神经导航在颅内肿瘤手术中的应用（附106例报告）

目的报告使用StealthStation神经导航系统在颅脑手术中应用的经验.方法应用StealthStation神经导航系统指导106例颅内肿瘤手术进行回顾性分析.术中对导航准确性进行监测并对46例不同部位病灶进行术中脑移位检测.结果首次平均坐标误差和10厘米预期准确性分别为3.60±1.60mm和3.12±1.77mm,经去除或重新注册"不准确”的皮肤坐标后两者分别降为2.34±0.91mm和2.79±0.93mm.有5例因平均坐标误差＞4mm加用表面注册,其结果为1.09±0.24mm.106例病人共108个病灶,除了活检1例(0.9%)外,全切除92个(85.2%)、次全切除8个(7.4%)、大部切除7例(6.5%).术中准确性分别为1.22±0.90mm和1.29±1.30mm.术后症状改善或不变98例(92.5%)、加重6例(5.7%)、死亡2例(1.9%).结论StealthStation神经导航系统在颅脑手术中提供术中动态跟踪、实时导航,准确可靠,有助于病灶全切除及降低手术并发症的发生.     

神经导航在颅脑手术中的应用(附70例临床分析)

目的　探讨StealthStation神经导航系统在颅脑手术中的应用。方法　观察 70例颅脑手术中应用StealthStation神经导航系统的情况 ,包括测量注册准确性 ,参考头架的不同使用方法对导航准确性的影响 ,检测术中准确性及不同部位病灶的术中脑移位 ,并对导航在不同肿瘤手术中的作用进行分析。结果　平均注册误差和 10cm预期准确性分别为 ( 2 5 6± 1 0 0 )mm和 ( 2 45± 0 78)mm。有 5例因平均注册误差 >4mm加用表面注册 ,结果误差减至 ( 1 0 9± 0 2 4)mm。除了微血管减压术 1例和活检 3例 (术后均症状改善或不变 )外 ,其余 66例病人共 67个病灶 ,全切除 5 5个 ( 82 9% )、次全切除 6个( 9 0 % )、大部切除 6例 ( 9 0 % )。术中持续准确性SA1、SA2和SA3分别为 ( 2 3 8± 1 2 7)mm ,( 1 2 1± 0 98)mm和 ( 1 3 5±1 13 )mm。症状改善或不变 5 8例 ( 87 9% )、加重 6例 ( 9 1% )、死亡 2例 ( 3 0 % )。结论　StealthStation神经导航系统在颅脑手术中提供术中动态跟踪、实时导航 ,准确可靠 ,有助于病灶全切除及降低手术并发症的发生。     

神经导航辅助胶质瘤手术

目的　评价神经导航系统在胶质瘤手术中的应用。方法　在 80例胶质瘤手术中 ,应用StealthStation神经导航系统指导手术操作。在其中 2 7例手术中测量硬膜、皮质以及病灶移位程度。在大脑浅表胶质瘤手术中 ,使用微导管栅栏法纠正脑移位的影响 ,判断肿瘤边界。结果　 80例平均座标误差为 (2 .0 3± 0 .89)mm ,10cm预期准确性 (2 .4 3± 0 .99)mm。术中硬膜、皮质以及病灶移位分别为 (3.4 4± 2 .39)mm、(7.5 8± 3.75 )mm以及 (6 .5 5± 3.19)mm。 5例虽然导航显示肿瘤残留 ,但未强行切除 ;其余 75例肿瘤全切 6 2例 (82 .7% ) ,次全或大部切除 13例 (17.3% )。术后症状改善或不变 6 8例 (85 .0 % ) ,术后症状加重或出现新症状 12例 (15 .0 % ) ,无死亡病例。结论　在胶质瘤手术中 ,术中脑移位是影响神经导航准确性的重要因素。微导管栅栏法简便、实用 ,有助于提高肿瘤切除率 ,降低手术并发症     

神经导航引导下直视手术治疗脑内小病灶

目的 探讨在神经导航辅助下微创手术治疗脑内小病灶的经验。方法 在神经导航系统辅助下显微外科手术治疗24例脑内小病灶。其中脑脓肿2例，脑囊虫5例，炎性肉芽肿2例，转移癌7例，海绵状血管瘤2例，星形细胞瘤2例，胶质细胞增生2例，中枢神经细胞瘤1例，生殖细胞瘤1例。结果 导航平均注册误差（2．3±0．45）mm。病灶全切16例，次全切3例，大部分切除2例，取病检3例。术后无死亡、无神经导航误差引起的并发症。全部病例恢复良好。结论 神经导航引导直视手术治疗脑内小病灶手术准确、安全，减少了术中的盲目性和并发症的发生。     

神经导航在颅内肿瘤显微手术中的应用

目的探讨神经导航在颅内肿瘤显微手术中的应用。方法应用神经导航系统完成28例颅内肿瘤手术并对其平均注册误差,术中病灶的精确定位,正常结构的保护及手术疗效进行回顾分析。结果28例平均注册误差为2.87±0.56 mm,术中病灶定位准确,全切除19例(67.9 %),次全切除3例(10.8 %),大部分切除4例(14.2 %),部分切除2例(7.1%),无手术死亡,术后神经功能保留良好。结论颅内肿瘤显微手术治疗应用神经导航技术,可以准确定位和切除病灶,保护神经功能和降低手术并发症的发生。     

神经导航辅助锁孔手术治疗功能区小病灶

目的探讨神经导航辅助锁孔显微手术切除脑功能区小病灶的应用价值。方法采用神经导航辅助锁孔显微手术切除18例脑功能区小病灶。术前将影像学资料输入神经导航系统进行三维重建,制定手术计划。术中实时导航指导手术切除范围,分析治疗结果。结果导航平均注册误差（2．05---0．62）mm,平均骨窗直径3．0cm。所有病例术中均准确定位病灶,其病灶全切17例,次全切除1例。术后16例病人恢复良好,原有症状均获得不同程度改善,1例原有神经症状加重,1例出现新的神经功能损害。结论神经导航辅助锁孔显微手术能准确切除脑功能区病灶,减少手术创伤,提高手术效果,降低死亡率、病残率,在显微神经外科手术中具有重要的临床应用价值。     

神经导航在单鼻孔入路垂体腺瘤切除术中的应用

目的探讨神经导航下经单鼻孔入路垂体瘤切除术的精确性和有效性。方法对15例垂体腺瘤患者采用单鼻孔入路显微手术切除,术前、术中利用神经导航系统对蝶窦前壁、鞍底的打开,腺瘤的切除进行引导。结果15例中12例肿瘤全切除,3例次全切除。神经导航平均注册误差为(0.8±0.5)mm。所有病例术中定位准确,术后神经、血管功能保留良好。结论在神经导航系统引导下经单鼻孔入路垂体腺瘤切除术可以达到入路精确,手术创伤小,病灶定位准确,神经、血管功能保留良好的目的。     

神经导航术中脑移位的研究

目的定量研究不同神经导航手术中的脑移位,评价术中脑移位对神经导航手术定位准确性的影响。方法在73例颅脑手术中应用StealthStation神经导航系统指导手术操作,制作骨瓣前在骨窗外作对照参考点,然后分别测量硬膜、皮层和病灶移位程度,并分别对不同病理性质肿瘤的移位情况进行分析。结果平均注册误差(2.13±0.74)mm,术中持续准确性为(1.17±0.67)mm;所有73例的硬膜、皮层和病灶移位程度分别为(2.80±2.48)mm、(5.14±4.05)mm以及(3.53±3.67)mm。胶质瘤组的硬膜、皮层和病灶移位均是最大的,而海绵状血管瘤组以及颅底肿瘤组的移位明显低于胶质瘤组。结论术中脑移位是影响神经导航手术定位准确性的重要因素,对不同性质和部位病变术中脑移位的了解有助于指导手术操作。     

神经导航在神经外科显微手术中的应用

目的探讨神经导航在神经外科显微手术中的应用。方法应用神经导航系统完成191例神经外科显微手术并对其平均注册误差,术中病灶的精确定位,正常结构的保护及手术疗效进行回顾分析。结果191例平均注册误差为(1.2±0.4)mm,术中病灶定位准确;全切除154例,次全切除23例,大部分切除11例,部分切除3例;无手术死亡,术后神经功能保留良好。结论神经外科显微手术中应用神经导航技术,可以准确定位和切除病灶,保护神经功能和降低手术并发症的发生。     

神经导航引导下的显微神经外科手术

目的：探讨神经导航在显微神经外科手术中的作用。方法：运用国产神经导航设备对27例颅内病变患者进行导航引导下的显微手术,其中肿瘤26例,炎性病变2例,病变体积为0．13cm^3-150.25cm^3,平均45．05cm^3。结果：病变全切18例（66．66％）,次全切除3例（11．11％）,大部切除4例（14．81％）,部分切除2例（7．41％）,无手术死亡。导航引导的注册精度误差平均为3．7mm。结论：在显微手术中运用导航技术可以更精确地寻找和切除脑内深部微小的病变,提高手术的成功率,减少手术并发症。     

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.     

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.     

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.     

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.     

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.     

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.