镇静清醒麻醉下手术切除语言功能区脑胶质瘤

目的探讨清醒麻醉下手术切除语言功能区胶质瘤并保全其语言功能的可行性及其治疗效果。方法选择位于语言功能区的脑胶质瘤患者10例,实施头皮神经干阻滞麻醉后全程清醒开颅手术,切除肿瘤中维持患者进行出声连续计数的语言功能监测,使尽可能全切肉眼可见肿瘤而保存功能脑区。结果清醒开颅手术全过程中麻醉满意,手术中患者能很好地完成语言监测配合,其中8例患者实现肿瘤的肉眼全切;术后未出现手术相关性语言障碍并发症;随访6～20个月,无肿瘤复发病例。结论局部阻滞麻醉下全程清醒手术能很好保障脑功能区病灶的开颅切除,术中出声连续计数的语言功能监测对安全切除语言功能区肿瘤有重要定位指导意义。     

Awake craniotomy and electrophysiological mapping for eloquent area tumours

Objective

An awake craniotomy facilitates radical excision of eloquent area gliomas and ensures neural integrity during the excision. The study describes our experience with 67 consecutive awake craniotomies for the excision of such tumours.

Methods

Sixty-seven patients with gliomas in or adjacent to eloquent areas were included in this study. The patient was awake during the procedure and intraoperative cortical and white matter stimulation was performed to safely maximize the extent of surgical resection.

Results

Of the 883 patients who underwent craniotomies for supratentorial intraaxial tumours during the study period, 84 were chosen for an awake craniotomy. Sixty-seven with a histological diagnosis of glioma were included in this study. There were 55 men and 12 women with a median age of 34.6 years. Forty-two (62.6%) patients had positive localization on cortical stimulation. In 6 (8.9%) patients white matter stimulation was positive, five of whom had responses at the end of a radical excision. In 3 patients who developed a neurological deficit during tumour removal, white matter stimulation was negative and cessation of the surgery did not result in neurological improvement. Sixteen patients (24.6%) had intraoperative neurological deficits at the time of wound closure, 9 (13.4%) of whom had persistent mild neurological deficits at discharge, while the remaining 7 improved to normal. At a mean follow-up of 40.8 months, only 4 (5.9%) of these 9 patients had persistent neurological deficits.

Conclusion

Awake craniotomy for excision of eloquent area gliomas enable accurate mapping of motor and language areas as well as continuous neurological monitoring during tumour removal. Furthermore, positive responses on white matter stimulation indicate close proximity of eloquent cortex and projection fibres. This should alert the surgeon to the possibility of postoperative deficits to change the surgical strategy. Thus the surgeon can resect tumour safely, with the knowledge that he has not damaged neurological function up to that point in time thus maximizing the tumour resection and minimizing neurological deficits.     

Pediatric awake craniotomy and intra-operative stimulation mapping

The indications for operating on lesions in or near areas of cortical eloquence balance the benefit of resection with the risk of permanent neurological deficit. In adults, awake craniotomy has become a versatile tool in tumor, epilepsy and functional neurosurgery, permitting intra-operative stimulation mapping particularly for language, sensory and motor cortical pathways. This allows for maximal tumor resection with considerable reduction in the risk of post-operative speech and motor deficits. We report our experience of awake craniotomy and cortical stimulation for epilepsy and supratentorial tumors located in and around eloquent areas in a pediatric population (n = 10, five females). The presenting symptom was mainly seizures and all children had normal neurological examinations. Neuroimaging showed lesions in the left opercular (n = 4) and precentral or peri-sylvian regions (n = 6). Three right-sided and seven left-sided awake craniotomies were performed. Two patients had a history of prior craniotomy. All patients had intra-operative mapping for either speech or motor or both using cortical stimulation. The surgical goal for tumor patients was gross total resection, while for all epilepsy procedures, focal cortical resections were completed without any difficulty. None of the patients had permanent post-operative neurologic deficits. The patient with an epileptic focus over the speech area in the left frontal lobe had a mild word finding difficulty post-operatively but this improved progressively. Follow-up ranged from 6 to 27 months. Pediatric awake craniotomy with intra-operative mapping is a precise, safe and reliable method allowing for resection of lesions in eloquent areas. Further validations on larger number of patients will be needed to verify the utility of this technique in the pediatric population.     

Factors associated with somnolence during brain function mapping in awake craniotomy

Somnolence during brain function mapping is one of the factors that inhibit the accomplishment of the goals of awake craniotomy. We examined the effect of anesthesia depth measured by bispectral index (BIS) during pre-awake phase on somnolence during brain function mapping and also explored the factors associated with somnolence. We examined the association between BIS values during pre-awake phase and somnolence during the first 30 min of brain function mapping in 55 patients who underwent awake craniotomy at Kyoto University Hospital from 2015 to 2018. The pre-awake BIS value was defined as the mean BIS value for 60 min before the removal of the airway. Somnolence during brain function mapping was the primary outcome, defined as either of the following conditions: inability to follow up, disorientation, or inability to assess speech function. Additionally, we compared patient or perioperative variables between patients with/without somnolence. Somnolence occurred in 14 patients (25.5%), of which 6 patients (10.9%) were unable to complete brain function mapping. There was no significant difference in the pre-awake BIS value between patients with/without somnolence (median: 46 vs. 49, P = 0.192). Somnolence was not significantly associated with age, gender, and the number of preoperative anticonvulsive drugs, but patients with somnolence had a significantly lower preoperative Western Aphasia Battery (WAB) aphasia quotient score (median 93.8 vs. 98.6, P = 0.011). We did not find an association between pre-awake BIS value and somnolence during brain function mapping. Somnolence likely occurs in patients with a low preoperative WAB aphasia quotient score.     

Utility of monitoring the serum levetiracetam concentration for intraoperative seizure control during awake craniotomy

Awake craniotomy is an established procedure for resecting brain tumors in eloquent lesions, and intraoperative seizure is one of the most important complications. Phenytoin is normally used to control intraoperative seizures. Recently, phenytoin was replaced with levetiracetam at our institution because the latter has fewer side effects. While the phenytoin dose is calibrated in accordance with the serum concentration, there is currently no consensus on a method of monitoring the serum concentration of levetiracetam or the effective concentration range needed to control intraoperative seizures during awake craniotomy. The present study therefore aimed to determine whether monitoring the serum levetiracetam concentration is useful for controlling intraoperative seizures during awake craniotomy. The intraoperative serum concentration of levetiracetam during awake craniotomy was measured in 34 patients and compared with that of phenytoin in 33 patients undergoing the same procedure. The levetiracetam concentration inversely correlated with body surface area (BSA) and estimated glomerular filtration rate (eGFR). Levetiracetam was superior to phenytoin in terms of the correlation between the serum concentration and the dose adjusted for BSA and eGFR (correlation coefficient, 0.49 vs 0.21). Furthermore, the serum levetiracetam concentration in patients with intraoperative seizures was below the 95% confidence interval (CI) of the regression line whereas the serum phenytoin concentration of two patients with seizures was within the 95% CI, indicating that evaluating the serum levetiracetam concentration against the BSA and eGFR-adjusted dosage may be useful in preventing intraoperative seizures during awake craniotomy by allowing prediction of the seizure risk and enabling more accurate dosage calibration.     

不同麻醉方式小骨窗开颅治疗高血压脑出血的临床分析

目的 比较不同麻醉方式下施行小骨窗开颅显微手术治疗高血压脑出血的疗效,探讨其临床应用价值.方法 回顾性分析2010-01-2013-01我科手术治疗的高血压脑出血并成功随访的患者296例,其中171例行局麻,125例行全麻.对比分析两组术后并发症发生率、近期GOS评分、半年后ADL分级等指标.结果 局麻病例术后肺部感染率、应激性溃疡发生率、病死率低于全麻组,再次出血、脑积水发生率以及近期、远期病残率无明显差异.结论 局麻下小骨窗手术治疗高血压脑出血,具有时间短、相对并发症少、节省住院费用等优点,值得临床推广.     

Awake far lateral craniotomy for resection of foramen magnum meningioma in a patient with tenuous motor and somatosensory evoked potentials

We report a patient with an infratentorial lesion resected under a far-lateral approach during awake craniotomy to optimize intraoperative monitoring. A 72-year-old man presented with falls, difficulty walking, and lower extremity weakness. MRI revealed a 2.2 by 2.3 by 2.8 cm mass at the right cervicomedullary junction, with mass effect on the adjacent spinal cord. During two attempts during surgical positioning under general anesthesia, motor evoked potentials were lost. Each time the operation was aborted. During the third operation, the patient underwent monitored, light anaesthesia and was awakened periodically to confirm conscious motor function. The operation proceeded without complication, and postoperatively there was no further decrease in motor function. This is, to our knowledge, the first use of an awake operation for an infratentorial meningioma via the far-lateral approach, demonstrating the technique may be used safely and can be useful in optimizing motor function monitoring.     

Awake craniotomy versus craniotomy under general anesthesia for the surgical treatment of insular glioma: choices and outcomes

Objective: To investigate differences in outcomes in patients who underwent surgery for insular glioma using an awake craniotomy (AC) vs. a craniotomy under general anesthesia (GA).

Methods: Data from patients treated at our hospital between 2005 and 2015 were analyzed retrospectively. The preoperative, intraoperative, postoperative, and longer term follow-up characteristics and outcomes of patients who underwent surgery for primary insular glioma using either an AC or GA were compared.

Results: Of the 52 identified patients, 24 had surgery using an AC and 28 had surgery under GA. The extent of resection was similar for the two anesthesia techniques: the median extent of resection was 61.4% (IQR: 37.8–74.3%) in the WHO grade <4 AC group vs. 50.5% (IQR: 35.0–71.2%) in the grade <4 GA group and 73.4% (IQR: 54.8–87.2%) in the grade 4 AC group vs. 88.6% (IQR: 61.2–93.0%) in the grade 4 GA group. Consistent with literature, there were more early neurological deficits after an AC, while the GA group showed more new late neurological deficits; however, these trends were not significant. Survival was similar between the two groups, with 100% 1- and 2-year survival in the grade <4 groups.

Conclusion: Our results showed that the extent of resection, neurological outcomes, and survival were similar using the two anesthesia techniques. Since AC is more challenging for the patient and for his or her caregiver after surgery, this finding has implications for clinical decision-making.     

神经外科术中唤醒麻醉患者术后神经心理功能与生活质量观察

目的观察神经外科术中唤醒麻醉对患者术后神经心理功能与生活质量的影响。方法选择我院2013-01—2014-06拟行大脑运动功能区择期手术并需行术中唤醒以确定功能区位置的患者31例为观察组,同时选取同期入院的30例拟行大脑运动功能区择期手术并行非唤醒麻醉患者为对照组,对2组患者术后的神经功能受损情况、心理状态与生活质量进行对比评价。结果观察组患者初期恢复15例,中期恢复12例,晚期恢复4例,恢复情况显著优于对照组(P0.05)。观察组情绪异常发生率16.1%,与对照组(13.3%)相比无显著性差异(P0.05);观察组术中知晓率54.8%,显著高于对照组(0,P0.05)。2组术后关于生活质量的8个维度评分均无显著性差异(P0.05)。结论神经外科术中唤醒麻醉在对病灶进行准确定位、最大限度地保留脑功能的前提下可有效降低患者术后远期神经功能缺损发生率,同时未对患者术后的神经心理功能及生活质量带来显著影响,可作为切除位于或邻近大脑功能区肿瘤的主要麻醉术式。     

脑功能区手术唤醒麻醉与清醒程度的研究

目的分析大脑功能区手术唤醒麻醉中对病人清醒程度的影响因素,提出脑功能区定位时态的概念.方法对15例病人采用丙泊酚靶控输注（TCI）给药,按作者提出的脑功能区定位时态评判标准对清醒程度进行评估.结果术中唤醒状态下语言清晰者10例,指令应答准确8例,无痛9例;颅内压正常10例.定位时态优5例,良8例,差2例.13例唤醒麻醉手术过程顺利,2例因脑组织膨胀未定位.结论丙泊酚TCI给药是脑功能区手术唤醒术较好的麻醉方法.应用脑功能区定位时态的概念对提高麻醉清醒质量有临床指导意义.     

小骨窗开颅治疗高血压脑出血

本文报告在局麻下小骨窗开颅血肿消除术治疗高血压脑出血３１例。临床病情分级Ⅰ～Ⅲ度１６例中，７５％恢复良好，死亡率为１２．５％；Ⅳ度１５例中，４６．６７％恢复良好，死亡率为２６．６６％，表明临床病情分级决定脑出血的生命预后，该手术方式能降低重症脑出血的死亡率；探讨了该术式的手术适应证与禁忌证，讨论了手术时机、血肿部位、血肿量、血肿破入脑室、并发症与疗效的关系。     

唤醒麻醉结合皮层电刺激下切除皮层语言区病变21例临床分析

目的探讨唤醒麻醉结合皮层电刺激开颅手术切除语言功能区病变的价值。方法回顾性分析21例唤醒麻醉结合皮层下电刺激开颅手术术前准备、术中过程、术后康复等临床资料,所有病变均位于或紧邻语言功能区,病人均实施唤醒麻醉,术中先用双极电刺激器确定语言功能区,在确定的语言功能区外1cm,最大范围切除病变。结果病变全切17例(80.95%),次全切4例(19.05%)。术后短期运动性失语1例(4.76%),术中癫痫1例(4.76%),术后颅内血肿1例(4.76%)。远期复发2例,均为胶质瘤次全切除病人(9.52%),余患者恢复良好。结论唤醒开颅结合皮层电刺激手术可最大范围切除语言功能区病变,保护患者言语功能。     

清醒麻醉下切除脑功能区胶质瘤

目的探讨清醒麻醉下切除脑功能区胶质瘤的手术技巧及疗效。方法回顾性分析6例脑功能区胶质瘤病人的临床资料,均在神经阻滞、清醒麻醉下手术,术中神经导航、超声及神经电生理监测定位;切除肿瘤时,维持病人出声连续计数或读图的语言功能监测,或持续按键的运动功能监测。结果术中麻醉满意,肿瘤全切除5例,次全切除1例。术后神经功能障碍均不同程度好转;癫未再发作1例,药物可控制3例。术后出现偏瘫2例,术后无疼痛回忆。结论清醒麻醉下切除脑功能区胶质瘤,结合术中定位明确肿瘤切除范围,及肿瘤与脑功能区的关系,可最大限度地切除脑功能区病变和保护脑功能。     

Writing Errors of a Cantonese Dysgraphic Patient and their Theoretical Implications

This paper reports a case study of a Cantonese-speaking dysgraphic patient. Among his written errors were phonologically plausible errors that were mostly homophonous or differed only in tone from their target. They occurred not only in writing-to-dictation but also in written naming. Since his lexico-semantic system is hypothesized to be largely preserved, as evidenced by normal performance on non-verbal semantic tests and word-picture matching, the presence of homophone and tonal errors strengthened previous claims about the existence of a lexically-mediated non-semantic pathway of writing Chinese and access from the phonological output lexicon to the orthographic output lexicon. In addition, his non-character responses, particularly those involving substitution of constituent(s), almost always maintained the configuration of their target. This observation implies that orthographic representations contain not only information on the identity of components but also structural information. The latter may, among other possibilities, take the form of a template indicating the internal organization of the character or specification for position of occurrence for each constituent within the character.     

右美托咪定在成人脑功能区癫疒间手术开颅清醒期的镇静效果观察

目的：观察唤醒麻醉下行脑功能区癫疒间病灶切除术的成年难治性癫疒间病人,在术中清醒期连续泵注右美托咪定（dexmedetomidine,Dex）的镇静效果。方法拟在唤醒麻醉下行癫疒间病灶切除的成年病人48例,随机平均分为 LP、LD、MD、HD 组,术中清醒期分别泵注1.5μg/ml 丙泊酚、0.2μg/（kg·h）、0.4μg/（kg·h）和0.6μg/（kg·h）的 Dex 进行镇静。记录清醒时、开始镇静时（T0）、镇静后10 min （T1）、20 min （T2）、30 min （T3）、40 min （T4）、50 min （T5）、60 min （T6）各时间点的改良清醒镇静评分（OAA/S）、视觉模拟评分（VAS）、镇静深度指数（NI）、心率及不良事件。结果48例病人成功实施术中唤醒。镇静后Dex 各组心率明显低于 LP 组（P ＜0.05）。4组 NI 值均明显下降,镇静后各组均明显低于 T0（P ＜0.05）,T3后 HD 组显著低于其他各组（P ＜0.01）。OAA/S 在 LD、MD、LP 组随时间改变不明显,但 LP 组明显更低（P ＜0.05）。HD 组 OAA/S 始终低于 LD、MD 组,除 T1外各时间点均高于 LP 组（P ＜0.05）。LP、LD 组清醒期寒战发生率明显高于 MD、HD 组（P ＜0.05）。结论成年癫疒间病人在开颅手术清醒期使用 Dex 作为镇静药物,可提供满意的镇静效果,0.4~0.6μg/（kg·h）的剂量可明显降低寒战发生。     

Factor structure of the Spanish version of the Patient Health Questionnaire‐9 in Mexican women

Structure of the Spanish version of the nine‐item Patient Health Questionnaire (PHQ‐9) has been inconclusive. We report the factor structure of the PHQ‐9 in 55,555 women from the Mexican Teachers' Cohort (MTC). Factor structure of the PHQ‐9 was assessed by exploratory and confirmatory factor analyses in two sub‐samples (n = 27,778 and 27,777 respectively). A one‐factor model of the PHQ‐9 was the solution with the best fit to the data, exhibiting strong factor loadings (0.71 to 0.90) and high internal consistency (Cronbach's alpha = 0.89). A prevalence rate of moderate to high severity of depressive symptoms of 12.6% was identified. Results suggest that a global score is an appropriate measure of depressive symptoms and commend the use of the Spanish PHQ‐9 as a measure of depression for research and clinical purposes. Copyright © 2014 John Wiley & Sons, Ltd.     

Validity of the Patient Health Questionnaire (PHQ)-9 and PHQ-2 in general internal medicine primary care at a Japanese rural hospital: a cross-sectional study

Objective

Two depression screening tools, Patient Health Questionnaire (PHQ)-9 and PHQ-2, have not had their validity examined in general internal medicine settings in Japan. We examined the validity of these screening tools.

Methods

A total of 598 outpatients of an internal medicine clinic in a rural general hospital were enrolled consecutively and stratified by PHQ-9 score. Seventy-five patients randomly selected and 29 patients whose results from the PHQ-9 were considered to be positive for depressive disorder were then interviewed with a semistructured interview, the Mini International Neuropsychiatric Interview. We calculated diagnostic accuracy of the PHQ-9 and PHQ-2 to detect major depression and that of the suicidality item of the PHQ-9 to detect suicidality using sampling weights with multiple imputations.

Results

Sensitivity and specificity for depression were 0.86 and 0.85, respectively, for the PHQ-9 with cutoff points of 4/5, and 0.77 and 0.95, respectively, for the PHQ-2 with cutoff points of 2/3. Sensitivity and specificity of the suicidality item of the PHQ-9 were 0.70 and 0.97, respectively.

Conclusion

In internal medicine clinics in Japanese rural hospitals, the PHQ-2 with an optimal cutoff point for each setting plus the suicidality item of the PHQ-9 can be recommended to detect depression without missing suicidality.     

Assessment of the 9-item Patient Health Questionnaire (PHQ-9) as a screen tool for symptoms of depression in community caregivers for adults with intellectual disabilities

The study aim was to determine the extent and determinants of reporting depressive symptoms in caregivers for persons with intellectual disabilities based on assessment of the 9-item Patient Health Questionnaire (PHQ-9). A cross-sectional study was conducted, recruiting 455 caregivers for adults with ID who were providing care in community residences, with complete PHQ-9 data being analyzed. The results indicated that the mean of each item scored on the PHQ-9 varied from 0.3 (Q9) to 1.1 (Q4). For two items (Q3 – “sleeping difficulties” and Q4 – “fatigue”), the respondents reported occurrence during several days in the previous two weeks. However, after scrutinizing the distribution of each item in the PHQ-9, 3.3–14.5% respondents reported that each item happened nearly every day, and 4.0–17.8% expressed that each happened more than half of the days in the previous two weeks. With respect to difficulties examined on the PHQ, 47% of cases expressed that it was somewhat difficult, 8.2% expressed that it was very difficult, and 4.5% felt that it was extremely difficult to work, care for things at home, or get along with others. Finally, a logistic regression model revealed that only one factor of self-perceived health status (fair/poor vs. excellent/very good, OR = 7.519, 95% CI = 3.03–18.68, p < 0.001) exhibited a statistically significant correlation with depressive symptom occurrence (PHQ-9 score ≧ 10) among the caregivers. The study highlights the need to strengthen appropriate health initiatives for monitoring mental health status and to provide necessary services for community caregivers for adults with ID.