颅内破裂动脉瘤合并脑内血肿的复合手术治疗

目的 探讨复合手术治疗颅内破裂动脉瘤合并脑内血肿的疗效。方法 回顾性分析簧圈栓塞术后行颅骨钻孔血肿腔引流术治疗的5例颅内破裂动脉瘤合并脑内血肿的临床资料。结果 5例头颅CT均表现为典型蛛网膜下腔出血（SAH）合并脑内血肿;DSA发现动脉瘤位于大脑前动脉A2段分叉部1例、大脑前动脉A2段1例、前交通动脉1例、颈内动脉后交通动脉1例、大脑中动脉分叉部1例;术前Hunt-Hess分级Ⅱ级2例,Ⅲ级2例,Ⅳ级1例。引流术后3~4 d血肿大部分引流干净,无再出血、感染及脑梗死。术后6个月GOS评分3分1例,4分1例,5分3例。结论 对合并脑内血肿的自发性SAH,首先应考虑动脉瘤破裂出血可能,需尽早行DSA检查明确诊断;复合手术对于部分未发生脑疝又合并脑内血肿的破裂动脉瘤是可行的,能取得良好的疗效。     

前循环破裂动脉瘤伴脑内血肿的 早期显微手术治疗

目的 探讨早期显微手术治疗前循环破裂动脉瘤伴脑内血肿的疗效。方法 2010年12月至2013年12月显微手术前循环破裂动脉瘤伴脑内血肿26例,均发病后3 d内手术,采用翼点入路或扩大翼点入路23例,经额纵裂入路3例。结果 术后随访3个月至2年,GOS评分5分11例,4分9例,3分4例,2分1例,1分1例;术后DSA或CTA复查动脉瘤夹闭满意,载瘤血管通畅。结论 对前循环破裂动脉瘤伴脑内血肿,早期显微手术清除血肿并夹闭动脉瘤能够取得较为满意的临床效果。     

早期动脉瘤术后两次出现迟发性缺血

脑的迟发性缺血是动脉瘤破裂后引起血管痉挛的一种并发症,其发病率及死亡率都高.脑血管痉挛的病因学不完全清楚,但大都认为蛛网膜下腔出血(SAH)是引起血管痉挛的主要病因.作者报导一例左颈内动脉瘤破裂经夹闭动脉瘤清除大部分蛛膜下血液后两次出现迟发性缺血症状,认为动脉瘤破裂,早期彻底清除蛛网膜下腔血液可能会影响血管痉挛的严重性和进程,并可防止严重的迟发性脑缺     

血管内栓塞治疗急性破裂性颅内动脉瘤的围手术期处理及并发症防治（附79例分析）

目的总结血管内栓塞治疗急性破裂性颅内动脉瘤的围手术期处理及并发症的防治方法。方法对79例动脉瘤性蛛网膜下腔出血（SAH）病人采用可脱性弹簧圈进行动脉瘤囊内栓塞；术前预防再出血，术后早期处理SAH，防治脑血管痉挛，并妥善处理并发症。结果瘤腔100％闭塞65个，95％闭塞8个，90％闭塞6个。术后GOS5分52例，4分12例，3分6例，2分4例，1分5例。全组病死率6．3％。术后68例随访3—58个月，均无再出血，1例复发者行再次GDC栓塞。结论动脉瘤性SAH病人在围手术期预防再出血，早期处理SAH，防治脑血管痉挛及延迟性缺血性神经功能障碍，对降低病死率及致残率具有重要意义。     

动脉瘤病人术后并发认知机能障碍的影响因素

目的 认知机能障碍是动脉瘤破裂后使病人失能的常见后遗症,故探讨动脉瘤破裂病人术后出现认知机能障碍原因及影响因素。方法 回顾性研究动脉瘤破裂手术治疗病人22例。参考病人术前Hunt—Hess分级,SAH Fisher评分及动脉瘤部位,探讨其与病人发生认知机能障碍的关系。结果 并发认知障碍8例;其中前交通动脉瘤表现为5例,左侧后交通动脉瘤2例,左侧大脑中动脉瘤1例。SAH Fisher评分3分6例,2分2例。发病时间：术后8～10d出现5例,14～16d2例,1例病人术后18d发病（已出院）。结论 结果表明,动脉瘤破裂手术病人并发认知功能障碍由多种综合因素导致。临床应早期重视病人术后认知功能障碍的防治,降低病人持久性认知机能障碍发病率,促进病人生活自理和社会活动参与能力。     

脑血管痉挛和手术时机对颅内破裂动脉瘤患者预后的影响

目的探讨脑血管痉挛(CVS)和手术时机对颅内破裂动脉瘤患者预后的影响。方法回顾性分析2008年11月至2009年3月经手术夹闭的71例颅内破裂动脉瘤患者的临床资料。利用经颅多普勒超声监测CVS,并分析CVS、手术时机与术中动脉瘤破裂发生率、术后主要并发症(CVS、脑积水)发生率和术后疗效(GOS评分)的关系。结果出院当天按GOS进行术后短期疗效评价,其中良好(GOS4～5分)54例,差(GOS2～3分)12例,死亡(GOS1分)5例。术前不同程度CVS患者术中动脉瘤破裂发生率、术后CVS和脑积水发生率以及患者预后良好率均无明显差异(P>0.05)。不同手术时期患者术中动脉瘤破裂发生率、术后并发症(CVS和脑积水)和患者预后良好率亦无明显差异(P>0.05)。中期手术患者中术前轻度或无CVS患者术后CVS的发生率显著低于术前中、重度CVS患者(P<0.05)。结论术前CVS程度和手术时机对颅内破裂动脉瘤患者总体预后并无显著影响;选择中期手术亦可以获得良好的治疗效果。     

一种新的蛛网膜下腔出血动物模型制作方法

目的 建立一种能更接近人脑动脉瘤破裂引起蛛网膜下腔出血(SAH)过程的动物模型.方法 通过介入法经股动脉路径穿刺兔颈内动脉,造成SAH,然后将60只实验兔按各时间点(对照组、假手术组、术后0h、3h、6h、12 h、1d、3d、7d、14 d)分成10组,每组6只,行脑血管造影,然后灌注-固定,处死后取基底动脉切片行HE染色观察,通过图像分析系统,测定动脉内径和血管壁厚度.结果 血管内穿刺法制作兔的SAH模型呈急性期脑血管痉挛(SAH后12 h)和迟发性脑血管痉挛(SAH后7d)双相改变.结论 此动物模型能较好地模拟动脉瘤性SAH后血管痉挛改变的病理过程.     

重组链激酶预防蛛网膜下腔出血后脑血管痉挛的实验研究

目的 研究重组链激酶（r-SK）对蛛网膜下腔出血（SAH）后脑血管痉挛（CVS）的预防作用。方法 采用枕大池二次注血法制成大白兔SAH模型,24h后经侧脑室穿刺置管,治疗1组注入1．25mg r-SK,闭管6h后开放引流,6h后再次注射、闭管、引流,如此反复3次;治疗2组一次性注入r-SK3．75mg;SAH组注入生理盐水1ml,方法同治疗1组;给药后6h、12h和1d、3d、5d、7d经各引流管引流的脑脊液（CSF）用于检测氧合血红蛋白（OxyHb）含量;制模前及制模后7d分别进行基底动脉（BA）造影,计算口径比,并进行组织学检查。结果（1）CSF中OxyHb含量SAH组逐渐上升,治疗1组、2组逐渐下降,注药后1～7d治疗1组、2组OxyHb含量较SAH组明显下降（P〈0．05～0．01）;第7d治疗1组OxyHb含量显著低于治疗2组（P〈0．05）。（2）SAH组BA管径明显缩小,呈重度痉挛;治疗1组、2组管径无明显变化。（3）组织学检查发现SAH组脑底表面有含铁血黄素沉着,血管周围有血凝块,BA内膜皱缩;治疗1组脑底无含铁血黄素沉着及血凝块,BA未见病理改变;治疗2组脑底有少量含铁血黄素沉着及血凝块,BA内膜轻度皱缩。结论侧脑室短期、少量反复注射r-SK并CSF引流可预防SAH后CVS的发生。     

显微夹闭术中颅内前循环动脉瘤破裂的预防与处理

目的探讨颅内前循环动脉瘤开颅夹闭术中动脉瘤破裂出血的处理和防范的策略、方法和技巧。方法回顾性分析2003年1月至2010年1月56例前循环颅内动脉瘤患者开颅显微手术夹闭的临床资料,结合文献对13例术中发生动脉瘤破裂出血的处理经验和技巧,以及防范方法进行总结。结果 13例出现术中动脉瘤破裂,均得以妥善处理,本组患者术后GOS 5分39例;GOS 4分8例;GOS 3分6例;GOS 2分0例;GOS 1分3例。结论应从麻醉、开颅到手术操作的各个环节尽量防范术中动脉瘤破裂,合理、间断和短时应用载瘤动脉临时阻断技术,可有效处理和防范术中动脉瘤破裂的危急情况。     

无蛛网膜下腔出血的破裂脑动脉瘤

目的 总结无蛛网膜下腔出血(SAH)的破裂脑动脉瘤的诊治经验.方法 对15例在起病后2 d内首次CT或MRI上表现为脑内出血(ICH),和(或)脑室内出血(IVH)、硬脑膜下血肿(SDH)和壁间出血(IMH)而无SAH的破裂脑动脉瘤患者的临床表现、影像学检查结果 、治疗方法 和预后进行回顾性分析.结果 本组首次CT或MRI检查表现为ICH者3例、IVH合并ICH者6例、SDH者1例、IVH者1例、IMH者3例和等高混合密度者1例.其中动脉瘤位于大脑中动脉6例、前交通动脉4例、后交通动脉3例、大脑前动脉1例和小脑后下动脉1例.开颅手术夹闭动脉瘤13例,血管内栓塞2例.出院时GOS评分:恢复良好8例、中残3例、重残3例和植物生存1例.本组15例占同期破裂脑动脉瘤的3.8%.结论 破裂脑动脉瘤首次CT扫描可表现为单纯ICH,和(或)IVH、SDH、IMH而无SAH,与CT扫描时间、动脉瘤的部位和指向以及出血量有关.早期控制颅内高压、及时诊断和有效处理破裂动脉瘤,是改善预后的关键.     

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.