微电极导向立体定向脑内核团毁损治疗帕金森病

目的：观察运用微电极导向立体定向术对不同靶点进行毁损治疗帕金森病的临床疗效。方法：386例帕金森病患者,应用微电极导向内侧苍白球腹后部和（或）丘脑（Vim)毁损术,判断其临床疗效。结果：手术即刻缓解对侧肢体症状383例（占98.7%)。康复出院365例（占94.5%)。结论：微电极导向技术能显著减少并发症,提高帕金森病的治疗效果。     

微电极导向多靶点毁损手术治疗帕金森病

目的总结微电极导向多靶点毁损手术治疗帕金森病的初步经验,探讨帕金森病的多靶点毁损手术治疗的方法.方法对24例临床表现为混合型的帕金森病患者进行了多靶点毁损手术治疗,单纯双侧PVP13例,单纯一侧PVP另一侧Vim7例,一侧PVP另一侧同期PVP加Vim4例.术毕、术后1周进行临床疗效观察,UPDRS综合评分对比.结果术毕所有患者的肢体活动灵活性立即得到改善,肢体震颤基本消失.3例术前药物所致“异动症”术后立即消除.术前和术后1周UPDRS评分开状态为61.56±19.65和27.03±10.42,下降56.09%;关状态为89.54±70.45和35.56±10.21,下降60.29%,差异显著.结论微电极导向技术的应用在多靶点毁损治疗中,对准确定位起着重要的保障作用,24例患者毁损术中,通过微电极记录均记录到清晰的苍白球腹后部和丘脑Vim核的放电波形以及出边界时波形消失的改变,保障了靶点定位准确.在PVP手术中,出苍白球腹后部边界后,均明确发现光线照射双眼后所诱发的视束反应电位,对避免视束损伤起重要的指导作用.术后没有发现视野改变.微电极导向多靶点手术治疗帕金森病能够较好控制帕金森病的双侧症状,并且并发症轻微,长期疗效有待于病例数的积累和进一步随访.     

微电极导向技术治疗帕金森病

目的探讨微电极导向技术治疗帕金森病方法、效果及评价.方法通过微电极导向记录技术对MRI定位靶点进行分析、调整和确认对27例帕金森病患者分别进行苍白球毁损术(17例),丘脑腹外侧核(Vim)毁损术(10例),评价手术后疗效.结果微电极导向技术治疗帕金森病总体有效率达98%,术后以UPDRS评分开关状态分别为12.3±9.1,13.2±8.9,较术前有明显改善.微电极确认功能靶点与MRI靶点存在差异,靶点调整率为40%.近期并发症为1%,无永久性并发症.结论微电极导向技术能显著提高手术定位准确率及成功率.     

微电极导向同期双侧腹后苍白球 毁损术治疗帕金森病

目的介绍微电极导向同期双侧腹后苍白球毁损术治疗帕金森病的方法与效果。方法应用微电极电生理记录技术术对毁损靶点进行确认定位,对３１例难治性帕金森病患者行同期双侧腹后内侧苍白球毁损治疗,术前及术后于开状态、关状态分别行改良Ｗｅｂｓｔｅｒ记分,计算改善率,评价其疗效。结果经微电极确认后的电生理靶点与ＣＴ定位靶点存在明显差异,靶点调整率８０６％。３１例手术均有效,其中治愈７例,明显进步２４例。Ｗｅｂｓｔｅｒ计分术后１周开状态改善率为７４２％±９５％,关状态改善率为８９１％±８９％。无永久性并发症。结论微电极导向同期双侧腹后苍白球毁损术安全、有效,具有明显临床治疗优势,微电极记录技术可使术中定位精确度大大提高。     

帕金森病外科治疗的适应症及毁损部位的选择

目的介绍微电极导向立体定向毁损手术治疗帕金森病的适应证及毁损部位选择的经验.方法 607例帕金森病患者采用微电极导向立体定向毁损手术治疗,病例选择至少满足三个原则①确诊为原发性帕金森病;②左旋多巴类药物治疗有效;③认知功能良好,术中能良好合作.毁损靶点选择主要按临床症状分型确定.以苍白球腹后内侧部作为常规基础性治疗靶点,术中如震颤症状改善不明显时,加行丘脑腹外侧核毁损.单纯震颤型患者可首先选择丘脑腹外侧核为靶点.结果手术有效率97.3%,术后患者Hoehn和Yahr分级及UPDRS评分及“药物所致运动障碍”均有显著改善.术后1周“开”状态改善率62.3%±10.6%,“关”状态改善率76.1%±8.7%,总并发症的发生率为5.6%,永久性并发症为1.3%.结论微电极技术能显著提高手术定位准确率及成功率.合适的病例选择对于良好的手术疗效是首要的.毁损靶点主要根据临床症状分型确定,以苍白球腹后内侧部作为常规基础性治疗靶点.     

微电极导向VL核和PVP核联合毁损治疗帕金森病

目的：对震颤、僵硬及运动迟缓帕金森病（ＰＤ）患者的立体定向手术方法学进行探讨。方法：应用微电极导向技术,对４３例ＰＤ患者,同侧丘脑腹外侧核（Ｖim/Vop)及苍白球腹后部（PVP）进行联合毁损术。结果：43例PD患者的肢体震颤、僵硬及运动迟缓均得到明显改善。术前术后Motor UPDRS积分,开状态及关状态均显著改善（P＜0．01）,无永久并发症。结论：应用微电极导向立体定向技术对伴有肢体震颤、强直及运动迟缓的ＰＤ患者,行同侧Ｖim核和PVP核联合毁损手术,能全面改善PD患者的症状,是一种安全有效的手术方法。     

单侧苍白球毁损术治疗不同类型帕金森病的疗效分析

目的 评价单侧苍白球腹后部毁损术对两种不同类型的帕金森病的近期和远期疗效。方法 应用微电极导向技术对46例帕金森病患者实施了单侧苍白球腹后部毁损术，其中震颤型20例和僵直迟缓型26例。采用“关状态”UPDRS Ⅲ评分对术后1月和术后1年的患者进行疗效评价并分析结果。结果 单侧苍白球腹后部毁损术对两组患者运动症状的近期改善率平均为59％和56％．经一年随访分别下降为54％和17％。结论 单侧苍白球腹后部毁损术稳定地改善震颤型帕金森病．而对僵直迟缓型帕金森病的疗效不稳定，远期疗效较差。     

微电极记录技术在手术治疗帕金森病中的作用

目的：介绍微电极记录技术在治疗帕金森病中的作用。方法：采用微电极细胞电生理记录技术进行术中靶点监测，对１００例帕金森病患者行苍白球腹后部（９６例）和丘脑腹外侧核（４例）毁损术，患者术前及术后评估采用ＵＰＤＲＳ积分，术中靶点更换率为８７％。结果：手术效果优良，有效率１００％，原有症状术后显著改善率平均达８９．４％，无永久并发症。结论：微电极的应用能显著减少手术并发症的发生，提高手术效果。     

伽玛刀丘脑腹中间核、腹嘴核毁损术治疗帕金森病及其他运动异常(附58例临床报道)

目的总结采用伽玛刀毁损丘脑腹中间核(ventrointermediatenucleus,Vim)、腹嘴核(ventrooralnucleus,VO)治疗58例帕金森病(parkinsondisense,PD)及其他运动异常性疾患,分析治疗后的临床变化过程及丘脑毁损灶的变化。方法采用4mm准直器单枪对靶点照射130Gy。参照微电极验证立体定向丘脑毁损术时确定靶点的方法确定靶点。结果随访2年以上的患者有40例,最长的患者随访了9年。在MRI上,丘脑毁损灶的变化可分为大而不规则形和小圆形,其容积在数10mm3到约600mm3。80%的患者效果良好而无明显并发症,震颤在治疗1年后减弱。如果震颤持续存在,则追加微电极验证的常规立体定向丘脑毁损术。结论伽玛刀丘脑毁损术治疗运动异常疗效明显。     

微电极引导定向手术治疗帕金森病的定位方法

目的:探讨微电极定位技术在苍白球毁损术及丘脑Vim核毁损术中的定位方法。方法:对698例次帕金森病患者定向手术中微电极定位资料进行总结和分析。结果:手术效果良好,定位特异并发症视野缺损和轻偏瘫发生率为1.7％。结论:良好的微电极定位技术可以增加手术的安全性和可靠性。     

磁共振结合微电极记录技术定位治疗帕金森病

目的：探讨磁共振扫描（ＭＲＩ）定位结合微电极记录技术在帕金森病（ＰＤ）立体定向手术治疗中的作用。方法：ＭＲＩ定位结合微电极记录技术,定向毁损法治疗ＰＤ２７０例,分析术中靶点更换,手术治疗效果和并发症发生情况。总结应用体会。结果：ＭＲＩ定位结合应用微电极记录技术,ＰＤ的立体定向外科手术治疗疗效优良,并发症少,无永久性并发症：脑内出血发生率为１．８６％,结论：ＭＲＩ定位结合微电极记录技术提高了ＰＤ的手     

烟雾病联合血管重建术后可逆性神经功能障碍的预测因素

目的探讨烟雾病患者颅内外血管联合重建术后发生可逆性神经功能障碍(RND)的预测因素。方法回顾性分析123例烟雾患者及其实施的138例颅内外血管联合重建术,记录其人口统计资料,临床表现,既往病史,RND并发症,以及手术相关资料。结果共计13例(9.42%)术后RND,发生于12名患者中。术前临床症状多次发作(多次定义为3次及以上)、一次手术双侧血管重建与术后RND密切相关(P<0.05,P<0.01)。缺血型烟雾病患者术后RND发生率(13.89%)高于出血型烟雾病患者(3.85%),但差异无统计学意义(P>0.05)。缺血型烟雾病中首发症状为TIA术后RND发生率为21.74%,首发症状为脑梗死者10.20%,二者差异无统计学意义(P>0.05)。首发症状为TIA者,术后RND发生率明显高于出血型烟雾病(P<0.05)。患者年龄,性别,手术与上一次卒中时间间隔,血管重建方式,是否单侧烟雾病,既往甲状腺、免疫疾病、高血压等病史与术后RND无明显关系。结论颅内外血管联合重建术后,首发症状TIA者比出血型烟雾病更易发生RND。但首发症状TIA与脑梗死者之间,缺血型烟雾病与出血型烟雾病之间,术后RND发生率均无明显差异。术前临床症状反复多次发作、一次手术双侧血管重建为术后RND的预测因素,因此双侧烟雾病的颅内外血管联合重建术不建议一次完成,而应分次进行。     

电生理功能定位在帕金森病手术治疗中的应用

目的 探讨神经元电生理功能定位在手术治疗帕金森病中的应用价值。方法 120例帕金森病患者,在微电极导向立体定向手术中分别应用运动电刺激和光反射电刺激检测方法,确定手术靶点位置,而后施行热频毁损术。手术后1年根据UPDRS评分评估疗效;手术后2周～3个月行MR检查比较手术前影像学定位与实际毁损靶点的偏差范围。结果 在手术中,微电极可在苍白球外侧和苍白球内侧记录到特征性的神经元电活动,有效确定靶点。手术前MRI解剖定位实际毁损靶点偏差<3mm,手术后1年UPDRS评分下降32.10％(P<0.01),症状改善程度依次为对侧肢体异动症(95％)、僵硬(72％)、震颤(72％)、运动迟缓及行走姿势(54％)。结论 微电极记录能有效地反映苍白球内侧的电生理学特征,提供细胞水平的“功能定位”。“有效针道”可以应用于苍白球腹后部切开术治疗帕金森病,从而提高治疗靶点的准确性,减少并发症的发生。     

立体定向苍白球毁损术的手术并发症

目的 全面和系统地分析苍白球毁损术并发症，并对并发症进行适当的分类。方法 统计1305例帕金森病患者，将并发症分为Ⅰ类并发症和Ⅱ类并发症。Ⅰ类并发症指并发症的发生与手术的定位不准确有关，包括：视野缺损、偏瘫。Ⅱ类并发症则指并发症的发生与手术的创伤有关，目前不能完全用定位偏差来解释，它包括：乏力感、流涎、吞咽困难、呃逆、音量降低、嗜睡、癫痫发作、肢体失用、精神错乱、脑出血、昏迷。结果 Ⅰ类并发症视野缺损和偏瘫的发生率分别为0.09%和0.26%，Ⅱ类并发症术后乏力达25.6%，音量减低11.6%，嗜睡12.6%，呃逆11.9%，流涎7.8%，吞咽困难4.1%。分期双侧苍白球毁损术发生率较高，分别为乏力47.6%，流涎26.6％，吞咽困难16.9%，音量降低20.5%。脑出血的17例。肢体失用3例，不明原因昏迷2例，术后短暂精神错乱4例。结论 苍白球毁损术的并发症种类较多，尽管多数并发症并非严重并发症，但是，值得注意的是苍白球毁损术的并发症在乏力、流涎、音量降低发生率较高，双侧手术要慎重，尤其是同期双侧苍白球毁损术。微电极手术的脑出血发生几率仍是较低的，是可以接受的低风险。     

Hereditary hemorrhagic telangectasia and spinal cord infarct: case report with a review of the neurological complications of HHT

Hereditary hemorrhagic telangectasia (HHT), also known as Osler-Weber-Rendu disease, is an autosomal dominant vascular dysplasia with high penetrance and variable expressivity. A wide variety of neurological complications have been reported in association with this condition. We report the first case of spinal cord infarction likely due to paradoxical embolization with HHT and review the literature on the neurological complications of this disorder. MEDLINE was employed to identify all published reports of HHT with neurological complications. We identified 44 references with a total of 436 cases of neurological complications of HHT. The most common complication was ischemic stroke and the main etiology for the vascular neurological complications in patients with HHT was pulmonary arteriovenous malformation. HHT should be considered in the differential diagnosis of any patient with cutaneous or mucosal telangiectasia or a history of unexplained epistaxis. HHT is associated with a diverse array of neurological disorders; most commonly ischemic and hemorrhagic stroke, transient ischemic attack, and brain abscess. While myelopathy secondary to arteriovenous malformation with HHT has been previously reported, this is the first instance of spinal cord infarction due to paradoxical embolization in this disorder.     

Early-onset Parkinson's disease and depression

Patients with Parkinsons disease (PD) in whom symptoms start before the age of 45 years (EOPD) present different clinical characteristics from those with the late-onset form of the disease. The incidence of depression is believed to be greater in patients with EOPD than with the late-onset form of the disease, although there is no risk factor or marker for depression in patients with PD. We studied 45 patients with EOPD to define the frequency of depression and to identify possible differences between the groups with and without depression. Depression was diagnosed in 16 (35.5%) of the patients, a higher incidence than in the population at large but similar to the figure for late-onset Parkinson disease; 8 (50%) of the patients had mild depression, 4 (25%) moderate depression and 4 (25%) were in remission. There was no relationship between depression and any of the clinical characteristics of the disease, although the EOPD patients with depression presented earlier levodopa-related complications and were more affected on the Hoehn-Yahr, UPDRS and Schwab-England scales.     

Bleeding complications in patients with coronary stents during non-cardiac surgery

Introduction

Patients with coronary stents often undergo non-cardiac invasive procedures. These are often associated with thrombotic and/or hemorrhagic complications. The type of procedure, perioperative antiplatelet therapy, and other patient-related factors influence the risk of postoperative haemorrhage. Our objective was to analyze the postoperative risk factors for hemorrhagic complications and to determine the impact of antiplatelet and anticoagulant therapy strategies on postoperative bleeding risk in patients with coronary stents undergoing non-cardiac surgery.

Patients and Methods

Prospective, multicentre observational cohort study of 1134 consecutive patients with coronary stents undergoing non-cardiac surgery between April 2007 and April 2009. The primary outcome measure was the occurrence of an hemorrhagic complication during the first 30 days following the surgery or intervention.

Results

Among the 1134 patients evaluated, 108 (9.5%) experienced a postoperative hemorrhagic complication (with a median time to occurrence of 5.3 days). These complications were considered major, involved the operative site, and required reoperation in 92 (85.2%), 92 (85.2%), and 20 (18.5%) of patients, respectively. Mortality in patients with a haemorrhagic complication was 12% (n = 13). Independent postoperative factors associated with haemorrhagic complications were identified as a high and intermediate bleeding risk procedure and the use and dose of anticoagulants. When interrupted before the procedure, resumption of antiplatelet treatment was delayed in patients developing early postoperative hemorrhagic complications.

Conclusion

Patients with coronary stents who undergo surgery are at high risk for hemorrhagic complications.     

微电极引导的苍白球腹后部毁损术与中医药治疗帕金森病的对比研究

目的 :通过微电极引导的苍白球腹后部毁损术和中医药疗法治疗帕金森病的对比研究 ,探讨手术疗法和中医药疗法各自的疗效特点和治疗适应证。方法 :应用微电极引导的苍白球腹后部毁损术治疗帕金森病 34例 ,手术包括同期双侧、分期双侧和单侧手术。针刺配合中药治疗帕金森病 5 6例。Webster帕金森病功能障碍记分法评分 ,将治疗前后和两组之间治疗结果进行对比。结果 :手术治疗组 34例帕金森病病人中 ,有 33例患者在手术过程中震颤、僵直、运动迟缓等主要症状均有不同程度的缓解 ,手术后这些症状也持续好转 ,但其症状缓解程度在不同的病人中有所不同。Webster帕金森病功能障碍记分法评分 ,术后 1周进步率为 5 0 %～ 99%者 2 6例 ,1%～ 49%者 7例 ,<1%者 1例 ,总有效率 97%。中医药治疗组 80 %以上的患者治疗一个月后主观症状改善 ,主要体征好转 ,基本生活能力得到提高。治疗 3个月后Webster帕金森病功能障碍记分法评分 ,进步率为 5 0 %～ 99%者 6例 ,1%～ 49%者 39例 ,<1%者 11例 ,总有效率为 80 4%。两组患者治疗前、后评分结果进行t检验 ,P <0 0 1,两组之间治疗结果的总有效率进行 χ2 检验校正 ,P <0 0 5。结论 :微电极引导的苍白球腹后部毁损术和中医药治疗帕金森病均可取得较为满意的疗效。手术组对     

苍白球腹后部毁损术中的靶点解剖定位和电生理定位

目的 总结苍白球腹后部毁损术中的靶点定位方法。方法 采用MRI扫描，前50例用坐标定位法计算靶点坐标，平均记录2．6个针道微电极信号；后191例采用坐标定位和图像定位相结合的方法计算靶点坐标，平均记录1．3个针道微电极信号。结果 MRI图像能显示苍白球各部分、内囊及视束等结构。微电极记录可确认苍白球内侧部边界、视束等结构。前50例患者坐标调整的百分数明显高于后191例患者。结论 MRI坐标定位和图像定位相结合，减少了个体差异引起的误差，使解剖定位更加准确。微电极记录技术是MRI定位方法的必要补充。     

Surgery for unruptured intracranial aneurysms in a low-volume neurosurgical unit

OBJECTIVES: To evaluate outcomes after surgical treatment for unruptured intracranial aneurysms in a low-volume neurosurgical unit. MATERIAL AND METHODS: Consecutive patients operated during the years 1988-98 at the Department of Neurosurgery, University Hospital of North Norway, were studied retrospectively. Procedure-related complications were registered. The modified Rankin Scale and the Glasgow Outcome Scale, Extended version (GOS-E), were used for assessment of outcome. RESULTS: Thirty-six aneurysms were repaired in 32 patients during 34 surgical procedures. Surgery-related central nervous system complications occurred in eight (25%) patients. The complication rate was 35% for the first 17 procedures, and 12% for the last 17. The latter group of procedures were performed during a period of 3 years, whereas the former group was spread over a period of 8 years. A favourable outcome (GOS-E score 6-8) was reached in 27 (84%) patients. CONCLUSION: Decision-making in patients with unruptured intracranial aneurysms must be based on knowledge about institution-specific complication rates, preferably followed on a prospective basis.