脊髓电刺激术治疗遗传性脊髓小脑性共济失调1例报道并文献复习

目的 探讨脊髓电刺激术（SCS）治疗遗传性脊髓小脑共济失调（SCA）步态障碍的有效性及可行性。方法 回顾性分析2021年7月SCS治疗的1例6型遗传性SCA(SCA-6型)的临床资料,并结合文献进行复习。结果 成功实施SCS,电极靶点设置在T9～11硬脊膜外间隙,在神经电生理监测下将电极调整至生理中线处。术后复查胸椎CT并三维重建示电极位置满意,术后2周开机行电刺激,制定个体化调控方案。术后1个月,开机状态下,病人步态不稳及平衡障碍明显改善。术后7个月,Tinetti步态与平衡试验量表评分由术前14分提升到24分;Barthel指数由40分提升至80分。术后1年,Tinetti步态与平衡试验量表评分达到25分,Barthel指数提升至85分。结论 我们探索性地将SCS应用于SCA病人,术后病人步态及平衡障碍显著改善。这为步态障碍病人提供了一种可行的、有效的治疗方式。由于目前国内尚无相关报道,这方面的经验尚少,需进一步开展多中心的临床随机对照研究,验证SCS治疗步态障碍的疗效,并探索最佳靶点位置、刺激参数等,以更好地帮助共济失调病人改善症状。     

脊髓电刺激治疗严重意识障碍的临床疗效分析

正随着急救医学和重症监护技术的发展,许多以往无法挽救的急危重症患者得到及时救治,但一些昏迷患者可能会转为植物状态和最小意识状态[1]。福州空军医院神经外科2014年3月至2015年11月应用脊髓电刺激(spinal cord stimulation,SCS)治疗重度意识障碍患者11例并长期随访,探讨术前电生理评估标准及促醒机制。一、对象与方法1.一般资料:男5例,女6例;年龄16~64岁,平均31.5岁。     

无创电/磁刺激治疗颅脑损伤后慢性意识障碍的体会

目的 探讨无创电/磁刺激治疗慢性意识障碍的效果。方法 回顾性分析2019年6月～2021年9月无创电/磁刺激治疗的144例慢性意识障碍的临床资料。常规对症治疗36例（对照组）,正中神经电刺激（MNS）治疗36例（MNS组）,重复经颅磁刺激（rTMS）治疗36例（rTMS组）,MNS联合rTMS治疗36例（MNS+rTMS组）。应用昏迷恢复量表（CRS-R）评估疗效。结果 治疗2周、1个月,无创神经电刺激治疗病人CRS-R评分明显高于对照组（P<0.05）,而且MNS+rTMS组明显高于MNS组和rTMS组（P<0.05）,MNS组和rTMS组之间无统计学差异（P>0.05）。四组治疗后不良事件（肺部感染、癫痫、交感神经兴奋发作）发生率均无统计学差异（P>0.05）。结论 对于慢性意识障碍病人,无创电/磁刺激治疗可改善病人意识状态,联合应用MNS+rTMS的效果更好。     

神经电生理监测下高颈段椎管神经鞘瘤的显微外科治疗

目的探讨高颈段椎管神经鞘瘤在神经电生理监测下显微手术方法及疗效。方法回顾性分析74例高颈段椎管神经鞘瘤的临床资料。椎管内外哑铃状肿瘤35例,椎管内肿瘤39例。结果在神经电生理监测下进行显微手术,肿瘤全切除70例(94.6%),次全切除4例(5.4%)。术后症状完全消失67例(90.5%),症状改善7例(9.5%)。术后均未发生脊髓和神经根损伤并发症,2例病人发生中枢神经系统感染,无死亡。6例失访,68例病人术后随访3个月～4年,2例术后复发(1例再次手术),其他病人恢复良好。结论神经电生理及显微手术技术联合应用显著提高高颈段神经鞘瘤的全切率,最大程度地保护脊髓、神经,减少术后复发及并发症,提高高颈段神经鞘瘤的疗效及安全性。     

中央丘脑脑深部电刺激治疗长期意识障碍的临床研究

目的探讨中央丘脑脑深部电刺激(deep brain stimulation,DBS)治疗长期意识障碍的时机、评估标准和疗效。方法回顾性分析17例采用DBS治疗的长期意识障碍病例资料,其中创伤性颅脑损伤8例,非创伤性颅脑损伤9例。应用临床行为、电生理和PET-CT评估脑干网状结构-丘脑-大脑皮质功能。DBS治疗靶点为中央丘脑。结果病人均临床随访1年。8例创伤性颅脑损伤病人中,有效5例,改善3例;9例非创伤性颅脑损伤病人中,有效3例,改善2例,无效4例;总体有效率为47.1%(8/17)。17例病人DBS治疗1年后,昏迷恢复量表修订版(CRS-R)评分较入院时均有显著提高(P 0.05)。术前PET-CT代谢保留是影响病人预后的重要因素(P 0.05)。结论长期意识障碍病人如果符合临床行为评估、电生理和脑代谢的手术入选标准,DBS可作为治疗意识障碍的有效手段。     

高颈段脊髓电刺激促醒颅脑创伤昏迷一例并文献复习

目的 研究高颈段脊髓电刺激对颅脑创伤昏迷的促醒作用.方法 观察1例重型颅脑创伤患者高颈段脊髓电刺激术后清醒时间、脑电图、诱发电位及脑血流的变化.结果 患者术后2个月逐渐清醒,脑电图逐渐转为正常α节律,诱发电位潜伏期延长逐渐改善,脑血流明显增加.结论 高颈段脊髓电刺激可能通过增加脑血流、恢复正常的神经电生理活动促醒颅脑创伤昏迷患者.

Abstract：

Objective To study the awoking effect of high cervical spinal cord stimulation on comatose patients with traumatic brain injury.Methods Recovery time,electroencephalogram(EEG),evoked patentials,cerebral blood perfusion after cervical spinal cord stimulation in a comatose patient were investigated.Results The patient emerged form conla at 2 months after spinal cord stimulation treatment.EEG gradually turned into a normal(rhythm,evoked potentials latency improved,and cerebral blood perfusion increased significantly.Conclusions High cervical spinal cord stimulation exerts its beneficial effects to comatose patients with traumatic brain injury by increasing cerebral blood perfusion and restoring normal cerebral electrical activity.     

脊髓电刺激治疗复杂区域性疼痛综合征

目的探讨脊髓电刺激术（spinal cord stimulation,SCS）治疗复杂性区域性疼痛综合征（complex regional pain syndrome,CRPS）的有效性。方法回顾性分析4例CRPS病例,其均经脊髓电刺激手术治疗并随访1年以上,采用视觉模拟疼痛评分（VAS）评估疼痛转归。结果病人术后VAS评分平均降低5．4,3例病人疼痛缓解大于50％,无手术并发症。结论SCS能够安全、有效地治疗CRPS。、     

重复经颅磁刺激对慢性意识障碍患者的促醒治疗研究

目的 探讨重复经颅磁刺激（rTMS）调控楔前叶对慢性意识障碍患者意识恢复的影响。方法 选取郑州大学第五附属医院神经外科2020年6月—2021年5月收治的慢性意识障碍患者11例,在常规治疗基础上应用楔前叶10 Hz rTMS治疗,单次刺激时间为14 min,每日2次,持续14 d,共28次。记录rTMS治疗前（T0）、治疗后（T1）及治疗结束后1个月（T2）的昏迷恢复量表修订版（CRS-R）评分;同时记录T0及T1时静息态脑电,分别使用频谱分析及功能连接性分析方法提取不同脑区脑电不同频段的能量及相干性。结果 与T0时相比,CRS-R评分在T1、T2时均提高（P<0.05）;额区alpha频段和顶区beta频段的能量在T1时提高,差异有统计学意义（P<0.05）;额-中央-顶区alpha和beta频段的相干性在T1时增强,差异有统计学意义（P<0.05）。结论 重复经颅磁刺激调控楔前叶能促进慢性意识障碍患者的意识恢复。重复经颅磁刺激调控楔前叶对慢性意识障碍患者静息态脑电产生的积极改变有助于解释意识恢复的神经机制。[国际神经病学神经外科学杂志, 2022, 49(2):5...     

电击伤致脑损害的临床特点及高压氧治疗的作用

目的 探讨电击伤致脑损害的临床特点及高压氧治疗的作用.方法 回顾性分析5例电击伤致脑损害患者的临床资料.结果 5例患者均为交流电击伤,合并高处坠落颅脑外伤1例,合并心跳呼吸骤停经心肺复苏4例.均有意识障碍,其中昏迷2例,格拉斯哥昏迷量表(GCS)评分5～6分,植物状态3例.血清丙氨酸转氨酶、肌酸激酶、乳酸脱氢酶水平升高.4例患者脑电图检查示双侧大脑半球以慢活动为主,伴少量低幅α活动.头颅MRI示双侧大脑皮质和(或)基底节、海马、小脑长T2信号4例；正常1例.经常规和高压氧治疗,到电击伤后6个月时,4例患者意识转清,但遗留认知功能障碍,1例患者处于最小意识状态.结论 电击伤致脑损害的意识障碍程度重,清醒后多有认知功能障碍；高压氧治疗对改善预后有显著效果.     

脑创伤长期意识障碍患者脑干反射表现与清醒结果的关系

目的 探讨脑创伤(TBI)长期意识障碍患者脑干反射(BSR)表现与清醒预后的关系.方法 记录自2010年3月至2011年6月南方医科大学珠江医院神经外科收治的60例重型TBI后意识障碍超过2周患者的BSR表现.以TBI后6个月患者是否清醒为标准,分为清醒组与未清醒组,两组间运用独立样本x2检验筛选出有意义的指标. 结果 60例重型TBI患者6个月内清醒36例,清醒率为60.0％.BSR的异常概率为23.8％,BSR中左侧睫脊反射,左侧垂直性眼前庭反射,双侧瞳孔对光反射以及双侧眼心反射出现阴性的表现在清醒与未清醒组间差异差异有统计学意义(P＜0.05),上述BSR异常时患者的未清醒率较高. 结论 BSR的表现可客观、准确地反映TBI长期意识障碍患者的脑损伤程度并对患者的清醒结果进行预测.     

Medical aspects of the minimally conscious state in children

The minimally conscious state is a condition of severely altered consciousness in which minimal but definite behavioral evidence of self or environmental awareness is demonstrated. This must be established on a reproducible or sustained basis by one or more of four types of behaviors including simple command-following, gestural or verbal ‘yes/no' responses, intelligible verbalizations, or purposeful behaviors. The minimally conscious state can occur in children and usually is due to acquired brain injuries (traumatic and non-traumatic), central nervous system degenerative and neurometabolic disorders or congenital or developmental disorders. It is assumed that the lower limit of the minimally conscious state occurs when patients emerge from a vegetative state. What remains uncertain is how we can assess the upper limits, that is the degree of improvement that indicates that an individual is no longer minimally conscious. It also is unknown if, when and to what extent children can emerge from a minimally conscious state and whether their prognosis is better than children who are vegetative. It is assumed that the minimally conscious state may become ‘permanent' 12 months after traumatic brain injury and 3 months after non-traumatic injury although there have been no studies that have examined this issue. Medical and rehabilitative treatment of children in a minimally conscious state should be provided to maintain comfort, reduce complications, and optimize functional recovery.     

小骨窗微创手术治疗老年高血压脑出血32例的临床分析

目的探讨小骨窗微创手术治疗老年高血压脑出血的临床效果。方法分析32例经小骨窗微创手术治疗的高血压性脑出血老年患者的临床资料。结果按日常生活能力评价（ADL）标准,患者术后3个月,完全恢复日常生活（ADLⅠ级）3例;部分恢复或可独立生活（ADLⅡ级）9例;需人帮助,扶拐可走（ADLⅢ级15例;卧床,有意识（ADLⅣ级）2例,植物生存（ADLⅤ级）1例;死亡2例。结论小骨窗微创手术具有创伤小、安全有效、简单快捷等优点,是治疗笔年人高血压性脑出血比较理想的方法。     

视觉威胁反应在判断严重意识障碍程度的应用

目的用强弱光源作为视觉威胁刺激物,与CRS-R量表中以手指为刺激物的视觉威胁反应进行对比,比较严重意识障碍患者对不同视觉威胁刺激物的敏感性差异;在此基础上研究视觉威胁反应能否作为意识的指标。方法随机选择89例严重意识障碍(DOC)患者,采用The JFK Coma Recovery Scale-Revise(JFK改进的昏迷恢复量表,以下简称CRS-R)对其进行床边测量。对于视觉威胁反应项,分别对患者采取手指、弱光、强光刺激物进行刺激,比较反应的差异。结果植物状态(VS)和最小意识状态(MCS)患者对手指视觉威胁刺激的反应具有显著的差异(P0.001),植物状态和最小意识状态患者对强光视觉威胁刺激的反应具有显著的差异(P0.001)。最小意识障碍患者对手指、强光两种视觉威胁刺激的反应没有显著性的差异(P0.05),植物状态患者对手指、强光两种视觉威胁刺激的反应没有显著性的差异(P0.05)。结论严重意识障碍患者(n=89)对不同刺激物(手指、弱光、强光)的反应无显著性差异;视觉威胁反应(手指和光)能反映意识。     

Bispectral analysis of electroencephalogram signals during recovery from coma: preliminary findings

The aim of this study was to investigate the accuracy of bispectral index (BIS), spectral edge frequency (SEF 95%), total power (TOTPOW) and frontal spontaneous electromyography (F-EMG) in monitoring consciousness in severely brain damaged patients. In 29 patients a total of 106 sedation-free and good quality EEG epochs were correlated with the level of consciousness as assessed by means of the Glasgow Liège Scale (GLS) and the Wessex Head Injury Matrix (WHIM). The strongest correlation with behavioural measures of consciousness was observed with BIS recordings. An empirically defined BIS cut-off value of 50 differentiated unconscious patients (coma or vegetative state) from conscious patients (minimally conscious state or emergence from minimally conscious state) with a sensitivity of 75% and specificity of 75%. These preliminary findings are encouraging in the search for electrophysiological correlates of consciousness in severe acute brain damage.     

Degrees of functional connectome abnormality in disorders of consciousness

Understanding the neuronal basis of disorders of consciousness can help improve the accuracy of their diagnosis, indicate potential targets for therapeutic interventions, and provide insights into the organization of normal conscious information processing. Measurements of brain activity have been used to find associations of the levels of consciousness with brain complexity, topological features of functional connectomes, and disruption of resting‐state networks. However, obtainment of a detailed picture of activity patterns underlying the vegetative state/unresponsive wakefulness syndrome and the minimally conscious state remains a work in progress. We here aimed at finding the aspects of fMRI‐based functional connectivity that differentiate these states from each other and from the normal condition. A group of 22 patients was studied (9 minimally conscious state and 13 vegetative state/unresponsive wakefulness syndrome). Patients were shown to have reduced connectivity in most resting‐state networks and disrupted patterns of relative connection strengths as compared to healthy subjects. Differences between the unresponsive wakefulness syndrome and the minimally conscious state were found in the patterns formed by a relatively small number of strongest positive correlations selected by thresholding. These differences were captured by measures of functional connectivity disruption that integrate area‐specific abnormalities over the whole brain. The results suggest that the strong positive correlations between the functional activities of specific brain areas observed in healthy individuals may be critical for consciousness and be an important target of disruption in disorders of consciousness.     

Residual cognitive function in comatose, vegetative and minimally conscious states

PURPOSE OF REVIEW: The clinical evaluation of cognition in non-communicative severely brain-damaged patients is inherently difficult. In addition to novel behavioural 'consciousness-scales', the role of para-clinical markers of consciousness, such as event related potentials and functional neuroimaging is reviewed. RECENT FINDINGS: New behavioural scales for vegetative and minimally conscious patients have been shown to reduce diagnostic error but regrettably remain underused in clinical routine. Electrophysiological studies have confirmed their role in estimating outcome and possibly cognition. Several recent functional neuroimaging studies have shown residual cortical function in undeniably vegetative patients. This cortical activation, however, seems limited to primary 'low-level' areas and does not imply 'higher-order' integration, considered necessary for conscious perception. Minimally conscious patients show large-scale high-order cerebral activation, apparently dependent upon the emotional relevance of the stimulation. SUMMARY: Careful clinical assessment of putative 'conscious behaviour' in vegetative and minimally conscious patients is the first requirement for their proper diagnosis and management. Complementary functional neuroimaging and electrophysiological studies will have a major impact on future clinical decision making and may guide selective therapeutic options. At present, more experimental evidence and the elucidation of methodological and ethical controversies are awaited prior to their routine clinical use.     

How should functional imaging of patients with disorders of consciousness contribute to their clinical rehabilitation needs?

PURPOSE OF REVIEW: We discuss the problems of evidence-based neurorehabilitation in disorders of consciousness, and recent functional neuroimaging data obtained in the vegetative state and minimally conscious state. RECENT FINDINGS: Published data are insufficient to make recommendations for or against any of the neurorehabilitative treatments in vegetative state and minimally conscious state patients. Electrophysiological and functional imaging studies have been shown to be useful in measuring residual brain function in noncommunicative brain-damaged patients. Despite the fact that such studies could in principle allow an objective quantification of the putative cerebral effect of rehabilitative treatment in the vegetative state and minimally conscious state, they have so far not been used in this context. SUMMARY: Without controlled studies and careful patient selection criteria it will not be possible to evaluate the potential of therapeutic interventions in disorders of consciousness. There also is a need to elucidate the neurophysiological effects of such treatments. Integration of multimodal neuroimaging techniques should eventually improve our ability to disentangle differences in outcome on the basis of underlying mechanisms and better guide our therapeutic options in the challenging patient populations encountered following severe acute brain damage.     

Association of medial prefrontal cortex connectivity with consciousness level and its outcome in patients with acquired brain injury

Medial prefrontal cortex (mPFC) is usually known for participating in virtually all self related processing. However, few have investigated the role of mPFC in modulating conscious awareness. This study aimed to depict the relationship between the mPFC connectivity and the severity and outcome of the disorders of consciousness (DOC) among patients with acquired brain injury. Thirty-four patients with DOC (17 in a minimally conscious state and 17 in an unresponsive wakefulness syndrome/vegetative state) and 11 healthy controls were recruited, underwent clinical assessment and resting-state functional MRI scan, and were further followed up to evaluate recovery outcome using the Glasgow Outcome Scale. The mPFC connectivity was then analyzed, by comparing DOC patients to healthy controls at baseline, and by comparing “recovered consciousness” and “non-recovered consciousness” patients at follow-up, as identified by graph theory. As a result, enhanced mPFC connectivity against weakened posteromedial cortex connectivity was observed in a minimally conscious state, not in an unresponsive wakefulness syndrome/vegetative state. Besides, increased mPFC connectivity was significantly associated with consciousness recovery. In conclusion, the mPFC connectivity could possibly serve as a mark to track the severity and outcome of DOC.     

Neurometabolic coupling in the vegetative and minimally conscious states: preliminary findings

The objective of this study was to determine the integrity of the homoeostatic coupling relationship between neuronal electrical function and cerebral metabolism in the vegetative and minimally conscious states. Ten patients who met recognised diagnostic criteria (six in the vegetative state and four minimally conscious) were investigated using simultaneous electroencephalography and positron emission tomography. It was found that the coupling between neuronal electrical activity and regional glucose metabolism was preserved in all the minimally conscious patients but was absent in all the vegetative state patients. Our preliminary results suggest patients in the vegetative state may endure an impaired coupling relation between neuronal electrical function and cerebral energy metabolism.