标准化开颅技术在额颞切口开颅中的应用

目的 探讨标准化开颅技术运用于额颞切口开颅的效果。方法 回顾性分析2017年2月至2018年3月由同一术者利用标准化开颅技术完成的36例额颞弧形切口开颅手术病例的临床资料,额外侧入路13例,翼点入路23例。结果 36例中,29例切开颞肌,7例未切开;骨瓣大小4 cm×3 cm~7 cm×8 cm;出血量5~65 ml,平均24.2 ml;开颅时间18~45 min,平均29.2 min。结论 额颞切口标准化开颅技术简单、快速,适合年轻医生学习掌握,尤其是基层医院。     

翼点入路帽状腱膜下筋膜间及骨膜下三种开颅方法的优缺点比较

1方法本科为了探索脑外科手术中的翼点入路,采用了包括标准翼点入路、扩大翼点入路,及其它各种改良翼点入路。手术病种有脑内血肿清除术,开颅垂体瘤切除术,鞍区脑膜瘤切除术,颅咽管瘤切除术等。分为三组,其中A组以帽状腱膜下分离皮瓣,再以切口处切开颞肌形成肌骨瓣或游离骨瓣。B组,于帽腱膜下游离到颞肌前四分之一处时,切开颞筋膜,从颞深筋膜浅深层之间继续向前分离到关键孔。C组,切口全部切至骨膜层,然后从骨膜下全层分离皮肤,颞肌及骨膜,行成肌皮瓣。2结果见表1。表1三种不同翼点入路方法的优缺点面神经损伤率(%)操作繁简程度术野暴露A…     

自体颅骨帽状腱膜下保存及回植

我院自 2 0 0 0年以来对颅内压增高需去骨瓣减压患者采用自体颅骨带蒂转移至帽状腱膜下保存 ,待颅高压消退后再将保存颅骨回植于原骨窗 ,达到颅骨成型满意效果。现报告如下 :资料与方法　　 1 .临床资料 :本组 3 0例 ,男 1 9例 ,女 1 1例。年龄在 1 9～ 71岁。颅脑损伤 2 3例 ,自发性脑内血肿 5例 ,高血压脑出血 2例 ;去骨瓣左额颞 1 0例 ,右额颞 8例 ,左颞顶 5例 ,右颞顶 5例 ,左颞顶枕 2例。颅骨瓣面积 4cm× 5cm～ 7cm× 8cm ,骨瓣回植时间 3 0～ 95d。2.手术方法 :在开颅去骨瓣减压术中 ,选择适合埋藏颅骨的帽状腱膜下间隙 ,用锐性分离…     

橡胶膜在颅骨修补期的应用

我院自1993年以来在颅脑损伤开颅减压时骨窗内垫置橡胶膜,颅骨修补时皮下不分离,出血极少,手术时间缩短三分之二,修补时间提前,骨性愈合率提高。现报告33例如下：1资料和方法1．1　临床资料　本组男21例,女12例,年龄4－52岁,平均28岁。缺损部位：额部9例,额项21例,枕顶部3例。缺损面积,4cm×4cm－10cm×12cm,平均8cm×7cm。缺损原因均为外伤术后减压所致。皮下隔离材料：医用乳胶手套片或硅橡胶膜。1．2　方法步骤　①手术减压时头皮切口大于骨瓣切口1cm。②骨窗骨瓣各钻3个直径1．5cm的小骨孔,孔内预置5cm长的软钢丝,颅骨修…     

骨水泥修补颅骨缺损78例临床观察

我院于 1990～ 2 0 0 1年用骨水泥修补颅骨缺损 78例 ,效果满意 ,总结如下。1　资料与方法1 1　临床资料　男 5 6例 ,女 2 2例 ,年龄 6～ 49岁 ,二期修补时间 3～ 10个月 ;缺损原因 :外伤术后 71例 ;肿瘤术后 7例。缺损部位 :额颞部 47例 ,额部 10例 ,颞部 14例 ,顶枕部 7例 ;缺损面积 :最大 10cm× 9cm ,最小 2 5cm× 3cm。1 2　手术操作　全麻下 (或局麻 ) ,超过颅骨边缘 0 5cm切口或沿原切口达颅骨 ,显露缺损区域。此时 ,将骨水泥与单体混合并搅匀 ,面团期时揉成饼状贴于缺损区域 ,用剪刀修剪其与缺损区域形态相符 ,并用手按压到满意的…     

小骨窗与常规骨瓣开颅治疗高血压脑出血效果分析

目的 比较小骨窗与常规颞顶瓣开颅术治疗高血压脑出血的效果.方法 符合标准的高血压脑出血病人113例,分为2组,其中小骨窗组57例,常规骨瓣组56例.所有病人均经CT扫描为幕上出血.小骨窗治疗组根据血肿部位采用小骨窗开颅术(3 cm×3 cm).常规骨瓣组根据血肿部位采用颞顶瓣或额颞瓣开颅减压方法( 6 cm×8 cm).结果 小骨窗开颅治疗组病人恢复良好率明显高于常规骨瓣组,长期昏迷和中残率低于常规骨瓣组(P<0.05),小骨窗治疗组患者术后脑水肿和切口脑脊液漏发生率均低于常规骨瓣组(P<0.05).结论 小骨窗开颅术治疗高血压脑出血病人的疗效明显好于常规颞顶瓣开颅术.     

翼点入路手术致面神经颞支损伤

翼点入路为神经外科常用手术入路之一,也是我们近年来处理前、中颅窝病变的主要手术入路。但该入路在分离皮瓣时可有30％同侧面神经颞支损伤。我们遇到3例报告如下。 病例报告 例1男,55岁。因视力下降2月于96年3月7日入院。查体无面神经功能障碍。CT扫描示:垂体腺瘤。3月19日行开颅垂体瘤切除术。取右侧翼点入路皮肤弧形切口,帽状腱膜下解剖分离皮瓣,向颞下翻开肌骨     

九种小骨窗开颅手术入路的实用性探讨

目的为了减少对颅内病变患者在开颅手术入路过程中的损伤，同时保证病变得到恰当的处理。方法我们对每个病变的手术进行个体化设计，在常规手术入路的基础上进行改良、或重新设计和创新，将皮肤切口、骨窗面积进行缩小处理。结果小骨窗开颅成功手术治疗127例颅内病变患者，病变种类涉及脑肿瘤、脑实质和脑室内出血、炎症病变和血管压迫性功能病变。经过借鉴、探索和改进形成了相对成熟的9种小骨窗开颅手术入路。具体的做法是：根据病变的部位、种类、大小、距脑表的深度、周围结构和可以利用的自然通道等因素决定小骨窗开颅与否和具体的入路。在眉弓外侧、颞区中后部、窦汇区、乙状窦后区、枕鳞部、矢状中线和大脑凸面各部设计皮肤小切口和做小骨窗(直径2．5～3．0cm)开颅手术，采取腰大池置管脑脊液外引流使脑组织回缩增加显露，借助影像资料、解剖标志，立体定向架、神经导航和术中超声等方法定位病变，使用显微神经外科手术技术达到既安全有效又创伤较小地消除或解决病变。但如果病变很大、或有严重脑水肿、涉及脑表或颅底广泛、或属于难处理的脑血管病变，一般不适合小骨窗开颅手术。结论小骨窗开颅手术有其实用性，但也有使用的局限性。手术选择和成功与否取决于病变的特征、个体化手术设计、术者的显微手术技术、以及可以利用的辅助手段。     

自体带膜骨瓣腹壁或胸壁保存后修补颅骨缺损

我科从 2 0 0 2年 5月至 2 0 0 4年 5月对 8例颅脑损伤或脑出血发生脑疝者行去骨瓣减压术后 ,将带膜骨瓣埋藏于腹壁或胸壁下 ,择期将自体带膜骨瓣用丝线缝合固定于骨窗修补颅骨缺损。现总结如下。1　资料与方法1 1　一般资料 :男 5例 ,女 3例 ,年龄 1 9～ 4 3岁 ,平均 38 9岁。外伤 6例 ,脑出血 2例。骨瓣成形情况 :额颞顶大骨瓣 5例 ,颞顶骨瓣 3例 ,大小约 1 4cm× 1 0cm～ 1 2cm× 8cm。1 2　手术方法 :急诊骨瓣成形开颅 ,术毕将骨瓣凸面向上埋藏于腹壁或胸壁下 ,最好带大于 1 / 2骨瓣面积的骨膜。骨瓣为大骨片离断者 ,将其用生物胶粘合…     

原发性颅骨尤文肉瘤1例

1病例报告男,22岁,因左额颞部包块进行性增大5个月入院。入院检查:左额颞约10 cm×12 cm大小包块,质软,轻度压痛,边界不清,局部皮肤温度高,表浅静脉怒张。CT示左额颞颅内外占位性病变,颅骨反应性增生,轻度脑水肿(图1)。术中见肿瘤血供丰富,边界不清,无明显包膜,质硬,部分组织坏死呈白色乳糜状,侵犯颞肌深层及颅骨,颅骨增生,翼点处骨质破坏约1.5 cm×2 cm,头皮下肿瘤通过其与颅内肿瘤相连;颅内肿瘤部分位于蝶骨嵴前后,大部分位于硬脑膜外,广泛侵蚀硬脑膜,向前下至颅前、中窝底,由脑膜中动脉供血。术中分块全切除肿瘤。病理诊断:尤文肉瘤(EW…     

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.