内镜下经单鼻孔蝶窦人路鞍区手术的解剖研究

目的 研究内镜下经单鼻孔蝶窦入路中各解剖标志的辨认,探讨如何确认和根据不同的鞍区肿瘤生长方式扩大显露蝶窦前壁.方法 对甲醛固定的成人尸头标本(10例)和新鲜成人尸头标本(5例)经颈内动脉灌注红色乳胶、颈内静脉灌注蓝色玻璃胶后,经单侧鼻孔人路导入内镜,再剖开一侧鼻腔进行解剖观察和测量.结果 腭咽弓到蝶窦开口下缘距离为(15.13±1.99)mm.中鼻甲后部下缘到鞍底中心距离为(10.20±0.15)mm,去除蝶窦内分隔后蝶窦容量为(8.73±2.90)mL,鞍底厚度为(3.68±1.96)mm;鼻中隔和蝶窦前壁之间在不同平面的夹角差异有统计学意义(P＜0.05).结论 对难以找到蝶窦开口者,可根据蝶窦前壁特有的橄榄状隆起、蝶窦前壁和中鼻甲位置关系及蝶窦开口和腭咽弓距离确定蝶窦前壁;犁骨居中可为鞍底中线的定位标志;扩大入路适用于往鞍区各个不同方向生长的肿瘤手术.     

经单鼻孔-蝶窦入路手术准确定位的解剖学研究

目的通过经单鼻孔-蝶窦入路的解剖学研究，为临床经单鼻孔-蝶窦手术安全切除垂体腺瘤提供准确定位的解剖学资料。方法用成人尸头湿标本20例．在显微镜下对经单鼻孔-蝶窦入路手术准确定位重要的解剖学标志：鼻中隔后缘上端、蝶窦开口、蝶嵴、犁骨、蝶窦间隔、鞍底等进行解剖观察和测量。结果（1）前鼻棘至鞍底、蝶窦口、颈内动脉和视神经的距离分别为（70．20±0．98）mm、（57．29±0．68）mm、（69．66±0．74）mm、（70．95±1．03）mm。（2）蝶窦开口至鞍底、视神经、颈内动脉、鞍结节中点、鞍背中点以及犁状骨游离面下缘（后鼻腔与咽部交界处）距离分别为（14．62±0．80）mm、（13．25±0．99）mm、（14．38±0．82）mm、（15．03±1．21）mm、（25．24±1．08）mm、（17．21±0．59）mm。（3）20例标本中有17例鞍底骨板在蝶窦内形成隆凸，可作为窦内鞍底确定的标志。（4）鼻中隔后缘上端、蝶嵴、犁骨后缘与鞍底中部垂直相对。结论蝶窦开口是定位蝶窦前壁重要的解剖标志。鼻中隔后缘上端、蝶嵴、犁骨后缘可作为确定鞍底中线的定位标志。     

门齿中点与外耳道中点假想连线对经鼻蝶入路的定位作用简

目的探讨经鼻蝶入路手术的一种方便、实用的解剖定位方法。方法在14例（28侧）尸头标本上模拟经鼻蝶入路,尸头取正中后仰位,侧面观察使门齿中点与外耳道中点假想连线垂直于地面,鼻窥器平行于这一连线逐步深入进入鼻腔进行观察。在矢状位上验证这一假想连线对定位的准确性,同时测量相关解剖结构的数据。结果按照前述方法模拟手术,鼻窥器所撑开范围的头侧部分可见蝶窦的骨性开口,尾侧部分是蝶窦前壁;开放蝶窦后同样发现鼻窥器所撑开范围的头侧正是鞍底。尸头正中矢状位解剖证实手术的准确性。鼻前棘至蝶窦开口的距离为（56．65±4．20）m／n,鼻前棘至鞍底的距离为（71．30±4．56）mm。结论头颅侧面观门齿中点与外耳道中点的假想连线对经鼻蝶入路手术的方向性有重要的参考作用。     

单鼻孔经蝶入路垂体腺瘤切除术中蝶窦前壁的解剖学研究

目的通过对成人湿性头颅标本的解剖和数据测量,量化蝶窦前壁,为单鼻孔经蝶入路到鞍区的显微解剖提供准确定位数据。方法对20例(40侧)不同性别的成人头颅湿性标本进行血管灌注染色后,模拟单鼻孔经蝶入路垂体腺瘤切除手术,对蝶窦前壁进行解剖及数据测量。结果前鼻嵴至蝶窦开口上端中点(57.8±4.9)mm;蝶窦口上端中点距中线(3.4±1.0)mm。结论蝶窦口是经鼻蝶入路手术的重要解剖标志,以鼻腔底为基线矢状夹角为31.5°,沿鼻中隔进入约57.8 mm,再偏离鼻中隔约3.4 mm,即为蝶窦开口的上端中点。     

单鼻孔直达蝶窦入路垂体瘤切除术鞍底的精确定位

目的 探讨经单鼻孔直达蝶窦入路垂体瘤切除术鞍底定位.方法 77例垂体瘤术前行蝶窦矢状位、冠状位CT扫描,并测量前颅底鞍底夹角(简称颅鞍角)、鞍底斜坡夹角(简称鞍斜角)的大小,前鼻棘到颅鞍角、鞍斜角的距离,在头颅MRI上测量颈内动脉海绵安段之间的最短距离;术中在正中矢状位先找到颅鞍角,向后下绕过鞍底找到鞍斜角,通过两个夹角,正确定位鞍底.结果 ≥90°颅鞍角61例,<90°颅鞍角16例,≥190°鞍斜角48例,<90°鞍斜角29例,前鼻棘到颅鞍角的平均距离(64.90±7.41)mm,前鼻棘到鞍斜角的平均距离(71.74±7.70)mm;所有患者都正确找到鞍底,切除肿瘤,手术顺利.结论 蝶窦欠状位、冠状位CT扫描可以正确了解蝶窦、鞍底的形态和位置;头颅正中矢状位上的前颅底鞍底夹角和鞍底斜坡夹角可直接应用于经鼻蝶安入路垂体瘤切除术鞍底的精确定位.     

内窥镜下经鼻腔-蝶窦入路切除垂体腺瘤的解剖学研究

目的为进一步推广和提高内窥镜下经鼻腔-蝶窦入路提供帮助.方法采用解剖尸头直接观察和内窥镜下测量距离,结合活体的CT、MRI图像上观察及测量的方法,对15例30侧尸头、100侧CT片和100例MRI片的手术入路相关解剖学特点和解剖距离进行研究.结果全鞍型蝶窦占82%,29%合并枕骨气化,蝶上筛房出现率为11%;前鼻棘至蝶窦口的距离为60.39±5.38mm;前鼻棘至鞍底距离为75.47±6.36mm;视神经管多位于蝶窦口侧上方、蝶筛交界处,蝶窦口至视神经管的最短距离为11.09±1.48mm.颈内动脉多位于蝶窦口的后外上方,蝶窦口至颈内动脉的最短距离为17.14±1.63mm.结论内窥镜技术适合于经鼻腔蝶窦入路切除鞍区肿瘤;术前的影像学检查、对于手术相关的解剖学结构的认识及熟练的窥镜手术操作技能是保证手术成功的关键因素.     

单鼻孔经蝶入路鞍区手术的蝶窦前壁解剖学研究

目的为单鼻孔经蝶入路鞍区手术准确寻找堞窦口、避免副损伤提供解剖学依据。方法采用15个防腐头颅标本,在手术显微镜下鼻中隔及蝶窦前壁进行解剖学观察。结果鼻中隔在前、中、后部的厚度分别为4.2±0.6mm、4.9±0.9mm、5.2±0.8mm、鼻小柱根部至蝶窦口下极的距离为60.40±3.20mm、与鼻腔底水平的夹角为31.5±2.7。蝶窦口下极距离鼻后中隔动脉上支和下支分别为3.82±0.35mm、6.62±0.48mm。结论鼻中隔中部切口入路最为值得提倡;蝶窦口这一解剖学标志在单鼻孔经蝶入路鞍区手术中极为重要;开放蝶窦口下界不应超过3.5mm。     

内镜下经鼻-蝶窦入路蝶鞍周围解剖学研究

目的研究内镜下经鼻-蝶窦入路的解剖学,为临床内镜经蝶垂体病变手术提供形态学基础。方法选择10具经动脉灌注染料的成人尸体头部标本,男8具,女2具;模拟扩大经鼻-蝶窦手术入路,同时测量海绵窦内重要解剖结构与鞍底的距离。结果根据蝶窦后壁骨性结构特征将蝶窦腔分为中间腔、旁中间腔以及外侧腔等5个部分。扩大经鼻-蝶窦手术入路可清晰地显示鞍底的骨膜、硬脑膜外层、海绵窦内侧壁,海绵窦内的颈内动脉及其分支血管、动眼神经、滑车神经、外展神经及眼神经等重要解剖结构;打开蝶骨平台可显示视神经、视交叉、垂体柄、鞍膈及视丘下部等解剖结构。蝶鞍周围结构与鞍底中线的距离分别为视神经管隆起(5.72±1.56)mm,颈内动脉管隆起(5.42±1.38)mm,鞍膈(10.01±1.46)mm,视交叉(14.96±1.42)mm,海绵窦内颈内动脉(11.02±2.06)mm,海绵窦内动眼神经(13.75±1.79)mm,海绵窦内滑车神经(15.14±1.53)mm,海绵窦内外展神经(12.68±1.52)mm。结论内镜下扩大经鼻-蝶窦手术入路可清晰地显露蝶鞍周围的解剖结构,适用于鞍旁、鞍上病变的手术治疗。     

内镜下经鼻蝶窦入路至鞍上区的解剖与临床初步应用

目的研究内镜下扩大经鼻蝶窦入路至鞍区、鞍上区的显露范围，及手术入路中重要的解剖标志与其相互位置关系。结合该入路切除鞍结节脑膜瘤的临床应用体会，探讨内镜在此区域手术中面临的主要问题和解决办法。方法选择10例灌注尸头标本，采用显微镜解剖2例，其中冠状位和矢状位切开各1例；另8例标本模拟经鼻蝶窦入路。在内镜和显微镜下扩展显露鞍前及鞍上区的主要解剖标志，并研究其相互位置关系。对2例女性鞍结节脑膜瘤病人，采用神经导航经鼻蝶窦入路手术，肿瘤切除过程中和切除后分别应用成角内镜观察肿瘤周围结构及切除情况，肿瘤切除后以脂肪、人工硬膜及明胶海绵重建鞍底。结果内镜下在颅前窝向外侧显露的主要限制是两侧的眶内侧壁和视神经管；选择三个平面测量向侧方的显露范围，分别为筛骨鸡冠后缘平面（19．1±2．65）mm，鞍结节前方10mm的蝶骨平台平面（23．2±2．35）mm，两侧视神经管内口平面（13．1±2．18）mm。内镜下可清晰显示双侧视神经、视交叉、垂体柄、前交通动脉复合体等颅内结构。2例鞍结节脑膜瘤病人均达到肿瘤全切除，视力部分改善，术后均出现脑脊液漏，再次经原入路手术修补后痊愈。结论采用单纯内镜或内镜辅助的经鼻蝶窦入路可更直接达到鞍前及鞍上区病变，避免了经过重要的神经血管结构及对脑组织的牵拉。颅底骨质磨除位置和范围以及颅底的修补和重建是采用该入路需要解决的主要问题。     

伴甲介型、鞍前型蝶窦的垂体腺瘤经蝶入路手术治疗研究

目的 探讨伴甲介型、鞍前型蝶窦的垂体腺瘤经蝶人路手术治疗的方法及特点.方法回顾性分析中山大学附属三院神经外科自2004年6月至2009年6月收治的32例经蝶入路手术治疗的伴甲介型、鞍前型蝶窦的垂体腺瘤患者的临床资料,其中伴甲介型蝶窦的垂体腺瘤5例,伴鞍前型蝶窦的垂体腺瘤27例.根据术前CT多平面重建、CT仿真内镜及MRI影像资料,指导术中暴露鞍底,切除肿瘤.结果 未使用定位设备的情况下,术中均能顺利暴露鞍底,切除肿瘤,平均手术时间86min.术后3 d内MRI复查示肿瘤全切除25例,次全切除6例,大部分切除1例.结论 对于伴甲介型、鞍前型蝶窦的垂体腺瘤经蝶入路手术治疗,通过术前详细的影像学检查、术中磨钻及显微镜或内镜的使用,术中能准确辨认及充分暴露鞍底、切除肿瘤.     

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。     

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     

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 vincristine in the inhibition of angiogenesis in glioblastoma

Objective: Vincristine, a microtubule-destabilizing drug, was found to exhibit anti-angiogenic effects and anti-tumoral activity. However, the precise mechanism by which vincristine inhibits angiogenesis in glioblastomas is not well understood. Our aim was to investigate whether vincristine affects vascular endothelial growth factor (VEGF) expression in glioblastoma cells and determine whether it is mediated by the downregulation of hypoxia-inducible factor-1α (HIF-1α).

Methods: We investigated the expression of HIF-1α in glioblastoma tissues resected from patients and in human glioblastoma cell lines using immunohistochemistry, Western blot analysis, and immunocytochemistry. In addition to an MTT assay assessing the effect of vincristine on cell proliferation and viability, the effects of vincristine on VEGF mRNA expression and HIF-1α protein were examined using real-time RT-PCR and Western blot analysis under 1% O₂ (hypoxia).

Results: HIF-1α was expressed in the majority of glioblastoma tissues and was detected mainly in the nucleus. Strong immunoreactivity for HIF- 1 α was found often in the hypercellular zones. Under hypoxic conditions, HIF-1α protein levels in the glioblastoma cell lines increased, primarily localizing into the nucleus similar to glioblastoma tissues. Exposure of glioblastoma cells to vincristine resulted in enrichment of the G₂-M fraction of the cell cycle, which suggests that vincristine-mediated growth inhibition of glioblastoma is correlated with mitotic inhibition. Using doses lower than those found to reduce the viability and proliferation of cells by 50% (IC₅₀), vincristine decreased both the expression of VEGF mRNA and the level of HIF-1α protein in hypoxic glioblastoma cells. In addition, following exposure to vincristine, the expression of VEGF mRNA was correlated with HIF-1α protein levels.

Conclusions: Our results suggest that the mechanism by which vincristine elicits an anti-angiogenic effect in glioblastomas under hypoxic conditions might be mediated, in part, by HIF-1α inhibition.     

脑电图预测痫性发作研究进展

癫痫(epilepsy)是由脑部神经元高度同步化异常放电所致的临床综合征,系神经系统的常见病,困扰着全世界约1%的人群.每次神经元的阵发性放电或短暂的脑功能异常称为痫性发作(seizures).     

The Burden of Agoraphobia in Worsening Quality of Life in a Community Survey in Italy

ObjectiveCurrent nosology redefined agoraphobia as an autonomous diagnosis distinct from panic disorder. We investigated the lifetime prevalence of agoraphobia, its association with other mental disorders, and its impact on the health-related quality of life (HR-QoL). MethodsCommunity survey in 2,338 randomly selected adult subjects. Participants were interviewed with the Advanced Neuropsychiatric Tools and Assessment Schedule (ANTAS), administered by clinicians. The diagnoses were based on the ICD-10 criteria. The Short-Form Health Survey (SF-12) was used to quantify HR-QoL. ResultsIn the sample, 35 subjects met the criteria for agoraphobia (1.5%), with greater prevalence among women (2.0%) than men (0.9%): odds ratio (OR) 2.23; 95% CI: 1.0-5–2. Agoraphobia was more often seen among those with (n=26; 1.1%) than without (n=9; 0.4%) panic disorder: OR=8.3; 2.9–24.4. Co-morbidity with other mental disorders was substantial. The mean score of SF-12 in people with agoraphobia was 35.2±7.8, with similar levels of HR-QoL in people with (35.3±7.9) or without (34.8±7.3) panic disorder: ANOVA: F(1;33)=0.0; p=1.00. ConclusionOne out of seventy people may suffer from agoraphobia in their lifetime. The attributable burden in terms of HR-QoL is substantial and comparable to the one observed for chronic mental disorders such as major depression, post-traumatic stress disorder, or obsessive-compulsive disorder.     

Developmental effects of in vivo and in vitro inhibition of nitric oxide synthase in neurons

The diffusible chemical messenger nitric oxide (NO) is involved in neuronal plasticity and it is, therefore, supposed to play a role in brain development. A shortage of NO during the critical period of brain maturation may theoretically have long-lasting consequences on the organization of the adult brain. We have performed in neonatal rats a chronic inhibition of the enzyme responsible for NO production, nitric oxide synthase (NOS), from postnatal day 3 to postnatal day 23, through administration of the competitive antagonist N-nitro-L-arginine methylester (L-NAME). The calcium-dependent catalytic activity resulted almost completely inhibited throughout the period of treatment and it took more than 4 days after its suspension to get a full recovery. The expression of the neuronal isoform of the enzyme (nNOS), revealed by immunoblotting, was unchanged during the treatment and after it. The histochemical reaction for NADPH diaphorase was reduced at the end of the treatment and recovered in concomitance with the recovery of the catalytic NOS activity. No gross structural alterations were detected in brain morphology. The levels of three neurotransmitter-related and one astrocytic marker were unchanged in the cerebellum, hippocampus and cortex of 60-day-old rats which had been neonatally treated. A similar lack of significant effects on neurochemical brain maturation was also noticed in a parallel series of experiments, in which a short pulse of NOS inhibition was performed at a critical prenatal time of brain development, from gestational day 14 to gestational day 19. In vitro, chronic exposure of cerebellar granule cells to L-NAME (500 microM) resulted in slight decrease of surviving neurons after 8 days in culture and in better resistance to the challenge of stressful culture conditions. The present results suggest that the basic plan of brain organization can be achieved despite an almost complete NOS inhibition during the maturation period. In vitro, NOS inhibition may bring to more pronounced consequences on neuronal viability and function.     

自噬参与帕金森病发病的研究进展

近年来,蛋白质的降解障碍被认为是帕金森病（Parkinson’Sdisease,PD）发病过程中的重要因素,人们已经公认泛素一蛋白酶体系统（ubiquitin--pro—teasomesystem,UPS）功能异常或衰竭能够导致细胞内异常蛋白蓄积、细胞功能障碍,甚至细胞凋亡。与此同时,蛋白降解的另一条途径——自噬-溶酶体途径（autophagy—lysosomepathway,ALP）也已成为了生命科学领域的研究热点,自噬与神经变性疾病,尤其是PD的关系日益受到人们的重视。     

Midazolam in treatment of various types of seizures in children

Midazolam is a recently developed water-soluble benzodiazepine that shares anxiolytic, muscle relaxant, hypnotic and anticonvulsant actions with other members of this class. There are limited studies that midazolam can be used successfully to treat seizures in adults and children. In this study, 0.2 mg/kg intramuscular (IM) midazolam was administered to 11 children (eight boys and three girls), aged 3 days to 4 years (mean age 1.8±1.4 years), with seizures of various types. In all but one child, seizures stopped in 15 s–5 min after injection. No side effects were observed. These results suggest that IM administration of midazolam may be useful in a variety of seizures during childhood, especially in case of intravenous (IV) line problem.