脊髓硬脊膜动静脉瘘的显微外科治疗

目的总结应用术前脊髓血管造影、X-线及术中吲哚菁绿荧光造影技术显微手术切除脊髓硬脊膜动静脉瘘(spinal dural arteriovenous fistulas,SDAVF)的治疗经验。方法回顾性分析8例SDAVF病人的临床资料,在脊髓血管造影、X-线及吲哚菁绿术中荧光造影辅助下行显微手术切除SDAVF,对其疗效进行随访。结果全部病例SDAVF完全切除。随访9~17个月,症状好转7例,稳定1例。结论术前脊髓血管造影、X-线及术中吲哚菁绿荧光造影可以显著提高手术成功率。     

颅内动脉瘤夹闭术中荧光造影"假阴性"原因探讨

目的 探讨吲哚菁绿荧光血管造影在颅内动脉瘤夹闭术中"假阴性"的原因及处理措施.方法 回顾分析2008年11月-2011年10月7例颅内动脉瘤夹闭术中吲哚菁绿荧光血管造影"阴性"患者手术治疗经过,分析术中吲哚菁绿荧光血管造影在显示动脉瘤夹闭完全性方面的局限性及应对原则.结果 7例患者均于术中吲哚菁绿荧光血管造影显示"阴性".但在剪开或刺破动脉瘤瘤体后出现少量渗血.经迅速清理瘤颈渗血并调整动脉瘤瘤夹位置,渗血消失.结论 吲哚菁绿荧光血管造影是术中监测动脉瘤是否夹闭完全的重要方法.但具有一定局限性,瘤颈较宽、瘤颈血栓形成或血管壁粥样硬化,以及蛛网膜分离不完全等情况均可能导致"假阴性"结果.因此,对于术中夹闭动脉瘤后吲哚菁绿荧光血管造影"阴性"的患者,仍需配合其他监测方法,进一步确认动脉瘤夹闭情况.     

吲哚菁绿荧光强度分析在颅内动脉瘤术中的应用

目的 探讨吲哚菁绿血管造影及荧光强度分析在颅内动脉瘤夹闭术中的作用.方法回顾性分析吲哚菁绿血管造影及荧光强度分析在47例颅内动脉瘤患者夹闭术中的作用.术中行吲哚菁绿荧光血管造影,观察动脉瘤、载瘤动脉及分支血管的血流情况,并通过荧光强度分析软件进行分析.结果47例中有4例通过吲哚菁绿血管造影检测到动脉瘤夹闭不全,术中荧光强度分析为3例动脉瘤的夹闭提供了重要信息.结论 吲哚菁绿血管造影能在术中对术野血流情况进行实时的分析,而通过荧光强度分析可进一步提高吲哚菁绿血管造影对血流分析的准确性.     

颅内动脉瘤夹闭术中荧光造影“假阴性”原因探讨

目的探讨吲哚菁绿荧光血管造影在颅内动脉瘤夹闭术中＂假阴性＂的原因及处理措施。方法回顾分析2008年11月-2011年10月7例颅内动脉瘤夹闭术中吲哚菁绿荧光血管造影＂阴性＂患者手术治疗经过,分析术中吲哚菁绿荧光血管造影在显示动脉瘤夹闭完全性方面的局限性及应对原则。结果 7例患者均于术中吲哚菁绿荧光血管造影显示＂阴性＂,但在剪开或刺破动脉瘤瘤体后出现少量渗血,经迅速清理瘤颈渗血并调整动脉瘤瘤夹位置,渗血消失。结论吲哚菁绿荧光血管造影是术中监测动脉瘤是否夹闭完全的重要方法,但具有一定局限性,瘤颈较宽、瘤颈血栓形成或血管壁粥样硬化,以及蛛网膜分离不完全等情况均可能导致＂假阴性＂结果。因此,对于术中夹闭动脉瘤后吲哚菁绿荧光血管造影＂阴性＂的患者,仍需配合其他监测方法,进一步确认动脉瘤夹闭情况。     

脊髓血管母细胞瘤的显微外科治疗

目的 探讨脊髓血管母细胞瘤的显微外科治疗方法.方法 回顾性分析16例脊髓血管母细胞瘤病人的临床资料.术前均行血管造影,其中完全栓塞或部分栓塞9例.术中采用吲哚菁绿血管造影再次确认相关血管,采用显微外科手术切除肿瘤.结果 16例脊髓血管母细胞瘤均全切除.术后随访3个月,根据McCormick脊髓功能状态分级:明显改善12例,无变化3例,加重1例.结论 脊髓血管母细胞瘤通过显微外科手术切除可以取得良好疗效,术前血管造影栓塞和术中荧光血管造影有利于减少术中出血,提高手术安全性.     

吲哚菁绿术中荧光血管造影在颅内动脉瘤手术中的应用

目的 探讨吲哚菁绿术中荧光血管造影在颅内动脉瘤于术中的应用,减少术后并发症,提高手术的安全性.方法 回顾性总结18例25个颅内动脉瘤.术中动脉瘤夹闭前后均行吲哚菁绿荧光血管造影检查,根据造影结果,必要时调整动脉瘤夹.术后复查CT判断有无缺血梗死,复查DSA或CTA判断动脉瘤夹闭情况.结果 术中荧光血管造影发现动脉瘤残颈1例,载瘤动脉狭窄2例,远端分支狭窄1例,穿通支闭寨1例,均根据造影结果及时调整动脉瘤夹.术后复查CT无缺血性梗死出现,1例术后因动脉瘤夹闭不全出血,二次手术清除血肿,并调整动脉瘤火.16例复查DSA或CTA见动脉瘤夹闭完全,架桥血管通畅.结论 吲哚菁绿术中荧光血管造影对于判断载瘤动脉是否狭窄、动脉瘤是否有残颈、动脉瘤远端血管和穿支血管是否狭窄或闭寒、架桥血管是否通畅有重要的参考价值,可有效的减少术后并发症,提高手术的安全性,足一种方便快捷、安全有效的术中血管造影技术.     

吲哚菁绿荧光血管造影在脑肿瘤手术中的应用

目的 探讨吲哚菁绿荧光血管造影在脑肿瘤手术中的作用.方法 回顾性分析102例脑肿瘤病人的临床资料,其中低级别胶质瘤14例,高级别胶质瘤56例,脑膜瘤18例,转移瘤12例,血管网状细胞瘤2例.所有病人均行吲哚菁绿荧光血管造影,并在整合荧光造影的手术显微镜下切除肿瘤.结果 本组共实施吲哚菁绿荧光血管造影205次,均成功完成;单次造影所需时间约4 min,术中可实时辨认造影血管的动脉期、毛细血管期和静脉期.术后出现一过性皮疹1例,所有病人均未出现严重过敏现象.结论 在肿瘤切除前,吲哚菁绿荧光血管造影可实时动态观察瘤内和瘤周血管的血流情况;肿瘤切除后,可观察保留血管的情况.吲哚菁绿荧光血管造影是一种快速、简便和安全的造影方法.     

术中彩色多普勒结合荧光造影在脑动静脉畸形手术中的应用

目的探讨术中彩色多普勒结合吲哚菁绿血管造影在脑动静脉畸形（cAVM）手术的应用价值。方法回顾性分析46例cAVM的临床资料。手术切除cAVM过程中,使用彩色多普勒探查以确定畸形血管团位置和供血动脉来源,并与术前CTA对比。同时使用吲哚菁绿进行术中荧光造影,观察畸形血管团血流方向,以辨认浅表供血动脉及引流静脉。手术切除畸形血管后再行多普勒及荧光造影检查以评估手术效果。结果 46例病人术中彩色多普勒所示病变定位与术前CTA一致,术中彩色多普勒对深部供血动脉分辨良好,但8例（17.4%）病变血管在彩色多普勒下难以发现。荧光造影对浅表血管血液流向分辨清晰,手术切除畸形血管团完全。术后病人出现轻度神经功能损害6例,经术后康复锻炼后无明显后遗症,其他病人神经功能保留良好。结论术中彩色多普勒结合吲哚菁绿荧光造影对cAVM术中定位、供血动脉及引流静脉有良好的实时判断价值,有助于确定手术切除方案,准确切断供血动脉,减少术中出血及手术副损伤,降低术后畸形血管团残留率。     

后交通动脉瘤的显微手术治疗

目的 总结显微手术治疗后交通动脉瘤的经验.方法 回顾性分析108例后交通动脉瘤病人的临床资料,采用翼点入路显微手术治疗,行瘤颈夹闭术107例,动脉瘤包裹术1例.瘤颈夹闭后术中常规切开瘤体并行吲哚菁绿荧光血管造影.结果 动脉瘤颈完全夹闭107例,动脉瘤包裹1例.术中动脉瘤破裂18例.术前脑积水11例,术后改善6例,无明显改善5例.术后GOS评分:4～5分93例,2～3分11例,1分(死亡)4例.84例获随访6～12个月,无动脉瘤残留及复发.结论 显微手术是治疗后交通动脉瘤的理想方法,术中常规切开瘤体并行吲哚菁绿荧光血管造影可有效判断夹闭效果.     

动脉瘤夹闭术中辅助应用吲哚菁绿荧光造影的临床研究

目的 探讨动脉瘤夹闭术中辅助应用吲哚菁绿荧光造影(ICG)对手术的影响.方法 回顾分析动脉瘤夹闭术中辅助应用吲哚菁绿荧光造影及无造影辅助的共40例脑动脉瘤病例,比较两组患者术后脑缺血的发生率、预后情况以及术中造影对手术策略的影响.结果 20例术中辅助应用吲哚菁绿荧光造影的患者术后GOS分级显著高于非造影组,术后脑缺血...     

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.