全脑灌注在脑胶质瘤边界区分中的应用价值

目的探讨全脑灌注在脑胶质瘤边界区分中的应用价值。方法回顾性分析30例脑胶质瘤病例资料,低级别组(WHOⅠ~Ⅱ级)14例,高级别组(WHOⅢ~Ⅳ级)16例,均行全脑灌注扫描,测量CT增强与CT灌注上影像边界并求出面积,并在全脑灌注图显示的边界区、CT灌注边界外围区和健侧正常脑组织划定兴趣区,测量CBV。结果 CT灌注面积大于CT增强面积,差异有统计学意义(P0.05)。高级别、低级别取边界参考值,CBV差异有统计学意义,rCBV差异无统计学意义。低级别胶质瘤以CBV 1.770 0mL/100g为CT灌注边界截点时,灵敏度85.71%,特异度78.57%。高级别胶质瘤以CBV值2.275 0mL/100g作为判断CT灌注边界截点时,灵敏度93.75%,特异度93.75%。高、低级别都以rCBV为1.025 0为判断CT灌注边界截点,灵敏度93.33%,特异度83.33%。结论全脑灌注成像在胶质瘤边界区分有较高的临床应用价值。     

多层螺旋CT灌注成像对星形细胞肿瘤分级的准确性评价

目的 评价多层螺旋CT灌注成像(CTP)参数对星形细胞肿瘤分级的敏感性和特异性.方法 对第三军医大学第三附属医院野战外科研究所收治的53例脑肿瘤患者进行CTP检查,经手术和病理学证实为星形细胞肿瘤的30例患者纳入研究对象.CTP采用GE LightSpeed 64层螺旋CT机行灌注扫描,在AW4.2P后处理工作站对原始数据进行后处理,测定肿瘤最大灌注区和对侧正常组织的脑血流量(CBF)、脑血容量(CBV)、平均通过时间(MTT)及毛细血管表面通透性(PS).手术获取脑肿瘤标本进行组织病理学检查.结果 星形细胞肿瘤高级别组CBF、CBV和PS值均明显高于低级别组,差异有统计学意义(P<0.05),MTT值比较差异无统计学意义(P>0.05).受试者工作特征曲线(ROC曲线)分析表明,CBF、CBV和PS值对鉴别高、低级别星形细胞肿瘤的ROC曲线下面积分别为0.914、0.876和0.914,而MTT无鉴别作用,其ROC曲线下面积为0.455.采用CBF=62.635 mL/(100 g·min),CBV=4.310 mL/100 g和PS=5.925 mL/(100 g·min)作为分界点鉴别高、低级别星形细胞肿瘤的敏感性均为84.2%,特异性分别是81.8%、81.8%和91.9%.结论 多层螺旋CTP参数CBF、CBV及PS值对鉴别高、低级别星形细胞肿瘤具有较高敏感性和特异性.     

脑胶质瘤患者血清IGFBP-Ⅱ表达及临床意义

一、对象与方法1.研究对象:选取2003年12月至2004年9月在泸州医学院附属医院神经外科住院治疗的脑胶质瘤患者30例,平均年龄39.1岁,其中男17例,女13例,均行手术治疗,术后病理检查证实为脑胶质瘤。根据WHO(1993)分级标准,将其分为低级别组(Ⅰ~Ⅱ级)16例,高级别组(Ⅲ~Ⅳ级)14例。3     

磁共振波谱分析在脑胶质瘤分级中的应用价值

目的分析氢质子磁共振波谱(~1H-MRS)分析在脑胶质瘤分级中的应用价值。方法回顾性分析我院2013-01—2016-06收治的经术后病理或活组织病理检查确诊的36例脑胶质瘤患者的临床资料,均行常规磁共振(MRI)及~1H-MRS检查,依据世界卫生组织(WHO)2007年分级方法分为低级别胶质瘤组(n=15)和高级别胶质瘤组(n=21),对比分析2组肿瘤占位核心实质区、瘤周区域及对侧镜像区胆碱复合物(Cho)、N-乙酰-L-天门冬氨酸复(NAA)、肌酐(Cr)脂质(Lip)、乳酸(Lac)。结果所有患者肿瘤占位核心实质的Cho/Cr比值均较对侧镜像区升高,NAA/Cr、NAA/Cho比值较对侧镜像区降低(P0.05)。高级别胶质瘤NAA/Cho比值低于低级别胶质瘤,而Cho/Cr高于低级别胶质瘤(P0.05)。高级别胶质瘤瘤周区域Cho/Cr比值较对侧镜像区升高,NAA/Cho比值较对侧镜像区降低(P0.05);低级别胶质瘤瘤周区域Cho/Cr比值较对侧镜像区升高,NAA/Cr、NAA/Cho比值较对侧镜像区降低(P0.05)。高级别胶质瘤组20例出现Lac峰,14例出现Lip;低级别胶质瘤组6例出现Lac峰,1例出现Lip峰。Cho/Cr比值与病理级别呈正相关(r=0.812,P0.05),而NAA/Cho比值与病理级别呈负相关(r=-0.634,P0.001),NAA/Cr与病理级别无明显相关性(r=-0.060,t=0.241)。结论氢质子磁共振波普能够有效显示脑胶质瘤患者肿瘤周围水肿区及肿瘤实质区的代谢变化情况,可为胶质瘤临床术前分级提供客观依据,提高诊断的准确性。     

磁共振表观弥散系数及多体素磁共振波谱与脑胶质瘤增殖活性的相关性研究

目的探讨磁共振弥散加权成像(DWI)的表观弥散系数(ADC)值及多体素氢质子磁共振波谱(1H-MRS)所示代谢物比值与不同级别胶质瘤增殖活性的相关性及其应用价值。方法 2009年12月至2011年9月术前行DWI及多体素1H-MRS检查、术后病理学结果为脑胶质瘤病人40例,按照WHO标准分为低级别胶质瘤组(Ⅰ~Ⅱ级)与高级别胶质瘤组(Ⅲ~Ⅳ级),各20例;对比分析胶质瘤实质部位主要代谢物N-乙酰天门冬氨酸(NAA)、胆碱(Cho)、肌酸(Cr)比值(NAA/Cr、Cho/Cr、NAA/Cho)及ADC值、相对ADC(rADC)值在不同级别胶质瘤的变化及其与在相应肿瘤组织中Ki-67表达的相关性。结果高级别胶质瘤组Ki-67表达水平、Cho/Cr比值明显高于低级别胶质瘤组(P<0.01),而其ADC值、rADC值、NAA/Cr比值和NAA/Cho比值则明显低于低级别胶质瘤组(P<0.01)。相关分析表明,Cho/Cr值与Ki-67标记指数呈正相关(r=0.849,P<0.01);而NAA/Cho与NAA/Cr比值、ADC和rADC值均与Ki-67标记指数呈负相关(r分别为-0.944、-0.919、-0.935和-0.938,P<0.01)。结论多体素1H-MRS及DWI检查均能有效反应脑胶质瘤的增殖活性,其中瘤体的NAA/Cho比值的诊断价值最高,其联合瘤体的rADC值筛检可大幅提升MR对胶质瘤细胞增殖活性的诊断敏感性。     

640层螺旋CT脑灌注成像与CT血管成像在超早期脑梗死中的应用

目的探讨东芝Aquilion ONE 640层CT脑灌注成像(CTP)与CT血管成像(CTA)在超早期脑梗死患者中的应用价值。方法我院2014-06—2015-12收治的28例超早期脑梗死患者,均在发病后6h内实施CT平扫、CTP与CTA检查,分析平扫及灌注CT表现,计算CTP的达峰时间(TTP)、脑血流量(CBF)、脑血容量(CBV)各参数值,并与对侧及半暗带周边相应区灌注参数相对比;重建颈段和脑内动脉CTA图像,采用图像后处理技术显示病变血管情况,对动脉狭窄程度进行分级评价。所有患者3~7d内行多层螺旋CT复查,评估CTP与CTA在超早期脑梗死诊断中的临床价值。结果 28例患者经头颅CT平扫发现,11例有可疑脑缺血区,其余17例未见明显异常。行CT脑血管灌注成像发现,患者感兴趣区内rCBF、rCBV、rTTP(病变侧与对照侧灌注参数的相对比值)明显改变,脑梗死区较边缘区TTP更高,CBF、CBV更低,差异均有统计学意义(P0.01);半暗带区CBF、TTP与对侧比较差异有统计学意义(P0.01),而CBV对比差异无统计学意义(P0.05)。CTA检查发现,10例患者大脑中动脉闭塞,7例大脑中动脉狭窄,11例一侧颈内动脉狭窄或闭塞。结论 CTP早期发现脑梗死患者脑组织中的缺血半暗带,CTA检查可准确判断狭窄或闭塞血管,在脑梗死患者的早期诊断和指导溶栓治疗中有重要临床价值。     

MR扩散加权成像对脑胶质瘤病理分级的临床研究

目的 探讨MR扩散加权成像对脑胶质瘤病理分级的临床应用价值.方法 选择经病理证实的30例脑胶质瘤患者入组研究,患者行MR扩散加权成像,测量肿瘤实质的表观扩散系数(ADC)、相对表观扩散系数(rADC)值,并进行统计学分析.结果 30例脑胶质瘤中低级别胶质瘤14例(Ⅰ级1例,为毛细胞型星形细胞瘤;Ⅱ级13例,其中星形细胞瘤11例.1例为术后复发,另室管膜瘤、少突胶质细胞瘤各一例),高级别胶质瘤16例(Ⅲ级11例,均为间变性星形细胞瘤,1例为术后复发;Ⅳ级5例,其中胶质母细胞瘤4例,室管膜瘤1例).低级别胶质瘤的ADC、rADC均值分别为(1.36±0.16)×10-3 mm2/s、1.76±0.23,高级别胶质瘤的ADC、rADC均值分别为(1.08±0.10)×10-3mm2/s、1.36±0.16,高级别与低级别胶质瘤的ADC、rADC均值比较差异有统计学意义(P<0.05).以低级别胶质瘤肿瘤实质ADC、rADC值的下限1.20×10.3mm2/s、1.53作为判断阈值,本组中诊断正确率分别为86.7%、83.3%.结论 ADC、rADC值对脑胶质瘤病理分级的诊断有较高的准确性.     

脑胶质瘤手术前后凝血及纤溶指标的变化及其临床意义

目的 探讨脑胶质瘤病人手术前后凝血及纤溶指标变化及其临床意义。方法 选取2017年2月至2018年2月收治的脑胶质瘤120例,其中高级别60例（高级别组）,低级别60例（低级别组）,另选60例健康体检者为对照组。术前、术后1 d检测凝血与纤溶指标、血小板计数。结果 术前,高级别组与低级别组活化部分凝血活酶时间（APTT）、凝血酶原时间（PT）、血小板计数小于对照组（P<0.05）,高级别组明显低于低级别组（P<0.05）;高级别组与低级别组D-二聚体（D-D）、纤维蛋白降解产物（FDP）高于对照组（P<0.05）,高级别组明显高于低级别组（P<0.05）,高级别组纤维蛋白原（Fig）明显高于低级别组与对照组（P<0.05）。术后1 d,高级别组、低级别组APTT、PT、血小板计数明显小于术前（P<0.05）。APTT与胶质瘤分级呈明显负相关（r=-0.586;P<0.05）,D-D、FDP、Fig与胶质瘤分级呈明显正相关（r分别为0.692、0.813、0.524;P<0.05）。结论 脑胶质瘤存在凝血-纤溶系统障碍,手术可加重高凝血状态,APTT、D-D、FDP、Fig与胶质瘤分级关系密切。     

血清MCP-1、IL-6、TNF-α表达在脑胶质瘤患者手术疗效评价中的应用

目的探讨血清单核细胞趋化蛋白-1(MCP-1)、白介素-6(IL-6)、肿瘤坏死因子-α(TNF-α)表达在脑胶质瘤患者手术疗效评价中的应用价值。方法 104例脑胶质瘤患者根据肿瘤病理分级分为高级别组(51例)和低级别组(53例),另选取30例健康志愿者作为对照组,采集血清标本进行MCP-1、IL-6、TNF-α检测,对比几组患者的检测结果。结果脑胶质瘤Ⅰ级、Ⅱ级、Ⅲ级、Ⅳ级患者与对照组患者的MCP-1、TNF-α、IL-6水平比较差异有统计学意义(P0.05)。脑胶质瘤患者的血清IL-6与病理分级呈正相关(r=0.825,P0.05);TNF-α、MCP-1均与病理分级呈负相关(r=-0.796、-0.892,P0.05)。低级别组术后2w的TNF-α、IL-6、MCP-1与对照组比较(P0.05),高级别组术后2w的TNF-α、IL-6、MCP-1水平与低级别组比较(P0.05)。MCP-1、TNF-α、IL-6单独诊断高低级别脑胶质瘤的准确率分别为80.75%、75.86%、72.88%,三项联合检测对高低级别脑胶质瘤的诊断准确率为95.78%,显著高于各单项指标的诊断准确率(P0.05)。结论脑胶质瘤术后病理分级与血清MCP-1、IL-6、TNF-α表达相关,检测这三项血清指标能够为临床早期诊断脑胶质瘤高低级别,为评估手术方法与疗效提供依据。     

急性缺血性脑血管病76例多模式CT影像学分析

目的探讨76例急性缺血性脑血管病(AICVD)的多模式CT影像学特点。方法采用320排多层螺旋CT对76例AICVD(发病时间24h)患者急诊进行CT平扫(NCCT)+CT灌注成像(CTP)+CT血管成像(CTA)一站式扫描检查,分析灌注区脑血流量(CBF)、脑血容量(CBV)、平均通过时间(MTT)、达峰时间(TTP)等灌注参数变化及CT血管成像(CTA),并于入院后3d内行头颅MRI,评估其脑灌注特点及血管影像。结果在获取的76例CTP数据中,通过感兴趣区识别划分筛查,有59例患者有明确的异常CTP,有17例患者未发现明确感兴趣区。59例异常CTP中包括急性脑梗死47例,短暂性脑缺血发作(TIA)12例。急性脑梗死患者异常CTP特点:发病在4.5h以内的4例患者CTP表现为患侧CBF均较健侧下降,CBV正常或者轻度增高,MTT、TTP延长;发病时间在4.5~6h内的4例:其中2例CTP表现为CBF降低,CBV正常,MTT、TTP延长,2例表现为CBF降低,CBV轻度降低,MTT、TTP延长;发病时间在6~24h内的39例:其中30例梗死区与CTP异常脑灌注区部位一致,均表现CBF明显降低,CBV明显降低,MTT、TTP延长;12例TIA患者CTP均发现与临床症状相对应的灌注异常:MTT、TTP延长,CBF正常或减低,CBV升高。CTA发现责任动脉重度狭窄5例,血管闭塞10例,7例可见血流缓慢,排空延迟及侧支血管形成。结论多模式CT能够对AICVD提供血流灌注参数的变化及血管情况、供血区的血流动力学变化,对临床诊治具有一定参考价值,主要用于评估大脑半球卒中,多模式CT有临床价值。     

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.