胸腔镜下胸交感神经切断术治疗原发性手汗症疗效观察

目的分析胸腔镜胸交感神经干切断术治疗手汗症的安全性和有效性。方法 2006-05~2010-05,我们共收100例原发性手汗症患者,患者均在双腔气管插管全麻下接受胸腔镜交感神经干切断术,切断T2~T3,合并腋窝多汗者同时切断T4。结果全组手术顺利,无手术死亡。术中监测交感神经干切断前后手掌温度平均升高2.2℃,术毕患者手掌多汗的症状立即消失。患者平均手术时间(57.3±24.3)min,术后平均住时间院(2.0±0.8)d。15例患者出现不同程度的代偿性多汗,5例出现背痛,均能耐受。随访1~25个月无1例手汗症复发。结论电视胸腔镜胸交感神经干切断术治疗手汗症是一种安全、有效的微创外科技术,但其特有并发症的预防值得重视。     

胸腔镜下单孔胸交感神经链切断术治疗原发性手汗症

目的探讨电视胸腔镜下单孔胸交感神经链切断术治疗原发性手汗症的疗效和安全性。方法 2009年4月至2011年12月,80例原发性手汗症患者在胸腔镜下单孔操作,分别行T2～T5不同节段交感神经链切断术,术中持续监测双手掌温以判断手术疗效,随访症状缓解情况、有无复发以及代偿性出汗情况。结果全组病例手术均获成功,平均手术时间为(49.8±4.2)min,术后患者手掌多汗症状消失,双手转为干燥温暖状,双手掌皮肤温度均较术前显著升高(P<0.05),无严重并发症发生。77例患者随访1～32月,平均16.8月。1例单手手汗复发,已再次手术治愈。发生代偿性多汗38例(47.5%),其中中度出汗2例,轻度出汗36例。行单纯T3、T4或联合T3+T4胸交感神经链切断者代偿性多汗发生率为42.6%(29/68);余节段切断者代偿性多汗发生率为75.0%(9/12)。结论胸腔镜下单孔胸交感神经链切断术治疗手汗症具有操作简单、安全有效、创伤小等特点,值得临床推广。     

二孔法胸腔镜下胸交感神经干切断术治疗手汗症临床分析

目的总结二孔法胸腔镜下交感神经干切断术治疗手汗症的临床疗效。方法采用双腔气管插管静脉复合麻醉,经光源孔和操作孔二孔法胸腔镜下胸交干神经干切断术治疗手汗症59例,其中T3切断术17例,T4切断术9例,T3～4切断术33例。结果 59例手术均获成功,术后出现胸腔积液6例,均保守治愈。随访55例(93.2%),随访时间3～18个月,2例术后手掌再发多汗,但较术前减轻。结论二孔法胸腔镜下胸交感神经干切断术治疗手汗症安全、微创,操作方便,疗效肯定,值得推广。     

单孔法胸腔镜下双侧胸交感神经链切断术治疗手汗症89例分析

目的分析单孔法电视胸腔镜下胸交感链切断术治疗手汗症的可行性及疗效。方法 2007-05—2011-05我科接诊原发性手汗症患者89例,男47例,女42例,均于电视胸腔镜下行双侧T3-4交感神经链切断术手术治疗,手术均在单腔气管插管下进行,术中监测双手温度。结果本组全部患者均顺利完成手术,术后手汗立即消失,双手干燥、红润;无严重并发症或死亡。术后定期随访,未见复发,其中发现代偿性多汗8例,除1例外均较轻微,对日常生活影响不大。结论单孔法胸腔镜下双侧T3-4胸交感神经链切断术是治疗手汗症理想、安全、有效的方法,代偿性多汗发生率较高,术前应向患者讲明。     

CT引导下经皮穿刺胸交感神经调控治疗头面部多汗症

头面部多汗俗称"蒸笼头",与手汗症一样,都是多汗症的一种局部表现形式,胸腔镜下胸交感神经链切断术也是治疗头面部多汗症的经典术式[1],但和治疗手汗症比,要求切断交感神经链的部位高达T2水平,术后更易出现代偿性多汗[2-3].本文采用CT引导下经皮穿刺胸交感神经调控治疗头面部多汗症取得了良好效果,现报告如下.     

胸腔镜下交感神经链切断术治疗手汗症的围手术期护理

目的探讨胸腔镜下交感神经链切断术治疗手汗症的围手术期护理方法。方法回顾性分析46例原发性手汗症患者行胸腔镜下交感神经链切断术的临床资料。结果本研究所有病人手术效果满意,未出现严重并发症;10例术后出现程度各异的双下肢、胸背部代偿性出汗,4例发生闭合性气胸,经密切观察和对症治疗3~7d后满意出院。结论术前评估及术前准备充分、围手术期严密观察病情及加强护理是取得手术成功的重要保证。     

内窥镜胸交感神经链切断术治疗多汗症

目的： 总结内窥镜胸交感神经链切断术治疗手掌、腋窝多汗症的经验。方法： 回顾性分析５８ 例多汗症在胸腔内窥镜下进行双侧胸交感链第２， ３ 神经节切断的治疗效果。结果： ５８例多汗症（手掌多汗１５ 例， 腋窝多汗１７ 例， 两者兼有者２６ 例） 的手掌、腋窝多汗均治愈； 并发症： 气胸４ 例、代偿性多汗２ 例、肋间神经痛１ 例。结论： 内窥镜交感神经链切断术是治疗多汗症安全有效的方法。     

手掌多汗症和电视内镜胸2交感神经节切除术

手掌多汗症简称手汗症是亚热带地区年轻人常见的植物神经功能性疾病,发病率在局部地区调查约为0.3%[1],病因不明。手汗症药物治疗效果多不理想,且不能持久,传统的开胸或开放式交感神经节切除疗效确切,由于创伤大,必须切除部分肋骨和胸椎横突,已由新方法取代。1手术发展史1920年,Kotzareff介绍开胸交感神经切除术治疗手掌多汗症取得成功。1951年Kux改为胸腔镜电刀切除交感神经。1988年Chuang等[2]提出立体定向经皮上胸交感神经热凝技术,此法由于对靶结构定位欠精确也没有能进一步发展。1992年Kao等[3]开创电视胸腔镜交感神经节切除术治疗手…     

CT引导下经皮穿刺射频热凝治疗原发性头、手多汗症的疗效分析

目的探讨CT引导下经皮穿刺射频热凝治疗原发性头、手多汗症的疗效及并发症。方法对宁波市康复医院疼痛科自2017年6月至2019年5月收治的30例原发性头、手多汗症患者予CT引导下经皮穿刺T3或T4交感神经链射频热凝治疗,并随访12个月以评估患者疗效及总结并发症发生情况。结果术后24例患者的多汗症状明显改善,总体满意率为80%。术中5例患者出现胸腔、肺部穿刺损伤,其中4例为气胸、1例为血胸;术后7例患者出现胸背、腋下或上臂疼痛麻木,10例患者出现胸背代偿性多汗,2例患者出现胸背及双侧足部代偿性多汗。结论CT引导下经皮穿刺射频热凝治疗原发性头、手多汗症有着长期的治疗效果及相对较低的并发症。     

胸腔镜交感神经链离断术治疗多汗症效果的预测因素

目的探讨胸腔镜交感神经链离断术(endoscopic thoracic sympathectomy,ETS)对原发局灶性多汗症和颜面潮红的疗效,并试图通过亚组分析发现ETS术后获得更好疗效的患者特征。方法回顾性分析2005—2012年我院191例实施ETS术的患者,比较分析术后满意度、症状缓解度和并发症,特别是代偿性多汗(compensatory sweating,CS)的情况。结果97%的手掌多汗症,93%的头皮/面部多汗症的患者术后症状明显好转,缓解率高于腋下多汗症(71%)和面部潮红症(71%)(P0.001)。严重代偿性多汗(CS)在手掌多汗症的患者中出现率最低(8%),在腋下多汗症(26%)和头皮/面部多汗症(44.5%)的出现率最高(P=0.0003)。代偿性多汗(CS)最常出现在年轻患者中,其发生率随着年龄增长而下降(P=0.0006)。手术满意度亦随患者年龄增长而下降(P=0.004)。手掌多汗症的患者手术满意度最高(90%),头皮/面部多汗症患者的手术满意度最低(52%)(P0.02)。结论 ETS术后患者满意度最高的是年轻和手掌多汗症患者。不满意的患者主要由手术失败或未达预期效果或出现代偿性多汗(CS)。     

Diagnostic Difficulties and Treatment Implications

Summary: Differentiation between types of epileptic seizures has been aided in recent years by the introduction of intensive neurodiagnostic techniques and the development of increasingly detailed classification systems. Paradoxically, these developments have not simplified the task of matching the appropriate antiepileptic drug to a particular seizure type. It is reasonable to assume that anticonvulsant drugs will have different effects on different types of seizures, but faulty, circular reasoning can enter the picture if one also assumes that responses of seizures to different drugs signify different seizure types. There are several examples of differential diagnoses that can fall prey to this problem, including the diagnosis between partial seizures with secondary generalization and generalized tonic-clonic seizures, and the diagnosis between complex partial seizures and absence seizures with automatisms, among others. Considerations of etiology in future classification systems can further complicate the problem: should one then choose an anticonvulsant drug on the basis of individual seizure type or on the basis of the type of epilepsy? Ramifications of this issue extend even to the drug approval process. Official sanction is not given for use of a drug for a seizure type not included in the original efficacy studies, even if later scientific evidence shows that seizure type to be related to a type that is included. New trials must be undertaken. These problems arise from how we choose to classify seizures.     

Cognitive Dysfunction Associated with Antiepileptic Drug Therapy

Summary: Epilepsy is frequently associated with cognitive dysfunction. However, the reasons for this correlation are unclear. Possible influential factors include patient age; duration, frequency, etiology, and type of seizures; hereditary factors; psychosocial issues; and antiepileptic drug (AED) therapy. Whereas many of these factors are beyond the physician's control, AED therapy is one element that can be addressed in treatment decisions by recognizing the potential cognitive effects of particular AEDs. For example, phenobarbital impairs memory and concentration; phenytoin affects attention, problem solving ability, and performance of visuomotor tasks. In contrast, carbamazepine may affect concentration, while valproate would appear to have minimal effects on cognition. Moreover, cognitive effects of AEDs are amplified with coadministration of multiple anticonvulsants (polytherapy). A review of studies on the cognitive effects of monotherapy with AEDs, as opposed to those of polytherapy, provides evidence that drug-related cognitive dysfunction can be reversed if patients are switched to a simpler therapeutic regimen. Future research should be directed toward developing reliable measures for assessing and monitoring cognition, and understanding the particular cognitive side effects of each AED. Physicians also need to revise their opinions about which side effects are "tolerable" for epileptic patients.     

Hepatic Considerations in the Use of Antiepileptic Drugs

Summary: Virtually all of the major antiepileptic drugs (AEDs) can cause hepatotoxicity, although fatal hepatic reactions are rare. The mechanisms, incidences, and risk profiles for such reactions differ from drug to drug. With carbamazepine and phenytoin, hepatotoxicity may be due to drug hypersensitivity. Although the profiles of patients at risk have not been well-defined for these two antiepileptic drugs, it would appear from reports in the literature that older adolescents and adults are at higher risk than children of developing serious or fatal hepatotoxicity. Once hepatotoxicity develops, mortality rates are 10–38% with phenytoin and 25% for carbamazepine. The risk profile for valproate fatal hepatotoxicity has been more clearly defined. Those at primary risk of fatal hepatic dysfunction are children under the age of 2 years who are receiving multiple anticonvulsants and also have significant medical problems in addition to severe epilepsy. The risk is considerably lower for patients over the age of 2 years on valproate monotherapy. In contrast to the risk profile with other AEDs, adults receiving valproate as monotherapy have the lowest risk of hepatotoxicity. Fatal hepatic dysfunction coincident with valproate may be the result of aberrant drug metabolism. Concomitant use of AEDs that induce microsomal P450 enzymes (e.g., phenytoin and phenobarbital) may enhance the production of a toxic metabolite, and hence the greater risk of hepatotoxicity with polypharmacy.     

Vascular Malformations and Epilepsy: Clinical Considerations and Basic Mechanisms

Summary: Vascular malformations (VMs) are associated with epilepsy. The natural history of the various VMs, clinical presentation, and tendency to provoke epilepsy determine treatment strategies. Investigations have probed the mechanisms of epileptogenesis associated with these lesions. Electrophysiologic changes are associated with epileptogenic cortex adjacent to VMs. Putative pathophysiologic mechanisms of epileptogenesis include neuronal cell loss, glial proliferation and abnormal glial physiology, altered neurotransmitter levels, free radical formation, and aberrant second messenger physiology.     

Carbamazepine Efficacy in Adults With Partial and Generalized Tonic-Clonic Seizures

Summary: Carbamazepine and phenytoin are drugs of choice in initial monotherapy for adult partial and secondarily generalized tonic-clonic seizures. These designations reflect the results of the Veterans Administration Epilepsy Cooperative Study Group of 1985. An earlier comparative study of carbamazepine and phenytoin by Ramsay and associates found both drugs equally effective in controlling new-onset seizures. Among the advantages of carbamazepine is that it causes relatively few cognitive and dysmorphic side effects. Its disadvantages are its unavailability in parenteral formulation and its metabolic autoinduction. The latter must be compensated for by planned dosage increases to maintain therapeutic plasma steady-state levels during the first 2 or 3 months of treatment. Carbamazepine is judged a drug of choice in the treatment of these secondarily generalized tonic-clonic seizures, and the drug of choice in children, adolescents, and women susceptible to the dysmorphic side effects associated with other anticonvulsant agents.     

Etiologic and Preventive Aspects of Epilepsy in the Child–Bridging the Gap Between Laboratory and Clinic

Summary: Four broad categories of basic phenomena are pertinent to developing ways to prevent epilepsy. These include mechanisms of epileptogenesis, ictal initiation and temporary entrainment by the seizure discharge of normally functioning brain, seizure propagation, and control mechanisms that function both to restrain the cascade of epileptic events culminating in a seizure and to arrest the epileptic event and restore the interictal state. In newborns and children, hypoxia-ischemia is a major factor leading to epileptogenesis, and several schemes are proposed to classify, quantify, and prevent hypoxic-ischemic encephalopathy. Control mechanisms must be better understood in order to develop prophylactic recommendations for epilepsy, and an experimental model of "kindling antagonism" may increase our understanding of these. Programs of prevention of seizures in children will evolve only if basic researchers and clinicians work productively together to develop an adequate understanding of factors important in epileptogenesis and antiepileptogenic control mechanisms.     

Epilepsy and anomalies of neuronal migration: MRI and clinical aspects

Neuronal migration disorders are the result of disturbed brain development. In such disorders, neurons are abnormally located. In diagnosing these conditions, magnetic resonance imaging is superior to any other imaging technique. This enables us to improve our knowledge of the clinical correlates of neuronal migration. With reference to migrational disorder, a retrospective study of all 303 patients with epileptic seizures referred for magnetic resonance imaging during a 3-year period was performed, 13 patients (aged 12-41, mean age 27) were identified. They represent 4.3% of the entire study group. Of the patients with known epilepsy, 6.7% and of the mentally retarded, 13.7% had migrational disorders. Four patients had schizencephaly as the dominant finding, one was classified as hemimegalencephaly, 2 had isolated heterotopias, and 6 had localized pachy- and/or poly-microgyria. The clinical pictures are complex. Ectopias of grey matter are recognised foci of epilepsy, but from an epileptological and a clinical viewpoint little attention has been given to these disorders. The present study shows that malmigration is not rare in epilepsy patients, especially not in the mentally retarded.     

Carbamazepine Efficacy and Utilization in Children

Summary: Carbamazepine is effective for preventing partial and generalized tonic-clonic seizures in children. Although absence epilepsies are more common in children than adults, an estimated 80% of children with epilepsy have seizure types or epilepsies that are potentially responsive to carbamazepine. The differential diagnosis of ictal staring is an especially important issue in children because absence and atypical absence seizures are more prevalent in children than adults. Age-related pharmacokinetic differences and drug interactions are major considerations in children. On average, children have higher clearance rates of carbamazepine, shorter half-lives, and higher ratios of carbamazepine-10, 11-epoxide to carbamazepine than adults. In addition, children with severe epilepsy are more likely to require multiple-drug therapy, which can lead to complex drug interactions. When carbamazepine is administered along with valproate, drug protein binding interactions can cause intermittent side effects.     

Predisposing and Causative Factors in Childhood Epilepsy

Summary: We review information from large studies of defined populations, examining the role of known factors and especially of prenatal and perinatal factors in contributing to nonfebrile seizure disorders of early childhood. We depend especially, but not exclusively, on the recently completed analyses from the Collaborative Perinatal Project of the National Institute of Neurological and Communicative Disorders and Stroke, the NCPP. About 4% of children in the NCPP who had at least one non-febrile nonsymptomatic seizure by the age of 7 years had a previous seizure during acute neurologic illness, such as meningitis or during the acute illness after trauma. Many such seizures should potentially be preventable. Of children with seizures, 10% had had a neonatal seizure and 13% had had a febrile seizure. Among the hundreds of prenatal and perinatal factors explored as predictors of childhood seizure disorders, the principal predictors identified were congenital malformations of the fetus, cerebral and noncerebral; family history of certain neurologic disorders; and neonatal seizures. In agreement with the British National Child Development Study, labor and delivery factors in the NCPP appeared to contribute very little to childhood seizure disorders. Maldevelopment, rather than damage at birth to an initially intact nervous system, appeared to be the more common mechanism. Most seizure disorders of early childhood remained unexplained by the large set of prenatal and perinatal characteristics examined.     

Classification of methods in transcranial Electrical Stimulation (tES) and evolving strategy from historical approaches to contemporary innovations

Transcranial Electrical Stimulation (tES) encompasses all methods of non-invasive current application to the brain used in research and clinical practice. We present the first comprehensive and technical review, explaining the evolution of tES in both terminology and dosage over the past 100 years of research to present day. Current transcranial Pulsed Current Stimulation (tPCS) approaches such as Cranial Electrotherapy Stimulation (CES) descended from Electrosleep (ES) through Cranial Electro-stimulation Therapy (CET), Transcerebral Electrotherapy (TCET), and NeuroElectric Therapy (NET) while others like Transcutaneous Cranial Electrical Stimulation (TCES) descended from Electroanesthesia (EA) through Limoge, and Interferential Stimulation. Prior to a contemporary resurgence in interest, variations of transcranial Direct Current Stimulation were explored intermittently, including Polarizing current, Galvanic Vestibular Stimulation (GVS), and Transcranial Micropolarization. The development of these approaches alongside Electroconvulsive Therapy (ECT) and pharmacological developments are considered. Both the roots and unique features of contemporary approaches such as transcranial Alternating Current Stimulation (tACS) and transcranial Random Noise Stimulation (tRNS) are discussed. Trends and incremental developments in electrode montage and waveform spanning decades are presented leading to the present day. Commercial devices, seminal conferences, and regulatory decisions are noted. We conclude with six rules on how increasing medical and technological sophistication may now be leveraged for broader success and adoption of tES.