中枢神经系统孤立性纤维瘤/血管外皮细胞瘤的临床分析

目的探讨中枢神经系统孤立性纤维瘤/血管外皮细胞瘤(SFT/HPC)的诊断、治疗及预后,以提高对此疾病的认识。方法回顾性分析2013-09-2019-02晋中市第一人民医院神经外科收治的5例SFT/HPC患者的临床资料。按照2016年WHO中枢神经系统肿瘤分类评估,总结其临床表现、影像学特征、治疗方法及预后。结果 5例SFT/HPC患者,其中4例全切除,1例次全切除;1例失访,2例未见明显肿瘤复发,2例肿瘤复发。结论 SFT/HPC的临床表现及影像学表现均无明显特异性,术前极易误诊。是否全切除肿瘤及肿瘤WHO分级是影响SFT/HPC患者预后的主要因素。     

影响颞下咽旁间隙恶性肿瘤预后的因素分析

目的 探讨影响颢下咽旁间隙恶性肿瘤患者预后的主要因素.方法 73例颞下咽旁间隙恶性肿瘤,全部行手术治疗,术后辅助放疗30例,辅助化疗9例.生存率计算采用Kaplan -Meier法,生存率差异比较采用Logrank检验,多因素分析采用Cox模型.结果 5年总生存率、癌症相关生存率和无进展生存率分别为46.7％、51.5％、40.6％.单因素分析显示,肿瘤与颅底关系、恶性程度、切缘状态、肿瘤大小与癌症相关生存和无进展生存均有相关性;而性别和病理类型仅与无进展生存相关.多因素分析显示,肿瘤大小是影响预后的重要独立因素.结论 肿瘤大小是影响颞下咽旁间隙恶性肿瘤预后的重要因素.     

脑胶质瘤患者生存期的相关因素分析

目的 探讨脑胶质瘤患者生存期的相关因素.方法 对资料完整的109例脑胶质瘤患者进行观察和分析,对可能影响脑胶质瘤生存期的因素采用Kaplan-Meier法和Cox回归分析进行统计学验证.结果 Kaplan-Meier法单因素分析显示年龄、部位、术前患者身体机能状况评分(KPS)、病理级别、瘤周水肿、肿瘤囊变、手术方式、术后放疗八个因素对患者生存时间产生显著影响;Cox回归多因素分析显示年龄、部位、术前KPS、病理级别、手术方式、术后放疗六个因素是决定患者生存时间的主要预后因素.结论 结合预后影响因素,注意治疗中的各环节,合理安排治疗模式,将有助于改善脑胶质瘤患者的预后.     

血管外膜细胞瘤p53和Ki-67的表达与肿瘤分级和复发的关系

目的 探讨中枢神经系统血管外膜细胞瘤(HPC)中p53及Ki-67的表达与肿瘤的分级和复发的关系. 方法 回顾性分析北京天坛医院自2005年1月采用至2008年1月手术切除治疗的97例中枢神经系统HPC患者的临床资料,HE染色97例FIPC标本并按照WHO标准进行分级;免疫组织化学染色检测并比较不同分级、复发和未复发肿瘤标本中p53和Ki-67的表达.结果 HE染色检测显示HPC分级Ⅱ级74例,Ⅲ级23例;随访结果显示未复发HPC 49例,复发39例;免疫组化检测结果显示Ⅱ级HPC中p53和Ki-67阳性细胞数均明显低于Ⅲ级,未复发病例的Ki-67和p53阳性细胞数均明显低于复发病例,差异均有统计学意义(P<0.05).结论 Ki-67、p53的表达越高,HPC的组织分级越高,复发风险越高,可作为判断HPC患者预后的指标.     

髓母细胞瘤预后影响因素的Cox模型分析

目的分析影响髓母细胞瘤预后的相关因素。方法应用Cox回归模型,对60例髓母细胞瘤患者的年龄、性别、病程、肿瘤体积、切除范围、放疗、uPA、uPAR、KDR9项指标进行预后单因素及多因素分析。结果Cox回归分析显示反应肿瘤生物学行为的uPA、uPAR和KDR与预后存在高度负相关关系。结论uPA、uPAR和KDR是决定髓母细胞瘤预后的最重要危险因素。     

颅内血管周细胞瘤2例报道并文献复习

目的探讨颅内血管周细胞瘤(HPC)的诊断、治疗,以提高对该病的诊治水平。方法回顾性分析手术治疗的2例颅内HPC的临床资料,并结合相关文献进行分析。结果术后病理结果均为HPC。术后均辅助放疗,术后随访0.5、1.5年,1例恢复良好、无复发,1例预后差、复发3次。结论 HPC确诊依赖病理检查;多采用治疗手术+放疗等综合治疗,预后不良。     

影响胶质母细胞瘤切除术后的预后因素分析

目的 探讨影响胶质母细胞瘤切除术后的预后因素.方法 对山东省三家医院1999-2004年经手术治疗且随访资料完整的205例胶质母细胞瘤进行回顾性研究,Kaplan-Meier单因素分析筛选预后相关因素,并通过Cox回归模型对筛选出的相关因素进行多因素分析.结果 患者中位生存期为12.0个月,术后6、12、18、24个月的积累生存率分别为82%、52%、27%、17%.多因素分析显示年龄、肿瘤部位、术前KPS评分、手术切除程度、术后放疗、化疗是影响预后的主要因素.结论 经多因素分析证实肿瘤的切除程度、术后放疗和化疗均能显著影响胶质母细胞瘤的预后,其中放疗是最具统计学意义的治疗方式.     

中枢神经系统复发性血管外膜细胞瘤临床特点分析

目的探讨中枢神经系统复发性血管外膜细胞瘤(HPC)的临床特点。方法回顾性分析46例复发性HPC病人的临床资料,均行手术全切除或次全切除肿瘤,其中辅助放疗29例,辅助伽玛刀治疗7例。采用统计学分析复发性HPC病人术后的生存期及生存期的影响因素。结果 46例病人术后随访3~164个月,平均生存期为(41.6±4.4)个月,术后1、2、3、4年生存率分别为80.4%、65.2%、59.2%和53.8%。所有复发性HPC病人中,复发1次30例,其平均生存期为(36.9±4.1)个月;复发2次及以上16例,其平均生存期为(39.7±7.0)个月。随访期间死亡18例,其平均生存期为(14.2±5.6)个月;存活28例,其平均KPS评分为(86.8±14.2)分。经统计学分析:复发性HPC病人的生存期与性别及肿瘤部位、大小、质地、病理分级之间无相关性(P0.05);复发1次与复发2次及以上病人的生存期间亦无显著差异(P0.05)。结论积极综合治疗复发2次及以上的HPC病人,预后仍可令人满意。     

经蝶入路切除垂体腺瘤的疗效及复发影响因素分析

目的 探讨经蝶入路手术切除治疗垂体腺瘤的疗效及肿瘤术后复发的影响因素。方法 对2009年1月至2015年1月收治的102例经蝶入路手术切除治疗垂体腺瘤患者的临床资料进行回顾性分析,采用Kaplan-Meier法估计不同特征患者的复发,采用Cox回归模型分析影响患者复发的相关因素。结果 术后,81.3%头痛消失,92.4%视力好转,83.8%泌乳停止,75.0%血糖恢复正常。102例术后随访12~64个月,16例（15.7%）出现复发,复发时间为12~60个月,中位无复发生存时间为36月（95% CI为 29.4~42.6）。多元Cox回归分析显示,侵袭性（HR=1.85,95% CI为1.11~3.11;P<0.05）、肿瘤非全切除（hr ci为1.25~4.49;P<0.05）和术后无辅助放疗（hr ci为1.04~4.07;P<0.05）是术后复发的危险因素。>结论 经蝶入路手术切除垂体腺瘤能明显改善患者的症状,总体疗效较好。侵袭性生长、肿瘤非全切除和术后无辅助放疗为肿瘤术后复发危险因素。     

非典型脑膜瘤的临床分析

目的探讨非典型脑膜瘤的诊断、治疗及预后相关影响因素。方法回顾性分析2001~2011年首都医科大学附属北京天坛医院收治的89例经病理证实的非典型脑膜瘤,应用Log-rank法和Cox回归进行统计分析,并结合文献对本病的特点、治疗方法和预后进行分析。结果 89例非典型脑膜瘤中72例肿瘤全切除,40例术后行放疗;中位PFS 72.6个月(2~102个月),2年、5年PFS率为74.5%、67.5%,OS率为93.6%、89.1%。单因素分析显示,继发肿瘤、女性、肢体瘫痪、KPS80的非典型脑膜瘤患者复发的风险增加(均P0.05)。多因素分析显示,继发肿瘤、肢体瘫痪患者的复发风险增加(均P0.05),KPS≥80患者有更长的存活时间(P0.05)。结论手术全切除是改善非典型脑膜瘤患者预后的重要手段;对未全切除者,术后推荐放疗。对于全切除的非典型脑膜瘤,首发症状为偏瘫、继发肿瘤、肿瘤存在骨侵袭、肿瘤存在脑侵袭。核有丝分裂象高、MIB-1指数高的患者为高危患者,存在这些危险因素中1项及以上者,推荐术后放疗。     

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.     

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.     

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.     

Anticonvulsant Drugs and Cognitive Function: A Review of the Literature

Summary: Alterations of cognitive function are separate from disturbances of behavior seen in association with epilepsy. The nature of the cognitive disability may to a certain extent depend on the seizure type. Partial seizures, mainly derived from a temporal lobe focus, impair memory tasks, while generalized seizures seem to have more effect on attentional abilities. A number of studies, reviewed in this paper, suggest that anticonvulsant drugs further impair cognitive function. Maximal impairments are seen in patients receiving polytherapy: rationalization of polytherapy improves cognitive abilities. Studies in children and adults have allowed differentiation of the effects of various commonly used antiepileptic agents. Maximal cognitive deficits are seen with. phenytoin, while phenobarbital and sodium valproate induce moderate disturbances, and carbamazepine seems relatively free from such toxicity. Further research is needed on the interrelationship between types of seizure disorders, types of anticonvulsant medications, and cognitive function.     

Effects of NMD A- and AMPA-Receptor Antagonists on Different Forms of Epileptiform Activity in Rat Temporal Cortex Slices

Summary: Lowering extracellular magnesium induces different patterns of epileptiform activity in rat hippocampus and entorhinal cortex. Short recurrent epileptiform discharges in the hippocampus are stable over time, whereas seizurelike events (SLEs) in the entorhinal cortex, the subiculum, and the neighboring neocortex develop into late recurrent discharges which are not blocked by clinically employed antiepileptic drugs. We tested the sensitivity of the different epileptiform discharge patterns to. /V-methyl-D-aspartate (NMDA)- and non-NMDA-receptor antagonists. As NMDA-receptor antagonist we used dextrorphan, ket-amine, and 2-aminophosphonovalerate (2APV); as α-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid (AMPA)-receptor antagonist we employed the quinoxaline derivative glutamate 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX). The findings show that the different patterns of epileptiform activity, including the late recurrent discharges, are sensitive to all NMDA-receptor antagonists. However, when dextrorphan was employed to suppress seizure-like events, later recurrent discharges did not develop during the remaining time course of the experiment. CNQX reversibly suppressed recurrent discharges in the hippocampus and SLEs in the entorhinal cortex. However, late recurrent discharges become insensitive to CNQX, even at a high concentration of 60 μM m. This finding suggests a prominent role for NMDA receptors in the generation of late recurrent discharges.     

Treatment Considerations in Anticonvulsant Monotherapy

Summary: The long-standing practice of polypharmacy in treating epilepsy is giving way to use of monotherapy. Monotherapy can improve seizure control as well as reduce the risk of serious idiosyncratic reactions, dose-related side effects, and complex drug interactions. Monotherapy also offers improved compliance and cost-effectiveness. The basis of monotherapy is accurate diagnosis and assessment of the patient's seizure type(s), followed by selection of a single appropriate anticonvulsant drug. Many patients currently treated with multiple anticonvulsants can be successfully converted to monotherapy with a carefully monitored program in which troublesome and redundant drugs are gradually withdrawn from the therapeutic regimen.     

The influence of comorbid depression on seizure severity

PURPOSE: To determine the relation between depressive symptoms and seizure severity among people with epilepsy. METHODS: A postal questionnaire was used to survey a nationwide community sample about seizures and depression. The Seizure Severity Questionnaire (SSQ) assessed the severity and bothersomeness of seizure components. The Centers for Epidemiological Studies-Depression scale categorized levels of depression. RESULTS: Respondents categorized as having current severe (SEV, n = 166), mild-moderate (MOD, n = 74), or no depression (NO, n = 443) differed significantly in SSQ scores (all p < 0.0001). People with SEV or MOD reported significantly worse problems than did those with NO depression for overall seizure recovery (mean, 5.3, 4.9, 4.5, respectively); overall severity (5.0, 4.5, 4.2); and overall seizure bother (5.3, 4.8, 4.4) (all p < 0.005). Cognitive, emotional, and physical aspects of seizure recovery also were rated worse among people with SEV than with NO depression (all p < 0.05). Symptoms of depression were significantly correlated with higher levels of all components of generalized tonic-clonic seizure severity (r = 0.33-0.48; all p < 0.0001), and partial seizures (r = 0.31-0.38; all p < 0.01). CONCLUSIONS: Clinically depressed people with epilepsy reported higher levels of perceived severity and bother from seizures, as well as greater problems with overall seizure recovery than did nondepressed people experiencing similar types of seizures. The pervasive influence of depressive symptoms on reports of seizure activity suggests that people with epilepsy should be screened for depression. These data highlight the importance of detecting and treating depression among people with epilepsy.     

Dextromethorphan: Cellular Effects Reducing Neuronal Hyperactivity

Summary: Dextromethorphan is a dextrorotary morphinan without affinity for opioid receptors, commonly used as an antitussive medication. During the past 5 years, interest in the compound and its demethylated derivative, dextrorphan, has been revived because additional neuroprotective and an-tiepileptic properties were found in in vitro studies, animal experiments, and a few clinical cases. Both morphinans are able to inhibit N -methyl-D-aspartate (NMDA) receptor channels and voltage-operated calcium and sodium channels with different potencies. The inhibition of the NMDA receptor is believed to be the predominant mechanism of action responsible for the anticonvulsant and neuroprotective properties of the compounds.