术中磁共振影像神经导航辅助经鼻-蝶垂体瘤切除术(附42例分析)

目的探讨术中磁共振影像(iMRI)神经导航技术在经鼻-蝶垂体瘤切除手术中的应用。方法在PoleStar N20 iMRI神经导航系统辅助下施行经鼻-蝶垂体瘤切除术42例。对临床资料、iMRI成像情况及其对手术进程和手术结果的影响等进行分析。结果术中扫描2～5次,平均(2.5±0.87)次。术中扫描发现肿瘤残留13例,其中2例因肿瘤包绕颈内动脉未进一步切除,另11例进一步切除后,达到影像学肿瘤全切除6例,次全切除5例。最终肿瘤的全切除率从69.0%提高到83.3%。无与iMRI相关的并发症。结论经鼻-蝶垂体瘤切除术中应用iMRI神经导航技术,为手术进程的指导及手术结果的实时判断提供了客观依据,从而提高了肿瘤的全切除率。     

术中磁共振联合神经导航在丘脑胶质瘤手术中的应用

目的探讨术中磁共振(iMRI)联合神经导航在丘脑胶质瘤的应用价值。方法回顾性分析2014-01—2017-02应用3.0T术中磁共振联合神经导航的28例丘脑胶质瘤手术患者的临床资料,评估术后肿瘤切除程度及术后功能状态。结果 28例患者第一次iMRI扫描17例仍有病变残留,进行扩大切除9例达到完整切除,全切率从39.3%提高到71.4%,8例肿瘤边缘累及运动功能皮质或皮质脊髓束无法行完整切除。术后6个月28例丘脑胶质瘤患者神经功能改善者20例,无变化6例,下降2例。结论术中磁共振联合神经导航有助于提高丘脑胶质瘤手术精准性和安全性,提高肿瘤切除程度,最小限度减少脑功能损伤,为术后手术效果提供帮助。     

多模态多维影像融合技术在脑胶质瘤手术中的应用

目的总结1.5T术中磁共振成像联合神经导航技术用于脑胶质瘤外科手术的初步经验。方法回顾49例脑深层或功能区胶质瘤患者临床资料,分析高场强术中磁共振成像联合神经导航技术对其手术策略、肿瘤切除程度、神经功能保留情况及对神经功能转归的影响。结果每例患者均于术中行磁共振成像扫描1～3次,平均(1.57±0.68)次。首次术中磁共振成像肿瘤全切除者17例、不同程度肿瘤残留者32例,显著影响手术策略构成比约为65.31%(32/49)。残留者中9例术中磁共振成像或神经电生理监测提示肿瘤边缘毗邻脑功能区或重要解剖结构,未行全切除;余23例重新注册经导航指引最终实现影像学全切除。初次手术肿瘤全切除率为34.69%(17/49),术中磁共振成像联合神经导航辅助下实现全切除率46.94%(23/49);最终影像学全切除率提高至81.63%(40/49)。术后6个月随访,19例神经功能改善,30例神经功能恢复或接近术前水平;无一例肿瘤进展。结论高场强磁共振成像联合神经导航技术用于脑胶质瘤外科手术可提高肿瘤全切除率,保护患者神经功能。     

脑胶质瘤的微创治疗(附60例分析)

目的探讨神经导航微创手术结合激光光动力(PDT)疗法治疗脑胶质瘤的疗效。方法回顾性分析60例脑胶质瘤病例。应用GE 350磁导航系统行精确定位,在实时导航监测下行显微手术切除肿瘤,对其中40例深部肿瘤采用锁孔手术路径;术后行PDT疗法30例。结果肿瘤全切除52例(86.7%),次全切除5例(8.3%),大部切除3例(5.0%)。术后出现新的神经功能缺失4例。术后第4天因多器官功能衰竭死亡1例。结论采用微创技术切除脑胶质瘤,能够最大限度地减少手术副损伤,降低手术并发症;结合采用PDT疗法,能明显提高病人生活质量,延长生存时间。     

术中磁共振影像神经导航手术的临床初步应用

目的:探讨术中核磁共振影像神经导航(intraoperative MR image-based neuronavigation)技术在神经外科手术的意义。方法:应用PoleStarN-20术中磁共振成像(iMRI)神经导航系统施行神经外科手术22例。对其临床资料、iMRI情况,及其对手术进程和手术结果的影响进行分析。结果:22例手术中,经鼻-蝶垂体瘤切除术10例,幕上开颅肿瘤切除术10例,幕下开颅肿瘤切除术2例。iMRI扫描次数从2～5次不等,平均2.6次。共有9例术中扫描发现有肿瘤残留,其中8例(36.4%),需做进一步的切除,最终肿瘤的全切率从60%提高到86.4%。无与iMRI相关的并发症。结论:iMRI神经导航技术的应用,为神经外科手术入路的选择、皮肤切口的设计、手术进程的指导及手术结果的实时判断提供了客观的依据,从而在提高手术的精确性和安全性的同时,提高了颅脑肿瘤的全切率。     

高场强术中磁共振成像对脑胶质瘤全切率的影响及其评估

目的 探讨高场强术中磁共振成像(iMRI)对脑胶质瘤手术全切率的影响及其意义.方法 自2009年2月至6月应用高场强iMRI施行脑胶质瘤切除术40例.运用术中影像数据对胶质瘤体积及全切率做回顾性分析.结果 术中第1次行iMRI扫描仅10例胶质瘤完全切除,30例肿瘤仍有残留,23例行进一步切除,其中21例胶质瘤最终全切除.最终肿瘤的伞切率从25%提高到78%,残存肿瘤的体积也明显下降.结论 高场强iMRI的应用显著提高脑胶质瘤手术的全切率.     

3.0T 术中磁共振实时影像功能导航联合术中神经电生理监测技术在岛叶胶质瘤手术中的应用

目的评价3.0 T术中磁共振成像(intraoperative magnetic resonance imaging,iMRI)联合弥散张量成像(diffusion tensor imaging,DTI)锥体束示踪导航及术中神经电生理监测(intraoperative neurophysiologicalmonitoring,IONM)技术在各种累及岛叶的胶质瘤切除手术中的应用价值。方法 2010年9月至2011年6月以3.0 T iMRI数字一体化神经外科手术中心为平台,在iMRI功能导航结合IONM下对18例累及岛叶的胶质瘤实施切除手术。其中对10例主侧半球肿瘤采用唤醒麻醉下术中直接皮质电刺激进行语言区定位。对所有18例岛叶胶质瘤,术中均采用DTI导航结合术中连续经皮质刺激运动诱发电位和皮质下电刺激进行锥体束定位。结果通过iMRI实时扫描,18例患者中有13例发现肿瘤残留,其中6例在iMRI实时影像导航下获得了进一步切除,使肿瘤的影像学全切除率从5/18提高至9/18。经Fisher检验,iMRI前、后的肿瘤切除率(包括全切除及次全切除)具有统计学意义(P=0.046)。9例因DTI导航或IONM提示切缘临近功能皮质或深部锥体束,而未强求全切除。10例主侧半球肿瘤患者中,术后近期(1周内)出现一过性语言功能障碍5例,随访至术后1个月,语言功能均恢复到术前水平或以上;18例患者中3例术后近期出现肢体运动功能障碍,随访至术后1个月,其中2例完全恢复。总体术后1个月的神经功能障碍仅1例。无iMRI及IONM相关的并发症发生。结论应用3.0 T iMRI术中实时影像导航联合DTI锥体束示踪成像技术及IONM技术有助于最大程度地安全切除岛叶胶质瘤。     

高场强术中磁共振对脑胶质瘤切除程度及手术策略的影响

目的 评价高场强术中磁共振(iMRI)对脑胶质瘤手术切除程度及手术策略的影响.方法 解放军总医院神经外科自2009年10月至2010年6月将高场强iMRI系统应用于胶质瘤切除术患者106例,术前了解术者的切除意图(全切、次全切、大部切除),术前1 d患者常规行MRI扫描,应用影像数据和软件计算术前肿瘤体积,术中常规使用神经导航手术,依据术者的需求采集影像.必要时行iMRI扫描计算术中残余肿瘤体积和肿瘤体积切除百分比,分析使用iMRI对肿瘤切除程度、手术策略的影响.结果 术前计划全切48例,次全切41例,大部切除17例.术中第一次扫描示42例(39.6%)完全切除,64例(60.4%)仍有残留,其中25例由于肿瘤与重要功能区或重要传导束紧邻而未作进一步切除,其余39例(36.8%)改进手术策略,标记出残留肿瘤后进一步手术,25例(23.6%)胶质瘤最终全切除,肿瘤体积切除百分比由(76.5±20.5)%提高到(94.2±8.7)%,差异有统计学意义(U=2.000,P=0.000);最终实际全切67例,次全切25例,大部切除14例,全切率有所提高.106例患者平均肿瘤体积切除百分比由第一次扫描时的(86.3±20.2)%提高到最终扫描时的(93.6±12.4)%,差异有统计学意义(U=4.000,p=0.000).结论 高场强iMRI的应用可显著提高脑胶质瘤的切除程度,改进手术策略.

Abstract：

Objective To evaluate the impact of high-field intraoperative magnetic resonance imaging (iMRI) on extension of resection and surgical strategy modification for glioma surgery. Methods One hundred and six patients, admitted to our hospital from October 2009 to June 2010, were performed glioma resections with the help of high-field iMRI. Questionnaires were filled and collected prospectively to record the surgeons' intention on the extent of resection (EoR) and the intra-operative estimation of EoR before every iMRI scan. The scan imagings were collected based on the request of the surgeon, and the percentage of tumor removal was calculated according to the iMRI data. The impact of iMRI on the tumor EoR and modification of surgical strategy was then evaluated. Results Preoperatively, 48 patients were intended to achieve total tumor removal, 41 sub-total tumor removal, and 17 partial removal. The first intraoperative MRI scan revealed that 42 (39.6%) patients achieved complete resection, while residual tumors were depicted in 64 (60.4%).Further tumor resections were performed in 39 patients (36.8%), but the other 25 patients could not perform further resection for their tumors were closely neighbored to the important functional region or important tracts. Finally, in the whole cohort, the percentage of tumor resection volume was increased from (76.5±20.5)% to (94.2±8.7)%, with significant differences (U=2.000, P=0.000); 67 patients got complete removal, 25 sub-total removal and 14 partial removal; The total removal rate was significantly increased from 45.3% (48/106) to 63.2% (67/106): the average percentage of tumor resection volume in the second time of scan ([93.6±12.41%) was obviously increased as compared with that in the first scan ([86.3±20.21%, U=4.000, P=0.000). Conclusion High-field iMRI may increase the extent of glioma resection, and has significant impact on the intraoperative modification of the surgical strategy.     

复发性胶质瘤的神经导航手术治疗(附28例临床报道)

目的探讨复发性胶质瘤的手术治疗及神经导航系统在手术中的作用。方法总结28例采用神经导航系统进行手术的复发性胶质瘤病人的病例资料。位于大脑半球深部者18例,浅部者8例,位于小脑者2例。手术经原切口进入者20例,改变切口者8例。结果导航平均注册误差小于2 mm。全切除22例(78.6%),次全切除4例(14.3%),大部切除2例(7.1%)。术后症状改善或不变25例(89.3%),加重3例(10.7%)。术后对21例随访6个月,均无复发;17例随访1年,复发2例;9例随访3年,复发5例。结论神经导航系统应用于复发性胶质瘤手术治疗,有助于肿瘤的术中定位和切除范围的实时判断,从而提高肿瘤的全切除率,延缓肿瘤再复发。     

术中超声辅助神经导航技术切除岛叶胶质瘤

目的 探讨术中超声及神经导航技术在岛叶胶质瘤手术中的应用价值.方法 回顾性分析2008年1月至2013年5月在术中超声和(或)神经导航指导下经显微手术治疗的23例岛叶胶质瘤患者的临床资料,重点关注肿瘤切除程度及术后神经功能损害情况.结果 术后影像学证实肿瘤全切除14例,次全切除或大部切除9例,其中应用术中超声辅助神经导航技术定位肿瘤组肿瘤全切除8例,单独术中超声组肿瘤全切除4例,单独神经导航组肿瘤全切除2例.术后随访5 ～52个月,术中超声辅助神经导航组术后早期及远期神经功能损害程度明显低于其他两组.结论 术中超声辅助神经导航技术切除岛叶胶质瘤,可提高肿瘤全切率,增加手术安全性.     

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.