高血压脑出血术后再出血的影响因素及防治措施

目的观察高血压脑出血手术治疗后再出血的原因及影响因素,为临床防治提供理论依据。方法回顾性分析2011-08—2013-08在我科手术治疗的高血压脑出血155例患者临床资料。术后26例患者再次出血,采用单因素及Logistic多因素回归分析筛查术后再出血的影响因素。结果术后26例患者再次出血,发生率为16.7%。单因素分析提示发病至手术时间、术后收缩压、术后舒张压、手术方式、凝血功能、术后躁动与术后再出血有关（P〈0.05）。术后舒张压超过120mmHg、术后收缩压超过200mmHg、发病至手术时间低于6h、术前凝血功能异常、躁动是术后再出血的危险因素,而微创引流并不是术后再出血的独立危险因素。结论高血压脑出血术后再出血与手术时机、术后血压控制、凝血功能等有关,与微创或开颅手术方式无关,注意危险因素,从而降低再出血发生率,改善预后。     

高血压脑出血穿刺碎吸术后发生再出血的原因分析

目的探讨穿刺碎吸术治疗高血压脑出血术后发生再出血的原因及预防方法。方法对经穿刺碎吸术治疗250例高血压脑出血术后发生再出血的12例患者的临床资料进行回顾性分析。结果穿刺术后再出血的发生率为4.8%。凝血功能明显异常,术后有2例再出血;因术前血压较高(收缩压200 mmHg,舒张压110 mmHg),术后有3例再出血;术中因抽吸用力过大,致术后1例再出血;术后因躁动不安,持续性、阵发性剧烈咳嗽,术后有3例再出血;其余3例再出血原因不明。结论掌握手术适应证和禁忌证,熟悉有关解剖知识,定位准确,按规范进行各项操作,有效地控制术前、术中、术后的血压,可以减少高血压脑出血穿刺碎吸术后再出血的发生。     

高血压脑出血术后再出血的影响因素分析

目的：研究高血压脑出血术后再出血的影响因素,为临床预防提供理论依据。方法回顾性分析2005-01-2013-01在渭南市中心医院神经外科住院经手术治疗的347例高血压脑出血患者的临床资料,其中术后再出血23例,采用病例对照研究对高血压脑出血术后再出血的影响因素进行非条件Logistic多元逐步回归分析。结果本组347例患者23例手术后24 h内发生再次出血,发生率6.63％（23/347）;单因素分析显示,年龄≥60岁、合并糖尿病、入院时GCS评分较低、口服阿司匹林、入院时舒张压＞90 mmHg、凝血异常、血肿量＞60 mL、中线结构移位和手术持续时间与术后再出血有相关性（P＜0.05）;多因素Logistic回归分析发现入院时舒张压＞90 mmHg（OR＝6.371）、凝血功能异常（OR＝21.832）和血肿量＞60 mL （OR＝28.548）是高血压脑出血术后再出血的危险因素（P＜0.05）。结论高血压脑出血术后再出血的发生率较高,入院时舒张压＞90 mmHg、凝血功能异常和血肿量＞60 mL是再出血的独立危险因素,积极处理以上危险因素对预防术后再出血至关重要。     

老年高血压患者基底节脑出血术后再出血的临床分析及对策

目的：探讨手术治疗老年高血压合并基底节脑出血术后发生再出血的原因及预防对策。方法随机在我院选择225例患有高血压并基底节脑出血的老年患者,采用手术方法治疗,其中75例发生术后再出血,定义为出血组,其余150例随机均分为预防组和对照组;采用单因素回归分析平均年龄、凝血时间、入院与手术相隔时间、血糖、血压控制、颅内血肿量;预防组患者采用特殊处理方法,对照组则为常规方法,对比2组患者发生术后再出血的几率。结果各项指标除年龄外均可能导致术后再出血,差异有统计学意义（P＜0·05）。结论有多种因素可引起老年高血压基底节出血术后再出血,通过对各种因素的探究及预防,在未发生再出血前通过多种方法减少发生再出血的可能性,提高患者生活质量。     

高血压脑出血术后再出血的原因分析及防治

目的：研究高血压脑出血术后再出血的原因及防治方法,以有效降低高血压脑出血患者病死、病残率。方法回顾分析我院2001－2011年手术治疗的326例高血压脑出血患者中出现术后再出血的36例患者的临床资料,总结发生原因及有效防治措施。结果本组术后43例（13.1％）出现术后再出血。术后血压过高、波动幅度过大及术中操作不当、止血不彻底是术后再出血的主要原因,术前应用抗凝药物、术后烦躁、呛咳、体温控制不良、手术时机过早也是术后脑出血的常见原因。结论选择正确的手术方式及适当的手术时机,提高手术技巧,严格控制围手术期血压,适当应用镇静药物,早期气管切开和进行早期体温控制可减少脑出血术后病人再出血几率,改善高血压脑出血患者的预后。     

立体定向联合显微手术治疗高血压性脑出血疗效及再出血危险因素分析

目的探讨立体定向联合显微外科手术治疗高血压性脑出血的疗效,以及手术再出血等危险因素分析。方法选取我科2010年1月~2013年1月的200例高血压脑出血病例,随机分为观察组与对照组,对比两组疗效;分析术后再出血原因、筛查其危险因素采用Logistic回归分析。结果术后早期,观察组在手术时间、术中出血量、下床活动时间、留院时间等指标明显优于对照组(P<0.05);术后1 m观察组NIHSS评分,明显低于对照组(P<0.05);对照组术后再出血发生率明显高于观察组(P<0.05)。危险因素中,伴有糖尿病、凝血功能异常、脑中线偏移程度、血肿破入脑室、手术时间过早、出血部位、血肿形状规则与否以及手术方式等,与术后再出血有显著相关(P<0.05)。结论立体定向联合显微外科治疗高血压脑出血较之传统开颅手术,能缩短手术时间、减少术中出血、促进患者神功功能恢复,还能减少再出血的发生率、提高患者生存质量;再出血危险因素分析提示,凝血功能异常(OR>2)、手术时间(<6 h)、出血部位为非基底节、血肿形状不规则等均提示为术后再出血发生的重要原因。     

高血压脑出血术后再出血的原因及防治

目的探讨高血压脑出血术后再出血原因及防治经验。方法2006-2012年手术治疗高血压脑出血65例,术后发生再出血15例,对其临床资料进行回顾性分析。结果本组高血压脑出血术后再出血发生率23.1%（15/65）,死亡率60.0%（9/15）。再出血的主要临床表现为意识障碍加深、瞳孔变化及骨窗张力增高。结论术中止血不彻底、术后血压明显波动是造成高血压脑出血术后再出血的主要原因,合理选择手术时机、术中妥善止血、术后积极控制血压可减少高血压脑出血术后再出血发生率。     

高血压脑出血术后再出血的相关因素分析

目的分析高血压脑出血术后再出血的相关因素。方法收集2013-01—2018-01贵州省人民医院神经外科手术治疗高血压脑出血患者988例,其中术后再出血41例,采用多因素Logistic回归分析41例再出血病例临床资料并判断影响高血压脑出血术后再出血的相关因素。结果患者的年龄、性别、高血压病程、基础疾病、发病至手术时间、术前GCS评分、术中血压等因素与术后再出血无明显相关性(P0.05),而出血量、显微手术技巧、使用止血材料、术后血压管理等因素与术后再出血密切相关(P0.05)。结论影响高血压脑出血术后再出血的因素较多,术中显微镜下精细操作及术后保持血压正常平稳等对预防高血压脑出血术后再出血具有重要意义。     

高血压性脑出血患者的术后再出血（附16例报导）

总结10年来高血压性脑出血患者于血肿清除术后短期再出血的16例患者资料,其发病率占同期高血压性脑出血血肿清除术的7.2％,其中12例行再次血肿清除术,死亡2例;4例行保守治疗,死亡2例。全组共死亡4例。结合文献加以讨论并指出:①首次术中止血不彻底:④术后血压剧烈波动;③存在凝血功能障碍足导致再出血的因素,且以前二者最常见。并例举再出血患者的临床表现,认为再出血一经确诊即应再次手术清除血肿。     

高血压基底节脑出血钻孔引流术治疗后再出血的预防

目的探讨高血压基底节脑出血钻孔引流术治疗后再出血的原因及预防。方法自2008年7月至2010年月收治高血压基底节脑出血患者51例,均应用钻孔引流术治疗。结果术后发生再出血3例。头皮切口止血不彻底,血液沿引流管进入脑内1例;血压控制不理想导致再出血1例;引流管头端插入右侧脑室三角区,拔除引流管后再出血1例。结论严格掌握手术适应证、积极控制血压、争取6h内手术、术中严格止血以及术中只抽出全部血肿量的10%～20%,这些措施均可减少高血压基底节脑出血钻孔引流术治疗后再出血发生率。     

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.