神经导航在颅底肿瘤手术中的应用

目的评价神经导航系统在颅底肿瘤手术中的应用.方法在74例颅底肿瘤手术中,应用StealthStation神经导航系统指导手术操作.术中应用神经导航实时定位颅底解剖标志点并判断肿瘤切除程度.结果74例平均坐标误差为(2.26+-0.99)mm,预期准确性为(3.00±0.92)mm.CT和MRI融合误差为1.04 mm.靶点准确性为＜2 mm.74例肿瘤全切55例,次全切除10例,大部切除8例,穿刺1例.术后症状改善或无变化61例(61/74),加重或出现新症状13例.2例死于与手术无关的原因,分别为窒息和多器官功能衰竭.结论在颅底肿瘤手术中,神经导航定位准确可靠,有助于提高肿瘤切除率,降低手术并发症.     

神经导航辅助胶质瘤手术

目的　评价神经导航系统在胶质瘤手术中的应用。方法　在 80例胶质瘤手术中 ,应用StealthStation神经导航系统指导手术操作。在其中 2 7例手术中测量硬膜、皮质以及病灶移位程度。在大脑浅表胶质瘤手术中 ,使用微导管栅栏法纠正脑移位的影响 ,判断肿瘤边界。结果　 80例平均座标误差为 (2 .0 3± 0 .89)mm ,10cm预期准确性 (2 .4 3± 0 .99)mm。术中硬膜、皮质以及病灶移位分别为 (3.4 4± 2 .39)mm、(7.5 8± 3.75 )mm以及 (6 .5 5± 3.19)mm。 5例虽然导航显示肿瘤残留 ,但未强行切除 ;其余 75例肿瘤全切 6 2例 (82 .7% ) ,次全或大部切除 13例 (17.3% )。术后症状改善或不变 6 8例 (85 .0 % ) ,术后症状加重或出现新症状 12例 (15 .0 % ) ,无死亡病例。结论　在胶质瘤手术中 ,术中脑移位是影响神经导航准确性的重要因素。微导管栅栏法简便、实用 ,有助于提高肿瘤切除率 ,降低手术并发症     

神经导航手术252例临床应用

目的 介绍神经导航手术的临床应用经验。方法 在1997年9月至2001年9月连续进行的252例神经外科手术中,使用StealthStation神经导航系统指导手术操作。结果252例平均坐标误差为（2.12±0.89）mm,预期准确性为（2.74±0.99）mm。在239病灶切除术中,病灶全切除85.7％,术后症状改善或不变87.9％。在7例内窥镜手术中,5例囊肿行开窗术、2例胆脂瘤次全切除。7例活检和4例穿刺成功率100％。结论 神经导航准确、可靠,有助于提高手术疗效,降低手术并发症。     

神经导航在颅内肿瘤手术中的应用（附106例报告）

目的报告使用StealthStation神经导航系统在颅脑手术中应用的经验.方法应用StealthStation神经导航系统指导106例颅内肿瘤手术进行回顾性分析.术中对导航准确性进行监测并对46例不同部位病灶进行术中脑移位检测.结果首次平均坐标误差和10厘米预期准确性分别为3.60±1.60mm和3.12±1.77mm,经去除或重新注册"不准确”的皮肤坐标后两者分别降为2.34±0.91mm和2.79±0.93mm.有5例因平均坐标误差＞4mm加用表面注册,其结果为1.09±0.24mm.106例病人共108个病灶,除了活检1例(0.9%)外,全切除92个(85.2%)、次全切除8个(7.4%)、大部切除7例(6.5%).术中准确性分别为1.22±0.90mm和1.29±1.30mm.术后症状改善或不变98例(92.5%)、加重6例(5.7%)、死亡2例(1.9%).结论StealthStation神经导航系统在颅脑手术中提供术中动态跟踪、实时导航,准确可靠,有助于病灶全切除及降低手术并发症的发生.     

神经导航辅助下显微手术治疗颅底中央区肿瘤

目的探讨神经导航系统在颅底中央区肿瘤显微切除术中的应用及其优越性。方法对36例颅底中央区肿瘤患者应用神经导航系统辅助下实施显微手术,术前将患者影像学信息导入神经导航系统进行解剖三维重建,并依据肿瘤部位应用神经导航系统设计个体化的手术切口,术中对手术入路、肿瘤及其周围重要解剖结构准确定位,判断肿瘤切除程度。结果本组病例神经导航注册误差为0．6-2．3mm,平均（1．1±0．3）mm。36例患者中肿瘤全切26例,次全切除10例（术后1月内均行γ刀治疗,死亡1例）。术后患者临床症状均得到改善或消失。结论 在颅底中央区肿瘤显微手术中应用神经导航系统能准确定位肿瘤与周围重要解剖结构,并引导手术操作,安全、准确地切除肿瘤,提高手术疗效,减少手术并发症的发生。     

神经导航术中脑移位的研究

目的定量研究不同神经导航手术中的脑移位,评价术中脑移位对神经导航手术定位准确性的影响。方法在73例颅脑手术中应用StealthStation神经导航系统指导手术操作,制作骨瓣前在骨窗外作对照参考点,然后分别测量硬膜、皮层和病灶移位程度,并分别对不同病理性质肿瘤的移位情况进行分析。结果平均注册误差(2.13±0.74)mm,术中持续准确性为(1.17±0.67)mm;所有73例的硬膜、皮层和病灶移位程度分别为(2.80±2.48)mm、(5.14±4.05)mm以及(3.53±3.67)mm。胶质瘤组的硬膜、皮层和病灶移位均是最大的,而海绵状血管瘤组以及颅底肿瘤组的移位明显低于胶质瘤组。结论术中脑移位是影响神经导航手术定位准确性的重要因素,对不同性质和部位病变术中脑移位的了解有助于指导手术操作。     

神经导航系统在经鼻蝶入路垂体腺瘤切除术中的应用

目的　评价神经导航系统在经鼻腔蝶窦入路垂体腺瘤切除术中的应用。方法　应用Brain LABVec torVision2 神经导航系统指导手术操作 ,2 1例患者术前行MRI或CT连续薄层扫描 ,将影像学资料输入导航系统计算机工作站 ,标记出肿瘤及重要结构后进行三维重建 ,设计出最佳手术入路 ,术中实时显示来指导定位中线结构、蝶窦前壁、鞍底、海绵窦、颈内动脉和斜坡等结构 ,并用以判断肿瘤的切除程度。结果　 2 1例注册误差 0 .3～ 1.8mm(平均 1.13± 0 .38mm) ;所有病例均在神经导航引导下经鼻蝶入路顺利到达肿瘤部位 ;肿瘤全切除 17例 ,次全切除 2例 ,大部切除 2例 ;术后 16例患者症状减轻 ,5例无变化 ,5例出现一过性尿量增多 ,无其他严重并发症。结论　在经鼻蝶显微手术中应用神经导航指导操作 ,手术顺利准确 ,肿瘤切除彻底 ,手术创伤小 ,并发症更少。     

神经导航在神经外科中的应用

目的:探讨和研究神经影像导航技术在神经外科领域的应用前景,尤其是位于重要功能区的颅内小病灶应用无框架立体定向影象导航技术,结合显微神经外科手术切除的经验和体会.方法:采用Stealth Station神经影象导航系统进行影象导航和显微手术切除的颅内病灶18例,男性11例,女性7例,年龄17～58岁.额叶6例(其中6例为于运动区),顶叶4例,枕叶2例,颞叶1例,桥小脑角2例,小脑半球3例.所有病例均常规应用影象导航下显微切除肿瘤或炎性肉芽肿.结果:影象导航总体误差1.8～3.7mm,平均2.68mm.手术病灶全切除14例,次全切4例,尤其位于运动区3例小病灶,手术全切除后无任何并发症.结论:影象导航系统定位准确,对病灶手术全切除、减少术后并发症具有重要价值,应用前景广阔.     

神经导航系统在颅内病变活检术中的应用

目的探讨神经导航系统在颅内病变活检术中的应用。方法对16例颅内病变病人术前行MRI或CT连续薄层扫描,在神经导航引导下行活检术。结果注册误差0.4~1.9mm,平均(1.38±0.45)mm;注册时间10~21min,平均(14±3.5)min;手术时间45~115min,平均(55±23)min,均准确完成手术。活检阳性率100%。无手术并发症。结论神经导航指导活检,具有简单迅速、定位准确、安全高效和阳性率高的优点。     

神经导航显微外科治疗颅底中央区脑膜瘤(附35例分析)

目的探讨神经导航系统在颅底中央区脑膜瘤手术中的应用价值。方法回顾性分析35例应用神经导航手术操作系统进行显微外科治疗的颅底中央区脑膜瘤病人的临床资料。本组针对不同类型的颅底中央区脑膜瘤,应用神经导航系统设计个体化的手术入路,术中应用显微外科技术,避免损伤重要结构,进行有效的肿瘤切除。结果肿瘤全切除28例,次全切除7例。术后早期严重并发症发生率为11.4%,包括动眼神经麻痹1例,脑内血肿1例(行血肿清除术后恢复良好),脑脊液漏1例,颅内感染1例。本组无死亡病例。随访6个月～2年,次全切除者中复发2例。结论应用神经导航系统设计个体化的手术入路,术中应用显微外科技术,精细操作,颅底中央区脑膜瘤大多可以获得成功的手术切除。     

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.     

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.