伏隔核毁损术治疗阿片类药物精神依赖的初步临床报告

目的探讨阿片类药物依赖的手术治疗方法,评价其可行性和安全性。方法采用立体定向双侧伏隔核壳部后下部分毁损术治疗35例病人。术后随访36~129 d;对伴发的烟草依赖症状改善情况,手术对睡眠、记忆力、性欲及工作能力的影响,术后不同时间段病人药物渴求程度的改变情况、重新非法用药情况等进行分析。结果该手术具有较高的安全性,可以明显改善大部分病人的睡眠障碍并提高工作能力,不影响性欲和记忆力;在术后不同时间段,病人吸烟量明显降低;阿片类药物渴求显著缓解,完全消除心瘾者27例,占77.1%,重新非法用药者3例,曾1次用药者2例。结论伏隔核毁损术可以有效地消除或部分缓解阿片类药物依赖病人的心理渴求,术后病人保持操守率明显优于常规药物治疗,值得进一步深入探索。     

立体定向双侧伏隔核毁损术治疗阿片类药物依赖

目的探讨阿片类药物依赖手术治疗的方法及其安全性。方法采用立体定向微创手术行双侧伏隔核壳部后下份的毁损术,治疗35例病人,对其术后近期和中期随访观察,随访时间36～129天;观察术后近期生理与精神表征的变化;伴发的烟草依赖症状改善情况的调查;手术对睡眠、记忆力、性欲及工作能力的影响;观察不同时间段术后病人药物渴求程度的改变情况及重新非法用药的分析。结果该手术具有较高的安全性,术中心率减缓的情况与术后心瘾消除的比率有一定关系,手术诱发的精神障碍是阶段性的和可逆的;手术可以明显地改善大部分患者的睡眠障碍并提高工作能力;在术后不同时间段,患者吸烟量明显降低;阿片类药物渴求得到显著缓解,完全消除心瘾者27例,占79．4％,重新非法用药者3例,可疑用药者2例。结论双侧伏隔核毁损术可以有效地消除或部分缓解阿片类药物依赖患者的心理渴求,术后病人的操守率明显优于常规药物治疗,而且该手术较安全、副损伤小,所造成的生理和精神障碍均为阶段性和可逆的,是一种值得深入探索的治疗药物依赖的方法。     

伏隔核毁损术对吸毒者酒精及尼古丁依赖的影响(附68例分析)

目的 研究伏隔核毁损术对阿片类药物依赖病人酒精及尼古丁依赖的影响。方法 对接受伏隔核毁损术的68例阿片类药物依赖伴酒精及尼古丁依赖病人进行随访，采用吗啡尿检及纳络酮催瘾实验判别术后是否阿片类药物复吸，采用饮酒问卷及尼古丁依赖自评量表对术前、术后不同时期酒精、尼古丁依赖程度进行评分并比较。采用问卷法调查术后病人再次饮酒、吸烟时主观感觉的变化。将饮酒及吸烟后的轻松、兴奋感分为增加，无变化和减弱三个等级，分析手术治疗阿片类药物依赖合并酒精及尼古丁依赖的疗效的相关性。结果 术后12个月，阿片类药物复吸率为54．8％，酒精及尼古丁依赖程度术前吸毒时和术前生理脱毒治疗时差异无统计学意义：术后酒精及尼古丁依赖程度为：术后0．5个月〈术后3个月〈术后6个月，而术后6个月与术后12个月比较差异无统计学意义．但仍远低于术前生理脱毒治疗时的水平。结论 针对阿片类药物依赖病人实施的伏隔核毁损术不但能明显降低吸毒者阿片类药物的心理依赖程度．而且对酒精及尼古丁依赖也有明显的抑制作用。     

内侧隔-斜角带核:阿片类药物精神依赖外科治疗的新靶点(附34例报告)

目的 探讨单纯双侧内侧隔-斜角带核毁损对阿片类药物精神依赖的治疗作用。方法 采用立体定向毁损双侧内侧隔一斜角带核后部治疗34例阿片类药物精神依赖病人，观察手术前后成瘾个体对药物的精神依赖和尼古丁依赖的变化情况．采用简明心理状况检查量表（MMSE）、汉密尔顿抑郁量表（HAMD）和焦虑量表（HAMA）评价手术对记忆、情感的影响。结果 随访12-18个月，精神依赖完全消除25例（73．5％），复吸9例。术后病人学习和记忆力无明显变化，抑郁和焦虑症状有显著性改善（P〈0．01）。结论 单纯内侧隔一斜角带核毁损治疗阿片类药物依赖有效。     

立体定向术对阿片类药物依赖者心理障碍治疗前后的对照研究

目的观察立体定向手术治疗对阿片类药物依赖病人术后近期病理性心理症状的影响。方法选择自愿要求手术的戒毒病人26例,采用90项症状自评量表（SCL-90）进行评估。治疗前后选择自身配对t检验,治疗前后与国内常模比较、治疗后与强制戒毒、冷火鸡脱毒、美沙酮脱毒治疗后比较采用单样本t检验。结果术后73.1%病人总体病理性心理障碍症状完全改善。57.7%病人的躯体不适症状、73.1%病人的强迫症状得到矫治。手术消除了80.8%病人的抑郁症状、69.2%病人的焦虑症状。同时手术也改善了69.2%病人的人际关系、57.7%病人的恐怖、73.1%病人的敌对、61.5%病人的偏执、57.7%病人的精神病和65.4%病人其他不良症状。与常模比较,术前SCL-90各项差异均有统计学意义（P〈0.05）,术后仅躯体症状差异有统计学意义（P〈0.001）。与强制戒毒组比较,术后SCL-90各项差异均有统计学意义（P〈0.05）;与冷火鸡组比较,仅躯体症状差异有统计学意义;与美沙酮组比较,躯体症状、抑郁、焦虑差异有统计学意义。结论手术能够不同程度地矫治阿片类药物依赖病人的病理性心理障碍,且近期疗效好于强制戒毒、冷火鸡和美沙酮疗法。     

深部脑刺激戒断阿片类药物精神依赖1例临床报道(附3个月随访结果)

目的在立体定向射频毁损手术的研究基础上,进行了1例深部脑刺激(deep brain stimulation,DBS)戒断阿片类药物精神依赖手术,探讨一种既能起到有效治疗作用,而又减少副损伤的外科治疗方法。方法药物依赖患者,男性,24岁,吸食海洛因等多种毒品成瘾5年,反复戒毒5次无效。在阿片脱毒术脱毒后,行双侧伏隔核DBS电极植入术,立体定向MRI定位,植入Medtronic 3387刺激电极及脉冲发生器。术后定期进行疗效随访,以及副作用、心理学量表和症状量表等评估。结果患者术后即停止吸毒,通过3个月的临床观察,至今无复吸现象。临床证实该方法较射频毁损方法微刨、副反应小,心理学量表(WMS、WEIS-RC和MMPI)评估未发现有记忆、智力和人格等方面影响。术后患者饮食较术前明显好转,体重增加,吸烟量明显减少;症状自评量表(SCL90、SAS和SDS)评估提示多因素均有明显改善。结论应用DBS外科方法戒断阿片类药物精神依赖,取得短期满意疗效。     

立体定向手术治疗药物依赖24例临床分析

目的探讨立体定向手术治疗药物依赖的方法。方法对24例药物依赖病人行立体定向脑深部核团毁损术治疗,靶点为双侧伏隔核各1点,双侧扣带回前部、中部、前部与中部中间各1点。结果病人出院时均符合戒断标准。随访1~6个月,2例复吸,22例正常生活。结论采用立体定向手术治疗药物依赖病人,近期效果肯定,相对安全,长期疗效有待观察。     

立体定向治疗海洛因心理依赖临床报道

目的探讨立体定向手术治疗药物依赖并评估手术安全性及疗效。方法采用CT引导下立体定向双侧杏仁核、伏膈核及扣带回射频毁损，术后147～253d内随访。结果70例病人中55例药物依赖心理完全消失，9例术后复吸，并发症少。结论立体定向手术是一种有效和可行的治疗药物依赖方法。     

立体定向手术治疗221例阿片类药物依赖的近期疗效与不良反应分析

目的观察脑立体定向手术治疗阿片类药物依赖近期效果及不良反应。方法运用明尼苏达多相人格调查表(minnesotamultiphasicpersonality,MMPI)、中国修订韦氏成人智力量表(wechsleradultintelligenceScale-RevisedinChina,WAIS-RC)、韦氏记忆量表(weehslermemoryscale,WMS)及自编药物依赖问卷、睡眠质量问卷、戒断症状清单、定向手术神经精神不良反应观察表作术前术后比较。结果MMPI中的疑病(Hs)、抑郁(D)、癔症(Hy)、心理病态(Pd)术后较术前显著降低,偏执(Pa)、精神分裂(Sc)、轻躁狂(Ma)则术后升高,均呈非常显著差异(P<0.01);药物依赖评分、术后总分、躯体依赖分、心理依赖分均比术前明显低,有非常显著差异(P<0.01);戒断症状评分与持续时间比较,术后较术前均低,有非常显著差异(P<0.01);睡眠评分与术后总分降低,术后睡眠效率增加,均有非常显著差异(P<0.01);术后2周WAIS-RC与术前比较,语言智商(VIQ)尚低于术前,有显著差异(P<0.05),操作智商(PIQ)较术前高,呈非常显著差异(P<0.01),全智商(FIQ)虽升高但无显著差异(P>0.05),记忆商(MQ)高于术前,有显著差异(P<0.05);随访时间平均8.9个月,复吸率为13.12%~16.29%;术后第1周最多见的不良反应:摸索动作(84.7%)、主观记忆差(55.3%)、计算困难(39.1%)、懒散少语(26.9%)、乱讲话(26.4%)、尿失禁(22.84%)、定向障碍(20.3%),术后第2周最多见:主观记忆差(26.9%)、懒散少语(21.3%)、摸索动作(18.78%)、计算困难(16.2%)、行为紊乱(10.12%),不良反应平均持续时间为6.94天。结论本手术对于治疗阿片类药物依赖效果显著,没有严重的近期不良反应,手术是安全的。     

《中国微侵袭神经外科杂志》2006年第11卷主题词索引

A阿片相关性障碍定向伏隔核射频毁损戒毒的毁损情况与疗效关系探讨(王学廉，贺世明，衡立君，等)(3)：108阿片相关性障碍内侧隔-斜角带核：阿片类药物精神依赖外科治疗的新靶点(附34例报告)(王克万，漆松涛，杨开军)(3)：112阿片相关性障碍手术戒毒复吸原因及影响因素的对比研究(王学廉，贺世明，李江，等)(8)：349鞍区肿瘤锁孔入路鞍区肿瘤切除术的术后护理(黄燕萍，周杰，荔志云)(11)：522 B鼻窦肿瘤内镜经鼻手术治疗侵犯颅内的巨大鼻窦黏液囊肿(刘海生，毕博学，郑佳平，等)(1)：12变形性肌，张力障碍立体定向双侧丘脑底核电刺激术治疗…     

Postsurgical outcome in pediatric patients with epilepsy: a comparison of patients with intellectual disabilities, subaverage intelligence, and average-range intelligence

PURPOSE: Intellectual disabilities are often associated with bilateral or diffuse morphologic brain damage. The chances of becoming seizure free after focal surgery are therefore considered to be worse in patients with intellectual disabilities. The risk of postoperative cognitive deficits could increase because diffuse brain damage lowers the patient's ability to compensate for surgically induced deficits. Several studies in adult patients have indicated that IQ alone is not a good predictor of postoperative cognitive and seizure outcome. Our study evaluated this subject in children and adolescents. METHODS: Pediatric patients with intellectual disabilities (IQ < or = 70), subaverage intelligence (IQ between 71 and 85), or average-range intelligence (IQ > 85) were matched according to several clinical and etiologic criteria to determine the influence of IQ (N = 66). RESULTS: No dependency of seizure outcome, postoperative cognitive development, and behavioral outcome on the IQ level was found. All groups slightly improved in attention while memory functions tended to decrease and executive functions were stable. School placement remained unchanged for the majority of patients. Between 67 and 78% were seizure free 1 year after surgery (Engel outcome class I). CONCLUSIONS: IQ alone is not a good predictor of postoperative outcome in pediatric patients with epilepsy. As with patients of average-range intelligence, the decision to operate on patients with a low level of intelligence should depend on the results of the presurgical diagnostics. If the results of the neuropsychological examination indicate diffuse functional impairment, this should not hinder further steps, if all other findings are consistent.     

手术对颞叶癫痫病人认知功能的影响

目的 探讨手术对颞叶癫痫病人认知功能的影响。方法 回顾性分析2017年1月至2020年1月手术治疗的60例颞叶癫痫的临床资料。38例采用前颞叶切除术（ATL）治疗,22例采用选择性海马杏仁核切除术（SAH）治疗。术后6个月,采用Engle分级评估预后。术前、术后6个月由专业人员采用面对面形式完成认知功能评估,采用韦氏智力测验量表测试智商;术前记忆量表甲套+术后乙套测验记忆功能,采用记忆商数（MQ）评估记忆功能。结果 术后6个月,Engle分级Ⅰ级35例,Ⅱ级20例,Ⅳ级5例。术后6个月,两组MQ和智商均明显增高（P<0.05）,而且,SAH组术后MQ明显高于ALT组（P<0.05）。结论 手术治疗可以改善颞叶癫痫病人的智商和记忆功能,SAH优于ATL。     

选择性杏仁核-海马切除术对内侧颞叶癫痫病人神经心理学的影响

目的 探讨选择性杏仁核-海马切除术（SAH）对内侧颞叶癫痫病人认知功能的影响。方法 回顾性分析2009年1月~2017年5月接受SAH治疗的67例内侧颞叶癫痫的临床资料,术前、术后3个月和术后1年均行详细的神经心理学评估,包括智商、记忆商和语言功能。结果 36例行左侧SAH,31例行右侧SAH。术后1年,癫痫控制效果达到Engel分级Ⅰ级50例,Ⅱ级7例,Ⅲ级8例,Ⅳ级2例。术后3个月,左侧手术病人言语功能、记忆商较术前明显降低（P<0.05）,右侧手术病人言语理解指数、语义流畅性测验明显改善（P<0.05）;术后1年,无论是左侧手术病人,还是右侧手术病人,智商、记忆商、言语功能较术后3个月略改善（P>0.05）;手术前后视觉记忆均无明显变化（P>0.05）。结论 海马硬化性内侧颞叶癫痫行SAH后,左侧手术病人会出现比较明显的言语和记忆功能减低。     

The cognitive outcome of hemispherectomy in 71 children

PURPOSE: Long-term neuropsychological outcome was studied in 71 patients who underwent hemispherectomy for severe and intractable seizures at The Johns Hopkins Hospital between 1968 and 1997 and who agreed to participate. Seizures were due to cortical dysplasias (n = 27), Rasmussen syndrome (n = 37), or vascular malformations or strokes (n = 7). Both presurgical and follow-up results are available and reported for 53 patients. METHODS: Patients and caretakers were interviewed, and patients were administered standard measures of intelligence, receptive and expressive language, visual-motor skills, adaptive/developmental functioning, and behavior. RESULTS: Mean age at surgery was 7.2 years. At follow-up, on average 5.4 years after surgery, 65% are seizure free, 49% are medication free, and, of those responding, none rated quality of life as worse than before surgery. Mean IQ was in the 70s for Rasmussen and vascular patients and in the 30s for cortical dysplasia patients. Language and visual-motor skills were consistent with IQ. For Rasmussen patients only, language was significantly more impaired for left than for right hemispherectomy, both before surgery and at follow-up. Adaptive skills were mildly impaired, with greatest impairment in the physical domain. Cognitive measures typically changed little between surgery and follow-up, with IQ change <15 points for 34 of 53 patients; of the remainder, 11 declined and eight improved. Behavior was free of major problems, but social interactions and activities were limited. CONCLUSIONS: The most significant predictor of cognitive skills at follow-up was etiology, with dysplasia patients scoring lowest in intelligence and language but not in visual-motor skills. Regardless of etiology, most patients showed only moderate change in cognitive performance at follow-up.     

Surgical Outcome in a Group of Low-IQ Patients with Focal Epilepsy

PURPOSE: Because a low IQ score indicates global brain damage, several authors consider it a contraindication for resective epilepsy surgery. This study reports the postoperative results of a small group of subaverage-intelligence patients with epilepsy who underwent focal resections. METHODS: We report on 16 patients who underwent focal resections (no callosotomy or hemispherectomy). All had IQ's <85 and were >13 years of age at the time of surgery. Low IQ was psychometrically assessed (mean IQ = 70) and confirmed by the patients' educational/occupational status. Clinical characteristics, findings from the preoperative workup, and the surgical treatment are described in detail. Postoperative outcome was evaluated with respect to seizure relief and cognitive/ socioeconomic development. RESULTS: Three months after surgery, 14 (87%) of 16 patients were completely seizure free, and nine (64%) of 14 were seizure free at the 1-year follow-up. Patients' cognitive abilities and socioeconomic status were mostly unchanged and in some cases improved. Seizure outcome was not related to IQ level, and there was no evidence of multiple epileptic foci in the patients with continued seizures. CONCLUSIONS: A low IQ level does not entail the presence of extended epileptogenic regions or multiple epileptic foci. Seizure-relief rates in our group concurred with the rates in patients of average intelligence, and the cognitive/socioeconomic outcome was favorable. We conclude that focal surgery in intellectually impaired patients can be recommended if the preoperative diagnostics confirm a circumscribed seizure onset.     

Surgical versus medical treatment for severe epilepsy: consequences for intellectual functioning in children and adults. A follow-up study.

We compared the effects of medical and combined surgical and medical treatment of refractory epilepsy on intellectual functioning in a group of children (n=13) and a group of adults (n=15).The patients were tested with the age-appropriate versions of Wechsler's intelligence scales twice prior to and once after epilepsy surgery. There were no significant differences between the groups in preoperative epilepsy-related variables, including age at onset. The IQ scores were submitted to two-way analyses of variance (ANOVA). We also evaluated individual changes in IQ scores.Adult patients maintained stable levels of performance after drug treatment as well as following surgery, while children declined in Full Scale IQ after both kinds of treatment. Children also declined in Performance IQ, but not in Verbal IQ after drug treatment, and in Verbal IQ, but not in Performance IQ after surgery. Three of six children who underwent a significant decline in Full Scale IQ before surgery did not show any further decline postoperatively.We have proposed a developmental model to account for the different findings in children and adults, and conclude tentatively that refractory, long-standing epilepsy may interfere with intellectual development both during drug treatment and following combined surgical and medical treatment in children, while the impact of long-standing refractory epilepsy of similar severity as in children is not strong enough to reduce intellectual performance in adults, irrespective of treatment modality.     

Preoperative IQ predicts seizure outcomes after anterior temporal lobectomy

PurposeIQ tests are frequently used in the preoperative neuropsychological assessment of candidates for anterior temporal lobectomy (ATL). We reviewed IQ test results and surgery outcomes to evaluate the roles of IQ tests in the preoperative work-up.MethodsA total of 205 adult patients who had undergone ATL and whose seizure outcomes were followed for 2 years after surgery were included. The short form WAIS-R was used to estimate intelligence. Multiple linear regression and logistic regression analyses were used to examine the variables for IQ and seizure outcomes.ResultsEducation, duration of epilepsy and gender were factors that accounted for 24.6% of the variance in the full-scale IQ (FSIQ) scores. The verbal IQ and performance IQ discrepancies at various magnitudes could not lateralize the seizure foci. Freedom of seizure was noted in 128 (62.4%) of the patients. Seizure outcomes, however, correlated with the preoperative FSIQ. After adjustment for variables that affect seizure outcomes, the FSIQ was an independent predictor of postoperative seizure outcomes (OR 1.04, 95% CI 1.01–1.06, p = 0.003). Of patients who had FSIQ lower than 70, 50% became free from seizures by 2 years after surgery.ConclusionsIn our study, IQ tests were unable to lateralize seizure foci but may serve as an independent predictor of postoperative seizure outcomes. Since a longer duration of epilepsy had deleterious effects on intelligence, earlier surgical intervention might better preserve neuropsychological function and, consequently, allow better seizure control after ATL. Nonetheless, patients with lower IQ scores could still benefit from ATL.     

颅内肿瘤患者智力损害的评价及术后随访

目的 评价颅内肿瘤及神经外科手术对患者智力的影响.方法 运用中国修订韦氏成人智力量表(WAIS-RC)对79例颅内肿瘤患者进行智力评估.按照简式(四合一)算法换算智商(IQ)、言语智商(VIQ)和操作智商(PIQ).结果 脑叶内肿瘤患者术前IQ(P＜0.01)、VIQ(P＜0.01)均显著低于健康对照组;优势半球肿瘤组术前IQ、VIQ明显低于健康对照组和非优势半球组;鞍区肿瘤组患者无智力受损.术后凸面脑外肿瘤组IQ、PIQ均降低.结论 颅内肿瘤可导致患者智力损害,脑叶内肿瘤及优势半球肿瘤所致智力损害较严重;神经外科医生应重视颅内肿瘤及其手术对患者智力的影响.     

Long-term outcomes of epilepsy surgery in tuberous sclerosis complex

Approximately 50% of patients with tuberous sclerosis complex (TSC) present intractable epilepsy, and surgery is an option for those patients. Hereby, we analyze long-term seizure control and neuropsychological outcomes of epilepsy surgery in patients with TSC. Clinical data were retrospectively collected from 66 patients with TSC and epilepsy followed up over 5 years, 51 of whom underwent epilepsy surgery between 2001 and 2011. Reductions in the number of seizures were analyzed at 1-year (1FU), 5-year (5FU), and 10-year (10FU) follow-ups visits after the operation. Influential factors on postoperative seizure free and intelligence quotient (IQ) and quality-of-life (QOL) outcomes were evaluated at 5FU. Resective procedures included 26 tuber resections, 15 lobectomies, and 10 tuber resections and lobectomies. Corpus callosotomies were performed as the adjunctive approach in 11 cases with low IQ. The percentages of seizure-free cases were 74.5% at 1FU, 58.8% at 5FU, and 47.8% at 10FU, and the predictive factor for long-term postoperative seizure freedom was the history of preoperative seizures and preoperative full-scale IQ. Significant improvements were found in performance IQ, full-scale IQ, and QOL in patients from the surgery group, particularly those who were seizure free after the operation. Our study showed that epilepsy surgery in TSC with epilepsy rendered improvements in seizure control, full-scale IQ, and QOL. Satisfactory long-term seizure control was often achieved with an early operation and without mental retardation, and improvements in QOL and IQ were frequently observed in postoperative patients who remained seizure free.     

Resective surgery for intractable focal epilepsy in patients with low IQ: predictors for seizure control and outcome with respect to seizures and neuropsychological and psychosocial functioning

PURPOSE: To investigate possible predictive factors for seizure control in a group of children and adults with low IQs (IQ, < or =70) who underwent resective surgery for intractable focal epilepsy and to study outcome with respect to seizures and neuropsychological functioning. We also studied psychosocial outcome in the adult patients. METHODS: Thirty-one patients (eight children younger than 18 years) with a Wechsler Full Scale IQ of 70 or less underwent comprehensive neuropsychological assessments before and 2 years after surgery. Adults also completed the Washington Psychosocial Seizure Inventory (WPSI). Univariate analyses were used to identify variables differentiating between patients who became seizure free and those who did not. Pre- and postoperative test results were compared by t test for dependent samples. RESULTS: Forty-eight percent of the patients became seizure free, 52% of those with temporal lobe resection and 38% of those with extratemporal resection. Only one variable was predictive for seizure outcome: duration of epilepsy. In one third of the patients, who had the shortest duration of epilepsy (<12 years), 80% became seizure free. Significant improvement was seen regarding vocational adjustment in adults (WPSI). Seizure-free adults improved their Full Scale IQ scores. No cognitive changes were found in seizure-free children or in patients who did not become seizure free. CONCLUSIONS: A good seizure outcome was obtained after resective surgery in patients with intractable focal epilepsy and low IQ, provided that treatment was done relatively shortly after onset of epilepsy. No adverse effects were seen on cognitive and psychosocial functioning.