双相抑郁患者前额叶及海马磁共振质子波谱成像研究

目的探讨双相抑郁患者前额叶及海马磁共振质子波谱(proton magnetic resonance spectroscopy,1H-MRS)的代谢物变化特点,为其神经生物学研究提供线索。方法应用磁共振质子波谱成像技术检测26例双相抑郁患者(患者组)和26例单相抑郁患者及13例健康志愿者(对照组)双侧前额叶白质、前扣带回皮质、海马N-乙酰天门冬氨酸(N-Acetylaspartate,NAA)、胆碱(choline,Cho)、肌酸(creatine,Cr)3种代谢物,以Cr为参照物,分别计算双侧NAA/Cr和Cho/Cr比值。采用SPSS 13.0进行统计处理。结果患者组左侧前额叶白质NAA/Cr(1.65±0.31)低于对照组(2.37±0.36),左侧前额叶白质Cho/Cr(1.35±0.27)低于对照组(1.65±0.21),差异有统计学意义(P<0.05);右侧前额叶白质NAA/Cr、Cho/Cr值与正常对照组差异无统计学意义;患者组双侧前扣带回NAA/Cr、Cho/Cr值与正常对照组差异无统计学意义;患者组双侧海马NAA/Cr、Cho/Cr值与正常对照组差异无统计学意义;患者组与单相抑郁组的双侧额叶白质、双侧前扣带回皮质、双侧海马NAA/Cr、Cho/Cr值差异均无统计学意义。结论双相抑郁患者可能存在左侧前额叶神经元功能下降和膜磷脂代谢异常,其代谢物特点存在偏侧化。     

伴有自杀意念的双相情感障碍患者前额叶 磁共振波谱研究

目的 借助氢质子磁共振波谱检测手段探讨双相情感障碍患者自杀意念与前额叶各代谢 物之间的关系。方法 2017 年 4 月至 2019 年 8 月收集新疆维吾尔自治区人民医院临床心理科 21 例 1 个 月内未经治疗的双相情感障碍患者,按有无自杀意念分为有自杀意念组（12 例）与无自杀意念组（9 例）, 应用氢质子磁共振波谱技术分别检测两组左右侧前额叶 N- 乙酰天门冬氨酸 / 肌酸（NAA/Cr）、胆碱 / 肌 酸（Cho/Cr）、谷氨酸和谷氨酰胺复合物 / 肌酸（Glx/Cr）、肌醇 / 肌酸（mI/Cr）的比值。结果 有自杀意念的 双相情感障碍患者组右侧前额叶 mI/Cr 值高于无自杀意念的双相情感障碍患者组,差异有统计学意义 （P＜ 0.05）;两组在左右侧前额叶 NAA/Cr 值、Cho/Cr 值、Glx/Cr 值及左侧前额叶 mI/Cr 值的比较中差异均 无统计学意义（P＞ 0.05）;有自杀意念的双相情感障碍患者组左侧前额叶 mI/Cr 值与发病年龄呈正相关 （r=0.661,P＜ 0.05）。结论 有自杀意念的双相情感障碍患者右侧前额叶肌醇代谢水平增高;有自杀意 念的双相情感障碍患者发病年龄越大,左侧前额叶肌醇代谢水平就会越高     

脑梗死相关白质疏松患者磁共振波谱与认知功能关系的研究

目的研究脑梗死患者白质疏松的磁共振波谱表现特点,以及白质疏松的磁共振波谱与认知功能的关系,为血管性认知功能障碍的早期识别及防治提供依据。方法选择51例脑梗死伴白质疏松患者及21例非白质疏松者进行简易智能状态测验(MMSE)、画钟试验测试、Fuld物体记忆测验(FOM)、快速词汇测验(RVR)及WAIS数字广度测验;同时行头颅磁共振成像(MRI)及双侧额叶白质的磁共振波谱(MRS)检查,测定N-乙酰天门冬氨酸(NAA)、肌酸(Cr)及胆碱(Cho)的浓度。分析白质疏松的MRS表现特点及其与认知功能障碍的关系。结果重度脑白质疏松组Cho/Cr值明显高于无、轻及中度疏松组;Cho/Cr值与白质疏松程度呈正相关;左侧额叶白质NAA/Cr值与MMSE评分及画钟试验评分正相关;右侧Cho/Cr值与WAIS数字广度测验评分负相关。结论双侧额叶白质区MRS改变主要为Cho/Cr值升高,并且与白质疏松程度正相关。血管性认知障碍与双额叶白质区神经纤维损害不一定完全一致。     

双相抑郁患者前额叶和前扣带回皮质氢质子波谱研究

目的:研究双相抑郁患者前额叶皮质、前扣带回皮质代谢物的相对含量。方法:对30例未服药双相抑郁患者和30名健康志愿者的前额叶皮质、前扣带回皮质进行氢质子波谱(1H-MRS)扫描,双相抑郁患者经6周药物治疗后再次做1H-MRS扫描,检测N-乙酰天门冬氨酸(NAA)、胆碱(Cho)、谷氨酸复合物(Glx)、肌酸(Cr)4种代谢物。结果:双相抑郁组左侧前额叶皮质、双侧前扣带回皮质NAA/Cr值均显著低于正常对照组(P<0.05),Cho/Cr值、Glx/Cr值均显著高于正常对照组(P<0.05),双相抑郁组右侧前额叶皮质NAA/Cr、Cho/Cr、Glx/Cr值两组比较差异无统计学意义(P>0.05)。经药物治疗后,左侧前额叶皮质、双侧前扣带回皮质NAA/Cr值较治疗前升高,Cho/Cr值、Glx/Cr值较治疗前降低,差异有统计学意义(P<0.05)。结论:前额叶和前扣带回皮质NAA、Cho、Glx含量的改变与双相抑郁的发生和药物的疗效有关。     

双相情感障碍不同临床分期患者脑磁共振波谱特征 及其与认知功能损害的关系

目的 探讨双相情感障碍（BD）不同临床分期患者脑磁共振波谱特征及其与认知功能损 害的关系。方法 将2016 年2 月至2018 年2 月收治的120 例BD 患者按临床分期分为Ⅱ期（n=28）、Ⅲ期 （n=47）、Ⅳ期（n=45）,选取30 例健康人作为对照组,均采用认知功能成套测试（MCCB）评定认知功能,BD 患者采用磁共振氢质子波谱成像（1H-MRS）技术测定额叶、基底节、小脑胆碱复合物（Cho）、肌酸（Cr）、N- 乙酰天门冬氨酸（NAA）,计算NAA/Cr、Cho/Cr 值,分析脑生化代谢与认知功能损害的关系。结果 （1）除 韦氏记忆量表（WMS-Ⅲ）外,不同临床分期BD患者各维度评分均较对照组低（P＜ 0.05）,随临床分期的 上升,各评分降低,Ⅳ期＜Ⅲ期＜Ⅱ期（P＜0.05）;（2）不同分期BD患者额叶左侧NAA/Cr、左右侧Cho/Cr、 基底节左右侧NAA/Cr、左侧Cho/Cr、小脑区左右侧NAA/Cr及Cho/Cr比较差异均无统计学意义（P＞0.05）, Ⅳ期组额叶左侧NAA/Cr 及基底节右侧Cho/Cr低于Ⅲ期、Ⅱ期组（P＜ 0.05）,Ⅲ期低于Ⅱ期组（P ＜0.05）; （3）额叶左侧NAA/Cr及基底节区右侧Cho/Cr与BVMT-R评分呈正相关（P＜0.05）。结论 BD 不同分期患 者均存在一定程度认知受损,伴额叶左侧NAA/Cr、基底节区右侧Cho/Cr 脑生化代谢异常,且与认知功 能评分呈正相关。     

磁共振波谱分析对轻微型肝性脑病患者的诊断价值

目的研究磁共振波谱分析(MRS)对轻微型肝性脑病(MHE)患者的诊断价值。方法应用3.0MR机对26例MHE患者进行扣带回和额叶的单体素点分辨自旋回波波谱序列扫描。计算N-乙酰天门冬氨酸(NAA)、肌酐(Cr)、胆碱(Cho)、肌醇(mI)和谷氨酰胺复合物(Glx)的峰下面积,计算NAA/Cr、Cho/Cr、mI/Cr、Glx/Cr的值,并与正常对照组比较。结果与正常对照组相比,MHE组扣带回和额叶的Cho/Cr、mI/Cr显著降低(P<0.01～0.001),Glx/Cr值显著升高(均P<0.005),NAA/Cr值差异无统计学意义(均P>0.05)。结论MHE患者MRS检查显示扣带回和额叶Cho、mI水平降低,Glx水平升高,MRS对MHE的诊断有显著价值。     

精神分裂症偏执型和双相Ⅰ型患者海马氢质子波谱研究

目的 比较精神分裂症偏执型和双相障碍I型躁狂发作患者海马代谢特点的异同.方法 对符合美国精神障碍诊断与统计手册第4版(DSM-IV)诊断标准的25例精神分裂症偏执型患者、20例双相I型躁狂发作患者和32名正常对照进行氢质子波谱扫描,检测双侧海马的N-乙酰天门冬氨酸(NAA)、胆碱(Cho)、肌醇(mI)及肌酸(Cr)4种代谢产物,以Cr为参照物,分别计算双侧NAA/Cr、Cho/Cr及ml/Cr.统计方法采用多组间单因素方差分析及偏相关分析.结果 精神分裂症组右侧海马Cho/Cr比正常对照组升高,差异有统计学意义(P＜0.05),而两患者组的差异无统计学意义(P＞0.05).双相I型躁狂组左侧海马mI/Cr较精神分裂症组和正常对照组均升高,差异有统计学意义(P＜0.05).双相I型躁狂组左右海马NAA/Cr的单侧化指数与1.0相比差异无统计学意义(P＞0.05).偏相关分析显示两患者组的右侧海马NAA/Cr均与病程呈正相关(P＜0.05).结论 精神分裂症偏执型患者可能存在右侧海马神经细胞膜损害;双相I型躁狂发作患者可能存在左侧海马神经细胞磷脂酰肌醇信号传导损害.     

抑郁症首次发病患者海马磁共振质子波谱成像的研究

目的 探讨抑郁症首次发病患者海马的磁共振质子波谱(1H-MRS)代谢物质的变化.方法 对99例首次发病的抑郁症患者和26例健康对照组行磁共振常规扫描及1H-MRS检查,测量双侧海马N-乙酰天门冬氨酸(NAA)、胆碱复合物(Cho)和肌酸(Cr)三种代谢物质,计算NAA/Cr和Cho/Cr比值.结果 抑郁症患者海马NAA/Cr左右侧比值(1.23±0.16;1.16±0.16)低于对照组NAA/Cr左右侧比值(1.38±0.23;1.31±0.26),差异有显著性(P<0.05);抑郁症患者海马体部Cho/Cr左右侧比值(1.19±0.14;1.18±0.12)高于对照组Cho/Cr左右侧比值(1.14±0.12;1.11±0.14),差异有显著性(P<0.05).对照组左右侧NAA/Cr和Cho/Cr比较差异无显著性(P>0.05).抑郁症组右侧NAA/Cr低于左侧,差异显著(P<0.05);左侧Cho/Cr高于右侧,差异不明显(P>0.05).结论 抑郁症患者可能存在双侧海马神经细胞代谢功能障碍,右侧神经细胞功能障碍较左侧明显.     

老年抑郁症患者脑磁共振波谱成像研究

目的 应用磁共振波谱成像(MRS)研究老年抑郁症患者脑内神经环路物质代谢异常,探讨其发病机制.方法 对23例老年抑郁症患者(抑郁症组)及18名老年健康志愿者(正常对照组)行常规磁共振及三维磁共振氢质子波谱(<'1>H-MRS)检查,测量双侧额叶背外侧白质、前部扣带回皮质、杏仁核、海马、丘脑的N-乙酰天门冬氨酸(N从)、胆碱(Cho)与肌酸(Cr)的比值,对两组各部位的比值分别进行独立样本t检验.结果 (1)抑郁症组额叶背外侧白质(2.28±0.32)、前部扣带回皮质(2.19 ±0.39)、杏仁核(1.95 ±0.22)、海马的Cho/Cr比值(2.38 ±0.30)均高于正常对照组(分别为1.88 ±0.40、1.68±0.30、1.66±0.24、2.00±0.34),差异有统计学意义(P＜0.01～0.05);而丘脑Cho/Cr比值与对照组的差异无统计学意义(P＞0.05).(2)抑郁症组前部扣带回皮质(2.08 ±0.26)、杏仁核(2.20 ±0.27)、海马的NAA/Cr比值(2.10 ±0.27)低于正常对照组(分别为2.58 ±0.35、2.52±0.22、2.44±0.24),差异有统计学意义(P＜0.01～0.05);而额叶背外侧白质及丘脑未见明显变化(P＞0.05).结论 老年抑郁症患者额叶背外侧白质、前部扣带回皮质、杏仁核、海马的Cho/Cr比值明显高于对照组,提示边缘系统-皮质-纹状体-苍白球-丘脑环路的功能受到影响,该神经环路在老年抑郁症发病机制中可能起一定作用.     

脑梗死磁共振波谱分析的临床应用

磁共振波谱分析能定量检测脑梗死患者脑组织的生化代谢。脑梗死灶周围的Lac升高,而NAA正常或轻度降低可作为判断缺血半暗带的指标;通过检测比较NAA/Cr、mI/Cr、Cho/Cr及NAA/mI比值可辅助诊断血管性痴呆及其预后的判断;检测Glx/Cr、Cho/Cr的比值可辅助诊断卒中后抑郁障碍及其治疗效果的评价;NAA、Cho可作为卒中后失语语言功能区生化、代谢的指标。     

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.