去骨瓣减压术治疗大面积脑梗死18例临床分析

目的探讨去骨瓣减压术治疗大面积脑梗死的临床效果。方法回顾性分析2003-01~2008-01收治的18例经去骨瓣减压术治疗的大面积脑梗死患者的临床资料。结果18例患者存活17例,死亡1例。随访3~6个月,根据GOS评分,恢复良好9例,中残5例,重残3例。结论对保守治疗无效的大面积脑梗死患者,去骨瓣减压术能显著改善患者的预后。合理选择手术适应证,及时把握手术时机以及充分手术减压是取得良好预后的关键。     

去骨瓣减压术治疗大面积脑梗死(附30例报道)

目的 探讨去骨瓣减压治疗大面积脑梗死的意义、手术适应证及手术技巧。方法 回顾分析2010年7月～2015年7月江门市中心医院神经外科收治的30例大面积脑梗死行去骨瓣减压术患者的临床资料,总结分析其手术的意义、手术时机及手术操作的体会。结果 25例患者术后存活,5例死亡。去骨瓣减压术后格拉斯哥昏迷评分(GCS)较术前明显改善(t=-5.08,P<0.05)。术前瞳孔散大24例,术后有16例瞳孔缩小(80%)。术后绝大多数病例CT中线移位较术前回复(28/30)。术后3个月时GOS评分4分7例,3分17例,2分1例,1分5例。结论 去骨瓣减压术是大面积脑梗死的有效治疗手段,早期外科干预、术中充分减压可提高大面积脑梗死患者的生存率。     

标准大骨瓣减压术联合硬脑膜翻转及颞肌贴敷治疗 大面积脑梗死35例

目的 探讨标准大骨瓣减压术联合硬脑膜翻转及颞肌贴敷治疗大面积脑梗死的临床疗效。方法 回顾分析用标准大骨瓣减压联合硬脑膜翻转及颞肌贴敷治疗的35例大面积脑梗死的临床资料。结果 出院时存活32例,死亡3例;病死率为8.6%。存活的32例术后6个月GOS评分,5分5例,4分19例,3分8例。结论 标准大骨瓣减压联合硬脑膜翻转及颞肌贴敷能明显降低大面积脑梗死的死亡率。     

内科保守治疗与不同手术时机去骨瓣减压治疗大面积脑梗死的对比研究

目的对比内科保守治疗与不同手术时机去骨瓣减压手术治疗大面积梗死的临床效果。方法选取我院收治的60例急性大面积梗死患者,根据治疗情况及手术时机的不同,分为A组(内科保守治疗)、B组(脑疝发生后行去骨瓣减压手术)、C组(脑疝发生前行去骨瓣减压手术)各20例。比较3组治疗后NIHSS、GCS、BI、mRS评分、功能恢复状况、病死率及预后情况。结果与治疗前相比,3组治疗后1个月NIHSS评分均明显下降(P0.05),且C组下降幅度更大,3组比较差异有统计学意义(P0.05);3组治疗后GCS、BI及mRS评分比较差异均有统计学意义(P0.05),C组GCS及BI评分最高,mRS评分最低。治疗后6个月,3组病死率、功能恢复状况及预后比较差异均有统计学意义(P0.05)。讨论去骨瓣减压术治疗大面积脑梗死的疗效及短期预后情况显著优于内科保守治疗,且脑疝前期实施手术有利于患者生存率的提高及功能恢复、预后情况的改善。     

后颅窝去骨瓣减压加侧脑室额角穿刺置Ommaya囊治疗大面积小脑梗死的疗效

目的探讨大面积小脑梗死的手术治疗经验。方法应用后颅窝去骨瓣减压+侧脑室额角穿刺置Ommaya囊治疗11例大面积小脑梗死。结果 11例术后存活9例,死亡2例。存活者术后随访6~24个月,术后半年1例ADL评分10分,严重功能缺陷,生活完全需要依赖;1例ADL评分35分,重度生活依赖;2例ADL评分40~60分,中度生活依赖;3例ADL评分75~95分,轻度生活依赖;2例ADL评分100分,生活完全可以自理。结论后颅窝去骨瓣减压+侧脑室额角穿刺置Ommaya囊治疗大面积小脑梗死有效。     

翼-颞联合入路去骨瓣减压术治疗大面积脑梗死

目的探讨对符合适应证的大面积脑梗死的患者行“翼-颞联合入路”去骨瓣减压术后的临床效果。方法回顾性分析2006年8月至2008年8月间收治34例大面积脑梗死病例,24例行标准大骨瓣减压术（标准组）,10例行“翼-颞联合入路”去骨瓣减压术（改良组）,以Barthel指数（BAI）和格拉斯哥预后评分（GOS）评定临床效果。结果术后1d,两组脑组织膨出体积比例差异有显著性（t=2．788,P〈0．05）。所有患者均获随访。术后3、6个月,两组病死率比较差异无显著性（P=0．291,0．148,P〉0．05）;而术后3、6个月BAI、GOS评分比较差异都有显著性（t=7．329,4．076,8．734,3．818;P〈0．05）。结论翼-颞联合入路去骨瓣减压术具有操作简便,暴露及减压充分等优点,根据患者的具体情况进行翼-颞联合入路去骨瓣减压术是一种较好的治疗大面积脑梗死的方法。     

重型颅脑外伤性大面积脑梗死24例临床治疗体会

目的探讨重型颅脑外伤性大面积脑梗死的发病机制、临床诊断和治疗。方法回顾性分析24例颅脑外伤性大面积脑梗死患者的临床资料、诊断与治疗。结果 19例患者入院后急诊手术治疗,行血肿清除,去骨瓣减压术。5例血肿量较少患者先行保守治疗,复查CT示大面积脑梗死形成后,行去大骨瓣减压术。药物治疗包括予钙离子拮抗剂,自由基清除剂,保持血容量稳定。伤后6个月,行格拉斯哥预后评分(glasgow outcome scale,GOS)死亡5例,植物生存4例,重残6例,中残7例,良好2例。结论重型颅脑外伤性大面积脑梗死患者病情危重,早期诊断,及时合理的手术治疗,术后抗血管痉挛,改善脑血管微循环有助于改善患者的预后。     

大面积脑梗死伴发脑疝的手术治疗

目的探讨大面积脑梗死伴发脑疝的外科手术治疗原则及疗效。方法本组12例患者,男8例,女4例,年龄49～75岁,左侧半球大面积梗死者7例,右侧5例;手术前GCS评分大于8分4例,5～8分7例,小于5分1例;其中11例一侧瞳孔散大,1例双侧瞳孔散大;所有患者均行去骨瓣减压术及硬膜扩大修补术。结果本组术后存活9例,占75%;3例死亡,占25%。随访6个月,在随访期内无死亡病例,其中GOS评分4分3例,3分5例,2分1例。结论去骨瓣减压术是大面积脑梗死伴发脑疝形成患者的一种有效治疗方法,它能大大降低患者的病死率和致残率,提高患者的生活质量。     

颅脑外伤去大骨瓣减压术后并发脑膨出、颅内血肿及脑梗死的临床分析

目的探讨颅脑外伤去大骨瓣减压术后主要并发症:脑膨出、新发颅内血肿或/和脑挫裂伤病灶扩大及脑梗死三者的发生率及其预后情况。方法对48例颅脑外伤去大骨瓣减压术后患者进行回顾性探讨。提出了自己测量脑膨出的方法;统计术后脑膨出的发生率,不同时间段测量脑膨出程度,术后新发颅内血肿或/和脑挫裂伤病灶扩大以及脑梗死等的发生率、部位;并与患者术前GCS评分、伤后六个月GOS评分进行分析。结果颅脑外伤去大骨瓣减压术后,(1)脑膨出发生率为77%,手术后14d脑膨出程度最显著。(2)新发颅内血肿或/和脑挫裂伤病灶扩大发生率为58.3%;其部位可以在手术野内、手术同侧非手术区甚至在手术对侧。(3)脑梗死发生率12.5%,均在手术侧。(4)本组伤后六个月GOS评分:死亡率10.4%;预后不良率56.2%(含植物生存率16.7%;重度残废率39.5%);预后较好率33.4%(含中度残废16.7%;恢复良好16.7%)。结论颅脑外伤去大骨瓣减压术后,脑膨出、新发颅内血肿或/和脑挫裂伤病灶扩大、脑梗死等的发生率高,虽然去大骨瓣减压术可以降低死亡率但植物生存率、重度残废率高,手术要慎重。     

大骨瓣减压术治疗脑梗死所致脑疝

目的 探讨开颅大骨瓣减压术对大面积脑梗死所致脑疝的手术时机及手术方法.方法 对大面积脑梗死所致天幕疝12例采用大骨瓣减压术,同时剪开硬脑膜.结果 10例早期手术者均存活,1例死亡,1例病危出院.结论 大骨瓣减压术治疗大面积脑梗死所致脑疝是有效的方法.     

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.     

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.