颅眶沟通性肿瘤显微手术探讨

目的讨论颅眶沟通性肿瘤的特点及手术治疗方法。方法35例颅眶沟通性肿瘤病人中,采用额下硬膜外入路手术切除4例,额颞眶颧入路2例,眶上-翼点入路10例,改良翼点入路17例,翼点和颞下联合入路2例。先切除颅内肿瘤,再开眶切除眶内肿瘤。结果肿瘤全切29例,次全切4例,部分切除2例,肿瘤全切率为82.9%（29/35）。结论对于颅眶沟通性肿瘤,充分的术前准备,正确的手术入路选择,细致的术中操作,耐心的颅底重建以及多科的协调合作,是手术成功的重要保证。     

蝶眶脑膜瘤18例手术治疗临床分析

目的 探讨经颅入路显微切除蝶眶脑膜瘤的手术方法、疗效及随访结果.方法 对18例蝶眶脑膜瘤患者选用额颞入路、眶颧入路或眶颧结合扩大前颅窝底入路硬膜外结合硬膜内切除肿瘤,在硬膜外磨除增生的蝶骨大翼骨质、眶上裂、视神经管开放减压,其中经额颞入路15例,眶颧入路2例,眶额结合扩大前颅窝底入路1例,术前、术后均有视觉功能评价、手术录像及术后影像评估肿瘤切除程度.结果 肿瘤切除程度:Simpson Ⅰ级2例,SimpsonⅡ级6例,SimpsonⅢ级8例,SimpsonⅣ级2例.18例患者术后突眼情况均有好转,视觉功能改善13例.随访6 -56个月(平均25.3个月),2例患者肿瘤复发.结论 选择合适的手术入路显微切除蝶眶脑膜瘤,可获得充分显露和眶尖、球后减压,可有效缓解突眼、视觉障碍及眼肌麻痹.因肿瘤多累及眶尖、眶上裂、海绵窦等重要结构,肿瘤难以全切,术后容易复发.     

颅眶沟通陛肿瘤显微手术40例分析

目的 分析颅眶沟通性肿瘤显微手术治疗的方法 和效果.方法 2009年1月～2010年3月采用经眶-翼点入路和经眶-额下入路两种显微手术入路治疗颅眶沟通性肿瘤共40例,其中经眶-翼点入路显微手术26例,经眶-额下入路显微手术入路14例.两种手术入路均先切除颅内肿瘤,再开眶切除眶内肿瘤.结果 肿瘤全切34例,次全切除5例,部分切除1例.肿瘤全切除率达到85%.结论 ①应根据肿瘤大小、位置和侵袭范围采用不同手术入路,在充分暴露和直视下广泛切除颅眶沟通性肿瘤;②熟练的解剖知识及手术技巧、恰当的手术入路、成功的手术操作和及时处理术后并发症是治疗的关键;③颅底缺损应给予修补和重建,硬脑膜的严密修复是避免脑脊液漏及颅内感染的关键.     

颅眶交界区肿瘤的分型及手术治疗

目的探讨颅眶交界区肿瘤的分型及手术方法。方法根据肿瘤主体位置和侵袭方向,将32例颅眶交界区肿瘤分为眶颅型（7例）、颅眶型（11例）、颅鼻眶型（8例）和眶尖-视神经管型（6例）。均行显微手术切除肿瘤,其中采用经额下硬膜外入路11例,眶-翼点入路15例,额颞眶颧入路6例;对8例颅鼻眶型肿瘤联合使用经鼻内镜、鼻侧切开入路。术后按颅底缺损位置和范围分别采用游离骨膜瓣、人工脑膜补片及带蒂膜瓣修补硬膜缺损,并用钛板修复颅底骨缺损。结果肿瘤全切除27例,次全切除5例。无手术死亡及颅内感染、脑脊液漏、搏动性突眼等严重并发症发生。结论根据肿瘤主体位置和侵袭方向进行肿瘤分型和选择手术入路,显微手术切除颅眶交界区肿瘤,同时修复颅底缺损,能提高手术疗效和减少术后严重并发症的发生。     

颅眶沟通性肿瘤显微手术40例分析

目的分析颅眶沟通性肿瘤显微手术治疗的方法和效果。方法 2009年1月～2010年3月采用经眶-翼点入路和经眶-额下入路两种显微手术入路治疗颅眶沟通性肿瘤共40例,其中经眶-翼点入路显微手术26例,经眶-额下入路显微手术入路14例。两种手术入路均先切除颅内肿瘤,再开眶切除眶内肿瘤。结果肿瘤全切34例,次全切除5例,部分切除1例。肿瘤全切除率达到85%。结论①应根据肿瘤大小、位置和侵袭范围采用不同手术入路,在充分暴露和直视下广泛切除颅眶沟通性肿瘤;②熟练的解剖知识及手术技巧、恰当的手术入路、成功的手术操作和及时处理术后并发症是治疗的关键;③颅底缺损应给予修补和重建,硬脑膜的严密修复是避免脑脊液漏及颅内感染的关键。     

经颅入路切除眶内或颅-眶沟通性肿物

目的 探讨经颅入路切除眶内或颅-眶沟通性肿瘤的手术方法。方法 均采用双侧额部发际内冠状切口,根据肿瘤大小、占据眶内的部位以及是否有颅内侵犯,调整皮肤切口的长短,选择合适的开颅骨瓣：单侧额部入路、经额经眶上缘入路或经额经颧经眶上缘入路。对单纯眶内肿瘤,采用硬膜外入路;对眶-颅沟通性肿瘤,先经硬膜内处理肿瘤的颅内部分,然后打开眶顶和（或）眶外侧壁切除眶内肿瘤。结果 全切除26例,部分切除3例,无手术死亡。术后除1例有动眼神经麻痹,另2例遗患侧眼失明外,无其它手术并发症。结论 经颅入切除眶内或颅-眶沟通性肿瘤时,选择合适的开颅骨瓣而使肿瘤得以充分显露是手术成功的基础;采用显微外科技术是提高全切除率、减少并发症的关键。     

扩大翼点入路切除前中颅底病灶的临床体会

目的探讨改良的经颅底扩大翼点入路（包括经眶额入路、经颧弓入路和眶颧弓入路）切除前中颅底病灶的优越性和适应证.方法经标准翼点入路11例,眶额入路19例,颧弓入路4例,眶颧弓入路4例.结果病灶全切除33例,次全切除及大部分切除4例,无法处理病灶1例,无一例出现脑牵拉损伤.结论经颅底扩大翼点入路处理颅底病灶比标准的翼点入路显露更好,正常脑组织侵袭性更小.改良的经颅底扩大翼点入路不仅适于前中颅底肿瘤的切除,而且可应用于脑血管病和脑外伤的手术治疗.     

眶尖肿块的神经外科治疗

目的探讨眶尖肿块经眶翼点入路手术治疗方法。方法回顾分析11例眶尖肿块患者的临床表现,手术方法。结果11例均采用眶翼点入路,肿物全切8例,大部切除3例,无手术死亡,疗效满意。结论此类肿块部位特殊,累及眶内及颅内,单纯经眼眶入路或经颅入路对肿块的显露均难满意,全切困难,采用眶翼点入路显露良好,可在直视下切除肿瘤,神经外科技术的应用可明显提高手术疗效,减少并发症。     

海绵窦眶尖肿瘤的显微手术治疗

目的 分析海绵窦眶尖肿瘤显微外科治疗的手术方法和治疗效果。方法 回顾分析过去4年间，采用显微手术治疗18例海绵窦眶尖肿瘤的临床资料。所有病例均采用额颢切口(翼点入路)，其中有5例加颧弓离断(扩大翼点入路)方法开颅。结果 肿瘤全切除12例，次全切除3例，大部分切除2例，活检1例；无手术死亡及严重并发症，神经继发损伤症状出现率为44．4％。结论 ①现代影像学可明确海绵窦眶尖解剖结构，根据肿瘤大小、位置和侵袭范围，采用翼点入路、扩大翼点入路方法开颅；②熟练掌握解剖知识及手术技巧，选择恰当的手术入路，成功地手术切除和及时处理术后并发症等是治疗的关键；③颅底缺损应给予修补和重建，避免脑脊液漏及颅内感染也是一个关键的问题。     

颅眶沟通性肿瘤的显微外科治疗

目的探讨颅眶沟通性肿瘤显微手术治疗的效果及其相关技巧。方法 2000年5月至2011年5月对27例颅眶沟通性肿瘤患者进行了手术治疗。根据肿瘤的生长方式及对眼眶的累及情况选用不同的手术入路,其中经额颞眶顶入路手术17例,眶上-翼点入路5例,改良翼点入路5例。结果肿瘤全切除21例,次全切除4例,部分切除2例;肿瘤全切除率为77.8%(21/27)。术后病理学检查示脑膜瘤19例,转移癌2例,视神经胶质瘤1例,视神经纤维瘤4例,泪腺混合瘤1例。术后随访6年,2例死亡,22例仍存活,3例随访半年后失去联系。结论颅眶沟通性肿瘤首选的治疗方法为手术,选择合适的手术入路、娴熟的显微手术操作对于全切除肿瘤及减少术后并发症十分重要。     

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.