经鼻入路显露斜坡区的内镜解剖研究

目的探索内镜下经鼻入路显露斜坡区的可行性,确定相关技术与显露范围。方法选择30具成人颅底标本测量相关解剖数据,选用福尔马林固定的成人尸头5具,灌注后进行解剖,模拟内镜经鼻入路显露斜坡。结果在颅骨标本上测量以下数据:内耳门间距,颈静脉结节间距,颈静脉孔间距以及舌下神经管间距。在尸头标本上测量鼻小柱到咽结节的距离,鼻小柱到枕大孔前缘的距离。采用内镜经鼻入路,可显露后床突至枕大孔前缘,侧方至翼腭窝的广阔区域。结论内镜下经鼻入路显露斜坡区是可行的。     

内镜颅底外科的发 展简

内镜颅底外科起步于20世纪90年代,解剖学特征使内镜颅底外科开始于颅底中线病变的外科治疗。鞍区是最早应用内镜经鼻颅底外科技术的颅底区域,20世纪90年代初,一些学者开始尝试采用单纯内镜经鼻入路切除垂体腺瘤。而后又用于视神经减压和脑脊液鼻漏修补。张秋航等于1998年在国内率先发表内镜经鼻入路切除垂体腺瘤的临床研究。现已延伸至切除鞍内颅咽管瘤、脑膜瘤、囊肿、鞍区恶性肿瘤及空蝶鞍综合征。目前,内镜经鼻入路在欧美发达国家已是垂体腺瘤切除的首选和主流入路。     

颅底脊索瘤的内镜经鼻手术治疗分型及入路

目的 探讨一种适合内镜经鼻手术治疗需要的颅底脊索瘤临床分型及入路选择方法.方法 回顾性分析2007年8月至2012年8月于我院使用内镜经鼻手术治疗的133例颅底脊索瘤病例资料.依据内镜经鼻手术斜坡解剖区域分类方法对脊索瘤进行临床分型.其中,主体位于颅底中线区域116例:(1)主体位于前颅底6例;(2)主体位于上斜坡7例;(3)主体位于上中斜坡42例;(4)主体位于中下斜坡8例;(5)主体位于下斜坡21例;(6)主体位于全斜坡32例.主体位于中线及中线旁区域(广泛型)17例.全部病人均行内镜经鼻手术切除.中线区域型共使用4种内镜经鼻手术入路:内镜经鼻-前颅底入路、内镜经鼻-上斜坡入路、内镜经鼻-中斜坡入路、内镜经鼻-下斜坡入路.广泛型使用内镜经鼻手术入路结合其他开颅手术入路进行肿瘤切除.结果 病变全切为26例(20％),次全切62例(47％),大部切除38例(29％),部分切除7例(5％).结论 制定适合内镜经鼻手术的斜坡解剖区域划分,并以此为基础对颅底脊索瘤进行临床分型,可以更好地指导内镜经鼻切除颅底脊索瘤的手术入路选择.     

内镜经鼻入路显露颅颈交界区腹侧的解剖研究

目的提供内镜经鼻入路显露颅颈交界区腹侧的解剖学依据。方法选用30具骨性颅底和颈椎标本,测量与经鼻入路相关的解剖数据。选用10具经红色和蓝色乳胶灌注的尸头,在0°和30°内镜观察下,采用经鼻入路显露颅颈交界区腹侧结构。结果枕髁间距(16.12±1.86)m m,寰椎前弓长度为(15.84±1.18)m m,齿突高(14.96±2.19)m m,齿突最大横径为(10.34±0.80)m m。采用内镜经鼻入路,可切除寰椎前弓、齿状突和枕大孔前缘,显露颅颈交界区腹侧硬膜下结构。内镜经鼻入路的手术标志包括:下鼻甲、后鼻孔、鼻咽部黏膜、咽鼓管咽口、头长肌和颈长肌、枕大孔前缘和寰椎前弓、齿状突尖、寰枕关节。结论内镜经鼻入路可充分显露颅颈交界区腹侧硬膜下结构。     

内窥镜下经鼻蝶入路鞍区及上斜坡区解剖研究

目的研究经鼻蝶入路鞍区及上斜坡区的内镜解剖,确定解剖标志及内镜手术操作范围。方法选取10例灌注尸头,模拟经鼻蝶窦入路,在内镜下显露鞍区及上斜坡区,确定解剖标志,测量相关数据。结果视神经隆起、颈内动脉隆起、视神经颈内动脉隐窝及斜坡凹陷是蝶窦后壁的重要解剖标志。内镜下显露范围广泛,从鞍区至枕骨大孔前缘、寰枢椎,外侧可达海绵窦及斜坡颈内动脉、枕髁和咽鼓管。结论熟悉掌握内镜下鞍区及上斜坡区重要解剖结构及其相对位置关系,是进行中央颅底区手术的关键。     

扩大的内镜下经鼻至斜坡腹侧区入路手术的相关解剖研究

目的 研究扩大的内镜下经鼻至斜坡腹侧区入路手术的显露范围、解剖标志点及相关结构的距离.方法 取甲醛固定后成人头颅湿标本20例,显微镜下解剖观察经鼻至斜坡腹侧区手术入路的解剖标志点,测量相关解剖结构的距离;取新鲜成人头颅标本5例,完全模拟内镜下经鼻至斜坡腹侧区入路手术.在内镜下扩展显露斜坡区的主要解剖标志点,并研究其相互位置关系.结果扩大的内镜下经鼻至斜坡腹侧区入路手术的标志点包括中鼻甲、后鼻孔、咽鼓管咽口、鼻咽部黏膜、双侧蝶窦口、头长肌和颈长肌、咽结节、枕骨大孔前缘中点、颈内动脉、蝶腭动脉等.自鼻前棘至中下斜坡腹侧中线相关结构(咽结节、枕骨大孔前缘中点)的距离分别为(78.23±2.58)mm、(89.60±2.52)mm;经鼻人路完全暴露中下斜坡区,最短距离为(89.60±2.52)mm.颅底骨质磨除范围分别以两侧翼管和破裂孔为界,翼管左、右侧距中线距离为(9.25±0.55)mm、(9.19±0.50)nml,破裂孔左、右侧距中线距离为(10.64±0.83)toni、(10.75±0.84)mm,比较差异无统计学意义(P>0.05).结论 相关解剖结构及对脑组织的牵拉、颅底骨质磨除位置和范围是扩大的内镜下经鼻至斜坡腹侧区入路手术需要解决的主要解剖学问题.     

内镜下扩大经鼻蝶入路至斜坡区的解剖学研究

目的探索内镜下经扩大鼻蝶入路显露斜坡区的可行性,为切除斜坡区病变提供解剖学参考。方法在10例成人头部固定标本上,内镜下模拟扩大经鼻蝶手术入路显露斜坡区,观察有关显微解剖标志。结果扩大经鼻蝶内镜入路可磨除从鞍后到斜坡、枕骨大孔前缘的骨性结构;可显露斜坡区腹侧硬膜下的椎基底动脉及其分支、后交通动脉及其与大脑后动脉汇合处、动眼神经、脑干腹侧等结构。此入路的手术标志主要包括:蝶筛隐窝、蝶窦开口、视神经隆突、颈内动脉隆突与颈内动脉视神经隐窝、咽结节、枕骨大孔前缘。结论内镜下扩大经鼻蝶手术入路可充分显露鞍后-斜坡区的腹侧硬膜下结构,适用于此区病变的手术治疗。     

内镜下经眶入路的解剖学和临床应用进展

内镜下经眶入路是颅底外科手术的一种新路径,可单独或联合其他入路治疗前颅底和中颅底病变,是内镜下经鼻入路和传统颅底外科手术的重要补充。本文旨在总结内镜下经眶入路的相关解剖学研究进展及其在颅底外科的应用现状。     

个性化内镜技术在经鼻入路岩斜区病变手术中的应用

研究背景岩斜区位于颅底,位置深在,周围解剖结构复杂,给手术安全切除该部位病变带来极大挑战.目前岩斜区病变的手术入路主要有开颅经侧方入路和内镜下经鼻入路.本研究探讨内镜技术在经鼻入路岩斜区病变手术中的应用及其有效性和安全性.方法 纳入2018年1月至2020年12月在福建医科大学附属第一医院治疗的6例岩斜区病变患者,均行...     

经蝶窦入路至鞍区及周围结构:显微解剖与内镜解剖的比较

目的比较经蝶入路至鞍区及周围结构的内镜手术与显微手术显露范围的差异。方法选10具汉族成人灌注尸头，采用经蝶入路，5具进行内镜解剖，5具进行显微解剖。结果采用经蝶入路，在蝶窦内内镜下可观察到更多的周围结构，利于确定鞍底、海绵窦与鞍结节位置。在显露硬膜下结构时，内镜下侧方可显露海绵窦外侧壁，前方可显露双侧嗅神经和直回。结论同显微经蝶手术相比，内镜经鼻蝶手术在蝶鞍周围区域的显露范围更宽广。     

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.