TCD动态监测静脉窦血栓形成五例

目的评价静脉窦血栓形成患者经颅多普勒超声(TCD)检测静脉侧枝的开放和再通情况以及颅内压变化。方法用TCD 2MHz探头检测5例静脉窦血栓形成患者的颅内静脉的血流速度以及动脉频谱形态的变化。结果 5例静脉窦血栓形成患者的颅内静脉(大脑中深静脉、基底静脉)的血流速度均明显增高(139cm/s,118 cm/s,99 cm/s,103 cm/s,58cm/s),动脉频谱呈高阻力,经过治疗,随着病情的好转,颅内静脉血流速度下降,颅内动脉频谱由高阻力型恢复正常。结论 TCD能可靠无创、准确地检测颅内静脉,在病程中通过多次的TCD检查,可以评价静脉窦血栓形成静脉侧枝的开放和再通情况以及颅内压变化。     

脑静脉窦血栓血管内治疗的临床分析

目的应用经颈动脉溶栓、静脉窦置管溶栓、静脉窦球囊扩张术和静脉窦支架植入术治疗脑静脉窦血栓,探讨血管内治疗的适应证及疗效。方法分别采用单纯经颈动脉溶栓(方案1)、经颈动脉溶栓并静脉窦置管溶栓(方案2)、经颈动脉溶栓并静脉窦置管溶栓、静脉窦球囊扩张术(方案3)及经颈动脉溶栓并静脉窦置管溶栓、静脉窦支架植入术(方案4)综合治疗104例脑静脉窦血栓患者,观察4种治疗方案的临床疗效。结果治疗后,所有患者脑循环时间均降至<14s,颅内压由治疗前的(350.29±80.12)mmH2O降至(247.92±75.53)mmH2O,组间差异具有统计学意义(t=83.670,P=0.000)。应用改良Rankin量表评价患者预后,0级71例(68.27%),1级26例(25.00%),2级6例(5.77%),3级1例(0.96%),4级0例,5级0例,4种治疗方案组之间差异无统计学意义(Z=13.150,P=0.065)。结论脑静脉窦血栓的血管内治疗安全、有效,经颈动脉溶栓与静脉窦置管溶栓、静脉窦球囊扩张术及静脉窦支架植入术联合应用,可提高治疗慢性、多发性脑静脉窦血栓的疗效。     

单发和多发脑静脉血栓形成的临床特征分析

目的 探讨单发和多发脑静脉血栓形成(CVT)患者的临床特征和短期预后. 方法 总结分析136例CVT患者的血栓部位及受累静脉窦/静脉数目,依受累颅内静脉窦/静脉数目将患者分为单发CVT组和多发CVT组,采用单变量分析比较2组患者的临床特点及预后. 结果 单发CVT组44例,多发CVT组92例(其中累及2个部位45例,3个部位35例,4个部位9例,5个部位3例).最常受累的静脉窦/静脉为横窦/乙状窦(86.8%),其后依次为上矢状窦(58.1%)、直窦(18.4%)、大脑深静脉系统(7.4%)和皮层静脉系统(2.9%).单变量分析显示单发CVT组患者平均发病年龄大于多发CVT组,但短期预后好于多发CVT组,比较差异有统计学意义(P＜0.05);多发CVT组患者出现颅内实质病变及合并颅外静脉血栓的几率高于单发CVT组,同时治疗前颅内压≥300mm H2O的患者比例高于单发CVT组,比较差异有统计学意义(P＜0.05). 结论 CVT中以多发CVT所占比例较高,最容易受累的部位为横窦/乙状窦和上矢状窦.与单发CVT相比,多发CVT患者颅内压较高,多合并颅外静脉血栓,出现静脉性脑梗死和脑出血的几率较高,临床病情重,预后相对较差.     

经颈动脉溶栓治疗脑静脉窦血栓的影像学及组织病理学研究

目的观察经颈动脉溶栓治疗兔脑静脉窦血栓的影像学及组织病理学变化,以为临床应用提供依据。方法39只新西兰兔随机分为对照组(15只)、抗凝组(12只)和溶栓组(12只),建立兔脑静脉窦血栓模型,施行经颈动脉溶栓治疗。脑血管造影检查计算脑循环时间,免疫组织化学检测和血管分析方法检测CD31表达水平,并计数微血管密度。结果经颈动脉溶栓治疗后,溶栓组动物脑循环时间[(4.78±0.54)s]低于抗凝组[(6.75±0.46)s]和对照组[(7.00±0.50)s](均P<0.05);溶栓组动物微血管密度[(4.55±0.20)%]明显高于抗凝组[(3.55±0.23)%]和对照组[(2.28±0.70)%](均P<0.01)。结论经颈动脉溶栓治疗脑静脉窦血栓的临床疗效肯定,即使治疗后静脉窦仍呈闭塞状态,仍可使患者脑循环时间明显下降、微血管密度明显增加。     

脑静脉窦血栓的综合血管内治疗

目的评价综合应用颈动脉溶栓、静脉窦置管溶栓及静脉窦支架置入术治疗脑静脉窦血栓的疗效。方法对我科1997年7月～2005年6月收治的99例脑静脉窦血栓患者进行综合血管内治疗,其中5例患者接受静脉窦置管溶栓合并静脉窦支架置入术(方案1),38例患者接受颈动脉溶栓合并静脉窦置管溶栓(方案2),56例患者接受单纯颈动脉溶栓(方案3),观察3组患者的临床疗效。结果经治疗,99例患者中有94例颅内压降至300 mm H_2O, 75例患者静脉窦实现再通,93例患者循环时间降至11 s以下。结论综合应用颈动脉溶栓、静脉窦置管溶栓及静脉窦支架置入术等方法治疗脑静脉窦血栓是一种安全、有效的手段。     

脑静脉血栓形成诊断和治疗的临床分析

[关键词]脑静脉血栓形成溶栓治疗脑静脉血栓形成(cerebralvenousthrombosis,CVT)是发生在颅内静脉系统包括静脉窦、大脑深、浅静脉一种少见的血栓栓塞性疾病,临床表现多样,易误诊。现对我们救治的22例CVT患者报道如下,并对实施过静脉窦接触溶栓的资料进行分析和文献回顾。1资料1.1一般资料:从南京卒中注册数据库1809例病例中,查询符合CVT诊断的共22例,为2002年9月至2005年3月的住院患者,其中男13例,女9例,年龄16～60岁,平均37.2岁,经MR、磁共振静脉血管成像(magneticresonancevenography,MRV)或数字减影血管造影(digitalsubtractionan…     

单侧静脉窦支架置入治疗特发性颅内压增高症

目的了解静脉窦狭窄在特发性颅内压增高症中所起的作用以及腔内支架治疗的可行性。方法回顾性研究应用静脉窦内支架成形术治疗静脉窦狭窄的特发性颅内压增高症的患者,观察资料包括临床症状、眼底检查、颅内压测定、脑血管造影情况、治疗方法、疗效及安全性。结果研究期间共有7例特发性颅内压增高症患者行逆行脑静脉造影并行静脉窦测压后行静脉窦支架置入术,其中4例伴有头痛,1例伴有鼻漏,术后伴发症状均有改善;7例患者均有视力下降,术后6例视力有所好转,1例术后视力无好转。结论怀疑存在静脉窦狭窄的特发性颅内压增高患者应行逆行脑静脉造影并且静脉窦测压。对于因静脉窦狭窄引起症状的患者,静脉窦内支架置入是一种可供选择的治疗方案。     

慢性粒单核细胞白血病合并颅内静脉系统血栓形成1例报告

颅内静脉系统血栓形成(cerebral venous thrombosis,CVT)是多种原因所致的脑静脉及静脉窦血液回流和脑脊液吸收障碍,导致脑组织瘀血、水肿及颅内压增高等一系列病理生理改变以及相应局灶症状的一组疾病.CVT发病率低,约占所有卒中事件的0.5％～1％.慢性粒单核细胞白血病(chronic myelomonocytic leukemia,CMML)是临床上罕见的慢性髓系白血病,而以白血病为病因的颅内静脉系统血栓形成病例尚未见报道,现将我科收治的1例慢性粒单核细胞白血病合并颅内静脉系统血栓病例报告如下.     

脑静脉系统流出端影像学特征及其与颅内压增高的关系研究

目的 对比观察颅内压增高与正常压力状态下脑静脉系统流出端的影像学特征,描述该段血管汇入静脉窦前的狭窄形成,结合前期实验结果探讨脑静脉系统参与颅内压调节机制中该血管狭窄节段可能的生物学意义及临床应用价值. 方法 选取40例颅内占位性病变(非血管性疾病)致颅内压增高患者为研究对象,10例正常志愿者作为对照组,磁共振静脉血管成像技术扫描成像,获得脑桥静脉及脑内静脉窦原始影像,以最大强度投影进行图像后处理,记录脑桥静脉汇入静脉窦前即两者交界处的影像学特征.并测量不同压力状态下脑桥静脉的直径.结果 颅内高压患者的脑桥静脉直径大于对照组,并且大部分颅内压增高患者(32/40)可出现影像学上脑静脉流出端磁共振信号的减弱甚至消失,形成影像学上的明显狭窄,而正常志愿者中仅有1例出现类似的信号减弱.结论 脑桥静脉作为脑静脉系统的最后通路,在颅内压增高时形成的狭窄结构提示其可能参与脑静脉系统自身体积变化的被动调节,进而对颅内压的调节发挥重要的作用.压力增高时脑桥静脉直径增加也从另外一方面说明该狭窄结构限制了静脉血液向颅外的顺畅引流,导致静脉血液的淤积并进一步增加了颅内压力.     

应用M模-TCD评价脑静脉及静脉窦血栓形成患者深静脉的动力学改变

目的 明确M模经颅多普勒检查（M模-TCD）在评估脑静脉及静脉窦血栓形成（cerebral vein andsinus thrombosis，CVT）患者大脑深静脉动力学改变中的价值。方法 应用M模-TCD（DWL Doppler Box，德国）对4例脑静脉系统血栓形成患者（观察组）及4例年龄及性别匹配的健康志愿者（对照组）的大脑中深静脉（dMCV）进行检测，记录dMCV的峰血流速度及脉动指数。结果 对照组中，dMCV的检出率为75％，平均峰血流速度为（14±2）cm/s；CVT患者中，dMCV的检出率为87.5％，4例患者均检测出一侧或两侧dMCV的峰血流速度的明显增加，平均峰血流速度为（55±25）cm/s。两组峰血流速度的差值具有统计学意义（P <0.01）。结论 对于CVT患者来说，M模-TCD可提供一种可靠、快速的检测深静脉动力学改变的非介入性技术。颅内深静脉血流速度的增加可能为CVT诊断的一个间接标准。     

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.     

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.     

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.     

Special Pharmacokinetic Considerations in Children

Summary: Pediatric patients have greater degrees of pharmacokinetic variability and unpredictability than adults. This variability results from the effects of pharmacogenetics, age and growth, prior and current comedication, and disease. Newborns with seizures have the least predictable dosage requirements, and their needs change as drug-eliminating mechanisms mature in the neonatal period. Infants have the highest relative capacities to eliminate antiepileptics of any age group and require the largest relative doses. In addition to age-related trends, children demonstrate the same drug-specific, pharmacokinetic phenomena that adults do, including nonlinear phenytoin elimination, nonlinear valproate binding, and autoinduction of carbamazepine. Intercurrent illness and drug interactions further modify the age-related pharmacokinetic patterns in children and make dosage requirements even more unpredictable. Recent studies have shown that febrile illness can affect drug elimination, sometimes decreasing drug levels by 50% or more. Intermittent treatment with benzodiazepines administered either orally or rectally can be an important adjunct and help minimize this type of problem for children with marginally controlled epilepsy. Intermittent benzodiazepines are also helpful for children who have febrile seizures and who need only occasional antiepileptic protection.