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迷走神经刺激疗法治疗癫痫

Authors
Steven Karceski, MD
Steven C Schachter, MD
Section Editor
Timothy A Pedley, MD
Deputy Editor
April F Eichler, MD, MPH
Translators
韩雁冰, 副主任医师

引言

癫痫患者的主要治疗方法是应用抗癫痫药(antiepileptic drug, AED)，但约1/3的癫痫患者用药时仍有癫痫发作[1]。对于癫痫发作不能由药物完全控制的这1/3患者，其癫痫发作被称为难治性或耐药性癫痫。难治性癫痫患者可尝试抗癫痫药物联合治疗。联合用药可能有助于减少癫痫发作总数，但多药治疗经常导致更多的副作用。当药物不足以控制癫痫发作时，医生经常会转而考虑非药物治疗选择，包括：癫痫外科手术、生酮饮食和迷走神经刺激器(vagus nerve stimulator, VNS)疗法。

1997年，美国食品药品监督管理局(Food and Drug Administration, FDA)批准VNS Therapy System™(Cyberonics股份有限公司)作为AED难治的部分性发作的辅助治疗，用于成人和12岁以上青少年患者。本专题将总结癫痫患者行VNS治疗的相关解剖学、可能的作用机制和临床结果。癫痫治疗的其他方面将单独讨论。 (参见“成人癫痫处理概述”和“耐药性癫痫的评估和治疗”)

解剖学与治疗机制

迷走神经由约20%传出纤维(将从脑部离开的信号发出的神经细胞)及80%传入纤维(将信号传向脑部的神经细胞)组成[2]。若对迷走神经施以电刺激，则所施加的刺激有80%将返回到迷走神经起源的脑干。电刺激施加在迷走神经(第Ⅹ对脑神经)神经元的轴突，迷走神经神经元的胞体在结状神经节和颈静脉神经节，于脑干的孤束核(nucleus of the solitary tract, NTS)形成双侧突触。迷走神经传入通路由NTS投射到脑部多个区域，包括脑桥核和中脑核、小脑、丘脑和皮层。简言之，施予其中一侧迷走神经的电流脉冲能传输到脑的两侧，到达脑的许多不同区域。

一条迷走神经通路(可能与癫痫治疗尤为相关)经桥脑臂旁核上升至前脑[3]。此通路将内脏起源的感觉传输到丘脑腹后小细胞核，再投射到岛叶皮层[4]。臂旁核还投射至其他丘脑核、杏仁核和基底前脑。迷走神经的这些投射传输到的部位常常被发现是发生癫痫发作的位置。因此，VNS可能起作用的一个途径是通过与癫痫生成区域的连接。

VNS可能发挥作用的另一途径则是通过蓝斑。蓝斑是另一个接收NTS传入的脑桥核。尽管蓝斑接收的迷走神经传入信号没有臂旁核的密，但蓝斑对VNS的抗癫痫作用可能是必不可少的，正如使用消融术和免疫标记技术的动物研究所表明的那样[5,6]。

             

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Literature review current through: 2017-06 . | This topic last updated: 2017-04-04.
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