Přínos jednotlivých intraoperačních elektrofyziologických metod u dětských epileptochirurgických pacientů

• Název práce v češtině: Přínos jednotlivých intraoperačních elektrofyziologických metod u dětských epileptochirurgických pacientů
• Název v anglickém jazyce: A practical value of different intraoperative electrophysiological methods in pediatric epilepsy surgery patients
• Klíčová slova: intraoperační elektrofyziologické metody, elektrokortikografie (ECoG), elektrického stimulačního mapování (ESM), motorické evokované potenciály (MEP), farmakorezistentní epilepsie (FRE), resekční epileptochirurgie, dětská epileptochirurgie, malformace kortikálního vývoje (MCD) vývoje,
• Klíčová slova anglicky: intraoperative electrophysiology, electrocorticography (ECoG), electrical stimulation mapping (ESM), motor-evoked potential (MEP), intractable epilepsy, resective epilepsy surgery, pediatric epilepsy surgery, malformations of cortical development (MCD) development, Cognitive outcome, Long-term epilepsy-associated tumours
• Akademický rok vypsání: 2011/2012
• Typ práce: disertační práce
• Jazyk práce: čeština
• Ústav: Klinika dětské neurologie (13-441)
• Vedoucí / školitel: prof. MUDr. Pavel Kršek, Ph.D.
• Řešitel: skrytý - zadáno a potvrzeno stud. odd.
• Datum přihlášení: 30.09.2014
• Datum zadání: 30.09.2014
• Datum potvrzení stud. oddělením: 30.09.2014
• Datum a čas obhajoby: 31.08.2020 15:30
• Datum odevzdání elektronické podoby: 28.05.2020
• Datum odevzdání tištěné podoby: 29.05.2020
• Datum proběhlé obhajoby: 31.08.2020
• Oponenti: prof. MUDr. David Netuka, Ph.D.
• Konzultanti: doc. MUDr. Michal Tichý, CSc.

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Předběžná náplň práce

ABSTRAKT
Epilepsie, jako nejčastější chronické neurologické onemocnění, postihuje významnou část populace (0,5–1 %). Farmakorezistentní epilepsie má u dětí významně negativní vliv na kvalitu života, rozvoj psychiatrických komorbidit, neurokognitivní výkonnost a přináší i riziko náhlého úmrtí. Resekční epileptochirurgie, která představuje jedinou kurativní léčbu tohoto onemocnění, může zásadně zvrátit nepříznivou životní prognózu pacientů. Předpokladem dobrého pooperačního výsledku je kompletní odstranění epileptogenní zóny (EZ) a zachování funkčně významných elokventních oblastí (EC).
Cílem této postgraduální práce je posoudit přínos jednotlivých intraoperačních elektrofyziologických (iEF) metod u dětských epileptochirurgických pacientů.
V první studii jsme zhodnotili význam intraoperační elektrokortikografie (iECoG) při určení rozsahu resekce i predikci výsledků operace. Současně jsme prokázali, že modifikace operačního plánu na základě iECoG nepředstavuje zvýšené riziko významných komplikací.
Druhá studie hodnotí přínos intraoperačního elektrického stimulačního mapování (ESM) a monitorace motorických evokovaných potenciálů (MEP) při lokalizaci a následném sledování funkce motorického elokventního kortexu a pyramidové dráhy. Studie prokázala, že nový ESM protokol, vypracovaný v našem centru, představuje spolehlivou metodu, která se osvědčila v celém věkovém i etiologickém spektru dětských epileptochirurgických pacientů v prevenci vzniku a predikci výskytu pooperačních motorických deficitů.
Ve třetí studii jsme posoudili význam iEF technik v kontextu současných trendů chirurgické léčby epilepsie u dětí. Zjistili jsme, že význam těchto metod roste. Je to dáno měnícím se spektrem pacientů, jakož i optimalizací iEF protokolů. Ty nám umožňují úspěšně operovat i mnohem složitější pacienty se stabilními výsledky a to jak z pohledu kontroly záchvatů a výskytu pooperačních komplikací, tak i z pohledu neurokognitivní výkonnosti (studie č. 4).
Závěrem lze říct, že metody iEF monitorování představují účinné a bezpečné techniky umožňující intraoperační identifikaci a ohraničení epileptogenní zóny a motorických elokventních oblastí (kůry a dráhy). To zvyšuje pravděpodobnost kompletní resekce epileptogenní zóny a významně snižuje riziko pooperačních deficitů. Přitom ovšem nelze opomenout, že představují pouze část komplexní diagnostiky a péče o epileptochirurgické pacienty.

Předběžná náplň práce v anglickém jazyce

ABSTRACT
Epilepsy, as the most common chronic neurological disease, affects a significant part of population (0.5–1%). Drug resistant epilepsy has a significant negative effect on the quality of life, psychiatric comorbidities, neurocognitive performance and the risk of SUDEP in children. Therefore, resective epilepsy surgery, the only curative treatment of this condition, can fundamentally reverse this unfavorable prognosis. An inevitable prerequisite for a good postoperative result is complete removal of the epileptogenic zone (EC) and preservation of eloquent areas (EC). At present, even with improving and new preoperative non-invasive methods, we don't have an exclusive diagnostic method for theirs delineation.
The aim of this PhD study is to assess benefit of individual intraoperative electrophysiological (iEF) methods in pediatric patients with focal intractable epilepsy.
The first study evaluates the importance of intraoperative electrocorticography (iECoG) in the localization of EZ. The study proved that iECoG serves as a reliable tool to guide surgical resection and may predict results of epilepsy surgery. iECoG-based modification of surgical plan is not associated with increased risk of significant complications.
The second presented study analyzed the contribution of intraoperative electrical stimulation mapping (ESM) and motor evoked potential (MEP) monitoring in the localization and subsequent monitoring of motor eloquent cortex and pyramidal pathway. The study showed that new ESM protocol developed at our center represents a reliable method for preventing and predicting postoperative motor deficits in entire age and etiological spectrum of children undergoing resective epilepsy surgery proximal to eloquent motor regions.
In the third study, we assessed value of iEF techniques in the context of current trends of epilepsy surgery in children. The importance of these methods is growing. This is due to the changing spectrum of patients, as well as the optimization of iEF protocols. They represent an important factor that allow us to successfully cure more complex patients with stable long term results in terms of seizure control, postoperative complications and neurocognitive performance (4th study).
In conclusion, iEF monitoring methods represent effective and safe techniques leading to intraoperative identification and delineation of the epileptogenic zone and motor eloquent areas (cortex and pyramidal tract). This increases chance of achieving complete resection of the epileptogenic zone and significantly reduces the risk of postoperative neurological deficits. However, they are only a part of a complex diagnostic and treatment protocol of candidates of epilepsy surgery in childhood.