联合应用经颅多普勒超声(TCD)及定量脑电图(qEEG)评估单侧大脑中动脉重度狭窄或闭塞者脑功能改变的临床价值

目的探讨联合应用经颅多普勒超声(transcranial doppler,TCD)及定量脑电图(quantitative electroencephalogram,qEEG)对单侧大脑中动脉(middle cerebral artery,MCA)重度狭窄或闭塞者脑功能改变的早期诊断价值。方法对2012年5月-2014年9月在吉林大学第一医院神经内科经TCD诊断单侧MCA重度狭窄或闭塞者74例,包括症状组45例及无症状组29例,及年龄性别匹配的健康对照组25例,应用联合了EEG及TCD的神经监护仪、核磁共振灌注成像(perfusion weight imaging,PWI)、美国国立卫生研究院卒中量表(national institute of health stroke scale,NIHSS)评分,分别比较MCA重度狭窄或闭塞侧与健侧脑区的qEEG相对波段功率(relative band power,RBP)、软脑膜侧支的血流动力学参数、脑灌注及神经功能缺损程度。结果与无症状组比较,症状组qEEG的δ波、θ波RBP值高,而α波RBP值低(P0.05)。症状组MCA分布区δ波RBP值狭窄侧较健侧高,α波、β波RBP值低(P0.01)。TCD显示MCA重度狭窄或闭塞侧大脑前动脉、大脑后动脉血流动力学的参数无症状组高于症状组(P0.05)。PWI显示CBF下降组δ波RBP值较CBF正常组高(P0.05)。症状组全脑区δ波RBP值与NIHSS分值呈正相关(r=0.83,P=0.000)。结论 qEEG的RBP参数是评估MCA重度狭窄或闭塞者脑缺血神经功能缺损的预测指标。TCD联合qEEG的神经血流监护仪是评估MCA狭窄神经元功能、侧支循环及脑组织灌注的新工具。     

经颅多普勒量化评估单侧颈内动脉重度狭窄或闭塞侧支循环的可行性

目的探讨经颅多普勒(TCD)量化评估单侧颈内动脉(ICA)重度狭窄或闭塞侧支循环的可行性。方法经多模式影像证实为单侧ICA重度狭窄或闭塞者145例,用TCD及DSA评估侧支循环,并行一致性检验。对结果一致的128例进一步行TCD侧支循环量化评分,设定前交通动脉(ACo A)开放3分、后交通动脉(PCo A)开放2分、眼动脉(OA)开放1分。将128例患者分症状组及无症状组,对两组侧支循环评分行受试者工作特征曲线(ROC)分析。以诊断最佳界值为截点分侧支循环不良组及良好组,比较两组患侧TCD及CT灌注(CTP)参数,并与Alberta卒中项目早期CT评分(ASPECTS)行相关性分析。结果 (1) TCD评估ACo A、PCo A、OA与DSA的一致性均极佳(Kappa值=0.879、0.787、0.770,P 0.05)。(2)症状组与无症状组侧支循环评分间差异具有显著性(P 0.05)。(3) TCD侧支循环评分3.5分为诊断最佳界值,敏感度为73.7%,特异度为84.4%。(4) TCD及CTP参数:侧支循环不良组患侧大脑中动脉的平均流速、基底节区及颞叶的脑血流量和脑血容量均明显低于侧支循环良好组,而平均通过时间和达峰时间较侧支循环良好组明显延长(均P 0.05)。(5) TCD侧支循环评分与ASPECTS呈高度正相关(r=0.767,P 0.05)。结论 TCD可以量化评估单侧ICA重度狭窄或闭塞病变的脑侧支循环,对临床诊疗具有指导意义。     

颈内动脉严重狭窄时脑部症状与Willis环侧支循环建立的关系

目的应用经颅超声多普勒(TCD)检测颈内动脉(ICA)严重狭窄,探讨Willis环的侧支循环与临床症状之间的相关性.方法分析34例ICA严重狭窄患者(其中有症状组16例和无症状组18例)侧支循环的类型、大脑中动脉(MCA)的平均血流速度(Vm)、脉动指数(PI)及频谱改变,并与30例正常人进行对照.结果存在3种侧支循环类型前交通动脉(ACOA)型,后交通动脉(PCOA)型,眼动脉(OA)型.无症状组的侧支循环中,ACOA型占88.9%,狭窄侧MCA Vm为59.1±8.7cm/s;有症状组ACOA型占50%,有4例未检出侧支循环,狭窄侧MCA Vm为48.6±7.3cm/s(P＜O.OO1).所有患者狭窄侧的MCA PI减低(p＜O.001),且频谱低平呈波浪状,波峰变钝,失去收缩峰的特征.结论TCD可以发现ICA严重狭窄患者Willis环侧支循环的显著异常改变,研究Willis环的侧支循环对ICA产重狭窄患者治疗和授后的判断其有重要的临床价值.     

大脑中动脉闭塞患者侧支循环与脑灌注研究

目的探讨大脑中动脉(MCA)闭塞患者脑侧支循环建立情况及其对脑灌注的影响。方法 46例单侧MCA闭塞患者,均行320排CT血管成像(CTA)联合CT灌注成像(CTP)检查,根据侧支循环分布状况分为侧支循环丰富组和侧支循环减少组,获取双侧MCA供血区的各项脑灌注参数值,即局部脑血流量(cerebral blood volume,CBV)、局部脑血容量(cerebral blood flood,CBF)、达峰时间(time to peak,TTP)及平均通过时间(mean transit time,MTT),用Rcbv、Rcbf、Rttp、Rmtt表示患侧与健侧各灌注参数的比值。对比分析健患两侧的脑灌注差异及两组患者脑灌注的不同。结果相比健侧,患侧MCA供血区TTP明显延长(P0.05),CBV、CBF略升高(P0.05),MTT略延长(P0.05)。侧支丰富组Rcbv、Rcbf均高于侧支减少组(P0.05),Rmtt低于侧支减少组(P0.05),Rttp高于侧支减少组(P0.05)。结论丰富的脑侧支循环可以有效地改善闭塞MCA远端缺血区脑组织的血流灌注。     

大面积脑梗死血管成像及血流动力学改变研究

目的 探讨大面积脑梗死颅内血管成像及血流动力学变化特点.方法 对39例大面积脑梗死患者在急性期进行颅脑MRI、MRA及TCD检查观察颅内血管成像及血流动力学变化情况.结果 39例大面积脑梗死患者中颈动脉闭塞7例,大脑中动脉闭塞17例,大脑中动脉狭窄及远端分支减少15例,大脑前动脉狭窄及闭塞5例,大脑后动脉狭窄3例,TCD显示大面积脑梗死病侧MCA Vm、ICA Vm明显低于对照组(P<0.05)和病灶对侧(P<0.05),双侧ACA Vm与对照组比较无显著差异:血管搏动指数和阻力指数(PI、RI)与对照组比较明显增大有显著差异(P<0.05).结论 大面积脑梗死患者MRA可直接了解颅内闭塞情况及狭窄程度,TCD可了解颅内血流动力学改变及血管阻力,从而了解梗死区血供情况,间接了解颅内压,为判断病情及预后提供参考.     

单侧大脑中动脉狭窄的脑磁共振灌注成像研究

目的探讨大脑中动脉(MCA)不同狭窄程度时的脑磁共振灌注加权成像(PWI)表现。方法对31例经DSA诊断为单侧MCA狭窄或闭塞患者行脑磁共振PWI检查,并对不同程度MCA狭窄状态下患侧和健侧大脑半球的脑灌注参数局部脑血流量(rCBF)、局部脑血容量(rCBV)、局部平均通过时间(rMTT)、局部达峰时间(rTTP)进行定量分析。结果31例患者中,DSA诊断单侧MCA轻中度狭窄14例,其中脑灌注异常11例;患侧大脑半球rTTP较健侧显著延长(P0.01)。MCA重度狭窄或闭塞17例,均出现异常灌注;患侧大脑半球rTTP较健侧显著延长(P0.01),而患侧rCBF较健侧明显减少(P0.05),患侧rMTT健侧亦显著延长(P0.05)。结论通过脑灌注成像参数综合分析,磁共振PWI能准确评估MCA狭窄程度和脑组织血供情况,可为脑缺血的临床诊断提供重要价值。     

颈内动脉狭窄性短暂性脑缺血发作的磁共振波谱研究

目的 利用磁共振波谱(1H magnetic resonance spectroscopy, 1H-MRS)探讨单侧颈内动脉(internal carotid artery, ICA)重度狭窄或闭塞性短暂性脑缺血发作(transient ischemic attack, TIA)的脑代谢改变.方法 28例经数字减影血管造影(digital subtraction angiography, DSA)证实为单侧ICA重度狭窄或闭塞性TIA患者,应用3.0T MRI行1H-MRS检查, 测量患侧和对侧大脑半球半卵圆中心的代谢物氮-乙酰天门冬氨酸(N-acetylaspartate, NAA)、胆碱(choline, Cho)、肌酸(creatine, Cr)的波峰下面积,比较两侧各代谢物峰下面积比值NAA/Cho、NAA/Cr和Cho/Cr的差异,并观察有无乳酸(lactate, Lac)峰.结果 28例单侧ICA重度狭窄或闭塞的TIA患者,1H-MRS显示患侧半卵圆中心的NAA/Cho、NAA/Cr比值显著低于病变对侧(P＜0.05),Cho/Cr比值显著高于病变对侧(P＜0.05),5例患者于患侧出现Lac峰.结论 1H-MRS能够早期发现ICA重度狭窄或闭塞性TIA患者的脑代谢异常, 对于早期治疗和判断预后具有重要价值.     

经颅多普勒超声结合二氧化碳试验评价颈内动脉狭窄患者的脑血管反应

目的:检测颈内动脉(intracranial artery,ICA)狭窄患者的脑血管反应性(CVR),探讨其狭窄程度与脑血管反应性之间的关系,以期为临床治疗及预防提供依据.方法:对不同程度ICA狭窄患者,采用德国DWL型经颅多普勒超声(TCD)检测仪,结合二氧化碳试验分别测得过度换气、吸入CO2气体、屏气后的大脑中动脉(MCA)的脑血流速度以计算CVR.结果:①病例组中ICA-MCA狭窄患者通过过度换气、吸入CO2气体、屏气后MCA的最大速度变化率、平均速度变化率均显著低于对照组(P＜0.05);②病例组轻、中、高度ICA狭窄或者闭塞ICA-MCA狭窄患者吸入CO2气体后各组MCA血流速度增加率依次减低,并且两两比较,P＜0.05,差异有显著意义.ICA-MCA狭窄患者由于血管狭窄、闭塞、血流受阻使CVR功能降低,狭窄程度越重,CVR功能越差,发生低灌注的危险性越大.结论:经颅多普勒超声检测CVR可行,可作为评估CVR的简便手段之一.     

微创手术对不同血肿量患者脑血流动力学的影响

目的观察不同血肿量患者手术治疗前后的经颅多普勒(TCD)参数变化, 探讨该手术对不同血量患者的治疗价值.方法以简易立体定向手术治疗46例脑出血患者, 以TCD术前、术后第3、 7 d动态检测大脑中动脉血流参数.结果血肿量愈大, 术前双侧MCA平均流速愈低, Ⅱ、Ⅲ、Ⅳ组不对称性改变, 患侧低于健侧(P＜0.05), 而Ⅰ组患者健、患侧差异无统计学意义(P=1.00); 血肿量大于30 ml组患者术前和术后第3 d的健侧与健侧比较、患侧与患侧比较差异无统计学意义(P＞0.05), 而Ⅰ组患者术前与术后第3、 7 d健、患侧MCA流速差异无统计学意义(P＞0.05);血肿量大于30 ml组患者术后第7 d健、患侧与术前比较差异有极显著性意义(P＜0.01).结论微创手术能有效地清除血肿, 改善脑灌注, 血肿愈大愈明显.     

蛛网膜下腔出血继发迟发性缺血性神经功能障碍患者TCD的动态观察

目的　研究蛛网膜下腔出血 (SAH)继发迟发性缺血性神经功能障碍 (DINDS)患者经颅多普勒(TCD)的动态变化。方法　应用TCD动态检查 2 3例SAH继发DINDS的患者 ,根据DINDS侧大脑中动脉(MCA)平均血流速度 (Vm)的改变分为流速增高组与流速正常组 ,并进行比较。结果　流速增高组DINDS侧MCA的Vm与脉动指数 (PI)均呈进行性增高并均高于对侧 (均P <0 0 1) ,且早于DINDS临床症状出现 (P <0 .0 1) ;流速正常组DINDS侧MCA的PI进行性增高并高于对侧 (P <0 0 1) ,同时Vm进行性减慢并低于对侧(P <0 0 1) ,早于DINDS临床症状出现 (P <0 .0 1)。结论　SAH继发迟发性脑血管痉挛 (DCVS)发生于脑底动脉 ,和其远端小动脉的TCD表现不同 ,两者的变化均早于临床症状出现。     

Factors associated with satisfaction with care among patients with epilepsy

OBJECTIVE: The purpose of the work described here was to determine those variables associated with satisfaction with care among patients with epilepsy. METHODS: We interviewed patients followed at a tertiary epilepsy center. Predictor variables included age, gender, race, education, income, insurance, seizure frequency, and Quality of Life in Epilepsy-10 inventory (QOLIE-10) results. Target variables were the subscales of the Short Form Patient Satisfaction Questionnaire (PSQ-18). We used univariate analysis to identify those variables significantly associated with the subscales and multiple linear regression to determine those independently significant. RESULTS: The study population comprised 193 patients. Lower education and better QOLIE-10 scores were independently associated with general satisfaction with care. The mental health scale was associated with general satisfaction with care. Lower educational level was the only variable independently associated with patient satisfaction with communication, the financial aspect of care, and time spent with physician. CONCLUSION: Lower educational level and better quality of life are the main variables associated with higher general satisfaction with care among patients with epilepsy.     

Treatment with rituximab in patients with polyneuropathy with anti-MAG antibodies

Journal of Neurology -     

Surgical Outcome in Patients with Epilepsy with Occult Vascular Malformations Treated with Lesionectomy

Summary: Purpose: This retrospective study reports the long-term surgical outcome of patients with medically refractory epilepsy and vascular malformations who were treated with lesionectomy. A detailed analysis of surgical failures had been performed in an attempt to define predictors of surgical success and failure.
Methods: Fifteen patients with medically intractable epilepsy and angiographically occult vascular malformations (AOVMs) were treated surgically with lesionectomy at Duke University Medical Center. Lesionectomy consisted of removal of the AOVM and surrounding hemosiderin-stained brain only, without the use of electrocorticography (ECoG) to guide resection.
Results: Eleven (73%) patients are seizure free after lesionectomy. Three showed no significant improvement, and one patient died, presumably after a seizure. Age of onset, duration of seizures, age at resection, and gender did not affect outcome. All patients with neocortical AOVMs in whom EEG findings correlated with the site of the lesion were seizure free after lesional resection. Treatment failures were associated with the presence of multiple intracranial lesions, poorly localized or diffuse EEG findings, discordant positron emission tomography (PET) imaging, or with a lesion in close proximity to the limbic system.
Conclusions: Lesionectomy, with removal of surrounding hemosiderin-stained brain, can be considered the procedure of choice in carefully selected patients with epilepsy with occult vascular malformations.     

Children with ADHD and motor dysfunction compared with children with ADHD only

The purpose of this study was to identify group differences in children with attention-deficit-hyperactivity disorder and motor dysfunction (ADHD-MD) and ADHD only, and to evaluate the medication responsiveness of ADHD-MD. Sixty-three children (49 males and 14 females; mean age 9 years 10 months, SD 2 years 10 months) underwent a triple blind, placebo-controlled crossover study evaluating two dose levels of methylphenidate (0.3 mg/kg and 0.5 mg/kg [corrected], twice daily) and placebo. Forty-nine trials were completed. Nineteen were children with ADHD-MD, 44 had ADHD only. Behavior and functioning were assessed at home and at school. Treatment effects were assessed using the Abbreviated Symptom Questionnaire for Parents and Teachers. Children with ADHD-MD were more likely to have severe ADHD-combined type and other neurodevelopmental and behavioral problems. Both groups of children had a linear dose response to medication (placebo, low, high) and there was no evidence of a group by dose interaction or an overall group effect at home or school. The lack of group effect suggests that these children responded to medication like the other subgroups.     

Valproate is associated with new-onset oligoamenorrhea with hyperandrogenism in women with bipolar disorder.

BACKGROUND: Preliminary evidence suggests that valproate is associated with isolated features of polycystic ovarian syndrome (PCOS), while contradictory data support an association between epilepsy and PCOS. The development of PCOS features after initiation of valproate was therefore examined in women with bipolar disorder using a standardized definition of PCOS. METHODS: Three hundred women 18 to 45 years old with bipolar disorder were evaluated for PCOS at 16 Systematic Treatment Enhancement for Bipolar Disorder sites. A comparison was made between the incidence of hyperandrogenism (hirsutism, acne, male-pattern alopecia, elevated androgens) with oligoamenorrhea that developed while taking valproate versus other anticonvulsants (lamotrigine, topiramate, gabapentin, carbamazepine, oxcarbazepine) and lithium. Medication and menstrual cycle histories were obtained, and hyperandrogenism was assessed. RESULTS: Among 230 women who could be evaluated, oligoamenorrhea with hyperandrogenism developed in 9 (10.5%) of 86 women on valproate and in 2 (1.4%) of 144 women on a nonvalproate anticonvulsant or lithium (relative risk 7.5, 95% confidence interval [CI] 1.7-34.1, p = .002). Oligoamenorrhea always began within 12 months of valproate use. CONCLUSIONS: Valproate is associated with new-onset oligoamenorrhea with hyperandrogenism. Monitoring for reproductive-endocrine abnormalities is important when starting and using valproate in reproductive-aged women. Prospective studies are needed to elucidate risk factors for development of PCOS on valproate.     

血管内栓塞治疗未破裂脑动静脉畸形并发癫痫患者的预后分析

目的分析血管内栓塞治疗未破裂脑动静脉畸形(CAVM)并发癫痫患者的预后情况。方法选择2013年3月至2017年6月收治的符合诊断标准的CAVM并发癫痫发作患者49例为研究对象,分析血管内栓塞治疗后患者的临床症状、生活质量(QOLIE-31)改善情况。结果患者经血管内栓塞治疗后,QOLIE-31各项指标(除了药物影响)评分均明显提高,高于治疗前(P0.05);Spetzler-Martin分级与Engel分级的I~II级例数多于治疗前(P0.05),同时Spetzler-Martin分级I~II级生活质量评分(76.04±18.33)分明显高于III~V级的(65.65±16.76)分(P0.05);Engel分级I~II级的生活质量评分(75.25±17.78)分明显高于III~V级的(66.23±13.22)分(P0.05);血管内栓塞比例80%的生活质量总评分(78.37±18.87)分明显高于栓塞比例80%的(64.16±16.92)分(P0.05);术后患者的头疼症状中重度例数明显低于治疗前(P0.01);患者的NIHSS评分和MRS评分均明显低于治疗前,头疼症状的生活质量评分高于治疗前(均P0.05)。结论血管内栓塞能明显改善未破裂脑动静脉畸形并发癫痫患者的头疼症状、癫痫发作情况、神经功能缺损,提高血管内栓塞比例能够提高患者生活质量。