大脑中动脉重度狭窄及闭塞患者侧支循环及脑灌注评估与预后的关系

目的 探讨大脑中动脉重度狭窄及闭塞的急性脑梗死患者责任血管范围侧支循环及磁共振灌注状态与预后的关系。方法 选取2018年1月-2019年7月在徐州医科大学附属医院神经内科住院行CT血管成像检查诊断单侧大脑中动脉重度狭窄及闭塞的急性脑梗死患者79例,根据侧支循环情况分为侧支循环良好组及侧支循环不良组,均行磁共振灌注加权成像检查,比较灌注参数情况、入院时与治疗7 d后NIHSS评分及出院3个月后的MRS评分、出院3个月内终点事件情况。结果(1)侧支循环良好组患侧rCBV增加,rTTP、rMTT延长(P均<0.01); 侧支循环不良组患侧rTTP、rMTT延长,患侧rCBF降低(P<0.01);(2)侧支循环不良组患侧rMTT、rCBV低于侧支循环良好组(P<0.05);(3)侧支循环良好组入院时、治疗7 d后NIHSS评分、出院3个月后MRS评分、出院3个月内终点事件发生率均较侧支循环不良组低(P<0.05)。结论 良好的侧支循环及脑灌注状态对大脑中动脉重度狭窄及闭塞导致急性脑梗死患者的预后改善有重要意义     

血清TGF-β1水平与急性脑梗死侧支循环及预后相关性分析

目的探讨血清转化生长因子β1(TGF-β1)水平与急性脑梗死侧支循环形成及预后之间的关系。方法选择2016-01—2017-04于郑大五附院神经内科住院的大脑中动脉狭窄或闭塞的急性脑梗死患者96例,根据TCD检测侧支循环代偿情况分为侧支循环开放组及侧支循环未开放组,分别抽取2组发病第1天、10天、90天的静脉血标本,同时设立健康对照组50例,留取静脉血标本,ELISA法检测血清TGF-β1水平,对比分析侧支循环开放组及侧支循环未开放组患者的NIHSS评分及mRS评分。结果 (1)侧支循环开放组血清TGF-β1水平较侧支循环未开放组高,差异有统计学意义(P0.05);脑梗死急性期血清TGF-1较健康对照组下降,差异有统计学意义(P0.05)。(2)侧支循环开放组NIHSS评分明显低于侧支循环未开放组,差异具有统计学意义(P0.05);发病90d时mRS评分比较,侧支循环开放组mRS评分≤2分比例明显多于侧支循环未开放组,差异有统计学意义(P0.05)。结论血清TGF-β1水平与急性脑梗死患者侧支循环形成及预后有一定相关性。     

转化生长因子1和Toll样受体4与急性脑梗死患者静脉rt-PA溶栓后侧支循环代偿的相关性研究

目的 探讨急性脑梗死患者静脉rt-PA溶栓后侧支循环的影响因素及侧支循环代偿与转化生长因子1(TAK1)、Toll样受体4(TLR4)水平的相关性。方法 采用回顾性分析方法,收集急性脑梗死且接受重组组织型纤溶酶原激活剂(rt-PA)治疗的72例患者,根据软脑膜评分方法(rLMC)评分将患者分为侧支循环较好组(39例)和侧支循环较差组(33例); 收集患者一般的临床数据和血清,用ELISA实验检测患者血清TLR4和TAK1水平。结果 侧支循环较好组糖尿病和高血压患者的比例均少于侧支循环较差组(P<0.05); 侧支循环较好组与侧支循环较差组比较rLMC评分较高,NIHSS评分较低(P<0.05); 侧支循环较好组TLR4和TAK1水平均低于侧支循环较差组(P<0.05); 侧支循环较好组溶栓后24 h后NIHSS评分、30d后NIHSS评分和90d后MRS评分均低于侧支循环较差组(P<0.05)且侧支循环较好组预后良好患者的比例高于侧支循环较差组(P<0.05); rLMC评分与患者血清TLR4和TAK1水平呈负相关(r=-0.819,-0.701,P<0.01); 多因素二分类logistic回归分析显示,糖尿病、高血压病、TLR4和TAK1水平增加均为影响侧支循环建立的危险因素。结论 rLMC评分与TLR4和TAK1的水平呈负相关,急性脑梗死患者糖尿病、高血压病、TLR4和TAK1的水平增加均为静脉rt-PA溶栓后侧支循环代偿不良的影响因素     

大脑中动脉急性闭塞患者侧支与临床结局的CTA评价

目的评估首次发生急性大脑中动脉(middle cerebral artery,MCA)闭塞患者的临床及影像学资料,探讨侧支循环与临床结局的相关性。方法回顾性分析确诊大脑中动脉为首发病变责任血管脑梗死的39例患者,应用CTA评估侧支循环,根据侧支循环评分,分为Pc0组、Pc1组、Pc2组,详细采集所有入组患者的一般资料,并进行NIHSS评分、脑梗死容积评分,用Logistic回归模型对各组一般资料及NIHSS评分、脑梗死容积数据进行分析。各侧支循环级别组间高危因素比较差异无统计学意义。结果 Pc0组患者NIHSS评分、脑梗死容积评分高于Pc1组及Pc2组。结论病变责任血管为大脑中动脉的急性期脑梗死患者,利用CTA影像可有效评估侧支循环的建立状态,对脑梗死的临床诊断和治疗方案的选择具有重要的指导价值,同时对临床结局的预测提供有力依据。     

多时相CTA联合CTP全脑灌注成像在缺血性脑卒中患者侧支循环影像学诊断中的应用价值

目的 探讨多时相CTA联合CTP全脑灌注成像在缺血性脑卒中患者侧支循环影像学诊断中的应用价值。方法 选择2016年3月-2019年3月本院收治的83例缺血性脑卒中患者作为观察对象,经ASPECTS侧支评估法实施侧支循环分级,将得分0～3分患者纳入侧支循环不良组,将得分4～5分者纳入侧支循环良好组; 通过NIHSS评分判定缺血性脑卒中患者预后,分析侧支循环和缺血性脑卒中患者预后的相关性。结果 侧支循环良好组患者的梗死核心区rMTT、rCBV、rTTP均高于侧支循环不良组(P<0.05); 2组患者梗死核心区rCBF比较无明显差异(P>0.05); 侧支循环良好组、侧支循环不良组患者的缺血半暗带rMTT、rCBV、rTTP比较无明显差异(P>0.05); 侧支循环良好组患者的缺血半暗带rCBF高于侧支循环不良组(P<0.05); 侧支循环良好组、侧支循环不良组患者入院时NIHSS评分比较无明显差异(P>0.05); 侧支循环良好组患者入院2周后、随访3个月后的NIHSS评分均低于侧支循环不良组(P<0.05)。结论 多时相CTA联合CTP全脑灌注成像在缺血性脑卒中患者侧支循环影像学诊断中能评估侧支循环水平,而建立良好的侧支循环能改善缺血性脑卒中患者的预后。     

缺血性卒中病变血管和侧支循环代偿的研究

目的 观察缺血性卒中患者的责任病变血管及其侧支循环代偿方式,探讨脑动脉闭塞或严重狭窄时侧支循环的代偿作用与牛津郡社区卒中项目(OCSP)临床症状分型之间的关系.方法对211例缺血性卒中患者采用OCSP分型(完全型前循环梗死36例,部分前循环梗死94例,后循环梗死31例,腔隙性梗死50例),进行数字减影全脑血管造影检查,判定梗死的责任血管、侧支循环是否建立及代偿方式.结果 检出有病变血管的患者198例,共累及病变血管206支,责任血管为颈内动脉98条、大脑中动脉54条、椎动脉27条、颈总动脉6条、基底动脉5条、锁骨下动脉4条、大脑前动脉及大脑后动脉各2条;经Willis环代偿98例,软脑膜支吻合115例,颅外代偿46例.结论脑动脉病变最多位于颈内动脉、大脑中动脉,其次位于椎动脉,前循环病变较后循环病变具有更高的梗死发生率;侧支循环代偿以Willis环最充分,软脑膜支吻合最常见;脑梗死的临床分型受病变血管与侧支循环代偿的综合影响.     

急性脑梗死后侧支循环建立的影响因素临床分析

目的探讨急性脑梗死后侧支循环建立的影响因素。方法收集2012年6月~2014年7月在梧州市工人医院(广西医科大学第七附属医院)神经内科住院的217例存在脑动脉狭窄或闭塞的急性脑梗死患者的临床资料,采用Binary Logistic回归方法,分析侧支循环形成的影响因素。结果 (1)共出现侧支循环开放137例(63.1%),单纯初级侧支54例(39.4%),单纯次级侧支45例(32.8%),初、次级侧支联合开放38例(27.7%),其中前循环动脉病变158例患者有侧支开放108例(68.4%),后循环动脉病变59例患者有侧支开放29例(48.6%)。(2)不同程度的脑动脉狭窄对侧支循环形成的影响比较差异有统计学意义(P<0.05)。(3)无侧支循环组吸烟史发生率(58.9%)明显高于有侧支循环组(40.5%),比较差异有统计学意义(P<0.05);有侧支循环组收缩压明显高于无侧支循环组,比较差异有统计学意义(P<0.05);其它的影响因素两组比较均无统计学意义(P均>0.05)。结论 (1)侧支循环建立以一级侧支循环为主,其中前循环侧支开放较后循环几率大,脑动脉狭窄程度越重,侧支循环开放的几率越大;(2)脑卒中危险因素吸烟和收缩压可影响侧支循环的建立。     

脑实质强化程度预测急性前循环大血管闭塞性脑梗死血管内治疗后出血转化风险研究

目的 评估急性前循环大血管闭塞性脑梗死血管内治疗术后CT平扫脑实质强化程度预测出血转化 （hemorrhagic transformation，HT）的临床价值。 方法 连续收集2017年1月-2019年9月在威海市中心医院及兰陵县人民医院卒中中心接受血管内治 疗的急性前循环大血管闭塞性脑梗死患者的影像学资料。根据术后即刻头颅CT显示的造影剂外渗情 况评估脑实质强化程度，分为脑实质无或轻度强化组和中重度强化组，术后24～36 h行头颅CT评估 HT情况。比较两组HT发生率，探讨血管内治疗术后即刻CT平扫脑实质强化程度与HT的关系。另外，根 据术前CTP结果，比较中重度强化组术前梗死侧和健侧表面通透性（permeability surface，PS）的差异， 并比较两组梗死侧相对PS（relative PS，rPS）的差异。 结果 共纳入30例接受血管内治疗的急性脑梗死患者，术后CT显示脑实质中重度强化组14例，发 生HT者7例（50.0%）；无或轻度强化组16例，发生HT者1例（6.3%），差异有统计学意义（P =0.04）。 中重度强化组患者梗死侧PS值高于健侧[2.99（2.90～3.10）mL/（100 g·min）vs 2.00（1.97～2.33） mL/（100 g·min），P =0.01]，中重度强化组梗死侧rPS高于无或轻度强化组（1.44±0.28 vs 1.10±0.07， P =0.01）。 结论 急性前循环大血管闭塞性脑梗死血管内治疗术后即刻CT显示的脑实质强化程度可能是预测 HT的一种直观有效的影像学标志物。     

高海拔地区急性中动脉供血区AIS后侧支循环建立的影响因素分析

目的探究高海拔地区急性大脑中动脉供血区急性缺血性脑卒中(AIS)患者侧支循环建立的影响因素。方法收集2019年10月至2020年10月青海省人民医院神经内科收治的急性大脑中动脉供血区AIS患者85例,均首次发病且均来自高海拔地区(平均海拔高度2500~4500米),根据基于扩散加权成像(DWI)的阿尔伯特(Alberta)卒中早期CT评分(DWI-ASPECTS)分成侧支循环建立良好组和侧支循环建立不良组,收集分析两组患者的一般资料、既往病史、实验室及影像学检查指标。结果侧支循环建立良好组入院及出院时美国国立卫生院神经功能缺损评分(NIHSS)和入院及出院时改良Rankin评分量表(mRS)均较侧支循环建立不良组明显偏低,差异有统计学意义(P0.05);侧支循环建立良好组及不良组患者在性别、民族、冠状动脉粥样硬化性心脏病史、酗酒史、三酰甘油(TG)、高密度脂蛋白(HDL-C)、血清尿酸(UA)水平差异无统计学意义(P0.05);在年龄、吸烟史、高血压病、24h平均收缩压、24h平均舒张压、糖尿病、中性粒细胞淋巴细胞比值(NLR)、血小板与淋巴细胞比率(PLR)、糖化血红蛋白(HbA1C)、胆固醇(TC)、低密度脂蛋白(LDL-C)、血清同型半胱氨酸(Hcy)水平及颈动脉斑块比较,差异均有统计学意义(P0.05),Logistic多因素分析显示:年龄、糖尿病、LDL-C、NLR和Hcy是侧支循环建立不良的影响因素。结论高海拔地区大脑中动脉供血区AIS后良好侧支循环的建立可改善患者的症状及预后;年龄、糖尿病、NLR、LDL-C及Hcy水平均与急性大脑中动脉供血区AIS后侧支循环的建立密切相关。     

大脑中动脉重度狭窄或闭塞患者脑梗死病灶类型与CT灌注成像分析

目的比较大脑中动脉(MCA)重度狭窄或闭塞患者不同脑梗死病灶类型的灌注状态。方法对89例MCA严重狭窄或闭塞患者进行头颅320排CTA+CT灌注成像检查,比较不同梗死病灶类型患者MCA闭塞率、侧支循环程度、MCA供血区灌注情况。结果 89例患者中,穿支动脉梗死(PAI)8例(9.0%)、皮质分支动脉梗死(PI)7例(7.9%)、大面积梗死(LTI)7例(7.9%)、分水岭梗死(BZI)43例(48.3%)、多发性脑梗死(MI)13例(14.6%)、无梗死灶11例(12.4%);不同类型梗死灶间MCA M1段病变、血管闭塞及不良侧支循环比率差异无统计学意义(均P0.05)。不同类型梗死灶局部脑血流量(rCBF)患健比、达峰时间(TTP)患健比差异有统计学意义(均P0.05)。BZI组rCBF患健比显著高于LTI组与无梗死灶组(均P0.05);LTI组及BZI组TTP患健比显著高于无梗死灶组及PAI组(均P0.05),MI组TTP患健比较无梗死灶组升高(P0.05)。LTI组MCA供血区低灌注发生率显著高于无梗死灶组(P0.05)。不同亚型BZI组间低灌注异常及不良侧支循环率差异有统计学意义(均P0.05),各灌注参数、MCA M1段病变及闭塞比率差异无统计学意义(均P0.05)。结论 LTI为失代偿期表现,低灌注发生率最高,其余类型为代偿期表现。皮质下型分水岭梗死较其他亚型侧支循环差,低灌注发生率更高,与血流动力学受损为主要病因的观点相符。MCA重度狭窄或闭塞患者脑梗死病灶类型以BZI为主。     

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.