脑边缘系统肿瘤(附91例分析)

目的 探讨边缘系统肿瘤的临床病理特点以及显微手术治疗策略，特别是锁孔手术的可行性及其疗效。方法 对91例脑边缘系统肿瘤的临床特点、手术方法和病理特点进行系统的回顾性分析。对34例肿瘤直径2.5cm中的32例及57例〉5cm中的9例采用锁孔手术．包括改良翼点入路、眶上额下眉弓入路、发际内过中线横切口的锁孔手术；其余均采用传统开颅手术，如翼点入路，额下入路、纵裂入路等。结果 脑边缘系统肿瘤常见于中青年病人；癫痫发作常是首发或惟一的症状。肿瘤全切53例（58．2％），次全切38例（4l、8％）。术后病理结果示低级别胶质瘤79例（86．8％），海绵状血管瘤4例，间变性星形细胞瘤4例，神经胶质增生2例，动静脉畸形1例．胶质肉瘤1例。结论 脑边缘肿瘤以低分级胶质瘤和其他良性肿瘤为主，继发性癫痫发作是其主要临床表现。对部分肿瘤直径〈5cm的病人．应用锁孔手术可获得满意疗效。     

边缘系统胶质瘤的临床病理特征及手术治疗

目的 对边缘系统胶质瘤的临床特征，手术切除及效果进行分析。方法 对1997年10月至2000年4月进行切除的19例边缘系统胶质瘤病人的临床表现，病理类型，影像学特征，手术及预后进行回顾性分析。结果 19例病人均进行了肿瘤切除。14例全切，5例次全切，术后除各有2例病人出现暂时运动性失语和对侧肢体偏瘫外，均恢复良好，无严重的手术并发症及手术死亡。结论 边缘系统胶质瘤源于原始皮质，MRI能清楚地显示肿瘤的大小，部位，范围和界限，可以进行广泛性肿瘤切除而不损伤或很少损伤重要结构。     

锁孔手术治疗低级别胶质瘤的远期疗效观察

目的探讨锁孔手术治疗低级别胶质瘤的远期疗效。方法回顾性分析85例幕上低级别胶质瘤病人的临床资料,其中传统手术组37例,锁孔手术组48例,对两组病人的手术参数及预后进行统计学分析。结果两组病人的5年生存率、肿瘤全切率及手术时间差异无统计学意义(均P>0.05);术中输血率、并发症发生率、术中平均出血量及术后平均住院时间差异有统计学意义(均P<0.05)。结论对于位置较深、直径≤4 cm的幕上低级别胶质瘤可以采用锁孔手术治疗,远期疗效与较传统手术无差别。     

神经导航辅助显微手术治疗边缘系统胶质瘤(附36例分析)

目的 探讨神经导航辅助显微手术治疗边缘系统胶质瘤的疗效.方法 回顾性分析神经导航辅助显微手术治疗36例边缘系统胶质瘤的临床资料,对神经导航术中应用的优越性、精确性等进行分析.结果 本组神经导航平均注册误差(1.6±0.8)mm,肿瘤和大脑中动脉、基底核等重要解剖结构定位准确.肿瘤全切除30例,部分切除6例.术后神经功能未受明显影响,无手术并发症及死亡.结论 神经导航辅助显微手术治疗边缘系统胶质瘤具有定位准确、可动态示踪、实时导航、侵袭性小和安全可靠等优点,有助于提高肿瘤全切除率及减少手术并发症.是边缘系统胶质瘤治疗的首选方法.     

边缘系统低级别脑胶质瘤的诊断与显微手术治疗

目的 探讨边缘系统低级别胶质瘤应用显微手术广泛性切除的可行性及其效果。方法 回顾分析我院1995年2月至2000年12月应用显微手术广泛性切除的38例边缘系统低级别胶质瘤,就其疗效进行随访研究。结果 肿瘤全切除21例,次全切除12例,部分切除5例。术后无1例死亡,8例术后出现短暂性失语和反应迟钝,5例发生命名性失语,2例术后癫痫小发作,28例术后恢复良好,头颅CT或MRI检查无肿瘤残存征象。30例获得随访,56％的病例2年内未见复发。结论 边缘系统低级别胶质瘤起源于异生皮层和中间皮层,通过显微手术广泛性切除肿瘤而不致损伤重要功能结构,术后辅以放疗可明显延长生存期。     

边缘系统胶质瘤的诊断与手术治疗

目的探讨边缘系统胶质瘤的诊断和手术治疗效果，分析影响预后的因素。方法回顾性分析我院2000年2月-2005年5月应用显微手术广泛性切除的23例边缘系统胶质瘤，就其疗效进行随访研究。结果术后头颅CT或MRI检查无肿瘤残存征象。病理分级参照WHO分级，提示星形细胞肿瘤12例，间变性星形细胞瘤9例，少突胶质细胞肿瘤2例。术后症状较术前明显改善的有17例，不变5例，加重1例，术后无死亡。19例获得随访，17例3年内未见复发。结论术前充分了解肿瘤的解剖位置和周围结构的毗邻关系，充分解剖外侧裂，利用脑组织的自然解剖间隙可以实现肿瘤全切而不致重要功能结构的损伤。     

边缘系统低级别胶质瘤与顽固性癫痫

目的 探讨边缘系统低级别胶质瘤致顽固性癫痫的临床特征、手术方法及疗效。方法 对自1993年3月一2000年12月本科因顽固性癫痫进行手术切除的11例边缘系统低级别胶质瘤作一回顾性分析。结果 11例患者中10例以癫痫起病，平均病程26个月，发作类型为复杂性部分性发作和继发性全身发作。11例患者均经扩大翼点入路行胶质瘤全切加上标准前额叶切除。术后病理为少枝突胶质瘤3例，星形细胞瘤Ⅰ级5例，星形细胞瘤Ⅰ—Ⅱ级3例。11例患者随访10个月一3年，复查CT或MRI检查，无肿瘤复发迹象，癫痫控制满意。结论 边缘系统低级别胶质瘤致顽固性癫痫，病程长，久治不愈，年龄偏轻，通过完全的肿瘤切除加上标准前额叶切除，可大大降低肿瘤的复发率，极好地控制癫痫。     

边缘系统低级别脑胶质瘤的诊断与显微手术治疗

目的 :探讨边缘系统低级别胶质瘤应用显微手术广泛性切除的可行性和其效果。方法 :回顾性分析我院1995年 2月～ 2 0 0 0年 12月应用显微手术广泛性切除的 38例边缘系统低级别胶质瘤 ,就其疗效进行随访研究。结果 :术后无 1例死亡 ,8例术后出现短暂性失语和反应迟钝 ,2例术后癫痫小发作 ,2 8例术后恢复良好 ,头颅 CT或 MRI检查无肿瘤残存征象。 30例获得随访 ,76 %的病例 3年内未见复发。结论 :边缘系统低级别胶质瘤起源于异生皮层和中间皮层 ,通过显微手术广泛性切除肿瘤而不致损伤重要功能结构 ,术后辅以放疗可明显延长生存期     

颅内大型胶质瘤的显微外科治疗

目的探讨颅内大型胶质瘤的显微外科治疗方法和效果。方法对52例直径大于5cm的颅内胶质瘤患者采用显微外科手术方治疗。结果52例患者中，显微镜下肿瘤全切44例，次全切及大部分切除8例，无手术死亡及严重并发症发生。术后随访40例，时间1～3年，肿瘤复发13例。结论显微外科治疗颅内大型胶质瘤效果显著，在保护重要功能结构区的前提下尽量全切肿瘤是确保手术疗效的关键。     

经眶上锁孔入路切除鞍区大型肿瘤的显微手术技巧探讨

目的探讨经眶上锁孔显微手术切除鞍区大型肿瘤的技巧。方法对63例瘤体为3.0cm×2．0cm×2.0cm-11cm×9cm×9cm的鞍区大型肿瘤（包括33例垂体腺瘤，16例颅咽管瘤，9例脑膜瘤及胚胎生殖细胞瘤、视神经纤维瘤、胶质瘤、巨大蛛网膜囊肿和拉克囊肿各1例），采用经眶上锁孔入路手术切除，并探讨肿瘤显露、切除方法和重要神经结构和血管的保护方法。结果肿瘤全切56例（88．9％），大部分切除7例，未全切者部分病例行放射治疗。术后1例死亡。术后主要并发症有尿崩症、硬膜下积液。随访5月-4．5年（平均2．6年），3例肿瘤复发。结论采用眶上锁孔入路显微手术切除鞍区大型肿瘤效果好、创伤轻，并节省手术时间。     

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.