精神疾病的扣带回立体定向毁损术

目的探讨扣带回立体定向毁损术治疗药物难治性精神病,包括抑郁症、双相情感障碍、强迫症及顽固性疼痛的临床疗效。方法对23例经精神科专科医师正规药物、心理、行为治疗无效的顽固性精神疾病患者,包括强迫症3例、抑郁症10例、双相情感障碍6例、顽固性疼痛4例,采用MR定位立体定向双侧扣带回毁损术,术中用电阻抗及高频电刺激验证靶点,80℃、60s射频毁损。术前、术后由精神科医师分别采用Y-BOCS量表,Hamilton焦虑量表、Hamilton抑郁量表、疼痛的VRS评分进行评价。结果4例顽固性疼痛的患者疼痛明显减轻。10例抑郁症手术患者中6例完全治愈,2例显著缓解,2例复燃。6例双相情感障碍抑郁相患者中,4例缓解,2例有复燃。强迫症患者3例均有效。无严重手术并发症。结论磁共振导向立体定向双侧扣带回毁损术定位精确,对顽固性精神病有明显疗效。     

脑立体定向双侧扣带回射频毁损术后并发症、疗效与靶点关系分析

本文报告应用DZY—A多功能脑立体定向仪行脑立体定向射频毁损双侧扣带回前端治疗难治性精神病15例,其中6例出现术后并发症。比较出现并发症及未出现并发症组病人靶点位置明显偏前(P<0.0005),平均20.44±3.24mm(靶点至侧脑室额角尖之间的距离)。5例采用多靶点治疗的病人60％出现术后并发症。出现并发症组与未出现并发症组疗效无显著差别。作者认为扣带回毁损术疗效好,并发症少,多靶点治疗破坏范围大,并发症多。且扣带回毁损偏前对旁中央小叶、中央回的影响小。     

帕金森病Vim核立体定向射频毁损灶的MR影像学研究

目的　探讨帕金森病Vim核立体定向射频毁损灶的MRI表现及其与疗效的关系。方法　 2 3例帕金森病患者接受Vim核立体定向射频毁损术 ,在手术后的早期 (16例 )、晚期 (7例 )进行MRI随访 ,了解毁损灶的MRI表现、大小及其与疗效的关系 ,并且计算毁损灶的位置与原靶点坐标的误差。结果　 16例患者在术后 3～ 7天复查MRI ,T1加权像 :中心为细小的长T1低信号点 ,中间为短T1高信号环 ,最外为长T1低信号环 ,周边有不规则的水肿带 ;T2 加权像 :中心为细小的长T2 高信号点 ,中间为短T2 低信号环 ,最外为长T2 高信号环 ,周边有不规则的水肿带。 7例患者术后 1～ 2年复查MRI,毁损灶的MRI表现为长T1长T2 类圆形信号。毁损灶的位置与原靶点的误差小于 1mm。结论　帕金森病立体定向射频毁损灶的大小与毁损的温度、时间、毁损针的直径和长度成正比 ,晚期MRI随访提示如果靶点位置正确 ,毁损灶大小在 5 .0mm× 5 .2mm× 8.1mm左右 ,则能产生较好的疗效     

扣带回毁损术后尿失禁解剖及临床分析

目的 研究扣带回毁损术后尿失禁的原因及防治措施。方法 回顾分析10例顽固性精神病的立体定向扣带回毁损术术后发生尿失禁的状况，解剖观察12例扣带回毁损灶和胼周动脉及其分支的关系。结果 术后因扣带回毁损术引起的尿失禁6例，1周内恢复者1例，1～3个月恢复3例，3个月后仍未恢复者2例。旁中央动脉是供应旁中央小叶的主要血管，旁中央动脉位置相对恒定，且两侧旁中央动脉不对称分布，扣带回毁损灶后界波及旁中央动脉的有9例，其中波及双侧旁中央动脉的有5例。结论 扣带回立体定向毁损术的疗效是肯定的，其术后常见的并发症尿失禁，在不影响疗效的基础上通过精确细化靶点坐标等措施是应该可以得到防治的。     

立体定向扣带回毁损术后尿失禁原因分析及预防措施(附3例报告)

我院应用立体定向扣带回毁损治疗精神分裂证11例,发生暂时性尿失禁3例,现将尿失禁的原因及预防措施分析如下。手术方法及靶点坐标:颅骨钻孔及脑室造影后,采用射频热疑毁损扣带回,78℃时间60秒。尿失禁3例采用的解剖坐标为:离中线5mm,额角尖端后20～30mm,侧脑室顶0mm。未发生尿失禁的8例采用的解剖坐标为:离中线6mm,额角尖端后20～30mm,侧脑室顶0mm。体会:立体定向扣带回毁损术后尿失禁屡有报道,发生率29％～40％,本组发生率27.3％。暂时性尿失禁虽非手术严重并发症,但给病人带来一定痛苦。从本组资料表明,正中平面向外5mm的3例病人均出现尿     

立体定向核团毁损术治疗难治性强迫症27例分析

目的：探讨立体定向核团毁损术治疗难治性强迫症的临床疗效。方法对27例难治性强迫症病人,采用C T导向立体定向手术对双侧扣带回、内囊前肢实施多靶点毁损治疗。术前在256层螺旋C T 扫描下定出双侧扣带回、内囊前肢拟毁损的靶点,术中用电阻抗监测验证靶点,70℃射频毁损60～75 s。术前及术后6个月及1 a由精神病专科医师独立进行Yale-Brown强迫症量表、Hamilton抑郁量表、Hamilton焦虑量表的评定比较。结果本组27例手术病人中强迫症状完全消失13例,显效8例,有效3例,无效3例。7例病人在术后出现记忆力下降和定向障碍,6例术后2周恢复;5例出现尿失禁,在1周后缓解;1例出现一侧肢体轻偏瘫,复查头颅CT 未见出血,经扩血管及高压氧等治疗3周后肌力恢复。结论螺旋CT导向立体定向双侧扣带回、内囊前肢毁损术对顽固性强迫症病人疗效明显,可有效提高患者的生活质量,恢复社会功能。     

帕金森病立体定向射频毁损灶的MRI表现

目的探讨帕金森病立体定向射频毁损灶的MRI表现及其与疗效的关系.方法通过对19例帕金森病患者立体定向射频毁损术后的早期、晚期MRI随访,了解毁损灶的MRI表现及其与疗效的关系.结果19例患者在术后3～7天复查MRI,T1W中心为细小的长T1低信号点,中间为短T1高信号,最外为长T1低信号环,周边有不规则的水肿带,T2W中心为细小的长T2高信号点,中间为短T2低信号,最外为长T2高信号环,周边有不规则的水肿带.7例患者术后1～2年复查MRI,毁损灶的MRI表现为长T1长T2类圆形信号.毁损灶的位置与原靶点的误差小于1mm.结论帕金森病立体定向射频毁损灶的大小与毁损的温度、时间成正比,晚期MRI随访提示如果靶点位置正确,毁损灶大小在5mm×5.2mm×8.1mm左右,则能产生较好的疗效.     

选择性多靶点联合毁损治疗难治性精神障碍

目的 探索以正电子发射断层扫描(positron emission tomography,PET)为主要依据进行选择性立体定向多靶点毁损治疗药物难治性精神障碍.方法 本组符合药物难治性精神障碍共46例,其中精神分裂症34例,精神发育迟滞伴攻击行为10例,强迫症2例.所有患者在术前均行PET扫描.根据患者PET结果,对目前常用的治疗精神障碍靶点进行调整,拟定个性化毁损靶点.立体定向多靶点毁损后对患者疗效进行评估.结果 PET显示本组87%患者存在不同程度的脑代谢异常,额叶代谢降低为63.1%,颞叶代谢减低21.8%,双侧扣带回区代谢增高26.1%.根据以上结果,颞叶代谢降低则同侧杏仁核不做毁损,扣带回代谢增高给予扩大毁损范围.术后经量化评估,疗效满意,没有出现严重并发症.结论 PET是目前唯一反应精神异常患者脑内代谢情况的影像学检查,其结果对制定个性化手术方案有重要参考价值.     

磁共振微电极记录辅助脑内核团毁损治疗帕金森病

目的：探讨磁共振（MRI）扫描定位结合术中微电极记录技术及靶点选择在帕金森病立体定向手术治疗中的作用。方法：MRI扫描定位结合微电极记录,脑立体定向毁损法治疗帕金森病89例,其中Vim毁损6例,Gpi毁损71例,Gpi Vim毁损12例,结果：根据MRI扫描确定的靶点坐标与通过微电极记录确定的最终毁损靶点坐标不符的9例,变更范围1-3mm,患者震颤、僵直及运动减少等症状改善显著,术前及术后UPDRS评分经t检验统计有显著差异。结论：选择合适的靶点,MRI扫描结合术中微电记记录技术,提高了帕金森病手术疗效,减少了手术并发症。     

多靶点毁损治疗帕金森病疗效分析

目的 ;探讨立体定向多靶点毁损治疗帕金森病(PD)的方法和影响疗效的因素。方法应用南京麦迪柯科技公司98-3型脑立体定向计算机辅助规划手术系统,螺旋CT薄层扫描解剖定位,对37例PD患者进行苍白球和(或)丘脑多靶点毁损手术,分析术后患者的靶点影像学改变和影响临床疗效的因素。结果随访3~5年,按PD联合评分标准(UPDRS)进行评分,显效24例(64.86%),改善9例(24.32%),无效4例(10.81%)。3年后复发再手术3例(8.1%),3例双侧手术,近期效果满意。并发症:术后3天内对侧肢体先肌痉挛后轻度偏瘫者4例(11.0%),远期出现肢体麻木、语音低、智能减退者4例(10.81%)。CT/MRI复查靶点毁损灶消失3例(8.10%),靶点毁损灶稳定34例(91.89%),无其它并发症及死亡。结论单靶点毁损且毁损灶小复发率高,多靶点毁损远期并发症高,靶点毁损术治疗PD近期疗效好,远期差。     

Impact of bilateral anterior cingulotomy on neurocognitive function in patients with intractable pain

Although the cingulate cortices are important with regard to neurocognitive functions, outcome studies usually fail to identify evident cognitive dysfunction following anterior cingulotomy. The aim of this study was to document any impairment of neurocognitive functions following anterior cingulotomy. Between September 2002 and April 2004, 10 patients underwent stereotactic bilateral anterior cingulotomy for intractable cancer pain. A neuropsychological assessment of each patient was performed 1 day prior to surgery and 1 week and 1 month post-operatively. Assessment of pain relief was evaluated with a short form of the McGill pain questionnaire. Six of the 10 patients achieved fair to good pain relief following the cingulotomy procedure. Most neurocognitive functions, including language, memory, motor, visual-constructional, and intellectual functions, remained unaffected. A decline in focused attention performance was identified at the early post-operative assessment. The results of this longitudinal evaluation will help to better define the risk-to-benefit profile of cingulotomy for intractable pain.     

Stereotactic co-registration of magnetic resonance imaging and histopathology in post-mortem multiple sclerosis brain

A number of groups have examined the pathological substrate of signal changes on magnetic resonance imaging (MRI) in post-mortem (PM) brain of patients with multiple sclerosis (MS). Such studies will benefit from using a standardized method to reliably co-register regions of interest on MRI and tissue specimens. We investigated the usefulness of a stereotactic navigation system for this purpose. We also addressed the sensitivity of different standard MRI sequences with regard to lesion conspicuity in PM MS brain. Post-mortem brains of eight patients with MS were studied. Formalin-fixed coronal slices were placed in the head frame of a stereotactic system. Proton density-, T2-weighted and fast fluid-attenuated inversion recovery (FLAIR) scans were obtained and visually matched with scans that had been previously obtained on the same, but fresh, specimens. Guided by the stereotactic target points, the dissection of the fixed specimens was performed. After processing the blocks for embedding in paraffin, sections were stained with haematoxylin-eosin and Luxol fast blue. T2-weighted MRI of fixed brain revealed 24 areas suspected to be MS lesions, all of which were confirmed histologically. Three of these lesions were not visible on macroscopic inspection. There were 14 additional hyperintensities on T2-weighted or FLAIR MRI of the fresh specimens, five of which did not correlate to MS lesions histologically. Stereotactic navigation is a useful approach to co-register MRI and histopathology in PM brain of MS patients and may improve the precision of MRI-guided sampling of tissue specimens. Standard T2-weighted MRI appeared to be the single most useful approach for lesion detection in fresh and fixed specimens.     

中枢性疼痛的神经外科治疗

目的 研究中枢性疼痛的神经外科治疗策略.方法 根据疼痛性质和部位的不同,行立体定向中脑毁损术1例、双侧扣带回前部毁损术2例、中脑加双侧扣带回联合毁损术9例、运动皮层电刺激术(MCS) 11例、脊髓电刺激术(SCS)3例和脊髓后根入髓区(DREZ)切开术79例次.结果 术后患者疼痛均不同程度减轻,1个月以内镇痛疗效满意,VAS评分较术前均显著降低(P＜0.01).随访12 -36个月,观察术后6个月以上的长期疗效,发现中脑加双侧扣带回联合毁损术好于单纯中脑或扣带回前部毁损术的效果;MCS和SCS治疗的多数患者疗效有波动;DREZ切开术的长期疗效满意,82.1％的臂丛神经撕脱后疼痛患者能够保持50％以上疼痛缓解率,88.9％的脊髓损伤后疼痛患者止痛疗效长期稳定.结论 神经外科止痛手术能够确实有效地治疗中枢性疼痛,脊髓损伤、脊神经根撕脱等脊髓水平的中枢性疼痛应该首选DREZ切开术治疗,对于脑梗死、脑出血等原因造成的中枢性疼痛,MCS是一种可供选择的治疗手段.     

双侧扣带回毁损术治疗海洛因精神依赖

目的探讨双侧扣带回毁损术治疗海洛因精神依赖的临床疗效和可能的作用机制。方法对4例海洛因成瘾病人术前行美沙酮脱毒治疗;之后采用MRI定位立体定向扣带回毁损术,在双侧扣带回前中1/3交界处射频制造毁损灶;术后进行康复治疗和帮助其回归社会。结果均顺利接受了治疗全过程,无明显并发症。随访半年,2例病人无复吸;1例术后1个月内偶有复吸,其后无复吸;另1例病人术后4个月起复吸。操守较好者焦虑、抑郁等精神症状明显缓解,海洛因渴求程度明显减轻。结论双侧扣带回毁损术治疗海洛因精神依赖,安全、近期有效;可能与精神症状的缓解有关,长期效果有待随访。     

MRI定位下立体定向活检术在颅内多发疑难病例诊断中的应用

目的探讨MRI定位立体定向活检术的优点及其在颅内多发疑难病例诊断中的应用价值。方法安装Leksell-G型定位框架,采用MRI扫描,确定靶点的位置。对22例临床表现不典型或影像学上较难诊断的多发疑难占位患者施行立体定向活检手术。结果22例患者均未出现因活检手术造成的颅内出血、偏瘫等严重并发症。所有患者均得到明确的病理诊断及相应的治疗。结论MRI定位立体定向活检手术具有准确性高的优点,能够有效的诊断颅内多发疑难病例。     

MRI定向下核团毁损术治疗难治性精神分裂症

目的 应用MRI定向下核团毁损术治疗难治性精神分裂症,并对其疗效及并发症进行评估.方法 采用MRI定向下脑内单靶点或组合靶点射频毁损术治疗38例难治性精神分裂症,术后6月依据全国精神外科协作组1990年标准对疗效进行评价.手术前后应用简明精神量表BPRS及各因子分评价手术效果.结果 38例患者术后6月恢复8例,显著进步15例,进步12例,无效3例,加重0例,有效率92.1%;15例次术后出现早期一过性并发症,均在术后2周内恢复.术后简明精神量表BPRS总分及焦虑忧郁、缺乏活力、思维障碍、激活性、敌对猜疑等因子分均明显下降,术前、术后有显著性差异(P<0.05).结论 MRI定位下核团毁损术治疗难治性精神分裂症效果显著,精确,安全.     

Impairments of attention after cingulotomy.

BACKGROUND: Outcome studies have generally not indicated significant cognitive disturbances after cingulotomy. There is now considerable evidence that the cingulate may play an important role in emotional behavior and attention. OBJECTIVE: To characterize impairments of attention associated with bilateral lesions of the anterior cingulate cortex produced by cingulotomy. METHODS: Twelve patients who underwent cingulotomy for treatment of intractable pain were administered tests of attention, executive functions, response intention and production, and a broad range of other neurocognitive functions before surgery and again 3 and 12 months after surgery. Data from this within-subjects repeated-measures design were analyzed by multivariate analysis of variance procedures. RESULTS: After cingulotomy, patients initially had executive and attentional impairments. By 12 months, these had resolved into more circumscribed deficits, with greatest impairments on tasks requiring intention and spontaneous response production, and milder impairments of focused and sustained attention. Other aspects of attention and other cognitive functions were generally unaffected. CONCLUSION: The anterior cingulate cortex modulates response intention and focused attention.     

立体定向手术治疗顽固性中枢神经痛

目的研究脑立体定向手术治疗顽固性中枢神经痛(central pain,CP)的临床应用。方法CP患者6例,包括丘脑及脑桥梗塞4例,丘脑出血1例,丘脑梗塞合并颈髓损伤1例。所有病例均在局麻下行双侧扣带回及双侧伏核(nucleus accumbens,NAc)毁损。手术前后采用视觉模拟评分(visual analog scale,VAS)、McGill疼痛问卷(mcGill pain questionnaire,MPQ),口述描绘评分法(verbal rating scales,VRS)进行评分,同时记录手术前后患者使用镇痛剂的种类和最大剂量。将术后1周,1个月,3个月,6个月的评分和术前比较,采用自身配对t检验。结果术后6例患者从1周到6个月止痛效果较好,最长1例随访18个月,止痛效果稳定,除1例丘脑出血后疼痛患者目前偶尔口腹止痛片外,其余患者到目前为止未用任何麻醉镇痛剂治疗。VAS,MPQ,PPI,VRS评分手术前后差异显著(P<0.01)。结论脑立体定向双侧伏核+双侧扣带回损毁手术治疗CP具有较好的治疗效果,超过1年的长期疗效有待进一步观察。     

Stereotactic Amygdalohippocampotomy for the Treatment of Medial Temporal Lobe Epilepsy

PURPOSE: This study was carried out to assess the safety and efficacy of stereotactic ablation of the amygdala and hippocampus for the treatment of medial temporal lobe epilepsy. METHODS: Twenty-two stereotactic amygdalohippocampotomies were performed in 19 patients with unilateral temporal lobe seizures by using magnetic resonance imaging (MRI) localization for target planning and radiofrequency techniques for lesion production. Seizure frequency was assessed at 3-monthly follow-up visits. Two lesion groups were defined. In group I, four to 11 (mean, 6.4) discrete lesions were made, encompassing the amygdala and anterior 13-21 mm (mean, 16.8 mm) of the hippocampus. In group II, a large number of confluent lesions were made (mean, 26.0; range, 12-54) encompassing the amygdala and anterior 15-34 mm (mean, 21.5 mm) of the hippocampus. MRI scanning was carried out 24 h and 6-9 months after surgery. RESULTS: In five group I patients, one (20%) experienced a favorable seizure outcome. Of 15 group II patients, one of whom had previously undergone limited lesioning and was also analyzed as part of group I, nine (60%) experienced a favorable seizure outcome, with two seizure free. MRI scans at 6- to 9-months' follow-up disclosed discrete areas of atrophy in the amygdala and hippocampus, interspersed with preserved brain in the group I patients. More uniform and complete destruction of amygdala and hippocampus was evident in group II patients. All lesions were confined to the amygdala and hippocampus, sparing the parahippocampal gyrus (PHG). CONCLUSIONS: The extensive amygdalohippocampal ablation in group II patients improved seizure outcome compared with more limited ablation in group I, but these results were not so good as those from temporal lobectomy in a similar patient group. When considered together with the results of selective amygdalohippocampectomy, and temporal resections that spare hippocampus or amygdala (all producing similar outcomes, and all involving resection of the entorhinal cortex), this study suggests a pivotal role of the entorhinal cortex in temporal epileptogenesis.     

Cingulate gyrus volume and metabolism in the schizophrenia spectrum

BACKGROUND: The cingulate gyrus, which is involved in affect, attention, memory and higher executive functions, has been implicated as a dysfunctional region in schizophrenia. Postmortem studies report cytoarchitectural changes in the anterior cingulate gyrus (ACG) and functioning imaging studies show correlations between the degree of hypometabolism of the anterior cingulate and clinical symptoms in schizophrenia. METHODS: Unmedicated patients with schizophrenia (n=27) and schizotypal personality disorder (SPD) (n=13), as well as sex- and age-matched control subjects (n=32), were studied with (18)F-fluorodeoxyglucose positron emission tomography (PET) scans and magnetic resonance imaging (MRI). As a control over mental activity, all subjects performed a verbal working memory task during the PET protocol. The cingulate gyrus was first outlined on the MRI scans and, after coregistration, the coordinates were applied to the PET scans to yield a three-dimensional metabolic map of the cingulate gyrus for each subject. A statistical resampling method was used to analyze the metabolic differences between groups. RESULTS: Compared with controls, patients with schizophrenia had lower relative glucose metabolic rates in the left anterior cingulate and the right posterior cingulate gyrus (PCG) assessed by 3-D significance probability mapping. SPD patients had higher glucose metabolic rates (GMRs) in the left posterior cingulate than did controls. Furthermore, volumetric measurement with MRI showed the left anterior cingulate and Brodmann area 24' to be smaller in schizophrenic patients than controls. CONCLUSIONS: Compared with controls, patients with schizophrenia have metabolic and volumetric reductions in a cingulate gyrus area that is related to higher executive functions. Schizotypal patients rely more on sensory association areas to perform a cognitive task than do controls and seem to be a group that is partially distinct in its physiological and functional characteristics.