Onyx胶栓塞治疗硬脑膜动静脉瘘的初步体会

目的 总结应用Onyx胶栓塞治疗硬脑膜动静脉瘘的初步结果 及经验.方法 采用Onyx胶经血管内栓塞治疗18例影像学证实的硬脑膜动静脉瘘.对所有患者的临床特征及血管内治疗过程进行同顾性分析.结果 15例采用动脉入路、1例采用动静脉联合入路、2例采用静脉入路进行栓塞治疗.13例患者经栓塞后瘘口完全闭塞,3例大部分柃塞,2例部分栓塞,死亡1例.17例患者随访3～24个月,症状完全消失或无加重.造影显示病变1例复发.结论 Onyx胶是血管内栓塞治疗硬脑膜动静脉瘘的理想材料,通过动脉入路对大多数患者能较好的弥散并栓塞瘘口,短期疗效满意.对于动脉入路难以到达瘘口而静脉窦通畅者,可行动静脉入路或静脉入路进行.其长期效果有待进一步的随访评价.     

Onyx胶介入栓塞治疗硬脑膜动静脉瘘19例疗效分析

目的总结血管内栓塞治疗硬脑膜动静脉瘘(DAVF)的经验和体会。方法回顾性分析使用Onyx胶栓塞19例DAVF病人的临床资料。经动脉入路栓塞9例,经静脉入路栓塞7例,经动静脉联合入路栓塞3例。结果辅助弹簧圈栓塞9例,辅助球囊栓塞7例,单纯Onyx胶栓塞3例。瘘口完全栓塞18例;大部分栓塞1例,术后血流明显变慢,需二次栓塞。术后原有症状不同程度缓解或消失,并发外展神经麻痹3例。完全栓塞病例术后3个月复查未见复发。结论 DAVF通过Onyx胶血管内治疗能够达到良好的治疗效果。     

Onyx和／或弹簧圈栓塞治疗海绵窦区硬脑膜动静脉瘘

目的探讨经不同入路应用Onyx、弹簧圈或二者联合栓塞治疗海绵窦区硬脑膜动静脉瘘的疗效。方法回顾性分析21例经DSA证实为海绵窦区硬脑膜动静脉瘘患者的临床资料。21例患者中,15例经岩下窦入路栓塞,2例经面静脉或颞浅静脉一眼静脉人路栓塞,4例经动脉入路栓塞;单纯使用Onyx栓塞11例,单纯用弹簧圈栓塞3例,用弹簧圈联合Onyx栓塞7例,其中2例注入Onyx过程中使用封堵球囊保护颈内动脉。结果栓塞术后即刻造影显示瘘口完全闭塞17例,大部分闭塞4例。栓塞术后所有颅内杂音均消失。术后出现同侧眼睑下垂加重2例,动眼神经麻痹1例,外展神经麻痹2例,3月后均改善。16例患者随访3～62个月,平均随访28个月;6例经DSA随访未见复发,10例电话或门诊随访症状改善。结论使用Onyx、弹簧圈或二者联合进行栓塞治疗海绵窦区硬脑膜动静脉瘘,静脉入路为首选,必要时可使用封堵球囊保护供血动脉,可以取得较为满意的疗效。     

Onyx结合微弹簧圈经静脉入路治疗硬脑膜动-静脉瘘

研究背景采取单纯微弹簧圈栓塞供血动脉姑息治疗硬脑膜动静脉瘘的方法,在栓塞血管巢近端供血动脉后,可出现新的供血动脉并可能改变静脉引流途径,从而增加颅内出血风险。闭塞引流静脉是一种十分有效的治疗方法,且经静脉途径闭塞引流静脉成功率较高,本研究尝试经静脉入路注射液体栓塞剂Onyx结合微弹簧圈栓塞治疗硬脑膜动静脉瘘,并探讨其疗效。方法经静脉入路栓塞治疗12例硬脑膜动静脉瘘患者(海绵窦区8例、横窦乙状窦区4例),通过脑血管造影检查及临床随访评价疗效。结果术后即刻全脑血管造影检查瘘口完全闭塞者11例、瘘口处血流速度明显减慢者1例。随访3个月至3年,临床症状完全消失者11例、明显缓解者1例。结论应用液体栓塞剂Onyx结合微弹簧圈经静脉入路栓塞治疗硬脑膜动静脉瘘安全有效。     

血管内栓塞治疗侧窦区硬脑膜动静脉瘘 （附10例报道）

目的 探讨侧窦（横窦-乙状窦）区硬脑膜动静脉瘘（LSDAVF）的血管内栓塞治疗的方法及有效性。方法 回顾性分析2011年7月至2016年6 月血管内栓塞治疗的10例LADAVF的临床资料,经右侧股动脉-颈外动脉-脑膜中动脉Onyx胶栓塞8例,经左侧股静脉-下腔静脉-颈内静脉球囊保护下 Onyx胶栓塞2例。结果 术后即刻造影完全栓塞8例,大部分栓塞2例,未出现并发症。术后随访6个月~2年,8例无加重及复发,2例异位复发。结论 血 管内栓塞治疗LSDAVF是一种相对安全、简单、有效的治疗方法,必要时需配合静脉窦球囊保护下进行;闭塞瘘口同时闭塞部分无功能静脉窦存在短期 内异位复发可能。     

非Galen静脉脑动静脉瘘的血管内治疗

目的探讨血管内栓塞治疗非Galen静脉脑动静脉瘘(NCAVF)的效果。方法回顾性分析8例NCAVF临床病例资料,其中单瘘口7例,多瘘口1例;3例采用单纯弹簧圈栓塞,5例采用弹簧圈辅助Onyx胶栓塞。结果术后即刻造影示一次完全栓塞瘘口6例,分期完全栓塞1例,近全栓塞1例。术后随访3~24个月,造影无复发,8例病人术后症状均得到缓解。结论弹簧圈或弹簧圈辅助Onyx栓塞治疗非Galen静脉脑动静脉瘘可行,效果良好。对于高流量瘘,弹簧圈可降低血流,辅助Onyx栓塞瘘口。     

前颅窝底硬脑膜动静脉瘘的外科治疗

目的 分析12例前颅窝底硬脑膜动静脉瘘(dural arteriovenous fistulas, DAVFs)外科治疗方法和结果,探讨治疗的必要性及如何提高疗效.方法 行六血管全脑血管造影,结合CT、MRI,分析影像学特点,全麻下进行经颅手术夹闭瘘口或血管内栓塞治疗.3例经眼动脉分支供血动脉到接近瘘口处用10%～20%的NBCA胶栓塞,1例经颌内动脉分支接近瘘口用ONYX胶栓塞,2例经颌内动脉以PVA栓塞;6例(包括1例经静脉入路血管内治疗失败后)经前颅窝底入路用动脉瘤夹直接夹闭位于筛板的瘘口的静脉端.结果 6例前颅窝底DAVFs直接手术夹闭瘘口治愈;4例经动脉入路栓塞治愈;2例经动脉入路栓塞治疗后好转.结论 前颅窝底DAVFs直接手术效果好;经动脉入路栓塞到瘘口静脉端也可治愈,但需防止并发症.     

球囊辅助栓塞硬脑膜动静脉瘘

目的评估球囊辅助栓塞硬脑膜动静脉瘘的临床效果。方法回顾性分析2010年10月至2012年8月收治的17例硬脑膜动静脉瘘患者的临床资料,其中位于横窦、乙状窦区11例,颈静脉孔区4例,上矢状窦区2例;均行球囊辅助栓塞硬脑膜动静脉瘘;6例经动脉途径栓塞,3例经静脉途径栓塞,8例经动脉及静脉相结合途径栓塞。结果 17例患者中,栓塞后即刻造影复查示,瘘口完全消失11例,部分消失6例。17例病人随访3个月~2年,无加重及复发者;瘘口完全消失13例,部分消失4例。结论球囊辅助栓塞硬脑膜动静脉瘘是一种安全、有效的方法。     

远端血管阻断辅助微导管超选经栓塞硬脑膜动静脉瘘

目的介绍远端血管阻断辅助微导管超选技术在经动脉入路栓塞硬脑膜动静脉瘘术中的应用。方法硬脑膜动静脉瘘患者2例。1例为天幕缘区硬脑膜动静脉瘘,供血动脉来自脑膜中动脉和枕动脉,采用弹簧圈闭塞枕动脉远端主干。另一例为前颅窝底硬脑膜动静脉瘘,供血动脉为双侧眼动脉之筛前、筛后动脉,采用球囊临时阻断于颈内动脉眼动脉开口远端。结果微导管在弹簧圈及球囊支撑下均超选人与主干血管成角明显且迂曲的供血动脉远端,微导管头端接近瘘口,以液态栓塞材料完全消除瘘口。结论对于供血动脉迂曲且与主干血管成角明显的硬脑膜动静脉瘘,远端血管临时或永久阻断有利于使微导管头端超选至理想位置,最终保证瘘口栓塞。     

静脉入路栓塞治疗海绵窦区硬脑膜动静脉瘘

目的总结经静脉入路栓塞治疗海绵窦区硬脑膜动静脉瘘的手术经验。方法回顾性分析15例海绵窦区硬脑膜动静脉瘘的临床资料,均采用Onyx或联合可脱性弹簧圈填塞病变侧海绵窦,同时闭塞瘘口。经股静脉-岩下窦入路11例,经股静脉-面静脉-眼上静脉入路4例。结果治疗后即刻造影显示海绵窦和瘘口完全闭塞14例,残留少量眼上静脉引流1例(术后6个月复查造影显示残留瘘口消失)。术后眼部症状加重1例,经对症治疗术后6d症状逐渐改善;展神经麻痹1例,自行恢复。随访3～28个月,未见复发病例。结论 Onyx经静脉入路栓塞海绵窦区硬脑膜动静脉瘘是安全有效的。     

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.