短暂性脑缺血发作患者的初步智力研究

目的 (1)探讨短暂性脑缺血发作(transient ischemic attacks,TIAs)患者在临床症状消失后是否遗留智力障碍;(2)明确颈内动脉系统TIAs与椎一基底动脉系统TIAs患者智力改变的异同。方法 对34例TIAs患者(其中颈内动脉系统TIAs和椎一基底动脉系统TIAs各17例)和34例对照分别进行修订韦氏成人智力量表检测。结果 (1)TIAs患者的各项量表评分均明显低于对照组(除图形拼凑项的P值小于0.05外,其余各项的P值均小于0.01);(2)除椎-基底动脉系统TIAs患者图片排列项的等值量表分明显低于颈内动脉系统TIAs外(P<0.05),其余各项评分两组无显著性差异(P>0.05)。结论 (1)TIAs患者在症状消失后可能依旧存在不同程度的智力障碍;(2)椎-基底动脉系统TIAs患者的智力(主要是理解能力)损害可能比颈内动脉系统TIAs患者更加严重。     

短暂性脑缺血发作患者记忆功能障碍的特点及其相关因素的研究

目的研究颈内动脉系统和椎-基底动脉系统短暂性脑缺血发作(TIA)患者在临床症状消失后的记忆功能障碍的特点及其与TIA的病程、次数及持续时间与记忆障碍的相关性。方法对42例颈内动脉系统和36例椎-基底动脉系统TIA患者在TIA末次发作后3～7d进行临床记忆量表(甲套)、简易精神状态检查量表(MMSE)、Zung抑郁自评量表测试,并与30名健康对照者进行比较;同时对TIA发作的病程、次数、持续时间与记忆障碍进行相关性分析。结果(1)颈内动脉系统组和椎-基底动脉系统组在临床记忆量表中除无意义图形再认外,其余各项的等值量表分均比正常对照组明显下降(均P<0.01),两组在临床记忆量表中的各项等值量表分比较差异无统计学意义。(2)颈内动脉系统组的即刻记忆、语言能力及MMSE总评分,椎-基底动脉系统组地点定向力、注意力和计算力及MMSE总评分均低于正常对照组(均P<0.05)。(3)颈内动脉系统和椎-基底动脉系统TIA患者的病程、发作次数、发作持续时间与临床记忆量表和MMSE的各项等值量表分之间无相关性。结论(1)颈内动脉系统和椎-基底动脉系统TIA患者在症状消失后可遗留不同程度的短时记忆障碍。(2)颈内动脉系统TIA患...     

428例短暂性脑缺血发作患者的临床资料分析

目的 分析短暂性脑缺血发作(TIA)的临床特点,探讨影响其预后的相关因素.方法 回顾性分析428例顺序入组的VIA患者的临床资料,按受累血管分为颈内动脉系统TIA和椎-基底动脉系统VIA两组,分别比较其症状持续时间和相应动脉狭窄与否与患者预后的相关性.结果 本研究共纳入VIA患者428例,其中颈内动脉系统295例(68.93%),椎-基底动脉系统133例(31.07%).颈内动脉系统TIA患者中,症状持续时间<10min者94例(31.86%),10min～1h者147例(49.83%),1～6h之间者44例(14.92%),>6h者10例(3.39%);椎-基底动脉系统TIA患者中,症状持续时间<10min者40例(30.08%),10min～1h者56例(42.11%),1～6h之间者24例(18.05%),>6h者13例(9.77%).患者的预后与发作持续时间显著相关(P<0.005).颈内动脉系统TIA患者接受血管检查276例,相应动脉有狭窄者148例(53.62%),其中,症状缓解者动脉狭窄发生率为47.17%,反复发作后缓解者54.59%,发展为梗死者62.5%;椎-基底动脉系统VIA患者受检117例,相应动脉有狭窄者37例(31.62%),其中,症状缓解者发生率28.00%,反复发作后缓解者28.24%,发展为梗死者85.71%.患者的预后与发作持续时间有相关性(P<0.05).椎-基底动脉系统TIA患者的预后与相应动脉狭窄密切相关(P<0.01),颈内动脉系统TIA患者转归与重度相应动脉狭窄相关(P<0.05).结论 TIA患者的预后与症状持续时间及相应动脉狭窄密切相关.在临床工作中,应密切关注TIA症状持续时间,并应高度重视患者脑动脉狭窄情况的检查.     

短暂性脑缺血发作患者的记忆功能研究

目的 观察颈内动脉系统短暂性脑缺血发作(TIA)的患者在症状消失后是否遗留记忆障碍;并探讨颈内动脉狭窄、TIA的病程,次数及持续时间的长短对记忆功能的影响。方法 35例颈内动脉系统TIA患者在末次发作后平均(8±6)天接受临床记忆量表(甲套)的测试,61名正常对照者也接受同样的量表测试。结果(1)TIA患者的记忆商(memory quotient,MQ),总量表分及其指向记忆、联想学习、图像自由回忆和人像特点联系回忆项的等值量表分与正常对照相比,均有明显下降,而两组在无意义图形再认项的评分上无显著性差异(P>0.05)(2)TIA组内伴颈内动脉狭窄者的总量表分和无意义图形再认项的等值量表分均明显低于无狭窄者(P<0.05)。(3)TIA的病程、发作次数及持续时间的长短与临床记忆量表的MQ及各项等值量表分之间均无明显的相关性(P>0.05)。结论(1)颈内动脉系统TIA患者在症状消失后可遗留不同程度的短时记忆障碍。(2)伴颈内动脉狭窄的TIA患者与无狭窄者相比短时记忆尤其是视觉记忆损害更重。(3)TIA患者的病程、发作次数及每次发作持续时间的长短对记忆功能无明显影响。     

中华成人智力量表与韦氏成人智力量表中国修订版的相关研究

目的考察及评估中华成人智力量表(Intelligence Scalefor Chinese Adult,ISCA)和韦氏成人智力量表中国修订版(Wechsler Intelligence Scale for Adut-Chinese Revised,WAIS-RC)的一致性。方法对120名智能正常成人(年龄16~79岁),随机分为两组,以抗衡顺序前后检测ISCA和WAIS-RC。结果①ISCA结构效度分析12个测试项目的累计解释方差为71.72%,两量表的一致性测定Kappa值为0.694。②ISCA与WAIS-RC量表总分及各分量表之间显著相关(总粗分之间r=0.935;言语分量表之间r=0.910;操作分量表之间r=0.917;ISCA的流体智力与WAIS-RC的操作测验之间r=0.831;ISCA的晶体智力与WAIS-RC的言语测验之间r=0.904;ISCA的注意/记忆与WAIS-RC的操作测验之间r=0.888,P值均小于0.01)。结论ISCA与WAIS-RC量表具有很高的一致性。     

短暂性脑缺血发作97例临床分析

目的探讨短暂性脑缺血发作(TIA)的临床特征、影像学资料和治疗效果。方法回顾性分析2002年～2006年间临床诊断为TIA的97例患者．将其分为两组,即颈内动脉系统TIA组和椎基底动脉系统TIA组,分析其临床资料、影像学资料和治疗随访结果。结果本研究中TIA患者发病到就诊时间的几何均数为3．31 d,发作持续时间为12．32 min,发作持续时间是否超过1 h与能否复发或进展为卒中无显著关系;TIA患者的危险因素包括高血压、冠心痛、糖尿病和脑梗死病史;CT发现脑梗死灶的阳性率为29．4%～50%,MRI阳性率为100%;随访3个月发现,脑梗死发生率为4．5%:两组患者在发病到就诊时间、持续时间、危险因素、CT阳性率及脑梗死发生率等方面均无显著性差异。结论颈内动脉系统和椎基底动脉系统TIA存在共同的临床特征,多数TIA患者不能及时就诊,发作持续时间几何均数接近文献报道水平;发作持续时间是否超过1 h不影响3个月预后。     

短暂性脑缺血发作与颅内外血管狭窄的关系

目的探讨短暂性脑缺血发作(TIA)与颅内外血管狭窄的关系。方法给68例TIA患者进行颈部B超、经颅多普勒(TCD)以及心脏超声检查,对其中56例有明显脑血管狭窄的患者进一步行数字减影血管造影(DSA)检查。结果56例行DSA检查的患者中,显示大脑中动脉狭窄(或闭塞)6例,颈内动脉狭窄(或闭塞)21例,锁骨下动脉狭窄8例,椎基底动脉狭窄(或闭塞)28例。大动脉狭窄性TIA44例,其中颈内动脉系统16例,椎基底动脉系统28例;栓塞性TIA18例,其中颈内动脉系统15例,椎基底动脉系统3例;腔隙性TIA4例;血管痉挛性TIA2例。结论TIA患者大多存在颅内外血管狭窄,其与TIA有密切关系。     

椎基底动脉系统TIA患者的血液流变学改变

目的 探讨椎基底动脉系统短暂性脑缺血发作(TIA)患者的血液流变学改变及其临床意义。方法 对318例椎基底动脉系统TIA患者在末次发作后36h内进行血液流变学检查。结果 TIA组与对照组比较,全血粘度、红细胞压积、红细胞聚集性及纤维蛋白原等各项指标均无明显增高(P>0.05)。结论 椎基底动脉系统TIA的发病因素可能与血液流变学异常的关系意义不大。     

3.0T HR-MRI评估椎-基底动脉粥样硬化斑块在TIA病情发展中的价值

目的分析3.0 T高分辨率磁共振成像(3.0 T HR-MRI)评估椎-基底动脉粥样硬化斑块稳定性在短暂性脑缺血发作(TIA)的应用价值。方法选取2015年2月至2018年2月期间于本院诊治的TIA患者80例,所有患者均行3.0 T HR-MRI检查出椎-基底动脉粥样硬化斑块,记录椎-基底动脉粥样硬化斑块分布和厚度,并根据斑块稳定性将患者分为斑块稳定组(n=38)和斑块不稳定组(n=42),比较两组患者TIA发作次数以及发作持续时间,门诊随访1年,比较两组患者脑梗死或TIA再发时间、TIA再发次数及脑梗死例数。结果椎-基底动脉粥样硬化斑块最容易在背侧壁形成,斑块厚度以0.5～1.5mm为主;斑块不稳定组患者TIA发作次数显著多于斑块稳定组患者(P0.05),TIA发作持续时间显著长于斑块稳定组患者(P0.05);随访1年发现,斑块不稳定组患者脑梗死或TIA再次发作时间显著短于斑块稳定组患者(P0.05),TIA发作次数、脑梗死例数高于斑块稳定组患者(P0.05)。结论 3.0 T HR-MRI能够评估椎-基底动脉粥样硬化斑块分布、厚度等情况,并对斑块进行定性分析,进一步预测TIA病情发展,为脑血管病二级预防提供更多依据。     

脑小血管病认知障碍与影像特征分析

目的观察分析脑小血管病(CSVD)认知障碍与磁共振影像特征,为早期发现及治疗依据。方法选取脑小血管病患者86例,另选取80例健康志愿者为对照组。应用MMSE、临床记忆量表、WAIS-RC对86例脑小血管病患者进行认知评估,并分析其磁共振影像特征。结果脑小血管病患者MMSE评分、记忆商数MQ、语言智商VIQ、作业智商PIQ、总智商FIQ与对照组比较下降明显(P0.05);LI组无意义图形再认、人像特点回忆、算术、数字广度、木块图、数字符号的等值量表分下降更显著(P0.01);WML组数字广度、算术、图画填充、木块图、数字符号、图形拼凑、图片排列测试的等值量表分下降更显著(P0.01);CMB组在图像自由回忆、无意义图形再认、数字广度、图画填充、木块图、图片排列测试的等值量表分下降更显著(P0.01);LI、CMB、WML共存组各项测试分值均显著下降(P0.01)。结论脑小血管病存在认知障碍,且磁共振特征可以提示其认知障碍特点,早期发现其磁共振异常表现可以早期进行CSVD防治,延缓及改善CSVD认知障碍。     

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.