立体定向治疗帕金森病的CT影像学研究

目的评价CT扫描在立体定向治疗帕金森病术前病例筛选、毁损灶定位中的价值,探讨术后毁损灶CT表现及其与疗效的关系。方法采用GE—speedⅡ型螺旋CT分别行平扫筛选、CT扫描计算机靶点定位立体定向丘脑腹外侧核（Vim）或苍白球腹后外侧部（Gpi）毁损及CT术后复查。结果CT定位术前准确率为92．52％,术后证实准确率为83．67％,治疗有效率为94．56％,并发症发生率为5．44％,症状再发率为3．61％。结论CT扫描定位导引立体定向治疗原发性帕金森病靶点定位准确,疗效显著、稳定持久;术前CT筛选适应证、术中及时电生理刺激纠偏,术后及时复查CT,是保证疗效、减少或避免并发症必不可少的环节。     

立体定向微电极导向射频毁损术治疗帕金森病375例

目的 探讨立体定向微电极导向射频毁损术治疗帕金森病(PD)及术后可能出现的并发症。方法 采用CT定位，立体定向微电极细胞电生理记录技术进行术中靶点监测，对375例PD病人的苍白球和(或)丘脑腹外侧核进行射频毁损术治疗。结果手术效果优良，原有症状术后改善率91％。结论 立体定向微电极导向射频毁损术是目前治疗PD的一种安全有效方法。     

微电极引导结合术中电生理刺激定位射频对帕金森病患者肢体震颤与僵直及运动迟缓的改善作用

目的:探讨立体定向微电极引导结合术中电生理刺激精确定位射频治疗帕金森病的方法和疗效。方法:98例帕金森病患者为1998-05/2003-12河北医科大学第一医院神经外科收治,对患者先进行螺旋CT扫描影像学定位后,术中在微电极监测引导下进行细胞生理定位并结合电生理刺激验证进行丘脑腹中间核和/或苍白球腹后内侧部射频毁损术。观察术前术后对药物反应情况和症状改善程度。结果:电生理监测下的立体定向射频毁损术对帕金森病患者的震颤、僵直、运动迟缓均有明显的改善,其中对震颤的缓解率为100%,运动迟缓改善率69%,僵直症状术后75%明显改善。Hoehn-Yahr分级显著改善,并发症的发生率较单独应用电刺激明显减少。结论:术中应用微电极技术结合电生理刺激的立体定向射频毁损术对帕金森病有良好的治疗效果。     

微电极引导结合术中电生理刺激定位射频对帕金森病患者肢体震颤与僵直及运动迟缓的改善作用

探讨立体定向微电极引导结合术中电生理刺激精确定位射频治疗帕金森病的方法和疗效。方法：98例帕金森病患为1998—05／2003-12河北医科大学第一医院神经外科收治，对患先进行螺旋CT扫描影像学定位后，术中在微电极监测引导下进行细胞生理定位并结合电生理刺激验证进行丘脑腹中间核和／或苍白球腹后内侧部射频毁损术。观察术前术后对药物反应情况和症状改善程度。结果：电生理监测下的立体定向射频毁损术对帕金森病患的震颤、僵直、运动迟缓均有明显的改善，其中对震颤的缓解率为100％，运动迟缓改善率69％，僵直症状术后75％明显改善。Hoehn-Yahr分级显改善，并发症的发生率较单独应用电刺激明显减少。结论：术中应用微电极技术结合电生理刺激的立体定向射频毁损术对帕金森病有良好的治疗效果。     

微电极引导立体定向术治疗帕金森病

目的 :探讨磁共振扫描 (MRI)结合微电极导向技术定位在帕金森病 (PD)立体定向毁损手术中的作用。方法 :MRI扫描解剖定位结合微电极记录电生理验证 ,行立体定向苍白球PVP核 /丘脑Vim毁损术 78例 ,分析术中靶点移位情况 ,手术效果和并发症发生率。结果 :PD患者肢体震颤、僵硬及运动迟缓均得到明显改善 ,术前术后UPDRS评分均显著改善 (P <0 0 5 ) ,无严重及永久并发症 ,脑内出血发生率低。结论 :MRI结合微电极记录导向技术显著提高PD手术治疗靶点定位精度及疗效。     

微电极导向立体定向射频治疗帕金森病的疗效研究

目的 探讨微电极导向立体定向射频治疗帕金森病。方法 通过微电极对 105例经 CT定位选择苍白球和丘脑腹外侧核靶点的神经核团放电信号描记,找出其界值,明确苍白球内侧部 (Gpi)和丘脑中间核 (Vim)生理靶点,达到治疗的目的。结果 Gpi生理靶点与 CT靶点更换率 65.26％, Vim生理靶点与 CT靶点更换率 22.59％,治愈率 97.14％,并发症 0.95％。结论 采用微电极导向技术可达到细胞水平的精确定位。     

脑立体定向术治疗60例帕金森病的临床研究

目的：本研究旨在运用脑立体定向技术治疗帕金森病(PD)，研究靶点的选择、影像学定位、电生理刺激，评估手术疗效。方法：通过GT或MR导向，辅以电生理刺激矫正靶点，对60例帕金森病患者行丘脑(Vim)或苍白球腹后部(PVP)进行射频术；或对底丘脑核(STN)进行脑深部刺激(DBS)。根据术前、术后Webster和UPDRS评分比较临床治疗效果。结果：在60例的手术治疗中，包括2例进行了对侧：二次PVP手术，5例进行了DBS。结果：显示有效率100％，术后1个月Webster评分下降了30％，UPDRS评分下降了37％；术后3个月Webster评分下降了31％，UPDRS评分下降了39％。患者生活质量明显提高，无永久性手术并发症和死亡。结论：从治疗效果来看，PD的手术治疗优于单纯的药物治疗；通过MR导向，术中运用电生理刺激和微电极定位使靶点更加准确；对于PD的主要症状的控制，选择Vim或PVP是最佳的靶点；DBS对PD症状的控制较毁损疗效持久，且并发症少；PD患者第二次手术靶点应首选PVP。     

微电极导向内侧苍白球腹后部毁损术改善帕金森病合并轻中度抑郁的机制

目的分析评估微电极导向内侧苍白球腹后部毁损术对帕金森病(PD)合并轻中度抑郁的疗效,探讨其机制。方法PD合并轻、中度抑郁患者36例,于微电极导向单侧苍白球腹后部毁损术前10d及术后2周进行肢体运动功能障碍及抑郁疗效的评估。结果36例患者术后在肢体运动功能障碍明显改善的同时,其抑郁情绪亦有明显的改善,Webster记分、SDS总分、HAMD总分均较术前明显降低(P<0.01),有效率91.67%。靶点更换率100%,经微电极导向技术再确认的靶点较影像学确定的靶点更偏向内侧苍白球的内侧及腹侧。结论微电极导向的内侧苍白球腹后部毁损术对PD合并的轻、中度抑郁有明显的改善作用。     

脑慢性深部电刺激治疗难治性帕金森病及特发性震颤

目的 应用脑慢性深部电刺激 (DBS)治疗难治性帕金森病 (PD)及特发性震颤 (ET),并对其疗效作出评价。方法 对 6例 PD患者及 2例 ET患者采用磁共振导向立体定向及术中电生理验证方法。将刺激电极分别植入丘脑腹中间核及丘脑底核,并同期植入刺激发生器。结果 6例患者术后获得了显著的疗效,震颤完全消失,肌张力恢复正常,步态、姿势明显改善,未出现任何并发症。结论 DBS作为目前最理想的手术方法治疗药物难治性 PD、 ET,具有极少副作用、可逆转性的优点,能完全控制震颤,明显改善肌张力障碍、步态、姿势等运动障碍。     

计算机辅助、立体定向脑内靶点定位结合术中电生理刺激治疗帕金森氏病的围术期护理

我院自1999—2003年应用计算机辅助立体定向脑内靶点定位结合术中电生理刺激治疗帕金森氏病116例，取得满意效果，现将围手术期护理经验总结如下。     

微电极导向立体定向毁损术改善帕金森病症状的中远期疗效分析

目的评价微电极导向立体定向毁损术治疗帕金森病 ( PD) 的中远期疗效及总结临床治疗经验 . 方法对行微电极导向选择性苍白球腹后部和 /或丘脑损毁术的 102例次 PD患者的临床及随访资料进行分析 . 结果全组随访 3个月～ 2年 . 其中 72例随访 1年以上 , 平均 1.6年 . 6例患者的运动迟缓症状于手术半年后有不同程度的复发 , 震颤、僵直、药物诱发的运动障碍等症状及大部分患者的日常生活活动基本维持稳定的改善 . 无严重、永久的并发症 . 结论微电极导向立体定向毁损术治疗 PD有普遍稳定的疗效 , 其中以震颤、僵直及药物所致的运动障碍的改善稳定性较好、运动迟缓及中轴症状次之 . 除毁损靶点的精确定位外 , 适应证的合理选择以及科学合理的术后用药和康复治疗是全面提高疗效、改善患者中远期生存质量的重要因素 .     

颅底脑膜瘤立体定向放射治疗与手术相结合初探

目的：探讨立体定向放射治疗颅底脑膜瘤与开颅手术相互关系和必要性。方法：回顾性分析了43例颅底脑膜瘤手术加立体定向放射治疗和手术加立体定向放射治疗再加手术治疗以及立体定向放射治疗后再行手术的临床资料。结果：本组43例全部随访12～48月。其中12例手术加立体定向放射治疗12月缩小率为25.00％，48月缩小率为66．69％，肿瘤控制率100％。19例手术加立体定向放射治疗再加手术治疗肿瘤控制率94．74％，无效率5．26％。12例行立体定向放射神经治疗后再行手术治疗，肿瘤控制率91．67％无效率9．33％。结论：对于血运丰富的肿瘤经立体定向放射治疗后在开颅手术中出血少、损伤轻、肿瘤大部能全切。手术加主体定向放射治疗和手术加立体定向放射治疗再加手术成为提高治脑膜瘤疗效的又一种选择。     

CT监视立体定向抽吸术治疗850例脑内血肿临床分析

目的：总结CT监视立体定向抽吸术治疗脑内血肿时间,方法及结果,进一步提高疗效,降低致残率和病死率。方法：通过CT监视立体定向血肿抽吸术治疗脑出血850例,包括皮质下血肿156例,基底节血肿563例,丘脑血肿86例,脑干血肿40例,小脑血肿5例;血肿大小：＜30ml 115例,30－60ml 336例,61－100ml 343例,＞100ml 56例。抽吸距发病时间3－7小时57例,7－72小时449例,72小时－7日315例,7－14日29例。结果：存活685例,死亡165例,病死率19．4％;不同部位血肿病死率：脑干血肿57．5％,丘脑血肿31．4％,基底节血肿19．6％,皮质下血肿3．9％,小脑血肿无死亡。血肿一次抽吸≥85％者432例,血肿一次抽吸50％－84％者306例,血肿一次抽吸＜50％者108例,完全无法抽出4例。结论：超早期和早期CT监视立体定向抽吸术治疗脑内血肿,是一种简单、安全和有效的微侵袭治疗方法。     

MRI引导下立体定向活组织检查诊断中枢神经系统淋巴瘤

目的:探讨MRI引导下立体定向活组织检查(活检)手术在中枢神经系统淋巴瘤诊断中的应用,提高中枢神经系统淋巴瘤的诊断水平.方法:对16例疑诊中枢神经系统淋巴瘤的患者行MRI引导下立体定向活检手术.安装Leksell立体定向头架,行MRI扫描,计算靶点取标本,所取标本送病理学检查.结果:16例患者手术成功率100％,经病理证实,均诊断为中枢神经系统淋巴瘤,其中15例为弥漫性大B细胞淋巴瘤,1例为Burkitt淋巴瘤.术后复查CT有4例出现血肿,1例患者于术后第4日出现迟发性出血、脑疝,行开颅手术后死亡.结论:立体定向活检术对于明确诊断中枢神经系统淋巴瘤,具有重要的应用价值.     

A prospective cost-effectiveness study of trigeminal neuralgia surgery

OBJECTIVES: Approximately 8000 patients with trigeminal neuralgia undergo surgery each year in the United States at an estimated cost exceeding $100 million. We compared 3 commonly performed surgeries (microvascular decompression, glycerol rhizotomy, and stereotactic radiosurgery) to evaluate the relative cost-effectiveness of these operations for patients with idiopathic trigeminal neuralgia. METHODS: Prospective nonrandomized trial at a tertiary referral center from July 1999 to December 2001. One hundred twenty-six consecutive patients underwent 153 operations (microvascular decompression, n=33; glycerol rhizotomy, n=51; stereotactic radiosurgery, n=69). Preoperative characteristics were similar between the groups with respect to sex, pain location, duration of pain, and atypical features. Facial pain outcomes were classified as excellent (no pain, no medications), good (no pain, reduced medications), fair (>50% pain reduction), and poor. The cost per quality adjusted pain-free year was compared between the groups. Mean follow-up was 20.6 months. RESULTS: Patients having microvascular decompression more commonly achieved and maintained an excellent outcome (85% and 78% at 6 and 24 months) compared with glycerol rhizotomy (61% and 55%, P=0.01) and stereotactic radiosurgery (60% and 52%, P<0.01). No difference was detected between glycerol rhizotomy and stereotactic radiosurgery (P=0.61). The cost per quality adjusted pain-free year was $6,342, $8,174, and $8,269 for glycerol rhizotomy, microvascular decompression, and stereotactic radiosurgery, respectively. Reduction in the average cost of morbidity and additional surgeries to zero did not make either microvascular decompression or stereotactic radiosurgery more cost-effective than glycerol rhizotomy. Both microvascular decompression and stereotactic radiosurgery would be more cost-effective than glycerol rhizotomy if the cost of additional surgeries after glycerol rhizotomy increased 79% and 83%, respectively. DISCUSSION: This analysis supports the practice of percutaneous surgeries for older patients with medically unresponsive trigeminal neuralgia. At longer follow-up intervals, microvascular decompression is predicted to be the most cost-effective surgery and should be considered the preferred operation for patients if their risk for general anesthesia is acceptable. More data are needed to assess the role that radiosurgery should play in the management of patients with trigeminal neuralgia.     

微电极引导立体定向手术改善老龄帕金森病患者静止性震颤、僵直及运动迟缓的效果分析

目的介绍微电极引导立体定向手术治疗老龄帕金森病(PD)改善静止性震颤、僵直、运动迟缓的方法和结果。方法采用立体定向手术,术中行微电极记录技术靶点监测,对28例70岁以上老龄PD患者行丘脑腹外侧核(VL)、苍白球腹后内侧部(Gpi)射频毁损,其中2例A型(震颤型)患者行单侧VL毁损术,1例A型患者行双侧VL毁损术;26例行Gpi毁损术,其中1例行同期单侧Gpi及VL毁损术,术前及术后12月应用motorUPDRS量表进行评价。结果2例VL毁损术后12月,肢体静止性震颤完全或基本消除,其中1例下颌静止震颤有明显缓解;26例行Gpi毁损术,术后静止性震颤、僵直、运动迟缓均有较大改善。结论微电极引导立体定向手术是治疗老龄PD的有效手段之一,但是要严格掌握适应证。     

Factors affecting the use of peritoneal dialysis among the ESRD population in India: a single-center study.

OBJECTIVES: Factors such as limited health-care budget allotment and poor accessibility of the majority of the population to hemodialysis (HD) facilities should favor the use of peritoneal dialysis (PD) in India. However, only 6% of end-stage renal disease patients undergoing dialysis in India are on PD. We undertook this prospective study to evaluate various factors that could contribute to this low rate of use of PD at a tertiary-care state-run hospital in Northern India. METHODS: All the patients who entered our HD or PD program from August 2001 to December 2003 were interviewed using a preset questionnaire. The questionnaire recorded their basic disease and comorbidity, social and demographic characteristics, awareness of the various modalities of renal replacement therapy (RRT), and the reasons for choosing their present modality of therapy. Treating nephrologists were also interviewed with respect to the factors that, in their opinion, were responsible for the limited use of PD at our institute. RESULTS: In total, 342 patients on HD, 66 patients on PD, and 24 nephrologists were interviewed. The rate of PD use was 16.2%. Mean age of patients on HD and PD was 34.6 +/- 11.8 years and 62.9 +/- 10.3 years respectively (p < 0.0001). The incidence of diabetes mellitus and coronary artery disease in the HD and PD populations was 2.5% and 62.5%, and 9.1% and 46.7% respectively (p < 0.0001 for both). Only 30.4% of patients on HD were aware of PD as a modality of RRT and 83.6% of them found PD to be expensive, 65.4% had low enthusiasm toward a domiciliary therapy such as PD, and 61.5% were not recommended PD by their nephrologist. Only 5 (7.6%) patients were initiated on PD directly, the remaining 61 patients were shifted from HD after a mean duration on HD of 185.3 +/- 15.4 days: 67.1% were shifted due to poor tolerance of HD, 29.4% were advised to shift to PD because of comorbidity and vascular access problems, and only 3.3% took up PD because of the independent lifestyle it offered. None of the interviewed nephrologists routinely discussed PD in predialysis counseling. They found financial constraints (100%), lack of patient enthusiasm (100%), doubtful patient compliance (83.2%), and lack of an organized PD program (79.2%) to be the main factors limiting more widespread use of PD at our institute. CONCLUSIONS: Peritoneal dialysis is an underused modality of RRT at our institute. The patients who are taken up for PD at our institute are elderly and have a higher incidence of other comorbid conditions, such as diabetes mellitus and coronary artery disease. Also, most patients who switch to PD do so due to their unsuitability for HD rather than by their own choice. The factors contributing to this low rate of use of PD are ignorance of PD, increased cost of therapy, low enthusiasm toward domiciliary therapy, and lack of adequate infrastructure for PD at our institute. Effective predialysis counseling, reduction in the cost of the therapy, and development of an adequate infrastructure can increase the rate of use of PD.     

肾上腺无功能性肿瘤26例分析

１９８３年７月至１９９３年６月期间共收治肾上腺无功能性肿瘤２６例,占同期肾上腺肿瘤的１４．２％。资料显示Ｂ超是早期筛选和诊断的有效手段,ＣＴ检出率达１００％。本组恶性肿瘤占３８．５％,最小直径仅２ｃｍ,故即使是无功能性肿瘤也宜手术治疗。术前应行详细的生化检查以便与“静止性”有功能肾上腺肿瘤,特别是“静止性”嗜铬细胞瘤相鉴别。     

The effect of technique failure on outcome in black patients on continuous ambulatory peritoneal dialysis.

BACKGROUND: We previously reported that, while black patients have a better patient survival than white patients on peritoneal dialysis (PD), they also have a significantly higher technique failure rate (39% vs 8%, p < 0.0001). The purpose of this study was to determine the effect of technique failure/transfer to hemodialysis (HD) on patient survival in black PD patients. METHODS: We retrospectively evaluated 137 incident black patients entering our PD program from January 1987 to December 1997. During the course of follow-up, 82 (60%) patients remained on PD (PD group) while 55 (40%) patients were permanently transferred to HD (PD-HD group). The primary outcome measured was patient survival. RESULTS: Average age was 49 +/- 15 years, 42% were male, and 40% had diabetes mellitus. At baseline, serum creatinine was 10.8 +/- 5.4 mg/dL, serum albumin 3.4 +/- 0.7 g/dL, body mass index 27.3 +/- 6.5 kg/m2, peritoneal transport status was high in 18% and high-average in 61%, and residual glomerular filtration rate was 3.4 +/- 3.5 mL/minute. There were no significant differences in clinical features, nutritional status, peritoneal transport, residual renal function, or dialysis adequacy at baseline between the PD group and PD-HD group. While a greater proportion of patients transferring to HD had cardiac disease (53% vs 32%, p < 0.05), there were no other significant differences in 15 comorbid conditions assessed at baseline. The primary reason for transfer was peritonitis (64%) and the overall peritonitis rate in the PD-HD group was significantly higher than in the PD group (2.21 vs 1.17 episodes/patient-year, p < 0.0001). Overall follow-up was 34 +/- 25 months for PD group and 44 +/- 26 months for PD-HD group (p < 0.01), with a mean time on PD prior to transfer to HD of 22 +/- 18 months. During the course of follow-up, there were no significant differences between the two groups in the number of patients transplanted or deaths. Patient survival at 1, 2, and 5 years was 91%, 80%, and 57% for PD group and 96%, 92%, and 55% for PD-HD group [p = not significant (NS)]. A risk-adjusted time-dependent Cox regression analysis resulted in an adjusted relative risk of death that was not significantly different for those who transferred from PD to HD versus those who remained on PD (relative risk 1.49; 95% confidence interval 0.77-2.89; p = NS). CONCLUSIONS: In black patients on PD, transfer to HD is not associated with any significant difference in patient survival compared to patients remaining on PD. While a high rate of peritonitis predisposes to technique failure, we found no features at baseline predictive of patients at greatest risk to fail PD. Since technique failure does not portend a poorer prognosis, PD remains a viable option for black patients entering an end-stage renal disease program.