神经内镜锁孔入路与传统开颅术治疗颅内血肿的对比研究

目的研究评价神经内镜锁孔入路清除颅内血肿的临床疗效及安全性。方法回顾性分析21例颅内出血患者采用神经内镜治疗的临床资料,另随机选择同期30例采用传统开颅显微镜下血肿清除术治疗颅内血肿患者作为对照组。以病死率、血肿量,血肿清除率、感染率、GCS评分、mRS评分、GOS评分等作为疗效指标。结果神经内镜组血肿清除率明显高于传统手术治疗组,两组差异具有明显统计学意义,且神经内镜组术后感染率低于对照组。两组在病死率、GOS评分、出院时GCS评分、6个月mRS评分方面差异均无统计学意义。而神经内镜组患者术后恢复良好率(GOS≥4)明显高于对照组,差异具有统计学意义。结论神经内镜经锁孔入路治疗颅内血肿临床疗效满意,具有较高的血肿清除率,明显降低术后感染发生率,显著提高患者术后的神经功能恢复。     

神经内镜手术治疗高血压脑出血破入脑室的临床分析

目的探讨神经内镜手术治疗高血压脑出血破入脑室的手术方法和治疗效果。方法回顾性分析2017年1月至2021年1月天津市第五中心医院神经外科收治的16例高血压脑出血破入脑室患者的临床资料。所有患者均行神经内镜手术治疗。术后进行门诊或电话随访, 以改良Rankin量表评分(mRS)和格拉斯哥预后评分(GOS)评估患者的预后。观察患者的并发症发生情况。结果 16例患者的手术时长为(132.8±32.9)min(90～190 min)。术后24 h的血肿清除率为(80.6±10.6)%。1例术后再次发生脑出血后死亡。15例患者术后随访6个月, GOS为(3.2±1.1)分(1～5分), mRS为(3.6±1.6)分(1～5分)。随访期间发生脑积水1例。结论神经内镜手术治疗高血压脑出血破入脑室具有操作时间短、血肿清除率高、远期脑积水发生率低的优点。     

高血压脑出血神经内镜微创手术与开颅血肿清除术的临床比较分析

目的比较高血压脑出血神经内镜微创手术与开颅血肿清除术的临床特点与疗效。方法收集77例高血压脑出血手术患者的手术时间、手术失血量和GCS评分等临床资料,根据其治疗方案分为神经内镜微创手术组与开颅血肿清除术组,以第3个月GOS评分作为预后指标。采用SPSS10.0,比较两种手术方式手术时间、手术失血量、血肿清除率及其GOS预后评分的差别,观察、分析手术疗效。结果神经内镜微创手术组与开颅血肿清除术组两组病例术前临床资料无明显差异(P值均0.05)。在手术时间上,神经内镜组平均手术时间(1.6±0.5)h,开颅血肿清除术组平均手术时间(4.6±1.8)h(P0.01);在手术失血量上,神经内镜微创组平均手术失血量33.2±6.2mL,开颅血肿清除术组平均手术失血量(406.4±305.6)mL(P0.01);在血肿清除率上,神经内镜组脑内血肿平均清除率为88.6%±6.2%,开颅组平均血肿清除率为69.4%±27.9%(P0.05);在GOS预后方面,在26例术后随访满3月神经内镜组患者中恢复良好6例,轻度残疾10例,重度残疾5例,植物状态4例,死亡1例(家属放弃治疗后院内死亡)。开颅组49例患者中,恢复良好7例,轻度残疾8例,重度残疾13例,植物状态12例,死亡6例。3例因经济原因在术后放弃治疗脱失。神经内镜微创组患者预后优于开颅组患者预后(P0.05)。结论神经内镜高血压脑出血手术是一种更具有微创、高效、快速、出血少等特点的高血压脑出血手术方法。     

阿替普酶辅助颅内血肿微创手术在中等量基底节区脑出血治疗中的临床疗效

目的探讨阿替普酶辅助颅内血肿微创手术对基底节区中等量脑出血临床疗效和安全评估。方法选取我院从2012年1月~2016年7月收治的GCS评分8~10分的基底节区中等量脑出血患者63例,分为实验组和对照组,实验组进行阿替普酶辅助颅内血肿微创手术治疗,对照组给予内科保守治疗。通过GCS、NIHSS、日常生活活动能力量表(ADL)及mRS量表评价两组患者治疗效果,并进行比较。结果两组患者出血量在治疗前无明显差异;出院时复查CT显示,实验组治疗后血肿几乎全部清楚或吸收,对照组血肿量无明显减少,两组之间具有统计学意义(P0.05)。实验组治疗后NIHSS评分较治疗前明显下降(P0.05),而对照组治疗前后变化无明显统计学差异。实验组治疗后GCS评分较治疗前明显增加(P0.05)。出院3个月后实验组患者的ADL评分较对照组明显增加(P0.05),mRS评分较对照组明显降低(P0.05)。结论阿替普酶辅助颅内血肿微创手术治疗基底节区脑出血能更快清除颅内血肿,减轻血肿压迫造成的脑损伤,从而减少患者致残率和死亡率,安全有效。     

B超引导神经内镜微创手术治疗高血压脑出血的临床研究

目的探讨B超引导神经内镜微创手术治疗高血压脑出血(HICH)的临床效果,评价及其应用价值。方法将150例HICH患者随机分成两组,分别为研究组75例,应用B超引导神经内镜微创手术治疗;对照组75例,接受开颅血肿清除术治疗。对两组患者的GOS优良率、血肿清除率、术中失血量、颅内压变化及格拉斯哥昏迷评分(GCS)、并发症发生率差异进行统计学分析。结果治疗后两组患者的GOS优良率及血肿清除率均明显高于治疗前(P0.05);研究组患者术中失血量明显少于对照组(P0.05);治疗后两组患者的颅内压明显低于治疗前(P0.05),且研究组患者治疗后的颅内压显著优于对照组(P0.05);治疗后两组患者的GCS评分明显高于治疗前(P0.05),且研究组患者治疗后的GCS评分显著高于对照组(P0.05);治疗后,两组患者发生颅内感染4例,脑积水1例,其他并发症11例;研究组患者并发症发生率明显低于对照组(P0.05)。结论 B超引导神经内镜微创手术治疗HICH的疗效显著,具有较高的临床应用价值。     

脑淀粉样血管病相关性脑出血的临床研究

目的 分析总结脑淀粉样血管病(cerebral amyloid angiopathy,CAA)相关性脑出血(CAA-related hemorrhages,CAAHs)的临床特征、影像表现及预后.方法 回顾住院的14例CAAHs,符合“很可能CAA”或“可能CAA”患者的临床及影像学资料,分析本病的临床特征、影像表现及影响预后的因素.结果 本组患者的最主要临床表现为头痛(28％),其次是肢体麻木、力弱(20％).CAAHs患者的出血位置多发于脑后部(很可能CAA枕叶57.1％,可能CAA顶叶36.4％).脑出血破入脑室的比例为27.2％,出血量5～90ml,平均24ml,59.1％患者CT可见脑白质低密度改变.入院时格拉斯哥昏迷评分(Glasgow Coma Scale,GCS)为13.0(7.0),出院时GCS评分为15.0(4.0),GCS评分出院比入院时明显增加(t=5.850,P=0.000).1例患者行颅内血肿清除及去骨瓣减压术后死亡,死亡率为7％.出院时改良Rankin量表(modified Rankin Scale,mRS)为3.3±0.4.患者出院时mRS与入院GCS评分(P =0.040)及脑出血体积(P =0.018)显著相关.结论 CAAHs是老年脑出血患者较常见原因,多灶、复发性脑叶出血是影像学特点,CT上脑白质低密度改变很常见.患者预后可能与入院时GCS评分及脑出血体积有显著相关.     

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。     

影响青年人自发性脑出血预后的相关因素分析

目的研究影响青年自发性脑出血患者预后的相关因素,指导青年自发性脑出血的治疗。方法回顾性分析2012年1月~2014年12月镇江市第一人民医院神经外科收治的53例青年自发性脑出血手术治疗患者的临床资料。根据发病后3个月时的格拉斯哥预后量表(GOS)评分,将患者分为预后良好组(GOS评分≥4分)和预后不良组(GOS评分≤3分)。比较两组患者的格拉斯哥昏迷量表(GCS)评分、收缩压、平均动脉压、出血量、血脂水平、发病时随机血糖水平、血肿是否破入脑室、凝血功能、肝功能及肾功能,分析其是否与预后有关。结果预后良好组与预后不良组的GCS评分、收缩压、平均动脉压、出血量、血脂水平、发病时随机血糖水平比较,差异有统计学意义(均P0.05);而凝血功能、肝功能及肾功能的差异无统计学意义(均P0.05)。结论影响青年人自发性脑出血预后的有关因素较多,GCS评分、收缩压、平均动脉压、出血量、血脂水平、发病时随机血糖水平与其预后有显著的关系,可用于预测青年自发性脑出血的预后。     

锁孔入路显微手术治疗自发性小脑出血

目的探讨经锁孔人路治疗白发性小脑出血的有效性与安全性,及彻底清除第四脑室内积血对解除脑积水的重要性。方法回顾性分析37例自发性小脑出血病人的临床资料,均采取经枕部锁孔人路显微手术治疗,显微镜下彻底清除脑实质内和第四脑室内积血。结果本组平均血肿清除率为95.8％±0．9％。术后3个月随访,按GOS评分：恢复良好15例,轻度残疾10例．重度残疾9例,植物状态2例,死于心脏病1例。术后行脑室外引流术8例,无手术并发症发生。经统计学分析：术前GCS评分、血肿最大直径、血肿体积及脑干受压情况与病人预后差异有统计学意义（P〈0．05）。结论经锁孔人路治疗自发性小脑出血具有简单、微创、疗效好、并发症少的优点。彻底清除第四脑室内积血可有效减少采用脑室外引流术。     

开颅减压手术治疗出血性颅内静脉窦血栓并发脑疝的疗效分析

目的探讨开颅减压手术治疗出血性颅内静脉窦血栓并发脑疝的疗效。方法回顾性分析2019年10月至2022年8月首都医科大学附属北京天坛医院神经外科学中心(5例)和拉萨市人民医院神经外科(2例)行开颅减压手术治疗的7例出血性颅内静脉窦血栓并发脑疝患者的临床资料。术前患者格拉斯哥昏迷评分(GCS)中位数为6分(3～11分)。所有患者术前影像学检查均显示颅内静脉窦血栓出血伴脑疝征象, 且患者意识障碍进行性加重。患者均行去骨瓣减压手术, 5例患者同时行血肿清除术。以术后1周GCS及术后3～6个月改良Rankin量表评分(mRS)评价疗效及预后。结果 7例患者手术均顺利完成。术后1周GCS为3～15分。2例于术后1 d死亡, 1例于术后31 d死亡。4例生存患者的随访时间为3～36个月。术后患者口服抗凝药物治疗3～12个月。3～6个月复查头颅CT静脉血管成像或磁共振静脉成像未见颅内新发静脉窦血栓形成及出血。至末次随访, 预后较好(mRS 1～2分)2例, 预后较差(mRS 3分)2例。结论对于出血性颅内静脉窦血栓并发脑疝的患者, 开颅减压手术可在一定程度上改善患者预后, 但该病总体预后较差。     

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.     

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.     

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.     

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.     

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.     

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.