高龄急性轻型缺血性卒中早期阿替普酶静脉溶栓疗效观察

目的 探讨高龄轻型缺血性卒中3 h内行阿替普酶静脉溶栓治疗的疗效及安全性。 方法 将我院2015年10月-2017年10月连续收治入院的发病3 h内48例高龄急性轻型缺血性卒中患者 随机分为阿替普酶静脉溶栓组24例和未溶栓组24例。比较两组患者入院时的一般情况,基线美国 国立卫生研究院卒中量表（National Institutes of Health Stroke Scale,NHISS）评分,治疗24 h后颅内出 血转化率,治疗后90 d改良Rankin量表（modified Rankin Scale,mRS）评分及90 d病死率。 结果 阿替普酶静脉溶栓组和未溶栓组患者一般临床资料、基线NIHSS评分比较,差异无统计学意 义。阿替普酶静脉溶栓组和未溶栓组治疗24 h后颅内出血转化率分别为4.17%和0（P =1.000）,两组 90 d病死率均为4.17%（P =1.000）,阿替普酶静脉溶栓组及未溶栓组90 d mRS评分为0～2分的比率 分别为83.33%和54.17%（P =0.029）。 结论 早期阿替普酶静脉溶栓治疗高龄急性轻型缺血性卒中不增加急性期颅内出血转化的风险, 可以改善高龄轻型缺血性卒中患者预后,不增加病死率。     

替罗非班治疗阿替普酶静脉溶栓后再闭塞的疗效观察

目的观察替罗非班治疗急性缺血性脑卒中阿替普酶静脉溶栓后再闭塞的疗效及安全性。方法发病4.5h内急性缺血性脑卒中患者行阿替普酶静脉溶栓再闭塞的患者60例,随机于再闭塞后予以静脉泵入替罗非班治疗(首剂5μg/kg静脉推注3min,续以0.075μg·kg~(-1)·min~(-1)静脉持续泵入24h)30例(B组)及常规治疗30例(A组)。观察2组溶栓前、溶栓后症状加重时及24h、7d时NIHSS评分,90d改良Rankin量表(mRS)评分及病死率、症状性颅内出血的发生率。结果溶栓前、溶栓后症状加重(再闭塞)时,2组NIHSS评分差异无统计学意义(P0.05)。24h、7d时NIHSS评分2组差异有统计学意义(P0.05)。90d时mRS≤2分2组差异有统计学意义(P0.05);2组病死率差异无统计学意义(P0.05);2组症状性脑出血发生率差异无统计学意义(P0.05)。结论替罗非班治疗急性缺血性脑卒中阿替普酶静脉溶栓后再闭塞是有效的、安全的。     

动静脉联合血管再通治疗急性脑卒中的疗效和安全性分析

目的观察在急性缺血性脑卒中患者中应用动静脉联合血管再通治疗的疗效和安全性。方法对2011年11月至2014年12月收治的急性缺血性脑卒中[美国国立卫生研究院卒中量表(NIHSS)评分≥10分]83例患者进行回顾性分析。将单纯静脉溶栓治疗的62例患者归为溶栓组;将静脉溶栓后无好转再行动脉内支架取栓治疗的21例患者归为取栓组。对两组进行疗效和安全性比较:1治疗7 d时比较两组NIHSS及改良Rankin(m RS)评分;2比较治疗后24 h的出血转化率和治疗后7 d的病死率。结果溶栓组和取栓组基线特征除高血压病史外余均差异无统计学意义(P﹥0.05)。两组疗效比较,治疗后7 d,NIHSS评分和m RS评分均差异无统计学意义(P﹥0.05)。两组安全性比较,治疗后24 h头颅CT显示出血转化率差异无统计学意义(P﹥0.05),两组治疗后7 d的病死率差异无统计学意义(P﹥0.05)。结论动脉取栓治疗的安全性与静脉溶栓治疗比较差异无显著性,且疗效未见比静脉溶栓治疗更好,可能与取栓治疗时间存在延误有关。     

阿替普酶静脉溶栓治疗急性缺血性卒中临床分析

目的探讨不同剂量重组组织型纤溶酶原激活剂(reconstructive tissue plasminogen activator,rt-PA,阿替普酶)静脉治疗合并房颤的急性缺血性卒中的安全性与疗效。方法选择2017-01-2019-11在河南科技大学第一附属医院神经内科接受rt-PA静脉溶栓治疗的70例合并心房颤动的急性缺血性脑卒中患者为实验组,选择同时期未给予rt-PA静脉溶栓治疗的38例合并心房颤动的急性缺血性脑卒中患者为对照组。将实验组患者随机分为低剂量组(0.6 mg/kg,A组)与标准剂量组(0.9 mg/kg,B组)。记录实验组溶栓前和溶栓后7 d NIHSS评分,记录对照组入院时和入院7 d NIHSS评分,记录3组患者7 d内的颅内出血发生情况和90 d病死率,采用改良Rankin量表(mRS)对各组患者90 d预后进行分析。结果低剂量组和标准剂量组患者溶栓后7 d较溶栓前NIHSS评分改善率均较对照组增高,差异有统计学意义(P0.05)。rt-PA静脉治疗后,低剂量组颅内出血发生率和90 d病死率均低于标准剂量组,但组间比较无显著性差异(P0.05);低剂量组与标准剂量组90 d预后良好率比较差异无统计学意义(P0.05)。结论对于合并心房颤动的急性缺血性脑卒中患者,低剂量rt-PA与标准剂量rt-PA在功能恢复方面相比无显著性差异,但具有潜在较低的脑出血率及病死率。     

rt-PA治疗合并缺血性脑白质病变的急性缺血性卒中患者的疗效评价

目的研究急性缺血性脑卒中(acute ischemic stroke,AIS)合并缺血性脑白质病变(white matter lesions,WML)患者行静脉溶栓治疗的有效性和安全性。方法收集天津市环湖医院神经内科四病区2018年10月-2019年7月期间收治的199例合并缺血性WML且发病在4.5 h内AIS患者,其中溶栓组患者99例,非溶栓组患者100例,进行回顾性分析。分析各组患者入院时、治疗后24 h及7 d的NIHSS评分,治疗后3 m的改良Rankin评分,分析溶栓后24 h不良事件发生情况(症状性颅内出血、非症状性颅内出血)和卒中相关病死率的差异性。结果溶栓组与对照组相比较,治疗24 h及7 d NIHSS评分水平明显下降(P 0.05)。3 m时远期预后溶栓组优于对照组(P 0.05)。溶栓后24 h颅内出血方面,溶栓组为7例(7.1%),非溶栓组为0,差异有统计学意义(P 0.05)。但两组之间的症状性脑出血、死亡率比较无统计学差异。结论合并缺血性脑白质病变的AIS患者行静脉溶栓治疗比非溶栓组预后明显要好,溶栓组比非溶栓组增加了一定的出血转化风险,但不会导致症状性颅内出血等不良反应的发生,也不会增加患者的死亡率,静脉溶栓治疗对于合并缺血性脑白质病变的AIS患者具有很高的安全性。     

心源性脑栓塞患者尿激酶静脉溶栓的疗效及安全性

目的探讨心源性脑栓塞患者尿激酶静脉溶栓的疗效及安全性。方法 64例急性缺血性卒中患者在发病6h内接受静脉溶栓治疗,根据患者既往史及入院时心电图检查结果将患者分为心房颤动组(22例)和非心房颤动组(42例),所有患者溶栓前行美国国立卫生研究院卒中量表(NIHSS)评分,溶栓后3个月行改良Rakin量表(mRS)评分。结果心房颤动组和非心房颤动组溶栓后3个月mRS评分0~1分患者比例差异无统计学意义(P0.05),心房颤动组和非心房颤动组症状性颅内出血比例差异无统计学意义(P0.05)。结论心房颤动不影响急性缺血性卒中患者静脉溶栓治疗的远期疗效,心房颤动患者行静脉溶栓不增加症状性颅内出血风险。     

早期静脉溶栓治疗急性轻型缺血性卒中的疗效观察

目的探讨早期静脉溶栓治疗急性轻型缺血性卒中的疗效及安全性。方法将70例首次急性轻型缺血性脑卒中患者随机分为溶栓组(35例)及未溶栓组(35例)。溶栓组于入院后给予重组组织型纤溶酶原激活剂(rt-PA)静脉溶栓治疗,未溶栓组给予阿司匹林(100 mg/d)口服。于出院时采用NIHSS评分评价患者神经功能缺损情况,治疗3个月后采用mRS评价患者预后。结果入院时溶栓组及未溶栓组患者一般临床资料差异无统计学意义(均P0.05)。与未溶栓组患者比较,溶栓组患者出院时NIHSS评分显著降低,预后良好的比率显著增高(P0.05~0.01)。两组患者均未发生症状性脑出血及死亡。结论静脉溶栓治疗可以显著改善轻型缺血性卒中患者的预后,并且不会增加其颅内出血的风险。     

支架取栓治疗脑前循环急性大血管闭塞型中重度缺血性脑卒中的疗效分析

目的评价Solitaire支架取栓治疗脑前循环急性大血管闭塞型中重度缺血性脑卒中的疗效及风险。方法纳入2013年1月至2016年9月内蒙包头市中心医院神经内科连续收治的颅内前循环急性大血管闭塞型中重度缺血性脑卒中患者55例,根据治疗方法的不同分为静脉溶栓组(27例)和支架取栓组(28例),比较分析2组患者临床资料差异、治疗前后美国国立卫生研究院神经功能缺损评分(NIHSS)的变化、治疗后24h内症状性颅内出血(sICH)发生率、治疗后30d内死亡率及治疗后90d时改良Rankin量表评分(mRS)差异。结果 2组发病时间(症状出现到准备治疗时间)比较,差异具有统计学意义(P0.05);与治疗前相比,支架取栓组在治疗后即刻、治疗后24h时、治疗后7d时、治疗后2w时NIHSS评分均降低,差异有统计学意义(P0.05);与静脉溶栓组相比,支架取栓组治疗后7d时NIHSS评分降低不明显(P0.05),治疗后2w时NIHSS评分明显降低(P0.05);2组24h内症状性颅内出血发生率及30d内死亡率无明显差异(P0.05);治疗90d时支架取栓组良好预后率明显优于静脉溶栓组。结论 Solitaire支架取栓治疗脑前循环急性大血管闭塞型中重度缺血性脑卒中比静脉溶栓治疗更有效,而治疗风险并未增加。     

心房颤动相关性脑梗死超早期rt-PA静脉溶栓治疗临床研究

目的观察急性脑梗死合并房颤患者超早期rt-PA静脉溶栓的疗效及安全性。方法选择神经内科急性脑梗死进行溶栓患者104例,根据有无房颤分为房颤组和非房颤组,其中房颤组42例,非房颤组62例,比较2组患者溶栓前后NIHSS评分、日常生活活动能力(ADL量表评分),以及颅内出血、死亡等不良结局情况。结果房颤组和非房颤组患者在入院时NIHSS评分、入院时的ADL评分、溶栓时间(发病至开始溶栓的时间)、糖尿病患者占比等差异均无统计学意义(均P0.05),但平均年龄、高血压占比差异均有统计学意义(均P0.05)。非房颤组溶栓前、溶栓后24h及7d时NIHSS评分比较差异有统计学意义(P=0.000),ADL评分差异有统计学意义(P=0.000)。房颤组溶栓前、溶栓后24h、7d时NIHSS评分比较差异有统计学意义(P=0.003),ADL评分比较差异有统计学意义(P=0.000)。房颤组溶栓后患者颅内出血转化11例,症状性颅内出血2例,不良结局6例,而非房颤组颅内出血转化为3例,无症状性颅内出血,不良结局2例,2组颅内出血转化差异有统计学意义(P=0.001),症状性颅内出血(P=0.076)及不良结局(P=0.078)差异无统计学意义(P0.05)。多因素回归分析提示房颤患者是颅内出血转化的独立危险因素(P=0.009)。结论房颤相关性卒中患者溶栓后虽明显增加颅内出血转化风险,但不增加症状性颅内出血及不良结局的风险。     

基层医院rt-PA静脉溶栓治疗急性脑梗死临床分析

目的探讨基层医院rt-PA静脉溶栓治疗急性脑梗死的溶栓流程及临床疗效。方法以2011-02—2013-07我院收治的41例急性脑梗死患者为研究对象,随机分为溶栓组和对照组,分别进行rt-PA静脉溶栓治疗和常规治疗,比较2组临床疗效、溶栓前、溶栓后12h、7d、14d2组NIHSS评分、不良反应及病死率。结果溶栓组17例,总有效率94.12%;对照组24例,总有效率83.33%。2组疗效比较差异具有统计学意义(P0.05)。溶栓前,2组NIHSS评分比较,差异无统计学意义(P0.05)。溶栓后12h、7d、14d2组NIHSS评分均明显降低,且组间差异具有统计学意义(P0.05)。2组泌尿道出血及牙龈出血差异具有统计学意义(P0.05)。2组非症状性灶内出血差异无统计学意义(P0.05)。结论基层医院使用rtPA静脉溶栓治疗急性脑梗死疗效显著,患者NIHSS评分得到明显改善,安全性高。     

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.     

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.     

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.     

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.     

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.     

Pediatric Epilepsy Surgery

Summary: The use of implantable arrays of epidural electrodes has made it possible to carry out extraoperative electrocorticography (ECoG) and functional localization in the awake child. This has permitted cortical excisions that are determined by criteria similar to those obtained during surgical procedures performed under local anesthesia in adults. In addition, the method also permits simultaneous ECoG and video monitoring during the child's symptomatic seizures, providing additional important localizing information that is impractical to obtain in operations under local anesthesia. We report our experience with 75 children, ages 5 months to 15 years, whom we have managed with epidural electrode arrays. The method of extraoperative ECoG is described and illustrative cases are presented to demonstrate its feasibility and utility in children. In addition, we call attention to gliomas as a common cause of chronic focal seizures in children. Of 49 children undergoing resection and followed for from 1 to 14 years (mean of 5.8 years), 32 (65%) are either seizure free or have had a significant reduction in seizure frequency that has unambiguously improved their quality of life. The results are analyzed further by relating the surgical outcome to each of the pathologic entities that caused the seizures. This analysis reveals the variety of neurological conditions that commonly cause intractable focal seizure disorder in children and distinguishes those pathologic entities in which the seizure disorder is apt to respond to surgical intervention from those that will not.