荧光引导在颅内肿瘤术中应用研究进展

颅内最常见的恶性肿瘤（如胶质瘤、转移瘤等）常呈浸润性生长,边界不清,手术全切率低,尤其是功能区肿瘤,手术风险高,因此,术中如何判断肿瘤边界对手术切除肿瘤及脑功能的保护至关重要。荧光引导切除术主要是通过荧光染色肿瘤组织,     

脑磁图与神经导航结合在脑功能区肿瘤切除中的初步应用(附31例报道)

目的 探讨脑磁图功能区定位与神经导航结合在肿瘤神经外科的应用价值.方法 选择31例功能区肿瘤患者术前行脑磁图(Magnetoencephalography,MEG)确定肿瘤范围及相邻皮质功能区位置,将影像数据输入Brain-LAB导航系统工作站,进行三维重建并制定手术计划,标记肿瘤病灶及其临近重要功能区,应用显微外科技术切除病变,术后进行临床和影像学评价.结果 肿瘤全切除26例,次全切除2例,大部切除3例.术后新增一过性功能障碍8例.结论 MEG是一种无创检查方法,结合神经导航将病灶与功能区定位应用于肿瘤神经外科,能够有针对性地选择手术入路,并在术中更精确地保护功能区,从而使功能区损伤的机会大为减少.     

脑磁图功能定位在脑功能区肿瘤手术中的应用

目的 评价脑磁图(MEG)功能定位在脑功能区肿瘤手术的应用价值.方法 回顾性分析24例肿瘤位于功能区及其附近病人的临床资料.术前行MEG功能定位,术中结合神经导航系统实时定位肿瘤及功能区,指导肿瘤切除和功能保护.结果 肿瘤位于功能区6例,与功能区部分重叠6例,功能区边缘5例,功能区外1-2cm7例.肿瘤全切除20例,次全切除4例.术后出现一过性神经功能障碍加重6例,持久性功能障碍加重4例.结论 MEG功能定位是术前无创功能定位技术,能够明确肿瘤与功能区位置关系,应用于功能区及附近肿瘤手术,可减少神经功能障碍的发生,提高病人术后生活质量.     

fMRI对皮层运动功能区脑膜瘤外科治疗的意义

目的提高脑皮层运动功能区脑膜瘤的显微手术效果。方法12例皮层运动功能区脑膜瘤患者术前均行CT、MRI及fMRI检查,5例行DSA检查,7例行MRA检查。术中在显微镜下分离肿瘤包膜,肿瘤予以瘤内分块切除。结果肿瘤全切除10例,近全切除2例,无手术死亡。术后肌力好转4例,肌力无改变6例,肌力下降或加重2例,其中1例经脱水、激素及高压氧治疗后好转,1例无变化。功能保护率91.7%(11/12)。12例术后随访1～2年,无肿瘤复发。结论采用显微神经外科技术可提高皮层运动功能区脑膜瘤的全切率,术前行fMRI及DSA或MRA检查,则有助于术中保护脑功能区皮质、矢状窦和中央沟静脉,减少并发症。     

脑转移瘤的伽玛刀治疗

癌症是危及人类生命最重要的病因之一,而在癌症病人中,又有20～30％的病人会发生脑转移瘤。目前由于对原发病灶治疗手段的进步和神经影像学的发展,脑转移瘤病人还在呈不断上升的趋势。 脑转移瘤不是一个独立的疾病,而是机体恶性肿瘤扩散的一个表现。脑转移瘤的治疗一直是神经外科领域中较难解决的问题,因肿瘤生长快,常为多发,同时伴有机体其他单位的恶性肿瘤,而给治疗方式的选择带来了困难。对转移瘤的治疗基本上是姑息的,治疗的目的是改善或维持病人生存质量,延长生命,避免因转移性肿瘤所致的死亡。 以往的治疗是采用开颅手术或手术加放疗或单纯放疗,对于单个的、外科手术能够切除的病灶可采用显微外科技术摘除,但开颅手术与病人的年龄、身体状况等因素密切相关,同时对位于脑重要功能区的单     

清醒麻醉下切除脑功能区胶质瘤

目的探讨清醒麻醉下切除脑功能区胶质瘤的手术技巧及疗效。方法回顾性分析6例脑功能区胶质瘤病人的临床资料,均在神经阻滞、清醒麻醉下手术,术中神经导航、超声及神经电生理监测定位;切除肿瘤时,维持病人出声连续计数或读图的语言功能监测,或持续按键的运动功能监测。结果术中麻醉满意,肿瘤全切除5例,次全切除1例。术后神经功能障碍均不同程度好转;癫未再发作1例,药物可控制3例。术后出现偏瘫2例,术后无疼痛回忆。结论清醒麻醉下切除脑功能区胶质瘤,结合术中定位明确肿瘤切除范围,及肿瘤与脑功能区的关系,可最大限度地切除脑功能区病变和保护脑功能。     

超高场磁共振功能成像辅助切除躯体感觉区胶质瘤(附5例报告)

目的应用超高场磁共振功能成像技术进行手术前后研究脑躯体感觉功能区肿瘤与功能区的定位,辅助切除躯体感觉功能区胶质瘤。方法5例邻近或累及躯体感觉功能区的胶质瘤患者,术前行双手持物对接刺激策略,在3.0T磁共振采用血氧水平依赖(BOLD)原理进行图像采集,经工作站(Leonardo syngo 2003A,Siemens)提供的BOLD功能图像分析软件包进行分析获得脑运动功能区的激活图像,参与神经外科手术方案的制定。所有患者均在唤醒麻醉下进行显微外科手术,在术前脑功能磁共振图像指导下利用皮质直接电刺激定位感觉区与运动区。在保护脑功能区功能不受损的前提下,最大程度地切除胶质瘤。术前、术后均行KPS评分,判断患者的状态。结果(1)5例躯体感觉功能区胶质瘤,通过此项技术获得了较好的BOLD功能磁共振成像感觉功能区激活图像,定位躯体感觉功能区。(2)患者在唤醒麻醉下,在术前脑功能磁共振图像指导下利用直接皮质电刺激快捷、准确进行中央后回定位,两者具有良好的一致性。结论应用3.0T MRI可以于术前更好地利用BOLD技术显示躯体感觉功能区与脑胶质瘤的解剖关系,以指导唤醒麻醉下直接皮质电刺激定位躯体感觉功能区的手术,实现最大程度保护患者重要的功能并最大程度地切除肿瘤。     

脑功能区胶质瘤手术中的新技术

目的探讨切除脑功能区胶质瘤手术新技术与方法。方法48例脑功能区胶质瘤经术前常规MRI、弥散张力成像(DTI)和fMRI定位大脑皮层功能区及功能投射纤维束,以神经导航为前导,在术中全麻唤醒状态下,通过术中B超定位脑内病灶,皮层体感诱发电位(Co-SEP)及皮层直接电刺激术(Co-ST)脑功能区定位,并在清醒状态下切除病变。术后随访时间3-42个月。结果16例Co-SEP确定中央沟,42例Co-ST明确运动区,16例Co-ST确定语言运动区;肿瘤全切35例,次全切除9例,部分切除4例。术后1个月神经症状好转44例,术后出现暂时性局部神经症状36例;长期局部神经症状加重4例,无手术死亡。全部患者无手术痛苦回忆。结论术中全麻唤醒、皮层-皮层下电刺激术和脑超声技术是切除功能区胶质瘤必备的三项基本技术;术前fMRI与DTI为脑功能区手术提供十分重要信息,神经功能导航为术中功能区定位提供重要前导,综合使用这些现代技术能够在术中明确脑功能区与肿瘤切除范围的关系,做到最大限度地切除脑功能区病变和保护脑功能。     

功能区胶质瘤的手术治疗进展

大脑功能区胶质瘤的手术治疗是神经外科临床工作的一个难题。最大程度地切除病灶，同时尽可能地保护正常脑功能，避免术后神经功能缺失，提高病人术后生活质量，是脑功能区胶质瘤手术治疗的最高目标。在唤醒麻醉下，术前功能神经影像、术中大脑皮质刺激定位、电生理监测、神经导航和术中成像（超声、MRI）等技术的应用，已成为当前脑功能区胶质瘤手术的重要辅助手段。本文对脑功能区胶质瘤外科治疗进展，尤其是功能定位方法进行综述。     

立体定向X-刀加血脑屏障开放化疗治疗脑转移瘤

<正>脑转移瘤是最常见的颅内恶性肿瘤之一,随着医学影像学技术的发展及肿瘤患者生存时间的延长,肿瘤脑转移的发病率有逐年上升趋势[1]。颅内多发转移瘤及位于脑深部及重要功能区的脑转移瘤,一直是神经外科的治疗难点之一。我科1998-04-2010-09采用德国Brain LAB X-刀,加用血脑屏障开放、颈动脉灌注化疗相结合的方法治疗脑转移瘤患者102例,取得较好效果,现报告如下。1资料与方法     

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.     

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.