显微镜下小骨窗外侧裂入路手术治疗高血压基底节出血43例

目的 探讨显微镜下小骨窗外侧裂入路手术治疗高血压基底节出血的疗效.方法 对43例高血压性基底节区出血(血肿量<60 ml)采用小骨窗开颅经外侧裂入路显微镜下清除血肿.结果 全部病例血肿清除满意,术后24h内复查了解血肿清除情况,35例血肿清除100%,8例血肿清除90%以上.结论 小骨窗开颅经外侧裂入路显微手术具有创伤小,能满意的达到清楚血肿的目的 ,是治疗高血压性基底节区出血(血肿量<60 ml)的有效手术方法之一.     

小骨窗经外侧裂入路手术治疗高血压性基底节区出血并脑疝

目的 探讨小骨窗经外侧裂入路手术治疗高血压性基底节区出血并脑疝的疗效。方法 回顾性分析2013年8月至2016年8月采用小骨窗经外侧裂入路手术治疗的156例高血压性基底节区出血合并脑疝的临床资料。结果 术后24小时复查头颅CT,血肿清除90%以上123例,80%~90% 33例。术后随访6个月至1年,按日常生理能力分级:Ⅰ级33例,Ⅱ级72例,Ⅲ级26例,Ⅳ级10例,Ⅴ级7例,死亡8例。结论 小骨窗经外侧裂入路手术能及时并彻底清除血肿、可靠止血,疗效满意,可提高生存率,改善生存质量,是治疗高血压性基底节脑出血合并脑疝较理想的手术方法。     

小骨窗侧裂入路显微手术治疗高血压性基底节区出血的临床体会

目的 探讨小骨窗侧裂入路显微手术治疗高血压性基底节区出血的临床疗效。方法 2008年3月至2014年4月采用小骨窗侧裂入路显微手术治疗高血压性基底节区出血86例。结果 术后12 h复查头颅CT,34例血肿完全清除,28例残余血肿量<10 m1,22例残余血肿量为10~20 ml。7例术后再出血;死亡6例,病死率为6.98%。80例生存患者术后随访3~6个月,按日常生活活动能力分级评估预后:Ⅰ级14例,Ⅱ级19例,Ⅲ级29例,Ⅳ级12例,V级6例。结论 小骨窗侧裂入路显微手术治疗高血压性基底节区出血,可以提高患者的治愈率,降低病死率。     

小骨窗经侧裂入路显微手术治疗高血压基底节脑出血患者回顾性分析

目的回顾性分析小骨窗经侧裂入路显微手术结合医用胶整复颅骨治疗高血压基底节脑出血的手术要点及疗效。方法选择2010年6月至2014年5月收治的31例高血压基底节脑出血(Hypertensive basal ganglia hemorrhage,HBGH)患者,采用小骨窗经侧裂入路显微手术清除血肿,术毕使用医用胶将颅骨碎片和骨屑黏合复位。结果患者全部存活,血肿清除率达90%以上者26例,70%~90%5例;术后1个月、6个月头颅CT检查显示颅骨外形良好,未见头骨膨出、内陷和脑受压,无皮下积液。术后6个月ADL评分结果为:Ⅰ级11例,Ⅱ级15例,Ⅲ级4例,Ⅳ级1例。结论采用小骨窗经侧裂入路显微手术结合医用胶整复来治疗高血压基底节脑出血,血肿清除率高,患者术后康复较好,并发症少,颅骨外形良好,而且成本低,方法简便,适于在硬件设备相对落后的基层医院使用。     

经侧裂-岛叶入路小骨窗显微手术治疗高血压性基底节区出血

目的 探讨经侧裂-岛叶入路小骨窗显微手术治疗高血压性基底节区出血的临床疗效。方法 选取33例高血压性基底节区脑出血患者,24 h内采用经侧裂-岛叶入路小骨窗显微手术清除血肿。结果 术后24 h内复查头颅CT显示:血肿清除>90% 18例,70%~90%为11例,<70%为4例。术后死亡2例。31例术后随访6个月,恢复良好26例（83.9%;日常生活能力分级Ⅰ~Ⅲ级）,恢复不良5例（16.1%;日常生活能力分级Ⅳ~Ⅴ级）。结论 经侧裂-岛叶入路小骨窗显微手术治疗高血压性基底节区出血,手术路径短,清除血肿彻底,手术并发症少,疗效可靠。     

显微手术外侧裂入路治疗高血压丘脑出血

目的 观察显微手术外侧裂入路显微手术治疗高血压性丘脑出血的疗效.方法 对36例高血压性丘脑出血采用经外侧裂入路小骨窗开颅或去骨瓣减压开颅,显微镜下清除血肿.结果 全部病例血肿清除满意,术后24h内复查了解血肿清除情况,23例血肿清除100%, 6例血肿清除90%以上,7例血肿清除80%以上.结论 外侧裂入路显微手术创伤小,止血可靠,能有效降低颅内压,是治疗高血压性基底节区出血的有效手术方式之一.     

小骨窗经侧裂岛叶入路微创治疗基底节高血压脑出血临床分析

目的 探讨小骨窗经侧裂岛叶入路微创治疗基底节区高血压脑出血的手术要点及疗效.方法 选取我科近年来经CT证实的基底节脑出血,且双瞳孔未散大的患者,行小骨窗经侧裂入路岛叶切开显微镜下清除基底节脑出血.结果 本组中1例死亡,占4.8%;再出血4例,占19.0%;经随访6个月,用日常生活能力( ADL)分级法进行评价,恢复良好率(ADL Ⅰ～Ⅲ级)达90.5%.结论 小骨窗经侧裂入路岛叶切开术具有创伤小、易清除血肿、止血彻底、功能恢复良好等优点.是基底节区脑出血首选的手术方式.     

小骨窗经侧裂岛叶入路血肿清除术治疗基底节高血压性脑出血患者的短期随访研究

目的 分析小骨窗经侧裂岛叶入路血肿清除术治疗基底节高血压性脑出血(HICH)患者的短期随访效果。方法 选取2016年5月-2018年7月本院收治的102例基底节HICH患者,根据手术入路不同分组,各51例; 对照组行小骨窗经颞叶皮质入路手术,观察组行小骨窗经侧裂岛叶入路血肿清除术; 比较2组血肿清除率、手术一般情况(手术时间、术中出血量、住院时间)、格拉斯哥昏迷评分法评分(GCS)、神经元损伤指标[S100B蛋白、神经元特异性烯醇化酶(NSE)]水平、格拉斯哥预后量表分级(GOS)、并发症总发生率。结果 观察组血肿清除率<60%、60%～80%、81%～90%、>90%的患者分别占3.92%、25.49%、33.33%、37.25%,优于对照组的17.65%、50.98%、19.61%、11.76%(P<0.05); 观察组手术时间长于对照组,术中出血量低于对照组(P<0.05); 观察组术后7、14 d GCS评分高于对照组(P<0.05); 观察组术后7、14 d血清S100B蛋白、NSE水平低于对照组(P<0.05); 观察组预后优良率(60.78%)与对照组(56.86%)比较无明显差异(P>0.05); 观察组并发症总发生率(1.96%)与对照组(5.88%)比较无明显差异(P>0.05)。结论 小骨窗经侧裂岛叶入路血肿清除术治疗基底节HICH对脑组织损伤较小,能提高血肿清除率,减少术中出血量,早期改善患者昏迷状态,可作为治疗基底节HICH的一种方法。     

小骨窗开颅血肿清除术与神经内镜下经外侧裂入路血肿清除术治疗高血压脑出血疗效对比

目的 探讨小骨窗开颅血肿清除术与神经内镜下经外侧裂入路血肿清除术治疗高血压脑出血（HICH）患者的疗效及安全性。方法 回顾性分析107例HICH患者资料,小骨窗开颅血肿清除术48例为小骨窗组,神经内镜下经外侧裂入路血肿清除术59例为神经内镜组。对比2组患者手术一般情况以及血肿清除率,比较2组患者术前及术后7 d的预后情况、神经功能缺损情况、血清炎症因子水平以及神经功能指标含量变化,观察并记录2组患者术后并发症。结果 神经内镜组的手术时间、脑脊液恢复时间以及置管时间较小骨窗组均显著缩短（P<0.05）,术中出血量较小骨窗组显著减少（P<0.05）,血肿清除率小骨窗组显著提高（P<0.05）;术后7 d,神经内镜组和小骨窗组的GOS评分较术前均显著提升（P<0.05）,NFDS评分较术前均显著降低（P<0.05）,组间对比差异有统计学意义（P<0.05）;术后7 d,神经内镜组和小骨窗组的血清IL-6水平均较术前显著升高（P<0.05）,但神经内镜组显著低于小骨窗组（P<0.05）;2组血清NSE水平、血清S100蛋白含量相比术前均显著降低（...     

超早期小骨窗经外侧裂-岛叶入路显微手术治疗基底节脑出血

目的探讨超早期小骨窗经外侧裂岛叶入路显微手术治疗高血压性基底节脑出血的疗效。方法回顾性分析47例高血压性基底节脑出血6h内超早期手术,采用小骨窗开颅,显微镜下经外侧裂－岛叶入路,清除血肿。结果血肿完全清除36例,血肿清除〉95％11例。术后按日常生活能力分级法随访3～6个月,Ⅰ级9例,Ⅱ级14例,Ⅲ级15例,Ⅳ级6例,V级3例。结论超早期小骨窗经外侧裂－岛叶入路显微手术治疗高血压性基底节脑出血是一种创伤小的治疗方法。     

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.