颅骨钻孔微创穿刺治疗高血压脑出血临床观察

目的 探讨颅骨钻孔脑室引流管血肿穿刺引流治疗高血压脑出血的疗效.方法 颅骨钻孔应用14号脑室引流管穿刺血肿进行抽吸及注入尿激酶引流血肿.结果 81例中10例死亡,71例生存.按ADL分级,Ⅰ-Ⅱ级31例,Ⅲ级26例,Ⅳ级14例.良好率70.37%.结论 颅骨钻孔微创穿刺抽吸血肿、液化引流治疗高血压脑出血创伤小、血肿消除快、效果满意.     

软通道置管引流术治疗高血压脑出血

目的探讨软通道置管引流术治疗高血压脑出血的效果。方法对92例高血压脑出血患者行额部头皮切开,颅骨钻孔,血肿腔置硅胶软引流管抽吸、引流,加尿激酶应用,清除血肿。结果患者出院后随访6个月-1年,16例痊愈,41例生活自理,22例有意识,但卧床不起,5例植物状态生存,死亡8例。结论软通道置管、抽吸加引流及血肿腔内注入尿激酶治疗高血压脑出血能彻底清除血肿,迅速缓解颅内压,效果较好。     

尿激酶对钻孔引流术治疗高血压脑出血引流效果的影响

目的探讨尿激酶对钻孔引流术治疗高血压脑出血引流效果及患者预后的影响。方法我院2009年1月至2013年1月采用钻孔引流术治疗高血压脑出血患者126例,按尿激酶使用剂量分为A组（48例）和B组（78例）。A组给予血肿腔内注射2-4万单位尿激酶,B组给予血肿腔内注射5-10万单位尿激酶。使用尿激酶后48 h内复查头部CT判断血肿引流效果。结果A组复查头颅CT示血肿清除率≥85%的患者所占比例（60.4%,29/48）明显低于B组（83.3%,65/78;P〈0.05）。A组术后再出血发生率（8.3%,4/48）与B组（9.0%,7/78）无统计学差异（P〉0.05）。术后随访6月,根据GOS评分,A组恢复良好9例,中残24例,重残11例,植物生存4例;B组恢复良好18例,中残42例,重残13,植物生存5例。两组患者预后无统计学差异（P〉0.05）。结论大剂量尿激酶可以提高钻孔引流术治疗高血压脑出血的引流效果,但是没有显著增加再次出血的风险。     

慢性硬膜下血肿钻孔引流术中尿激酶应用分析

目的总结慢性硬膜下血肿钻孔引流术中尿激酶应用的经验。方法回顾性分析2010年1月至2012年12月共32例慢性硬膜下血肿的临床资料,患者行钻孔引流术及术后向血肿腔注入尿激酶治疗。结果经钻孔引流术后第2天复查头颅CT,12例（37.5%）血肿基本清除;20例（62.5%）的血肿仍有较多残留,给予注入尿激酶后8例患者血肿明显缩小或消失,12例患者硬膜下残留少量积液,随访3月无复发。结论钻孔引流术治疗慢性硬膜下血肿的残留量及复发率较高,经向血肿腔注入尿激酶辅助治疗后,可以明显改善引流效果,减少复发机会。     

三维重建单(双)靶点定向置管引流术治疗高血压壳核出血

目的回顾性分析三维重建单(双)靶点定向置管引流术治疗高血压壳核出血的疗效,验证该方法的有效性和可行性。方法将133例壳核脑出血病人的CT定位扫描资料输入计算机工作站,对血肿进行三维重建,根据血肿量的大小和形状设计1～2个靶点和引流管路径。应用立体定向技术将引流管(外径5mm,内径3mm)送至颅内预定靶点,术中应用10ml注射器轻柔抽吸血肿液化部分,术后将尿激酶(1～2万IU)注入血肿腔内,夹闭引流管2h后自然引流,每12h重复1次。复查CT证实剩余血肿量为最初的10%~15%时拔除引流管。结果平均置管1.5 d(1～3d),平均血肿排空率92.8%。术后1个月病死率6.0%,远期随访(平均22个月)病死率11.3%,优良率74.4%。结论该方法治疗高血压壳核脑出血,血肿排空较彻底,疗效可靠,尤其适用于血肿量较大(>25ml)且形态不规则的颅内血肿。     

自制双腔引流管钻孔引流治疗高血压性脑出血

目的探讨自制双腔引流管在高血压性脑出血的疗效。方法回顾性分析42例高血压性脑出血病人的临床资料,观察术后再出血、血肿清除效果及预后。结果术后随访33例,ADL分级Ⅰ级17例,Ⅱ级10例,Ⅲ级4例,Ⅳ级1例,Ⅴ级1例。死亡9例。结论自制双腔引流管钻孔引流治疗高血压性脑出血,可直接引流颅内血肿,具有加强引流效果、注药方便、有效防治再出血、颅内逆行感染及引流管脱出风险,其预后较单腔引流管引流具有更好疗效。     

神经导航辅助钻孔引流术治疗小脑出血30例

目的 探讨神经导航辅助下钻孔引流术治疗小脑出血的效果。方法 神经导航辅助下钻孔引流术治疗小脑出血患者30例,部分患者术后经引流管将尿激酶注入血肿腔溶解引流残余血肿。结果 导航系统误差为（1.04±0.45）mm,术后6 h血肿清除率为（61±21）%;术后24 h血肿清除率为（78±11）%,术后48 h血肿清除率为（85±9）%,术后无再出血发生。术后3个月GOS评分,良好16例,中残8例,重残4例,死亡2例。结论 神经导航辅助钻孔引流术治疗小脑出血操作简单,手术安全,血肿清除效率高,为治疗小脑出血提供了新的选择。     

CT定位微创治疗高血压脑出血脑疝患者疗效分析

目的探讨CT定位微创抽吸注入尿激酶引流脑内血肿治疗高血压脑出血脑疝的短期临床疗效。方法回顾性分析35例脑出血脑疝患者微创穿刺血肿清除术,CT定位,YL-1型颅内血肿穿刺针抽吸引流,并用生理盐水反复冲洗,术后血肿腔内注入尿激酶。患者术前格拉斯哥昏迷评分(GCS)、血肿量、发病距手术时间、血肿清除率和出院时的生存情况。结果出院时意识状况:神清4例,浅昏迷7例,中度昏迷3例,深昏迷4例,死亡8例,死亡率22.9%,8例中6例死于脑干功能衰竭,1例死于肺炎,1例死于再出血。另外9例因放弃治疗而死亡,总死亡17例。存活18例中,随访出院后3个月GOS评分优良率27.8%。结论微创抽吸注入尿激酶引流脑内血肿术治疗高血压脑出血脑疝患者,创伤小,时间短,及时缓解了脑疝,为抢救患者赢得宝贵时间,提高了患者的生存率。     

钻孔引流治疗高血压性脑出血的临床体会

目的：研究单纯血肿腔钻孔引流术治疗高血压性脑出血病人的临床疗效。方法：我科自2000年5月－2002年6月对106例高血压性脑出血病人采用血肿腔钻孔引流术，依据CT及MRI图像所显示的血肿形态，徒手定向，采用血肿的纵轴或横轴二种入路，术后每日或隔日向血肿腔内注入1万U－2万U尿激酶，夹闭2－3小时后敞开引流管，视血肿清除情况，保留引流管3－7天。结果：施钻孔引流术106例，男74例，女32例，治愈24例，显效61例，死亡12例，临床治愈率22．3％，临床显效率57．8％，死亡率11．8％。结论：高血压性脑出血是临床中比较常见一种的急性脑血管病，其死亡率和致残率非常高，传统的手术方式为开颅清除血肿及去骨瓣减压，此种手术由于术中分离牵拉正常的脑组织，导致术后病人脑水肿加重，部分神经功能缺失，临床疗效差。随着诊治手段的改进，临床和实验研究的不断深入，单纯钻孔引流由于创伤小，操作简便，目前已日益受到瞩目。     

锥颅血肿引流术治疗高血压脑出血218例

目的探讨锥颅血肿引流术治疗高血压脑出血的手术效果,以减轻病残率,提高生存率,提高患者生存质量。方法高血压脑出血所有患者均经过头部CT检查确诊,根据不同的出血量(多田法计算),分别采用局麻或强化麻醉下锥颅软通道引流血肿,或锥颅血肿引流配合脑室外引流,或单纯行脑室外引流术。结果引流2～6d后复查头部CT,示血肿完全消失38例,血肿减少90%以上74例,血肿减少85%以上86例,减少50%以上16例,血肿减少30%～50%有4例;未发生切口及颅内感染;术后死亡21例。结论锥颅血肿引流术治疗高血压脑出血能提高患者的临床生存率,减少病残率,取得了满意的临床效果。     

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.