MRI导向立体定向活检手术在颅内疑难病例诊断中的应用

目的 探讨MRI导向立体定向活检手术的准确性及其在颅内疑难病例诊断中的应用价值。方法 安装CRW立体定向框架,采用MRI容积扫描与多层重建技术,对26例临床表现不典型或CT扫描不能发现明确病灶的患者施行立体定向脑活检手术。结果 26例患者均未出现因活检手术而造成的出血、偏瘫等严重并发症。所有患者均得到明确的病理诊断及相应的治疗。结论 MRI导向立体定向活检手术在准确性上明显优于CT导向活检手术;对于颅内疑难病例的诊断,也是一种有效的手段。     

立体定向脑内病灶活检的临床意义

目的 探讨先进图像引导立体定向脑组织活检术方法 ,明确其在神经系统疾病诊断中的意义.方法 回顾性分析1987年12月至2009年1月立体定向脑内病灶活检的1187例病历资料,其中男性694例(58.5%),女性493例(41.5%);年龄1～85岁(平均39.7岁).CT(含正电子发射断层扫描)引导活检607例,MRI(含氢质子磁共振波谱成像)引导活检580例;采用常规框架立体定向活检手术726例,采用无框架立体定向机器人活检手术461例(含定向引导神经内镜活检).早期450例立体定向手术定位,采用CT或MRI图像测量靶点坐标方法 ,不能立体显示穿刺途径;后期737例立体定向手术定位,采用计算机三维重建病灶方法 ,能够立体显示穿刺路径.结果 活检明确组织病理学诊断1156例(活检阳性诊断率97.4%).本组中983例(82.8%)获得肿瘤学病理诊断,主要包括神经胶质瘤、转移性肿瘤、原发性淋巴瘤、生殖细胞瘤等;173例(14.6%)为非肿瘤性病变,其中包括多发硬化和瘤样脱髓鞘病变、神经变性疾病、炎性病变、寄生虫病等.活检穿刺手术并发少量血肿(<10 ml)而无神经功能障碍20例(1.7%),较大血肿(>10ml)需要外科处理(置管引流或开颅血肿清除)9例(0.8%);活检出血导致死亡3例(0.3%).本组无颅内感染病例.结论 先进影像技术引导的立体定向脑组织活检术是一种微侵袭、可靠的脑内疾病确定诊断手段.生化成像、功能成像技术的发展,为立体定向引导的活检技术赋予了崭新的内容.     

微电极导向立体定向手术治疗帕金森病应用

目的 评价微电极导向立体定向脑内核团毁损术和脑深部电刺激(Deep brain stimulation，DBS)治疗帕金森病的临床疗效。方法 1999年4月～2003年3月采用微电极导向立体定向毁损手术治疗帕金森病510例(毁损手术组)和DBS治疗帕金森病30例(电刺激组)。毁损手术组中行单侧苍白球腹后部毁损术(Posteroventral pallidotomy，PVP)385例，丘脑腹中间核(Ventral intermedius，Vim)毁损术9l例，行同期同侧PVP和Vim毁损术12例，同期双侧PVP8例，分期双侧PVP10例，分期一侧PVP、另一侧Vim毁损术4例。电刺激组中，刺激靶点为丘脑底核(Subthalamic nucleus，STN)29例和Viml例，其中单侧18例，双侧12例。结果 毁损手术组术后UPDRS运动评分，在“关”状态下，症状改善率为47．3％，在“开”状态下症状改善率38．7％。开一关症状和异动症均消失。220例随访平均11．6月，其中显效130例(59．1％)，改善75例(34．1％)，无效15例(6．8％)。电刺激组术后在“关”状态下UPDRS运动评分改善率45．2％。在“开”状态下改善率25．7％，30例随访平均10．3月，其中18例于1月内调整参数后再无调整参数，12例术后需再次调整参数。结论 对伴震颤的帕金森病苍白球损毁术较丘脑损毁术更有效。脑深部电刺激能有效控制病人的运动症状。     

痉挛性脑瘫患儿SPR术后的功能康复

脑性瘫痪(CP)是指出生前到出生后1个月发育时期内非进行性脑损伤所致的综合征,主要为中枢性运动障碍,姿势异常。按照临床表现可分为痉挛型、手足搐动型、强制型、共济失调型、震颤型、肌张力低下型和混合型。其中痉挛型占2/3,此型最适合手术治疗。我院2000年6月~2002年6月对85例脑瘫患儿实行了SPR手术治疗,我们对此组患儿心功能锻炼进行了早期干预,纠正其异常活动姿势,通过对患儿1~2年的,随访收到良好的效果。报告如下:1临床资料1.1对象:2000年6月~2002年6月我院对诊断符合1998年全国小儿脑瘫座谈会诊断标准的85例痉挛型脑瘫患儿实行SPR…     

CT立体定向术脑组织活检的护理

我院自1987～1989年应用本院放射科设计制造的WL-86型CT立体定向仪,对32例脑部病变患者进行了脑组织活检术,其中8例为CT立体定向引导纤维导管脑内窥镜活检。现将手术前后护理体会报告如下: 一、临床资料患者32例,男18例,女14例,年龄6～72岁。病变部位:脑叶深部19例,丘脑、鞍区、脑于旁等部位13例。二、术前护理1.做好术前准备:①完成血常规及出、凝血时间等检查;②做好手术前备皮;③CT立体定向仪及内窥镜严格消毒后备用;④准备鲁米那、安定等     

胚胎中脑黑质脑内移植治疗帕金森病长期随访观察

本文报告膝用胚胎中脑黑质细胞脑仙移植治疗６例晚期帕金森病，包括１例脑立体定向丘脑毁损后震颤复发者，经移植治疗后治疗良好效果。本组病例韦氏计分平均从２１份降至１１分。其中２例经术后３，９，１４个ＣＴ，ＭＲＩ随访，脑内移植物体积增大，症状和体征明显改善。     

帕金森病外科治疗研究进展

帕金森病是以运动障碍为主要表现的神经退行性疾病,药物治疗以缓解运动症状为核心。外科治疗始于立体定向技术的应用,以核团毁损术与脑深部电刺激术为主要术式。帕金森病外科治疗可以部分改善临床症状,但不能延缓疾病进展。目前基于神经营养因子及神经递质替代的基因治疗方法正在研究中,它可能是帕金森病治疗较有前景的治疗方案。该文就帕金森病脑深部电刺激术及基因治疗的研究进展予以综述。     

乳腺钼靶立体定位手术活检在TO乳腺癌诊断中的应用

目的 探讨乳腺钼靶立体定位手术活检技术在T0乳腺癌诊断中的价值。方法 利用乳腺钼靶立体定位手术活检技术，对22例乳腺隐匿性可疑病变进行立体定位手术活检。结果 22例隐匿性可疑病变均一次性准确定位，切除完整，诊断准确率100％；其中9例乳腺癌，2例导管内乳头状瘤，11例小叶增生。结论 乳腺钼靶立体定位手术活检技术，定位准确，诊断明确；能确定乳腺隐匿性病变的性质。     

双侧丘脑底核脑深部刺激治疗帕金森病

目的 探讨双侧脑深部刺激(Deep brain stimulation，DBS)系统治疗帕金森病(Parkinson’s disease，PD)的手术方法和效果。方法 对13例具有双侧症状的帕金森病进行同期双侧丘脑底核双通道DBS治疗。术中采用磁共振扫描结合微电极记录技术进行靶点定位。术后用UPDRS运动评分评价刺激效果。结果 13例PD术后随访3月—3年，平均6．3月。脉冲发生器开启时，在“关”状态下，UPDRS运动评分症状平均改善率62．3％，其中对左旋多巴类药物反应敏感改善率达75．5％；在“开”状态下，UPDRS运动评分症状改善率24．2％。未发现任何并发症。结论 双侧丘脑底核脑深部刺激治疗可明显改善PD患运动功能。     

脑立体定向术治疗难治性精神分裂症患者的观察与护理

目的探讨脑立体定向杏仁核毁损术(下称脑立体定向术)治疗难治性精神分裂症的围术期护理。方法对采用脑立体定向术治疗的72例难治性精神分裂症患者进行观察及护理,评价疗效。结果优5例,显进28例,进步35例,无效4例。患者妄想、冲动伤人、毁物等症状改善明显。术后并发颅内出血1例,脑水肿3例,脑脊液漏2例,均在细心观察和精心护理下1~2周内恢复。结论脑立体定向术是目前治疗难治性精神分裂症效果较好且创伤小的手术,手术后有效的观察护理是预防并发症、提高疗效的关键。     

Significance of Papillary Lesions at Percutaneous Breast Biopsy

Background The management of nonpalpable papillary lesions found in specimens obtained by percutaneous breast biopsy is controversial. We reviewed the treatment of patients found to have papillary lesions by stereotactic, sonographic, or fine-needle aspiration breast biopsy to identify indications for surgical excision. Methods Consecutive patients with intraductal papilloma, atypical papilloma/papilloma with atypical ductal hyperplasia, papillary neoplasm, and papillomatosis according to percutaneous breast biopsy were identified from radiology records. The charts were reviewed to identify patients who had subsequent surgical excision, and the pathologic findings were correlated with the biopsy method and indications for surgery. Results Papillary lesions were found in 120 biopsy samples from 109 patients. Malignancy was found at operation in 19 (24%) of 80 lesions that underwent surgical excision: 12 (63%) were ductal carcinoma-in-situ, 4 (21%) were infiltrating ductal carcinoma, 2 (11%) were infiltrating papillary carcinoma, and 1 (5%) was intracystic papillary carcinoma. Malignancy was found in 9 (30%) of 30 fine-needle biopsy papillary lesions, 6 (35%) of 17 core biopsy papillary lesions, and 4 (12%) of 33 stereotactic biopsy papillary lesions. Malignancy was missed significantly less frequently with stereotactic biopsy (P < .05). Conclusions Malignancy is frequently found at surgical excision for papillary lesions found on percutaneous breast biopsy. Malignancy is missed significantly less frequently with stereotactic biopsy.     

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??Stereotactic guided mammotome biopsies in diagnosis of suspicious breast microcalcifications LEI Yu-tao*, HOU Kuan-yong, LIU Yi,et al.*General Suregery, Peking University Third Hospital, Beijing 100191??China Corresponding author??LEI Yu-tao??E-mail??leiyt@vip.sina.com Abstract Objective To evaluate the clinical application of stereotactic guided Mammotome biopsy in the diagnosis of breast microcalcifications. Methods During November, 2007 and December, 2008, we diagnosed and treated 21 patients with 29 untouched calcification lesions, aged 28 to 67 with an average of 46.6. Excision or biopsy of the lesions was performed using Mammotome biopsy under stereotactic guidance, and then all cases were followed up in 1-9 months. Results 29 lesions from 21 patients were excised with stereotactic guided Mammotome biopsy. 15 lesions completely removed appeared as clustered calcifications in diameter <1cm. 5 lesions in 4 patients were diagnosed as DCIS, the others were showed to be hyperplasia, in which 7 lesions appeared as fibrocystic hyperplasia, 3 lesions accompany with varying degrees of ductal epithelial hyperplasia, and 1 lesion with papilloma formation. 1 patient after operation appeared hematoma at the puncture site, which absorbed naturally after 2 weeks.. In the follow-up study, 4 patients undergoing mastectomy appeared without recurrence, and others show no signs of malignancy. Conclusion Stereotactic guided Mammotome biopsy is position fixed accurately and minimally invasive to breast surgery, especially suitable for breast microcalcification.     

Movement disorders following nonfunctional neurosurgery

OBJECT: Knowledge is scarce about movement disorders that follow neurosurgical operations other than functional stereotactic surgery. The cases of 14 patients who suffered from movement disorders secondary to craniocerebral or spinal surgery are analyzed. None of these patients was initially treated by any of the authors. METHODS: Twelve patients underwent surgery for cerebral diseases. Nine of these patients harbored tumors and three patients had neurovascular disorders. Two patients underwent spinal surgery for cervicothoracic ependymoma or for multiple cervical disc herniations. Twelve of the 14 patients had immediate postoperative side effects such as hemiparesis, ataxia, and somnolence. In all but two patients, movement disorders became manifest only after a delay. Dystonic movement disorders developed in eight patients, unilateral tremors in three patients, unilateral facial myokymia in one patient, and hemichorea-hemiballism in two patients. The mean delay of onset for tremor was 5 weeks and that for dystonic movement disorders was 5.5 months. Movement disorders were transient in three patients; however, they were persistent in 11 patients at a mean follow-up period of 5 years. These movement disorders caused marked persistent disability in four patients. Lesions of the contralateral striatum were identified in patients with dystonic syndromes and lesions of the dentatothalamic outflow in patients with tremors. In three patients who had postoperative basal ganglia lesions after partial removal of astrocytomas, tumor regrowth was later documented. Medical treatment in patients with persistent movement disorders rendered only limited benefit. Two patients improved with botulin injections. In one patient postoperative hemidystonia was alleviated by contralateral thalamotomy. CONCLUSIONS: Dystonic syndromes and tremors are the most common movement disorders that occur after craniocerebral and spinal surgery. Postoperative movement disorders can lead to various degrees of functional disability. The pathoanatomical correlations are similar to those described in other patients with secondary movement disorders.     

Stereotactic biopsy for intracranial lesions: reliability and its impact on the planning of treatment

Background. The authors present a retrospective analysis of 308 computed tomography (CT)-guided stereotactic biopsies in 300 patients in order to evaluate the reliability and efficacy of the stereotactic biopsy for intracranial lesions. Method. All patients were suffering from undetermined intracranial lesions and treated at Seoul National University Hospital between January 1993 and December 1999. Age ranged from three to 79 years (mean 41); the male to female ratio was 180:120. All patients underwent CT-guided stereotactic biopsy for the histological verification and/or evacuation of the cyst using Riechert-Mundinger stereotactic system®. Findings. Histological diagnosis was made in 275 patients (diagnostic yield 91.7%). Diagnostic yield was better in group with frozen section examination during the stereotactic procedure than the group without it (p=0.01). Neoplastic lesions were more likely to be diagnosed in stereotactic biospy than non-neoplastic lesions (p=0.02). Among 30 patients who underwent craniotomy after the stereotactic biopsy, the histological diagnoses after the craniotomy were identical to those of the stereotactic biospy in 29 patients (diagnostic accuracy 96.7%). Two patients died within seven days after the stereotactic biopsy (mortality 0.6%). The postoperative new neurological deficit or aggravation of the neurological status was found in 19 patients, including transient cases of seven patients (permanent morbidity rate 3.9%). Histologically malignant gliomas and deeply-located lesions were the significant risk factors for the development of complications. In 148 cases, histological diagnosis of the stereotactic biopsy was different from the preoperative clinical diagnosis. Among these cases, the treatment plan was changed after stereotactic biopsy in 81 cases. Conclusions. Stereotactic biopsy for intracranial lesions is a reliable and relatively safe procedure. It is also a very efficacious method especially in patients who need histological confirmation for the treatment.Published online July 25, 2003     

立体定位Mammotome穿刺活检诊断乳房可疑恶性钙化的研究

目的探讨钼靶立体定位麦默通手术在乳房钙化灶诊断中的应用。方法收集2007年11月至2008年12月北京大学第三医院院收治的21例未触及乳房肿物的乳房钙化灶病例,年龄28～67岁,平均46.6岁。行钼靶立体定位麦默通穿刺活检手术。结果共切除乳房钙化灶29个。其中15个病灶为局限性簇状钙化灶,直径≤1cm,15个局限性钙化灶均完整切除。4例病人5个病灶病理证实为导管内癌,其余24个病灶病理证实为乳腺增生症,7个病灶表现为纤维囊性增生,有3个病灶伴有不同程度的导管上皮增生,1例伴有乳头状瘤形成。术后1例发生了穿刺部位血肿,自然吸收。全部病例均得到随访,平均9个月,4例乳腺癌病人行乳房切除,无复发,其余17例穿刺部位无肿块及陈旧血肿,3例复查钼靶未见可疑恶性征象。结论钼靶立体定位引导麦默通穿刺手术诊断乳房钙化灶,准确、微创、安全。     

Stereotactic interstitial radiosurgery for cerebral metastases

OBJECT: The Photon Radiosurgery System (PRS) is a miniature x-ray generator that can stereotactically irradiate intracranial tumors by using low-energy photons. Treatment with the PRS typically occurs in conjunction with stereotactic biopsy, thereby providing diagnosis and treatment in one procedure. The authors review the treatment of patients with brain metastases with the aid of the PRS and discuss the indications, advantages, and limitations of this technique. METHODS: Clinical characteristics, treatment parameters, neuroimaging-confirmed outcome, and survival were reviewed in all patients with histologically verified brain metastases who were treated with the PRS at the Massachusetts General Hospital between December 1992 and November 2000. Local control of lesions was defined as either stabilization or diminution in the size of the treated tumor as confirmed by Gd-enhanced magnetic resonance imaging. Between December 1992 and November 2000, 72 intracranial metastatic lesions in 60 patients were treated with the PRS. Primary tumors included lung (33 patients), melanoma (15 patients), renal cell (five patients), breast (two patients), esophageal (two patients), colon (one patient), and Merkle cell (one patient) cancers, and malignant fibrous histiocytoma (one patient). Supratentorial metastases were distributed throughout the cerebrum, with only one cerebellar metastasis. The lesions ranged in diameter from 6 to 40 mm and were treated with a minimal peripheral dose of 16 Gy (range 10-20 Gy). At the last follow-up examination (median 6 months), local disease control had been achieved in 48 (81%) of 59 tumors. An actuarial analysis demonstrated that the survival rates at 6 and 12 months were 63 and 34%, respectively. Patients with a single brain metastasis survived a mean of 11 months. Complications included four patients with postoperative seizures, three with symptomatic cerebral edema, two with hemorrhagic events, and three with symptomatic radiation necrosis requiring surgery. CONCLUSIONS: Stereotactic interstitial radiosurgery performed using the PRS can obtain local control of cerebral metastases at rates that are comparable to those achieved through open resection and external stereotactic radiosurgery. The major advantage of using the PRS is that effective treatment can be accomplished at the time of stereotactic biopsy.     

Stereotactic biopsy and resection of thalamic astrocytomas

In this study of 72 patients who had histologically verified thalamic astrocytomas, 44 patients underwent stereotactic serial biopsy, 22 underwent stereotactic resection of the neoplasm, and an additional 6 patients underwent stereotactic biopsy followed by stereotactic resection of the tumor at a later date. Of the 50 patients who underwent stereotactic biopsy, 3 were neurologically worse after the procedure (morbidity, 6%), and 3 additional patients with Grade 4 astrocytomas who preoperatively were rapidly deteriorating neurologically, died within 30 days of the procedure. Of the 28 patients who underwent stereotactic resection, 14 were neurologically improved after the procedure, 10 were unchanged, and 4 were worse. One additional patient died 10 days postoperatively. Thirty-four patients had Grade 4 astrocytomas: 27 underwent stereotactic biopsies. The mean survival after biopsy and irradiation for patients with Grade 4 astrocytomas was 21.4 weeks. The mean survival was 62 weeks in 7 patients with Grade 4 astrocytomas who underwent stereotactic resection and radiation therapy. The mean survival time after biopsy and radiation therapy for patients who had Grade 3 and Grade 2 lesions was 54.4 weeks and 91 weeks, respectively. Twenty-three patients had pilocytic astrocytomas; 8 underwent stereotactic biopsies, and 19 underwent stereotactic resection of the tumor (4 of these underwent biopsy prior to resection). There was no neurological morbidity, but one patient died after resection. Many of those who underwent resection were deteriorating due to an enlarging tumor mass or recurring cyst, and had undergone more conservative therapies such as biopsy and radiation. Even though stereotactic biopsy is appropriate in many patients harboring thalamic astrocytomas, selected patients with significant mass effect from solid tumor or recurring cyst can benefit from stereotactic resection.     

Stereotactic biopsy for intracranial space-occupying lesions: clinical analysis of 550 cases.

OBJECT: To investigate the role of stereotactic biopsy in planning the optimal management of intracranial space-occupying lesions. PATIENTS AND METHODS: Between December 1989 and December 1999, stereotactic biopsy was performed in 550 patients with intracranial mass lesions that were deep-seated or located in the functional area. There were 340 males and 210 females, and their ages ranged from 4 to 75 years. All the procedures were done under local anesthesia with a Leksell stereotactic system. A CT scan was used to determine the coordinates in the first 420 cases and the Aero Tech Stereotactic Surgical Plan System in the subsequent 130 patients. RESULTS: Brain tumors were diagnosed pathologically in 475 patients (86.4%), inflammatory process in 44 (8.0%), other lesions in 12 (2.2%) and no conclusive diagnosis was found in 19 (3.4%). The overall positive rate of biopsy was 96.6%, and the positive rate for brain tumor was 86.4%. Intracranial hematomas after biopsy were found in 13 cases (2.4%). Seizures occurred during the operation in 7 cases (1.2%), and slight and transient neurological deficits were found in 23 cases (4.2%). There were no deaths or other serious complications. CONCLUSIONS: The results suggest that the stereotactic biopsy is a reliable method to obtain histopathological diagnosis of intracranial mass lesions, and it is also of great help in selecting the appropriate management.     

Independent predictors of morbidity after image-guided stereotactic brain biopsy: a risk assessment of 270 cases

OBJECT: Image-guided stereotactic brain biopsy is associated with transient and permanent incidences of morbidity in 9 and 4.5% of patients, respectively. The goal of this study was to perform a critical analysis of risk factors predictive of an enhanced operative risk in frame-based and frameless stereotactic brain biopsy. METHODS: The authors reviewed the clinical and neuroimaging records of 270 patients who underwent consecutive frame-based and frameless image-guided stereotactic brain biopsies. The association between preoperative variables and biopsy-related morbidity was assessed by performing a multivariate logistic regression analysis. Transient and permanent stereotactic biopsy-related morbidity was observed in 23 (9%) and 13 (5%) patients, respectively. A hematoma occurred at the biopsy site in 25 patients (9%); 10 patients (4%) were symptomatic. Diabetes mellitus (odds ratio [OR] 3.73, 95% confidence interval [CI] 1.37-10.17, p = 0.01), thalamic lesions (OR 4.06, 95% CI 1.63-10.11, p = 0.002), and basal ganglia lesions (OR 3.29, 95% CI 1.05-10.25, p = 0.04) were in'dependent risk factors for morbidity. In diabetic patients, a serum level of glucose that was greater than 200 mg/dl on the day of biopsy had a 100% positive predictive value and a glucose level lower than 200 mg/dl on the same day had a 95% negative predictive value for biopsy-related morbidity. Pontine biopsy was not a risk factor for morbidity. Only two (4%) of 45 patients who had epilepsy before the biopsy experienced seizures postoperatively. The creation of more than one needle trajectory increased the incidence of neurological deficits from 17 to 44% when associated with the treatment of deep lesions (those in the basal ganglia or thalamus; p = 0.05), but was not associated with morbidity when associated with the treatment of cortex lesions. CONCLUSIONS: Basal ganglia lesions, thalamic lesions, and patients with diabetes were independent risk factors for biopsy-associated morbidity. Hyperglycemia on the day of biopsy predicted morbidity in the diabetic population. Epilepsy did not predispose to biopsy-associated seizure. For deep-seated lesions, increasing the number of biopsy samples along an established track rather than performing a second trajectory may minimize the incidence of morbidity. Close perioperative observation of glucose levels may be warranted.