帕金森病的定向手术适应证

目的 确定各类帕金森病的定向手术适应证。方法 回顾分析1478例帕金森病定向手术，对手术后的手术疗效和某些相关并发症进行评估，进而推断各类帕金森病的定向手术适应证。结果 苍白球毁损术对服用左旋多巴类药物有效的震颤患者均有效，服用左旋多巴类药物震颤无效的患者，苍白球毁损术的手术疗效效果很差，单侧丘脑Vim核毁损术对震颤改善极佳，96.9%的患者彻底消失，同期同侧苍白球＋兵脑Vim核毁损术对震颤改善极佳，96.9%的患者彻底消失，同期同侧苍白球＋丘脑Vim核毁损术的患者震颤改善率为96.3%，苍白球毁损术对僵直、运动迟缓的疗效也显示出与左旋多巴服药的反应的规律性，服药效果好的手术效果好，但是，与震颤不同的是，服药无效的也有一定的疗效。启动不能患者，其手术效果都不佳，流涎、吞咽困难发生率在单侧苍折球毁损术患者中较低，乏力发生率较高，分期双侧苍白球毁损术中患者年龄较大的较易发生乏力、流涎、吞咽困难。结论 我们的临床实践认为左旋多巴类药物服药反应是一个非常重要的判定指标，僵直、运动迟缓、药物引起的“开－关”、异动症服药有效的患者，苍白球毁损术的效果较好；震颤则有所不同，凡是左旋多巴不能完全控制的，采用苍白球＋丘脑Vim核毁损术则手术效果非常满意，启动不能患者手术应该极其慎重，手术的帮助不大。我们不主张同期双侧苍白球毁损术，分期双侧苍白球毁损术也要慎重。     

运动障碍性疾病立体定向脑深部刺激术和毁损术中脑出血原因分析

目的 分析运动障碍性疾病立体定向手术中脑出血危险因素,以降低脑出血并发症.方法 对689例运动障碍性疾病进行了立体定向脑深部刺激术(DBS)和毁损术,共有853个靶点进行了手术治疗,其中丘脑底核(STN)刺激术188个,丘脑腹中间核(Vim)刺激术5个,苍白球内侧部DBS 2个,苍白球腹后部毁损术(PVP)478个,Vim毁损术180个.结果 术后无症状性脑出血14例,症状性脑出血10例.有高血压病史患者脑出血发牛率明显高于无高血压病史患者.在微电极记录2-4条针道的手术靶点中,脑出血发生率显著高于微电极记录1条针道的脑出血发生率.DBS、PVP及Vim毁损术靶点脑出血发生率分别为0.5%、3.6%及3.3%,前者发生率明显低于后两者.结论 高血压病史是帕金森病立体定向手术并发脑出血的危险因素,微电极记录针道数与脑出血发生率成明显正相关,脑深部刺激术是较毁损术更安全的外科治疗方法.     

刺激术和毁损术在双侧立体定向手术治疗帕金森病中的比较

目的比较脑深部刺激术和毁损术在双侧立体定向手术治疗帕金森病中的优缺点。方法69例帕金森病病人进行了双侧手术治疗,其中同期双侧丘脑底核(STN)脑深部刺激术(DBS)11例,同期一侧苍白球腹后部毁损术(PVP),另一侧STNDBS3例,分期一侧PVP或腹中间核(Vim)毁损术、另一侧STN或VimDBS9例;分期双侧PVP或Vim毁损术41例,同期双侧PVP5例。平均随访9.3个月。结果UPDRS评分显示刺激术和毁损术均能显著改善对侧肢体震颤、僵硬和运动迟缓症状,双侧刺激术还能改善步态和姿势症状,但双侧毁损术可加重语言、吞咽及流涎等症状,并发症较高。结论双侧DBS是具有双侧症状的帕金森病病人手术治疗的最佳术式,双侧毁损术并发症较高,应严格慎重采用。     

微电极导向多靶点毁损术治疗帕金森病

目的　评估微电极导向多靶点毁损术的手术疗效及不同手术方式的适应证选择。方法　应用微电极导向多靶点毁损术治疗帕金森病 83例 ,其中同期双侧苍白球毁损 1 0例 ,同期同侧苍白球加丘脑毁损 3 0例 ,分期双侧多靶点毁损43例。以术前及术后 1周UPDRS积分计算改善率评价疗效。结果　 83例均有显著近期疗效 ,其中同期双侧毁损的改善率为 83 4% ,同期同侧毁损的改善率为 78 5% ,分期双侧毁损的改善率为 85 2 %。术后 3 6%出现轻度并发症。单项症状改善率最高为僵直 (95 7% ) ,余依次为震颤 (95 1 % )、行动迟缓 (90 9% )、步态 (70 % )、平衡 (68% )。平均随访 1年 ,除 1例复发外 ,余疗效均稳定。结论　微电极导向多靶点毁损术是治疗帕金森病的最有效方法 ,根据手术适应证选择手术方案有助于提高疗效。     

分期双侧多靶点毁损术治疗帕金森病疗效的相关因素分析

目的　探讨分期双侧多靶点毁损术治疗帕金森病 (PD)疗效的相关因素。方法　将 387例需手术治疗的PD患者按年龄、手术方式、两次手术的间隔时间、毁损电极粗细 4项进行分组 ,探讨上述因素与疗效、并发症的关系。结果　二次手术近期疗效显著 ,分期双侧苍白球腹后内侧部 (PVP)毁损术是应用最多的术式 ;双侧丘脑腹中间 (Vim)核毁损术并发症的发生率高 (10 0 % ) ;5 5岁以上的患者并发症发生率 (2 9 70 % )明显高于 5 5岁以下的患者 (12 6 6 % ) (P <0 0 5 ) ;二次手术间隔时间在半年以内者并发症的发生率 (41 6 7% )高于间隔半年以上者 (P <0 0 5 ) ;1 8mm电极的治疗效果 (98 0 1% )好于 1 1mm电极 (96 6 1% ) ,但并发症的发生率却高于 1 1mm的电极 ,达 2 8 4 8% (P <0 0 5 )。结论　分期双侧PVP毁损术相对安全 ;分期一侧PVP加对侧Vim核毁损可减少并发症 ;术前选好手术适应证、术中控制毁损灶大小可减少并发症的发生 ;二次手术应以单靶点毁损为宜 ,时间间隔宜在半年以上。     

帕金森病核团毁损术疗效与并发症的关系

目的：进一步总结帕金森病的微电极导向苍白球腹后部毁损术和丘脑腹中间核毁损术疗效。方法：微电极导向立体定向核团毁损术治疗帕金森病患者300例。对近期进行的100例患者在手术靶点选择、手术方法、手术疗效和并发症等方面进行总结，并与早期进行的100例手术患者比较。结果：近期进行的100例患者手术效果较好，并发症发生率低。结论：根据患者症状选择合适的毁损术能提高手术疗效；对靶点采用磁共振成像（MRI）图像和座标相结合的定位方法,可减少个体差异引起的误差；适当减少微电极记录针道数，降低毁损温度，能减轻电极与脑组织粘连，减少脑出血等并发症。     

高血压性脑出血手术时机的选择

我院从 1998年以来对 78例高血压性脑出血的病人采取了手术治疗。从手术时机角度分成超早期及早期 (<7h)、中期(8h～ 5d)、晚期 (>6d)。三组病例出血部位 (基底节区 )和出血量 (均大于 3 0ml)无大差别。但结果有差异。现分析如下。1　临床资料1 1　脑出血意识状态分级　见表 1。表 1　脑出血后意识状态分级分级意识状态主要体征Ⅰ级清醒或嗜睡伴不同程度偏瘫及 /或失语Ⅱ级嗜睡或朦胧伴不同程度偏瘫及 /或失语Ⅲ级浅昏迷　　偏瘫、瞳孔等大Ⅳ级昏迷　　　偏瘫、瞳孔等大或不等Ⅴ级深昏迷　　去大脑强直或四肢软瘫、单或双侧瞳孔散大1 2　术…     

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。     

帕金森病毁损术治疗的手术方式选择与疗效关系

目的：总结帕金森病（PD）苍白球和丘脑毁损术的手术方式选择与手术效果关系。方法：对213例PD患者进行了221次微电极导向立体定向手术治疗。临床分型;震颤型17例,僵直型38例,震颤僵直型158例,其中苍白球腹后部毁损术（PVP）171例;丘脑腹中间核（Vim)毁损术21例;同期同侧PVP和Vim毁损术8例;同期双侧PVP5例,分期双侧PVP8例。结果：术后UPDRS评分发现上述各种术式在“关”状态下和“开”状态下症状均有明显改善。改善率分别为50.8%-60.8%和28.7-36.6%,但以多靶点毁损术为佳。同期双侧PVP发生明显构音障碍,吞咽困难1例,结论：应根据不同症状选择不同术式,PVP对僵直、“开-关”现象、异动症,肢体无力及肌肉酸痛效果较好,震颤效果略微差一些,对运动迟缓、连带动作、语言发音也有一定改善率,但对平衡,步态及姿势等轴性症状效果较差。甚至个别症人术后步态障碍加重。Vim毁损术对震颤效果最为理想,同期双侧PVP手术易产生并发症,应慎重采用。     

癌症顽痛丘脑毁损止痛手术的并发症分析

目的 探讨癌症顽痛丘脑毁损止痛手术的并发症和防治措施。方法 对56例癌症顽痛病人行丘脑中央中核毁损止痛手术，对其术后发生的并发症进行回顾性分析。结果 本组发生并发症20例，其中非特异性5例：颅内出血4例，肺部感染1例；特异性15例：嗜睡4例，偏瘫3例，尿失禁3例，构音障碍2例，动眼神经麻痹1例，感觉异常1例，呃逆1例。颅内大出血1例及肺部感染1例病人死亡，余并发症经止血、脱水、激素等治疗大多恢复。结论 对癌症顽痛病人施行丘脑毁损手术应严格掌握手术适应证．个体化设计靶点，实行精细的手术操作，以减少并发症的发生。     

Complications of gamma knife surgery for Parkinson disease.

BACKGROUND: Many medical centers throughout the world offer radiosurgery with the gamma knife (GK) for pallidotomy and thalamotomy as a safe and effective alternative to radiofrequency ablative surgery and deep brain stimulation for Parkinson disease (PD). The reported incidence of significant complications varies considerably, and the long-term complication rate remains unknown. DESIGN: We describe 8 patients seen during an 8-month period referred for complications of GK surgery for PD. RESULTS: Of the 8 patients, 1 died as a result of complications, including dysphagia and aspiration pneumonia. Other complications included hemiplegia, homonymous visual field deficit, hand weakness, dysarthria, hypophonia, aphasia, arm and face numbness, and pseudobulbar laughter. In all patients, lesions were significantly off target. CONCLUSIONS: The 8 patients with PD seen in referral at our center for complications of GK surgery highlight a spectrum of potential problems associated with this procedure. These include lesion accuracy and size and the delayed development of neurological complications secondary to radiation necrosis. Gamma knife surgery may have a higher complication rate than has been previously appreciated due to delayed onset and underreporting. We believe that the risk-benefit ratio of the GK will require further scrutiny when considering pallidotomy or thalamotomy in patients with PD. Physicians using this technique should carefully follow up patients postoperatively for delayed complications, and fully inform patients of these potential risks.     

Pallidotomy versus pallidal stimulation

Both posteroventral pallidotomy and pallidal deep brain stimulation (DBS) have a documented effect on Parkinsonian symptoms. DBS is more costly and more laborious than pallidotomy. The aim of this study was to analyse the respective long-term effect of each surgical procedure on contralateral symptoms in the same patients. Five consecutive patients, two women and three men, who at first surgery had a mean age of 64 years and a mean duration of disease of 18 years, received a pallidotomy contralateral to the more symptomatic side of the body. At a mean of 14 months later, the same patients received a pallidal DBS on the side contralateral to the pallidotomy. All patients had on-off phenomena and dyskinesias. There were three left-sided and two right-sided pallidotomies, and, subsequently, two left-sided and three right-sided pallidal DBS. The latest evaluation was performed 37 months (range 22-60) after the pallidotomy and 22 months (range 12-33) after the pallidal DBS. Mean UPDRS motor score pre-operatively was 49 and at last follow-up 33 (32.7% improvement, p<0.05). Appendicular items 20-26 contralateral to pallidotomy remained improved more significantly than contralateral to DBS. Dyskinesia scores were also improved more markedly contralateral to the pallidotomy. Two patients exhibited moderate dysarthria and one patient severe dysphonia following DBS. Symptoms contralateral to the chronologically older pallidotomy, especially dyskinesias, rigidity and tremor, were still more improved than symptoms contralateral to the more recent pallidal DBS, despite numerous post-operative patient visits to optimise stimulation parameters.     

分期立体定向双侧多靶点毁损术治疗帕金森病

目的:探讨分期双侧多靶点毁损术的疗效、适应证、靶点的选择及并发症。方法:对比第一次手术350例与第二次手术387例患者的UPDRS评分、评分改善率、并发症及主要症状改善率，进行统计学分析。结果两次手术均有显著近期疗效，二次手术单项症状改善率为震颤95．3％、僵直94．6％、运动迟缓82．9％、步态62．4％、平衡65．3％、异动症和痛性痉挛96．4％，总有效率97．2％。第二次手术总体改善率较第一次低，一过性特异性并发症增多，能于短期内恢复，永久性并发症发生率为5．43％。美多巴用量较术前减少。结论:分期双侧多靶点毁损术治疗帕金森病是一种有效、安全的方法，术前选好手术适应证、手术方式至关重要，两次手术间隔时间以半年以上为宜。     

Outcomes following staged bilateral pallidotomy in advanced Parkinson's disease

The authors assessed clinical outcome for up to one year after staged bilateral pallidotomy in 14 patients with advanced PD. One year after surgery, dyskinesias were virtually abolished and there were significant reductions in "off" time (67%) and activities of daily living "off" scores (24%), as well as nonsignificant reduction in "off" motor score (39%); "on" scores were unchanged. One patient developed a visual field deficit; two had transient confusion. Staged bilateral pallidotomy improves motor function in selected patients with advanced PD.     

Neurological complications following liver transplantation.

Neurological complications occurred in 4 (19%) of 21 consecutive patients (Group II) undergoing orthotopic liver transplantation, compared with a 47% (9/19) incidence in our initial series (Group I). In Group II, the neurological problems included new recurrent headaches and delayed intracerebral hemorrhage (1 patient), partial third nerve palsy and brachial plexopathy (1 patient), and ataxic dysarthria with encephalopathy (2 patients). Seizures, noted in 8 of 9 neurologically affected Group I patients, were not encountered in Group II. Of the 4 patients in the entire series with the cerebrocerebellar syndrome, 2 had partial recovery after stopping treatment with cyclosporine, 1 stabilized when cyclosporine was discontinued but later worsened when rechallenged, and 1 had full recovery but died following a second transplantation. Brain magnetic resonance images appeared normal in 3 of the 4 patients. Complications affecting vision included cortical blindness in 2 patients and occipital lobe hemorrhage in 1. All completely recovered. Survival was comparable for patients with and those without neurological complications (69% and 63%, respectively). Immediate withdrawal of cyclosporine at the onset of a change in mental status or dysarthria and improvement in intra- and postoperative management may have contributed to the decreased incidence of neurological complications.     

Is drooling secondary to a swallowing disorder in patients with Parkinson's disease?

Drooling is a common manifestation in Parkinson's disease (PD). It causes psychosocial difficulties and can result in aspiration and chest infection. Previous studies point to an association between swallowing problems and sialorrhea. The aim of this study was to determine if drooling is associated with dysphagia in PD patients. Sixteen PD patients with diurnal drooling were assessed using a modified barium swallowing with videofluoroscopy, and a drooling score. Changes in the oral stage of swallowing were seen in 100% of the patients; and in the pharyngeal stage, in 94% of the patients. The results showed a correlation between the drooling scale score and the level of dysphagia (−0.426; p<0.05). Patients with the worst dysphagia had the worst drooling.     

Stereotactic pallidotomy and thalamotomy in the treatment of primary dystonia

BACKGROUND AND PURPOSE: The goal of the study was to assess the results of the stereotactic pallidotomy and thalamotomy in the treatment of primary dystonia. MATERIAL AND METHODS: Thirty patients with primary dystonia underwent twenty-eight stereotactic pallidotomies and twenty two thalamotomies. The operations were based on the fused images of computed tomography and magnetic resonance imaging, and were verified by an intraoperative neurophysiological investigation. Neurological and neuropsychological assessments were performed before surgery and at 3 days, 3 and 6 months after the operation. The Mann-Whitney U test was used to find out statistic differences between subgroups and the Wilcoxon test to compare results between particular assessments. RESULTS: The statistic analysis showed postsurgical amelioration of the neurological state lasting at least 6 months. A better long-term outcome was revealed in the subgroup of pallidotomies vs. thalamotomies, in the subgroup with the onset of dystonia after the age of 35 vs. earlier onset, and in the subgroup of the focal and local dystonia vs. generalized dystonia. The statistically significant improvement was achieved at a depression level and the statistically significant deterioration was not stated in the mental status after the operations. A very low percentage of neurological complications after the operations was found in the study. CONCLUSIONS: The stereotactic pallidotomies and thalamotomies are effective and safe options in the treatment of the intractable cases of primary dystonia. Both resulted predominantly in contralateral improvement of motor functions. However, the results of pallidotomies are better than thalamotomies six months after the surgery. The improvement of the mood without cognitive deterioration was revealed in the neuropsychological tests after the operations. Only few, persistent and mild complications were ascertained in the study.