经小脑延髓裂夹闭小脑后下动脉远端动脉瘤

目的探讨经小脑延髓裂入路手术夹闭小脑后下动脉远端动脉瘤的优点及显微手术技巧。方法 23例手术夹闭小脑后下动脉远端动脉瘤均经后颅窝正中开颅,经小脑延髓裂入路,显微镜下夹闭小脑后下动脉远端动脉瘤。结果 23例患者,共33枚动脉瘤,完全夹闭31枚,2枚切除,夹闭率94.9%。无一例手术死亡。结论经小脑延髓裂入路夹闭小脑后下动脉远端动脉瘤,不需切开小脑下蚓部,可有效的清除第四脑室血肿,降低脑压。使血管神经显示更加清楚,不损伤任何小脑组织,能最大限度地减少牵拉血管及神经组织,减少动脉瘤的术中破裂,使手术更安全。术后患者不良反应小。     

小脑动脉远端动脉瘤的介入治疗

目的总结小脑动脉远端动脉瘤的临床和影像学特征,探讨血管内介入治疗方法的安全性及有效性。方法回顾性分析8例小脑动脉远端动脉瘤病人的临床资料,动脉瘤位于小脑上动脉(SCA)2例,小脑前下动脉(AICA)3例,小脑后下动脉(PICA)3例;其中伴小脑动静脉畸形(AVM)4例。单纯弹簧圈栓塞动脉瘤3例,弹簧圈同时闭塞动脉瘤及载瘤动脉5例;生物胶栓塞AVM 3例,伽玛刀治疗AVM 1例。结果动脉瘤均达到完全栓塞,术后出现小脑梗死2例。出院时改良Rankin评分:0分2例,1分5例,2分1例。随访2~40个月,均无动脉瘤再次出血、复发及死亡病例。结论小脑动脉远端动脉瘤血管内介入治疗安全可行,能有效预防短、中期再出血,但需定期血管造影随访以防止复发。     

小脑后下动脉远端动脉瘤的临床治疗

目的 总结小脑后下动脉( PICA)远端动脉瘤的临床特点,探讨其临床治疗方式的选择.方法 回顾性研究16例PICA远端动脉瘤的临床特点及治疗.6例行后正中入路开颅动脉瘤夹闭术;4例行枕下远外侧入路动脉瘤夹闭术;6例行血管内栓塞术.结果 术后15例恢复良好,1例死亡,1例合并交通性脑积水,行脑室-腹腔分流术.15例出院时均无神经系统阳性体征,随访患者恢复良好.结论 对于PICA远端动脉瘤的治疗,应根据患者的临床情况及动脉瘤和PICA的形态,可以选择开颅夹闭或血管内栓塞.     

颅内动脉瘤栓塞术后复发的手术治疗

研究背景血管内介入治疗是目前颅内动脉瘤的首选治疗方法,但复发率较高,部分患者因再次栓塞困难须行手术夹闭治疗。本文回顾分析行手术夹闭治疗的11例栓塞不全或复发的颅内动脉瘤患者的临床资料,结合国内外相关文献报道,探讨手术治疗原则和技巧。方法 11例栓塞不全或复发的颅内动脉瘤患者共有12个动脉瘤,其中前交通动脉动脉瘤3个,大脑中动脉动脉瘤3个,后交通动脉动脉瘤2个,大脑前动脉、椎动脉、基底动脉尖端和小脑上动脉动脉瘤各1个;小动脉瘤7个,大动脉瘤4个。所有患者均于手术显微镜下行动脉瘤夹闭术,11个夹闭完全,1个行椎动脉近端阻断术;术中7个动脉瘤内弹簧圈予以保留,5个予以去除或部分去除。结果所有患者术后平均随访22个月,Glasgow预后分级评分较术前增加或无变化9例(9/11),其中1例术后左侧肢体肌力减退,肌力3级,出院时恢复至4~5级;2例死亡,1例术前病情较重、出院后即死亡,1例载瘤动脉血栓形成、继发肺炎死亡。结论血管内介入治疗后复发动脉瘤具有较高的手术难度,只要进行充分的术前评估和手术方案设计,手术夹闭治疗依然能够取得安全有效的效果。     

小脑后下动脉动脉瘤

小脑后下动脉动脉瘤(PICCA)是临床中比较少见且处理困难的一种疾病.小脑后下动脉的行程复杂且解剖变异大.PICCA的手术入路主要有枕下远外侧入路及经髁凹入路,在PICA的近端及过渡段行动脉瘤孤立术或夹闭载瘤动脉需行血管重建术.部分小脑后下动脉动脉瘤可行血管内介入治疗.手术治疗及血管内介入治疗两者都有相应的适应症及并发症,目前还不能互相替代.     

急诊手术治疗大脑中动脉动脉瘤破裂合并脑内血肿

目的 总结大脑中动脉动脉瘤破裂合并脑内血肿的急诊手术方法 及疗效.方法 急诊手术治疗大脑中动脉动脉瘤破裂合并脑内血肿患者13 例,术中均先清除部分血肿减压,然后采用经侧裂近端-远端入路行动脉瘤夹闭术.8 例患者术前行CTA 检查明确动脉瘤,5 例患者直接手术探查发现动脉瘤.结果 13例患者均在血肿清除同时成功夹闭动脉...     

小脑前下动脉瘤11例临床分析

目的 总结小脑前下动脉瘤的临床和影像学特点，以及手术夹闭与介入治疗两种方法的治疗效果。 方法 回顾性分析首都医科大学附属北京天坛医院神经外科2012年1月-2019年12月收治的小脑前 下动脉瘤患者的基线信息、临床表现、动脉瘤特点、治疗方式和治疗效果。 结果 共收治11例小脑前下动脉瘤患者，其中显微外科手术夹闭动脉瘤5例，治愈率100%，术后2例 （40%）出现不完全性失语和手术侧面瘫，随访均无复发；介入治疗6例，5例（83.3%）完全栓塞动脉 瘤，其中2例（33.3%）闭塞动脉瘤远端载瘤动脉，1例（16.7%）栓塞治疗失败，术后1例（16.7%）出现 记忆力下降，1例（16.7%）出院1个月后动脉瘤破裂，并最终死亡。 结论 对于小脑前下动脉瘤，积极干预对于挽救患者生命意义重大，开颅手术夹闭和介入治疗都是 可选的治疗方式，两者均效果确切。     

开颅动脉瘤夹闭术治疗介入困难的小脑后下动脉动脉瘤

目的探讨开颅动脉瘤夹闭术治疗介入困难的破裂小脑后下动脉动脉瘤(PICA)的临床疗效。方法回顾性分析2010年9月至2013年4月应用开颅动脉瘤夹闭术治疗6例曾行血管内介入治疗失败的破裂PICA患者的临床资料。结果所有病例术前常规行骨窗位头颅血管成像(CTA)及全脑数字减影血管造影(DSA),明确动脉瘤大小、形态、瘤顶指向、位置,以及与周围组织结构关系,制定最佳手术入路。2例PICA延髓前段及1例延髓侧段动脉瘤采用枕下远外侧入路,1例延髓侧段PICA动脉瘤采用枕下乙状窦后入路,2例PICA扁桃体段动脉瘤采用枕下后正中入路。随访时间为3~28个月,平均10.5个月。所有患者恢复良好,无任何神经功能缺损,格拉斯哥预后评分(GOS)均为5分。CTA或DSA复查示6例PICA动脉瘤夹闭术后均无残留或复发。结论开颅动脉瘤夹闭术是破裂PICA动脉瘤难以实施血管内治疗时的一种安全、可靠的治疗方法,术前骨窗位CTA有助于制定最佳手术入路。     

复发性颅内动脉瘤的治疗探讨

目的 探讨复发性颅内动脉瘤的复发机制及治疗方法.方法 对我科1997～2004年间行动脉瘤夹闭术或血管内介入治疗后复发的18例动脉瘤患者(前循环动脉瘤13例,后循环动脉瘤5例1的临床表现、影像学资料进行综合分析,建立个体化治疗方案,其中15例患者行再次血管内介入治疗,4例宽颈动脉瘤辅以颅内支架,3例行手术夹闭.结果 15例行血管内介入治疗患者均栓塞良好.3例手术完全夹闭.术后1例死亡,2例偏瘫,15例恢复满意.结论 针对不同情况的复发性动脉瘤患者实施个体化治疗方案,分别进行手术夹闭、血管内介入或联合治疗可提高患者生存质量.     

小脑前下动脉-小脑后下动脉共干复合体动脉瘤2例报告及文献复习

目的探讨发生在共干变异的小脑前下动脉(AICA)远端动脉瘤的临床特点、治疗及并发症预防。方法回顾性分析2例合并共干变异的AICA远端动脉瘤破裂出血患者的临床资料。其中1例患者以弹簧圈加ONYX胶栓塞,并闭塞载瘤动脉;另1例患者给予弹簧圈栓塞,并闭塞载瘤动脉。并对相关文献进行复习。结果 2例患者术后均并发小脑梗死,行后颅窝减压术。患者均遗留面、听神经功能障碍,随访半年无明显恢复。其中1例患者在术后5个月行DSA复查,未见动脉瘤复发。结论对合并共干变异的AICA远端动脉瘤,为减少动脉瘤复发和再出血的风险,在血管内治疗时闭塞载瘤动脉;但可能出现严重的并发症,应慎重考虑。或可保留载瘤动脉通畅,以防止继发小脑梗死及面、听神经功能障碍。     

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.     

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.     

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.