脑磁图和功能磁共振在脑功能区占位手术中的应用

脑外科手术常常面对这样的难题,通过手术切除了肿瘤,但由手术而产生的对脑的损害比这些疾病本身对脑的损害还要严重,特别是当病变与运动中枢和语言中枢联系在一起的时候。这些严重后果常常由于术前没有准确的功能区定位所致。CT、MRI神经影像为脑部手术病灶提供了大体解剖信息,但功能区脑组织的移位、病灶与功能区皮层毗邻关系等重要信息无从反映,功能磁共振（fMRI）和脑磁图（MEG）是近年来兴起的无创性脑功能检测技术,对于脑功能区占位手术入路设计,手术过程中避免损伤功能区组织和术后出现神经功能障碍的评估等问题提供了重要信息。     

功能区皮层下小病灶相关性癫痫的手术治疗

目的评价综合应用多种定位技术治疗功能区皮层下小病灶相关性癫痫的手术方法及效果。方法 58例功能区皮层下小病灶引起的癫痫患者,在立体定向仪导向下,开放直视手术切除病灶,术中皮层脑电图(ECoG)监测定位致痫灶,术中神经电生理监测(IOM)判断致痫区的功能以及二者的重叠程度,辅助以麻醉唤醒定位语言区、实时超声检查病变切除程度,根据监测结果分别采取致痫灶切除术、多处软膜下横切术(MST)或皮层低功率电凝热灼术妥善处理致痫灶。结果病灶全部切除52例,少量残留6例。病灶区域ECoG监测除波幅略有降低外无明显异常13例,行占位病灶切除术;ECoG明显异常,在非主要功能区8例,行占位病灶+周边致痫皮层切除术;ECoG明显异常而又在主要功能区37例,行占位病灶+功能区致痫皮层多处软膜下横切术(MST)或低功率电凝热灼术。ECoG监测发现痫样放电消失、基本节律大致恢复正常29例,仍残留少量棘波13例,残存较多棘波且基本节律轻到中度异常16例。随访1～5年,EngelⅠ级46例,EngelⅡ级8例,EngelⅢ级4例,总有效率100%。出现暂时性轻偏瘫17例,暂时性失语8例,无严重永久性并发症。结论综合应用立体定向引导、术中IOM、ECoG、麻醉唤醒及实时超声定位治疗功能区小病灶相关性癫痫,能够精准定位并切除病灶及处理致痫灶,避免损伤功能区,是一种微创、安全、有效的手术方法。     

经脑沟入路切除脑功能区深部小病灶:22例报告

目的探讨脑功能区深部小病灶手术切除的方式和方法。方法 22例位于脑功能区深部小病灶,均采用立体定向引导,经脑沟入路的方式进行病灶显微手术切除。结果 22例病灶均获得全切除,术后3例短期内功能下降,3个月后有不同程度的恢复。结论立体定向引导经脑沟入路进行脑功能区深部小病灶显微手术切除,可以在保留皮层功能的情况下切除病灶。     

立体定向治疗功能区皮层下小肿瘤性癫痫的临床研究

目的探讨立体定向治疗在功能区皮层下小肿瘤性癫痫中的应用方法、治疗效果及术后并发症发生情况。方法回顾性分析2011年6月~2016年5月我院神经外科收治的功能区皮层下小肿瘤性癫痫患者67例,通过立体定向进行功能区皮层下靶向微创手术的35例患者为观察组,通过开颅手术进行肿瘤切除的32例患者为对照组,比较两组患者手术效果及术后并发症。结果随访2~36个月,观察组患者立体定向术后总有效率97.2%显著高于对照组患者总有效率75.0%(P0.05);立体定向手术6个月后进行随访,结果显示病灶全切的满意率为94.2%高于次全切、部分切除的满意率68.6%(P0.05)。结论原发性脑肿瘤是引发癫痫的常见因素,采用立体定向对脑功能区皮层下小肿瘤及其至痫灶进行切除,不仅可以对病灶进行精准定位,还能够有效的减少对脑功能区的损伤,均有精确、微创的优势。     

神经导航辅助显微外科切除颅内海绵状血管瘤

<正>海绵状血管瘤(cavernous hemangioma,CA)是脑血管畸形的一种,随着影像学技术的迅速发展,其检出率越来越高,所发现的病灶也越来越小,这对病灶的手术切除提出了更高的技术要求。目前手术切除病灶是CA治疗的根本方法,病灶反复出血或位于重要功能区以及反复癫痫发作是最主要的手术指征[1]。如果CA病灶体积较小,位置深入,术前病灶准确定位困难,手术时容易造成周围组织的损伤,引起术后不同程度的神     

皮层电极埋藏对累及运动功能区病灶切除的意义

目的 探讨手术治疗毗邻和侵犯中央区的病灶周边运动功能区的保护方法.方法 回顾分析6例病灶累及中央区的病例资料(5例为药物难治性癫痫,1例为颅内转移瘤),采用神经导航定位病灶,第一次手术埋藏皮层电极覆盖病灶,术外患者清醒状态下实施皮层电刺激定位躯体运动区,绘制病灶与功能区关系图,第二次手术依据皮层电刺激结果行病灶切除.结果 6例患者第一次术后,均成功实施皮层电刺激,准确定位病灶周边运动功能区.依据关系图第二次手术3例患者(2例药物难治性癫痫,l例颅内转移瘤)行病灶全切,3例患者(3例药物难治性癫痫)行部分病灶切除.术后无一例出现神经功能缺损.结论 神经导航定位病灶指导埋藏皮层电极,术外行皮层电刺激定位病灶周边运动功能区,绘制功能区与病灶关系图指导第二次手术切除病灶,是在保护患者运动功能前提下,最大范围切除累及中央区病灶的一种安全有效的方法.     

开放性立体定向锁眼手术切除颅内小病灶

目的 探讨开放性立体定向“锁眼”手术切除颅内小病灶的手术方法和优越性。方法 20例颅内小病灶(直径在0．6～3cm)在CRW立体定向仪及手术计划系统指导下，采用小切口，环钻开颅，显微外科手术，表浅病灶直接沿脑沟分离完整切除，功能区皮层下病灶，在导针引导下沿非功能区皮层下斜形径路分块切除。结果 在CRW定向系统精确定位下，病灶全切率达100％，5例功能区病灶术后神经功能保护良好，无手术并发症及死亡。结论 立体定向引导的“锁眼”显微手术切除颅内小病灶，是一种定位精确、微创、安全、有效的手术方法。     

全麻唤醒和术中电刺激在脑功能区病灶性癫痫手术中的应用

目的 探讨全麻唤醒和术中电刺激在脑功能区病灶性癫痫手术中的应用及意义.方法 对11例涉及脑功能区病灶性癫痫患者术前行MRI和头皮视频脑电图检查,其中6例行fMRI检查.全麻下手术,其中7例行食道咽腔导管插管全麻唤醒.术中皮层脑电图定位痫样放电皮层,皮层电刺激定位皮质功能区,根据病灶、致痫皮层和皮层功能区关系选择相应手术方式,在切除病灶时作皮层电刺激以保护皮质下功能传导束.结果 10例病灶全切除,1例次全切除.术后2例暂时性偏瘫.随访6～24月,患者无神经功能障碍,Kamofsky评分平均100分,使用1种抗癫痫药物,癫痫控制满意.结论 食道咽腔导管插管全麻唤醒屉一种安全、简便的麻醉唤醒方法;术中电刺激监测能够最大限度切除病灶,妥善处理致痫皮层,有效保护脑功能区,改善患者的生活质量.     

立体定向显微手术治疗中央沟附近脑囊虫性肉芽肿

脑实质内的囊虫性肉芽肿病灶较小,传统开颅手术很难准确找到病灶,往往会造成脑功能区皮质及血管损伤,导致术后功能障碍.2002年10月至2006年12月,我们对位于中央沟附近的17例脑囊虫性肉芽肿进行立体定向导向下显微手术切除,手术定位准确,创伤小,效果满意,现报告如下.     

导航辅助皮层功能拓扑定位在累及功能区致痫灶手术中的初步应用

目的 应用神经导航影像融合并结合皮层电刺激功能定位技术,初步实现三维可视化皮层功能拓扑定位,辅助累及皮层功能区致痫灶的手术,提高疗效.方法 1例药物难治性癫痫患者,行双侧皮层电极埋藏覆盖中央区,术后予皮层脑电图监测,并实施皮层电刺激定位功能区.神经导航系统融合头颅MRI和CT影像,三维可视化拓扑定位皮层功能和致痫灶,第二次手术在导航辅助定位保护功能区的前提下,行致痫灶切除术,对累及功能区的病变实施皮层热灼术.结果 患者成功埋藏32导、24导及6导皮层电极各一枚覆盖中央区,皮层脑电图监测捕获临床发作4次,定位致痫灶;皮层电刺激确定功能区.神经导航影像融合建立覆盖皮层电极的三维大脑模型,还原电生理资料,实现拓扑定位.手术成功实施病灶切除,术后无发作情况,无并发症.结论 应用神经导航影像融合技术,使作为脑-机接口的脑皮层电极技术与影像学技术相结合,将皮层电极的空间位置,精确融合在基于头颅MRI建立的大脑皮层解剖模型上,还原皮层脑电图和皮层电刺激结果,实现三维可视化拓扑定位,对于累及功能区致痫灶的神经外科手术具有重要指导意义.     

视频脑电图在小儿癫痫诊断中的应用

目的评价视频脑电图(video-EEG)在小儿癫诊断中的应用价值。方法对126例具有发作性症状的患儿进行连续8h的包括清醒、睡眠、诱发试验及必要的认知测验的视频脑电图监测。结果经发作期视频脑电图证实,39例初诊为癫性发作的患儿中14例(35%)为非癫性发作;15例其他症状发作中13例(86%)为非癫性发作。64例样放电患儿中51例(80%)确定发作类型,22例(34%)确定癫类型。视频脑电图可发现短暂轻微的癫发作及样放电引起的一过性认知损伤。结论视频脑电图在排除非癫性发作、确定癫性发作的类型、评价脑电-临床关系方面可提供准确可靠的证据,进一步提高癫的临床诊断水平。     

Neuroprotective properties of memantine in different in vitro and in vivo models of excitotoxicity

The pathogenesis of stroke, trauma and chronic degenerative diseases, such as Alzheimer's disease (AD), has been linked to excitotoxic processes due to inappropriate stimulation of the N-methyl-D-aspartate receptor (NMDA-R). Attempts to use potent competitive NMDA-R antagonists as neuroprotectants have shown serious side-effects in patients. As an alternative approach, we were interested in the anti-excitotoxic properties of memantine, a well-tolerated low affinity uncompetitive NMDA-R antagonist presently used as an anti-dementia agent. We explored in a series of models of increasing complexity, whether this voltage-dependent channel blocker had neuroprotective properties at clinically relevant concentrations. As expected, memantine protected neurons in organotypic hippocampal slices or dissociated cultures from direct NMDA-induced excitotoxicity. However, low concentrations of memantine were also effective in neuronal (cortical neurons and cerebellar granule cells) stress models dependent on endogenous glutamate stimulation and mitochondrial stress, i.e. exposure to hypoxia, the mitochondrial toxin 1-methyl-4-phenylpyridinium (MPP+) or a nitric oxide (NO) donor. Furthermore, memantine reduced lethality and brain damage in vivo in a model of neonatal hypoxia-ischemia (HI). Finally, we investigated functional rescue (neuronal capacity to migrate along radial glia) by memantine in cerebellar microexplant cultures exposed to the indirect excitotoxin 3-nitropropionic acid (3-NP). Potent NMDA-R antagonists, such as (+)MK-801, are known to block neuronal migration in microexplant cultures. Interestingly, memantine significantly restored the number of neurons able to migrate out of the stressed microexplants. These findings suggest that inhibition of the NMDA-R by memantine is sufficient to block excitotoxicity, while still allowing some degree of signalling.     

Role of glutathione in repair of free radical damage in hippocampus in vitro.

Depletion of glutathione (GSH), an intrinsic antioxidant, increases vulnerability to free radical damage in a number of cell systems. This study investigates the role of GSH in limiting electrophysiological damage and/or recovery from free radical exposure in slices of guinea pig hippocampus. Synaptic potentials (PSPs) and population spikes (PSs) were recorded from field CA1. Free radicals were generated from 0.006% peroxide through the Fenton reaction. Analysis of the input-output curves showed that peroxide treatment decreased PSPs and impaired ability of the PSPs to generate PSs as previously reported. Recovery was nearly total within a half hour. Treatment with 5 mM buthionine sulfoximine (BSO) for 2 h depleted hippocampal GSH to 79.2% of control values. The extent of free radical damage was not increased. Recovery, however, was only partial. GSH was further depleted by oxidation with diamide or covalent bonding with dimethyl fumarate (DMF) immediately before and during the peroxide treatment. Neither diamide nor DMF treatment in BSO-incubated tissue enhanced peroxide-induced electrophysiological deficits. Following these treatments, however, tissue showed little recovery from free radical damage. We conclude that glutathione is essential for repair processes in hippocampal neurons exposed to oxidative damage.     

Storage of lipofuscin in neurons in mucopolysaccharidosis

Summary A histochemical and ultrastructural study was made on the brain of a 23-year-old man with Sanfilippo's syndrome. In accordance with previous reports the cortical nerve cells contained a PAS-positive lipid storage substance. This showed intense autofluorescence in UV-light and was positive with various stains for lipofuscin. The storage material appeared ultrastructurally as inclusion bodies composed of short lamellated membranes, granular material, and vacuoles. In addition, concentrically and transversely lamellated membranous cytoplasmic bodies were observed in the nerve cells. It is concluded that the PAS-positive lipid storage material in the neurons was composed partly of lipofuscin in addition to other lipids presumably glycosphingolipids.Supported by a grant from the Expressen Prenatal Research Foundation