RU2743833C1 - Method for surgical treatment of structural epilepsy in children - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to neurosurgery. Craniotomy is performed with dissecting a dura mater. Laparoscopic approach is performed. Omentum flap on the base with a gastroepiploid artery is cut out. Flap is removed from the peritoneal cavity and visual and dopplerographic assessment of vascularisation is performed. Flap is then dissected longitudinally between the vascular arcades until the length required for transplantation is achieved. Formed omentum flap is delivered in a subcutaneous tunnel through a craniotome defect on the convexital surface of the cerebral hemisphere. That is followed by excising the arachnoid membrane and altered brain tissues with simultaneous multiple subpial transections. Moved omentum is expanded, covered with a dapple flap and fixed to it with separate sutures. Bone fragment is fixed in the initial position with the transosseous sutures.

EFFECT: method enables the surgical treatment of structural epilepsy in infants, reducing the traumatism of the surgical intervention, higher clinical effectiveness ensured by reduced frequency of epileptic seizures, improved cognitive, sensory, motor and trophic functions in a child.

1 cl, 8 dwg, 1 ex

Description

The proposed invention relates to the field of medicine, namely to neurosurgery and can be used to treat epilepsy with organic brain damage in children.

It is known that symptomatic epilepsy in children occurs due to many reasons, namely: asphyxia during childbirth, vascular and infectious brain lesions, congenital heart defects and postnatal arterial hypotension and heart failure, cerebral strokes, with hemostatic disorders (hemorrhagic disease of the newborn in the form of hemorrhagic stroke, intraventricular hemorrhage), traumatic brain injury, Moya-Moya disease (Nikiforov A.S., Konovalov A.N., Gusev E.I. Clinical neurology. In three volumes. - T. III (part 2): Fundamentals neurosurgery / Under the editorship of A. N. Konovalov. - M .: JSC "Medicine" Publishing House, 2004. - S. 204-206).

Clinical manifestations of structural epilepsy in organic brain damage are manifested by convulsive paroxysms (myoclonic, complex partial and / or generalized tonic-clonic seizures) in combination with motor (hemiparesis, paraparesis, tetraparesis or cerebral palsy syndrome) and cognitive deficits, mental retardation (finger A.B., Shabalov N.P. Hypoxic-ischemic encephalopathy of newborns: a guide for doctors. - St. Petersburg: Peter, 2001. - S. 11-18).

Modern methods of neuroimaging (MSCT, MRI), during the intermediate and recovery periods of brain damage, reveal morphological changes in these patients in the form of focal and multifocal cerebral necrosis (cystic changes in the brain), peri-ventricular leukomalacia, gliosis, meningeal scars.

Correction of organic changes in the brain is carried out by both conservative and surgical methods of treatment - excision of the meningeal scar, drainage of cysts, functional hemispherotomy, multiple subpial transections; in case of severe circulatory disorders, direct arterial anastomoses and arteriopial synagismosis are performed.

A known method of surgical treatment of organic changes in the brain by carrying out multiple subpial transections. For this, a craniotomy is performed, the proposed zone of epileptiform activity is exposed, and subpial transections are performed under the control of an intraoperative EEG using a special knife. For this, after dissection of the dura mater and excision of the arachnoid membrane, electrocoagulation of the pial membrane is performed. For subpial resection, a knife is inserted in this place to a depth of 1.5 - 2.0 cm, due to the movement towards oneself across the gyrus, its intersection is carried out after 10 - 13 mm. In the projection of the gyrus, up to 15-20 transections are carried out, the total transection section includes the entire zone of pathological changes in the EEG signal. (Blount JP., Langburt W, Otsubo H, Chito-ku S, Ochi A, Weiss S et al. // Multiple subpial transections in the treatment of pediatric epilepsy. J. Neurosurg. / Volume 100 / September, 2004. - 118 -124).

The disadvantages of this method include the high risk of vascular disorders associated with damage to the cortical or pial vessels and the inability to control the perfusion of the affected cerebral hemisphere.

The closest in technical essence to the proposed is a method of surgical treatment of epilepsy, including transposition of the omentum to the brain (Rafael N., Mego R. Omental Transplantation for Epilepsy // J. Neurosurg./Volume.95/ September, 2001. P. 543- 544).

The known method is carried out in several stages: first, a laparotomy and omentum mobilization are performed; then the section of the omentum in the subcutaneous tunnel is moved to the damaged area of the brain; then craniotomy and dissection of the dura mater are performed; after that, the temporal lobe is resected; then the omentum in the subcutaneous tunnel, through the craniotomic defect, is moved to the infratemporal region to the anterior perforated plate and to the medial and lateral surfaces of the temporal lobe; the omentum is fixed with sutures to the meninges; the wound is sutured in layers.

The disadvantages of this method include the high trauma of the intervention due to the performance of laparotomy for cutting out the omentum flap and due to craniotomy with temporal lobectomy for transposition of the omentum to the basal surface of the temporal lobe. In addition, resection of the temporal lobe together with the pial and cortical vessels impairs the possibility of forming anastomoses between the vessels of the omentum and the brain.

Also, the disadvantages of the known method include the limitation of its use in young children, due to their age anatomical features - the size of the greater omentum required for its transposition onto the convexital surface of the brain.

The objective of the proposed technical solution is to develop a method for the surgical treatment of structural epilepsy in young children with organic brain damage.

The technical result of the proposed method is to increase the effectiveness of treatment by reducing the frequency of epileptic seizures, improving cognitive, sensory, motor and trophic functions in a child.

The technical result of the proposed method for the surgical treatment of structural epilepsy in children is achieved by the fact that the method includes access, mobilization and transposition of the omentum to the damaged area of the brain, performing craniotomy with dissection of the dura mater, moving the omentum in the subcutaneous tunnel through the craniotomic defect into the infratemporal region to the medial and lateral surface of the temporal lobe, its fixation with sutures to the meninges and layer-by-layer wound closure.

Distinctive techniques of the proposed method are that they carry out a laparoscopic approach, the omentum flap is cut out on the basis of the gastroepiploid artery, removed from the peritoneal cavity and a visual and Dopplerographic assessment of vascularization is carried out, after which the flap is dissected longitudinally between the vascular arcades until the length required for transplantation is reached,

Then the formed omentum flap is carried out in the subcutaneous tunnel through the craniotomic defect and brought out to the convexital surface of the cerebral hemisphere. After that, the arachnoid membrane and altered brain tissues are excised with simultaneous multiple subpial transections. The displaced omentum is straightened, closed with a flap of the dura mater and fixed to it with separate sutures. The bone fragment is fixed in its original position with transosseous sutures.

Comparative analysis with the prototype showed that the proposed method differs from the known by the above techniques and, therefore, meets the criterion of patentability "novelty".

The conducted patent research, as well as the analysis of scientific and medical information reflecting the existing level of treatment of chronic cerebral ischemia complicated by structural epilepsy in children, did not reveal technical solutions that have distinctive techniques of the proposed method.

The authors of the proposed method found that the longitudinal separation of the omentum strand between the vascular arcades allows to achieve the necessary elongation to ensure the possibility of its transposition into the brain. The authors of the proposed method found that the length of the formed omentum strand of 35 - 45 cm provides the possibility of its movement in the subcutaneous tunnel on the vascular pedicle to the trepanation window.

Cutting out the omentum flap on the base with the gastroepiploid artery allows you to preserve the great vessels and, thus, to ensure sufficient blood supply to the omentum strand.

Excision of the arachnoid membrane, cyst walls, multiple subpial transections provide a decrease in the frequency of convulsive paroxysms due to resection of the epileptogenic zone, and also create conditions for the formation of multiple synangismosis between the omentum and the brain parenchyma.

Straightening the displaced omentum, closing it with a flap of the dura mater and fixing it with separate sutures makes it possible for it to engraft in the brain parenchyma.

The location of the omentum along the entire length of the brain wound ensures the formation of encephaloomentosynagismosis, thereby preventing the formation of a meningeal scar.

The foregoing allows us to conclude that the proposed technical solution meets the criterion of "inventive step".

The method of surgical treatment of structural epilepsy in children against the background of chronic cerebral ischemia in pediatric patients constituting the claimed invention is intended for use in practical health care. The possibility of its implementation is confirmed by the methods and means described in the application, therefore, the claimed invention meets the condition of patentability "industrial applicability".

The proposed method is carried out as follows. After being anesthetized, the patient is supine and standard laparoscopy is performed. On the basis of the gastroepiploid artery, an omentum flap is cut out, its strand is removed from the peritoneal cavity. Visual and dopplerographic assessment of the omentum vascularization pattern is performed, after which it is dissected longitudinally between the vascular arcades while maintaining the great vessels. The dissection is carried out until the required length is reached.

Osteoplastic trepanation is performed in parallel with the release of the omentum. The dura mater is opened with a semi-oval incision with the base to the sagittal sinus. Throughout the wound, the arachnoid membrane is excised, intracerebral cysts are drained under EEG control, and multiple subpial transections are performed.

The omentum flap, after passing it in the subcutaneous tunnel and through the bone defect, is moved to the convexital surface of the cerebral hemisphere and fixed with separate sutures to the dura mater. A flap of the dura mater covers the displaced omentum and is sutured with separate sutures. The bone flap is fixed with separate transosseous sutures.

The essence of the proposed method is illustrated by a clinical example:

Patient F. At the age of 2.5 years was treated in January - February 2016 in the neurosurgical department of the OGAUZ GIMDKB with complaints of seizures of a tonic-clonic nature in the early morning hours, delayed motor and psychoverbal development.

Anamnesis of the disease: according to the mother, at the age of 1 month of life he had pneumonia, mechanical ventilation for 7 days. At the age of 6 months, an examination was carried out at the OGAUZ GIMDKB - atrophic internal hydrocephalus (a consequence of an acute intrapartum trauma). Compensation, chronic subdural hematohydromas are more on the left. Cystic subcortical leukomalacia of the left hemisphere of the brain. Spasmodic quadriparesis, harsher in hands. GMFCS scale - 3 level. Cerebral palsy risk. Structural epilepsy in the form of focal and bilaterally synchronous myoclonic serial seizures, an onset period, pharmacoresistant course.

Life history: Child from 2nd pregnancy, 2 births. Childbirth at 40 weeks. Birth weight - 3850 g, height - 53 cm. Estimation on the Apgar scale 8-9 points. Applied to the chest for 1 day. Discharged from the hospital on the 4th day, diagnosis: Period-stress reaction. In the first year of life, observation of a neurologist with a diagnosis of P91, G91. Past diseases: ARVI are rare. Vaccination was carried out according to an individual schedule. No allergic reactions were noted.

Objectively at the time of examination: the state of moderate severity, clear consciousness. Calm reaction on examination. The state of health does not suffer, the position is active, the correct physique, sufficient nutrition. The chest evenly participates in the act of breathing, auscultatory vesicular breathing, no wheezing. Percussion sound is clear. The cardiac region is not changed, the auscultatory tones are pure rhythmic, there are no murmurs, the percussion borders of cardiac dullness correspond to the age norm. The tongue is clean and moist. The abdomen on examination is soft, painless, the liver does not come out from under the edge of the costal arch, the spleen is not enlarged. The tapping symptom is negative. Stool and urine output are not disturbed.

Neurological status: Dolichocephalic skull. Assessment of the cranial nerves: there is an intermittent divergent squint on the right, other cranial nerves are intact. Increased muscle tone in the pyramidal type in the flexors of the arms and extensors of the legs. When supported, a cross of the lower limbs is noted in the middle third of the thigh. Pronatory setting of the right hand. The level of spasticity on the Ashworth scale is 3 points on the left and 2 points on the right. The strength of the hands on the left and on the right is 2 points; from the feet on the left 2 points, on the right 3 points. Deep tendon reflexes from the arms S more than D, from the legs S more D. The abdominal is alive. Pathological reflexes are triggered spontaneously. The child does not walk, does not sit down on his own, does not get up, speaks, only individual words, reacts to the addressed speech, play activity is presented. Vegetative sphere: dermographism is red, persistent, hyperhidrosis in the distal extremities.

Survey performed:

MRI of the brain from 01/28/2016. Conclusion: Atrophic internal and external hydrocephalus (a consequence of acute intrapartum trauma). Cystic subcortical leukomalacia of the left cerebral hemisphere (Fig. 1, A - axial, B - sagittal sections).

EEG from 01/25/2016 Conclusion: Regional generalized epileptiform activity is registered, an acute-slow wave, in amplitude exceeding the level of the background recording with an emphasis on the frontal leads of the right hemisphere.

Oculist from 25.01.2016 Conclusion: The fundus of the eye is without pathology.

02/01/2016 - MSCT of the brain with angiography of cerebral vessels. Conclusion: There is a depletion of the vessels of the left hemisphere cortex.

Operation 02/03/2016: Revascularization of the ischemic region of the brain using an omentum on a vascular pedicle, multiple subpial transections.

Laparoscopy - (pneumoperitoneum, pressure 10 mm Hg) under endotracheal anesthesia with the patient in the supine position, three trocars (5 mm) were inserted into the abdominal cavity. With the help of coagulation, the separation of the greater omentum from the tape of the transverse colon was performed. Further, the immobilization of the omentum was continued from the hilum of the spleen and from the greater curvature of the stomach with the intersection of art.gastroepiploica sinistra. A strand is formed, consisting of a large omentum, feeding on art.gastroepiploica dextra. The length of the omentum is equal to the distance from the navel to the upper edge of the parietal bone. In the epigastric region, a transverse incision was made up to 3 cm long, the tissues of the anterior abdominal wall were divorced, a strand of the omentum was removed from the peritoneal cavity. A visual and dopplerographic assessment of the omentum vascularization pattern was performed (Figs. 2, 3), after which its longitudinal dissection was made between the vascular arcades with the achievement of the required length - 35 cm. A semi-oval incision of soft tissues was made in the parieto-occipital region on the left, hemostasis, the periosteum was skeletonized, 2 milling holes were applied, a bone flap was formed and removed, in addition, infratemporal decompression was performed. Through a separate incision of soft tissues in the neck region, a conductor was passed into the epigastric region in the subcutaneous tunnel, along which the omentum was removed from the epigastral region to the neck region on the left. The dura mater was opened with a cruciform incision, the latter sharply thickened to 5-6 mm, with a mass of new small vessels on the ventral surface. The arachnoid membrane is dissected, ischemic areas of the brain are revealed, intracerebral cystic formations are identified (Fig. 4).

Performed electrocorticography and encephalotomy with excision of the walls of intracerebral cysts. Additionally, subpial transections were plotted in the zones of changes in the Eco-EEG signal. In the subcutaneous tunnel, the omentum is passed into the main wound and moved to the cerebral cortex (Fig. 5), fixed with separate sutures (prolene 7/0) to the dura mater. Guiding sutures on the dura mater. The bone flap was fixed with three separate sutures (Fig. 6). Layer-by-layer sutures on the aponeurosis and skin. Aseptic dressing.

The postoperative period was smooth, the sutures were removed on the 12th day. Epileptic seizures in the early postoperative period were not registered.

Routine examination of the patient in 6 months. The child's condition is stable. The child became more active emotionally, began to play with toys. There were small speech changes, more syllables appeared and began to pronounce individual words inconsistently. In motor terms, I began to sit longer with my legs down. Epileptic seizures were not observed 6 months after the operation. Performed MSCT angiography of the brain from 08.08.2016: the state after transposition of the omentum (Fig. 7). Signs of asymmetric external hydrocephalus, leukoencephalomalacia. In the soft tissues of the parieto-occipital region, a network of blood vessels can be traced (Fig. 8).

Routine examination of the patient in 14 months. Complaints about delayed motor and psychoverbal development. Neurological status: dolichocephalic skull, painless palpation, no limitation of movements in the cervical spine. Holds the head in the midline. From the side of the cranial nerves: intermittent divergent squint on the right. Difficulty swallowing solid food is noted. The functions of other cranial nerves are not impaired.

Motor sphere: Limitation of movement in the limbs due to increased muscle tone in the flexors of the arms and extensors of the legs. The strength of the hands on the left and on the right is 2 points; from feet - 2 points on the left, 3 points on the right. The level of spasticity on the Ashworth scale is 3 points on the left and 2 points on the right. Deep tendon reflexes from the arms S more than D, from the legs S more D. The abdominal is alive. Pathological reflexes are triggered spontaneously. The child does not walk, when supported with a cross in the middle third of the thigh, does not sit down on his own, does not get up, does not walk. Can do better left hand movements. The right hand is the pronator setting of the hand. There is no phrasal speech, speaks only individual words, reacts positively to addressed speech, game activity is presented. Pain sensitivity is not impaired. There are no pelvic abnormalities. There were no seizures on examination. Meningeal symptoms are negative. Vegetative sphere: dermographism is red, persistent, hyperhidrosis, acrocyanosis was not noted. The child is on polytherapy: valproate 375 mg / day and oxcarbazepine 600 mg / day. Control EEG from 03.08.2017 Conclusion: No epileptic activity was registered.

Conclusion: Structural epilepsy in the form of generalized propulsive and retropulsive seizures, tonic-clonic seizures. History of status. Pharmacoresistant course, period of remission. Atrophic internal hydrocephalus. Cystic subcortical leukomalacia of the left hemisphere of the brain. Cerebral palsy, double hemiplegia. Assessment of the severity of the child's movement disorders according to the GMFCS level V, MACS level V. Operation from 03.02.2016: Revascularization of the ischemic region of the brain using an omentum on a vascular pedicle, multiple subpial transections. Concomitant diagnosis: FRP. Acetonemic state. Dysfunction of the biliary tract.

Currently, the proposed method treated 3 children of early age (2.5 - 5.0 years) with structural epilepsy in the form of focal seizures against the background of severe hypoxic-ischemic encephalopathy that arose in the perinatal period.

When evaluating long-term results (12-24 months), all patients with severe neurological deficit and pronounced morphological changes in the brain showed an increase in strength by 0.5-1 point (on a 5-point scale) and a decrease in spasticity in the extremities by an average of 1 point on the Ashworth Scale. There was a decrease in the frequency of seizures by 50% or more in the pharmacoresistant course of epilepsy. Clinically significant changes in the cognitive sphere concerned most of all changes in the emergence of interest in surrounding objects, no significant dynamics from the side of speech and memory were noted. It is also necessary to note an improvement in emotional reactions in children with a predominance of positive ones, namely, the ability to smile.

Thus, the proposed method makes it possible to increase the effectiveness of treatment by improving cognitive, sensory, motor and trophic functions, stopping or reducing the frequency of epileptic seizures.

Claims (1)

A method of surgical treatment of structural epilepsy in children, including access, mobilization and transposition of the omentum to the damaged area of the brain, performing a craniotomy with dissection of the dura mater, moving the omentum in the subcutaneous tunnel through the craniotomy defect into the infratemporal region to the medial and lateral surfaces of the temporal lobe, its fixation sutures to the meninges and layer-by-layer suturing of the wound, characterized in that a laparoscopic approach is performed, the omentum flap is cut out on the basis of the gastroepiploid artery, removed from the peritoneal cavity and a visual and Dopplerographic assessment of vascularization is performed, then the flap is dissected longitudinally between the vascular arcades until the required length transplantation, after which the formed omentum flap is carried out in the subcutaneous tunnel through the craniotomic defect, brought out to the convexital surface of the cerebral hemisphere, after which the arachnoid membrane and altered brain tissue are excised from one belt multiple subpial transections, then the displaced omentum is straightened, closed with a flap of the dura mater and fixed to it with separate sutures, the bone fragment is fixed in its original position with transosseous sutures.

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