术中直接皮质电刺激在功能区胶质瘤手术中的应用

目的探讨直接电刺激在脑功能区胶质瘤手术中的应用方法和临床意义。方法对2003年1月-2012年1月接受大脑功能区胶质瘤手术中行功能区直接电刺激的157例患者的临床资料进行回顾总结。结果术中经皮质电刺激4例呈阴性,其余153例分别刺激出运动功能区皮质(139例)、感觉功能区皮质(21例)和语言相关功能区皮质(91例);计数中断阳性区域主要位于左侧中央前回下方、额下回盖部、额下回三角部、额中回后部和额上回后部。术后MRI显示全切除92例(58.60%)、次全切除55例(35.03%)、部分切除10例(6.37%)。术后病理证实:低级别胶质瘤共110例(70.06%),包括星形细胞瘤71例、少突胶质细胞瘤26例和少突星形细胞瘤13例;高级别胶质瘤47例(29.94%),分别为胶质母细胞瘤19例、间变性星形细胞瘤15例和间变性少突胶质细胞瘤13例。术后53例(33.76%)出现短暂性肢体运动障碍、39例(24.84%)出现短暂性语言功能障碍,仅4例(2.55%)发生永久性神经功能障碍。结论皮质电刺激技术是一种可靠无创的脑功能区定位方法,用于脑胶质瘤外科手术可最大程度并安全切除肿瘤。     

基于颅骨骨窗的国人大脑功能区定位

目的 探讨基于颅骨骨窗划分的国人大脑重要功能区定位关系。方法 选取13具成人尸头，保留颞上线、鳞状线、矢状缝、冠状缝、人字缝、前囟点、冠状点、鼻根等骨性标志，形成额骨上窗、额骨下窗、顶骨上窗、顶骨下窗、颞骨窗、枕骨窗共六个骨窗，观测中央前回、中央后回、额下回等重要脑功能区以及脑膜中动脉在各骨窗内的定位和分布情况。结果 中央前回分布于额骨上窗、顶骨上窗，其中点在中线上位于前囟点后方约4.2 cm[右侧（4.17±0.92）cm，左侧（4.31±1.1）cm]，与矢状缝夹角约54°[右侧（53.6±7.47）°，左侧（54.63±3.54）°]。中央后回位于顶骨下窗，其中点在中线上位于前囟点后方约6.2 cm[右侧（64.51±0.87）°，左侧（63.63±1.76）°]，与矢状缝夹角约64°[右侧（64.51±0.87）°，左侧（63.63±1.76）°]。额下回位于额骨下窗，而颞上回及颞横回的大部分位于颞骨窗，距状沟则位于枕骨窗；脑膜中动脉仅分布在顶骨上、下窗，其出现率分别为73.12%、67.42%。结论 基于颅骨骨窗划分的大脑重要功能区的定位关系对于术前规划及术中定位有一定指导意义。     

应用术中直接电刺激最大安全切除功能区胶质瘤

目的 探讨直接电刺激在功能区胶质瘤手术中应用的意义.方法 回顾性分析157例大脑功能区胶质瘤术中直接电刺激的临床资料.结果 皮质电刺激4例阴性刺激,139例刺激出运动区皮质,21例感觉区,91例出现语言相关区皮质.数数中断的阳性区主要位于左中央前回下方、左额下回盖部、左额下回三角部、左额中回后部和额上回后部.术后MRI示胶质瘤全切92例(58.6％),次全切55例,部分切除10例.术后53例出现短暂肢体运动障碍;39例出现短暂语言功能障碍,4例(2.5％)出现永久性神经功能障碍.结论 术中直接电刺激是一种可靠元创的脑功能区定位方法,在胶质瘤手术中应用此技术可达到最大安全切除肿瘤,同时为国人功能区脑皮质定位提供帮助.     

多导硬脑膜外体感诱发电位对大脑皮质躯体运动感觉功能区的定位

目的 探讨运动皮质电刺激电极植入术中利用多导硬脑膜外体感诱发电位定位大脑皮质躯体运动感觉功能区的方法 及意义.方法 对13例利用运动皮质电刺激术治疗中枢性疼痛患者进行多导硬脑膜外体感诱发电位监测,并对所采集到的信号进行脑诱发电位地形图处理分析.结果 11例患者记录到波幅较高的波形,精确判断出大脑皮质功能区中央后回、中央前回和中央沟的位置,2例波幅较低,效果欠佳.结论 多导硬脑膜外体感诱发电位可较准确、实时地确定大脑运动感觉功能区,利于治疗用刺激电极的准确植入.     

3D重建脑表面中央前回辨识及初级皮层运动功能分布研究

目的研究利用三维重建脑表面成像辨识中央前回的方法及其可靠性。方法难治性癫痫经术前评估需要进行颅内电极植入的病例12例,术前行3T磁共振结构像扫描及运动功能磁共振测试,颅内电极植入后行头颅CT扫描。利用磁共振数据,用Brainvoige软件进行脑表面三维重建,并与硬膜下电极CT融合。根据中央前回的形状走行特点,在重建的脑表面上标记中央前回,进而辨识标记术区中央前回。用皮层电刺激和功能磁共振验证所标记中央前回的可靠性。结果 12例均进行了脑表面三维重建,并标记出了中央前回,硬膜下电极CT电极点与三维脑表面融合。统计中央前回上电极点101个,电刺激运动响应73个,响应率72%;对照组中央前回前1cm（统计中央前沟前2个电极范围）,130个电极,17个电极有运动响应,响应率13%,p值小于0.05;功能磁共振手的运动100%中央前回有激活,中央前回前无明显激活。电刺激及功能核磁均验证了本研究方法确定中央前回准确可靠。结论脑表面成像辨识中央前回准确可行,可以利用各初级运动皮层分布的距离进行详细的初级运动皮层的绘制定位。     

恶性大脑中动脉综合征43例临床分析

目的探讨大脑中动脉主干梗死的病因、临床表现及疗效。方法对43例恶性大脑中动脉综合征临床表现、头颅CT、MRI、MRA、TCD、空腹血糖、血脂等危险因素进行分析。结果大脑中动脉主干梗死以栓塞多见，早期栓塞面积越大、血糖水平越高，预后越差。结论发现缺血性脑血管的危险因素，有利于预防恶性大脑中动脉综合征发生。     

以前庭神经元炎表现伴痛性痉挛起病的多发性硬化1例

患女．51岁，因剧烈眩晕伴呕吐3d于2001年12月30日入院．无耳呜耳聋．入院前1周曾患感冒。入院查两眼水平旋转性眼震，四肢肌力正常．巴彬斯基氏征阴性。入院5d后出现右下肢触碰后痉挛性剧痛．反复发作。入院查头颅CT正常．头颅MRI示双侧额顶叶小缺血灶．颈髓MRI正常。电测听正常．眼震电图示中枢性眼震。给以地塞米松静滴2周改泼尼     

小儿急性外伤性脑内血肿快速消散一例

患儿男性，14个月。因“头部外伤后哭闹不止2h”入院。患儿不慎从3m高处摔下，致头颅外伤，哭闹不止。伤后50min在外院行头颅CT检查，发现左颞顶叶脑挫裂伤，左顶骨骨折，蛛网膜下腔出血（大脑纵裂内）而转入我院。查体：患儿呈嗜睡状态，刺激后哭闹，左颞顶部巨大头皮血肿，直径约10cm，前囟处触之压力较高。双瞳孔等大等圆，直径3．0mm，光反射迟钝。右侧肢体活动较左侧明显幅度小、频率少。于伤后4．5h复查头颅CT发现左颞顶叶原脑挫裂伤处形成脑内血肿，血肿最大层面长径60mm，宽径30mm，延续4个层面，根据多田氏公式计算血肿量约为36ml。意识状态由嗜睡变为昏睡，可唤醒，并唤醒后哭闹。继续予以保守治疗，并做好随时开颅手术的术前准备。伤后10．5h血肿较前有所缩小。伤后50．5h血肿基本完全消散。     

扩大前颅底入路显露斜坡中央凹陷区的量化研究

目的量化研究扩大前颅底入路中每一步骤骨切除后所获得斜坡中央凹陷区显露范围及手术自由度变化，为其临床应用提供客观依据。方法10％甲醛溶液同定的头颅标本20例，在CT辅助下利用立体定向仪在头颅标本上标记斜坡中央凹陷区中心点。采用扩大前颅底入路，骨切除分四步进行：单纯额下蝶窦斜坡，额下蝶筛窦斜坡，扩大额下蝶筛窦斜坡，扩大截眶、视神经管内侧壁磨除。每一步完成后分别测量斜坡中央凹陷区的显露范围和位于斜坡中央凹陷区中心点上方15cm处术者操作空间的面积。结果随着骨切除范围的增加，斜坡中央凹陷区的显露范围和手术自由度逐渐增加，最显著的变化发生在扩大额下蝶筛窦斜坡完成后，所获得的显露范围为（210±18）mm^2，占整个入路完成后的（96±1）％，所获得的手术自由度为（4035±376）mm^2，占整个入路完成后的（91±8）％。结论扩大前颅底入路在完成扩大额下蝶筛窦斜坡后即能较好的显露斜坡中央凹陷区，并能提供足够的手术自由度，主要适用于硬膜外颅底中线部位肿瘤的切除。     

开瓣减压术抢救大面积脑梗塞12例

开瓣减压术抢救大面积脑梗塞１２例河北省张家口市２５１医院神经内科李英杰王振金陈恒年报道１９９０年２月～１９９５年２月，我院对１２例大脑中动脉主干梗塞病人行开瓣减压术。男８例，女４例，年龄３６～７１岁。头颅ＣＴ示病侧额颞顶大片低密度影，侧脑室受压，中线...     

Leptomeningeal carcinomatosis from urinary bladder adenocarcinoma: A clinicopathological case study

We report a 73‐year‐old male patient with leptomeningeal metastasis from urinary bladder adenocarcinoma. He was presented with prominent hyperactive delirium during the course of the disease. Meningeal carcinomatosis was detected 5 days before his death, but the primary site of the malignant tumor could not be determined. Necropsy revealed leptomeningeal infiltration of many adenocarcinoma cells that covered the cerebrum. The leptomeninges of the right middle frontal gyrus, superior temporal gyrus, precentral gyrus and inferior parietal lobe were most severely affected by tumor cell infiltration. Cerebral edema was found to extensively cover the basal part of the temporal lobe. In the cerebrum, tumor cells were clustered in the perivascular spaces and had invaded localized areas of the frontal lobe. Vascular cell adhesion molecule (VCAM)‐1 expression was detected in the small vessels of the cerebral upper cortical layers and of temporal subcortical u‐fibers. Numerous astrocytes positive for cytokeratin AE1/AE3 were found in the frontal and temporal lobes. Meningeal carcinomatosis from urinary bladder adenocarcinoma is extremely rare and up‐regulation of the adhesion molecules in the meningeal adenocarcinoma was confirmed.     

Structural brain abnormalities in patients with schizophrenia and their healthy siblings

OBJECTIVE: The authors sought to investigate the contribution of genotype on structural brain abnormalities in schizophrenia. METHOD: Intracranial volumes and volumes of the cerebrum, white and gray matter, lateral and third ventricles, frontal lobes, caudate nucleus, amygdala, hippocampus, parahippocampal gyrus, and the cerebellum were measured in 32 same-sex siblings discordant for schizophrenia and 32 matched comparison subjects by means of magnetic resonance imaging. RESULTS: Third ventricle volumes did not differ between the schizophrenic patients and their healthy siblings. However, both had higher third ventricle volumes than did the comparison subjects. The schizophrenic patients had lower cerebrum volumes than did the comparison subjects, whereas the cerebrum volume of the healthy siblings did not significantly differ from the patients or comparison subjects. Additionally, patients with schizophrenia displayed a volume reduction of the frontal lobe gray matter and a volume increase of the caudate nuclei and lateral ventricles compared to both their healthy siblings and comparison subjects. Intracranial volume, CSF volume, or volumes of the cerebellum, amygdala, hippocampus, or the parahippocampal gyrus did not significantly differ among the patients, siblings, and comparison subjects. CONCLUSIONS: Healthy siblings share third ventricle enlargement with their affected relatives and may partially display a reduction in cerebral volume. These findings suggest that third ventricular enlargement, and to some extent cerebral volume decrease, may be related to genetic defects that produce a susceptibility to schizophrenia.     

Distribution of tuft-shaped astrocytes in the cerebral cortex in progressive supranuclear palsy

The deposition of abnormal levels of tau protein is a major neuropathological feature of progressive supranuclear palsy (PSP), and the presence of tuft-shaped astrocytes is a neuropathological hallmark of PSP. We examined the topographic distribution of tuft-shaped astrocytes in the cerebral hemisphere by Gallyas-Braak silver staining in three Japanese autopsy cases of typical PSP. The distribution of tuft-shaped astrocytes was relatively uniform between cases. Tuft-shaped astrocytes were identified predominantly in posterior frontal areas such as the precentral gyrus and premotor and supplementary motor areas (Brodmann areas 4, 6 and 8). Tuft-shaped astrocytes were most dense in areas of cortical convexity, and they were more abundant in the crests of the cerebral gyri than in the valleys of the cerebral sulci. The temporal, parietal and occipital cortices, including the hippocampal formation and cingulate gyrus, were relatively free of tuft-shaped astrocytes. We confirmed involvement of the cerebral cortex in the pathology of PSP, and showed the widespread presence of tuft-shaped astrocytes, particularly in the precentral gyrus and premotor and supplementary motor areas, to be an essential neuropathological feature of PSP. The extra-pyramidal and pyramidal signs, supranuclear oculomotor abnormalities and other cortical signs associated with PSP may be related to the high density of tuft-shaped astrocytes in the precentral gyrus and premotor and supplementary motor areas. Dementia, apraxia, aphasia and frontal lobe signs may also result, at least in part, from this cortical involvement.     

An autopsy case of long-course multiple system atrophy (MSA) with remarkable atrophy and numerous NCI in the temporal lobe]

The patient was 66 year-old man with no family history of neurological diseases. At age 51, he showed initial symptom of parkinsonism, and was revealed a cerebellar atrophy by CT at age 52. He was suffered from malignant syndrome followed by renal dysfunction, which needed hemodialysis therapy. At age 54, he admitted to our hospital, when he showed parkinsonism, ataxia and dysautonomia. Neuroimaging study disclosed typical findings of multiple system atrophy (MSA), and dilatation of inferior horn of the lateral ventricle. In the next year, he lost of amburatory function, and showed low cognitive function of 5 scores in HDSR. At age 57, he was tracheostomised because of complete paralysis of the vocal cord abductor muscles. MRI study disclosed marked temporal lobe atrophy. He was complicated with bladder carcinoma, and died of multiple organ failure at age 66. The brain weight was 1,115 g. Gross neuropathological findings were temporal lobe dominant cerebral atrophy and marked pontocerebellar atrophy. Meningitis and sepsis were seen in the cerebrum, and some infarctions in the temporal and frontal lobes. Besides the typical degenerative findings of MSA, remarkable temporal lobe atrophy with enlargement of the inferior horn of lateral ventricle was observed. There were numerous number of neuron containing neuronal inclusion body (NCI) in the hippocampal cortex, dentate fascia and parahippocampal gyrus. In spite of small amount of NFT in the parahippocampal gyrus, there were no se- nile plaque, tau-positive structure except NFT, argyrophilic grain or Pick body. This case was a long-survived MSA with remarkable atrophy of the temporal lobe. The characteristic neuropathological finding was numerous numbers of neurons containing NCI in the cotices arround the inferior horn. Although frontal lobe dominant cerebral lobe atrophy is common in the long-survived MSA cases, extreme temporal lobe atrophy is rare condition. There may be a MSA subtype strongly affecting temporal lobe with numerous NCI.     

Increased perfusion in motor areas after constraint-induced movement therapy in chronic stroke: a single-photon emission computerized tomography study.

Hemiparesis is the most common deficit after cerebral stroke. Constraint-induced movement therapy (CIMT) is a new neurorehabilitation method that emphasizes task-relevant repetitive training for the stroke hand. Twelve chronic stroke patients were studied with single-photon emission computerized tomography at rest before and after the two-week CIMT period. Increased perfusion was found in motor control related areas. The specific areas with an increase in perfusion in the affected hemisphere were in the precentral gyrus, premotor cortex (Brodmann's area 6 (BA6)), frontal cortex, and superior frontal gyrus (BA10). In the nonaffected hemisphere, perfusion was increased in the superior frontal gyrus (BA6) and cingulate gyrus (BA31). In the cerebellum increased perfusion was seen bilaterally. The brain areas with increased perfusion receive and integrate the information from different sensory systems and plan the movement execution. Regional cerebral perfusion decreased in the lingual gyrus (BA18) in the affected hemisphere. In the nonaffected frontal cortex, two areas with decreased perfusion were found in the middle frontal gyrus (BA8/10). Also, the fusiform gyrus (BA20) and inferior temporal gyrus (BA37) in the nonaffected hemisphere showed decreased perfusion. Intensive movement therapy appears to change local cerebral perfusion in areas known to participate in movement planning and execution. These changes might be a sign of active reorganization processes after CIMT in the chronic state of stroke.     

Assessing brain function in post-traumatic coma by means of bit-mapped SEPs, BAEPs, CT, SPET and clinical scores. Prognostic implications.

Sixty-eight severely head injured comatose patients were studied. Bit-colour-mapped SEPs to median nerve stimulation, BAEPs, CT and SPET regional values and ICP were assessed in relation to clinical information in evaluating cerebral function. All these variables were related to a 1-year outcome. Statistical tests confirmed the higher predictive reliability of both neurophysiological and perfusive (SPET) functional parameters compared to CT structural findings. Generally, SEPs appeared to be more reliable in predicting outcome than BAEPs. Modifications of frontal components could occur independently of post-central ones, being closely related to underlying cerebral lesions. The parameter showing the greatest correlation with outcome in the first recording session was the P25 latency, whereas this prognostic role was mainly assumed by the amplitude value of the frontal N30-P45 complex in a second recording session carried out during the third week following head trauma.     

Language after bilateral cerebral infarctions: role of the minor hemisphere in speech

Language was studied in four patients with bilateral cerebral infarctions. Bilateral destruction of the third frontal gyri did not necessarily produce the severely limited language output characteristic of global or severe Broca aphasia; for Broca aphasia to occur, there must be extensive frontoparietal damage in the dominant cerebral hemisphere. Thus, the marked recovery of language after lesions limited to the dominant third frontal gyrus is mediated by adjacent areas of the dominant hemisphere, and not by the nondominant third frontal gyrus. The nondominant hemisphere nevertheless has a limited capacity to produce oral speech after extensive damage to the dominant hemisphere and may play an appreciable, although still subsidiary, role in normal articulation. The central gyri and rolandic operculum may be more essential than the third frontal gyri for well-articulated speech.     

Cortical reorganization for response regulation with unilateral thalamic stroke detected by functional MRI

To understand neural reorganization of response regulation after stroke, a 54-year-old woman with a chronic left thalamic stroke performed a task requiring decisions about the directionality of an arrow during cerebral functional magnetic resonance imaging. Her performance was compared to 13 matched healthy control subjects. Her behavioral responses were slower but as accurate. Bilateral frontal activations were observed in the right medial frontal gyrus (BA 9), left superior frontal gyrus (BA 45), and left frontal rectus gyrus (BA 11). Activation in the right medial frontal gyrus, along with activity in close proximity to the anterior cingulate cortex, was observed, which may reflect reorganization of activity after the loss of function of the anterior cingulate cortex.     

Resting quantitative cerebral blood flow in schizophrenia measured by pulsed arterial spin labeling perfusion MRI

Arterial spin labeling (ASL) perfusion MRI is a relatively novel technique that can allow for quantitative measurement of cerebral blood flow (CBF) by using magnetically labeled arterial blood water as an endogenous tracer. Available data on resting CBF in schizophrenia primarily come from invasive and expensive nuclear medicine techniques that are often limited to small samples and yield mixed results. The noninvasive nature of ASL offers promise for larger-scale studies. The utility of this approach was examined in 24 healthy controls and 30 patients with schizophrenia. Differences between groups in quantitative CBF were assessed, as were relationships between CBF and psychiatric symptoms. Group comparisons demonstrated greater CBF for controls in several regions including bilateral precuneus and middle frontal gyrus. Patients showed increased CBF in left putamen/superior corona radiata and right middle temporal gyrus. For patients, greater severity of negative symptoms was associated with reduced CBF in bilateral superior temporal gyrus, cingulate gyrus, and left middle frontal gyrus. Increased severity of positive symptoms was related to both higher CBF in cingulate gyrus and superior frontal gyrus and decreased CBF in precentral gyrus/middle frontal gyrus. These findings support the feasibility and utility of implementing ASL in schizophrenia research and expand upon previous results.