3D-CTA模拟翼点入路在基层医院急诊破裂颅内动脉瘤夹闭术中的应用

目的探讨3D-CTA模拟翼点入路在基层医院急诊破裂颅内动脉瘤夹闭术中的临床意义。方法选取2016年12月至2019年12月我院收治的破裂颅内动脉瘤患者40例,患者入院后均急诊完成头颅CT平扫及头颈部CTA检查,数据重建后行术前翼点入路模拟并与术中显微镜下图像对比,以指导手术。结果结合头颅CT平扫,均准确判断出责任动脉瘤,术前3D-CTA模拟翼点入路,与术中显微镜下现实入路情况相符。术中两者对比并调整至一致,具有导航功能,对手术辅助作用大。本组40例患者经手术治疗并随访3月,90%预后良好。结论通过急诊CT及3D-CTA技术,可在最短时间内使术者了解颅内出血及颅内动脉瘤的相关信息并指导手术,提高了基层医院急诊颅内动脉瘤夹闭术的成功率,并改善患者的预后。     

非优势供血侧翼点入路手术夹闭前交通动脉瘤(附12例报告)

目的研究经非优势供血侧翼点入路手术夹闭前交通动脉瘤的疗效和安全性。方法在前交通动脉瘤患者中术前经三维DSA(3D-DSA)研究前交通动脉复合体的局部解剖,模拟两侧翼点入路对前交通动脉复合体和动脉瘤的显露,12例选择非优势供血的一侧翼点入路手术获得对动脉瘤和复合体的满意显露。结果 12例前交通动脉瘤均顺利夹闭,动脉瘤和前交通动脉复合体显露满意,夹闭动脉瘤方便、顺利、安全,夹闭后均切开动脉瘤确认夹闭可靠。11例痊愈,1例需要生活护理。结论术前通过在3D-DSA上模拟翼点入路,选择暴露动脉瘤和前交通动脉复合体最清楚、夹闭动脉瘤最方便的一侧为手术入路。这种入路仍能获得良好的近端控制,且夹闭动脉瘤方便、安全。     

3D-DSA、CTA在颅内动脉瘤个体化锁孔手术中的应用价值

目的 探讨三维数字减影血管造影(3D-DSA)、多排螺旋CT血管成像(CTA)技术对锁孔手术治疗颅内动脉瘤的应用价值.方法 福建医科大学附属第一医院神经外科自2007年4月至2009年6月应用3D-DSA、CTA技术分析动脉瘤的影像学特征,个体化设计锁孔手术并治疗颅内动脉瘤患者175例(192个动脉瘤),其中眶上锁孔人路38例(40个动脉瘤),翼点锁孔入路132例(146个动脉瘤),额锁孔纵裂入路3例(4个动脉瘤),颞下锁孔入路2例(2个动脉瘤),分析3D-DSA、CTA在颅内动脉瘤锁孔手术策略中的应用与意义.结果 本组患者均一次性成功完成手术,其中动脉瘤夹闭188个,动脉瘤包裹4个.术后复查DSA或CTA显示动脉瘤均夹闭满意.GOS评分显示术后良好165例,轻残6例,重残2例,死亡2例.结论 3D-DSA、CTA可清晰显示颅内动脉瘤三维形态特征,为个体化的锁孔手术入路设计提供依据,是手术成功的前提.     

30例颅内前循环动脉瘤开颅夹闭术体会

目的 总结颅内前循环动脉瘤开颅夹闭术经验。方法 回顾性分析2017年5月至2019年5月收治的30例颅内前循环动脉瘤的临床资料,均采用改良翼点入路或扩大翼点入路开颅夹闭术治疗。结果 30例中,27例夹闭满意,1例大脑中动脉动脉瘤夹闭术后大脑中动脉M2下干闭塞引起偏瘫,1例大脑中动脉动脉瘤夹闭术后3个月后并发脑积水行脑室-腹腔分流,1例死亡。出院时改良Rankin量表评分0~2分27例,3~6分3例。术后6个月,按GOS评分:4~5分26例,3分2例,2分1例,1分1例。结论 对于颅内前循环动脉瘤,良翼点入路或扩大翼点入路,暴露充分、术式成熟、并发症少,术中合理选择动脉瘤夹及血管穿通支的保护尤其重要     

颅内多发动脉瘤的3D-CTA诊断及手术治疗

目的探讨颅内多发动脉瘤的3D-CTA诊断价值和开颅动脉瘤颈夹闭和（或）血管内栓塞治疗效果。方法回顾性分析39例经3D-CTA确诊的颅内多发动脉瘤临床资料,36例采用开颅动脉瘤颈夹闭和/或血管内栓塞治疗,一期单侧翼点入路开颅动脉瘤颈夹闭术18例,双侧翼点或翼点＋前纵裂入路动脉瘤颈夹闭术6例;二期开颅动脉瘤颈夹闭术3例;开颅动脉瘤颈夹闭术＋血管内栓塞术4例;单纯血管内栓塞术5例。手术夹闭动脉瘤颈64个,血管内栓塞14个,11个动脉瘤未予处理。结果39例共发现动脉瘤89个,其中2个动脉瘤30例,3个动脉瘤7例,4个动脉瘤2例;31例术后复查3D-CTA,其中30例显示动脉瘤夹闭良好或完全栓塞,1例动脉瘤颈夹闭不全术后一个月动脉瘤再次破裂出血,再次开颅手术夹闭,痊愈出院,随访3个月至7年,按GOS预后分级,良好29例,轻残5例,重残2例,死亡3例均因动脉瘤再次破裂未处理。结论3D-CTA可靠、快捷、安全,可作为颅内多发动脉瘤的首选诊断方法,开颅动脉瘤颈夹闭和/或血管内栓塞治疗效果良好。     

3D Slicer三维影像重建在颅内动脉瘤夹闭术中的应用

目的 探讨3D Slicer三维影像重建技术在颅内动脉瘤开颅夹闭术中的应用价值。方法 回顾性分析2020年7～9月经翼点入路开颅夹闭术治疗的12例颅内动脉瘤的临床资料。术前利用3D Slicer软件三维重建动脉瘤模型及其周围血管和部分骨性结构,并模拟手术入路,显示手术视野下动脉瘤与毗邻结构的位置关系;术中参考立体模型,寻找动脉瘤并根据解剖结构实时定位,实现精准夹闭。结果 12例均顺利完成三维影像重建,将三维模型与术中所见进行对比,9例正确反映术中真实解剖情况,3例术中对比效果欠佳,小动脉瘤（直径<5 mm）以及小血管重建效果相对较差,但是动脉瘤周围主要血管结构对比一致。12例动脉瘤均顺利实施开颅夹闭术,术中没有出现动脉瘤破裂。术后次日复查颅脑CTA示载瘤动脉通畅,未见新增出血,动脉瘤夹闭良好。术后3个月,复查CTA未见动脉瘤复发;GOS评分5分8例,4分3例,3分1例。结论 3D Slicer三维影像重建制作的颅内动脉瘤三维立体模型,可获得更多的立体解剖信息,加深对病变局部解剖的认识,指导制定手术计划,减少术中动脉瘤破裂的风险,提高手术效果。     

改良翼点入路夹闭颅内前循环动脉瘤87例体会

目的 探讨改良翼点入路显微手术夹闭颅内前循环动脉瘤的效果。方法 回顾性分析2016年1月至2018年1月经改良翼点入路显微手术夹闭治疗的87例颅内前循环动脉瘤的临床资料。结果 术后死亡3例。84例存活病人术后随访1~1.5年,按GOS评分:恢复良好39例,中残27例,重残11例,植物生存7例。结论 改良翼点入路手术夹闭颅内前循环动脉动疗效良好。     

CTA指导破裂的前交通动脉动脉瘤显微夹闭术

目的 探讨CTA在破裂的前交通动脉瘤诊断和治疗中的作用.方法 对26例前交通动脉瘤破裂致自发性SAH患者进行术前CTA检查及CTA手术模拟,26例均行翼点入路开颅夹闭动脉瘤手术,以术前CTA与术中所见进行比较.结果 CTA对前交通动脉瘤的诊断与术中符合率100%,术前CTA与术中所见基本一致.结论 术前CTA检查和手术模拟对成功夹闭破裂的前交通动脉瘤具有较大的应用价值.     

显微镜下经翼点入路夹闭前循环破裂动脉瘤的疗效分析

目的探讨显微镜下经翼点入路治疗颅内前循环动脉瘤的经验。方法采用回顾性分析我院神经外科自2014年2月自2017年10月收治前循环动脉瘤采用显微外科翼点入路颅内动脉瘤患者40例。结果 40例动脉瘤手术均一次性夹闭成功,术后三个月至半年GOS评价预后恢复良好32例,轻残4例、重残3例,死亡1例。结论显微外科翼点入路颅内动脉瘤夹闭术是治疗前循环动脉瘤一种安全、微创、有效的治疗方法。     

显微手术治疗前交通动脉动脉瘤(附115例报道)

目的探讨前交通动脉动脉瘤显微手术治疗的临床效果。方法回顾性分析2009年1月至2016年1月显微手术治疗的115例前交通动脉动脉瘤的临床资料,术前均行3D-CTA(和/或)3D-DSA检查并模拟手术入路,经翼点入路施行动脉瘤夹闭。结果术后随访3个月~3年,按GOS评分评定预后,恢复良好89例,中残18例,重残4例,死亡4例。术后发生严重脑血管痉挛4例,行去骨瓣减压术,其中2例术后3月行颅骨修补术时,GOS评分5分;2例并发脑积水行脑室-腹腔分流术,6月后随访,1例GOS评分4分,1例3分。结论三维影像模拟手术入路可充分了解动脉瘤形态及穿支血管情况,采用翼点入路手术夹闭前交通动脉动脉瘤,可降低并发症发生率,提高病人生存质量。     

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.     

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.