小脑动脉的临床解剖探讨

目的：为神经外科临床提供解剖学资料。方法：手术显微镜下观察５０例成人脑标本小脑动脉的起始、行径、主要分支、穿动脉及大致分布，检查各小脑动脉与出入脑干的颅神经的接触关系。结果：５０例人脑有小脑下后动脉（ＰＩＣＡ）９４支，小脑下前动脉（ＡＩＣＡ）９７支和小脑上动脉（ＳＣＡ）１１２支。２侧ＰＩＣＡ和１２侧ＳＣＡ接触三叉神经根，２侧ＡＩＣＡ接触面神经根，动脉与神经根接触多形成压迹。结论：小脑动脉的局部解剖有助于神经外科医生在颅后窝手术时，对这些动脉尤其是行程可能有变异的动脉及穿支要特别谨慎，避免损伤，并保护与小脑动脉关系密切的脑神经根；对某些脑干血管综合征患者及某些三叉神经痛、面肌痉挛患者采取相应的治疗。     

小脑下后动脉切断的实验研究

目的研究切断一侧小脑下后动脉（ＰＩＣＡ）的可行性及在增加延髓后区术野显露方面的作用。方法将ＰＩＣＡ分为４段（ＰＩＣＡ１－ＰＩＣＡ４），自ＰＩＣＡ１－ＰＩＣＡ３逐段切断实验。结果ＰＩＣＡ１、ＰＩ－ＣＡ２切断后果严重，ＰＩＣＡ３切断不仅安全可行，且能充分显露自同侧内耳门－导水管下端－对侧四室壁－枕大孔这一区域，无需切开小脑蚓部。结论ＰＩＣＡ１、ＰＩＣＡ２切断后果严重，ＰＩＣＡ３切断安全可行且具有较大的临床意义，为临床开辟了新的手术入路。     

实验性局灶性脑缺血再灌注动物模型的改进及评价

参照Ｋｏｉｚｕｍｉ和Ｌｏｎｇａ腔内线栓法制作大鼠大脑中动脉阻断（ＭＣＡＯ）模型，并予以改进：（１）根据大鼠头颈部血管铸型标本测得颈内动脉（ＩＣＡ）、大脑前动脉（ＡＣＡ）、大脑中动脉（ＭＣＡ）的内径和颈总动脉（ＣＣＡ）分叉部至ＭＣＡ起始部的距离，选择３－０单尼龙线（直径０．２０～０．２４９ｍｍ）代替Ｋｏｉｚｕｍｉ法覆以硅胶的４－０单尼龙线（直径０．１５～０．１９ｍｍ）及Ｌｏｎｇａ法单４－０尼龙线，插入深度１８．５±０．５ｍｍ。（２）仅在线栓进入时暂时夹闭翼腭动脉（ＰＰＡ），并不结扎，以防止ＩＣＡ内血栓形成，致再灌注时血流受阻。该模型成功率高达９２％，稳定性强，是较理想的实验性局灶性脑缺血模型。本文阐述了制作方法及应用评价。     

海绵窦上壁及内侧壁的显微解剖学研究

目的探讨海绵窦上壁和内侧壁的显微解剖，为手术提供解剖学参数。方法16例（32侧）湿性成人尸头标本，在显微镜下进行观测。结果（1）93．75％眼动脉发自颈内动脉床突上段，前床突的气化率为12．50％，颈动脉床突孔和床突间骨桥的出现率分别为21．88％和9．38％。（2）颈内动脉沿垂体下1／3走行的情况最常见，占43．75％，垂体有15．63％的情况出现侧突。（3）视神经和颈内动脉在蝶窦外侧壁上的隆起率分别为53．13％和81．25％。结论（1）经上壁入路可暴露海绵窦内绝大部分结构，对颅神经损伤的危险较小，同时应注意该区域的骨质变异。（2）在经内侧壁的手术中，颈内动脉的显露、移动和保护十分重要。     

岩斜区脑膜瘤的显微外科治疗

目的 提高岩斜区脑膜瘤的手术效果。方法 回顾性分析我院自１９９５年１月至１９９７年１１月连续收治的１８例岩斜区脑膜瘤。１３例肿瘤大于４．５ｃｍ。采用了经颞下－小脑幕、颞下－乙状窦前、颞下－迷路、枕下－＝极外侧入路。结果 肿瘤全切除１１例（６１％）,其中２例术后悔ｅｂｅｒ‘ｓ综合征,１例死于肺炎。结论 影响手术预后的最主要因素是小脑前下动脉ＡＩＣＡ）、小脑上动脉（ＳＣＡ）和小脑后下动脉（ＰＩＣＡ）及     

缺血性脑血管病伴OSAS患者的血压和血管舒缩功能观察

目的 观察缺血性脑血管病（ＩＣＶＤ）伴阻塞型睡眠呼吸暂停综合征（ＯＳＡＳ）患者平均动脉压（ＭＡＢＰ）、血浆降钙素基因相关肽（ＣＧＲＰ）和内皮素（ＥＴ）的变化及相互关系。方法 应用放免方法测量３１例患者血浆ＣＧＲＰ和ＥＴ含量,静息状态下测量血压;多元相关分析。结果 ＩＣＶＤ伴ＯＳＡＳ患者组ＭＡＢＰ、ＥＴ均炕于正常对照组（均Ｐ〈０．００１）,ＣＧＲＰ明显低于对照组（Ｐ〈０．００１）;ＣＧＲＰ与ＭＡＢＰ     

显微术中观察鞍上与鞍旁区脑膜瘤的供血特征

鞍上与鞍旁区脑膜瘤显微手术３８例，在手术显微镜下直接观察肿瘤的供血，发现颈内动脉（ＩＣＡ）系为肿瘤的主要供血来源。除岩斜坡－蝶区脑膜瘤２例外，按对肿瘤供血动脉的直接观察与电凝脑膜中动脉（ＭＭＡ）后肿瘤的血运状况，将其供血分四型：颈外动脉（ＥＣＡ）为主型例；ＩＣＡ－ＥＣＡ供血相当型６例；ＩＣＡ为主型１９例；ＩＣＡ单独供血型９例。肿瘤发生部愈近中线，ＩＣＡ供血趋势愈明显。ＥＣＡ主要供血者少见，并只见于鞍旁型脑膜瘤。     

岩斜区脑膜瘤的显微外科治疗(附18例报告)

目的提高岩斜区脑膜瘤的手术效果。方法回顾性分析我院自１９９５年１月至１９９７年１１月连续收治的１８例岩斜区脑膜瘤。１３例肿瘤大于４．５ｃｍ。采用了经颞下小脑幕、颞下－乙状窦前、颞下－迷路、枕下－极外侧入路。结果肿瘤全切除１１例（６１％）,其中２例术后发生Ｗｅｂｅｒ’ｓ综合征,１例死于肺炎。结论影响手术预后的最主要因素是小脑前下动脉（ＡＩＣＡ）、小脑上动脉（ＳＣＡ）和小脑后下动脉（ＰＩＣＡ）及其供应脑干的穿通支被肿瘤包裹和脑干受累,血管因素可能更为重要。     

巨大脑动脉瘤的手术探讨

目的　对应用不同手术方法治疗的１６ 例巨大脑动脉瘤（≥２５ｍｍ） 作回顾性分析。方法　近１０ 年来收治１６ 例巨大脑动脉瘤, 颈动脉系１２ 例： 外伤性右侧颈内动脉（ＩＣＡ） 瘤２ 例, 左侧颈总动脉（ＣＣＡ） 夹层动脉瘤１ 例, 右侧大脑中动脉（ＭＣＡ） 瘤２ 例, 前交通动脉（ＡｃｏＡ） 瘤１ 例,右（左） 颈内动脉（ＩＣＡ） 瘤６ 例; 椎基动脉系４ 例： 右侧小脑上动脉（ＳＣＡ） 瘤１ 例; 右侧椎基动脉连接处动脉（ＶＢＪＡ） 瘤１ 例, 右侧大脑后动脉（ＰＣＡ） 梭状动脉瘤２ 例。根据临床表现和神经放射学（ＣＴＤＳＡＭＲＩ） 评估。结果　１４ 例治愈,２ 例死亡。１４ 例生存者随访７ 月至５ 年, 按Ｓｕｎｄｔ 标准,结果满意９ 例, 良好４ 例, 差１ 例。结论　巨大脑动脉瘤的治疗, 特别是有占位效应者, 以闭锁瘤颈,切除膨大的瘤囊为宜     

脑血管病患者细胞间粘附分子—1的测定及意义

目的：探讨脑血管病患者血清细胞间粘附分子－１（ＩＣＡＭ－１）水平和脑血管病发病与治疗的关系。方法：用ＥＬＩＳＡ法测定脑血管病患者和正常对照组血清可溶性细胞间粘附分子－１（ｓＩＣＡＭ－１）含量。结果：脑血栓形成或脑出血患者血清ｓＩＣＡＭ－１含量均较对照组显著增高（Ｐ〈０．０１;Ｐ〈０．０１）;Ⅲ伴有高血压的脑血栓形成、脑出血患者血清ｓＩＣＡＭ－１含量较正常血压者显著增高（Ｐ〈０．０５）。结论：ＩＣＡ     

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.