颞下经天幕入路显微手术治疗岩斜区脑膜瘤

目的探讨颞下经小脑幕入路切除岩斜区脑膜瘤的显微手术方法和结果。方法 25例岩斜区脑膜瘤病人,全部经CT、MRI明确诊断,其中大型(瘤径2.5~4.4 cm)18例、巨大型(4.5 cm)7例。均采用颞下经小脑幕入路显微手术切除肿瘤。结果镜下全切除肿瘤20例(80%),大部分切除5例,无死亡。术后新增颅神经损伤11例。术后随访1~24个月,全切病例有4例复发。结论颞下经小脑幕入路是切除中上斜坡以上尤其是侵及麦氏腔的岩斜区脑膜瘤实用的手术入路。     

岩斜区肿瘤的显微手术治疗

目的 探讨岩斜区肿瘤的显微手术治疗方法及其效果。方法 自2010年10月至2014年10月收治岩斜区肿瘤23例,分别采用颞下经小脑幕入路（11例）、乙状窦后经小脑幕入路（7例）和幕上幕下（颞下-乙状窦后）联合入路（5例）进行手术切除。结果 23例岩斜区肿瘤中脑膜瘤9例,神经鞘瘤12例,胆脂瘤2例。颞下经小脑幕入路11例中,肿瘤全切9例,次全切2例;乙状窦后经小脑幕入路7例均全切除;幕上幕下联合入路5例中,次全切4例,部分切除1例。23例患者随访6~36个月;术前Karnofsky功能状态评分为（83.0±7.0）分,术后1月为（75.2±9.0）分,术后6个月为（80.0±6.0）分;6例次全切除及1例部分切除患者术后1月行伽玛刀治疗,在随访时间内未见肿瘤复发。结论 根据岩斜区肿瘤的不同类型,选择颞下经小脑幕入路、乙状窦后经小脑幕入路和幕上幕下联合入路,可以提供肿瘤全切率,减少并发症,提高手术疗效。     

经颞下经小脑幕入路切除岩斜区肿瘤

目的:探讨经颞下经小脑幕入路切除岩斜区肿瘤的方法。方法:结合本组15例就岩斜区肿瘤的手术方法及效果进行分析。结果:肿瘤全切除S例,近全切除2例,大部切除4例,部分切除1例。术后症状完全缓解4例,症状好转7例,症状加重2例。死于并发症2例。结论:经颞下经小脑幕人路切除岩斜区肿瘤,术野较大,肿瘤显露清楚,且能避开脑神经的阻挡,多能做到全切除或次全切除肿瘤。     

颞下经小脑幕锁孔入路解剖与临床应用

目的通过神经导航下颞下经小脑幕锁孔入路的解剖和手术方案研究,探讨该入路临床应用效果。方法应用成人头颅标本12例(24侧),模拟颞下经小脑幕锁孔入路,观察暴露的岩斜区解剖结构;利用神经导航技术定位标本岩骨内部结构,最大限度磨除岩尖,观察斜坡鞍后区,上、中斜坡区等结构;利用该入路切除11例临床颅底肿瘤,探讨该入路的安全性和实用性。结果颞下经小脑幕锁孔入路可完全暴露鞍旁区,通过海绵窦外侧壁的手术三角可对累及海绵窦内外病变进行直视手术;神经导航辅助下耳蜗、内听道等结构定位准确,头颅标本岩尖磨除后耳蜗内侧缘岩尖剩余最大骨质平均厚度(0.8±0.19)mm,内侧视角较非导航入路增加(8±2.5)°,后外侧视野增加了(25±3.2)°,获得(3.3±0.4)cm2硬膜显露,明显扩大了后颅窝的暴露范围。临床病例资料肿瘤全切除6例,次全切3例,大部分切除2例,手术时间与既往相比缩短1~1.5 h,术后新增脑神经损害症状或原有脑神经损害症状加重3例,无长期昏迷及手术相关死亡病例。结论神经导航辅助下颞下经小脑幕锁孔入路,能最大程度暴露蝶岩斜区病变,有利于提高肿瘤的全切率和术后疗效。     

颞枕经小脑幕入路显微手术切除岩斜区脑膜瘤

目的 探讨颞枕经小脑幕人路切除岩斜区脑膜瘤的可行性.方法 对18例经颞枕入路切除的岩斜区脑膜瘤患者进行回顾性研究.全部病例均在术前行MRI检查.结果 18例于术患者,肿瘤直径<3.0cm4例;3.0-4.5cm5例;>4.5 cm 9例,最大径可达到7.6 cm×7 cm X7 cm.全切8例,次全切9例,大部分切除1例.偏瘫2例,面瘫1例.听力减退1例,无脑脊液耳漏、失语.1例死亡.结论 颞枕经小腩幕入路切除岩斜区脑膜瘤具有可行性,可以使鞍旁海绵窦区、上中斜坡、岩骨背侧小脑脑桥角区暴露充分,利十该区域占位性病变的手术治疗.     

显微手术治疗岩斜区脑膜瘤

目的通过对28例岩斜区脑膜瘤的显微手术治疗，探讨岩斜区脑膜瘤经岩骨前入路和岩骨后入路手术治疗的效果。方法28例均采用显微手术治疗，采用传统的经乙状窦前入路9例，颞下经小脑幕入路4例，经乙状窦后入路9例，经改良的乙状窦前入路6例。结果肿瘤全切除16例，次全切除9例，大部切除3例，无死亡病例。结论显微手术治疗岩斜区脑膜瘤，根据肿瘤在岩斜区的不同位置采用相应的手术入路，以减少手术并发症，达到治愈的目的。     

岩斜区肿瘤的手术入路选择

目的探讨岩斜区肿瘤的手术入路选择,以提高岩斜区肿瘤的手术疗效。方法回顾性分析2000年1月至2009年12月经显微外科技术切除的92例岩斜区肿瘤,比较手术入路对手术结果的影响。根据肿瘤的临床和影像学特征,将岩斜区肿瘤分为四型。Ⅰ型,采用颞下-经天幕入路;Ⅱ型,采用颞下-经岩骨嵴入路,另有3例巨大型蝶岩斜坡型脑膜瘤采用经岩入路(幕上幕下联合或乙状窦前入路);Ⅲa,采用枕下乙状窦后入路;Ⅲb,采用乙状窦后-内听道上入路;Ⅳ型,经鼻-蝶入路切除。结果肿瘤SimpsonⅠ～Ⅱ级全切除83例。次全切除9例,其中Ⅰ型1例,Ⅱ型5例,Ⅲb型1例,Ⅳ型2例。术后新增脑神经功能障碍16例(17.4%),肢体偏瘫2例;另有2例KPS评分为50分,这2例随访3个月后基本恢复至术前状态。无死亡病例。结论对于不同类型的岩斜区肿瘤,选择合适的手术入路有助于提高疗效,减少术后并发症。乙状窦后及其改良入路、颞下-经天幕及其改良入路是岩斜区重要的手术入路。而硬膜外岩斜区肿瘤适合于采用经蝶入路手术切除。     

大型、巨大型岩斜区脑膜瘤的显微外科治疗

目的 探讨岩斜区脑膜瘤的手术切除程度,总结显微外科手术经验.方法 回顾性分析26例大型、巨大型岩斜区脑膜瘤患者的临床资料,采用显微外科手术切除肿瘤,其中颞下经小脑幕入路7例,枕下乙状窦后入路15例,幕上、下联合入路(颞下入路联合乙状窦后入路)2例,眶颧入路2例.结果 肿瘤全切(Simpson Ⅰ、Ⅱ级)13例,次全切(SimpsonⅢ级)4例,大部切除(Simpson Ⅳ级)9例.结论 追求肿瘤最大程度地切除并尽可能减少术后并发症的发生,根据肿瘤大小、生长方式、侵犯区域等因素个体化选择不同的手术入路.     

33例岩斜区肿瘤的显微外科治疗

目的探讨岩斜区肿瘤的显微切除技术。方法我科1997年8月至2006年12月采用显微外科技术切除33例岩斜区肿瘤，主要采用岩骨乙状窦前入关路、颞下经小脑幕入路、乙状窦后入路、幕上下联合入路4种入路。结果肿瘤全切除22例（66.7％），次全切7例，大部分切除4例。术后症状和体征完全消失13例，症状较术前减轻12例，颅神经症状同术前2例，出现新的神经功能障碍6例。结论术前充分的准备、选择合适的手术入路和娴熟的显微外科技术可以减少手术并发症的发生，降低病残率。     

经岩骨乙状窦前入路岩斜区脑膜瘤手术

目的 探讨巨大型岩斜区脑膜瘤的手术。方法 分析7例直径超过4cm的岩斜区脑膜瘤患手术及术后情况。结果 肿瘤手术显微全切5例,大部分切除2例。无一例死亡,术后并发症面瘫2例,后组颅神经麻痹2例,术后颅内感染4例,颞叶脑内血肿2例。结论 经岩骨小脑幕入路对岩斜区脑膜瘤的暴露十分有利,肿瘤全切率高,岩骨小脑幕入路开颅较复杂、费时及损伤大,Labbe’s静脉容易损伤,并且属于清洁-污染伤口,所以脑水肿脑出血及颅内感染发生率较高,主张只有较大而且波及颅中窝的岩斜区脑膜瘤,才使用经岩骨乙状窦前入路。     

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.