老龄帕金森病手术治疗的体会

目的：介绍微电极引导立体定向手术治疗老龄帕金森病的方法和结果。方法：采用CT/MRI双重影像学定位,术中行微电极记录技术靶点监测,对28例70岁以上老龄帕金森病患者行丘脑腹外侧核、苍白球腹后内侧部射频毁损,其中1例行单侧丘脑腹外侧核毁损术,1例行双侧丘脑腹外侧核毁损术;26例行苍白球腹后内侧部毁损术,其中1例行同期单侧苍白球腹后内侧部及丘脑腹外侧核毁损术,术前及术后12月应用motorUPDRS量表进行评价。结果：2例丘脑腹外侧核毁损术后12月,肢体静止性震颤完全或基本消除,其中1例下颌静止性震颤有明显缓解;26例行苍白球腹后内侧部毁损术,术后静止性震颤、僵直、运动迟缓均有较大改善。结论：微电极引导立体定向手术是治疗老龄帕金森病的有效手段之一。但是仍有可能出现严重的并发症。     

微电极导向选择性PVP核和(或)Vim核毁损术治疗帕金森病

目的：观察应用微电极导向立体定向术对不同靶点进行毁损治疗帕金森病临床疗效。方法：６３例帕金森病患者,进行微电极导向苍白球腹后部（ＰＶＰ核）和（或）丘脑（Ｖｉｍ核）毁损术,分析其术后临床症状的改善情况。结果：不同症状的改善率分别为：僵直９４．５％、震颤９２％、运动迟缓８６．５％、步态７２．７％、平衡６８．８％、关状态７７．９％。术后Ｍｏｔｏｒ ＵＰＤＲＳ积分“关”状态下降６３．４％,“开”状态下降５     

微电极导向颅内同期单侧双靶点毁损术治疗帕金森病的疗效及安全性的分析比较

近年来,以ＣＴ、ＭＲＩ和微电极导向内侧苍白球(Ｇｐｉ)腹后部毁损术已成为帕金森病外科治疗的主流。由于帕金森病临床症状的复杂性和多样性,有时仅靠Ｇｐｉ腹后部毁损术难以全面改善症状,尤其对重度静止性震颤和非帕金森病震颤疗效较差。因此,我们在成功使用多靶点毁损术并积累了一定经验的基础上[1],对合并重度震颤或其它类型震颤的帕金森病患者进行了同期单侧Ｇｐｉ腹后部加丘脑ｖｉｍ核双靶点联合毁损术。为评价其有效性及安全性,我们从1997年10月至1998年12月接受单靶点毁损术的患者中按同一临床标准选取50例,与1999年1～10月接受双靶…     

立体定向苍白球毁损术对难治性帕金森病的疗效观察

目的：探讨“难治性”帕金森病的手术治疗效果。方法：对３０例难治性帕金林病患者行立体定向苍白球毁损术治疗,观察术前术后对药物反应情况和症状改善程度。结果：苍白球毁损术对“难治性”帕金森病患者的僵直改善率为９２．０％,对运动迟缓改善率为８７．５％,对震颤改善率为７５．０％。Ｈｏｅｈｎ－Ｙａｈｒ分级显著改善。结论：苍白球毁损术对治疗“难治性”帕金森病有良好的治疗效果。     

帕金森病的定向手术适应证

目的 确定各类帕金森病的定向手术适应证。方法 回顾分析1478例帕金森病定向手术，对手术后的手术疗效和某些相关并发症进行评估，进而推断各类帕金森病的定向手术适应证。结果 苍白球毁损术对服用左旋多巴类药物有效的震颤患者均有效，服用左旋多巴类药物震颤无效的患者，苍白球毁损术的手术疗效效果很差，单侧丘脑Vim核毁损术对震颤改善极佳，96.9%的患者彻底消失，同期同侧苍白球＋兵脑Vim核毁损术对震颤改善极佳，96.9%的患者彻底消失，同期同侧苍白球＋丘脑Vim核毁损术的患者震颤改善率为96.3%，苍白球毁损术对僵直、运动迟缓的疗效也显示出与左旋多巴服药的反应的规律性，服药效果好的手术效果好，但是，与震颤不同的是，服药无效的也有一定的疗效。启动不能患者，其手术效果都不佳，流涎、吞咽困难发生率在单侧苍折球毁损术患者中较低，乏力发生率较高，分期双侧苍白球毁损术中患者年龄较大的较易发生乏力、流涎、吞咽困难。结论 我们的临床实践认为左旋多巴类药物服药反应是一个非常重要的判定指标，僵直、运动迟缓、药物引起的“开－关”、异动症服药有效的患者，苍白球毁损术的效果较好；震颤则有所不同，凡是左旋多巴不能完全控制的，采用苍白球＋丘脑Vim核毁损术则手术效果非常满意，启动不能患者手术应该极其慎重，手术的帮助不大。我们不主张同期双侧苍白球毁损术，分期双侧苍白球毁损术也要慎重。     

两种(核团)毁损术治疗帕金森病的疗效比较

目的 研究丘脑腹中间核（Vim核）毁损术与苍白球腹后内侧核（PVP）毁损术在治疗帕金森病（PD）的临床效果、术后反应及并发症。方法 回顾性分析我院从2000～2005年完成立体定向毁损术220例，行单侧Vim核毁损术125例（一组），PVP毁损术（二组）95例，对其两组临床效果、术后反应、并发症及头颅MRI扫描进行比较研究。结果两组术式手术有效率：Vim核124例（99．2％），PVP93例（97．9％）；术后反应：Vim核19例（15．2％），PVP7例（7．4％）；手术并发症：Vim核22例（17．6％），PVP2例（2．1％）。结论 帕金森病（PD）定向毁损术应根据震颤型、僵直型和运动不能型选择丘脑或／和苍白球毁损术，苍白球毁损术术后反应及并发症较丘脑毁损术明显减少，有显著差异。     

微电极引导的苍白球腹后部毁损术与中医药治疗帕金森病的对比研究

目的 :通过微电极引导的苍白球腹后部毁损术和中医药疗法治疗帕金森病的对比研究 ,探讨手术疗法和中医药疗法各自的疗效特点和治疗适应证。方法 :应用微电极引导的苍白球腹后部毁损术治疗帕金森病 34例 ,手术包括同期双侧、分期双侧和单侧手术。针刺配合中药治疗帕金森病 5 6例。Webster帕金森病功能障碍记分法评分 ,将治疗前后和两组之间治疗结果进行对比。结果 :手术治疗组 34例帕金森病病人中 ,有 33例患者在手术过程中震颤、僵直、运动迟缓等主要症状均有不同程度的缓解 ,手术后这些症状也持续好转 ,但其症状缓解程度在不同的病人中有所不同。Webster帕金森病功能障碍记分法评分 ,术后 1周进步率为 5 0 %～ 99%者 2 6例 ,1%～ 49%者 7例 ,<1%者 1例 ,总有效率 97%。中医药治疗组 80 %以上的患者治疗一个月后主观症状改善 ,主要体征好转 ,基本生活能力得到提高。治疗 3个月后Webster帕金森病功能障碍记分法评分 ,进步率为 5 0 %～ 99%者 6例 ,1%～ 49%者 39例 ,<1%者 11例 ,总有效率为 80 4%。两组患者治疗前、后评分结果进行t检验 ,P <0 0 1,两组之间治疗结果的总有效率进行 χ2 检验校正 ,P <0 0 5。结论 :微电极引导的苍白球腹后部毁损术和中医药治疗帕金森病均可取得较为满意的疗效。手术组对     

微电极导向苍白球腹后部毁损术治疗帕金森病的初步报道

目的 :探讨苍白球腹后部毁损术 (PVP)治疗帕金森病 (PD)的手术方法及疗效。方法 :采用坐标定位结合MRI图象定位 ,在微电极导向下 ,完成对 6例病人单侧苍白球腹后部 (Gpi)的定位 ,并实施毁损。结果 :6例患者的震颤、僵硬及运动迟缓均得到明显改善 ,UPDRS运动部分积分下降 ,无永久并发症。结论 :坐标结合 MRI图象法能准确定位 Gpi,微电极记录是其必要的补充 ,PVP能全面改善 PD患者的症状 ,是一种安全有效的方法。     

丘脑底核慢性电刺激与苍白球毁损术治疗帕金森病疗效比较

目的分别应用脑深部电刺激(deepbrainstimulation,DBS)和苍白球毁损术(posteroventralpallidot-omy,PVP)治疗原发性帕金森病(Parkinson'sdisease,PD),对照研究DBS和PVP对PD患者的震颤、肢体僵硬、运动迟缓的疗效。方法应用CT影像学与微电极电生理定位结合的方法进行靶点定位,为11例帕金森病患者进行同期双侧丘脑底核电极植入,26例患者进行分期双侧苍白球腹后部毁损术,经过至少6个月的随访并行UPDRS评分。结果11例同期进行双侧丘脑底核电极植入及26例分期进行双侧苍白球毁腹后部毁损术患者术后的震颤、肢体僵硬、运动迟缓症状均不同程度的改善,但以DBS手术的改善程度更为明显,两组患者手术前后的UPDRS评分下降程度差异显著(P<0.05)。结论双侧同期DBS是目前治疗PD相对较好的方法,双侧电极植入在改善肢体症状的同时可以明显控制、改善中轴症状,在治疗中晚期PD患者方面较PVP有较大的优势。     

帕金森病毁损术治疗的手术方式选择与疗效关系

目的：总结帕金森病（PD）苍白球和丘脑毁损术的手术方式选择与手术效果关系。方法：对213例PD患者进行了221次微电极导向立体定向手术治疗。临床分型;震颤型17例,僵直型38例,震颤僵直型158例,其中苍白球腹后部毁损术（PVP）171例;丘脑腹中间核（Vim)毁损术21例;同期同侧PVP和Vim毁损术8例;同期双侧PVP5例,分期双侧PVP8例。结果：术后UPDRS评分发现上述各种术式在“关”状态下和“开”状态下症状均有明显改善。改善率分别为50.8%-60.8%和28.7-36.6%,但以多靶点毁损术为佳。同期双侧PVP发生明显构音障碍,吞咽困难1例,结论：应根据不同症状选择不同术式,PVP对僵直、“开-关”现象、异动症,肢体无力及肌肉酸痛效果较好,震颤效果略微差一些,对运动迟缓、连带动作、语言发音也有一定改善率,但对平衡,步态及姿势等轴性症状效果较差。甚至个别症人术后步态障碍加重。Vim毁损术对震颤效果最为理想,同期双侧PVP手术易产生并发症,应慎重采用。     

Denervation study of synapses of organ of corti of old world monkeys

Fine structural characteristics of synapses in the spiral organ of Corti were examined, with reference to differences between inner and outer haircell systems, and to location of neurons of origin of efferent axons. Surgical interruption of crossed olivocochlear bundle, of vestibular nerve, of facial nerve, and excision of superior cervical ganglia were used to determine the pathways of efferent axons. Interruption of the vestibular nerve near the brainstem results in degeneration of all efferent terminals on outer hair cells. Mid-line lesions at, and caudal to, the facial colliculus result in degeneration of about half of these efferent terminals. Efferent synaptic bulbs to the inner hair-cell system are small, of the order of one micron, and form type 2 junctions with afferent dendrites. They tend to have more large dense-core vesicles (about 80 nm) than the large efferent terminals of the outer hair-cell system, and appear to be the terminals of axons in the habenula perforata, which exhibit varicosities laden with large dense core vesicles. The varicosities are unaffected by excision of the superior cervical ganglia. So far as our material can reveal, it appears that the varicosities in the habenula perforata do not survive vestibular root interruption, nor do the efferent processes in the internal spiral bundle or at the base of inner hair cells. Most interestingly, the afferent processes of the inner hair-cell system, as identified for example by their relation to pre-synaptic bodies in the inner hair cells, are subject to a trans-synaptic reaction after severance of the vestibular root. They undergo a dramatic cytological transformation, characterized by increase of volume, engorgement with microtubules, microfilaments, microvesicles of various sizes, and clusters of lysosomes. Thus, both the efferent and afferent terminals of the inner hair-cell system show marked cytological differences from the corresponding terminals of the outer hair cell system.     

Mechanism of action of tubocurarine on nicotinic cholinoreceptors of neurons of the sympathetic ganglia of rats

Tubocurarine (Tc) effect on membrane currents elicited by acetylcholine (ACh) was studied in isolated superior cervical ganglion neurons of rat using patch-clamp method in the whole-cell recording mode. The "use-dependent" block of ACh current by Tc was revealed in the experiments with ACh applications, indicating that Tc blocked the channels opened by ACh. Mean lifetime of Tc-open channel complex, tau, was found to be 9.8 +/- 0.5 s (n = 7) at -50 mV and 20-24 degrees C. tau exponentially increased with membrane hyperpolarization (e-fold change in tau corresponded to the membrane potential shift by 61 mV). Inhibition of the ACh-induced current by Tc (3-30 microM/1) was completely abolished by membrane depolarization to the level of 80-100 mV. Inhibition of ACh-induced current was augmented at increased ACh doses. It is concluded that the open channel block produced by Tc is likely to be the only mechanism for Tc action on nicotinic acetylcholine receptors in superior cervical ganglion neurons of rat.     

The effect of age of onset of PD on risk of dementia

Background Dementia occurs in the majority of patients with Parkinson’s disease (PD). Late onset of PD has been reported to be associated with a higher risk for dementia. However, age at onset (AAO) and age at baseline assessment are often correlated. The aim of this study was to explore whether AAO of PD symptoms is a risk factor for dementia independent of the general effect of age. Methods Two community-based studies of PD in New York (n = 281) and Rogaland county, Norway (n = 227) and two population-based groups of healthy elderly from New York (n = 180) and Odense, Denmark (n = 2414) were followed prospectively for 3–4 years and assessed for dementia according to DSM-IIIR. All PD and control cases underwent neurological examination and were followed with neurological and neuropsychological assessments. We used Cox proportional hazards regression based on three different time scales to explore the effect of AAO of PD on risk of dementia, adjusting for age at baseline and other demographic and clinical variables. Findings In both PD groups and in the pooled analyses, there was a significant effect of age at baseline assessment on the time to develop dementia, but there was no effect of AAO independent of age itself. Consistent with these results, there was no increased relative effect of age on the time to develop dementia in PD cases compared with controls. Interpretation This study shows that it is the general effect of age, rather than AAO that is associated with incident dementia in subjects with PD. Received in revised form: 22 December 2005     

Limits of deinstitutionalization--perspectives of relatives of psychiatric patients

After a hopeful beginning, the social process of the reintegration of those with severe mental illness has come to a standstill. I am led to wonder whether "the community" really wants to live together with people suffering from severe mental illness, and if so, how closely? As long as the medical treatment of mental illness provided by the general practitioners is fundamentally deficient, as they are not able to prescribe the necessary interventions--such as out-patient psychiatric nursing, and service providers in the out-patient sector are content with offering increasingly intensive forms of care for the less seriously ill at the cost of the Social Welfare System--the reintegration of those with serious mental illness remains an illusion--which is mainly to the benefit of providers of residential care in homes and hostels.