立体定向射频多靶点联合毁损治疗顽固性精神病

目的：探讨立体定向射频多靶点联合毁损治疗顽固性精神病的作用。方法：对18例顽固性精神病患行CT和MRI引导立体定向射频双侧杏仁核和内囊前肢联合毁损，症状不缓解病人行双侧扣带回及双侧尾状核下束切开毁损术。结果：术后随访3个月－3年，有效率为69％，无效率为31％。结论：立体定向射频多靶点联合毁损治疗顽固性精神病是一种较安全、有效的方法。     

立体定向多靶点联合毁损治疗难治性精神病

目的探讨立体定向下多靶点联合毁损脑内核团治疗难治性精神病的效果。方法对82例难治性精神病患者，根据临床表现、诊断分类实施立体定向不同靶点组合毁损治疗。结果本组82例患者经颅内多靶点联合毁损后，显效28例，有效40例，无效14例，总有效率为82．9％（68／82），术后智力均无变化。术后并发症包括高热4例，小便失禁12例，缄默9例及摸索7例，经对症处理后2～21d恢复。结论立体定向多靶点联合毁损是治疗难治性精神病行之有效的治疗方法。     

CT引导多靶点联合毁损术治疗难治性精神分裂症

目的：探讨CT引导立体定向多靶点联合毁损术治疗难治性精神分裂症的疗效。方法：对难治性精神分裂症患行双侧扣带回、内囊前肢及杏仁核毁损术，并随访判断疗效变化。结果：术后随访三至六个月，有效为88％，显效为43．5％，无效为12％。六个月至二年随访，有效为79．6％，显效为51．8％，无效为20．4％。结论：CT引导立体定向术多靶点联合毁损术治疗精神分裂症是一种较安全、有效的方法。手术后应配合药物等综合治疗，以巩固疗效。     

立体定向术治疗难治性精神病的近期疗效观察

目的探讨立体定向手术治疗难治性精神病的临床疗效。方法对140例难治性精神病患者,采用CT定位立体定向双侧杏仁核、内囊前肢、扣带回等多靶点组合毁损治疗。术中用电阻值和微电极电生理验证靶点。术后6个月由精神科医生对治疗效果进行评定。结果140例患者中,恢复12例、显著进步107例、进步17例、无变化4例,总有效率为97％。无严重并发症和后遗症发生。结论CT导向立体定向多靶点毁损术定位精确、安全、显效,是难治性精神病的有效治疗方法之一。     

立体定向核团毁损术治疗难治性强迫症27例分析

目的：探讨立体定向核团毁损术治疗难治性强迫症的临床疗效。方法对27例难治性强迫症病人,采用C T导向立体定向手术对双侧扣带回、内囊前肢实施多靶点毁损治疗。术前在256层螺旋C T 扫描下定出双侧扣带回、内囊前肢拟毁损的靶点,术中用电阻抗监测验证靶点,70℃射频毁损60～75 s。术前及术后6个月及1 a由精神病专科医师独立进行Yale-Brown强迫症量表、Hamilton抑郁量表、Hamilton焦虑量表的评定比较。结果本组27例手术病人中强迫症状完全消失13例,显效8例,有效3例,无效3例。7例病人在术后出现记忆力下降和定向障碍,6例术后2周恢复;5例出现尿失禁,在1周后缓解;1例出现一侧肢体轻偏瘫,复查头颅CT 未见出血,经扩血管及高压氧等治疗3周后肌力恢复。结论螺旋CT导向立体定向双侧扣带回、内囊前肢毁损术对顽固性强迫症病人疗效明显,可有效提高患者的生活质量,恢复社会功能。     

立体定向手术治疗顽固性癫痫(附28例报告)

报道我科近十年采用立体定向手术治疗顽固性癫痫28例,其中男20例,女8例。年龄5～49岁,病因较明确者17例。手术方法分1.立体定向杏仁核或联合靶点毁损术11例;2.立体定向胼胝体前部毁损术8例;3.立体定向胼胝体联合双侧杏仁核毁损术9例。平均随访4.2年,显着进步者11例,进步者11例,占78.6％。文章叙述了不同手术的方法及其指征,讨论了靶点与疗效的关系。     

精神疾病的扣带回立体定向毁损术

目的探讨扣带回立体定向毁损术治疗药物难治性精神病,包括抑郁症、双相情感障碍、强迫症及顽固性疼痛的临床疗效。方法对23例经精神科专科医师正规药物、心理、行为治疗无效的顽固性精神疾病患者,包括强迫症3例、抑郁症10例、双相情感障碍6例、顽固性疼痛4例,采用MR定位立体定向双侧扣带回毁损术,术中用电阻抗及高频电刺激验证靶点,80℃、60s射频毁损。术前、术后由精神科医师分别采用Y-BOCS量表,Hamilton焦虑量表、Hamilton抑郁量表、疼痛的VRS评分进行评价。结果4例顽固性疼痛的患者疼痛明显减轻。10例抑郁症手术患者中6例完全治愈,2例显著缓解,2例复燃。6例双相情感障碍抑郁相患者中,4例缓解,2例有复燃。强迫症患者3例均有效。无严重手术并发症。结论磁共振导向立体定向双侧扣带回毁损术定位精确,对顽固性精神病有明显疗效。     

扣带回不同区域毁损对精神障碍疗效影响研究

目的 探讨扣带回靶点定位的不同选择在立体定向手术治疗顽固性精神障碍中的临床意义.方法 运用立体定向技术,螺旋CT与坐标定位相结合计算靶点坐标值,根据扣带回毁损位点的不同,将2005年6月至2007年5月间86例顽固性精神障碍患者分成研究组(靶点前移组)和对照组,行同期双侧杏仁核加扣带回多靶点组合射频热凝毁损治疗.采用全国精神外科协作组1990年制定的评定方法对结果进行评定. 结果两组临床效果差异无统计学意义,扣带回靶点前移组较对照组尿失禁发生率减少(P<0.05). 结论同期双侧杏仁核加扣带回多靶点毁损治疗顽固性精神障碍临床效果显著,扣带回靶点适当前移可明显降低尿失禁发生率.     

立体定向多靶点联合射频毁损术治疗难治性精神病

目的 探讨脑立体定向多靶点联合射频毁损手术在治疗难治性精神病中的作用。方法 对10例难治性精神病患者应用立体定向技术对颅内杏仁核、内囊前肢、扣带回等部位进行多靶点组合射频热凝治疗。应用简明精神病评定量表(brief psychiatric rating scale，BPRS)、社会功能量表(social disability screening schedule，SDSS)、韦氏智力量和临床记忆量表对治疗效果进行评定，并随访病人6个月～1年。结果 10例患者中治愈2例，显著进步3例，进步2例，无变化3例。手术前后BPRS、SDSS量表检查有显著差异，临床记忆量表测验、韦氏智力测验病人脑功能变化与术前无显著差异。结论 立体定向多靶点联合射频毁损手术是治疗难治性精神病的有效治疗方法，根据不同症状设计不同靶点组合做到手术计划个体化，对提高疗效、降低并发症有较大意义。     

分次双侧脑立体定向射频毁损术治疗帕金森病57例

目的 介绍分次双侧脑立体定向射频毁损术治疗帕金森病（PD）57例及术后可能出现的并发症。方法采用CT定位立体定向微电极导向射频毁损术。结果手术效果优良,原有症状术后改善率96．49％。结论分次双侧脑立体定向射频毁损术治疗帕金森病是一种安全有效的方法。     

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.