鞍结节脑膜瘤显微手术治疗策略

目的探讨鞍结节脑膜瘤的显微手术切除策略。方法回顾性分析82例鞍结节脑膜瘤的临床资料,均采用显微手术切除。经额外侧入路44例,经眶-额外侧入路28例,经眶-颧-额-颞入路7例,经翼点入路3例。术中磨除前床突和视神经管顶及外侧嵴,切除侵入视神经管内的肿瘤27例;磨除鞍结节,经蝶窦切除鞍前壁肿瘤12例。结果肿瘤SimpsonⅠ、Ⅱ级切除75例(91.5%),SimpsonⅢ级切除7例(8.5%);术后视力改善和稳定151只眼(92.1%),视力恶化13只眼(7.9%)。术后出现不同程度下丘脑症状2例,术后偏瘫1例,无手术死亡病例。结论正确选择手术入路,采用熟练的显微颅底外科技术是获得良好手术效果的保证。额外侧入路能提供良好的手术空间和视野,术后视觉症状改善明显。术中打开视神经管,仔细辨别并保护蛛网膜屏障中的小血管,是保障肿瘤全切除和术后视力恢复的关键。     

27例鞍结节脑膜瘤的显微手术体会

目的探讨鞍结节脑膜瘤显微手术治疗方法及效果。方法回顾性分析2010年3月~2016年3月显微手术治疗的27例鞍结节脑膜瘤的临床资料。所有病人术后随访6~24个月。结果 27例中,肿瘤Simpson分级Ⅰ级切除3例,Ⅱ级切除22例,Ⅲ级切除2例。术后视力改善13例,不变13例,恶化1例。术后出现视力减退3例、电解质紊乱3例、嗅觉减退3例、应激性溃疡2例、尿崩症2例、偏瘫1例。术后复发2例,均再次手术。结论根据鞍结节脑膜瘤大小、生长方式及视觉功能受损情况、术者操作习惯选择合适的手术入路,术中尽量分块切除肿瘤,充分识别蛛网膜屏障保护神经血管下丘脑等重要结构,可提高鞍结节脑膜瘤全切率,减少术后并发症。     

内侧型蝶骨嵴脑膜瘤显微手术治疗分析

目的 探讨内侧型蝶骨嵴脑膜瘤显微手术治疗情况.方法 对31例显微手术治疗内侧型蝶骨嵴脑膜瘤进行回顾性分析.结果 31例患者中肿瘤全切除(Simpson Ⅰ、Ⅱ)25例,次全切5例.术中证实肿瘤基底部主要位于蝶骨小翼、前床突,部分向周围延伸,侵蚀海绵窦,视神经管、眶内,术后大部分患者视力不同程度恢复,一过性偏瘫10例(10/31)视力恶化3例,1例死亡.结论 显微手术切除是内侧蝶骨嵴脑膜瘤最有效的治疗方法.掌握全面的解剖知识和熟练的手术技巧,选择恰当的手术入路,成功的肿瘤切除及术后并发症的及时处理是显微外科治疗的关键.     

鞍结节脑膜瘤的显微外科治疗(附30例报告)

目的探讨鞍结节脑膜瘤显微手术治疗效果。方法对30例行显微手术治疗的鞍结节脑膜瘤患者的临床资料及手术效果进行分析总结。结果肿瘤全切(Simpon分级Ⅰ、Ⅱ级)24例,次全切(Simpon分级Ⅳ级)4例,大部分切除2例。术中去骨瓣减压2例。手术死亡1例。术前有视力下降的26例患者中,术后早期视力改善20例,无变化4例,恶化2例。术后随访3～38个月,2例术中去骨瓣减压的患者分别于术后6个月及8个月时行颅骨缺损修补术;24例肿瘤全切病例中,3例患者有肿瘤复发,2例行二次手术,1例选择放射治疗。失访3例。结论鞍结节脑膜瘤位置深在,与周围血管神经等重要结构关系密切,但积极的显微外科手术治疗效果良好。     

鞍结节脑膜瘤的显微外科策略与手术技巧

目的探讨显微外科治疗鞍结节脑膜瘤的策略和手术技巧。方法回顾性分析31例鞍结节脑膜瘤的临床表现、影像学资料和显微外科治疗结果。其中行单侧额下入路5例,翼点入路9例,改良翼点入路11例,双额冠状开颅经纵裂入路6例。结果Simpson Ⅰ级切除4例,Ⅱ级切除23例,Ⅲ级切除4例。术后视力改善24例,无变化4例,视力下降3例。死亡1例。结论根据肿瘤不同的生长形态选择恰当的手术入路和计划,应用显微外科技术操作,能够显著提高肿瘤的全切率和降低并发症。     

嗅沟脑膜瘤的显微手术治疗

目的 探讨嗅沟脑膜瘤的临床特征及其治疗策略.方法 回顾性分析16例嗅沟脑膜瘤病人的临床资料,其中经冠状开颅双侧额下入路11例,经翼点入路5例.结果 肿瘤达Simpson Ⅰ级切除10例,SimpsonⅡ级切除6例,无手术死亡病例.术后头痛、精神症状和癫癎均不同程度改善,嗅觉障碍无改善,视力下降好转5例,无改善3例.术后新增精神症状6例.随访0.5～2年,肿瘤均未复发.结论 嗅沟脑膜瘤主要的临床症状是头痛和嗅觉障碍,选择合适的手术入路可明显改善病人的预后.     

鞍区脑膜瘤的临床特点与显微外科治疗

目的 探讨鞍区脑膜瘤的临床特点、诊断及手术治疗效果。方法 对122例经病理证实的鞍区脑膜瘤的临床资料进行回顾性分析。结果 Simpson Ⅰ级20例,Ⅱ 级61例, Ⅲ级18例,Ⅳ级23例。肿瘤全切除（Simpson Ⅰ~Ⅲ 级）99例,次全切除23例;全切除率为81.2%。术后3个月随访,首发症状（视力下降及头疼等）改善率为81%;术后6个月首发症状改善率为89%。1例肿瘤全切术后复发（因再次视力下降入院）。术后死亡2例。结论 对于鞍区脑膜瘤,仔细的术前评估、选择合适的手术入路,可以有效地提高显微手术效果。     

伴有视力障碍的内侧型蝶骨嵴脑膜瘤治疗及预后分析

目的探讨伴有视力障碍的内侧型蝶骨嵴脑膜瘤的手术治疗及术后视力改善情况。方法回顾性分析我院手术治疗的32例伴有视力障碍的内侧型蝶骨嵴脑膜瘤患者临床资料及术后随访结果。结果32例内侧型蝶骨嵴脑膜瘤患者,视力改善20例,未改善12例;肿瘤全切21例,次全切除8例,大部切除3例。术前有视神经萎缩的8例患者,术后随访6例视力无变化,2例视力恶化。小型肿瘤手术后视力改善（改善率90．0％）优于肿瘤较大者（大型及巨大型50．0％）;肿瘤全切的患者视力改善（改善率81．0％）优于未行全切者（改善率27．3％）。结论手术后视力改善与术前肿瘤大小、是否全切及术前有无视神经萎缩有关。     

眶内球后肿瘤的外科治疗探讨

目的探讨眶内球后肿瘤的外科治疗方法和疗效。方法对2000年至2006年收治的28例眶内球后肿瘤患者采用额下眶顶入路或眶外侧入路手术治疗,并根据病理诊断指导术后治疗。结果28例患者中,肿瘤全切除24例,次全切除3例,部分切除1例。术后视力改善4例（14.3%）,无变化22例（78.6%）,恶化2例（7.1%）。14例恶性肿瘤术后行放疗和/或化疗。随访6～14个月,肿瘤均无复发。结论手术是治疗眶内球后肿瘤的主要方法。手术虽不能明显改善术后视力,但对维系术前视力有帮助。恶性肿瘤术后还应行放疗和/或化疗。     

改良翼点入路显微切除鞍结节脑膜瘤

目的 总结经改良翼点入路显微手术切除鞍结节脑膜瘤的经验. 方法回顾性分析广州军区武汉总医院神经外科自2001年1月至2007年4月应用改良翼点入路显微手术治疗的26例鞍结节脑膜瘤患者的临床资料. 结果 26例患者获Simpson Ⅰ级切除11例,Ⅱ级切除14例,Ⅲ级切除1例.术后视力损害和视野缺损均有不同程度恢复23例,1例视力无改变,术后视力下降2例经治疗后改善.7例术后出现不同程度的尿崩,经对症治疗约10 d后好转.无1例死亡.随访6个月～5年,肿瘤无复发. 结论改良翼点入路可对中颅窝、前颅窝、鞍区及鞍旁病变进行良好暴露,能处理各种类型的鞍结节脑膜瘤,提高全切除率,减少术后并发症,值得临床推广应用.     

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.     

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.     

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.     

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.     

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.     

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.