侧脑室、三脑室神经内镜应用解剖

目的：了解神经内镜下脑室的解剖特点和重要解剖标志及比较不同脑室入路的特点。方法：10例成年国人尺头、10例脑积水患者。用内镜分别从侧脑室的额角、枕角、三角区和颞角进入,观察镜下所见和脑室内各组织的毗邻关系。结果：（1）进入脑室的穿刺点有四个：额角、枕角、三角区、颞角穿刺点;（2）经额角入路暴露范围最大,前至额角,后至枕角,下至三脑室及导水管;（3）从枕角入咱可借助脉络丛定位;（4）经三角区入路既可向前进入额角,双可向后下方进入颞角,脉络从和室间孔是重要的标志。结论：（1）侧脑室形态固定,解剖标志明确,应用神经内窥镜可使脑室内的部分病变在直视下切除,并且创伤较小;（2）大多数病变采用额角、枕角入路,三角区和颞角入路可用为补充。     

前纵裂窥镜“锁孔”入路对Willis环前部的局部解剖学研究

目的探索神经内窥镜经前纵裂“锁孔”入路到达Willis环前部的可行性,为窥镜治疗该区域病变提供解剖学基础。方法本组采用6例福尔马林固定的成人尸头、4例新鲜少年尸头,用0°个软镜、0°、6°、30°硬镜交替配合使用,探讨了前纵裂窥镜“锁孔”入路。结果额部皮肤采取横行皱纹切口1.5－2cm,骨孔1cm。手术通道位于前纵裂内,窥镜经胼胝体池和鞍结节之间的解剖裂隙到达Willis环的部。窥镜“锁孔”入路可以到达Willis环前部、鞍区以及双侧视神经－颈内动脉间隙。结论内窥镜解剖是在尸头上模拟经“锁孔”入路的手术。只有掌握沿途定位标志,明确手术解剖路径,才能在“锁孔”入路中不迷失方向,为窥镜治疗Willis环前部动脉瘤、胼周动脉瘤以及鞍区其他病变如垂体瘤、颅咽管瘤、鞍结节脑膜瘤等提供了解剖学基础。     

经胼胝体前部入路的侧脑室和第三脑室显微和内镜解剖研究

目的探讨经胼胝体前部入路侧脑室和第三脑室显微镜和内镜解剖特点,为微创切除侧脑室和第三脑室病变减少并发症、提高手术效果提供解剖学依据。方法应用5具新鲜尸头模拟经胼胝体前部入路,在显微镜及神经内镜下观察侧脑室及第三脑室的重要解剖标志及其毗邻关系,测量重要解剖标志的间距。结果显微镜下侧脑室内可观察到脉络丛、隔静脉、丘纹静脉、室间孔、透明隔,内镜可进一步观察部分额角、枕角及三角区;神经内镜下第三脑室底壁从前向后依次可见视交叉、漏斗隐窝、灰结节、乳头体和中脑导水管。结论经胼胝体前部入路手术,通过颅内自然裂隙进入,直视下操作,解剖标志清楚;神经内镜辅助显微镜,可进一步扩大视野,减少对周围重要结构损伤;熟悉该入路的解剖标志及相关解剖有助于提高手术效果。     

幕上下乙状窦前迷路后锁孔入路的设计与显微解剖学研究

目的探讨幕上下乙状窦前迷路后锁孔手术的可行性和手术入路。方法采用8具经10%甲醛溶液固定的尸体头颅标本,于耳后做一长度约7 cm的“C”形头皮切口,上至耳郭上缘,下至耳屏间切迹水平,耳后距耳郭1 cm。磨除部分乳突后联合颞部开颅,形成一3.5cm×3cm大小的骨窗,暴露并剪开乙状窦前和颞部硬脑膜,牵开颞叶和小脑半球,显微镜下观察所显露的解剖结构。结果通过调整显微镜角度,幕上下乙状窦前迷路后锁孔入路可显露同侧桥小脑角区、脑桥前区、脑桥侧方、小脑幕上区的结构。结论幕上下乙状窦前迷路后锁孔入路可很好地显露上述结构,应用现代显微外科技术,可在不磨除迷路的情况下进行岩斜区脑膜瘤、中小型听神经瘤、脑桥腹外侧肿瘤、基底动脉瘤等手术。     

经胼胝体侧脑室入路至丘脑区域的显微镜与内镜解剖学研究

目的观察经胼胝体侧脑室入路至丘脑的相关解剖标志,比较显微镜与內镜在暴露方面的互补性,为临床应用提供解剖学基础。方法 6具(12侧)红、蓝色乳胶灌注的头颅标本,模拟经胼胝体侧脑室入路暴露丘脑,显微镜联合内镜依次交替观察纵裂、透明隔间腔、侧脑室、三脑室四个阶段的解剖结构,并测量相应数据。结果纵裂阶段:胼缘动脉、扣带回、胼周动脉和胼胝体为主要解剖标志。透明隔间腔阶段:透明隔和穹窿体为主要解剖标志。显微镜和內镜均能较好的暴露纵裂和透明隔间腔内的解剖结构。侧脑室阶段:室间孔、透明隔静脉、丘纹静脉、脉络丛、穹窿体、尾状核体部为主要解剖标志。内镜可以弥补显微镜下额角前部(25.7mm±1.7mm vs.14.2mm±1.2mm,P0.05)、丘脑外侧1/3(12.1mm±0.7mm vs.7.0mm±0.9mm,P0.05)和后侧2/5(28.8mm±1.4mm vs.18.7mm±1.4mm,P0.05)的视野死角。三脑室阶段:由于受穹窿体和大脑内静脉的限制,显微镜和内镜都不足以有效暴露丘脑内侧面。结论经胼胝体侧脑室入路暴露丘脑的过程中解剖标志明确,显微镜和内镜的配合有助于辨认重要解剖结构、弥补术野死角。     

锁孔入路显微手术治疗颅内病变87例分析

目的总结锁孔入路显微手术治疗颅内病变的经验。方法采用锁孔入路显微手术治疗颅内病变87例,其中眉弓入路35例,包括动脉瘤31例,垂体腺瘤4例;颞下锁孔入路2例,包括岩斜区脑膜瘤1例,颅中、后窝三叉神经鞘瘤1例;乳突后锁孔入路28例,包括原发性三叉神经痛16例,面肌痉挛12例;个体化小切口22例,包括海绵状血管瘤4例,凸面脑膜瘤18例。结果术中术野均能清晰暴露,术中无因病情变化或暴露不良而扩大切口及骨窗者。肿瘤均获全切除,动脉瘤均顺利夹闭,三叉神经痛与面肌痉挛均成功探查到责任血管。术后病人死亡1例,颅内感染1例,均为动脉瘤病人;皮下积液11例,包括采用眉弓入路8例,个体化小切口3例。结论锁孔入路显微手术治疗颅内病变具有暴露小、微创、并发症少、恢复快等优点。     

便携式视频显微镜经大脑纵裂胼胝体上段、经胼体入路的解剖研究

目的研究便携式视频显微镜经大脑纵裂胼胝体上段、经胼胝体入路的显露范围和观察效果。方法将新鲜和灌注固定的成人尸头标本各5例,在便携式视频显微镜下,经大脑纵裂胼胝体上段、经胼胝体入路暴露并观察侧脑室和第三脑室。结果经大脑纵裂胼胝体上段、经胼胝体入路,在便携式视频显微镜下解剖观察,侧脑室和第三脑室的结构显示清楚,图像逼真。结论便携式视频显微镜经大脑纵裂胼胝体上段、经胼胝体入路能够完成侧脑室和第三脑室的显微解剖。     

眉间锁孔入路手术的显微解剖学研究

目的 观察眉问锁孔入路手术的显露范围并测量相关解剖学参数,以为临床应用提供依据.方法 应用眉间锁孔入路模拟手术并结合局部解剖对12具(24侧)成年国人尸头标本进行研究.形成约3.00 cm×2.50 cm大小骨窗,于手术显微镜下观察显露范围,并测量相关解剖学参数.选择1例典型鞍区脑膜瘤患者,施行眉间锁孔入路手术,观察手术疗效及预后.结果 手术显微镜下观察骨窗显露范围.可见额极、额底、筛板、鸡冠、嗅沟、嗅柬、蝶骨平台、鞍结节、前床突、后床突、小脑幕、视交叉、视神经、颈内动脉、大脑前动脉、大脑中动脉、大脑镰、上矢状窦、胼胝体、前连合和终板等组织结构;打开终板,可见第三脑室.测量双侧眶上孔(眶上切迹)之间距离为(45.92±5.86)mm;双侧滑车上切迹之间距离为(33.14±4.23)mm;鼻额缝至双侧内眦连线距离(16.25±1.52)mm;骨窗中心点至视交叉前缘中心点距离(64.30±3.20)mm,至鞍结节中心点距离(57.38±2.72)mm,至鞍膈中心点距离(67.04±2.89)mm,至终板中心点距离(66.18±3.79)mm,至前交通动脉距离(60.64±4.61)mm.1例患者施行眉间锁孔入路肿瘤切除术,疗效满意.结论 眉间锁孔入路手术可较好地显露前颅底及鞍区中线附近的解剖结构,推荐用于前颅底和鞍区中线附近病变的手术以及前交通动脉动脉瘤的夹闭,具有切口小、骨窗小、刨伤小、额叶损伤少、嗅觉易保留等优点,但也存在并发感染、脑脊液漏的风险,且不适用于脑肿胀患者.     

乙状窦前-迷路后锁孔入路的内镜解剖学研究

目的探讨经乙状窦前-迷路后锁孔入路的内镜解剖学特征,着重讨论内镜下定位的解剖学标识。方法取10具20侧经10％甲醛溶液固定的成人头颅标本,采用耳后“C”形切口,长度约6cm,模拟乙状窦前-迷路后入路,神经内镜下观察显露的解剖结构。结果骨窗开口前缘与内耳道口后唇距离为（14．0±3．6）mm。通过调整内镜角度,经乙状窦前-迷路后锁孔入路可清晰显示岩斜区脑神经及附近走行血管。结论相对于手术显微镜而言,内镜对周围结构的显露更为广泛。临床实践中,应制定个体化治疗方案,联合使用内镜和显微镜,以充分发挥各自的优势。     

经眉眶上锁孔入路与经翼点锁孔入路的解剖学对比研究

目的对比研究经眉弓眶上锁孔入路和经翼点锁孔入路的解剖学特点,为临床应用提供形态学基础。方法对25具成人颅骨标本进行骨性解剖学数据测量。于15具成人尸头上分别模拟经眉弓眶上锁孔入路和经翼点锁孔入路解剖,比较其切口、暴露范围及操作空间等,同时观察鞍区各间隙内的结构。结果经眉眶上锁孔入路中,颧突与同侧前床突的距离为(6.02±0.22)cm,角度为34.09°±3.19;°经翼点锁孔手术入路中,翼点与同侧前床突距离为(5.03±0.29)m m,角度为63.61°±4.78°。经统计学分析,均有显著性差异。结论两种手术入路能不同程度地暴露鞍区各个间隙内的结构。经翼点锁孔入路操作距离较短,具有良好的暴露范围和宽广的操作空间。     

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.     

Special Pharmacokinetic Considerations in Children

Summary: Pediatric patients have greater degrees of pharmacokinetic variability and unpredictability than adults. This variability results from the effects of pharmacogenetics, age and growth, prior and current comedication, and disease. Newborns with seizures have the least predictable dosage requirements, and their needs change as drug-eliminating mechanisms mature in the neonatal period. Infants have the highest relative capacities to eliminate antiepileptics of any age group and require the largest relative doses. In addition to age-related trends, children demonstrate the same drug-specific, pharmacokinetic phenomena that adults do, including nonlinear phenytoin elimination, nonlinear valproate binding, and autoinduction of carbamazepine. Intercurrent illness and drug interactions further modify the age-related pharmacokinetic patterns in children and make dosage requirements even more unpredictable. Recent studies have shown that febrile illness can affect drug elimination, sometimes decreasing drug levels by 50% or more. Intermittent treatment with benzodiazepines administered either orally or rectally can be an important adjunct and help minimize this type of problem for children with marginally controlled epilepsy. Intermittent benzodiazepines are also helpful for children who have febrile seizures and who need only occasional antiepileptic protection.