前交通动脉动脉瘤70例治疗分析

目的 探讨前交通动脉动脉瘤的治疗方法及疗效。方法 回顾性分析70例破裂前交通动脉动脉瘤患者的临床资料,显微手术治疗40例,血管内栓塞治疗30例。术后随访1个月到3年,GOS评分4~5分为预后良好,1~3分为预后不良。结果 显微手术治疗的40例患者中,术中动脉瘤破裂共7例,其中死亡2例;40例患者中,预后良好28例,预后不良12例。血管内栓塞治疗的30例患者术后即刻造影按Raymond分级评价栓塞程度:1级12例,2级10例,3级8例;1例因术中动脉瘤破裂死亡;5例（8根血管）术中发生严重脑血管痉挛,维拉帕米超选灌注治疗后7根血管脑血管痉挛得到完全缓解。结论 显微手术和血管内栓塞是治疗前交通动脉动脉瘤的有效方法;维拉帕米超选灌注治疗脑血管痉挛有一定效果。     

老年破裂前循环脑动脉瘤手术策略探讨

目的 探讨预防老年破裂颅内动脉瘤术后脑血管痉挛的显微手术策略.方法 回顾性分析规范手术技巧早期治疗57例60岁以上的颅内动脉瘤病人的临床资料.结果 术后有症状血管痉挛8例,其中后交通动脉瘤术后6例,迟发性血管痉挛性脑梗死死亡1例;脑积水行脑室-腹腔分流术3例.患者出院时按GOS评分,术后恢复良好46例,轻残8例,重残2例,死亡1例.结论 手术夹闭是治疗动脉瘤确实有效的方法,早期手术及规范手术技巧可提高手术效果,降低术后脑血管痉挛及致残率.     

动脉瘤破裂蛛网膜下腔出血早期显微手术结合抗血管痉挛药物治疗的效果观察

目的探讨动脉瘤破裂蛛网膜下腔出血早期显微手术结合抗血管痉挛药物治疗的临床疗效。方法选取2012-05—2014-04我院收治的动脉瘤破裂蛛网膜下腔出血患者48例,给予早期(3d内)显微手术夹闭动脉瘤,并结合术中术后抗痉挛药物治疗,总结分析患者的临床表现、影像学特点,按拉格拉斯哥预后评分(GOS)评价综合处理后的临床疗效。结果48例患者术中探查见蛛网膜下腔出血,破裂动脉瘤周围有血凝块合并脑血管痉挛,在分离瘤颈的过程中有8例动脉瘤破裂;术后脑血管造影显示,除1例床突旁动脉瘤有小部分残颈外,余47例动脉瘤均消失,原有脑血管痉挛症状减轻或消失,除2例术后发生脑血管痉挛外,余均未发生脑血管痉挛。治愈和好转共39例,好转率为81.25%;术后发生一过性偏瘫和原有偏瘫加重者共7例,出院时明显好转5例;出院时重度残疾2例,轻度残疾4例,死亡1例。结论早期手术可以有效防止颅内动脉瘤再次破裂出血,降低病死率;围手术期合理使用抗痉挛药物,对预防脑血管痉挛疗效显著。     

破裂前交通动脉瘤血管内治疗前后肢体功能变化原因探讨

目的探讨破裂前交通动脉瘤的介入治疗前后肢体功能变化的可能原因。方法回顾性分析行血管内介入治疗的前交通动脉瘤20例患者的临床资料,分析术前影像学检查结果、手术方式和术后影像学检查结果,以及术前及术后肢体功能变化情况。结果 4例患者术后肢体出现瘫痪或瘫痪加重,但经治疗后多数恢复满意,4例患者在脑血管造影时发现有3例伴明显脑血管痉挛,未出现肢体功能变化的患者脑血管造影时未发现无脑血管痉挛或轻度血管痉挛。结论破裂前交通动脉瘤血管内治疗前后肢体功能变化的原因与脑血管痉挛密切相关。     

未破裂前交通动脉瘤血管内治疗的临床分析

目的总结未破裂前交通动脉瘤血管内治疗疗效,探讨栓塞方案、并发症及其预防。方法回顾性分析血管内治疗50例未破裂前交通动脉瘤病人的临床资料,并进行影像学和临床随访。结果术中动脉瘤破裂1例,术中血管痉挛1例。术后即刻造影Raymond 1级栓塞44例,Raymond 2级栓塞6例。31例行DSA随访(34.5±7)个月,复发(Raymond 3级)2例;50例临床随访(49±10.9)个月,术后偏瘫1例。结论前交通动脉瘤破裂风险较高,血管内栓塞未破裂前交通动脉瘤是一种微创、相对安全、有效的干预方法。     

破裂性大脑中动脉瘤的临床特点及血管内栓塞治疗

目的总结破裂性大脑中动脉瘤的临床特点以及血管内栓塞治疗的疗效与技术要点。方法对32例破裂性大脑中动脉瘤患者用电解可脱性弹簧圈（GDC）进行动脉瘤囊内栓塞；术后早期处理出血。结果32个动脉瘤中27个瘤腔100％闭塞，3个95％闭塞，2个90％闭塞。术后30例临床痊愈，2例死亡，死亡率6．3％。术中并发脑血管痉挛4例；术后并发脑梗塞1例。1例复发者经二次补充GDC栓塞治愈。全组出现与栓塞技术相关的并发症4例。术后随访3～72个月均无再出血。结论对破裂性大脑中动脉瘤采用GDC进行血管内囊内栓塞疗效可靠；早期栓塞及有效的术后处理是提高破裂性大脑中动脉瘤治愈率的重要方法。     

早中期手术辅助抗血管痉挛药物治疗颅内破裂动脉瘤

目的 总结颅内破裂动脉瘤合并蛛网膜下腔出血的早中期手术治疗经验。方法 1998年11月～2002年8月施行早中期手术治疗破裂动脉瘤合并蛛并网膜下腔出血患者40例,其中经翼点开颅侧裂入路或半球间入路行瘤蒂夹闭术39例;余1例为无明显瘤颈的床实上眼动脉段动脉瘤,行包裹术。手术后常规应用甘露醇,麻醉苏醒后立即应用扩血管解痉药物,持续治疗14d。结果 于发病后1个月根据GOS分级标准评估疗效,优21例(52.50％);良10例;差8例;死亡1例。手术后脑血管造影检查显示,除1例前交通动脉动脉瘤、1例床突旁动脉瘤有小部分残颈,其余38例患者动脉瘤均消失,而且原有脑血管痉挛症状减轻或消失。除2例出现脑血管痉挛症状外,余均未发生明显的手术后并发症。结论 在颅内动脉瘤破裂的早期施行手术治疗,可尽早解除再出血的危险;围手术期辅助应用抗血管痉挛及扩容药物治疗,可使患者获得较好疗效。     

前交通动脉动脉瘤手术时机与疗效的相关性分析（附48例报告）

目的探讨Hunt-Hess分级Ⅳ、Ⅴ级前交通动脉瘤（ACoA）病人手术时机对疗效的影响。方法回顾性分析1997年1月至2012年6月开颅手术夹闭48例Hunt-Hess分级Ⅳ、Ⅴ级ACoA患者的临床资料,分析不同手术时机术中发生动脉瘤破裂、术后并发症和预后的差异。结果早期手术病人37例,GOS评分4～5分19例,GOS评分2～3分6例,GOS评分1分12例;术中动脉瘤破裂5例（13.5%）;术后发生并发症28例（75.7%）;延期手术11例,GOS评分4～5分5例,GOS评分2～3分1例,GOS评分1分5例;术中动脉瘤破裂2例（18.2%）,术后发生并发症8例（72.7%）。两组术中动脉瘤破裂发生率、术后并发症发生率和预后差异均无统计学意义（P〉0.05）。结论 Hunt-Hess分级Ⅳ、Ⅴ级ACoA患者早期、延期手术术中动脉瘤破裂、术后并发症及临床预后无差别,考虑到保守治疗期间再出血及血管痉挛的发生,其治疗应依病情变化尽早积极手术治疗。     

显微外科手术治疗颅内动脉瘤48例

目的探讨颅内动脉瘤的手术时机、术中动脉瘤破裂的处理和术后脑血管痉挛的防治及处理。方法回顾性分析2005年7月至2007年7月48例动脉瘤显微手术治疗患者的临床资料。结果48例均予手术夹闭动脉瘤，同时清除颅内血肿2例。术后出现症状性血管痉挛19例，其中17例经治疗后症状明显缓解。随访1～3个月，病人恢复良好者36例，轻残者8例，重残者2例，死亡2例（呼吸道感染1例，大面积脑梗死1例）。结论颅内动脉瘤早期施行显微手术疗效较好。术中避免动脉瘤破裂以及正确处理术中破裂出血，充分解剖暴露瘤体瘤颈，避免盲目操作，术后积极防治脑血管痉挛是手术成功的关键。     

前交通动脉破裂动脉瘤血管内介入治疗体会

目的 总结前交通动脉破裂动脉瘤血管内介入治疗的经验。方法 回顾性分析2015年1月至2017年12月采取血管内介入治疗的35例前交通动脉破裂动脉瘤的临床资料。29例行单纯弹簧圈栓塞,6例宽颈动脉瘤行支架辅助栓塞。结果 34例栓塞成功;1例支架辅助弹簧圈栓塞术中动脉瘤破裂出血,术后死亡。术后发生严重血管痉挛2例,经积极抗血管痉挛、保持脑灌注、改善脑循环等综合治疗,对侧下肢乏力好转。34例术后随访0.5~1年,均无复发或再出血。结论 血管内介入治疗是前交通动脉破裂动脉瘤的有效方法。     

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.     

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.     

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.     

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.