重型颅脑损伤合并脑疝的救治与预后分析

目的总结重型颅脑损伤合并脑疝的救治经验并分析其预后情况。方法回顾性分析68例重型颅脑损伤合并脑疝患者的临床资料,根据不同手术方法、GCS评分与病情分别分析其预后情况。结果GCS评分3～5分患者的死亡率显著高于GCS评分6～8分患者(P＜0．05),幕上去大骨瓣减压 颅内血肿清除 小脑幕切开手术方式治疗的患者死亡率明显低于单侧幕上去大骨瓣减压 颅内血肿清除手术方式治疗的患者(P＜0．05)。结论重型颅脑损伤合并脑疝的临床疗效与GCS评分和手术方式密切相关。     

重型颅脑创伤患者血清COR、ACTH及血糖的变化

目的评估重型颅脑创伤患者伤后不同时期的血清皮质醇(COR)、促肾上腺皮质激素(ACTH)及血糖水平的变化,及其在伤情判断与预后中的作用。方法前瞻性选择重型颅脑创伤患者56例,正常对照组23例,重型颅脑创伤患者按入院时GCS评分分为重型组(6～8分)、特重型组(3～5分)两个亚组,治疗4个月后对比预后评分(GOS评分),测定不同时期血清COR、ACTH及血糖浓度。结果 GCS 3～5分与6～8分组血清COR、ACTH及血糖浓度入院后5 d内均显著增高,与对照组比较差异有显著性(P<0.01),GCS 3～5分组血清COR、ACTH、血糖浓度高于GCS 6～8分组(P<0.05)。GCS 3～5分组死亡率明显高于6～8分组,颅脑损伤组第1 d血清COR、ACTH、血糖浓度均显著高于对照组(P<0.01)。结论重型颅脑创伤患者伤后血清COR、ACTH及血糖均有不同程度的增高,监测血清COR、ACTH及血糖浓度可作为判断患者病情轻重、治疗效果和预后的一项重要指标。     

重型颅脑损伤患者上消化道出血的预防

颅脑损伤后急性上消化道出血是最常见并发症之一,相关报道其发生率达16％-47％,在严重脑损害达40％-80％,死亡率可达30％-50％[1]。现将我院1997年3月至2000年10月收治117例重型颅脑损伤（GCS3-8分,昏迷6小时以上）患者预防上消化道出血的经验报告如下。     

血糖变化对急性严重颅脑损伤程度及预后评估的价值

目的探讨急性严重颅脑损伤患者血糖变化与预后的关系,为颅脑损伤患者伤情及预后判断提供理论依据。方法根据发病与否分为颅脑创伤组和对照组;以入院时GCS评分判定病情分成3~4分组(10例),5~6分组(15例),7~8分组(23例);按照预后分为存活和死亡2组。结果急性颅脑创伤患者的血糖含量明显高于对照组(P<0.01);GCS评分3组间血糖值有显著性差异(P<0.01);血糖水平与GCS评分呈显著负相关(r=-0.721,P<0.01);死亡组的血糖含量明显高于非死亡组(P<0.01)。结论颅脑损伤后血糖值可作为判断伤情的指标,应重视颅脑损伤患者血糖监测,努力控制高血糖,提高急性严重颅脑创伤患者的治愈率。     

重型颅脑损伤死亡原因分析及预防

目的 探讨重型颅脑损伤的死亡因素和防治对策。方法 回顾我院1998-11～2003-11收治116例重型颅脑损伤病人的临床资料。结果 116例重型颅脑损伤病人中GCS6～8分73例，死亡12例，死亡率16．44％：3～5分43例，死亡21例，死亡率48．84％；GCS3～8分116例，死亡33例，死亡率28．45％。结论 重型颅脑损伤应尽早确立主要临床诊断、及早解除脑受压、积极防治并发症，是降低死亡率的关键。     

颅脑损伤并发上消化道出血机制及防治

目的：探讨颅脑损伤并发上消化道出血机制及防治。方法：回顾性分析本科自1995年以来诊治颅脑损伤477例,其中并发上消化道出血54例。结果：颅脑损伤越严重,GCS评分越低,上消化道出血发生率越高。脑干及下丘脑部损伤后上消化道出血发生率高。重型颅脑损伤患者预防用药后上消化道出血发生率低于未用药者。结论：出血与GCS评分、受伤程度有密切关系,同时,早期预防用药能降低其发生率,提高治愈率。     

颅脑损伤并发上消化道出血机制及防治

目的 :探讨颅脑损伤并发上消化道出血机制及防治。方法 :回顾性分析本科自 1995年以来诊治颅脑损伤 4 77例 ,其中并发上消化道出血 5 4例。结果 :颅脑损伤越严重 ,GCS评分越低 ,上消化道出血发生率越高。脑干及下丘脑部损伤后上消化道出血发生率高。重型颅脑损伤患者预防用药后上消化道出血发生率低于未用药者。结论 :出血与GCS评分、受伤程度有密切关系 ,同时 ,早期预防用药能降低其发生率 ,提高治愈率     

颅脑损伤并发上消化道应激性溃疡出血的预防及诊治分析

目的研究颅脑损伤后并发上消化道应激性溃疡出血的发病因素和预防、诊治。方法发现颅脑损伤后并发上消化道应激性溃疡出血者均静脉给予氨甲环酸及洛赛克,同时,胃内注入凝血酶、云南白药及去甲肾上腺素一冰盐水等综合治疗。结果96例颅脑损伤患者中,并发消化道应激性溃疡出血者12例,GCS评分6～8分10例,3～5分2例,死于消化道应激性溃疡出血者3例,证实颅脑损伤越重,GCS评分越低,高龄患者,本身基础病越重,其发生消化道应激性溃疡出血及病死率越高。结论颅脑损伤病人应注意并发消化道应激性溃疡出血的可能性,密切观察,并采取综合性防治措施,去除应激因素,改善预后。     

重型颅脑损伤256例临床分析

目的 探讨重型颅脑损伤治疗方法,提高重型颅脑损伤的治愈率和降低致残率、死亡率。方法 对我院2000-01～2005-12收治的256例重型颅脑损伤（GCS≤8分）的患者救治效果进行回顾性分析。结果 256例患者中,174例患者GCS评分6～8分,82例特重型颅脑损伤（GCS评3～5分）,恢复良好148例（57．8％）,中残57例（22．3％）,重残以及植物状态13例（5．1％）,死亡38例（14．9％）。结论 重型颅脑损伤应加强院前急救处理．早期明确诊断,手术中应充分减压以减轻对脑干的压迫,早期行气管切开、亚低温治疗和使用钙离子拮抗剂,昏迷时间较长者行高压氧治疗,密切监测生命体征和颅内压变化,积极防治并发症,是提高治俞率、改善预后和降低致残率、死亡率的有效措施.     

改良CT图像评分对重型颅脑损伤昏迷患者预后评估的临床价值

目的 探讨改良CT图像评分对重型颅脑损伤昏迷患者预后评估的作用. 方法 回顾性分析南方医科大学附属花都医院神经外科自2010年6月至2011年9月收治的90例重型颅脑损伤昏迷患者的临床资料,根据预后分为清醒组和昏迷组.应用改良CT图像评分法对患者的CT图像进行评分,并分析其与患者病情严重程度及预后的关系. 结果 昏迷组患者的改良CT图像评分明显高于清醒组,差异有统计学意义(P＜0.05).GCS评分3～5分组患者改良CT图像评分明显高于6～8分组,差异有统计学意义(P＜0.05); Spearman相关分析显示患者改良CT图像评分与GCS评分呈负相关关系(r=-0.790,P=0.000). 结论 改良CT图像评分有助于评估患者病情、预后及指导临床诊治,具有良好的临床应用价值.     

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.