显微外科治疗8例颅眶沟通肿瘤

颅眶沟通肿瘤不多见,我院自1993-1999年共收治颅眶沟通肿瘤8例,报道如下。1 资料1.1 一般资料:本组男3例,女5例,年龄18-59岁,平均41岁。患者的首发症状为视力减退,5例同时伴有眶区疼痛及头痛。视力0.1以下者2例,0.1-0.5者3例,0.6-1.0者2例,眼前手动1例。眼球突出5例,眼球活动障碍4例,复视4例,眼球搏动伴血管杂音2例。所有肿瘤均行头颅CT及MRI检查,确诊为颅眶沟通肿瘤。4例表现肿瘤呈纺锤状及视神经眶内段呈均匀变粗的等信号及略高信号占位。边界较清晰,周边有轻度水肿。强化后有2例呈结节状类圆形的高信号强化。肿瘤主体在眶内2例,在颅内5例,1例在眶后部侵及视神经管。     

免疫性炎症所致的眶尖综合征一例

眶尖综合征以第Ⅱ、Ⅲ、Ⅳ、Ⅵ脑神经及第Ⅴ脑神经第一支损害为特征,临床表现为眼眶疼痛,视力严重减退或失明,轻度突眼,上睑下垂,眼球运动障碍,瞳孔散大,瞳孔对光反应减弱或消失,三叉神经第一支分布区感觉减退及眶静脉回流障碍.     

以视力障碍为首发症状的脑血管病临床特征分析

目的分析以视野缺损、视力下降为首发症状的脑血管病的临床特征,以减少临床误诊率。方法对40例以视力障碍为首发症状的脑血管患者的临床资料、诊疗经过及疾病转归进行全面分析。结果双眼同时视物不见、双眼片侧视物不见、双眼先后视力下降、单眼视力下降为患者就诊主诉。经完善检查后确诊前循环脑梗死8例,后循环脑梗死18例,颈动脉闭塞4例,烟雾病6例,脑血管畸形4例。单眼功能障碍主要为前循环障碍引起;后循环病变多表现单或双侧枕颞叶梗死,脑干梗死和基底动脉尖综合征。结论在脑血管病中以视力障碍为首发症状的病因中有前循环障碍、后循环障碍,单眼视力障碍多为前循环病变,是颈内动脉缺血或闭塞的眼部表现;双眼同时病变主要为后循环障碍累及枕颞叶所引发。     

经颅入路手术治疗创伤性视神经损伤

目的探讨颅脑创伤合并视神经损伤的治疗方法.方法经手术治疗20例颅脑创伤合并视神经损伤患者,17例经额下入路行额冠状皮瓣一侧额部开颅;3例眶上裂综合征患者行额颞切口,经眶尖外侧壁入路.评价手术后视力恢复的标准为黑朦、光感、眼前手动、眼前数指和能见标字视力表符号5个级别.术后视力提高2个级别以上者为有效,否则为无效.结果手术后65%(13例)的患者达到有效,其中3例眼球突出、1例眼球内陷患者术后均得到矫正.结论颅脑创伤合并视神经损伤患者,经额部或额颞入路手术行视神经减压,可取得良好效果.术后视力恢复与损伤后手术时间、手术方法相关,亦与视神经损伤程度有密切关系.     

颅眶沟通性病变临床特点及显微神经外科手术治疗

目的探讨颅眶沟通性病变的临床特点和显微外科手术疗效。方法回顾性分析48例颅眶沟通性病变的临床资料,均行显微手术切除,经眶额入路16例,翼点入路21例,扩大翼点入路6例,额颞眶颧入路5例。结果病变全切除36例,次全切除6例,部分切除6例。术后发生硬膜下积液1例,颅内感染2例,经治疗后痊愈;无颅内出血及脑脊液漏等并发症发生。随访2～31个月,平均14.5个月;无肿瘤复发或进展47例,死亡1例。多数病人术前症状好转。术后新发视力、视野障碍3例,眼球活动障碍或复视8例。结论颅眶沟通性病变良性肿瘤居多,以脑膜瘤最常见;显微手术切除为首选治疗方法,全切除率高,术后并发症少,且症状改善率高。     

眼运动神经麻痹50例病因分析

动眼、滑车及外展神经共同支配眼球运动。多种疾病可引起眼球运动神经麻痹 ,现将我院 1995～ 2 0 0 0年收治的眼运动神经麻痹 5 0例报告如下。临床资料一般资料　本组 5 0例 ,(男 2 9,女 2 1例 ) ,年龄 11～ 72岁 ,平均 4 3 6岁 ,5 0例中有动眼神经麻痹者 4 1例 ,外展神经麻痹者 33例 ,滑车神经麻痹者 15例。其中单纯动眼神经和外展神经麻痹各 15例和 8例 ,其余为滑车神经麻痹伴有动眼神经和外展神经麻痹或伴有动眼神经、外展神经麻痹。本组 5 0例中海绵窦综合片5例、眶尖综合征 3例、眶上裂综合征 2例、岩尖综合征 (Ｇａｄｅｎｉｇｏ综合征…     

眶内海绵状血管瘤(附8例报告)

目的探讨眶内海绵状血管瘤的手术治疗.方法经颅-眶顶入路切除眶内海绵状血管瘤8例.结果 8例均全切除,眼球突出和活动障碍得到不同程度的改善,视力有部分恢复,无严重并发症.结论经颅-眶顶入路是切除眶内海绵状血管瘤的入路之一,尤其适合那些位于眶尖及内侧的肿瘤.     

视神经脑膜瘤(临床、诊断和形态学)

作者研究了31例视神经脑膜瘤(M3H)患者的临床,诊断和形态学改变.女23例、男8例,年龄12～60岁.大部分病例确诊很晚,病后1～2年内确诊者5例,2～5年者15例,5～10年者11例.一、临床:22例首发症状为肿瘤侧视力下降,9例为眼球突出.全数病例肿瘤侧眼睑有不同程度的水肿.27例肿瘤侧眼球突出2～11mm.大多数病例肿瘤侧视力为0.1或以下,全数病例对侧视力正常.全数病例有不同程度的动眼神经障碍.14例视乳头水肿和不同程度的苍白,17例有继发性萎缩.     

累及双眼的痛性眼肌瘫痪1例报告

累及双眼的痛性眼肌瘫痪临床罕见,现报告1例如下。1病例女,50岁。因突发头痛1d于2004年2月1日入院。患者1d前无明显诱因出现双侧眼球后、眶区周围剧烈疼痛,伴恶心,无呕吐。查体无异常体征;腰穿脑脊液及头颅CT检查均正常。7d后,患者出现两眼各方向活动受限,眼球固定正中位,双侧瞳孔等大等圆,直径约2·5mm,对光及调节反射存在,眼球、眼眶无红肿;其他亦无异常。头颅MRI无异常。诊断为痛性眼肌瘫痪。给予地塞米松治疗28d痊愈。3月后及6月后随访2次,患者无复发,亦无其他异常。2讨论痛性眼肌瘫痪又称Tolosa-Hunt综合征,病因不明,考虑为眶尖、海…     

首发精神分裂症患者持续缓解的预测因素分析

目的:探讨首发精神分裂症患者1年持续缓解的临床与认知预测因素。方法:44例首发精神分裂症患者给予抗精神病药治疗1年,并在基线期采集患者人口学和临床资料,同时采用阳性与阴性症状量表(PANSS)评估疾病症状以及霍普金斯词语学习测验中文修订版(HVLT-R)、Stroop词色测验、彩色连线测验、词语流利测验中文版(VFT:VFL和VFC)评估认知功能;在治疗后4、8、12、24、36周和1年时随访,从第8周末至1年期间,历次访视PANSS量表8个核心条目评分均≤3分者被视为持续缓解(持续缓解组),其他患者视为病情波动(病情波动组)。结果:42例患者完成1年随访,其中24例(57.1%)患者持续缓解;与病情波动组(18例)比较,持续缓解组具有未治疗精神病期(DUP)较短、阴性症状较轻、阳性症状较重、HVLT-R和VFC得分较高的特点(P0.05或P0.001)。多元Logistic回归分析表明持续缓解的患者具有DUP短(OR:0.791,95%CI:0.629~0.995;P=0.003)、阴性症状分低(OR:0.775,95%CI:0.609~0.987;P=0.012)及阳性症状分高(OR:1.706,95%CI:1.040~2.800;P=0.004)是持续缓解的独立预测因素。结论:DUP短、阴性症状较轻、阳性症状较重是首发精神分裂症患者持续缓解的独立预测因素。     

可逆性后部白质脑病综合征的临床及影像学特点

目的 探讨可逆性后部白质脑病综合征（PRES）的临床和影像学特点。方法 回顾性分析7例PRES患者临床及影像学资料。结果 本组继发于妊娠高血压综合征3例,肾功能衰竭3例,高血压1例。临床表现：7例均有头痛及视物模糊,伴有癫痫发作6例,恶心、呕吐4例,轻偏瘫、共济失调各1例。6例行头颅CT检查,3例枕叶低密度影,其中2例广泛脑白质水肿;1例多发小血肿;2例未发现异常。7例MRI检查显示枕叶均受累,同时伴小脑受累3例,脑干2例,额顶叶皮质下白质2例,尾状核、丘脑各1例。在脑叶呈脑回样、在其他部位呈斑片样异常信号;T1WI呈略低或等信号,T2WI和Fair像呈高信号。2例增强扫描1例无强化,1例呈脑回样、斑片样和环状强化。4例DWI扫描,2例呈略高信号,1例呈低信号,1例未见异常。结论 头痛、视觉障碍和癫痫发作是PRES主要临床表现,影像学特征主要为大脑后部白质对称性长T1、长T2信号。     

伴有胼胝体压部可逆性病灶的临床症状轻微的脑炎/脑病1例报道并文献复习

目的探讨伴有胼胝体压部可逆性病灶的临床症状轻微的脑炎/脑病的临床特点、治疗及预后、发病机制。方法报道1例伴有胼胝体压部可逆性病灶的临床症状轻微的脑炎患者的诊治过程,总结其临床特征并复习相关文献。结果患者表现为发热、头痛、呕吐等非特异性脑膜炎症状,合并出现抗利尿激素分泌不当导致的低钠血症,头颅MRI检查发现胼胝体压部有可逆性的DWI高信号的孤立病灶,经抗病毒及对症治疗,临床痊愈。结论伴有胼胝体压部可逆性病灶的临床症状轻微的脑炎/脑病以头颅MRI上发现胼胝体压部可逆性病灶为特点,临床症状轻微,容易合并低钠血症,预后良好,病因及发病机制尚不清楚。     

以视力障碍为主要表现静脉窦血栓临床特点分析

目的 分析以视力障碍为主要表现的静脉窦血栓形成患者的临床特点,为此类静脉窦血栓形成患 者的诊治提供新思路。 方法 收集2004年1月-2016年7月以“视力障碍”住院的静脉窦血栓形成患者34例。对患者的人口学 资料、临床表现、实验室检查及影像学特征进行归纳总结。 结果 本组34例患者中男性18例（52.9%）,女性16例（47.1%）,平均发病年龄（36.1±12.9）岁,亚 急性起病11例（32.4%）,慢性发病23例（67.6%）。34例患者中感染引发疾病的有5例（14.7%）;非 感染因素29例（85.3%）。临床症状中视力下降29例（85.3%）（双眼视力下降23例,单眼视力下降6 例）,阵发性黑蒙8例（23.5%）,复视1例（2.9%）。伴随头痛9例,眼痛1例,颈痛1例,耳鸣2例,头晕1 例,症状性癫痫2例。主要体征为视盘水肿29例（双眼视盘水肿27例,单眼视盘水肿2例）;静态视 野检查中仅6例（17.6%）正常,18例（52.9%）表现为弥漫性视野缺损或全视野缺损,其中双眼受累11 例（32.4%）,单眼受累7例（20.6%）。33例患者行腰穿检查,颅内压<180 mm H2O者1例（3.0%）,颅内 压180～330 mm H2O者14例（42.4%）,颅内压﹥330 mm H2O者18例（54.5%）。34例患者均行影像学检查, 有7例（20.6%）仅累及1个部位静脉窦,26例（76.5%）累及2个或2个以上部位静脉窦,有12例（35.3%） 出现脑实质或脑膜病变,而多达22例（64.7%）无新发脑实质损害。 结论 以视力障碍为主要表现的脑静脉窦血栓好发于中青年,多隐匿起病,主要临床表现为高颅压, 近一半患者静态视野损害重,血栓好发于横窦和乙状窦,且好发于多个部位静脉窦,多数无明显的 脑实质损害。     

经鼻-蝶窦手术路径的体表定位及鼻-蝶窦区的三维CT影像解剖

目的 探讨三维螺旋CT在鼻-蝶鞍区影像解剖及经鼻-蝶窦垂体瘤手术入路的鞍底定位中的应用.方法 回顾性分析29例鼻-蝶鞍区螺旋CT扫描数据,以3D重建和剪切技术重建和观察鼻-蝶鞍区的3D解剖结构.分析鼻尖-耳轮上缘连线(鼻-耳轮线)与鞍底的关系.对14例垂体瘤患者术前、术后行螺旋CT扫描和重建,评估3D - CT和鼻-耳轮线在经鼻-蝶窦垂体瘤术前规划和术中鞍底定位中的可行性.结果 鼻-耳轮线在所有的研究对象中均与蝶窦相交,其中与鞍底相交者12例占42％.鞍底-斜坡交点至鼻-耳轮线的垂直距离是(3.6±1.8)mm.3D - CT能清晰地显示鼻-蝶鞍区的解剖结构,包括蝶窦及其分隔、颈动脉和视神经管隆起、鞍底等.为模拟手术入路和术中鞍底定位提供重要信息.结论 3D - CT技术可获得鼻-蝶鞍区高清晰度的三维空间解剖图像,有助于经鼻-蝶窦垂体瘤手术方案的制定和术中蝶窦和鞍底的定位.鼻-耳轮线可作为经鼻-蝶窦垂体瘤手术路径的体表定位.     

Tobacco-alcohol amblyopia. Clinical course in 33 patients

The clinical data of 33 patients with tobacco-alcohol-amblyopia are described. Usually, the visual disturbance concerned both eyes and was not associated neither with headache nor with painful eye movements. The fundus was very often normal. In the static perimetry mostly relative or absolute central scotomas were found, sometimes centrocoecal scotomas and very seldom paracentral scotomas. The colour vision was very often disturbed, usually the red-green discrimination. In the rule the amplitudes of the visual evoked potentials were diminished, the P-100 latency was delayed in 39%. A follow-up of 25 patients revealed that the visus and the results of the static perimetry improved in 72% during vitamin substitution (B1, B2, B6, B12, folic acid). In a few cases this improvement could be observed even though the alcohol drinking was not ceased. In most cases the disturbance of the colour vision and the pathologic visual evoked potentials, however, did not change.     

简易运动评分与GCS对颅脑损伤伤情评价的比较

目的探讨简易运动评分(SMS)对颅脑损伤伤病情评价的可靠性。方法对72例颅脑损伤患者,分别行SMS和GCS评价并比较其伤情和不同伤情患者的预后。结果两种评价均为颅脑损伤轻型者57例,均为中重型者12例;有3例GCS评为中重型,而SMS评为轻型;SMS与GCS对伤情的评价无明显差异(P>0.05)。两种方法均评为重型者4例,3例恢复差(GOS1～3分),1例恢复良好(GOS4～5分);8例均为中型者,2例恢复差,6例良好;57例均为轻型者均恢复良好;3例GCS评为中型,而SMS评为轻型者均恢复良好。SMS与GCS分别评为颅脑损伤轻型或中型或轻型者中,预后无明显差异(P>0.05)。结论与GCS相比,SMS可作为脑损伤病情的评价方法之一,简便易行,结果可靠。     

From the abducens nucleus to spatial memory: an ocular motor journey

Advances in our knowledge on eye movements over the last 25 years are reviewed, focusing on the author's experience. First, the advantages of binocular frontal vision, which is a common characteristic of all predator mammals, are compared to those of lateral vision, characterizing their preys. Binocular frontal vision implies a perfect parallelism of both eyes, which is ensured in the pons by means of the abducens nucleus, controlling abduction as well as adduction. The pathological example of the "one-and-a-half" syndrome, in which the abducens nucleus and the adjacent medial longitudinal fasciculus are simultaneously impaired, is described. The main brainstem syndromes involving vertical eye movements are also reviewed: in particular, the third nerve nucleus syndrome, in which both ipsilateral third nerve paralysis and contralateral superior rectus paralysis (with hypotropia) result from a unilateral third nerve nucleus lesion. A case of upbeat nystagmus (in the primary position of gaze) due to a small upper pontine lesion, probably affecting the ventral tegmental tract (VTT) is also reported. This is an opportunity to emphasize that, although a number of cases of upbeat nystagmus due to focal brainstem lesions affecting the upward vestibular pathway (UVP)--either at the upper pontine (VTT) or caudal medullary level--exist in the literature, no convincing cases with downbeat nystagmus (in the primary position of gaze) due to a focal brainstem lesion have been reported. Downbeat nystagmus could result from a UVP hyperactivity (secondary to a floccular lesion) and the notion that this pathway is physiologically predominant compared to the downward pathway, maybe due to gravity, is developed. A new hypothesis about the role of the caudal medulla in UVP is also proposed. Next, the cortical control of saccadic eye movements is reviewed, with a reminder that reflexive saccades are mainly triggered by the parietal eye field whereas intentional saccades depend upon the frontal eye field. The inhibition of reflexive saccades is mainly controlled by the dorsolateral frontal cortex (DLPFC), i.e. area 46 of Brodmann. A few examples of the use of saccades as a research tool and model in cognitive neurosciences are given. The use of memory-guided saccades allowed us to study spatial memory and led us to propose a relatively original conception of the cortical control of spatial memory in which the DLPFC, the parahippocampal cortex and the hippocampal formation could be involved successively according to specific periods of time. An experiment using functional magnetic resonance imaging in a paradigm studying decision is described, again with the involvement of the DLPFC in the decisional process. Lastly, the usefulness of eye movements in clinical neuro-ophthalmology at the bedside as well as in neurophysiological or even neuropsychological research in the laboratory is emphasized.     

静脉窦支架置入术治疗合并静脉窦狭窄的特发性颅内高压的单中心研究

目的 探讨静脉窦支架置入术对合并静脉窦狭窄的特发性颅内高压（idiopathic intracranial hypertension, II H）的治疗作用。 方法 回顾性分析2009年7月-2019年1月在解放军总医院第一医学中心确诊并行静脉窦狭窄支架置 入术的IIH患者的临床资料。术前清醒状态和术后即刻测静脉窦狭窄远近端压力差。术后1周复查腰椎 穿刺测颅内压,随访术后1年临床症状改善情况。术后6～12个月行DSA检查,评估静脉窦支架置入术 对合并静脉窦狭窄的IIH的治疗作用。 结果 共纳入97例患者,其中75例（77.3%）女性,22例（22.7%）男性,中位年龄35（15～57）岁。术 前存在视力障碍74例（76.2%）,头痛54例（55.7%）。97例患者行静脉窦狭窄支架置入治疗,其中93 例行单侧静脉窦狭窄支架治疗,4例行双侧静脉窦狭窄支架治疗。支架置入术中未发生并发症。支架 置入术后静脉窦狭窄远近端压力差减小（18.1±7.1 vs 1.1±1.0 mm Hg,P＜0.001）,腰穿检查脑脊液压 力显著下降（297.0±44.8 vs 215.0±41.2 mm H2O,P =0.004）。76例患者完成了1年临床随访,其中64例 视力障碍患者中56例（87.5%）明显好转,43例头痛患者中40例（93.0%）头痛减轻或消失。DSA检查随 访62例,3例（4.8%）出现支架内再狭窄,2例（3.2%）出现硬脑膜动静脉瘘。 结论 静脉窦支架置入术是治疗合并静脉窦狭窄的IIH的一种安全、有效的治疗方式。     

"Tram-track" sign and "donut configuration" in Tolosa-Hunt syndrome]

We report unique MRI abnormalities seen in a patient with Tolosa-Hunt syndrome (THS). A 60-year-old woman was admitted for left eye symptoms, including periorbital pain, numbness around the left eyebrow, blurred vision, delayed light reflex and impairment of abduction. Laboratory studies were unremarkable except for elevated erythrocyte sedimentation rates. T1-weighted MRI showed a mass lesion in the left orbital apex. Fat-suppressed T2-weighted MRI showed a hyperintense parallel linear lesion on the left optic nerve and a ring lesion around it, producing the "tram-track" sign on the axial view and the "donut configuration" on the coronal view. A diagnosis of THS was made, and corticosteroid therapy was started. Symptoms were improved rapidly, and MRI abnormalities disappeared. Reevaluation of MRI which had been taken at the previous episode of the right eye symptoms two years before also showed the "tram-track" sign and the "donut configuration" on the right. These signs are easy to be recognized and well reflect the stage of the disease. They are thus useful for diagnosing THS and evaluating the effect of the treatment. One should pay attention not only to the cavernous sinus and orbital apex, but also to the optic nerve for the MRI diagnosis of THS.     

A case of CNS aspergillosis developing orbital apex syndrome and causing mycotic aneurysm and the subsequent cerebral infarction]

A 79-year-old woman, with no immune deficit, had presented progressive visual disturbance, diplopia and ptosis of her left eye over 2 weeks. T1-weighted MR images with gadolinium showed a heterogeneously enhanced lesion extending from the left orbital apex along the optic nerve to the cavernous sinus. Although we could not detect fungus by a transsphenoidal biopsy, we suspected fungal infection because of high level of galactomanan antigen in serum. Despite antifungal chemotherapy, her symptoms did not improve. CT image on day 40 showed an aneurysm in the left internal carotid artery, on day 43 cerebral infarction in the left internal carotid artery distribution and on day 45 she died. Autopsy disclosed that aspergillus hyphae invaded the left sphenoid sinus, cavernous sinus and wall of the aneurysm. In this case, fungal infection in the frontal skull base including orbital apex caused mycotic aneurysm in the intracavernous portion of the left internal carotid artery. Skull base aspergillosis presenting orbital apex syndrome is itself rare and in addition, the occurrence of cerebral infarction in the mycotic aneurysm has hardly been reported. We should have cerebrovascular disease in mind as a complication of CNS aspergillosis.