实时超声在颅脑手术中的应用

目的 探讨术中超声在颅脑手术中的应用价值.方法 应用超声辅助切除邻近功能区或功能区及脑深部区域的病灶36例,开颅时实时定位,手术中示踪,关颅前评估手术效果.结果 本组术中超声定位检查36例,超声显示病变的大小、部位、性质与术前CT、MRI相吻合,根据超声提示能精确探查病变.结论 术中超声定位检查简单、有效、安全,有助于提高颅脑手术操作的精确性.术中超声定位有临床应用价值.     

术中超声联合神经导航辅助显微手术切除颅内肿瘤的临床研究

目的探讨术中超声联合神经导航在颅内肿瘤切除手术中的作用和价值。方法选择16例颅内肿瘤患者,利用MRI介导的神经导航系统引导开颅,采取合适的皮层入路,应用显微神经外科技术切除颅内肿瘤,利用术中超声判断病变切除的程度和范围,随访患者术后情况。结果所有病灶均在神经导航引导下开颅,神经导航术前对病变定位准确率为100%,骨窗暴露满意;术中超声能纠正术前神经导航定位的漂移;在其引导下14例获得全切除,2例获得次全切除;术后1例有对侧肢体肌力下降,1例轻度运动性失语,无颅内感染及死亡病例。结论术中超声联合神经导航辅助显微神经外科手术能提高颅内肿瘤定位的准确性,减少手术副损伤,提高肿瘤全切率,是一种安全有效的方法 。     

神经导航融合技术在颅底肿瘤中的应用

目的 探讨神经导航融合技术在颅底肿瘤中的应用。方法 通过术前准备、注册、CT与MRI等影像模式融合、术中导航定位,比较各种注册方法的精确性,融合精确度,术中定位精确性、术中持续精确性,扩大暴露范围等,提出和改进神经导航技术在颅底手术中的应用技术。结果 神经导航用于颅底肿瘤手术切除,术前有助于开颅皮肤切口及骨瓣的设计,选择最短的手术途径;术中可为肿瘤的切除定向定位,在颅底手术中使术者随时了解颅底肿瘤与周围重要解剖结构（如脑干、颅神经及重要血管等的关系）。结论 颅底肿瘤以及颅底结构位置相对固定,影响因素较小,脑移位最小,定位精确,及时反馈肿瘤的切除深度,增加手术的安全性,加快手术进程,避免脑重要结构的副损伤。     

功能神经导航和术中磁共振引导下精确切除毗邻大脑运动功能区的致(癎)病变

目的 评估功能神经导航和术中MRI引导对毗邻运动功能区致(癎)病变切除术的效果.方法 回顾性分析接受神经导航引导手术的14例癫(癎)病人,其中10例采用术中MRI.术前MRI扫描,融合影像,设计病变切除范围及入路,三维计划输入导航系统并投射至手术显微镜辅助手术.术中复查MRI,对残余病变重新定位,实施手术切除.术后定期进行随访.结果 病人均成功实施了功能神经导航,致(癎)病变、运动区皮质和锥体束投射在手术显微镜下,精确切除病变,同时运动区皮质和锥体束获得有效保护;术中MRI末次扫描提示致(癎)灶病变的切除范围达到术前计划.术后随访6～24个月,癫(癎)发作控制达Engel Ⅰ级12例,Engel Ⅱ级2例.未出现肢体肌力下降.结论 对于毗邻运动功能区的致(癎)病变,通过功能神经导航和术中MRI精准定位病灶和功能区,可以达到精准切除病变并保护正常脑功能的目的.     

术中实时超声导航在脑深部肿瘤切除术中的应用

目的 利用Brain Lab整体超声导航实时监测并切除脑深部肿瘤,探讨术中超声结合导航在神经外科手术中的价值.方法 应用Brain Lab整体超声导航系统对30例脑深部肿瘤进行显微神经外科手术,结合导航图像,术中超声动态了解病变移位情况,实时显示病变边界,进行移位后病灶的全切除.结果 术中实时超声证实在30例导航手术过程中均有不同程度的病灶移位,在超声引导下,探寻残余肿瘤并在监测下进一步全切除,术后未出现明显的并发症.结论 术中整体超声导航不仅可以在移位情况下重新准确定位肿瘤边界,而且可以在实时超声监测下进一步切除肿瘤,缩短手术时间,增加了全切除率,提高了手术的安全性.     

脑功能区胶质瘤手术中的新技术

目的探讨切除脑功能区胶质瘤手术新技术与方法。方法48例脑功能区胶质瘤经术前常规MRI、弥散张力成像(DTI)和fMRI定位大脑皮层功能区及功能投射纤维束,以神经导航为前导,在术中全麻唤醒状态下,通过术中B超定位脑内病灶,皮层体感诱发电位(Co-SEP)及皮层直接电刺激术(Co-ST)脑功能区定位,并在清醒状态下切除病变。术后随访时间3-42个月。结果16例Co-SEP确定中央沟,42例Co-ST明确运动区,16例Co-ST确定语言运动区;肿瘤全切35例,次全切除9例,部分切除4例。术后1个月神经症状好转44例,术后出现暂时性局部神经症状36例;长期局部神经症状加重4例,无手术死亡。全部患者无手术痛苦回忆。结论术中全麻唤醒、皮层-皮层下电刺激术和脑超声技术是切除功能区胶质瘤必备的三项基本技术;术前fMRI与DTI为脑功能区手术提供十分重要信息,神经功能导航为术中功能区定位提供重要前导,综合使用这些现代技术能够在术中明确脑功能区与肿瘤切除范围的关系,做到最大限度地切除脑功能区病变和保护脑功能。     

脑磁图与神经导航结合在脑功能区肿瘤切除中的初步应用(附31例报道)

目的 探讨脑磁图功能区定位与神经导航结合在肿瘤神经外科的应用价值.方法 选择31例功能区肿瘤患者术前行脑磁图(Magnetoencephalography,MEG)确定肿瘤范围及相邻皮质功能区位置,将影像数据输入Brain-LAB导航系统工作站,进行三维重建并制定手术计划,标记肿瘤病灶及其临近重要功能区,应用显微外科技术切除病变,术后进行临床和影像学评价.结果 肿瘤全切除26例,次全切除2例,大部切除3例.术后新增一过性功能障碍8例.结论 MEG是一种无创检查方法,结合神经导航将病灶与功能区定位应用于肿瘤神经外科,能够有针对性地选择手术入路,并在术中更精确地保护功能区,从而使功能区损伤的机会大为减少.     

功能区胶质瘤的手术治疗进展

大脑功能区胶质瘤的手术治疗是神经外科临床工作的一个难题。最大程度地切除病灶，同时尽可能地保护正常脑功能，避免术后神经功能缺失，提高病人术后生活质量，是脑功能区胶质瘤手术治疗的最高目标。在唤醒麻醉下，术前功能神经影像、术中大脑皮质刺激定位、电生理监测、神经导航和术中成像（超声、MRI）等技术的应用，已成为当前脑功能区胶质瘤手术的重要辅助手段。本文对脑功能区胶质瘤外科治疗进展，尤其是功能定位方法进行综述。     

全程唤醒麻醉下脑功能区病变切除手术:技术方法及初步结果

目的探讨无人工气道全程唤醒麻醉下脑功能区病变切除手术方法及其临床意义。方法 47例脑功能区病变病人均在无人工气道全程唤醒麻醉下开颅,采用头皮神经阻滞、切口和硬脑膜浸润麻醉,经神经导航和(或)术中超声定位病灶,直接皮质电刺激(DES)定位脑功能区皮质和皮质下结构,进行最大范围安全切除病变。结果所有病人在手术过程中获得安全、可靠的监控麻醉,病变全切除30例(63.8%),次全切除11例(23.4%),部分切除6例(12.8%)。术后新发短暂性神经功能障碍28例(59.6%),其中术后1个月内恢复至术前水平26例,遗留严重神经功能障碍2例,1例因放射冠区梗死而引起严重瘫痪,1例因放疗后期脑积水、肿瘤脊髓转移而病情恶化。结论无人工气道全程唤醒麻醉开颅手术能够避免全麻-唤醒-全麻时在拔除喉罩过程中出现的颅内压增高等风险,能根据手术需要随时唤醒病人,较好地配合手术。应用全程唤醒麻醉手术可做到最大限度地切除脑功能区病变和保护脑功能,是脑功能区病变手术的一种唤醒麻醉新方法。     

术中超声辅助神经导航在颅内小病灶手术中的应用

目的探讨术中超声辅助神经导航在颅内小病灶手术中的临床价值。方法总结分析2010年1月至2012年12月我院经术中超声辅助神经导航手术的颅内小病灶18例患者的临床资料,重点分析术中纠正脑移位的意义、超声图像的价值和手术操作技巧。结果颅内小病变18例患者,12例术中发现单纯神经导航脑移位2～8mm,平均4.3mm。术中应用超声辅助神经导航技术定位病灶准确性100%。18例患者,经术后影像学证实病变全切除17例,大部分切除1例。术后偏瘫1例,术后出血1例并经原切口入路清除。术后无死亡病例。结论超声可以纠正神经导航的脑移位,术中超声显示海绵状血管瘤和钙化病变边界最好。术中超声辅助神经导航技术对于寻找定位深部或功能区小病灶意义重大。     

Epilepsy and anomalies of neuronal migration: MRI and clinical aspects

Neuronal migration disorders are the result of disturbed brain development. In such disorders, neurons are abnormally located. In diagnosing these conditions, magnetic resonance imaging is superior to any other imaging technique. This enables us to improve our knowledge of the clinical correlates of neuronal migration. With reference to migrational disorder, a retrospective study of all 303 patients with epileptic seizures referred for magnetic resonance imaging during a 3-year period was performed, 13 patients (aged 12-41, mean age 27) were identified. They represent 4.3% of the entire study group. Of the patients with known epilepsy, 6.7% and of the mentally retarded, 13.7% had migrational disorders. Four patients had schizencephaly as the dominant finding, one was classified as hemimegalencephaly, 2 had isolated heterotopias, and 6 had localized pachy- and/or poly-microgyria. The clinical pictures are complex. Ectopias of grey matter are recognised foci of epilepsy, but from an epileptological and a clinical viewpoint little attention has been given to these disorders. The present study shows that malmigration is not rare in epilepsy patients, especially not in the mentally retarded.     

Classification of methods in transcranial Electrical Stimulation (tES) and evolving strategy from historical approaches to contemporary innovations

Transcranial Electrical Stimulation (tES) encompasses all methods of non-invasive current application to the brain used in research and clinical practice. We present the first comprehensive and technical review, explaining the evolution of tES in both terminology and dosage over the past 100 years of research to present day. Current transcranial Pulsed Current Stimulation (tPCS) approaches such as Cranial Electrotherapy Stimulation (CES) descended from Electrosleep (ES) through Cranial Electro-stimulation Therapy (CET), Transcerebral Electrotherapy (TCET), and NeuroElectric Therapy (NET) while others like Transcutaneous Cranial Electrical Stimulation (TCES) descended from Electroanesthesia (EA) through Limoge, and Interferential Stimulation. Prior to a contemporary resurgence in interest, variations of transcranial Direct Current Stimulation were explored intermittently, including Polarizing current, Galvanic Vestibular Stimulation (GVS), and Transcranial Micropolarization. The development of these approaches alongside Electroconvulsive Therapy (ECT) and pharmacological developments are considered. Both the roots and unique features of contemporary approaches such as transcranial Alternating Current Stimulation (tACS) and transcranial Random Noise Stimulation (tRNS) are discussed. Trends and incremental developments in electrode montage and waveform spanning decades are presented leading to the present day. Commercial devices, seminal conferences, and regulatory decisions are noted. We conclude with six rules on how increasing medical and technological sophistication may now be leveraged for broader success and adoption of tES.     

Hepatic Considerations in the Use of Antiepileptic Drugs

Summary: Virtually all of the major antiepileptic drugs (AEDs) can cause hepatotoxicity, although fatal hepatic reactions are rare. The mechanisms, incidences, and risk profiles for such reactions differ from drug to drug. With carbamazepine and phenytoin, hepatotoxicity may be due to drug hypersensitivity. Although the profiles of patients at risk have not been well-defined for these two antiepileptic drugs, it would appear from reports in the literature that older adolescents and adults are at higher risk than children of developing serious or fatal hepatotoxicity. Once hepatotoxicity develops, mortality rates are 10–38% with phenytoin and 25% for carbamazepine. The risk profile for valproate fatal hepatotoxicity has been more clearly defined. Those at primary risk of fatal hepatic dysfunction are children under the age of 2 years who are receiving multiple anticonvulsants and also have significant medical problems in addition to severe epilepsy. The risk is considerably lower for patients over the age of 2 years on valproate monotherapy. In contrast to the risk profile with other AEDs, adults receiving valproate as monotherapy have the lowest risk of hepatotoxicity. Fatal hepatic dysfunction coincident with valproate may be the result of aberrant drug metabolism. Concomitant use of AEDs that induce microsomal P450 enzymes (e.g., phenytoin and phenobarbital) may enhance the production of a toxic metabolite, and hence the greater risk of hepatotoxicity with polypharmacy.     

Vascular Malformations and Epilepsy: Clinical Considerations and Basic Mechanisms

Summary: Vascular malformations (VMs) are associated with epilepsy. The natural history of the various VMs, clinical presentation, and tendency to provoke epilepsy determine treatment strategies. Investigations have probed the mechanisms of epileptogenesis associated with these lesions. Electrophysiologic changes are associated with epileptogenic cortex adjacent to VMs. Putative pathophysiologic mechanisms of epileptogenesis include neuronal cell loss, glial proliferation and abnormal glial physiology, altered neurotransmitter levels, free radical formation, and aberrant second messenger physiology.     

Neonatal Seizures: Problems in Diagnosis and Classification

Summary: The clinical identification of neonatal seizures is critical for the recognition of brain dysfunction; however, diagnosis is often difficult because of the poorly organized and varied nature of these behaviors. Current classification systems are limited in their ability to communicate motor, autonomic, and electroencephalo-graphic features of seizures precisely and to provide a basis for uniform effective diagnosis, therapy, and determination of prognosis. Recent investigations of neonates, utilizing bedside electroencephalographic/polygraphic/ video monitoring techniques, have provided the basis for improved diagnosis and classification of seizures in the newborn. These studies have demonstrated that not all clinical phenomena currently considered to be seizures require electrocortical epileptiform activity for their initiation or elaboration. In addition, the specific clinical character of the phenomena considered to be seizures, the clinical state of the infant, and the character of the EEG indicate the probable pathophysiological mechanisms involved and suggest probable etiologies, prognosis, and therapy. Similarities between animal models that demonstrate reflex physiology and neonates with motor automatisms and tonic posturing suggest that these clinical behaviors may not be epileptic in origin but, rather, primitive movements of progression and posture mediated by brainstem mechanisms. Although not all clinical behaviors currently considered to be neonatal seizures may have similar pathophysiological mechanisms, they are clinically significant because they all indicate brain dysfunction.     

Valproate Monotherapy in the Management of Generalized and Partial Seizures

Summary: For decades, therapeutic tradition has promoted the concept of polypharmacy in the management of epilepsy. In recent years, however, studies have shown that, for most patients, monotherapy can provide comparable or better seizure control than administration of multiple anticonvulsants, while diminishing the potential for adverse reactions, drug interactions, and poor compliance. Valproate is an important monotherapeutic agent that is highly effective in the control of idiopathic primary and secondarily generalized epilepsies, and partial seizures that do not generalize. Comparative studies have found that valproate is at least as effective as phenytoin and carbamazepine in the treatment of generalized and partial seizures. Given the similar efficacy, other factors such as pharmacokinetics and side effects may therefore determine anticonvulsant selection for monotherapy.     

Carbamazepine Efficacy and Utilization in Children

Summary: Carbamazepine is effective for preventing partial and generalized tonic-clonic seizures in children. Although absence epilepsies are more common in children than adults, an estimated 80% of children with epilepsy have seizure types or epilepsies that are potentially responsive to carbamazepine. The differential diagnosis of ictal staring is an especially important issue in children because absence and atypical absence seizures are more prevalent in children than adults. Age-related pharmacokinetic differences and drug interactions are major considerations in children. On average, children have higher clearance rates of carbamazepine, shorter half-lives, and higher ratios of carbamazepine-10, 11-epoxide to carbamazepine than adults. In addition, children with severe epilepsy are more likely to require multiple-drug therapy, which can lead to complex drug interactions. When carbamazepine is administered along with valproate, drug protein binding interactions can cause intermittent side effects.     

Un nouveau cadre conceptuel de travail pour la psychiatrie

In an attempt to place psychiatric thinking and the training of future psychiatrists more centrally into the context of modern biology, the author outlines the beginnings of a new intellectual framework for psychiatry that derives from current biological thinking about the relationship of mind to brain. The purpose of this framework is twofold. First, it is designed to emphasize that the professional requirements for future psychiatrists will demand a greater knowledge of the structure and functioning of the brain than is currently available in most training programs. Second, it is designed to illustrate that the unique domain which psychiatry occupies within academic medicine, the analysis of the interaction between social and biological determinants of behavior, can best be studied by also having a full understanding of the biological components of behavior.