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Invasive Stimulationsverfahren und EEG-Diagnostik bei Epilepsien

Invasive stimulation procedures and EEG diagnostics in epilepsy

  • Leitthema
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Zusammenfassung

Eine Epilepsiebehandlung durch Stimulation wurde experimentell und in kleinen Fallserien bereits seit den 1970er Jahren durchgeführt. Seit Einführung der Vagusnervstimulation 1997 und intrakranieller Stimulationsverfahren seit 2011 in die klinische Patientenversorgung stellt die invasive Stimulationsbehandlung eine sich rasch entwickelnde, wenngleich zahlenmäßig in Europa noch nicht stark genutzte Behandlungsoption dar. Während die Vagusnervstimulation vor allem in den USA häufig eingesetzt wird, sind intrakranielle Stimulationsverfahren regional unterschiedlich verfügbar. Um die Effektivität der Stimulationsverfahren sowie Kriterien zur Indikationsstellung weiterzuentwickeln und eine geringe Komplikationsrate zu sichern, ist insbesondere bei den intrakraniellen Stimulationen eine Konzentration auf operativ erfahrene Zentren und eine multizentrische Datensammlung und -evaluation erforderlich.

Invasive EEG-Ableitungen mit subduralen Platten- und Streifenelektroden und mehr noch mit stereotaktisch implantierten Tiefenelektroden werden in den letzten Jahren immer häufiger in der prächirurgischen Epilepsiediagnostik angewendet. Sie kommen zum Einsatz, wenn die epileptogene Zone und deren Ausdehnung durch nichtinvasive Verfahren nicht genau genug bestimmbar ist oder nicht sicher von eloquenten Kortexarealen abgegrenzt werden kann. Komplikationen umfassen intrakranielle Blutungen, Infektionen oder auch erhöhter Hirndruck. Allerdings sind überdauernde Defizite oder schwerere Komplikationen selten (≤2 %). Da invasive Ableitungen bei komplexeren Fällen zum Einsatz kommen, bleibt das postoperative Anfallsoutcome hinter dem Outcome derjenigen Fälle zurück, deren noninvasive Diagnostik bereits eine klare Resektionsstrategie erkennen lässt. Es liegt aber bei weitem über der Anfallsfreiheitsrate, die durch eine alleinige weitere Therapie mit Antikonvulsiva erreicht werden würde.

Abstract

Stimulation has been performed experimentally and in small case series to treat epilepsy since the 1970s. Since the introduction of vagus nerve stimulation in 1997 and intracranial stimulation methods in 2011 into patient care, invasive stimulation has become a rapidly developing but infrequently used therapeutic option in Europe. Whereas vagus nerve stimulation is frequently used, particularly in the USA, intracranial stimulation differs in its regional availability. In order to improve the efficacy of stimulation, develop criteria for its use and assure low complication rates, a concentration on experienced centers and multicenter data acquisition and sharing are needed.

Invasive electroencephalographic (EEG) monitoring with subdural electrodes and especially with stereotactically implanted depth electrodes have been used increasingly more often for presurgical evaluation in recent years. They are applied when non-invasive diagnostics show insufficient results to exactly identify the location and extent of the epileptogenic zone or cannot be adequately distinguished from eloquent cortex areas. Complications include intracranial hemorrhage, infections and increased intracranial pressure but lasting deficits or even death are rare (≤2 %). The outcome of invasive monitoring is inferior to non-invasive monitoring because of the higher degree of complexity of the cases; however, it is far superior to the seizure-free rates achieved by anticonvulsant drug treatment alone.

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Authors and Affiliations

  1. Epilepsiezentrum, Neurozentrum, Universitätsklinikum Freiburg, Breisacher Str. 64, 79106, Freiburg, Deutschland

    A. Schulze-Bonhage & M. Hirsch

  2. Epilepsiezentrum, Klinik für Neurologie, Universität Erlangen-Nürnberg, Erlangen, Deutschland

    H. M. Hamer & M. Hagge

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M. Hagge gibt an, dass kein Interessenkonflikt besteht. A. Schulze-Bonhage gibt an, Honorare für Referate oder Beratung seitens den Firmen Bial, Cerbomed, Cyberonics, Desitin, Eisai, Medtronic, Precisis und UCB erhalten zu haben. H. M. Hamer hat Honorare für Referate oder Manuskripte und/oder Unterstützungen für Fortbildungsveranstaltungen erhalten von Ad-Tech, Desitin, Eisai, GSK, IQWiG, Hexal, Ingelheim Boehringer, Nihon Kohden, Novartis, Pfizer und UCB Pharma sowie von den Universitäten Essen, Hamburg, Hannover, Marburg, München und Saarbrücken. Darüber hinaus hat er für Beratungen der Firmen Cerbomed, Desitin, Eisai, GSK, Pfizer und UCB Pharma Honorare erhalten. Er erhielt Unterstützung für Forschungsvorhaben von Desitin, Janssen-Cilag, GSK und UCB Pharma. M. Hirsch hat Honorare für Referate von Fa. USC B erhalten.

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Schulze-Bonhage, A., Hamer, H.M., Hirsch, M. et al. Invasive Stimulationsverfahren und EEG-Diagnostik bei Epilepsien. Nervenarzt 87, 829–837 (2016). https://doi.org/10.1007/s00115-016-0159-0

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