伴颅内外动脉狭窄或闭塞的分水岭脑梗死类型分析

目的探讨由颈内动脉(ICA)或大脑中动脉(MCA)狭窄或闭塞引起的分水岭脑梗死(WSI)的梗死类型及发病机制。方法 81例急性WSI患者根据责任血管分为ICA组(53例)及MCA组(28例)。根据MRI检查结果对两组梗死类型进行分析比较。结果 ICA组皮质前型及皮质前型+内WSI+皮质后型的比率显著高于MCA组(均P<0.05)。结论合并颅内外血管狭窄或闭塞WSI类型以内WSI及皮质后型梗死最常见。ICA病变患者WSI皮质前型常见,其发病机制可能为血流动力学障碍;MCA病变患者WSI皮质上型及合并融合性病灶多见,其机制可能为微栓子对远端血管的微栓塞。     

大脑中动脉狭窄程度与不同急性脑梗死模式的相关性研究

目的探讨大脑中动脉(MCA)狭窄程度与不同急性脑梗死病变模式的关系。方法回顾性分析324例急性脑梗死患者,根据头颅磁共振弥散加权成像(DWI)和磁共振血管成像(MRA),MCA狭窄程度分为轻、中、重度,患者梗死模式分为:单发性梗死(包括小的穿支动脉供血区梗死、大的穿支动脉供血区梗死、皮质分支动脉供血区梗死和大面积梗死)、分水岭梗死(CWI)和多发性梗死。比较不同模式的急性脑梗死患者的MCA病变情况。结果 324例急性脑梗死患者中,MCA狭窄致穿支动脉(PAI)梗死最为多见,占137例(42.28%);PAI患者MCA重度狭窄率与其他单发性梗死、多发性梗死和内分水岭梗死(IWI)患者相比较,差异具有统计学意义(P0.01)。内分水岭梗死、多发性梗死和大面积梗死的MCA重度狭窄率高于小穿支动脉梗死、大穿支动脉梗死、皮质穿支动脉梗死和外分水岭梗死(P0.05),而内分水岭梗死、多发性梗死和大面积梗死之间的MCA重度狭窄率相比差异无统计学意义(P0.05)。结论 MCA狭窄致PAI最为多见,但是MCA重度狭窄并非是PAI的重要原因;MCA重度狭窄易导致CWI(尤其是IWI)和多发性梗死;MCA重度狭窄也是导致LTI重要原因之一。     

大脑中动脉区梗死的DWI特点及与其供血动脉狭窄的关系

目的 探讨大脑中动脉(MCA)区脑梗死磁共振扩散加权成像(DWI)成像病灶分布特点及与其供血动脉狭窄程度的关系.方法 回顾性的分析经颅脑磁共振成像(MRI)的DWI序列诊断的急性脑梗死,选择病灶位于MCA分布区,且完善其供血动脉检查,包括头颈部CTA,或颅脑MRA加颈部血管超声的患者108例,排除心源性栓塞、特殊血管病变导致的脑梗死.将梗死按照部位分为腔隙型梗死(SSSI)、皮层下梗死(SI)和混合型梗死(MI),供血动脉分为正常、轻度(50％)、重度(50％)和闭塞.比较不同类型梗死组的供血动脉狭窄的发生率.结果 各种梗死类型的发生率之间差异无统计学意义(x2=1.08,P＞0.05).单纯MCA病变者53例(53/108,49.1％),单纯ICA病变者28例(28/108,25.9％),单纯MCA病变高于单纯ICA病变(x2=12.35,P＜0.01).同侧血管正常者以LI类型的梗死多见,而单纯ICA病变者以MI类型的梗死多见(x2=10.22;10.54,P＜0.01);三种梗死类型在单纯MCA病变患者中差异无统计学意义(x2=0.25,P＞0.05);在单纯MCA病变者中,SI梗死类型多见于MCA闭塞患者(x2=7.45,P＜0.05).LI梗死类型多见于MCA轻度或重度狭窄患者(x2=6.39,P＜0.05).结论 结合DWI和相应血管检查对于明确MCA区动脉粥样硬化性脑梗死的病因和机制有一定帮助.基底节区的腔隙梗死,相应血管检查正常提示小血管病的可能大;MCA存在一定狭窄则可能是穿支受累造成;ICA病变多累及皮层,包括皮层型分水岭区梗死;而不同程度的MCA病变其梗死形态没有本质区别,皮层下梗死更多见MCA闭塞患者.     

内分水岭脑梗死扩容治疗的临床研究

分水岭梗死(cerebral watershed infarction,CWI)也称脑交界区梗死或脑边缘带梗死,其发病率约占缺血性脑卒中的10％左右.根据神经病理解剖学可将其分为皮质分水岭区梗死和内分水岭区梗死(IWI).IWI一般与颈内动脉(internal carotid artery,ICA)狭窄和大脑中动脉(middle cerebral artery,MCA)狭窄有关,其梗死体积比腔隙性梗死大,在皮质下存在2个或2个以上圆形梗死灶,其发生主要由于ICA或MCA严重狭窄或闭塞导致的血流动力学障碍有关,是颈内动脉系统疾病的一个标志[1].CWI的病因及发病机制一直存在争论.Caplan等研究认为[2],血管狭窄造成的低灌注限制了血流冲刷微栓子的能力,血管狭窄造成湍流促进斑块上的栓子脱落,血流动力学障碍及微栓子的联合作用是CWI的发病基础.本组研究观察了扩容治疗ICA狭窄和/或MCA狭窄所致IWI与患者神经功能缺损改善和病变侧局部MCA血流改变的关系.     

不同类型内分水岭脑梗死患者的头颈CTA特征观察

目的探讨不同类型内分水岭脑梗死(IWI)与颅内外动脉狭窄及Willis环特征的关系。方法收集2014年1月~2016年5月丰县人民医院65例行头颈部CT血管成像(CTA)及头部磁共振弥散加权成像(DWI)的IWI患者,依据DWI的形态学特征分为部分型内分水岭脑梗死(P-IWI)组29例(44.6%)和融合型内分水岭脑梗死(C-IWI)组36例(55.4%),分析两组颅内外动脉狭窄及Willis环的特征。结果 (1)CTA显示65例患者中颈内动脉(ICA)或(和)大脑中动脉(MCA)狭窄≥50%的共有49例,占75.4%(49/65);MCA、ICA及串联病变发生率P-IWI组分别为71.4%(20/29)、17.2%(5/29)、10.3%(3/29);C-IWI组分别为80.6%(28/36)、58.3%(21/36)、44.4%(16/36)。(2)Willis环依据形态特征不完整者(缺如、发育不良)P-IWI组占55.2%(16/29),C-IWI组占52.8%(19/36)。结论不同类型IWI均与MCA狭窄密切相关,C-IWI是ICA串联狭窄发生的有效预测因子;颅内外血管狭窄的基础上,IWI与Willis环的不完整密切相关,两组间Willis环形态特征无显著差异。     

大脑中动脉狭窄脑梗死颅内血流动力学及侧支循环研究

目的 探讨大脑中动脉(MCA)狭窄或闭塞的脑梗死患者颅内血流动力学改变和侧支循环的代偿及神经功能缺损的关系.方法 通过经颅多普勒(TCD)检查,计算双侧大脑前动脉(ACA)、大脑后动脉(PCA)峰流速及其比值(RVACA、RVPCA),并与正常对照组比较.结果 共观察38例单侧MCA狭窄或闭塞的脑梗死患者.(1)病例组ACA、PCA血流速度代偿性增快,以ACA代偿为主(76.3%);(2)病例组RVACA明显较对照组高﹙P<0.01﹚;(3)MCA主干及皮层支梗死患者的RVACA明显较对照组及深穿支梗死组高﹙P<0.01,P<0.05﹚;MCA重度狭窄或闭塞脑梗死患者的RVACA较对照组及中度狭窄组高﹙P<0.05﹚;(4)病例组RVACA及RVPCA与NIHSS呈负相关(P<0.01﹚.结论 皮质软脑膜侧支吻合血管开放成为MCA狭窄或闭塞脑梗死侧支循环的主要途径,其代偿程度与预后相关.     

颈内动脉和大脑中动脉狭窄与闭塞患者的64排螺旋CT脑容积灌注成像

目的探讨64排螺旋CT脑容积灌注成像（CT perfusion imaging,CTP）与头颈CT血管成像（CT angiography,CTA）联合应用在颈内动脉（internal carotid artery,ICA）或大脑中动脉（middlecerebral artery,MCA）狭窄与闭塞患者中的应用价值.方法对5名健康人及17例患者（ICA狭窄11例、MCA狭窄6例）行CT平扫、CTP和CTA检查,分析灌注延迟表现与病变动脉及其狭窄程度的关系.结果17例患者8例CT平扫未见异常,9例有腔隙性脑梗死和（或）陈旧脑梗死.平均通过时间（mean transit time,MTT）和达峰时间（time to peak,TTP）图灌注延迟表现分为3型：Ⅰ型病变仅累及MCA区,Ⅱ型病变仅累及分水岭区,Ⅲ型病变累及MCA和分水岭区.ICA重度狭窄或闭塞患者Ⅲ型7例,MCA重度狭窄或闭塞患者Ⅰ型4例.64排CT可同时获得容积CTP和颅底动脉环动态CTA,其动态CTA图像质量与常规CTA近似.结论MTT、TTP能够敏感显示灌注损伤,对ICA或MCA重度狭窄或闭塞诊断、治疗及脑梗死发病机制研究有重要价值.64排CT可得到包括基底节在内的上下8个层面的图像,可以更多地显示16层以下螺旋CT显示不到的病变,如脑干、小脑的梗死等.CTP联合CTA能够早期诊断脑梗死,并同时从功能和形态学上综合分析脑缺血的程度和原因,获得更详细的信息,为临床医师尽早进行合理治疗提供客观的影像学依据.     

颈内和大脑中动脉狭窄与闭塞的梗死类型及卒中机制的研究

目的 研究单侧动脉粥样硬化性MCA/ICA狭窄与闭塞的急性缺血性脑卒中患者在DWI上的梗死类型及发病机制.方法 起病48h内DWI诊断的急性脑梗死伴有动脉粥样硬化性MCA/ICA狭窄与闭塞的131例患者,有潜在心源性栓子患者除外.急性期DWI上梗死病灶分为：（1）单发病灶（小的穿动脉梗死灶;大的穿动脉梗死灶,皮层支梗死,大面积梗死,分水岭梗死）;（2）多发梗死病灶.结果 131例患者,ICA51例,MCA80例.ICA出现最多的梗死类型：穿支动脉伴分水岭梗死,但与MCA比较,皮层支伴分水岭梗死具有统计学意义（8/51,P=0.001）.MCA以穿支动脉伴皮层支梗死最多,且与ICA比较,具有统计学意义（12/80,P=0.003）.MCA中任何皮层支梗死与狭窄程度无关,ICA中任何分水岭梗死与狭窄程度相关.结论 颈内和大脑中动脉狭窄与闭塞在DWI上的梗死类型有明显的不同,提示有着不同的卒中发病机制.     

颈内和大脑中动脉重度狭窄或闭塞的分水岭梗死类型与机制的研究

目的研究单侧动脉粥样硬化性大脑中动脉(MCA)及颈内动脉(ICA)重度狭窄或闭塞所致急性缺血性脑卒中患者分水岭梗死(WI)类型及发病机制。方法起病48h内DWI诊断的急性分水岭梗死伴有动脉粥样硬化性MCA/ICA重度狭窄与闭塞的患者102例,其中MCA组38例,ICA组64例,有潜在心源性栓子患者除外。急性期DWI上分水岭梗死病灶分为:(1)单纯分水岭梗死病灶;(2)含分水岭梗死的多发梗死病灶。结果 ICA组单纯分水岭梗死病灶较多,其中前+内分水岭梗死的例数最多,与MCA组比较具差异有统计学意义(P<0.05);ICA组复合梗死病灶中,出现最多的梗死类型为穿支动脉伴分水岭梗死,与MCA组比较差异具有统计学意义。MCA组以穿支动脉伴皮层支梗死伴分水岭梗死最多,且与ICA组比较,差异具有统计学意义(P<0.05)。结论颈内和大脑中动脉重度狭窄与闭塞所致分水岭梗死的类型有明显的不同,提示有着不同的发病机制。     

脑白质区域非腔隙性梗死灶与颅内外血管狭窄关系的探讨

目的 探讨脑白质区域非腔隙性梗死灶与颅内外血管狭窄的关系.方法 对30例脑白质区域非腔隙性梗死患者的头颅MRI以及主动脉弓、全脑数字减影血管造影(DSA)检查资料进行分析.结果 本组MRI示12例单侧基底节区片状异常信号中,DSA表现为一侧颈内动脉(ICA)起始部闭塞或高度狭窄9例,一侧大脑中动脉(MCA)M1段高度狭窄2例,无明确血管病变1例.6例基底节以及侧脑室旁白质区域病灶中,一侧ICA起始部闭塞或高度狭窄3例,一侧ICA C5段闭塞1例,一侧MCA M1段闭塞2例.4例侧脑室旁或半卵圆中心白质区域病灶中,一侧ICA C6段闭塞1例,一侧MCA M1段高度狭窄2例,无明确血管病变1例.8例皮质下上型或皮质下侧型分水岭脑梗死患者中,一侧ICA起始部闭塞或高度狭窄6例,双侧ICA起始部闭塞1例,一侧MCA M1段高度狭窄1例.结论 脑白质区非腔隙性梗死灶的发生与ICA系统大血管的狭窄或闭塞有密切的关系.     

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.     

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.     

Une phénoménologie de la dépendance à l'alcool. Une expérience primordiale de la « nostrité »

The phenomenological approach to alcoholism interestingly focuses on specific dynamics of interpersonal relationships displaying the founding of the Self from a primary “us” and its original basis in the human feast. Priorities for treatment intervention recommend to involve social setting and relationships of the patients, reaching their active participation to a motivational and long term group treatment, underlying the specific therapeutic effect of world exchanges. Biopsychosocial determination of alcoholism could be primarily based on components of interpersonal relationships. Regarding social background, drinking is one of the most famous supports for the achievement of the feast, a founding marker of present time. Taking an existential point of view, the feast appears as the heart of mankind because it presents a primary “us”, a plural state which indicates the beginning and founding of the Self from the others. During the feast, we regularly have to reach our Self from the “us” while avoiding two main dangers, drunkenness, an increase in the dizziness of upright verticality, and addiction, an opposite vertical surrender to alcohol and falling into in the alcoholic relapse, both situations imply a spatial domination and the disappearance of others. Treatment programs of alcohol addicts need to integrate the necessity of reaching the existential basic trust from the support of a group to the appropriation of the community which can be defined as an original “usness”.