影响脑转移瘤伽玛刀治疗效果相关因素分析

目的　探讨影响伽玛刀治疗脑转移瘤治疗效果的因素。方法　用伽玛刀治疗脑转移瘤 2 72例共 396个病灶。中心剂量 2 5～ 70Gy ,周边剂量 1 0～ 35Gy;靶点数 1～ 1 1个。并对肿瘤体积、数目、照射剂量、原发灶控制和全脑放疗等影响疗效因素进行统计分析。结果　本组病例随访 1 0～ 46个月 ,平均 2 4个月。 396个病灶完全缓解 32 6个 (82 3 % ) ,部分缓解 38个 (9 5 % ) ,无变化及进展 32个 (8 2 % ) ,平均生存期 (1 3 6± 7 9)个月。原发灶控制好者、伽玛刀治疗前后结合放疗、化疗者 ,其生存期较长。结论　伽玛刀是治疗脑转移瘤安全可靠的手段之一。并发症少、有效率高。伽玛刀治疗脑转移瘤的疗效主要与病灶体积、周边剂量等密切相关。肿瘤体积小于 1 5cm3,周边剂量大于 1 8Gy时 ,完全缓解率较高。     

姑息性伽玛刀治疗老年脑转移瘤

目的 总结姑息性伽玛刀治疗老年(≥65岁)脑转移瘤患者的治疗效果. 方法 福建医科大学附属协和医院伽玛刀治疗中心自2004年3月至2010年3月共治疗134例老年脑转移瘤患者,共治疗212次,治疗病灶403个,平均中心剂量及边缘剂量分别为(29.3±8.4) Gy和(15.9±4.8) Gy.Kaplan-Meier方法计算患者的中位生存期,Cox回归分析影响伽玛刀治疗效果的临床因素. 结果 获影像学随访的372个病灶中,完全消失66个(17.7％),部分缓解174个(46.8％),无变化94个(25.3％),部分进展38个(10.2％).Kaplan-Meier分析显示患者中位生存期为10.9个月.影响伽玛刀治疗效果的因素为治疗前KPS评分、脑转移预后分级(RPA分级)、转移瘤数目和原发肿瘤的控制情况. 结论 伽玛刀治疗老年脑转移瘤是安全有效的姑息性治疗手段,有助于维持患者良好的生活质量.     

肺癌脑转移瘤伽玛刀治疗

目的回顾性研究肺癌脑转移瘤伽玛刀治疗的疗效、生存时间及并发症.方法伽玛刀治疗42例肺癌脑转移瘤病人(151个病灶).年龄34-76岁,男29例,女13例.脑转移瘤的诊断依据典型的脑部CT或MRI影像表现及肺癌的诊断证据.应用Gamma plan3.01-5.12软件系统进行剂量计划,23004B型Gamma Knife治疗.肿瘤边缘剂量8～25Gy,平均21Gy,边缘等剂量线40～95%,肿瘤平均治疗容积4.75cm3.结果随访3～26个月,平均10.27个月,中位生存时间8个月(3～26个月),平均生存时间为10.27个月.1年的生存率35.7%,2年的生存率7.1%.肿瘤控制率为98.7%,在术后6～20个月有5个肿瘤先后复发.40例病人术前的症状体征明显缓解或消失,2例加重.有2例病人出现伽玛刀治疗后的并发症.结论伽玛刀放射外科治疗是一种安全、有效的脑转移瘤治疗方法.     

X-刀在脑转移瘤的补救治疗中的临床研究

目的 研究X-刀在脑转移瘤补救治疗中的价值。方法 应用X-刀治疗脑转移瘤233例,其中12例为行2次或3次X-刀治疗,重复行X-刀治疗的标准为复发的肿瘤部位分散或在以前行立体定向放射治疗的体积以外,KPS70分。第1次靶区平均周边剂量为20Gy(17～30Gy),肿瘤平均体积2.2ml(0.3～20.1ml);第2次靶区平均周边剂量为18Gy(15～30Gy),肿瘤平均体积2.4ml(0.4～12.5ml);第3次靶区平均周边剂量为15Gy,肿瘤平均体积1.2ml(0.4～6.8ml)。结果 本组病人中,第1次X-刀治疗35个病灶,1～2次治疗的中位时间为59周(5～104周),第2次治疗36个病灶,第3次治疗3个病灶。这12个病人中,在治疗过程中全部接受全脑放疗,全脑放疗的剂量为30～36Gy。实际第1次X-刀治疗的中位生存期82周,第2次X-刀治疗 的中位生存期21周。随访中有84％的病人获得影像学资料,90％局部控制,10％在疾病过程中进展,局部控制20周的占94.3％。生存质量提高者占91.7％(11/12)。12例接受X-刀治疗的病人有9例(75％)死亡,其中8例(89％)死于颅内病变,1(11％)例死于系统性疾病,中枢系统的死因为出现癌性脑膜炎或颅内多发转移。结论 SRS治疗后出现其他部位的颅内转移的脑转移瘤的患者,X-刀治疗可作为一种较好的补救治疗措施,延长生存期,提高生存质量。     

颅内多发性转移瘤保守剂量的立体定向放射外科治疗

目的评估多发性脑转移瘤患者经保守剂量的立体定向放射外科治疗后的生存期、肿瘤局部控制率及生活质量。方法回顾性研究了168例经伽玛刀治疗的颅内多发性脑转移瘤患者，其中45例（26．8％）为2个病灶，58例（34．5％）为3～5个病灶，65例（367％）病灶数在6～12个。病灶平均体积20cm^3，界于0．02～65．12cm^3之间，治疗以50％等剂量曲线包绕病灶，肿瘤平均中心剂量为26Gy（20～40Gy），周边剂量为13Gy（10～20Gy），总的剂量控制在200Gy以内。36例患者追加全脑放射治疗。结果所有患者无因伽玛刀治疗诱发严重并发症或致死，平均生存期是11个月，6个月时复查的MRI显示，总有效率为91．07％。平均随访10个月，157例生活能够基本自理，6例偏瘫，需要人照顾，5例死亡，死亡原因为系统性疾病。结论立体定向放射外科是治疗颅内多发、深部及重要结构的中等大小（≤20cm^3）转移肿瘤的首选，尤其实用于位于重要结构或者手术不能到达区域的转移性肿瘤。     

伽玛刀立体定向放射外科治疗脑转移瘤的疗效观察

目的探讨伽玛刀治疗脑转移瘤的近期临床疗效及不良反应。方法选择脑转移瘤患者48例（108个病灶）采用伽玛刀治疗,肿瘤周边剂量14-21Gy,平均18Gy;中心最大剂量32-40Gy,平均35.4Gy。结果对48例患者伽玛刀治疗后进行临床随访,随访时间为1-27个月,平均10个月,完全缓解8例（16.7%）,部分缓解26例（54.2%）,无变化10例（20.8%）,进展4例（8.3%）,肿瘤局部控制率为91.7%（44/48）。有神经系统症状33例患者,神经症状完全缓解11例（33.3%）,部分缓解21例（63.6%）,所有患者KPS评分均有上升。平均生存期17.4个月,未出现严重不良反应。结论伽玛刀治疗脑转移瘤具有疗效好、安全的优势,能有效提高脑转移瘤患者生活质量,延长生存期。     

脑转移瘤的伽玛刀治疗

目的 评价伽玛刀治疗颅内脑转移瘤的疗效,分析能够预测预后生存率的因素.方法 407例脑转移瘤患者接受了伽玛刀治疗,随访344例,共756个病灶,肿瘤体积平均为(8.2±5.1)cm3,中心剂量和周边剂量分别(27.1±4.9)Gy和(15.4±2.0)Gy.对计数资料用X2检验,生存分析采用Kaplan-Meier曲线.结果 经过平均(17.7±9.8)个月的随访,影像学提示肿瘤消失140个、缩小331个、不变222个、增大63个.死亡病例114(33.1%)例,伽玛刀治疗后的平均生存期为(12.1±6.0)个月.年龄＜65岁、单发脑转移瘤、KPS≥70的患者有较好的生存率,且具有统计学意义(P＜0.01).结论 伽玛刀治疗脑转移瘤具有良好的控制率.年龄＜65岁、无颅外病变加重、KPS评分≥70、转移瘤灶少、原发灶控制,是具有良好生存期的预后因素.     

X线立体定向加全脑常规放疗治疗脑转移瘤

目的:分析X刀加全脑放疗脑转移瘤的临床及影像学变化.方法:利用JX-100X刀系统加全脑放疗共治疗40例病人,其中有29例先行全脑常规放疗35～40Gy,而后行X刀治疗,¨例作X刀治疗后,再加全脑放疗.单次照射28例,治疗剂量16～22Gy,平均19.2Gy.分次照射12例,分割2～3次,治疗剂量6～12Gy/次,每周一次,总剂量达20～30Gy,平均25.4Gy.结果:40例均获3～26个月的随访,中位12个月,生存期为2～26个月,中位11.5个月,其中36例生存期超过6个月占90%,27例超过12个月占67.5%.2例超过26个月.治疗后6个月CT或MRI复查32例病灶明显缩小或消失占80%,3例出现新的转移灶占7.5%,4例无明显变化占10%.结论:X刀治疗与常规放疗相结合治疗脑转移瘤,优于单纯常规放疗.是治疗脑转移瘤的最佳方案之一.     

脑转移瘤的X—刀治疗

目的分析X刀加全脑放疗脑转移瘤的临床及影像学变化.方法利用JX-100X刀系统加全脑放疗共治疗40例病人,其中有29例先行全脑常规放疗35～40Gy,而后行X刀治疗,¨例作X刀治疗后,再加全脑放疗.单次照射28例,治疗剂量16～22Gy,平均19.2Gy.分次照射12例,分割2～3次,治疗剂量6～12Gy/次,每周一次,总剂量达20～30Gy,平均25.4Gy.结果40例均获3～26个月的随访,中位12个月,生存期为2～26个月,中位11.5个月,其中36例生存期超过6个月占90%,27例超过12个月占67.5%.2例超过26个月.治疗后6个月CT或MRI复查32例病灶明显缩小或消失占80%,3例出现新的转移灶占7.5%,4例无明显变化占10%.结论X刀治疗与常规放疗相结合治疗脑转移瘤,优于单纯常规放疗.是治疗脑转移瘤的最佳方案之一.     

伽玛刀治疗脑干转移瘤的影响因素及生存期分析

目的评价伽玛刀治疗脑干转移瘤的疗效。方法选取202医院放疗科2009—2012年接受伽玛刀治疗的脑干转移瘤患者34例,应用统计学软件SPSS 19.0生存分析中Kaplan-Meier法分析生存率,应用Log-Rank检验和Cox回归分析预后相关因素对生存期的影响。结果 2009-12—2012-12本中心共治疗34例脑干转移瘤患者,其中按发病部位分类:中脑7例,脑桥23例,延髓4例。按原发肿瘤分类:原发性肺癌14例,乳腺癌9例,肾癌5例,黑色素瘤6例。其中多发转移11例,单一病灶23例。年龄25~76岁,平均(53.71±12.95)岁。平均处方剂量(15.50±1.82)Gy,其中最小剂量10Gy,最大18.5Gy。肿瘤体积0.06~3.0(0.75±0.78)mL。伽玛刀治疗后中位生存期9.8个月,与生存期密切相关的预后因素是是否为单一病灶、有无黑色素瘤病史、肿瘤体积以及颅外病灶的控制情况。结论对体积0.75mL、原发肿瘤为非黑色素瘤的脑干转移瘤,应用15.5Gy的处方剂量,可取得较好的肿瘤局部控制率,提高生活质量,延长生存期,减少相关射线并发症。     

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.     

Special Pharmacokinetic Considerations in Children

Summary: Pediatric patients have greater degrees of pharmacokinetic variability and unpredictability than adults. This variability results from the effects of pharmacogenetics, age and growth, prior and current comedication, and disease. Newborns with seizures have the least predictable dosage requirements, and their needs change as drug-eliminating mechanisms mature in the neonatal period. Infants have the highest relative capacities to eliminate antiepileptics of any age group and require the largest relative doses. In addition to age-related trends, children demonstrate the same drug-specific, pharmacokinetic phenomena that adults do, including nonlinear phenytoin elimination, nonlinear valproate binding, and autoinduction of carbamazepine. Intercurrent illness and drug interactions further modify the age-related pharmacokinetic patterns in children and make dosage requirements even more unpredictable. Recent studies have shown that febrile illness can affect drug elimination, sometimes decreasing drug levels by 50% or more. Intermittent treatment with benzodiazepines administered either orally or rectally can be an important adjunct and help minimize this type of problem for children with marginally controlled epilepsy. Intermittent benzodiazepines are also helpful for children who have febrile seizures and who need only occasional antiepileptic protection.