静态功能磁共振分析方法在脑胶质瘤术前语言皮质定位中的初步应用

目的 探讨静态功能磁共振(rsfMRI)分析方法在脑胶质瘤术前语言皮质定位中的应用价值.方法 12例主侧半球脑胶质瘤患者行术前rsfMRI,结合语言任务态血氧饱和依赖功能磁共振成像(BOLD fMRI)定位脑语言皮质,采用唤醒开颅结合术中皮质电刺激验证rsfMRI定位语言皮质的敏感性.结果 12例成功行rsfMRI扫描,10例配合完成语言BOLD fMRI扫描.12例唤醒开颅成功,每例各定位1～7个皮质语言阳性位点,共46个.其中22个语言阳性位点在rsfMRI上显示,其显示语言区的敏感度为47.8％(22/46,12例),13个语言阳性位点在语言BOLD fMRI上表现为激活,敏感度为35.1％(13/37,10例).结论 rsfMRI有助于脑胶质瘤术前语言区定位,但其敏感性有待提高.     

应用术中直接电刺激最大安全切除功能区胶质瘤

目的 探讨直接电刺激在功能区胶质瘤手术中应用的意义.方法 回顾性分析157例大脑功能区胶质瘤术中直接电刺激的临床资料.结果 皮质电刺激4例阴性刺激,139例刺激出运动区皮质,21例感觉区,91例出现语言相关区皮质.数数中断的阳性区主要位于左中央前回下方、左额下回盖部、左额下回三角部、左额中回后部和额上回后部.术后MRI示胶质瘤全切92例(58.6％),次全切55例,部分切除10例.术后53例出现短暂肢体运动障碍;39例出现短暂语言功能障碍,4例(2.5％)出现永久性神经功能障碍.结论 术中直接电刺激是一种可靠元创的脑功能区定位方法,在胶质瘤手术中应用此技术可达到最大安全切除肿瘤,同时为国人功能区脑皮质定位提供帮助.     

皮质电刺激对颞叶癫病人颞后感觉性语言中枢和致灶关系的评估价值

目的探讨皮质电刺激对颞叶癫病人颞后感觉性语言中枢和致灶关系的评估价值。方法对15例致灶可能与语言区毗邻的颞叶癫病人,行左颞后颅内电极植入,并进行皮质电刺激完成致灶定位。选择与病人智力水平相适应的语言作业,所有病人于术中唤醒下行致灶切除。结果所有病人均能通过皮质电刺激确定感觉性语言区的精确位置。致灶和感觉性语言中枢相离11例,相切2例,相交2例。随访15例,时间21~36个月;根据Engel分级:Ⅰ级8例,Ⅱ级4例,Ⅲ级2例,Ⅳ级1例。术后语言障碍2例,部分恢复1例,无改变1例。结论感觉性语言中枢有明显的个体差异。皮质电刺激能够客观评估感觉性语言中枢的位置,据此判断其与致灶的关系,是一种有效和可靠的评估手段。     

脑功能区胶质瘤的现代手术策略

目的 探讨切除脑功能区胶质瘤手术新技术与方法.方法 112例胶质瘤患者在术中全麻唤醒状态下,通过术中B超或神经导航定位病灶,直接电刺激定位脑功能区结构,并在清醒状态下切除病变.术后随访时间3～84个月.结果 107例唤醒良好,术中有99例定位出运动区,61例定位出语言相关的功能区皮质,18例定位出感觉区.病变全切6...     

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。     

术中唤醒直接电刺激在运动区胶质瘤切除术中的应用

目的探讨术中唤醒直接电刺激在运动区胶质瘤切除术中的应用效果。方法回顾性分析2015年3月至2017年7月南部战区总医院神经外科收治的34例位于运动区胶质瘤患者的临床资料。其中肿瘤位于左侧16例,右侧18例;肿瘤位于辅助运动区或运动前区23例,中央叶9例,从辅助运动区或运动前区侵袭到中央叶2例。患者均采用全身麻醉术中唤醒技术,神经导航和(或)术中超声定位病变位置,直接电刺激定位皮质和皮质下重要功能区,按照功能边界切除胶质瘤。患者术后均行神经功能和肿瘤切除程度的评估。结果34例患者中,有24例术中直接皮质电刺激后出现运动反应,13例有异常感觉,10例定位出语言相关皮质。皮质下电刺激有24例出现运动反应,1例有异常感觉,8例语言紊乱。共有30例(88.2%)肿瘤切除达到功能边界,另外4例(11.8%)皮质下电刺激未发现功能纤维,均为高级别胶质瘤患者。34例患者术后48 h内复查头颅MRI显示,肿瘤全切除22例(64.7%),次全切除9例(26.5%),部分切除3例(8.8%)。34例患者的随访时间为(23.6±8.6)个月(11.3~39.3个月),其中29例(85.3%)术后早期新发神经功能障碍或原有神经功能障碍加重;发生晚期神经功能障碍较术前加重者3例(8.8%),其中轻度1例、中度1例、重度1例(2.9%)。术前存在神经功能障碍或颅内压增高的16例患者中,术后3个月有13例神经功能好转,2例维持在术前状态,1例为重度神经功能障碍。结论术中唤醒状态下直接电刺激定位和持续监测运动区皮质和皮质下白质纤维,可最大程度地安全切除运动区胶质瘤,其远期重度神经功能障碍的发生率较低,术后生命质量提高。     

术中直接皮质电刺激在功能区胶质瘤手术中的应用

目的探讨直接电刺激在脑功能区胶质瘤手术中的应用方法和临床意义。方法对2003年1月-2012年1月接受大脑功能区胶质瘤手术中行功能区直接电刺激的157例患者的临床资料进行回顾总结。结果术中经皮质电刺激4例呈阴性,其余153例分别刺激出运动功能区皮质(139例)、感觉功能区皮质(21例)和语言相关功能区皮质(91例);计数中断阳性区域主要位于左侧中央前回下方、额下回盖部、额下回三角部、额中回后部和额上回后部。术后MRI显示全切除92例(58.60%)、次全切除55例(35.03%)、部分切除10例(6.37%)。术后病理证实:低级别胶质瘤共110例(70.06%),包括星形细胞瘤71例、少突胶质细胞瘤26例和少突星形细胞瘤13例;高级别胶质瘤47例(29.94%),分别为胶质母细胞瘤19例、间变性星形细胞瘤15例和间变性少突胶质细胞瘤13例。术后53例(33.76%)出现短暂性肢体运动障碍、39例(24.84%)出现短暂性语言功能障碍,仅4例(2.55%)发生永久性神经功能障碍。结论皮质电刺激技术是一种可靠无创的脑功能区定位方法,用于脑胶质瘤外科手术可最大程度并安全切除肿瘤。     

胶质细胞瘤术中功能组织定位技术

大脑功能组织指与语言、运动和感觉功能密切相关的皮质和皮质下通路.胶质瘤术中功能组织定位术(techniques for functional brain mapping during glioma surgery)是脑皮质电刺激技术、电生理监测技术和功能磁共振技术在胶质瘤手术中综合应用而形成的专门技术.近年来,美国加州大学旧金山分校的Berger和华盛顿大学的Ojemann为代表的一批学者在该技术的发展和完善方面做了大量的基础研究工作和临床实践.该技术在最大程度切除胶质瘤的同时尽可能保留肿瘤附近的功能组织,避免术后失语、偏瘫和感觉异常,控制肿瘤性癫痫,延长胶质瘤患者术后生存时间,提高患者手术后生活质量等方面有重要作用.在欧美国家,该技术已成为胶质瘤手术中的必要步骤,国内尚少报道,本文作一简要介绍.     

脑功能区胶质瘤的手术策略

目的探讨唤醒麻醉状态下切除脑功能区胶质瘤的手术方法及意义。方法13例脑功能区胶质瘤经神经导航病灶定位术中唤醒麻醉,皮层诱发电位及皮层电刺激定位脑功能区,在清醒状态下切除脑功能区病变。结果全部病例均在术中获得安全可靠的麻醉唤醒,清醒状态下脑功能区的定位和最大限度地肿瘤切除,其中6例获得皮层体感诱发电位检测确定中央沟;9例经皮质刺激术明确运动区;4例通过皮质刺激术基本确定语言运动中枢。肿瘤全切11例,次全切除2例。术后出现暂时性神经功能障碍或功能障碍加重有11例,神经功能完全恢复正常10例。1例术中出现癫痫发作,1例在唤醒过程中出现一过性脑肿胀;全部患者术后无痛苦回忆。结论对脑功能区胶质瘤运用唤醒麻醉,神经导航病灶定位,皮层电刺激和皮层诱发电位定位脑功能区技术能较为可靠地明确脑功能区与肿瘤切除范围的关系,在清醒状态下切除肿瘤实时监测脑功能状态,能够最大限度地切除脑功能区病变和最大程度地保护脑功能。     

fMRI功能导航下切除汉语运动性语言区附近病变

目的探讨功能磁共振(functional magnetic resonance imaging,fMRI)导航在汉语运动性语言区附近病变手术中的应用价值。方法对43例大脑皮层运动性语言区附近病变患者,通过组块设计的汉语朗读任务,利用血氧水平依赖性功能磁共振成像(BOLD-fMRI)获得运动性语言区激活,利用磁共振弥散张量成像技术(diffusion tensori maging,DTI)获得白质纤维束走行,将结构影像、fMRI功能影像与DTI的各项异性系数(FA)图像同时传入导航系统,术中定位fMRI确定的语言区,在唤醒状态利用皮层电刺激技术进行语言区验证,避开运动性语言区在显微镜下切除病变。结果本组患者29例术前语言功能正常,14例有不同程度语言功能障碍。38例获得了有效的fM-RI语言区激活,进行了36例核心激活脑区与皮层电刺激比较:25例为重叠关系,11例为邻近关系。手术全切除17例,次全切除14例,大部份切除12例。术后语言功能8例较术前好转,31例无变化,4例出现短暂性运动性失语。结论汉语朗读任务所获得的fMRI运动性语言区激活具有良好的敏感性与准确性;fMRI导航手术可以提高汉语运动性语言区附近病变切除程度,减少术后运动性失语的发生。     

Mechanisms of the suppression of the nociceptive reflex of the opening of the mouth during stimulation of the structures of the limbic brain

The comparative effectiveness of the inhibitory influence of tetanic stimulation of hypothalamus, amygdala and limbic cortex on EMG-response of m. digastricus evoked by electrical stimulation of tooth pulp nociceptive afferents was studied in cats anesthetized with a mixture of chloralose and nembutal. It was found that inhibition of the EMG-component of the jaw-opening reflex is most pronounced in case of stimulation of medial and lateral region of the hypothalamus, the inhibitory effect of central and medial nuclei of the amygdala is less pronounced and the effect of the limbic cortex is the weakest. It was shown that the mechanism of the antinociceptive effect of tetanic stimulation of the hypothalamus is not related to the concomitant increase of the blood pressure. After stabilization of the blood pressure the suppressive effect of the hypothalamus remains without changes, that points out to a direct, primary, not baro-afferent mechanism of the inhibition of the activity of nociceptive neurons of the trigeminal sensory nuclei. Noradrenaline, injected intravenously, induced a large increase of the blood pressure accompanied by a pronounced inhibition of the pain reflex. Angiotensin causes the same degree of blood pressure elevation without changes in the amplitude of the EMG-response of the pain reflex. Hypothalamic and noradrenergic mechanisms for control of pain sensitivity are discussed.     

药物治疗与合并认知行为治疗对强迫症疗效的比较

目的探讨认知行为心理治疗(CBT)在强迫症(OCD)患者各亚型治疗中的有效性和规律性。方法本研究为临床对照研究。符合入组标准的强迫症患者按患者自愿原则分为两组,治疗观察3、6、12个月。疗效评定分别运用Yale-Brown强迫量表,自拟的自评好转程度量表和临床疗效评定。结果认知行为心理治疗合并药物治疗组31例,临床有效率70.9%,其中治愈率1.8%。单纯药物治疗组24例,临床有效率33.3%。Yale-Brown强迫量表和自评量表得分在6个月和12个月两组有显著差异(P<0.05)。其中强迫症亚型(怕脏型、反复检查型和反复担心型)的疗效比较,怕脏型在治疗3个月末两组间自评量表评分有显著性差异(P<0.05);反复担心型在治疗6个月末两组间Yale-Brown强迫量表总分有显著性差异(P<0.05);反复检查型两组间无统计学差异。结论认知行为心理治疗合并药物治疗强迫症的疗效明显优于单纯药物治疗。强迫症的亚型在治疗中的有效性次序为:反复担心型>怕脏型>反复检查型。     

Characteristics of the sympathetic innervation of the nictitating membrane and of the vasculature of the nose and tongue of the cat

Summary Vasomotor responses from the nasal mucosa and tongue, and contractions of the nictitating membrane, were recorded on stimulation of the cervical sympathetic or internal carotid nerves.Preganglionic sympathetic nerve fibres which elicited a membrane response possessed a lower threshold than those which evoked nasal vasoconstriction, while the latter displayed a lower threshold than fibres which evoked tongue vasoconstriction. The sympathetic vasodilator fibres to the tongue, whose activity was revealed after-receptor blockade, had a similar threshold to the vasoconstrictor fibres.Membrane contraction, nasal vasoconstriction and occasionally tongue vasoconstriction could be evoked by stimulating the internal carotid nerve. The postganglionic fibres innervating the nasal mucosa had a similar threshold to those of the nictitating membrane, which may indicate that there are small myelinated fibres innervating the mucosa.The preganglionic compound nerve action potential had four major components, S₁–S₄. S₁, S₂ and usually S₃ fibres were associated with membrane contraction; S₂, S₃ and sometimes S₁ fibres were associated with nasal vasoconstriction; and S₃, usually S₂ and occasionally S₁ fibres were associated with vasoconstriction in the tongue. It is concluded that each of these three groups of nerve fibres, but not S₄ fibres, may include fibres associated functionally with the three effectors.There was a considerable difference between the relative amplitude of the responses of the three effectors elicited by stimulation of the cervical sympathetic nerve at frequencies between 0.2 and 2 Hz. Vasoconstrictor responses were relatively larger than membrane contractions suggesting differences in the mechanisms of neurotransmission at the neuroeffector junctions.     

Development of the projection from the nucleus of the brachium of the inferior colliculus to the superior colliculus in the ferret

Neurons in the deeper layers of the superior colliculus (SC) have spatially tuned receptive fields that are arranged to form a map of auditory space. The spatial tuning of these neurons emerges gradually in an experience-dependent manner after the onset of hearing, but the relative contributions of peripheral and central factors in this process of maturation are unknown. We have studied the postnatal development of the projection to the ferret SC from the nucleus of the brachium of the inferior colliculus (nBIC), its main source of auditory input, to determine whether the emergence of auditory map topography can be attributed to anatomical rewiring of this projection. The pattern of retrograde labeling produced by injections of fluorescent microspheres in the SC on postnatal day (P) 0 and just after the age of hearing onset (P29), showed that the nBIC-SC projection is topographically organized in the rostrocaudal axis, along which sound azimuth is represented, from birth. Injections of biotinylated dextran amine-fluorescein into the nBIC at different ages (P30, 60, and 90) labeled axons with numerous terminals and en passant boutons throughout the deeper layers of the SC. This labeling covered the entire mediolateral extent of the SC, but, in keeping with the pattern of retrograde labeling following microsphere injections in the SC, was more restricted rostrocaudally. No systematic changes were observed with age. The stability of the nBIC-SC projection over this period suggests that developmental changes in auditory spatial tuning involve other processes, rather than a gross refinement of the projection from the nBIC.     

A contribution to the study of the architecture of the autonomic nervous system of the digestive tract of the rat

Summary The distribution of aminergic and non-aminergic nerve fibres to the different constituents of the wall of the digestive tract in various regions is described. Aminergic fibres synapse with all nervous perikarya. Densely interlacing networks of nerve fibres are found in both layers of the tunica muscularis and in the lamina muscularis mucosae. A finely meshed plexus is observed in relation to the wall of the blood vessels in the wall of the gut. There are many fibres connecting the muscular and the vascular plexus. No nerve fibres have been observed in direct relation to the epithelium.The functional implications of these findings are discussed.