弥散张量成像在听神经瘤术中面神经定位中的应用价值

目的探讨术前弥散张量成像(DTI)在听神经瘤手术面神经定位中的应用价值。方法回顾性分析2017年5月至2019年10月德阳市人民医院神经外科手术治疗的17例听神经瘤患者的临床资料。术前采用DTI重建追踪面神经的位置,以术中神经电生理监测结果作为金标准,计算DTI定位面神经的灵敏度、特异度、准确率及曲线下面积(AUC);采用Kappa一致性检验评价术前DTI重建面神经的结果与术中神经电生理监测面神经定位的一致性。结果17例患者术前行DTI重建均成功追踪面神经,术中采用神经电生理监测均成功定位面神经的实际位置,其中15例与术前DTI重建面神经的位置相符合,2例与DTI不相符合,包括1例术中神经电生理监测显示面神经位于肿瘤腹侧前上部,而术前DTI显示面神经位于肿瘤上级,1例术中神经电生理监测显示面神经位于肿瘤腹侧前下部,而术前DTI显示面神经位于肿瘤下级术前DTI定位面神经的灵敏度为83.3%,特异度为80.0%,准确率为76.5%,AUC=0.900(P=0.011),与术中神经电生理监测定位面神经具有一定的一致性(Kappa=0.734,P<0.01)。结论术前011对听神经瘤手术中面神经的定位具有较高的特异性,有助于术中保护面神经,从而减少面神经的损伤。     

弥散张量成像定位在听神经瘤切除术中的应用

目的 探究弥散张量成像（DTI）定位在听神经瘤切除术中的应用。方法 选取2017年1月—2020年1月在西安国际医学中心医院治疗的106例听神经瘤患者,收集患者临床资料。通过术前DTI定位与术中面神经电生理监测结果进行比较,分析两者检测结果的一致性。分析手术效果及术后患者面神经功能。结果 面神经均位于肿瘤腹侧,其中位于腹侧中央者最多（44例,占41.51%）,其次是腹侧前上部者（25例,占23.58%）。术前DTI结果与术中神经电生理监测结果相符合者有100例（94.34%）,不符合者有6例（5.66%）,差异无统计学意义（P>0.05）。患者术后面神经均实现解剖保留。术前面神经功能良好率为89.62%;术后2周、3个月、6个月以及1年,患者面神经功能良好率分别为74.53%、46.23%、53.77%及85.85%;患者术前与术后面神经功能分级比较,差异均具有统计学意义（P<0.05）。结论 术前通过DTI定位面神经与肿瘤位置较准确,且手术效果较好、面神经保留率较高,术后面神经有一定损伤,6个月后开始恢复,术后面神经功能障碍发生概率降低。 [国际神经病学神经外科学杂志, 2023, 50(6): 29-33]     

3DSlicer软件弥散张量成像纤维束追踪技术在听神经瘤手术中的应用

目的评价3DSlicer软件进行弥散张量成像纤维束追踪在听神经瘤术中的应用价值,探索一种有效的辅助听神经瘤术中保护面神经功能的方法。方法随机选取2020年3月至2020年8月河北医科大学神经外科收治的听神经瘤患者43例按患者志愿分为观察组(21例)与对照组(22例),观察组患者术前完善FIESTA、DTI等影像学检查,并利用3DSlicer软件重建肿瘤与面神经纤维并预判肿瘤与面神经的位置关系,术中联合神经电生理检测辅助听神经瘤手术切除,并记录术中面神经的实际位置;对照组仅利用神经电生理检测辅助定位面神经走行来指导手术完成。计算术前重建面神经位置与术中实际情况的符合率;比较两组患者术后1 w面神经功能(House-Brackmann标准)与听力保留率的差异。结果利用3DSlicer软件弥散张量成像纤维束追踪技术为观察组21例听神经患者重建面神经成功20例,重建失败1例;20例患者中17例术前重建的面神经位置与其术中实际位置一致,符合率为85%;观察组患者术后1 w面神经功能明显优于对照组(P0.05),听力保留率也高于对照组(P0.05)。结论应用3DSlicer软件弥散张量成像纤维束追踪技术可有效辅助听神经瘤术中面神经的精准定位,有利于术中寻找与保护面神经,提高听神经瘤患者术后面神经的功能保留率和听力保留率。     

面神经电生理监测下切除大型及巨大听神经瘤

目的探讨面神经电生理监测下切除大型及巨大听神经瘤技术。方法回顾分析22例大型及巨大听神经瘤临床资料,在面神经电生理监测下行显微手术切除,术后随访面神经功能。结果肿瘤全切除15例,次全切除7例。面神经自发肌电图在面神经受牵拉、挤压、生理盐水冲洗等操作过程中产生显著放电,刺激肌电图对寻找和辨认面神经具有重要作用。面神经位于肿瘤腹下方7例,腹上方2例,腹侧中部13例。所有病例面神经均解剖保留。术后随访6~42个月,面神经功能(House-Brackmann分级),H-B分级Ⅰ级11例,Ⅱ级5例,Ⅲ级2例,Ⅳ级4例。结论面神经电生理监测辅助显微手术对术中解剖与功能保留面神经具有重要价值。     

多模态影像融合辅助手术治疗听神经瘤

目的在多模态影像融合技术辅助下手术治疗听神经瘤,以提高肿瘤的全切除率和神经功能的保留率,初步实现听神经瘤的“精准”手术治疗。方法回顾性纳入2016年1月至8月解放军总医院神经外科在多模态影像融合技术辅助下手术治疗的听神经瘤患者,共30例。患者术前均采用循环相位稳态采集快速成像（FIESTA—C）和弥散张量成像（DTI）技术重建面神经,术中显微镜下验证所重建面神经位置的准确性。将重建的面神经、内听道水成像、颞骨薄层CT扫描重建并进行多模态融合,判断肿瘤与周围结构的关系。CT导航下确定内听道后壁的准确位置及需要磨除的范围,术中持续应用神经电生理监测。结果30例患者中,面神经重建成功率为100．0％,与实际位置符合率为93．3％（28／30）。17例进行导航,导航注册误差为0．30～0．92mm,平均（0．47±0．15）mm。39例中,肿瘤全切除28例（93．3％）,次全切除2例（6．7％）;面神经解剖保留28例（93．3％）,功能保留26例（86．7％）。术前均为不可用听力,术后无听力保留及改善。围手术期无死亡患者,无脑脊液漏、术区血肿及后组脑神经损伤症状。结论采用多模态影像融合技术辅助手术治疗听神经瘤可以提高肿瘤的全切除率和面神经功能的保留率,减少手术相关并发症。     

混合现实技术在听神经瘤手术中的应用价值

目的探讨混合现实技术在听神经瘤手术中的应用价值。方法回顾性分析2021年1月至2022年2月于河北医科大学第二医院神经外科行手术治疗的25例听神经瘤患者的临床资料。患者术前均行颞骨CT、循环相位稳态采集快速成像和弥散张量成像等检查, 利用3D-Slicer软件建立三维模型, 并经混合现实技术呈现三维模型影像, 预测肿瘤与面听神经的位置关系, 从而制定个体化的手术方案。以术中神经电生理监测结果作为金标准, 采用Kappa一致性检验评价术前重建面神经的走行与术中神经电生理监测定位的一致性。25例患者均经乙状窦后入路手术。术前及术后1周采用House-Brackmann分级评估患者的面神经功能。结果 25例患者术前均成功重建听神经瘤三维模型, 肿瘤重建后的中位体积为6.18 cm3 (0.73～16.86 cm3)。其中23例(92.0%)成功重建面神经, 余2例重建失败。开颅时关键孔定位的满意率为96.0%(24/25), 无静脉窦损伤的患者。术前成功重建面神经的23例患者中, 20例与术中神经电生理监测定位的面神经完全一致, 准确率为86.9%;Kappa一致性检验显示, 术前重建面神经...     

大型听神经瘤的显微手术治疗及术中面神经保护

目的 探讨显微手术切除大型（肿瘤最大径>3 cm）听神经瘤的疗效及术中面神经保护的方法。方法 回顾性分析2014年1月至2018年2月手术治疗的86例大型听神经瘤的临床资料,均在电生理监测下采用枕下乙状窦后入路显微手术。结果 肿瘤全切除83例,近全切除3例。面神经保留78例（91%）;术后1周面神经功能House-Backmann分级:1级11例,2级37例,3级22例,4级16例。术后门诊随访3~30个月,术区皮下积液4例,口唇疱疹9例,无死亡病例。结论 术前多模态肿瘤-神经评估,术中实时电生理监测,精细显微手术对大型听神经瘤全切和保留面神经功能可提供保障。     

面神经在大型听神经瘤中的分布变化规律

目的 探讨大型听神经瘤术中面神经与听神经瘤的相对解剖位置及规律.方法 通过同顾性分析133例大型听神经瘤的手术录像,分析面神经在听神经瘤的中的分布变化规律.结果 面神经在脑干端和内听道基底部的位置相对固定,在可识别面神经的病例中,在内听道口前上部有35例(26%),前下部的89例(67%),后下部6例(5%).在小脑脑桥角池中段位于肿瘤前上方11例(8%),前中部49例(37%),前下部63例(47%),后下部6例(5%).结论 掌握面神经在大型听神经瘤中的分布规律可以提高面神经的保护.     

大型听神经瘤手术中面神经监测的效果观察

目的了解大型听神经瘤手术中连续面肌肌电图监测对术中、术后面神经解剖和功能保留的作用。方法根据Gormley颅内肿瘤分型方法,100例听神经瘤患者中肿瘤直径为4.0～4.9cm者82例,5.0～5.9cm者16例,直径≥6.0cm者2例。手术前采用House等面神经功能分级标准进行评估,Ⅰ级65例,Ⅱ级33例,Ⅲ级2例。采用经乙状窦后入路显微外科手术切除肿瘤,术中施行面肌肌电图监测和直接电刺激。结果100例中肿瘤全切除或近全切除者94例,大部分切除6例。2例肿瘤切除过程中切断面神经者均行Ⅰ期端-端吻合;2例面神经被切断1/2者行断端吻合。手术后2周面神经功能评估Ⅰ级30例,Ⅱ级50例,Ⅲ级10例,Ⅴ级10例;手术后1年随访面神经功能Ⅰ级76例,Ⅱ级14例,Ⅲ级7例,Ⅴ级3例。结论大型听神经瘤手术中采用面神经监测对面神经的解剖和功能保留有明显效果。     

面神经功能保留角度探讨小型听神经瘤的治疗

目的从面神经功能保留角度探讨小型听神经瘤治疗方法的选择。方法回顾性分析直径1～3cm的听神经瘤43例,所有肿瘤均经MRI确诊,手术方法采用乙状窦后入路,对患者进行术前、术后面神经功能测定。结果小型听神经瘤经乙状窦后入路手术切除后,术后2W内面神经功能Ⅰ～Ⅲ级占77％,长期随访面神经功能Ⅰ～Ⅲ级占87％。结论采用乙状窦后入路切除小型听神经瘤对面神经的功能保留率较高,但是保留率不如立体定向放射外科,且手术并发症相对较高。     

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.     

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.