立体定向手术干预伏隔核治疗神经性厌食症

目的通过立体定向毁损术及脑深部电刺激能有效治疗神经性厌食症。方法共8例罹患神经性厌食症的患者通过立体定向手术干预伏隔核治疗神经性厌食症（其中6例患者接受双侧伏隔核毁损术,2例患者接受双侧伏隔核脑深部电刺激）。患者术前均接受正规的抗精神类药物及心理、营养治疗无效。患者术前及术后接受BMI指数、YBOCS,HAMA,HAMD量表的测定,评价疗效。结果 8例患者术后BMI指数均得到明显改善（P〈0.01）,除1名患者外,其余患者BMI指数均大于18.5kg/m^2。接受双侧伏隔核毁损术的患者术后YBOCS,HAMA,HAMD指数均得到立即改善,接受双侧伏隔核脑深部电刺激的患者术后经过程控,各项评定也均得到有效控制。结论伏隔核是治疗神经性厌食症的有效靶点,立体定向手术干预伏隔核可有效改善神经性厌食症患者的各项症状。     

伏隔核联合内囊前肢脑深部电刺激治疗难治性强迫症(2例病例报告)

目的脑深部电刺激正逐步取代传统毁损手术用于治疗难治性强迫症。然而,由于缺乏大样本量的前瞻性随机对照研究,最佳的刺激靶点及最优的刺激参数仍不甚明确。近年来,国际上涌现出一批采用内囊前肢或伏隔核为刺激靶点治疗难治性强迫症的小样本量报道,均提示不错临床疗效。为此,我中心采用伏隔核和内囊前肢同时刺激,探索更优多靶点组合及程控参数。方法 2015年12月到2018年5月四川大学华西医院神经外科完成2例双靶点脑深部电刺激治疗难治性强迫症病例,两例病例分别完成27个月和12个月临床随访,包括术前、术后强迫症状和一系列认知功能评估。结果开机后经过多次程控参数调整,两例患者不仅强迫症状明显缓解,而且焦虑抑郁情绪也有所改善。长期随访提示,两例患者强迫症状分别缓解75%和83%,均未出现明显的神经及认知功能废损。结论内囊前肢联合伏隔核DBS刺激难治性OCD证实了较好临床疗效。通过手术前后靶点影响分析及程控测试提示:内囊前肢腹侧中段联合伏隔核刺激提示更优靶点组合,即以较低能量达到明显改善强迫症状目的。     

立体定向下核团毁损术及脑深部电刺激术治疗难治性强迫症

目的探讨MRI定位下核团毁损术及脑深部电刺激术治疗难治性强迫症的疗效。方法应用MRI定位下射频热凝核团毁损术及脑深部电刺激术治疗难治性强迫症49例，其中30例行双侧内囊前肢毁损术，13例行双侧扣带回加双侧内囊前肢毁损术,6例行右侧伏隔核脑深部电刺激术加对侧内囊前肢毁损术。手术前后应用YALE-BROWN强迫症状量表、汉密尔顿抑郁量表、汉密尔顿焦虑量表对手术效果进行评价。结果术后6个月均获随访，其中临床痊愈28例，显著改善9例，轻度改善7例，无明显变化5例。22例术后早期出现一过性并发症，均在术后2周内恢复。术后焦虑，强迫，抑郁症状量表分数均明显下降（P〈0．01）。结论MRI定位下核团毁损术及脑深部电刺激术治疗难治性强迫症有显著疗效，并发症较轻，可以显著改善病人强迫、焦虑、抑郁症状。     

脑深部电刺激治疗药物难治性抽动秽语综合征的疗效观察

目的探讨脑深部电刺激(DBS)治疗药物难治性抽动秽语综合征(TS)的临床疗效, 初步观察以苍白球内侧部(GPi)与以中央中核-束旁核复合体(CM-Pf)为靶点的DBS在改善抽动症状方面的差异。方法回顾性分析2006年10月至2023年1月于首都医科大学附属北京天坛医院神经外科学中心接受DBS治疗且随访时间≥12个月的40例TS患者的临床资料。其中33例为GPi-DBS组, 7例为CM-Pf-DBS组。随访术后6、12个月患者临床症状的改善情况。临床症状的主要评估指标为耶鲁综合抽动严重程度量表(YGTSS)评分, 次要评估指标为贝克抑郁量表(BDI)、汉密尔顿抑郁量表(HRDS)、医院焦虑和抑郁量表(HADS)、耶鲁布朗强迫症严重程度量表(YBOSC)评分。对比分析两组YGTSS评分的改善情况。结果 40例患者术前, 术后6、12个月的YGTSS评分分别为(63.6±14.2)分、(42.0±15.0)分、(36.1±16.9)分, 差异有统计学意义(P<0.001);术后6、12个月YGTSS评分的改善率分别为(33.7±19.0)%、(43.1±23.3)%。BDI(24例)、...     

VPL/VPM联合PAG/PVG脑深部电刺激治疗神经性疼痛的疗效分析

目的 探讨丘脑腹后外侧核/腹后内侧核( VPL/VPM)脑深部电刺激(DBS)联合导水管周围灰质/脑室旁下丘脑核团(PAG/PVG) DBS治疗神经性疼痛的疗效.方法 对24例神经性疼痛患者进行回顾性分析,除早期2例只使用PVG作为靶点外,其他患者均采用VPL/VPM联合PAG/PVG DBS进行治疗,并在术前、术后3个月采用视觉模拟评分(VAS)评估疼痛级别,比较分析治疗效果.结果 22例成功接受VPL和PVG联合靶点治疗(其中5例为双侧),2例只接受单侧PVG- DBS.其中17例恢复良好(有效率70.8％),7例术后将DBS去除(1例颅内感染,6例疗效较差).所有患者术前VAS评分平均为(8.04±0.86)分,术后VAS评分平均为(3.13±1.44)分,P＜0.05.有效患者中VPL靶点的疗效均满意,PVG靶点的有效例数为12例.7例PVG靶点产生明显不良反应,VPL靶点无明显不良反应.结论 利用PVG/VPL联合治疗慢性神经痛有一定的疗效,但由于PVG的疗效不甚满意及不良反应较多,VPL也许更适合作为神经性疼痛治疗的靶点.     

脑深部电刺激治疗抽动秽语综合征10例疗效分析

目的 探讨脑深部电刺激术(DBS)治疗抽动秽语综合征(GTS)的安全性和有效性.方法 微电极记录双侧苍白球内侧部(Gpi)放电信号后,埋置DBS治疗GTS患者10例.采用耶鲁抽动严重程度综合量表(YRTSS)评估术后效果.随访时间2-24个月.结果 10例GTS患者症状较术前均有不同程度改善,改善率28.2%～80.0%.1例患者术后12个月埋植脉冲发生器部位皮肤破溃,脉冲发生器外露.拔除刺激器后3个月,症状改善稳定,没有恶化.另1例患者因活动时撞击胸部造成皮肤破溃,拔除脉冲发生器后,症状略有加重,但较术前仍有改善.后将脉冲发生器重置,症状改善,恢复早期术后状态.结论 通过对DBS治疗GTS患者安全性和有效性的评估,表明DBS是治疗难治性GTS的一种安全有效的术式.     

大脑脚间核脑深部电刺激改善帕金森病冻结步态的效果

目的探讨大脑脚间核脑深部电刺激对帕金森病冻结步态的改善效果。方法采用大脑脚间核脑深部电刺激(DBS)术治疗3例药物难治性冻结步态帕金森病患者。其中2例患者采用双侧大脑脚间核DBS,1例患者采用单侧大脑脚间核联合对侧丘脑底核DBS。采用UPDRSⅢ(27~30项)对患者的轴线症状进行评分,评估效果。结果术后2例双侧DBS术的患者改善率为63.6%和66.7%;单侧DBS术患者的改善率为57.1%。3例患者术后无明显并发症。结论大脑脚间核DBS术对药物难治性帕金森病冻结步态是一种安全有效的治疗方式。     

脑深部电刺激术治疗肌阵挛肌张力障碍综合征三例并文献复习

目的观察脑深部电刺激术(DBS)治疗肌阵挛肌张力障碍综合征(myoclonus dystonia syndrome,MDS)的长期疗效。方法对3例MDS患者行DBS治疗,并进行术后随访。采用UMRS(unified myoclonus rating scale)肌阵挛量表和Burke-Fahn-Marsden肌张力障碍量表(Burke-Fahn-Marsden dystonia rating scale,BFMDRS)评价治疗效果并复习文献。结果本组患者采用丘脑腹外侧中间核DBS,开启刺激后,患者肌阵挛和肌张力障碍的症状均得到明显改善。1例患者因在术后第30个月开始出现新发部位的严重肌张力障碍,后加行双侧苍白球内侧部电刺激术。平均随访64.7个月,肌阵挛平均改善99.1%,肌张力障碍量表运动评分平均改善85.3%,功能障碍评分平均改善78.8%。经长期随访患者疗效稳定。结论 DBS对MDS有良好的治疗效果。     

微电极引导立体定向核团毁损和脑深部电刺激治疗帕金森病

目的研究微电极引导立体定向颅内核团毁损和脑深部电刺激手术(deep brain stimulation,DBS)治疗帕金森病的临床疗效。方法分析我院116例应用微电极引导立体定向核团毁损术和85例应用脑深部电刺激术治疗的帕金森病患者的临床资料,获得术前、术后和DBS开启后6个月、1年、3年及5年的不同服药状态下帕金森病联合评分量表(UPDRS)的评分,比较手术前后UPDRS运动评分的差异。结果核团毁损术和DBS在术后6个月、1年和3年的随访中均能显著改善患者术前UPDRS运动评分,在第5年仅DBS组UPDRS运动评分较术前有改善,同时DBS组患者术后抗帕金森病药物用量较术前减少。结论核团毁损和脑深部电刺激手术均能显著改善帕金森病患者的UPDRS运动评分,DBS疗效更为长久。     

学历因素影响帕金森病脑深部电刺激术后焦虑和抑郁改善的研究

目的研究影响帕金森病患者脑深部电刺激(DBS)术后焦虑和抑郁改善的相关因素;包括学历水平、运动症状改善率等。方法北京天坛医院功能神经外科收治的90例帕金森病行DBS术患者。所有患者采用单侧或双侧DBS术进行治疗,术后1个月打开刺激器。分别于术前和术后1个月、3个月对患者进行评估和随访,内容包括患者基本资料、用药情况、量表评分。根据患者的汉密尔顿焦虑量表(HAMA)和汉密尔顿抑郁量表(HAMD)评分变化,评估患者焦虑和抑郁症状的改善程度;采用相关分析法分析影响DBS术后焦虑和抑郁改善的因素。结果本组患者DBS术后的焦虑和抑郁症状均明显改善(均P 0. 05)。大学学历组患者术后的焦虑症状明显改善(P 0. 05),大学以下学历患者术后的焦虑症状明显改善(P 0. 05)。大学学历组患者术后与术前的抑郁量表评分比较,差异无统计学意义;大学以下学历组患者术后抑郁症状改善明显(P 0. 05)。大学学历组患者术后的焦虑改善率与运动改善率呈正相关(r~2=0. 35,P 0. 05),大学以下学历组患者术后的焦虑改善率与运动改善率呈负相关趋势(r~2=0. 08,P=0. 09);大学学历组患者术后的抑郁改善率与运动改善率呈正相关趋势(r~2=0. 11,P=0. 26),大学以下学历组患者术后的抑郁改善率与运动改善率呈负相关趋势(r~2=0. 06,P=0. 13)。结论 DBS术后患者的焦虑、抑郁评分明显降低;大学学历患者术后的焦虑症状明显改善,大学以下学历患者术后焦虑、抑郁症状均明显改善。大学学历患者的焦虑、抑郁改善率与运动改善率呈正相关趋势,大学以下学历患者的焦虑、抑郁改善率与运动改善率呈负相关趋势。     

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.