介入栓塞与开颅瘤颈夹闭术治疗颅内动脉瘤的术前评估研究

目的评估介入栓塞与开颅瘤颈夹闭术治疗颅内动脉瘤的术前相关危险因素。方法回顾性分析颅内动脉瘤患者120例,根据手术方式分为开颅夹闭组及介入栓塞组各60例;记录术前相关影响因素及术后恢复情况,分析比较性别、年龄、Fisher分级、Hunt-Hess分级、动脉瘤部位、动脉瘤长轴与颈宽比(AR)、高血压及高血糖等术前影响因素对开颅夹闭术和血管内介入栓塞术治疗颅内动脉瘤疗效的影响。结果年龄是手术治疗的影响因素,60岁以上患者预后明显差于60岁以下患者(P0.05);Fisher分级中Ⅰ、Ⅱ级患者的预后明显优于Ⅲ、Ⅳ级患者(P0.05);Hunt-Hess分级越高,预后效果越差,但开颅夹闭术与介入栓塞术2组比较无明显差异(P0.05);动脉瘤的部位对预后有显著影响(P0.05),动脉瘤长颈和瘤颈比值(AR)对介入栓塞术组影响较大(P0.05),随着AR值增大采用介入栓塞术的疗效明显好转(P0.05);高血压及高血糖对介入栓塞术治疗的影响较小(P0.05);不同年龄对临时阻断载瘤动脉时间的耐受能力不同,导致其预后疗效有显著差异(P0.05)。结论年龄、Fisher分级、Hunt-Hess分级及动脉瘤部位是颅内动脉瘤患者开颅夹闭术和血管介入栓塞术术后疗效的共同影响因素。     

高龄破裂脑动脉瘤不同治疗方式的预后分析

目的探讨70岁以上高龄已破裂脑动脉瘤病人不同治疗方法的预后。方法回顾性分析18例高龄(≥70岁)已破裂脑动脉瘤病人的临床资料,其中Hunt-Hess分级:Ⅰ级8例,Ⅱ级4例,Ⅲ级3例,Ⅳ级2例,Ⅴ级1例。结果随访3~26个月,积极外科治疗者按Hunt-Hess分级:Ⅰ级者治愈4例(夹闭2例,介入治疗2例)、中残1例(夹闭);Ⅱ级者治愈1例(介入)、死亡1例(夹闭);Ⅲ级者死亡2例(夹闭),Ⅳ级者重残1例(夹闭)。保守治疗8例均死亡。结论对于70岁以上已破裂脑动脉瘤病人,合适病例可首选介入治疗;夹闭术也可选择,尤在伴颅内血肿时。     

显微手术夹闭与血管内介入栓塞治疗颅内破裂动脉瘤的疗效分析

目的 对手术夹闭和血管内介入治疗颅内破裂动脉瘤的疗效作初步分析.方法 对2008年1月-2009年12月在重庆医科大学附一院神经外科治疗的破裂动脉瘤患者进行随访,获得随访信息的病例共109例,病人术前状态采用Hunt-Hess分级评分,其中采用显微神经外科开颅手术79例,Ⅰ-Ⅱ级69例(87.3％),Ⅲ-Ⅴ级10例(12.7％),血管内介入治疗30例,Ⅰ-Ⅱ级26例(86.7％),Ⅲ-Ⅴ级4例(13.3％).出院时手术夹闭组Hunt-Hess分级Ⅰ-Ⅱ级69例全部预后良好,Ⅲ-Ⅴ级10例,6例预后良好,4例预后不良(1例死亡),平均住院恢复时间(22.7±3.2)天;介入栓塞组Hunt-Hess分级Ⅰ-Ⅱ级26例全部预后良好,Ⅲ-Ⅴ级4例,2例预后良好,2例预后不良(1例死亡),平均住院恢复时间(13.4±3.4)天.随访时间3个月～2年.结果 手术夹闭组预后良好76例(96.2％),不良3例(3.8％),其中死亡2例(2.5％),瘫痪1例(1.3％);介入栓塞组预后良好28例(93 3％),不良2例(6.7％),其中死亡1例(3.4％),瘫痪1例(3.4％).影像学上,手术夹闭组79例随访63例(79.7％),其中稳定59例(93.7％);介入栓塞组30例病例随访21例(70％),其中稳定19例(90.5％).差异无统计学意义(P=0.625).结论 本研究手术夹闭和介入栓塞两种治疗方法间近期临床效果及随访结果统计学均无显著差异.手术治疗组的完全夹闭率较介入栓塞组的完全栓塞率高,而介入栓塞组平均住院恢复时间明显低于手术夹闭组.     

高分级颅内破裂动脉瘤血血管内介入治疗预后的影响因素

目的 探讨高分级颅内破裂动脉瘤血管内介入治疗的预后及其影响因素。方法 回顾性分析2020年9月至2022年9月血管内介入术治疗的156例WFNS分级Ⅳ～Ⅴ级颅内破裂动脉瘤的临床资料。根据出院时改良Rankin量表（mRS）评分评估预后,mRS评分≤2分为预后良好,>2分为预后不良。采用多因素logistic回归模型分析预后不良的危险因素。结果 156例中,出院时预后不良68例（43.59%）,预后良好88例。多因素logistic回归分析显示,高血压、年龄≥70岁及SEBES评分≥3分为高分级颅内破裂动脉瘤病人出院时预后不良的独立危险因素（P<0.05）。结论 WFNS分级Ⅳ～Ⅴ级颅内破裂动脉瘤病人血管内介入术治疗的预后不良发生率较高,尤其是合并高血压、年龄≥70岁及SEBES评分≥3分的病人,预后不良风险更高。     

19例动脉瘤破裂合并颅内血肿的早期治疗体会

目的 探索动脉瘤破裂合并颅内血肿的早期(发病24h内)手术治疗效果.方法 对2007年10月～2008年10月19例破裂动脉瘤合并颅内血肿的早期手术病例进行了同顾性分析.按Hunt-Hess分级:Ⅱ级1例,Ⅲ级6例,Ⅳ级10例,Ⅴ级2例.术前采取螺旋CT三维血管成像技术诊断,以显微外科手术夹闭动脉瘤并清除颅内血肿.结果 2例由于术后严重的脑血管痉挛导致大面积脑梗死死亡,5例产生严重功能障碍,其余12例患者均取得了良好效果.结论 对于Hunt-Hess分级Ⅱ～Ⅳ级的患者,应早期诊断和手术,清除血肿并夹闭动脉瘤,根据术中脑组织肿胀的程度,决定是否去骨瓣减压,而Ⅴ级患者手术效果不理想.术后并发症的预防和处理也是影响患者预后的关键因素.     

前循环动脉瘤破裂并脑内血肿的显微手术治疗

目的探讨前循环动脉瘤破裂伴脑内血肿手术方法及疗效。方法前循环动脉瘤破裂并脑内血肿患者29例行显微手术治疗,总结其临床特点:动脉瘤部位、大小、形态、合并脑内血肿大小、形态,术前Hunt-Hess分级、手术方式及三个月随访的格拉斯预后评分。结果 Hunt-Hess分级Ⅲ级10例、Ⅳ级17例、Ⅴ级2例。17例患者术前经常规血管造影,12例行三维CT血管造影(3D-CTA)检查证实。29例术中诊断与术前诊断一致,前交通动脉瘤6例,后交通动脉瘤7例,大脑中动脉瘤16例,29例患者共31枚动脉瘤均成功夹闭,3个月后随访时GOS评分Ⅴ级14例,Ⅳ级7例,Ⅲ级4例,Ⅱ级2例,Ⅰ级2例。结论颅内前循环动脉瘤破裂并脑内血肿患者病情危重,早期夹闭动脉瘤,清除血肿,效果良好。     

显微手术夹闭治疗老年颅内动脉瘤的疗效(附49例报道)

目的 探讨显微手术夹闭治疗老年患者颅内动脉瘤的治疗效果.方法 回顾性分析49例60岁以上颅内动脉瘤患者的临床资料(包括破裂出血41例,未破裂出血8例).根据术前数字减影血管造影(DSA)和头颅CT血管造影(CTA)检查确认动脉瘤后,48例采用经翼点入路,1例采用经纵裂入路夹闭颅内动脉瘤,出院时根据格拉斯哥预后评分(GOS)评价预后.结果 根据GOS评分,41例破裂出血患者,Hunt-Hess分级Ⅰ~Ⅲ级28例,其中26例(93%)取得良好预后,重度残疾2例(7%);Hunt-Hess分级Ⅳ级13例,其中7例(54%)取得了良好的预后,重度残疾3例(23%),植物生存1例(8%),死亡2例(15%).未破裂动脉瘤8例,均取得良好预后(100%).结论 破裂动脉瘤的老年患者应尽可能早期手术,术前Hunt-Hess分级Ⅰ~Ⅲ级者预后良好,而Ⅳ级以上病死率和伤残率仍较高;未破裂动脉瘤老年患者应采取积极治疗.     

颅内破裂动脉瘤伴脑内血肿夹闭术后预后影响因素

目的 探讨颅内破裂动脉瘤伴脑内血肿夹闭术后预后的影响因素。方法 回顾性分析2010年1月至2017年12月开颅夹闭术治疗的107例颅内破裂动脉瘤伴脑内血肿的临床资料。术后3个月根据改良Rankin量表（mRS）评分评估预后,0~2分为预后良好,3~6分为预后不良。结果 107例中,预后良好65例;预后不良42例。多因素logistic回归分析结果显示血肿量≥48.58 ml、术前Hunt-Hess分级Ⅲ~Ⅴ级、术中血管区域的操作时间≥45.80 min及术后未行康复治疗为预后不良的独立危险因素（P<0.05）。结论 对于颅内破裂动脉瘤伴脑内血肿病人,血肿量大、术前Hunt-Hess分级高,术中尽量缩短血管区域操作时间、术后进行合理康复治疗,有助于改善病人预后。     

颅内动脉瘤治疗十年回顾(附1372例治疗及随访)

目的 总结十年颅内动脉瘤治疗经验,以提高其治疗效果.方法 2000年1月至2009年12月收治颅内动脉瘤1 372例,采用血管内栓塞治疗632例(697枚动脉瘤),显微手术夹闭740例(805枚动脉瘤).结果 按GOS评分,栓塞组Hunt-Hess 0～Ⅲ级564例患者中,良好536例(95.0%),死亡6例(1.1%);手术夹闭组Hunt-Hess 0～Ⅲ级患者566例,良好542例(95.8%),重残18例(3.2%),死亡6例(1.1%).栓塞组Hunt-HessⅣ～Ⅴ级68例患者中,良好32例(47.1%),重残18例(26.5%),死亡18例(26.5%);手术夹闭组Hunt-HessⅣ～Ⅴ级174例患者中,良好84例(48.3%),重残55例(31.6%),植物生存7例(4.0%),死亡28例(16.1%)死亡.两组Hunt-Hess 0～Ⅲ级患者的预后没有显著差别(P>0.05).本组Hunt-HessⅤ级26例,重残4例,植物生存3例,死亡19例.栓塞组DSA复查167例,动脉瘤仍致密填塞138例,不完全栓塞24例,复发5例;夹闭组DSA复查136例,安全夹闭129例,部分瘤颈残留7例.结论 血管内栓塞治疗和显微手术夹闭均是治疗颅内动脉瘤的有效方法,治疗应根据病人动脉瘤的部位、大小及经济状况等进行选择,前循环动脉瘤两种皆可,后循环动脉瘤应首选血管内栓塞.Hunt-Hess 0～Ⅲ级尽早诊断和治疗,Hunt-Hess Ⅳ级在出血3 d以后血管痉挛严重者应待其缓解后再行治疗,Ⅴ级疗效极差.     

高分级颅内破裂动脉瘤的血管内介入治疗

目的探讨Hunt-Hess分级为Ⅳ、Ⅴ级破裂动脉瘤的治疗效果。方法对15例病人在全麻下应用电解可脱弹簧圈(GDC)进行动脉瘤介入栓塞治疗。宽颈动脉瘤可先在载瘤动脉内植入血管内支架,进一步随访或同时以弹簧圈栓塞。结果本组无因介入治疗失败而转为开颅手术治疗者,介入治疗过程中无动脉瘤破裂出血发生。完全闭塞11例,大部分闭塞4例。结论血管内介入栓塞创伤小,不受病情及发病时间限制,适合用于治疗Hunt-Hess分级为Ⅳ、Ⅴ级的颅内破裂动脉瘤病人。     

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.