烟雾病致脑室出血的脑血管影像学特点

目的探讨烟雾病致脑室出血的脑血管影像学特点。方法回顾性分析64例烟雾病致脑室出血患者的临床资料。结果本组患者DSA检查示,双侧病变58例、单侧病变6例,合并动脉瘤4例;均见烟雾状血管。其中双侧大脑前动脉闭塞4例(6.3%),双侧大脑中动脉闭塞2例(3.1%),脉络膜前动脉远端闭塞41例(64.0%),后交通动脉远端闭塞11例(17.2%),单侧颈内动脉分叉处或大脑前动脉A1段、大脑中动脉M1段闭塞共6例(9.4%)。脉络膜前动脉异常扩张和延长108支(84.4%),后交通动脉异常扩张或延长26支(20.3%)。结论脉络膜前动脉和/或后交通动脉扩张、延长是烟雾病致脑室出血的脑血管影像学特点,并且这也可能是烟雾病致脑室出血的主要病因。     

显微缝合技术在治疗大脑中动脉分叉动脉瘤中的应用

目的探讨显微缝合技术在处理大脑中动脉分叉部动脉瘤的技巧及效果。方法回顾性分析2017年4月—2018年10月3例采用显微缝合技术处理的大脑中动脉分叉部动脉瘤患者的临床资料。结果3例患者均成功处理了动脉瘤,同时保证了M1末端血管及M2各分支血管的通畅,消除了动脉瘤破裂风险。患者术后未增加并发症,术后恢复良好。结论显微缝合技术是处理大脑中动脉分叉部复杂动脉瘤的有效方法,精细的手术操作及严密的手术计划能显著提高手术的成功率。     

家族性烟雾病1例报告

烟雾病(Moyamoya disease,MMD)是以脑血管造影发现双侧颈内动脉虹吸部及大脑前动脉、大脑中动脉起始部严重狭窄或闭塞,伴脑底异常团块状血管为特征的一种慢性脑血管闭塞性疾病;该病血管造影呈烟雾状,故又称烟雾病.     

56例短暂性脑缺血发作DSA分析

目的通过数字减影血管造影(DSA)研究短暂性脑缺血发作(transient ischemic attacks,TIA)与颅内-外供血动脉的关系,以探讨TIA的病因。方法对56例TIA患者行DSA全脑血管造影,观察颅内外供血动脉有无狭窄、狭窄程度及有无血管畸形等。结果 56例TIA患者中10例(17.86%)造影阴性,46例(82.14%)存在不同程度的责任血管病变,其中颅内外动脉狭窄40例(71.42%),动静脉畸形2例(3.57%),动脉瘤3例(5.36%),烟雾病1例(1.79%)。23例(41.07%)患者存在2处以上血管狭窄。结论颅内-外供血动脉狭窄是TIA的常见原因,动静脉畸形、动脉瘤、烟雾病等是TIA的少见病因,DSA对TIA患者病因检查有重要的临床价值。     

89例TIA患者颅内—外血管狭窄情况

目的 探讨短暂性脑缺血发作(TIA)与颅内—外血管狭窄的关系.方法 对89例TIA患者行数字减影血管造影(DSA)检查,按照患者TIA发作临床表现分为:颈动脉系组和椎基底动脉系组;按照发作次数分为非频发组(发作次数＜3次)和频发组(发作次数≥3次),比较各组患者颅内—外动脉狭窄的分布情况,比较不同发作频率间和各年龄段间患者颅内—外血管严重狭窄及闭塞的发生情况.结果 (1)本研究共63例患者存在颅内—外动脉狭窄,占70.78％.以颈内动脉颅外段最多,颅内动脉狭窄以大脑中动脉最多.颅内、颅外狭窄动脉比约为1.55∶1.(2)频发组颅内—外血管重度狭窄及闭塞的发生率高于非频发组(P＜0.05).(3)89例TIA患者以50～70岁居多,且重度狭窄及闭塞发生率随年龄增长而呈升高的趋势,但差异无统计学意义(P＞0.05).结论 颅内—外动脉狭窄是发生TIA的重要因素.DSA可以确定短暂性脑缺血发作患者是否存在血管狭窄及狭窄程度,对短暂性脑缺血发作治疗方案的选择起重要作用.     

手术治疗大脑前动脉远端外伤性假性动脉瘤(附1例报告及文献复习)

目的探讨外伤性颅内假性动脉瘤的临床表现、病理特点、影像学特征、治疗及预后。方法患者男性,34岁,因车祸致重型闭合性颅脑损伤,表现为大量脑内血肿和脑室、蛛网膜下腔出血。经急诊头颅CT、CTA和DSA检查拟诊为左侧大脑前动脉远端假性动脉瘤,并行外科手术治疗。结果术中清除血肿后证实左侧大脑前动脉远端分叉处血管裂伤,用10-0的尼龙线缝合了裂伤的血管壁。术后DSA复查假性动脉瘤消失且胼胝体缘动脉主干供血良好。考虑为大脑前动脉分叉处的剪切力造成了动脉裂伤。结论外伤性颅内假性动脉瘤罕见,易频发再破裂,致残率高,在颅脑损伤的临床诊治上需引起神经外科医生足够的重视。     

大脑中动脉分叉部动脉瘤并发脑内血肿的显微手术治疗体会

目的 探讨大脑中动脉分叉部动脉瘤并发脑内血肿患者的显微手术治疗技巧.方法 回顾性分析2007-01-2012-01来我院治疗的大脑中动脉分叉部动脉瘤并发脑内血肿患者36例,均进行显微手术治疗,并随访8～12个月,平均（10.3±0.3）个月,观察患者术后结局、并发症情况及预后.结果 36例患者中,动脉瘤夹闭29例,动脉瘤夹闭结合包裹处理6例,仅单侧动脉瘤夹闭处理1例;随访结果：癫（癎）1例,失语4例,偏瘫8例;根据哥斯拉量表评分,重度残疾4例,中度残疾5例,恢复良好27例.结论 大脑中动脉分叉部动脉瘤合并脑内血肿患者行显微外科手术治疗临床疗效显著.     

联合血运重建术结合颅骨钻孔治疗脑膜中动脉自发代偿的烟雾病的疗效分析

目的探讨颞浅动脉-大脑中动脉搭桥+脑-硬膜-颞肌-颅骨骨膜血管融通术(STA-MCA+EDMPS)结合颅骨钻孔治疗脑膜中动脉(MMA)自发代偿的烟雾病患者的疗效。方法回顾性分析2020年8月至2021年10月航空总医院神经外科采用STA-MCA+EDMPS+额部内侧颅骨钻孔手术治疗的19例(20例侧)MMA自发代偿的烟雾病患者的临床资料(儿童3例, 成人16例)。术后1周行头颅CT血管成像(CTA)三维重建, 以评估开颅范围及搭桥血管通畅性。术后12个月行门诊和(或)电话随访, 观察手术并发症。术后每6个月进行1次头颅CT或MRI检查, 以及全脑数字减影血管造影(DSA), 采用松岛分级评估侧支血管生长情况。术后1周、3个月、6个月复查头颅CT灌注成像(CTP)评估脑组织血流灌注。结果 19例患者的20例侧手术均顺利完成。术后头颅CTA三维重建显示联合血管搭桥手术覆盖MCA区域, 额骨钻孔位于额部内侧大脑前动脉(ACA)区域。术后1周CTA和CTP检查提示搭桥血管通畅, 搭桥区域脑血流灌注较术前改善。8例术前表现为短暂性脑缺血发作(TIA)症状的患者术后TIA症状全部消失。5例成人患者...     

载瘤动脉闭塞术治疗大脑后动脉夹层动脉瘤

目的 探索载瘤动脉闭塞术治疗大脑后动脉夹层动脉瘤的安全性和有效性.方法 回顾性分析应用载瘤动脉闭塞治疗的大脑后动脉夹层动脉瘤患者23例.动脉瘤均位于大脑后动脉P2段或以远部位.临床随访应用GOS评分.结果 23例患者手术均成功,无器械相关的并发症.其中4例术后出现并发症:再出血1例,轻偏瘫1例,偏盲2例.载瘤动脉完全闭塞的患者术后即刻造影显示动脉瘤和载瘤动脉完全闭塞.行姑息性闭塞治疗的5例中,1例死于术后再出血,其余4例随访DSA均显示动脉瘤有增大或复发.结论 载瘤动脉闭塞术对于大脑后动脉P2段及以远的夹层动脉瘤治疗是安全有效的.     

大脑中动脉分叉部动脉瘤的影像学特征与术式选择

目的探讨大脑中动脉分叉部动脉瘤的处理方法。方法回顾性分析46例大脑中动脉分叉部动脉瘤病人的临床资料,采用血管内治疗(血管内治疗组)26例,开颅手术夹闭(开颅夹闭组)20例;总结动脉瘤影像学特征,分析手术方式对治疗结果、临床预后、手术并发症及随访情况的影响。结果血管内治疗组:完全栓塞20例,近全栓塞6例,出院时GOS评分4~5分23例,1~3分3例;发生手术并发症14例。开颅夹闭组:完全夹闭18例,近全夹闭2例;出院时GOS评分4~5分16例,1~3分4例;发生手术并发症11例。36例随访6~24个月,均行DSA复查,动脉瘤复发3例(8.3%),均行二次栓塞并获得完全栓塞。与开颅夹闭组比较,血管内治疗组迟发性神经功能缺损发生率明显降低(P<0.05)。结论弹簧圈栓塞为大脑中动脉分叉部动脉瘤的首选治疗方法,动脉瘤偏小的宽颈动脉瘤可球囊辅助栓塞,偏大型动脉瘤趋向选择开颅夹闭术。新型solitaire-AB型支架可用于大脑中动脉分叉部大型或宽颈动脉瘤的支架辅助治疗。     

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.     

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.     

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.     

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.