以下几类[54, 55]：① 躯体感觉症状，多表现为分布于皮肤局限区域（口周、面部、手、上肢），或广泛区域的一种无痛的麻刺感、过电感或温热感，其他的躯体感觉还包括发紧感、颤动感及跳动感等；② 内脏感觉，主要表现为咽喉部紧缩感、恶心、胃气上升感、胸部紧缩感等，严重时可表现为呼吸困难、窒息；③ 口咽运动症状，主要与口咽部运动相关，如咀嚼、咂嘴、吞咽等，并与发作性呕吐有关；④ 躯体运动症状，例如过度运动症状，或者不对称强直、自动症等运动症状；⑤ 特殊感觉，包括特殊的味觉、听觉症状，以及前庭觉症状，如旋转，漂浮感，坠落感及头昏等；⑥ 意识清醒状态下的语言功能障碍；⑦ 植物神经症状，主要是指发作时心率变化（心率过快、过慢、心脏停博）、皮肤改变（苍白、潮红、汗毛竖立）等。这些先兆和发作期症状，可以支持或提示发作时岛叶-岛盖受累。
5.7.2.2 影像学
GAOFENBIANLVDE MRI SHIDAOYEDIANXIANDINGWEIZHENDUANDEZHONGYAOYIJU，TONGGUO MRI XIANSHIDEDAOYEQUYUBINGZAOCHANGKEZHENDUANDAOYEDIANXIAN。DANSHI，YOUYUDAOYEJIDAOGAIQUYUPICENGZHOUZHEDUO，JIAOXIAODE FCD HENNANQUEREN。PET JIANCHADUIYUTISHIDAOYE-DAOGAIDIANXIANJUYOUYIDINGDEZUOYONG，YOUQISHIYU MRI JINXINGRONGHEZHIHOU，CHANGKEFAXIANJUBUPICENGDEDIDAIXIEQU。FAZUOQI SPECT YEDUIDAOYE-DAOGAIQUDIANXIANYOUMINGQUEDEDINGWEIJIAZHI。VBM DUIBUFENDAOYE-DAOGAIQUDIANXIANJUYOUYIDINGDEDINGWEITISHIZUOYONG。
5.7.2.3 脑电图
DAOYEDIANXIANDETOUPI EEG BUJUTEYIXING，KEYIXIANSHIEYE、NIEYE、ZHONGYANGDINGQUDEJUXIANXINGYICHANGFANGDIAN，YEKEYISHIGUANGFANDEYICHANGDIANHUODONG，HUOJILUBUDAOMINGXIANDEYICHANGFANGDIAN。YOUSHI，JUBUDE、YICEDEMANBOHUODONGHUOMEIYOUJILUDAOMINGXIANDEYICHANGFANGDIANBENSHENJIUKENENGBEIKANZUOSHIDAOYEDIANXIANDETEZHENGXING EEG GAIBIAN。YOUXIEDIANXIANZAOLEIJIDAOGAIJIZHOUWEIPICENGDEHUANZHE，KEYIZAIE、NIE、DINGYEQUJILUDAOJUZAOXINGJIANBOHUODONG。ZONGTIERYAN，WULUNFAZUOJIANQIHUOFAZUOQITOUPI EEG，DINGWEIDAOYEDIANXIANDOUHENKUNNAN。
5.7.2.4 脑磁图
YUTOUPI EEG XIANGBI，MEG ZAIDINGWEIDAOYEDIANXIANFANGMIAN，JUYOUXIANZHUYOUSHI，MEG DUIYUCELIANGWEIYUDANAOGOULIENEINAOPICENGDEYICHANGFANGDIANGENGJIAMINGAN。DUIYUDAOYEDIANXIAN，YOUQISHIZAICELIENEIZHEFANDEDAOGAIPICENGDEYICHANGFANGDIAN，MEG JIANCHAJIAOWEIMINGAN。DUI MRI YINXINGBIAOXIANDEBINGLI，KEYITIGONGEWAIDEDINGWEIXINXI。
5.7.2.5 颅内电极记录
DAOYE-DAOGAIQUDIANXIANCHANGCHANGXUYAOYINGYONGLUNEIDIANJIJILUCAIDEYIMINGQUEZHENDUAN。YOUYUDAOYEDETESHUJIEPOUWEIZHI，JISHIYINGYONGYINGMOXIAPICENGDIANJIYEKENENGBUNENGMINGQUEDINGWEIDAOYE-DAOGAIQUDIANXIAN。CHANGXUYAOLIANHEYINGYONGSHENBUDIANJI，HUOJIANGWAICELIEFENKAI，ZAIDAOYEHEDAOGAIQUPICENGFANGZHIPICENGDIANJI。SEEG FEICHANGYOUZHUYUDINGWEIDAOYE-DAOGAIQUDIANXIAN。ZHIDEZHUYIDESHI，SEEG DIANJICAIJIDEFANWEIHENJUXIAN，QIEGAIBUFENXUEGUANSHIFENFENGFU，ZAISHEJI SEEG DIANJIZHIRUWEIZHIHEFANGSHISHI，XUZONGHEFENXIDIANJIZHIRUDEBADIANBUWEI、ZHIRUFANGSHIHELUJING，YIJIYINGYONGDIANJIDESHULIANG。
5.8 额叶癫痫患者术前评估策略
5.8.1 额叶的功能解剖
额叶是大脑最大一个脑叶，主要包括了中央运动区的 Broadmann 4 区和运动前区（6 区），额叶背侧的额眼区（8 区）、前额背外侧皮层（9 区）、额极区（10 区）和额眶回（11、12 区）、前扣带回（24、25、32、33 区）、中央下区（43 区）、Broca 区（44、45 区）、背外侧前额叶（46 区）和前额下回（47 区）。见图 5。
图5
额叶皮层的 Broadmann 分区
5.8.2 额叶的癫痫灶定位
5.8.2.1 症状学
额叶癫痫临床特点包括：夜间或睡眠中多发，发作时间短、频率高，且有丛集性发作，发作后意识恢复快，症状刻板，运动幅度大，可有对侧头眼偏转，不对称强直等特点。这些症状特点对癫痫灶的定位与定侧有一定的提示作用，但特异性较差，比如过度运动多见于额叶，也可以见于颞叶、岛叶等部位。头眼偏转同样可以见于额叶、颞叶、枕叶等脑区，还可以见于对侧或同侧半球。对症状学的全程顺序分析可能提供更多的定位、定侧信息[56]。
5.8.2.2 影像学
MRI SHIFOUKEYIFAXIANBINGZAOYUEYEDIANXIANSHUHOUXIAOGUOYOUMINGQUEXIANGGUANXING，SUOYIGAOCHANGQIANG（3.0T HUO 7.0T）MRI DEBOCENGDUOXULIEDESAOMIAO，TEBIESHI 3D-FLAIR、3D-T1 MPRAGE HEBAIHUIZHIJIEXIANZENGQIANGSAOMIAOFEICHANGZHONGYAO，KEYIFAXIANYIXIENAOPIZHIFAYUBULIANGXINGBINGBIAN。DUIYUBANSUIYINEIDEERTONG T2 BOCENGSAOMIAOJIAO FLAIR GENGRONGYIFAXIANBINGBIAN，ER 6～18 GEYUEDEHUANZHEWULUNSHI FLAIR HAISHI T2 XULIEDOUKENENGNANYIFAXIANBINGBIAN，SUOYIDUIYU MRI YINXINGDEEYEDIANXIANHUANERYAODUOCIJIANCHA MRI，YIQIFAXIANBINGZAO。VBM DENGYINGXIANGHOUCHULIKENENGBANGZHUFAXIAN MRI YICHANG。MRI YINXINGDEDIANXIANHUANZHEKEYIJINXING MRI-PET RONGHE、SISCOM HUO EEG-fMRI JIANCHA，BANGZHUDINGWEIEYEDIANXIANZAO。
5.8.2.3 脑电图和脑磁图
额叶内侧面、额叶底面相关的癫痫样放电应用常规头皮 EEG 监测困难，发作期 EEG 多伴明显的动作伪差，难以发现异常放电。而且额叶癫痫双侧传导甚至快于同侧半球内的传导，所以 EEG 上经常表现为双侧的异常放电。除了背外侧额叶癫痫外，EEG 对额叶癫痫定位困难，应用密集电极的 EEG 可以提高额叶癫痫的定侧及定位价值。发作间期 MEG 对额叶癫痫的定位有一定的帮助，MEG 源定位脑区为单灶且手术全切除者预后良好[57]。
5.8.2.4 颅内电极记录
LUNEIDIANJI EEG SHIEYEDIANXIANSHUQIANPINGGUZHONGDEZHONGYAOGONGJU，MRI YINXINGEYEDIANXIAN、GUANGFANXING MRI YICHANGDEEYEDIANXIAN、LEIJIHUOLINJINYUNDONGQUHEYOUSHICELEIJIYUYANQUDEEYEDIANXIANDOUYINGDANGKAOLVJINXINGLUNEIDIANJI EEG JIANCHA。DUIYUEYEDIANXIANHEBINGLUNEIJUXIANXINGFEIPIZHIFAYUBULIANGDEBINGZAO（RUHAIMIANZHUANGXUEGUANLIU、NAONANGCHONG、GAIHUAZAO、ZHONGLIU、JIEJIEXINGYINGHUAZHENGDEPICENGJIEJIE），QIEDIANXIANZHENGZHUANGXUEKEYIYONGBINGZAOJIESHISHI，HUO MRI YANGXINGHEBINGJINXINGXINGRENZHISUNHAIHEPINFANDIANXIANFAZUODEYINGYOUEREYEDIANXIAN，WULUNSHIFOULEIJIGONGNENGQU，JIANYIGENJU MRI HE PET DENGJIEGUOJINXINGYIQIQIECHUSHOUSHU，BUTUIJIANLUNEIDIANJIMAIZANG。XUYAOZHIRULUNEIDIANJIDINGWEIZHE，YINGDANGFUGAI MRI YANGXINGQUYU、FAZUOJIANQI EEG ZHUYAOXIANXINGFANGDIANQUYU、FAZUOQI EEG KEYIQIYUANQUYUHE PET、MEG、SISCOM JIANCHATISHIDEKENENGYICHANGQUYU，LINJINGONGNENGQUZHEHAIYINGDANGBAOKUOGONGNENGQU。LINGWAI，YOUYUEYEDIANXIANZAIZHENGZHUANGXUEHUODIANSHENGLISHANGKENENGYUDAOYE、NIEYEHEDINGYEJIANYOUZHONGDIE，SUOYICHANGGENJUWUCHUANGJIANCHAPINGGUJIEGUO，LUNEIDIANJIZHIRUSHIXUYAOXUANZEXINGFUGAISHANGSHUBUFENHUOQUANBUQUYU。DUIYUKAOLVDIANXIANZAOWEIYUEYENEICE、KOUDAIHUI、EKUANGHUI、SHUANGEYE、DAOYEZHEYOUXIANKAOLV SEEG DEFANGSHI，KEYIJIANSHAOCHUANGSHANGHETIGAODIANJIZHIRUZHUNQUEXING。DUIYUBINGZAOHUODIANXIANZAOZHUYAOLEIJIYUNDONGQUHEYOUSHICEYUYANQU，LUNEIDIANJIMAIZANGDEMUDECHULEQUEDINGDIANXIANZAO，GENGZHUYAOSHIWANCHENGGONGNENGQUDINGWEI，YINGDANGYOUXIANKAOLVYINGMOXIADIANJI（HUOJIEHENAOSHENBUDIANJI）EEG。
5.8.2.5 神经心理检查
SHENJINGXINLIJIANCHADUISHUQIANDINGWEIHEDINGCEDIANXIANZAOYOUYIDINGBANGZHU，GENGZHONGYAODEYONGYUSHUQIANYUSHUHOUDUIBIZONGHEPINGJIASHOUSHUXIAOGUO。
5.8.2.6 额叶各部分起源特点
BUTONGFAZUOZHENGZHUANGBIAOXIANKEYITISHIDIANXIANFAZUOQIYUANYUEYEDEBUTONGNAOQU。ZHONGYANGQUDIANXIANLINCHUANGSHANGZHUYAOBIAOXIANWEIYIDUICEYUNDONGZHENGZHUANGWEIZHUDEDUICEZHITIDEQIANGZHI、ZAOQIHUOWANQIZHENLUAN、DANCHUNYUNDONGZHENGZHUANG、BUDUICHENGQIANGZHIZISHI、KOUJIAOPIANXIE，YEKEYIBANYOUQUANMIANQIANGZHIZHENLUANFAZUO、QUTIGANJUEXIANZHAODENG。BA4 QUDEEYEDIANXIANYUHOUDEZHUYAOYINSUSHICUNZAI MRI BINGLIYICHANG，BENQUSHUQIANPINGGUDEZHONGDIANZAIYUYANGEDEZHENGZHUANGXUEFENXIHEGAOCHANGQIANG（3.0T HUO 7.0T）MRI DEBOCENGDUOXULIEDESAOMIAO，TEBIESHI FLAIR HEBAIHUIZHIJIEXIANZENGQIANGSAOMIAO，LINGWAI PET-MRI DERONGHEDUIFAXIANBINGZAOYEYOUJIAODAYIYI。DUIYUWUBINGLIZAOQIEKAOLVWEIYU BA4 QUDEDIANXIANJINXINGLUNEIDIANJIMAIZHIYUQIECHUXINGSHOUSHUZHILIAOXUSHENZHONG。
FUZHUYUNDONGQUFAZUOLINCHUANGSHANGZHUYAOBIAOXIANWEIBUDUICHENGDEQIANGZHIXINGZISHI，CHIXUSHIJIANJIAODUAN，KEYIBUBANYOUYISHISANGSHI。RUYICEZHITIQUQU，DUICEZHITISHENZHI，ZETISHIDIANXIANZAOWEIYUQUQUZHITICE。
前扣带回主要与导水管周灰质、伏隔核、杏仁核、前岛叶有密切的纤维联系，参与情感和自主神经功能，前扣带回癫痫常见的症状包括过度运动 I 型、恐惧、发笑、发作性噘嘴，但也可有痉挛发作等特殊形式，其癫痫发作症状多样，缺乏特异性，单纯依靠症状学定位非常困难。单纯局限于扣带回的癫痫 EEG 定位、定侧意义较小，对于同时累有额叶其它部位的扣带回癫痫 EEG 有 2/3 有一定定侧或定位的意义。怀疑扣带回癫痫的 MRI 阴性或广泛 MRI 异常的患者应当进行颅内电极植入的评估[58]，但由于上引流静脉及矢状窦粘连等原因，颅内硬膜下电极在中线扣带回及额顶叶背外侧皮层位置准确植入存在一定的风险，深部电极特别是 SEEG 成为扣带回癫痫灶定位的良好手段，考虑为扣带回癫痫时，SEEG 埋藏中至少应当 4 个电极覆盖前、前中、后中和后扣带回。
背外侧额叶癫痫可以有对称性轴性强直、撇嘴、简单的姿势性运动、发声等癫痫发作症状，但复杂的姿势性运动和固定的面部表情等很少出现。累及辅助运动区时会有不对称性强直、累及额眼区时会出现头眼偏斜，其类型多为先有短暂的向同侧偏，然后有较长时间的头眼向对侧偏斜。EEG 有较高的定侧和定位意义，但额叶癫痫向额叶外及对侧传导较快，所以放电范围多较广泛。MRI 检查及 MRI-PET 融合与其它部位额叶癫痫一样非常重要。MRI 阴性者应当进行颅内电极检查，需要进行功能区定位时可行硬膜下电极埋置[59]。
额极与额眶回癫痫临床上主要表现为恐惧等情绪和过度运动自动症、复杂的姿势性运动和固定的面部表情等。发作间期常规 EEG 定位与定侧癫痫灶困难。发作期多为运动伪差。MRI 阴性者应当进行 MRI-PET 融合检查，仍无明显病灶时，可行影像后处理、MEG、SEEG 电极的埋藏检查等[60]。额叶癫痫术前评估的检查策略见表 8。
表8
额叶癫痫术前评估的检查策略
5.9 顶枕叶癫痫（后皮层癫痫）患者术前评估策略
后皮层癫痫是指发作起始于枕叶、顶叶或后颞叶区域，或是其中 2 个或 3 个脑叶交界区的癫痫总称，是相对于常见的额叶癫痫和颞叶癫痫而言的。这 3 个脑叶并无明确的解剖学分界线，其划分是根据一些解剖学标记而设定的人为界限，此区的癫痫灶可能较大，跨越了人为的界限，在进行手术治疗时，也难以局限于人为界定的枕叶顶叶中，因此有时无法确切认定某例患者是枕叶癫痫、顶叶癫痫或是颞叶后部起源的癫痫[61]。Blume 等[62]在文章中也提到更愿意使用“后皮层癫痫”这一词，而不再勉强区分枕叶癫痫，顶叶癫痫或颞叶后癫痫。本规范也将起源于此区域的癫痫发作作为一组综合征进行讨论。
5.9.1 后皮层的功能解剖与传导路径
LEJIEHOUPICENGDIANXIANDELINCHUANGBIAOXIAN，HENZHONGYAODEYIDIANSHIYAOMINGQUEHOUPICENGQIYUANFAZUODECHUANBOKUOBUTEDIAN，JICHANGCHANGSHIXIANGQIANTOUBUKUOSAN。NIEYEXINPICENGJUYOUDALIANGDELIANLUOXIANWEILIANXINIEYEDEGEBUFEN，BINGLIANXINIEYEYUQITANAOYE，ZAI Broadmann 18、19 QUYU 37 QUZHIJIANYOUZHISHIQUDELIANLUOXIANWEI，ZAI Broadmann 7、40 QUYU 22 QUZHIJIANYOUZHIDINGYEDELIANLUOXIANWEI。ZHEIXIEDOUKENENGBAOKUOZAINIEYE、DINGYE、ZHENYEGANJUEYUNDONGQUZHIJIANDEFUZALIANJIEZHONG，PICENGDIANCIJIYANJIUYEZHENGSHINIEYEHOUBUQUYUYUQUTIHUODONGYOUGUAN，BINGYUTINGJUEHUOSHIJUEXINGSHIDEYUYANJIAOLIUYOUGUAN。WEIYUNIEHOUZHENQUDEFAZUOQIXIANXINGDIANHUODONGKEYITONGGUOBEICETONGLUKUOBUZHIZHONGYANGQU、EHOUHUOFUZHUYUNDONGQU，CHANSHENGXIANGYINGDELINCHUANGZHENGZHUANG；YEKEYITONGGUOFUCETONGLUKUOBUZHINIEYENEICEHUONIEYEPICENG，CHANSHENGNIEYEDIANXIANDEFAZUOZHENGZHUANG；HAIKENENGTONGGUOZHOUWEIPICENGDEKUOBU，CHANSHENGDINGYE、NIEHOU、DAOYE、ZHONGYANGQUPICENGDELINCHUANGFAZUOZHENGZHUANG。LIRU，JINGCELIEXIABUDEKUOSANKENENGJINBIAOXIANWEIBANZIDONGZHENG、XIONGMENBUSHI、KONGJUYIJISICENGXIANGSHIGANDENGLEISIQIYUANYUNIEYENEICEJIEGOUDEFUZABUFENXINGFAZUO。ERJINGCELIESHANGXIANGZHONGYANGQUKUOSANDEFAZUOKEYIYINQIBANYOUMINGXIANYUNDONG、GANJUEZHENGZHUANGHETIZHENGDEBUFENXINGFAZUO，KUOSANZHIFUZHUYUNDONGQUSHIKECHANSHENGYICHANGDEZISHI。
5.9.2 后皮层癫痫灶定位评估
HOUPICENGDIANXIANDEDIANXIANZAODINGWEIYETONGYANGYILAILINCHUANGZHENGZHUANGXUE、SHENJINGYINGXIANGXUE、FAZUOJIANQIHEFAZUOQI EEG DENGJIANCHASUOTIGONGDEDINGWEIYIJU。YOUYUSHEJINIEHOU、DINGYE、ZHENYE 3 GENAOQU，LINCHUANGFAZUODEBIAOXIANGENGJIAFUZA，YINCI，CHONGFENLEJIEQIYUANYUHOUPICENGDIANXIANFAZUODELINCHUANGTEDIANSHIFEICHANGZHONGYAODE。XIANGXIDEXUNWENHUANZHEBINGSHI，BAOKUOXIANZHAO、QISHIZHENGZHUANGHEZHENGZHUANGYANBIANGUOCHENG、FAZUOHOUDESHENJINGGONGNENGQUESHIQINGKUANG，YIJIBUTONGNIANLINGSHIQIDEZHENGZHUANGBIANHUADENGDENG，CHANGCHANGKEYITISHIDIANXIANZAOWEIYUHOUPICENG。
5.9.2.1 症状学
视觉先兆被认为可以强烈提示枕叶发作，视幻觉是在缺乏外界刺激的情况下出现的主观体验性的图形。在询问病史时，需要明确发作期视幻觉的颜色、形状、大小、位置、是否运动、持续时间、发作频率，以及是否有相关进展症状。简单的视幻觉，常常为几何图形、光点、直线等，上述这些症状往往起源于初级视觉皮层。复杂的视幻觉，包括物体、人物、风景等复杂图形或者图像。视错觉是对于真实影像的误解和错觉，比如视物显小、视物显大等。复杂的视幻觉和视错觉，主要在癫痫发作进展时出现，这些症状可以是癫痫发作的首发症状，但通常在简单视幻觉之后出现，上述症状可能累及到枕-顶或枕-颞交界区。其他常见的枕叶发作症状包括发作性快速眨眼、眼睑痉挛、双眼强直性偏转以及视像残留等。比较有意思的是双眼强直性偏转，即双侧眼球运动可分为两种，一种为平稳追踪运动，为持续性缓慢眼球运动，往往是同向运动，即定位信息在同侧，被认为与颞后枕交界处的中颞/颞上内侧（MT/MST）区相关；另一种与之相对应的眼球运动叫扫视运动，为快速的眼球运动，既有同向运动，又有反向运动[63, 64]。颞叶后部与枕叶交界的新皮层发作有时不仅出现视觉先兆，还可以出现失语等其他症状。明确的躯体基本感觉异常与顶叶感觉皮质间有很强的定位关系，可作为顶叶尤其是累及中央后回的癫痫灶的重要证据。但是，一些与顶叶发作有关的其他症状相对少见且定位比较困难，包括：双侧感觉异常、体像障碍、躯体失认、眩晕等[65]。部分患者的癫痫灶范围较大，可能同时累及颞后、顶叶、枕叶中的 2 个或 3 个部位。因此，临床所见的癫痫发作起始症状中可能混杂有后皮层不同脑叶的症状特点。
5.9.2.2 影像学
SHENJINGYINGXIANGXUEJIANCHAZAIHOUPICENGDIANXIANDEDINGWEIZHONGJUYOUFEICHANGZHONGYAODEZUOYONG，YOUQISHI MRI XIANSHIBINGZAOCHANGQIANGLIETISHIDIANXIANZAODEWEIZHI。FCD、RUANHUAZAO、DUOXIAONAOHUIJIXING、ZHONGLIUDENGSHICHANGJIANDEYINGXIANGXUEGAIBIAN，SHOUSHUYECHANGXUYAOQIECHUZHEIXIEBINGBIAN。DUIYU MRI YINXINGBIAOXIANDEHUANZHE，DIANXIANZAODINGWEICHANGCHANGSHIFENKUNNAN，XUYAOZIXIFENXIFAZUOZHENGZHUANGXUEBIAOXIAN，YOUQISHIXIANZHAOBIAOXIAN，JINXINGDINGWEIFENXI。XUYAOTEBIEQIANGDIAODESHI，HOUPICENGDIANXIANFAZUOQIZHENGZHUANGKENENGSHIYOUYUFANGDIANKUOBUZHIEYEHUONIEYEHOUCHUXIANDE，HENRONGYIWUDAOWEIEYE、NIEYEDIANXIAN。QITAYINGXIANGXUEJIANCHA，RU PET、SPECT、MEG DENGJIANCHADUIHOUPICENGDIANXIANZAODEDINGWEIYEJUYOUZHONGYAOTISHIZUOYONG，CHANGZUOWEI MRI JIEGUODEYOUYIBUCHONG，ERDUIYU MRI YINXINGDEHUANZHE，ZHEIXIEFUZHUJIANCHADEYANGXINGFAXIANKENENGSHIDIANXIANZAODINGWEIDEZHONGYAOTISHI。YINGYONG VBM HEQITAYINGXIANGHOUCHULIFENXIFANGFASUODEDEYANGXINGFAXIANYEKENENGDUIDIANXIANZAODINGWEIJUYOUTISHIZUOYONG。
5.9.2.3 颅内电极定位
YOUYUHOUPICENGDIANXIANZAODINGWEIKUNNAN，SHOUSHUQIECHUFANWEIBUYIQUEDING，YOUSHEJIYUNDONG、GANJUE、YUYAN、SHIJUE、RENZHIDENGZHONGYAOGONGNENGQU，YINCI，SHOUSHUZHILIAOSHIYIXIANGTIAOZHAN。ZAIFEIJUXIAN MRI BINGZAOXIANGGUANHOUPICENGDIANXIANDESHUQIANPINGGUZHONG，YINGYONGLUNEIDIANJIJILUCHANGCHANGSHIBIXUDESHOUDUAN。KEYIYONGLAIQUEDINGFAZUOQISHIDECEBIE、DIANXIANZAODEWEIZHIHEFANWEI，ZHIDINGSHIYIDESHOUSHUQIECHUJIHUA。DANGDIANXIANZAOWEIYUYUNDONG、GANJUE、YUYANDENGZHONGYAOGONGNENGQUFUJINSHI，HAIXUYAOLIYONGLUNEIDIANJIJINXINGPICENGDIANCIJIZHITU，DINGWEIGONGNENGQUDEJINGQUEWEIZHI。GEXIANGSHUQIANPINGGUSHOUDUANDEDAODEXINXIKEYIZUOWEILUNEIDIANJIZHIRUFANGANDEYIJU，BINGYICIXUANZEYINGYONGYINGMOXIAPICENGDIANJIHUO SEEG DIANJI。
5.10 幼小儿童患者术前评估策略
ILAE XIASHUDIANXIANWAIKEZUWEIHUIYU 1998 NIANCHENGLIERTONGDIANXIANWAIKEFENHUI，ZHESHOUZHIDINGTUIJIANERTONGDIANXIANHUANZHESHOUSHUZHILIAODESHIYINGZHENGBINGTANTAOHETUIGUANGZHENGGUIDESHUQIANPINGGUFANGFA。KEJIANERTONGDIANXIANWAIKEYUCHENGRENZHIJIANDEJUDACHABIE。
5.10.1 儿童难治性癫痫术前评估与成人之间的主要区别及特点
SHOUSHUMUDEBUTONG，YINERXUANZESHOUSHUDESHIYINGZHENGJISHIJIBUTONG：CHENGRENNANZHIXINGDIANXIANSHOUSHUZHILIAODEZHUYAOMUDESHISHIHUANZHEFAZUOXIAOSHICONGERNENGZHONGXINRONGRUSHEHUI，DULISHENGHUO、JIEHUN、JIUYE。ERERTONGSHOUSHUDEZHUYAOMUDEZAIYUXIAOCHUFAZUO，SHIHUANERSHENJINGXITONGJIRENZHIDENGFAYUGUOCHENGBUSHOUPINFANFAZUODEYINGXIANG，CONGERKEYIZHONGXINZOUSHANGZHENGCHANGDEFAYUZHENGGUI。DUIYUSHIHESHOUSHUDEHUANZHEYINGJINZAOSHOUSHUZHILIAO。
DILINGDIANXIANHUANERWAIKESHOUSHUFENGXIANGAO，SHOUSHUSHIJIYINGZIXIQUANHENG：SUIRANSHOUSHUZHILIAOYUEZAOYUEJISHIYUEHAO，DANZAOQIDIANXIANSHOUSHU，TEBIESHIZAIYINGYOUERQI，NAOWAIKESHOUSHUYAOCHENGDANGENGDADEFENGXIAN。JIANYICILEISHOUSHUYINGZAIJIBIEZUIGAODEDIANXIANZHONGXINNEIYOUSHENJINGNEIKEJISHENJINGWAIKEYISHENGGONGTONGPINGGUKAIZHAN。
DIANXIANHUANERSHUHOUDEKANGFUNENGLIQIANG。YOUYUERTONGSHENJINGXITONGJUYOUHENQIANGDEKESUXING，YUCHENGRENDIANXIANSHUHOUDEHUIFUNENGLIJIERANBUTONG，JUYOUHENDADEYOUSHI。ZAISHUQIANPINGGUSHI，YINGGENJUHUANERDENIANLINGJINSHENKAOLVGONGNENGSANGSHIYUFAZUOYUHOUDEGUANXI，ZHIDINGHELIDESHOUSHUJIHUA。
5.10.2 儿童难治性癫痫术前评估的主要内容
5.10.2.1 癫痫病因的判断
儿童难治性癫痫的主要致病因素很多，且有些仅在儿童期间才出现。针对患儿，虽然都是难治性局灶性癫痫，病因不同预后会非常不同。例如 Dravet 综合征的患儿，虽然发作起始非常局限，但切除性手术的预后非常不好。另一方面，如果癫痫为年龄相关的综合征，即使发作难以控制，也绝对不是手术的适应证。因此，明确患儿所患癫痫的病因及远期预后对于评估患儿能否手术至关重要[66]。
5.10.2.2 难治性癫痫的诊断
ZAOCHENGERTONGNANZHIXINGDIANXIANDEBINGYINFEICHANGDUO，PANDUANHUANERSHIFOUHUIFAZHANWEINANZHIXINGDIANXIAN，KEYISHIbbinXINTIYUYOUXUANJINZAOCAIQUSHOUSHUZHILIAO，YIMIANMANGMUSHIYONGDUOZHONG AEDs CONGERYANWUZHILIAOSHIJI。LIRU FCD HUANER，ZUIZHONGFAZHANWEIYAOWUNANZHIXINGDIANXIANDEKENENGXINGJIDA，WANQUANQIECHUSHOUSHUXIAOGUOHAO，JISHIFAZUOCHENGDUMEIYOUDADAONANZHIXINGDIANXIAN，YEYINGJINZAOSHOUSHUPINGGU。
5.10.2.3 儿童癫痫外科术前评估主要检查手段
① BINGSHIJISHENJINGXITONGCHATI：HUANERBINGSHIFEICHANGZHONGYAO，BUJINKEYITISHIDIANXIANDEBINGYIN、BINGLIJICHU，DUIPANDUANDIANXIANZAOBUWEIJISHOUSHUYUHOUYEFEICHANGZHONGYAO；② ZHANGCHENG VEEG JIANCE：ZHANGCHENG VEEG ZAISHUQIANPINGGUDINGWEIDIANXIANZAOZHONGSHIZHONGZHONGZHIZHONG，DUIYUZHENGZHUANGXUEDEFENXISUIRANZHONGYAO，DANJINYOUSHAOSHUHUANERKEYIMINGQUEQICUNZAIXIANZHAO，FAZUOGUOCHENGZHONGDEYISHIQINGKUANGYETONGYANGNANYIHUODE。ERTONGJUZAOXINGDIANXIANCHUXIANJUZAOXINGZHITIYUNDONGZHENGZHUANGDEBILIHENSHAO，XIANGFANCHANGHUIBIAOXIANCHUQUANMIANXINGDIANXIANDEZHENGZHUANG。YINCI，ZHIYIKAOZHENGZHUANGXUEPANDUANDIANXIANFAZUODEXINGZHIBINGJINXINGDINGWEI、DINGCEDIANXIANZAOFEICHANGKUNNAN。ZHANGCHENG VEEG ZHONGDEXINXIJIUFEICHANGZHONGYAO，ERTONGDIANXIANYUCHENGRENYOUZHEFEICHANGBUTONGDETEDIAN。SHOUXIAN，ZAICINIANLINGDUAN，TONGGUO EEG JIANBIEQUANMIANYUJUZAOXINGDIANXIANJUYOUHENDADETIAOZHANXING。QICI，ERTONGSHENJINGXITONGZHENGCHUYUFAYUJIEDUAN，HENNANKANDAOCHENGRENJUZAOXINGDIANXIANZHONGDEJUXIANXINGJIBO、JIMANBO。DANSHI，bbinXINTIYUYOUXUANKETONGGUOYIXIEERTONGTEYOUDEYICHANGFANGDIANXINGSHIJINXINGPANDUAN。FAZUOQI EEG KEBIAOXIANWEIFAZUOQISHIJUZAOXINGDIANYADIHUOSHUANGCE EEG BUDUICHENG。YOUXIEDIANXIANHUANER，SUIRANSHUQIANPINGGUZHONGWULUNCONGZHENGZHUANGHAISHI EEG SHANGKANDOUTISHISHIQUANMIANXINGFAZUO，RUSHIZHANGLIFAZUO，YINGERJINGLUANJIBUDIANXINGSHISHENFAZUODENG，DANYINGXIANGXUECUNZAIJUZAOXINGBINGBIAN，TONGYANGTISHIHUANERKENENGWEIJUZAOXINGQIYUAN，KEYISHOUYIYUSHOUSHUZHILIAO。ZHANGCHENGLUNEIDIANJIMAIZHIDINGWEIDIANXIANZAOZAIMUQIANCHENGRENNANZHIXINGDIANXIANSHOUSHUZHILIAOZHONGYINGYONGGUANGFAN，RANERDUIHUANERLAIJIANGQINGKUANGYAOFUZADEDUO。DUI<3 SUIDIANXIANHUANERSHISHIZHANGCHENGLUNEIDIANJIMAIZHIYINGFEICHANGSHENZHONG。YINWEICHUANGSHANGDA，SHIJIANZHANG，XUYAO 2 CISHENJINGWAIKESHOUSHU，DUIQUANSHENXITONGZHUANGKUANGDEYAOQIUFEICHANGGAO，SHOUSHUCHUXIANBINGFAZHENGDEJILVGAO；DUIYUGONGNENGQUDEPANDUANKEYICAIYONGYIXIESHUZHONGJIANCELAIMIBUSHANGSHUBUZU；③ YINGXIANGXUEJIANCHA：DUIYUZHENDUANDIANXIANZONGHEZHENG、DINGWEIDIANXIANZAOZHIGUANZHONGYAO。YOUQIZAIERTONGDIANXIANWAIKEZHONGGENGXIANDEYOUWEIZHONGYAO。HENDUOTISHIHUANERWEIJUZAOXINGDIANXIANDEWEIYIZHENGJUJIUSHI MRI ZHONGCUNZAIMINGQUEBINGZAO，RANER<1 SUIHUANER MRI DEZHENGQUEYUEDUJUYOUNANDU。ERTONGNANZHIXINGDIANXIANZHIXIANBINGZAOYOUQITUCHUDETEDIAN。ERTONGZHONGLIUXINGZHIXIANBINGZAODUOWEILIANGXINGFAYUXINGZHONGLIU，MINGQUEZHENDUANHOUSHOUSHUXIAOGUOHAO。FCD SHIERTONGJUZAOXINGDIANXIANZUICHANGJIANDEYUANYIN，DANYOUSHIHUIFEICHANGNANYISHIBIE。MRI ZHONG FLAIR CHENGXIANGDUI FCD DEPANDUANFEICHANGYOUBANGZHU，YINGZUOWEIBIXUDEJIANCHAXIANGMU。ERTONG FCD DELINGYIGETEDIANJIUSHIQIYICHANGFANWEIFEICHANGGUANGFAN，ZHIYOUCHEDIQIECHUFAYUYICHANGDENAOZUZHIFANGKESHIFAZUOCHEDIXIAOSHI，YINCIYOUSHIXUYIDINGCHENGDUXISHENGMOUXIEZHONGYAOSHENJINGGONGNENG。JIEJIEXINGYINGHUAZAIERTONGWANGUXINGDIANXIANZHONGHENCHANGJIAN，SUIRANCUNZAIQUANNAODUOFAJIEJIE，DANDUOSHUHUANERDECHANGGUIFAZUOSHIYOUDANYIZHIXIANJIEJIESUOYINQI，SHOUSHUCHEDIQIECHUHOUXIAOGUOHUIFEICHANGHAO。FAZUOJIANQI PET JIFAZUOQI SPECT DUIWUBINGZAOXINGERTONGDIANXIANJUYOUZHONGYAOZUOYONG，RANERZAIFENXIJIANCHAJIEGUOSHIXUYAOZHUYIYIXIAWENTI：YOUYUPINFANFAZUOXIANXIANGZAIERTONGDIANXIANZHONGHENCHANGJIAN，TONGSHIHAICUNZAIHENDUOLINCHUANGXIAFAZUO，YINGZHUYIJIANBIEJIEGUOSHIFOUWEIZHENZHENGDEFAZUOJIANQI PET；ERTONGHUANZHEDUOSHUSHINIEYEWAIDIANXIAN，FAZUOQI SPECT DUIYUCILEIDIANXIANZAODINGWEIKEYIQIDAOZHONGYAODEBUCHONGZUOYONG。DANERTONGDIANXIANFAZUODUOQISHIXUNSU，QIEWUFAPANDUANXIANZHAO，YAODEDAOZHENZHENGDEFAZUOQIJIEGUOFEICHANGKUNNAN。CHUSHANGSHUYINGXIANGXUEJIANCHAWAI，CHENGRENDIANXIANZHONGBOPUFENXI、MEG JI fMRI DENGZAILINCHUANGSHANGJUNYOUBEIYONGYUSHUQIANPINGGUDEBAODAO，RANERYOUYUERTONGPEIHEXINGCHA、TOUWEIXIAODENGTEDIAN，LINCHUANGSHANGSHISHIJIAOWEIKUNNAN；④ SHENJINGXINLIJIANCHA：ZAISHUQIANPINGGUZHONGBEIYONGYUPANDUANHUANERYUYANJIFEIYUYANJIYIGONGNENG、GAOJIZHILIHUODONGQINGKUANG、YOUSHIBANQIUCEBIEYIJISHUQIANSHUHOUZAICIFANGMIANDEBIANHUA；YOUYUPEIHENENGLIWENTI，DUIYU>5 SUIHUANERYINGYONGDEKENENGXINGJIAODA，ERDILINGERTONG，SHUQIANYINGCAIYONGERTONGFAYUPINGGULIANGBIAODUIHUANERBAOKUOYUNDONG、YUYANDENGGEGEFANGMIANJINXINGPINGGU。ZHEIDUIYUSHOUSHUSHIYINGZHENGJISHOUSHUXIAOGUOPINGJIAYIYIZHONGDA。
ZONGZHI，DILINGERTONGNANZHIXINGDIANXIANSHUQIANPINGGUYUCHENGRENSHUQIANPINGGUYOUHENDADEQUBIE，LINCHUANGSHANGYINGJIYUZUGOUZHONGSHI。
WENZHANGGONGXIANFENBU（PAIMINGANXINGSHIPINYIN）
ZONGCEHUA：WANGYUPING
GUWEN：DENGYANCHUN、FUXIANMING、HONGZHEN、JIANGYUWU、LISHICHUO、LIAOWEIPING、LIUXIAOYAN、LUANGUOMING、QINJIONG、WANGXUEFENG、WANGYI、WULIWEN、WUXUN、XIAOBO、ZHANGJIANGUO、ZHOUDONG、ZHOULIEMIN
ZHIBI：CAILIXIN、CHENJIA、CHENQIAN、CHENSHUHUA、GUANYUGUANG、JINLIRI、LIYUNLIN、LIANGSHULI、LINHUA、LINYICONG、LIUAIHUA、RENLIANKUN、SHAOXIAOQIU、WANGXIANGQING、WANGXUEYUAN、WANGYUPING、XUCUIPING、YANGDONGJU、YUTAO、ZHANGKAI、ZHANGXIATING、ZHOUJIAN
