无框架神经导航与立体定向开颅术的比较性研究

目的：探讨无框架神经导航手术和立体定向开颅术的各自特点。方法：回顾性总结自1999年2月-2000年12月间使用ASA-601V神经外科导航系统完成的38例导航手术和使用Leksell-G型定向开颅手术。结果：导航组;病灶全切34例,近全切3例,行动脉瘤加固术1例,立体定向开颅组;全组病例均守整切除病灶,二组都无严重并发症和死亡。结果：无框架神经导航手术和立体定向开颅术,均属于立体定向手术范畴。对于位于颅表或皮层下的病灶（直径≤5cm),适于行立体定向开颅术。而对于脑深部、边界不规则呈浸润性生长的病灶和颅底病灶,则适于行无框架神经导航手术。     

磁共振引导下等体积切除幕上胶质瘤

目的探讨应用立体定向技术和神经导航系统辅助等体积切除幕上胶质瘤。方法回顾性总结1995年10月至2003年8月完成的114例磁共振引导下幕上胶质瘤等体积切除病例,其中77例施行了立体定向开颅切除,37例行神经导航手术。对术式的优点和注意事项进行分析。结果立体定向开颅组均全切肿瘤。术后一过性运动障碍加重6例,语言障碍加重3例。导航手术组肿瘤全切34例,次全切除3例。术后出现不同程度的肢体肌力下降和(或)语言障碍7例。二组共有2例留有永久性轻瘫,1例不全性失语,其余均在短期内恢复。结论在磁共振引导下,应用立体定向开颅术和神经导航手术可对大脑半球不同部位的胶质瘤行影像学等体积切除,微导管法简便、实用,有助于提高肿瘤的全切除率和降低并发症。     

立体定向显微外科切除颅内小病灶

目的总结并探讨立体定向显微神经外科治疗颅内小病灶的优越性.方法回顾性分析42例接受立体定向辅助显微神经外科治疗的不同性质颅内占位病变病人的病历资料.结果本组病灶均全切,癫癎发作消失14例,改善11例,轻瘫病人术后肌力恢复,无死亡,无术后感染及手术致残,神经功能保留良好.结论立体定向辅助开颅手术定位简单而准确,开颅后病灶空间定位和区别病灶与正常组织间的界限也更容易,切除颅内小病灶后神经功能保全良好,手术时间和术后康复时间均可以明显缩短,符合目前微侵袭外科的要求,对于位于重要功能区、肉眼下病变组织与正常脑组织不易区分的小病灶具有明显的优势.     

无框扫描立体定向技术在神经外科手术中的应用体会

目的总结无框扫描立体定向技术在神经外科手术中的使用经验和体会。方法回顾分析46例运用无框扫描立体定向技术进行的开颅手术,均行手术规划和(或)术中导航,胶质瘤切除前先穿刺肿瘤边界,放置标记物。结果无框扫描立体定向技术定位误差1.5～2.5mm,平均误差1.8mm,100%准确直达靶点;肿瘤及动静脉畸形均全切除。结论无框扫描立体定向技术具有精确定位、实时导航和辨认组织的功能,且能有效应对术中脑组织漂移,操作简便,能明显减轻手术创伤,减少并发症,是微创神经外科手术的重要辅助技术。     

35例颅内海绵状血管瘤的外科治疗

目的 探讨颅内海绵状血管瘤手术方法及疗效。方法 回顾性分析2012~2019年手术治疗的35例颅内海绵状血管瘤的临床资料。21例采用神经导航辅助开颅手术治疗,10例采用立体定向手术,4例采用直接开颅手术治疗。结果 33例颅内海绵状血管瘤全切除,2例次全切;术后症状缓解17列,无变化16例,加重3例;无手术死亡病例。结论 针对具体情况,联合应用神经导航、立体定向、电生理技术切除颅内海绵状血管瘤,是一种安全有效的方法。     

立体定向引导显微手术切除脑功能区病变

目的探讨立体定向引导显微手术治疗脑功能区病变的临床效果和应用价值。方法应用立体定向仪和手术计划系统,对8例脑功能区病灶进行立体定向开颅显微手术切除。结果 8例病灶均定位准确,显微镜下全切。6例术前有癫痫的患者术后4例发作完全消失,另2例明显减轻。2例胶质瘤病人1例术后13月复发。2例转移瘤病人1例死于原发病,1例颅内再次转移。2例术前无神经功能障碍者术后出现对侧肢体无力,经治疗1例恢复,1例改善。3例合并神经功能障碍者术后均获得不同程度的改善。结论立体定向引导显微手术治疗脑功能区病变定位准确,侵袭性小,有助于提高病变全切率及降低手术并发症。     

导航下手术治疗脑血管疾病

目的：探讨无框架脑立体定位手术在治疗脑血管性疾病中的应用价值。方法：术前将MRI数据传入无框架脑立体定向导航系统（SealthStation)计算机工作站,进行三维建模,标记点定位,手术入路设计,开颅前行参考环及探针确认,标记点注册,设计手术切口,术中实时定位,1999年11月至2001年6月行无框架脑立体定向手术117例,其中动静脉畸形46例,动脉瘤42例,海绵状血管瘤29例,结果：颅内病灶或重要解剖定位结构准确,机显病灶定位误差均在2mm以内,术后神经功能损害4例,占3．4％,无手术死亡,结论：无框架脑立体定向手术能准确进行病灶定位,有效保护脑组织,减少神经损伤,切除病灶,改变了传统开颅手术模式,是微创神经外科的保证。     

立体定向开颅术中病灶边缘点的定位

目的：通过对脑深部病灶边缘点定位．在立体定向开颅手术中引导术，以期彻底切除病灶。方法：应用驹井式计算机体层摄影(CT)立体定向仪对11例脑深部病灶进行立体定向开颅手术，其中腔质瘤8例．转移瘤3例．直径25～45mm．影像学显示肿瘤边界不清。术前对病灶边缘点三维座标进行测量登记，术中通过导针引导切除病灶。结果：术后半月内增强CT或磁共振成像(MRI)扫描显示：9例病灶完全消失．2例肿瘤周边有少许残余。无手术死亡及昏迷等。结论：对于脑深部边缘不清的病灶，在立体定向开颅手术切除病灶时，对病灶边缘点定位．可较彻底切除病灶，减少手术病灶残留。     

脑内小病灶立体定向直视手术—82例临床分析

目的：应用立体定向直视手术，摘取颅内小病灶。方法：ＣＴ导向立体定向技术开颅治疗脑内小病灶８２例。其中额叶４２例，顶叶３４例，顶枕部４例，侧脑室１例，丘脑１例。临床表现以癫痫为主７５例，偏瘫２７例，偏身感觉障碍２１例，语言障碍１６例。采用ＣＴ导向立体定向显微直视手术切除病灶。结果：７９例术后神经损害症状消失，３例明显减轻，无新的神经损害症状，无手术并发症及手术死亡。结论：该方法是一种微侵袭手段     

影像导向立体定向开颅切除颅内病灶(12年临床经验总结)

目的探讨影像导向立体定向开颅切除颅内病灶的手术方法和术式特点。方法回顾性总结1991年5月～2003年5月完成的立体定向开颅术442例，病灶位于额叶225例，颞叶48例，顶叶96，枕叶33例，多发病灶40例。其中154例位于恼重要功能区。结果均成功切除病灶。术后一过性运动、语言、感觉障碍加重23例，癫痫发作3例，遗留永久性功能障碍2例。结论立体定向开颅术是一种定位精确、侵袭性小的手术方式，适用于功能区或皮质下病灶(直径≤5cm)的切除。     

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.