伽玛刀治疗颅底良性脑膜瘤长期疗效分析

目的总结评价伽玛刀(γ刀)治疗颅底良性脑膜瘤的长期疗效。方法217例患者平均年龄52.2±13.8岁(9～83岁),男性65例,女性152例;病史0.5～216个月,平均35.5个月,中位时间26个月;105例曾行手术治疗;肿瘤容积0.41～42.8cm3,平均6.8±6.1cm3;均行增强MRI定位扫描;边缘剂量10～20Gy,平均13.9±1.8Gy,中心剂量22.2～40Gy,平均27.7±4.6Gy;等剂量曲线40%～60%,平均49.53%;等中心数2～20个,平均10个。结果随访36～120(平均69.8±21.8)个月,肿瘤控制率为97.7%(212/217);临床表现:130例(59.9%)好转,78例(35.9%)稳定,9例(4.1%)恶化;9例曾出现一过性症状加重;2例(0.9%)出现放射性水肿;6例(2.8%)于γ刀后行显微外科手术切除。结论伽玛刀治疗颅底脑膜瘤可长期控制肿瘤生长,并发症较少,能保证患者良好的生存质量,即为术后残留或复发的患者提供了进一步治疗的方法,也为较小颅底脑膜瘤患者治疗的主要疗法。     

伽玛刀治疗良性颅底脑膜瘤

目的探讨伽玛刀放射外科治疗良性颅底脑膜瘤中长期疗效和毒性。方法选取了1997~2002年治疗的颅底脑膜瘤患者196例,肿瘤体积平均6.2±4.9cm3,给予中心剂量平均27.9±5.9Gy,周边剂量平均12.4±1.6Gy。随访根据治疗前后的影像表现和行为评分进行评估。结果平均随访期为53.4±18.2个月(36~96个月),有完整随访资料患者178例。肿瘤的控制率为93.3%;临床表现满意度(好转和稳定)92.7%,神经症状总改善率为93.8%,并发症少且轻微。结论伽玛刀可作为颅底较大脑膜瘤开颅术后的辅助治疗,也可作为较小肿瘤或对手术禁忌患者的首选性治疗;对长期控制肿瘤复发,保证患者良好的生存质量起重要的作用。     

伽玛刀治疗脑膜瘤的临床分析(附156例报道)

目的旨在评价和进一步提高伽玛刀治疗脑膜瘤的效果。方法1998年至2005年,应用OUR旋转式伽玛刀治疗并有完整随访资料的颅内脑膜瘤156例,男57例、女99例,平均年龄57±15岁,首选伽玛刀治疗者38例,术后残留98例,术后复发20例。肿瘤直径大小为12～41mm,平均34±5.2mm。术前Karnofsky行为评分平均85%±8.2%,肿瘤中心照射剂量24～30Gy(平均28±2.1Gy),边缘剂量8～18Gy(平均14±2.3Gy)。一般以40%以上等剂量曲线覆盖边缘,采用多个放射中心的联合照射。随访根据治疗前后的影像学表现和Karnofsky行为评分进行评估。结果156例得到随访1～6年,平均3年2个月,显效6例(3.8%)、有效145例(93%)、无效5例(3.2%),15例(9.6%)病人出现瘤周水肿,总有效率达到96.8%,Karnofsky行为评分平均90±6.7%。未发现因放射引起的长期损害。结论伽玛刀对脑膜瘤患者是一种安全有效的治疗手段,是对不能切除、手术后残余或复发脑膜瘤的重要补充治疗方法,可以控制肿瘤生长及改善患者的生存质量。     

岩斜脑膜瘤的伽玛刀治疗

目的评估伽玛刀治疗岩斜区脑膜瘤的疗效。方法1995～2000年,我们对66例岩斜区脑膜瘤病人进行了伽玛刀治疗,肿瘤体积0.32～29.4cm3,平均(5.87±5.10)cm3。周边剂量为7～14.4Gy,平均(12.4±1.6)Gy;中心剂量16～65Gy,平均(27.9±5.9)Gy。结果60例随访25～94个月,平均(57.8±22.3)个月:肿瘤体积缩小23例(38.3%),不变35例(58.3%),增大2例(3.3%);神经系统症状好转37例(61.7%),稳定20例(33.3%),加重3例(5.0%)。无严重并发症发生。结论伽玛刀治疗能很好地控制肿瘤,副作用轻微,可作为神经外科较大肿瘤的辅助性治疗,也可作为较小肿瘤或不适合手术的病人的主要治疗。     

伽玛刀治疗颅底良性脑膜瘤临床研究

目的探讨伽玛刀放射外科治疗良性颅底脑膜瘤中长期疗效和不良反应。方法选取了1998-2003年治疗的获得完全随访资料的颅底脑膜瘤患者166例,全组患者肿瘤体积0.42- 43.4cm3,平均(7.2±3.9)cm3,给予周边剂量平均(12.4±2.6)Gy,中心剂量平均(27.9±5.9)Gy,其中12例患者采用肿瘤体积分割二阶段治疗。对治疗前后的影像学改变、KPS评分和神经功能缺损评估。结果平均随访期为(55.4±18.2)个月(36-96个月)。总体控制率为95.2%(158/166);KPS评分得到显著提高,神经症状总体满意率为94.5%(157/166),主要副作用是放射性脑水肿11例(6.6%),有5例(3%)患者出现新的神经缺损。结论伽玛刀放射外科可以作为有手术禁忌或拒绝手术治疗体积较小脑膜瘤患者的首选性治疗,也可以作为颅底较大脑膜瘤开颅术后的辅助性治疗,能够较长期控制肿瘤复发,提高或保持患者的生存质量。     

伽玛刀治疗颅底大病灶的初步报告(附30例临床分析)

目的研究伽玛刀治疗颅底大病灶的效果。方法伽玛刀治疗颅底大病灶36例,随访30例,肿瘤周边剂量11~15Gy(13.7Gy),肿瘤直径为35~52mm(41mm)。结果随访1~9年,肿瘤的生长控制率为83.4%,临床表现改善率为43.4%(13/30),无变化40%(12/30),加重16%(5/30),出现新的颅神经功能障碍13%(4/30),因症状加重接受手术者5例。结论对身体状态难以耐受或拒绝手术的颅底大病灶患者,如果没有明显的颅高压表现,伽玛刀可作为初始治疗手段。     

脑膜瘤伽玛刀放射外科治疗的中期随访

目的总结评价伽玛刀放射外科治疗颅内脑膜瘤的效果.方法患者年龄20～81岁,其中男性12例,女性28例.14例为手术后复发或残留,其余26例根据典型影像学诊断.肿瘤容积1.2～34.2ml,平均11.6ml;中心剂量22.5～40Gy,平均30.2Gy;边缘剂量10～20Gy,平均14.5Gy;等剂量线为40%～60%;等中心数目2～14个,平均9.3.结果随访时间12～49个月,平均23.8个月.24例好转,11例无变化.3例恶化.影像学随访2例容积消失,14例容积缩小,20例容积无变化,影像学肿瘤控制率为90%.4例容积增大.结论伽玛刀治疗脑膜瘤创伤小,控制肿瘤生长,与外科治疗效果相当;平均剂量15Gy只有可以有效地控制肿瘤生长.     

松果体区肿瘤的伽玛刀治疗

使用立体定向伽玛刀（γ-刀）治疗松果体区肿瘤33例，肿瘤直径（X Y Z/3）10.0—45.5mm，平均23.5mm，体积0.443cm^3—35.4cm^3，平均12.1cm^3。肿瘤边缘剂量14—20Gy，平均15.2±1.7Gy。中心剂量25.0—42.8Gy，平均37.5±6.9Gy。影像定位仅为1.5T MRI。随访3—12个月。初步结果表明，病人的临床症状体征明显好转，9个月后促瘤生长控制率，即治疗有效率为96.2%，显效率92.3%，无严重并发症发生。提示γ-刀可作为松果体区肿瘤的有效治疗方法。     

颅底脑膜瘤的伽玛刀治疗

目的:评估伽玛刀(γ-刀)在治疗颅底脑膜瘤中的作用。方法:采用30％～60％等剂量曲线覆盖肿瘤,平均边缘剂量13.5Gy(10～16Gy),中心剂量32 Gy(20～45Gy) 治疗顿底啮膜瘤49例结果:平均随访15个月,17例病人保持或改善了治疗前的神经功能状态,4例加重;37例病人的影像学随访,14例肿瘤体积无变化,20例缩小,3例增大,肿瘤生长控制率达92％(34/37)。结论:早期随访结果提示γ-刀是治疗颅底脑膜瘤安全有效的手段。     

伽玛刀治疗海绵窦区的肿瘤

探讨各种海绵窦区肿瘤的诊断特点以及伽玛刀放射外科治疗的作用。文章回顾性地分析本中心1994年至2000年底Leksell伽玛刀治疗的168例累及海绵窦的各种肿瘤的临床资料,其中89例(53%)患者有开颅手术史,本组脑膜瘤88例,神经鞘瘤28例,垂体瘤22例,转移瘤14例,脊索瘤7例,海绵窦血管瘤4例,骨软骨瘤3例,巨细胞瘤1例和浆细胞瘤1例。全组肿瘤平均体积6.8mm3,给予肿瘤周边剂量7~18Gy,平均12.2Gy;中心剂量15~45Gy,平均26.7Gy;等中心曲线40%~80%,平均46%。有19例海绵窦病灶接受两次伽玛刀治疗。本组81.5%的病人随诊1~84个月,平均32.5个月。主要良性肿瘤…     

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.     

Special Pharmacokinetic Considerations in Children

Summary: Pediatric patients have greater degrees of pharmacokinetic variability and unpredictability than adults. This variability results from the effects of pharmacogenetics, age and growth, prior and current comedication, and disease. Newborns with seizures have the least predictable dosage requirements, and their needs change as drug-eliminating mechanisms mature in the neonatal period. Infants have the highest relative capacities to eliminate antiepileptics of any age group and require the largest relative doses. In addition to age-related trends, children demonstrate the same drug-specific, pharmacokinetic phenomena that adults do, including nonlinear phenytoin elimination, nonlinear valproate binding, and autoinduction of carbamazepine. Intercurrent illness and drug interactions further modify the age-related pharmacokinetic patterns in children and make dosage requirements even more unpredictable. Recent studies have shown that febrile illness can affect drug elimination, sometimes decreasing drug levels by 50% or more. Intermittent treatment with benzodiazepines administered either orally or rectally can be an important adjunct and help minimize this type of problem for children with marginally controlled epilepsy. Intermittent benzodiazepines are also helpful for children who have febrile seizures and who need only occasional antiepileptic protection.