三维螺旋CT血管造影在颅底肿瘤手术前评估中的应用

目的初步评估三维螺旋CT血管造影(3D-SCTA)在颅底肿瘤手术前的应用价值。方法对19例CT、MRI临床证实为颅底肿瘤患者采用多层面螺旋CT血管造影检查,采用表面遮盖法(SSD)和最大密度投影法(MIP)行3D图像重建,12例行伪彩SSD重建用以模拟手术入路,同期10例行核磁共振血管造影(MRA)和脑数字减影血管造影(DSA),7例行神经导航手术前规划及术中导航。结果3D-SCTA能清楚显示颅底肿瘤的形态及其与邻近大血管、颅骨的三维关系,为手术前选择手术入路提供了重要信息。结论3D-SCTA提供了颅底肿瘤与邻近血管和颅骨的三维空间图像,为常规二维影像的补充,对颅底肿瘤手术前评估有重要价值。     

3D-SCTA在颅底肿瘤手术前评估中的应用

目的 评估三维螺旋CT血管造影(3D-SCTA)在颅底肿瘤手术前的应用价值.方法 对32例CT、MRI临床证实为颅底肿瘤患者采用多层面螺旋CT血管造影检查,采用表面遮盖法(SSD)和最大密度投影法(MIP)行3D图像重建,21例行伪彩SSD重建用以模拟手术入路,同期15例行核磁共振血管造影(MRA)或脑数字减影血管造影(DSA),16例行神经导航手术前规划及术中导航.结果 3D-SCTA能清楚显示颅底肿瘤的形态及其与邻近大血管、颅骨的三维关系,为手术前选择手术人路和提供了重要信息.结论 3D-SCTA提供了颅底肿瘤与邻近血管和颅骨的三维空间图像,为常规二维影像的补充,对颅底肿瘤手术前评估有重要价值.     

多排三维螺旋CT血管造影在脑膜瘤手术前评估中的应用

目的评估多排三维CT血管造影(3D-CTA)对脑膜瘤手术治疗的指导价值。方法对48例CT、MRI临床证实为脑膜瘤患者术前行3D-CTA检查,其中病变位于矢状窦镰旁17例、蝶骨嵴12例、嗅沟7例、小脑幕6例、鞍结节4例、桥小脑角2例。CTA图像采用遮盖容积重建(SVR)、最大密度投影(MIP)和彩色表面阴影显示法(SSD)3种处理技术。对三维图像进行旋转、切割及相关测量,模拟最佳手术入路,对其影像学特点与手术中所见进行对比研究。结果3D-CTA能清楚显示脑膜瘤的形态及其与邻近大血管、颅骨的三维关系和静脉窦的开放程度,为术中正确处理静脉窦提供可靠的信息。可以模拟手术入路时观察到的血管,为手术前选择手术入路提供了重要信息,提高手术的安全性。结论3D-CTA提供了脑膜瘤与邻近血管和颅骨的三维空间图像,可清晰显示脑膜瘤与周围大血管关系,可以从多角度模拟手术路径,选择最佳手术入路,在脑膜瘤术前评估中有其独特的价值。     

螺旋CT血管造影及三维重建技术辅助脑深部肿瘤显微手术的应用研究

目的探讨螺旋CT血管造影及三维重建技术(3D-CTA)在脑深部肿瘤显微手术中的应用效果。方法回顾性分析27例经3D-CTA辅助的脑深部肿瘤显微手术病例,评估术前肿瘤的3D重建效果及术后疗效。结果所有肿瘤的术前3D重建图像均能清楚显示病灶部位、大小、轮廓以及邻近血管、骨质,并与术中实际观察一致。27例病例全切除23例,次全切除3例,大部切除1例;术后症状改善或不变25例,症状加重或出现新的症状2例,无死亡病例;术后1个月随访优良22例。结论 3D-CTA能够准确提供肿瘤与邻近血管和颅骨的三维影像,并能够任意调整、测量及模拟手术入路,对于脑深部肿瘤选择最佳手术入路、规避术中风险的个体化治疗提供了可视化依据。     

三维CTA及重建在颅底占位术前评估中的作用

目的 评估三维CTA及重建在颅底占位的临床应用价值。方法对19例经CT、MRI证实为颅底占位的患者行3D-CTA检查。采用AW4．0软件进行图像重建；同期有10例行MRA和DSA检查。结果3D-CTA能清晰显示颅底占位的形态及其与邻近血管、颅骨的三维关系。结论3D-CTA提供的占位与邻近血管、颅骨的三维空间关系对手术入路的选择、手术风险评估等具有重要参考价值。     

经鼻-蝶窦手术路径的体表定位及鼻-蝶窦区的三维CT影像解剖

目的 探讨三维螺旋CT在鼻-蝶鞍区影像解剖及经鼻-蝶窦垂体瘤手术入路的鞍底定位中的应用.方法 回顾性分析29例鼻-蝶鞍区螺旋CT扫描数据,以3D重建和剪切技术重建和观察鼻-蝶鞍区的3D解剖结构.分析鼻尖-耳轮上缘连线(鼻-耳轮线)与鞍底的关系.对14例垂体瘤患者术前、术后行螺旋CT扫描和重建,评估3D - CT和鼻-耳轮线在经鼻-蝶窦垂体瘤术前规划和术中鞍底定位中的可行性.结果 鼻-耳轮线在所有的研究对象中均与蝶窦相交,其中与鞍底相交者12例占42％.鞍底-斜坡交点至鼻-耳轮线的垂直距离是(3.6±1.8)mm.3D - CT能清晰地显示鼻-蝶鞍区的解剖结构,包括蝶窦及其分隔、颈动脉和视神经管隆起、鞍底等.为模拟手术入路和术中鞍底定位提供重要信息.结论 3D - CT技术可获得鼻-蝶鞍区高清晰度的三维空间解剖图像,有助于经鼻-蝶窦垂体瘤手术方案的制定和术中蝶窦和鞍底的定位.鼻-耳轮线可作为经鼻-蝶窦垂体瘤手术路径的体表定位.     

数字化鞍区肿瘤模型的构建及在手术规划中的应用

目的 采用虚拟现实技术构建数字化鞍区肿瘤模型,并探讨其在手术规划中的应用价值.方法 60例经MRI诊断为鞍区肿瘤的病例,术前行薄层CT、MRI扫描,以DICOM格式导入Dextroscope图像工作站,进行模型构建,观测入路相关解剖标志及肿瘤的毗邻关系,模拟手术进程,并与术中图像对照分析.结果 所有数字化模型均清晰显示了肿瘤、瘤周血管、骨质、视神经、脑组织等结构的形态及其毗邻关系,可随意观测手术径路各解剖结构;根据肿瘤的特点成功模拟了手术入路,制定了手术规划方案,术前模拟与术中实际情况一致.结论 所建模型图像逼真、立体感强烈,可为术者提供额外的三维立体解剖信息,是常规临床手术规划的有效补充;使用虚拟器械可在模型上重复模拟手术操作,是青年医师学习鞍区解剖和手术的便利工具.     

螺旋CT三维血管成像在脑膜瘤外科治疗中的应用

目的探讨螺旋CT三维血管成像（3D-CTA）对脑膜瘤及其周围组织的显示能力，评价其在外科治疗中的价值。方法脑膜瘤患者32例，所有病例均行CT平扫和增强扫描。图像送至AW工作站进行多平面重建（MPR）、最大密度投影（MIP）、容积再现（VR）、表面遮蔽法（SSD）后处理观察。结果重建图像显示瘤体充分强化，颅骨、血管、肿瘤三者立体关系显示清楚，主要的征象包括血管被肿瘤包绕，颅骨受侵犯，肿瘤周围组织移位等。结论3D-CTA可以充分显示脑膜瘤的影像特征，使血管充分强化，重建后可清楚显示肿瘤、血管及其与邻近组织的关系，有助于脑膜瘤的诊断及治疗方案的制订，评估手术风险。     

基于颅脑CT与MRI多模图像融合的3D打印模型制作及应用研究

目的研究基于颅脑CT与MRI图像融合的3D打印技术,制作颅脑三维虚拟模型及实体模型,探讨其在临床工作中的意义。方法利用1例小脑幕脑膜瘤患者颅脑CTA、MRI扫描所得的DICOM数据,CT图像分割重建颅骨、血管、头皮模型,MRI图像分割重建脑组织、肿瘤、脑室系统、头皮模型,以头皮模型为基准进行配准融合,完成复合三维虚拟模型的构建,优化处理后经3D打印技术制作实体模型,并邀请15名神经外科医师对模型进行独立评分。结果制作出高逼真度等比例的颅脑实体模型,问卷调查所有问题的平均分均4分。结论利用颅脑CT与MRI图像融合及3D打印技术制作的三维虚拟模型及其实体模型,对神经外科医师的疾病认识与手术应用、医患沟通、临床培训等方面有重要意义。     

三维CT血管造影在颅内动脉瘤诊断和治疗中的应用

目的评价三维CT血管造影（3D-CTA）在颅内动脉瘤破裂后蛛网膜下腔出血诊断中的价值及其对手术的指导意义。方法对136例蛛网膜下腔出血患者行螺旋CT检查，将数据输入工作站行图像三维重建。对其中95例行数字减影血管造影术（DSA）检查，41例直接手术证实。结果3D-CTA显示了瘤体的大小、方向，以及与载瘤动脉、邻近血管及骨质结构的相互关系；经手术、DSA证实本组3D-CTA对动脉瘤的诊断准确率为98．4％。假阳性率为1．6％，假阴性率为0。结论3D．CTA对颅内动脉瘤是一种无创、快速、高准确率的诊断技术；3D—CTA可显示各部位动脉瘤与载瘤动脉、邻近动脉分支及邻近颅骨的空间关系，对选择手术入路和手术方式有较大的帮助。     

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.     

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.     

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.