亚低温治疗重型外伤性颅脑损伤的临床对照观察

目的 比较亚低温治疗和常温治疗重型外伤性颅脑损伤的治疗效果,方法 50例重型颅脑损伤患者随机分为常温组26例和亚低温组24例.入院后病人均持续监测颅内压7 d.对照组维持正常体温,亚低温组入院后在3～7 h内将肛温降至33℃左右,并维持3～7 d.比较2组GCS评分、颅内压、临床预后指标.结果 在伤后第7天,亚低温组和...     

急性重型颅脑损伤早期亚低温治疗临床分析

目的：探讨早期亚低温治疗急性重型颅脑损伤的临床疗效。方法 GCS≤8分早期急性重型颅脑损伤患者126例随机分为亚低温治疗组61例及常温治疗组65例,监测2组的颅内压、血糖及脑水肿体积,比较2组治疗效果。结果6个月后2组GOS评定结果：亚低温治疗组痊愈26例（42.6％）,死亡11例（18.0％）;常温治疗组痊愈12例（18.5％）,死亡19例（29.2％）,2组比较差异有统计学意义（ P＜0.05）。2组颅内压第1天比较差异不明显,第2、3天亚低温组降低明显,且亚低温治疗组能明显降低血糖,缩短脑水肿时间,降低脑水肿程度。结论早期急性重型颅脑损伤采用亚低温治疗能缩短脑水肿时间,减少高血糖,从而缩短病程,减少并发症,减少伤残率,提高生存质量。     

重型颅脑损伤去骨瓣减压术后颅内压升高的亚低温治疗

目的 探讨亚低温治疗对重型颅脑损伤去骨瓣减压术后持续性颅内压升高的效果及安全性。方法 回顾性分析48例重型颅脑损伤去骨瓣减压术后仍存在持续性颅内压升高的临床资料,根据减压术后治疗方法分为亚低温组（22例,进行亚低温治疗）和常温组（26例,维持正常体温）。结果 与术后1 d相比,术后2~4 d,两组颅内压均呈明显下降趋势（P<0.05）,脑灌注压均呈明显增高趋势（P<0.05）,而且亚低温组变化更明显（P<0.05）。亚低温组肺部感染和水电解质紊乱发生率均明显高于常温组（P<0.05）。伤后6个月,亚低温组GOS评分1分2例,2分8例,3分4例,4分2例,5分6例;常温组1分8例,2分10例,3分4例,5分4例;两组预后无统计学差异（P>0.05）。结论 亚低温治疗能有效缓解重型颅脑损伤去骨瓣减压术后颅内压增高。     

重型颅脑损伤后高血糖与预后的关系

目的探讨重度脑损伤后高血糖反应及与预后的关系。方法对165例重型颅脑损伤患者(GCS≤8分)入院后24 h内测定的空腹血糖值进行回顾性分析,比较高血糖组(血糖值> 6.11 mmol/L)与正常血糖组的GOS良好率和死亡率,同时比较高血糖组中不同GCS的血糖水平。结果高血糖组GOS良好率(21.7 %)低于正常血糖组(35.6 %),而死亡率(43.5 %)高于正常血糖组(26 %);高血糖组中GCS 3~5分组血糖值(12.37±2.27)mmol/L明显高于GCS 6 ~ 8分组(9.0±2.0)mmol/L。以上数据经统计学处理,差异均有显著性(P<0.05)。结论重型颅脑损伤病人早期因应激反应或损伤下丘脑、脑干等因素易出现血糖升高,伤情越重,血糖越高,且严重影响预后,过高血糖是导致伤者死亡的重要因素之一。     

亚低温治疗重型颅脑损伤病人纤维蛋白原和D-二聚体的变化及其临床意义

目的观察重型颅脑损伤病人在亚低温和常温治疗状态下纤维蛋白原(Fbg)与D-二聚体(D-dimer)差异及其临床意义。方法43例单纯性、重型颅脑损伤病人随机分为亚低温治疗组和常温组,两组性别、年龄、GCS评分无显著差异。伤后5次(6h、12h、24h、48h、72h)检测Fbg和D-dimer,并记录GOS评分。结果①两组Fbg值在伤后6h、12h、24h、48h差异显著,但伤后72h两组差异不显著。两组Fbg值在伤后6h均较高,常温组升高幅度更明显。两组Fbg值在伤后12h下降,亚低温组降低程度较常温组小。②两组D-dimer在伤后6h明显升高,常温组升高更明显;其在伤后6h、12h、24h差异显著,而在伤后48h、72h差异不显著。③亚低温组GOS评分优于常温组,差异显著。结论在颅脑损伤后4h即开始实施亚低温治疗能改善伤后的高凝状态,并减轻继发纤溶亢进。亚低温治疗缓解了凝血功能紊乱,是其能起到脑保护作用和改善治疗效果的机制之一。     

亚低温治疗重型颅脑损伤的经验体会

目的比较亚低温与常温治疗重型颅脑损伤的临床疗效。方法病人被随机分为亚低温治疗组与常温治疗组进行治疗。评价治疗后两组患者神经功能恢复程度和日常生活能力。结果亚低温治疗除对弥漫性轴索损伤者无明显疗效外,对GCS≤5分者,原发性脑干损伤者均有显著的效果。结论亚低温治疗能显著降低重型颅脑损伤患者的颅内压,控制伤后早期的高糖血症。根据颅脑损伤的具体情况来设定亚低温治疗时间。对于GCS≤5分者,伤后6h内行亚低温治疗可明显提高疗效。     

重型颅脑损伤患者亚低温治疗凝血功能指标的变化与预后

目的观察重型颅脑损伤患者BPC、D-dimer、FIB的变化及与亚低温治疗预后的关系,并探讨重型颅脑损伤患者亚低温治疗的准入指标。方法收集重型颅脑损伤患者68例,随机分为亚低温治疗组及常温治疗组,2组患者除低温相关干预措施不同外,其余治疗方案均相同。治疗时观察分析各患者BPC、D-dimer、FIB变化与预后的相关性。结果 FIB在伤后6 h内,D-dimer在伤后12 h内均出现异常增高,两者在亚低温治疗患者上升程度均较常温组低,随后出现下降趋势。亚低温组无需血小板治疗者的疗效较需输注血小板治疗者好(P=0.000)。结论在颅脑损伤后6 h内开始实施亚低温治疗可以改善预后。曾发BPC<50×109/L患者,预后差,可作为评价预后的指标之一。     

大鼠颅脑损伤后亚低温治疗对Calpain及作用底物MAP-2表达的影响

目的探讨亚低温治疗对颅脑损伤后Calpain、MAP-2基因和蛋白表达的影响。方法将54只SD大鼠随机分为假手术组（n=6）、常温脑损伤组（n=24）和亚低温脑损伤组（n=24）。亚低温脑损伤组在液压打击伤后即接受持续4h的亚低温治疗。伤后6h、12h、24h和72h4个时间点分别处死3只常温脑损伤组和亚低温脑损伤组大鼠。荧光PCR、Western blot半定量检测皮质Calpain及MAP-2基因转录和蛋白的表达。结果颅脑损伤后12h及24h亚低温使Calpain mRNA表达增加（P〈0．05）,伤后6h、12h、24h和72h亚低温均可减少Calpain蛋白的升高,伤后12h及72h尤其显著（P〈0．05）。与假手术组比较,常温脑损伤组和亚低温脑损伤组MAP-2基因转录均减少（P〈0．05）;与常温脑损伤组比较,伤后6h、12h和24h亚低温可抑制MAP-2基因转录的下调,但亚低温脑损伤组MAP-2蛋白的表达均比同时间点常温组低（P〈0.05）。结论颅脑损伤后亚低温治疗的脑保护机制可能与调节Calpain蛋白的表达有关,而亚低温与MAP-2的关系还有待进一步研究。     

重型颅脑损伤患者亚低温治疗的临床研究

目的 通过比较重型颅脑损伤患者亚低温治疗组与常温治疗组的预后来证实亚低温治疗的脑保护作用. 方法 选取重型颅脑损伤患者76例(GCS≤8分),分为亚低温治疗组(36例)和常温治疗组(40例).常温治疗组患者应用脱水降颅压、营养神经、止血、抑制胃酸分泌、营养支持等常规治疗.亚低温治疗组患者除常规治疗外,合并应用冰毯实行亚低温治疗(患者躺在冰毯垫上,通过体表散热使中心体温和脑温降至所需温度,通常为32～34℃,并根据病情需要维持3～14 d).结果亚低温治疗组患者预后优于常温组,差异有统计学意义(P<0.05). 结论 亚低温治疗对重型颅脑损伤患者具有脑保护作用,能提高临床疗效,值得推广应用.     

亚低温在重型颅脑损伤中的临床应用体会

目的探讨亚低温在重型颅脑损伤救治过程中的价值。方法 2008年6月至2013年6月收治重型颅脑损伤(GCS≤8分)420例,分为亚低温组(185例)和常温组(235例);均进行标准大骨瓣减压术,亚低温组在常温组治疗的基础上,采用亚低温措施(直肠温度控制在32~34℃,治疗时间为4~7 d;同时监测病人的生命体征、颅内压等,预防并及时处理各种并发症)。结果治疗后6个月,亚低温组GOS评分明显优于常温组(P0.05)。治疗后12个月,亚低温组KPS评分明显优于常温组(P0.05)。结论在常规治疗的同时,采用亚低温措施对重型颅脑损伤病人的治疗有较好疗效,但应注意并发症等情况的预防和处理。     

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.