神经内镜第三脑室造瘘术治疗梗阻性脑积水

脑积水的治疗在现代神经外科手术中仍然是一大挑战。随着神经内镜技术与神经影像学的发展,使得神经内镜第三脑室造瘘术开展得越来越普遍,已成为一种安全有效的微侵袭技术。自2008年1月至2009年1月,本科采用神经内镜第三脑室造瘘术治疗梗阻性脑积水9例,现报告如下。     

神经内镜与开颅手术治疗高血压脑出血的疗效比较

目的 比较神经内镜手术与开颅手术两种方法治疗高血压脑出血的疗效.方法 回顾性分析2011年5月至2013年6月期间收治的54例接受手术治疗的高血压脑出血患者,将其分为神经内镜治疗组和开颅手术治疗组,其中神经内镜组28例,开颅手术组26例.术后随访3个月以上,观察两组患者的日常生活能力(ADL)评分,ADL评分Ⅰ～Ⅲ级为预后良好,ADL评分Ⅳ～Ⅴ级及死亡患者为预后不良.结果 神经内镜治疗组死亡1例,开颅手术治疗组死亡2例,差异无统计学意义(P＞0.05).ADL评价神经内镜治疗组良好率82.1％ (23/28),开颅手术治疗组53.9％(14/26),神经内镜治疗组疗效优于开颅手术治疗组,差异有统计学意义(P＜0.05).结论 应用神经内镜技术治疗高血压脑出血具有创伤小、疗效好等优点.     

神经内镜辅助下微血管减压术治疗面肌痉挛

微血管减压术(microvascular decompression,MVD)是治疗面肌痉挛最有效的外科治疗方法[1].但桥小脑角(cerebellopontine angle,CPA)区是后颅窝中非常重要的解剖区域,该区域神经及血管密布,由于术者操作不当、显露不良及责任血管复杂等原而影响手术治疗效果,传统的操作技术常可造成小脑肿胀、听力减退或丧失、面瘴、脑脊液漏等并发症.随着神经内镜的不断普及神经内镜辅助下MVD开展得越来越多,使面肌痉挛的治愈率明显提高,并发症发生率和复发率明显降低.     

神经内镜在脑肿瘤治疗中的应用

神经内镜最早在神经外科中的应用是用来治疗脑积水的,之后逐渐发展为治疗颅脑囊性病变犤1犦。随着神经内镜设备的不断发展和完善,以及临床经验的积累和神经内镜颅内解剖研究的深入,其应用范围越来越广。目前,神经内镜在部分颅内肿瘤的治疗中因其微创的特点,正发挥着越来越重要的作用。对于颅内肿瘤尤其是脑室内肿瘤或位于脑室壁周围的肿瘤,经过CT、MRI三维成像定位后,在CT或B超引导下,配合立体定向行神经内镜手术,可对其行活检、切除或置管内放疗。颅内肿瘤的内镜手术包括肿瘤活检和肿瘤切除两种,常需与立体定向技术相结合。内镜立体定…     

神经内镜在幕上高血压性脑出血治疗中的应用进展

正高血压性脑出血占全部脑卒中的10%～30%[1,2],好发于45～65岁中年人,发病后1年存活率为50%,5年存活率仅为29.2%,而且大部分存活者存在严重的神经功能缺失[3]。目前,对于大量幕上高血压性脑出血,手术是重要的治疗方法,手术方式主要有传统骨瓣开颅血肿清除术、置管引流术、神经内镜下血肿清除术等。目前,神经内镜技术越来越受到临床重视。本文就神经内镜技术在高血压性脑出血手术治疗中的最新进展进行综述。1神经内镜手术分类及手术设备Hopf等将神经内镜手术分为:①内镜神经外科     

微侵袭内镜神经外科的现状与展望

内镜在神经外科的应用已有几十年的历史 ,但真正被神经外科医生广泛的接受则仅有十几年。长期以来由于高精密技术限制以及光学技术和生产工艺等因素的影响 ,始终没有能够适用于多种神经外科手术的内镜和配套的设备 ,因此神经内镜的手术多限于三脑室底造瘘和脉络丛烧灼等简单操作。随着高科技的迅速发展 ,越来越多的高清晰度、多用途、灵活便利的神经内镜问世 ,使得微侵袭内镜神经外科得以迅速发展 ,特别是神经内镜与立体定向、导航、超声等结合应用 ,大大拓展了其在神经外科疾病治疗中的应用范围。二十世纪九十年代以来 ,欧、美、日等发达国…     

颅内蛛网膜囊肿研究进展

当前国内外对颅内蛛网膜囊肿(arachnoid cyst,AC)的研究越来越多,但在其发病机制、临床特征、诊断及治疗方法等方面仍存在较多的争议.囊肿的手术指征及手术方式也是目前争论的焦点之一.随着神经内镜技术的引进,越来越多的神经外科医生偏爱于神经内镜手术,但内镜治疗的可靠性即远期疗效仍缺乏长期的大宗的病例随访.AC是脑实质外非肿瘤性的良性病变,约占颅内占位性病变的1%~([1]).随着影像学设备的普遍运用,颅内囊肿的发现率有明显上升趋势.AC常多见于小孩,常因外伤后影像学检查发现,也因囊肿扩大或出血产生临床症状而发现.本文参阅了近几年国外文献研究进展,对AC的发病机制、诊断及治疗方法综述如下.     

神经内镜与显微镜在垂体瘤切除术的应 用简

垂体瘤是临床常见的颅内肿瘤，手术切除是主要的治疗手段，显微镜下和神经内镜下垂体瘤切除术是两种主要手术方式。国内外研究已先后报道神经内镜在垂体瘤治疗的优点，内镜优势已得到更多神经外科医师的认同。至于神经内镜能否完全取代显微镜手术尚有疑问，需进一步探讨。本文对两种术式展开综述．为临床医师在手术方法的选择上提供参考。     

神经内镜辅助显微手术治疗颅内表皮样囊肿

目的:探讨应用神经内镜辅助显微神经外科手术治疗颅内表皮样囊肿的疗效。方法:本组共12例,均为颅内胆脂瘤,手术采用神经内镜辅助显微神经外科手术进行治疗,在显微镜下切除大部分肿瘤后,再用神经内镜进行探查,切除残余肿瘤。结果:术后临床症状、体征均明显改善或消失,均未发生无菌性脑膜炎和迟发性颅内出血等并发症。结论:神经内镜辅助显微手术治疗颅内表皮样囊肿,有助于提高肿瘤全切率,提高手术疗效,降低手术并发症。     

内镜结合锁孔技术在微血管减压术中的应用

目的 探讨神经内镜结合锁孔技术在微血管减压术治疗原发性三叉神经痛中的应用.方法 回顾性分析65例应用神经内镜结合锁孔微血管减压术治疗的原发性三叉神经痛患者的临床资料、手术资料及随访结果.手术方式为经乳突后锁孔入路,并在垫入隔片前后均置入神经内镜行多角度观察.结果 1例用神经内镜探查时发现并存的责任动脉,11例内镜探查后调整隔片位置.65例患者中术后62例(95.4%)疼痛消失,2例(3.1%)疼痛减轻,总有效率98.5%.治疗有效的64例均获得随访,随访时间8～55个月,平均34个月.术后3年内2例复发,复发率3.1%.结论 锁孔技术手术创伤小,能减少术后并发症的发生;应用神经内镜探查能避免遗漏责任血管、协助调整隔片位置,提高手术有效性,降低术后复发率.     

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.     

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.     

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.