伽玛刀治疗颅内疾病3094例临床报告

目的： 探讨立体定向放射手术（伽玛刀） 对颅内疾病的疗效。方法： 用１．５Ｔｅｓｌａ 磁共振仪和γ－ ｐｌａｎ 计算机联网定位, γ－ ｐｌａｎ４．０ 版剂量规划系统作治疗方案设计, 剂量规划, 对３０９４ 例不同类型的颅内疾病包括肿瘤、血管畸形及功能性疾病等实施立体定向放射外科治疗, 病种达２０ 余种,年龄１．１～８６ 岁,周边剂量９～７５Ｇｙ,中心剂量１８～１５０Ｇｙ,等剂量曲线３０％ ～９０％ ,靶点数１～１２ 个。结果： 随访１０～４７ 个月, 统计结果表明： 伽玛刀疗效是确切的。对脑动静脉畸形, 随防一年半以上, 完全闭塞率可达４４．６％ , 体积越小, 周边照射剂量越大, 闭塞率越高。对颅内肿瘤的生长控制率, 良性肿瘤≥８０．０％ , 恶性肿瘤≥６６．７％ ,对功能性疾病的治疗有效率, 帕金森病为８５．２％ , 三叉神经痛为７６．９％ 。结论： 伽玛刀是治疗颅内疾病又一种可选择方法。治疗技术良好, 指征掌握严格, 可提高疗效, 降低并发症。     

垂体腺瘤的伽玛刀治疗

目的：评估伽玛刀（γ－刀）手术对垂体腺瘤的治疗效果。方法：对２９２例垂体腺瘤患者,用１．５Ｔ磁共振和γ－ｐｌａｎ计算机联网定位,Ｌｅｋｓｅｌ伽玛刀实施放射外科手术。肿瘤直径３．８～５１．１ｍｍ,平均１６．３ｍｍ,处方剂量９～３５Ｇｙ,平均２１．６Ｇｙ。结果：本组获随访２０４例（１２～３４个月,平均２１个月）,肿瘤消失３９例（１９．１％）,缩小１５６例（７６．４％）;激素值恢复正常１４例（１１．８％）,较术前下降９４例（７９．６％）;临床症状改善１９０例（９３．１％）,９例症状加重,３例肿瘤增大,２例开颅手术,１例死亡。结论：γ－刀是治疗垂体腺瘤安全、有效的一种方法,但要严格掌握适应证,对Ⅲ级以上肿瘤应首选手术治疗,γ－刀治疗后有可能加重垂体功能低下或诱发垂体危象。     

颅内囊性肿瘤伽玛刀治疗的容积效应

评价颅内囊性肿瘤经立体定向抽液前后容积变化在伽玛刀治疗中的作用。方法：对３９例颅内囊性肿瘤ＭＲＩ定位后,确定穿刺道和靶点坐标,采用立体定向技术抽吸瘤内囊液使肿瘤社会公德只缩小,然后二次ＭＲＩ室位行伽玛刀治疗。边缘剂量为１０－２５Ｇｙ,平均１５．１７Ｇｙ。确定３％风险概率为警戒线,应用Ｌｏｇｉｓｔｉｃ综合方程（Ｎｅｕｒｅｔ）分析剂量－容积关系和应用平均剂量１５Ｇｙ的社会公德只－风险概率的相关性。将抽     

X刀治疗颅内占位性病变

目的探讨立体定向放射外科治疗颅内占位性病变的疗效。方法采用立体定向等中心直线加速器治疗颅内不同的病变１２７例，等中心照射剂量为１５～３５Ｇｙ（平均２４５Ｇｙ），良性肿瘤周边剂量选取８０％等剂量线，恶性肿瘤选取９０％以上的等剂量线。结果８８例（６９３％）随访１个月至２年，其中病变消失３１例（３５２％），缩小３１例（３５２％），无变化２０例（２２７％），增大６例（６８％）。结论该技术治疗脑转移瘤效果最为满意，脑转移瘤在Ｘ刀治疗后结合全脑照射，肿瘤有效控制率达９２５％。     

三叉神经痛的伽玛刀治疗

目的　探讨伽玛刀治疗三叉神经痛（ＴＮ） 的方法和疗效。方法　采用１－５ Ｔ ＭＲ 影像、ＧａｍｍａＰｌａｎ 定位和治疗计划,Ｌｅｋｓｅｌｌ 伽玛刀（γ刀） 治疗７５ 例ＴＮ,其中６５ 例非肿瘤性ＴＮ,治疗靶点在三叉神经感觉根入桥脑区,单个４ ｍｍ 准直器,中心剂量７０～９０ Ｇｙ,５０ ％ 等剂量线限定靶点;１０ 例颅底肿瘤性三叉神经痛以肿瘤为照射靶区,中心剂量２０ ～３０ Ｇｙ,周边剂量１０ ～１５ Ｇｙ。结果　随访３ ～３８ 个月,全组疗效优者占５７－３％ ,良占３０－７ ％ ,有效占５－３％ ,总有效率９３－３％ ,非肿瘤性ＴＮ总有效率９２－３ ％ 。４ 例于５ ～１７ 个月疼痛复发。全组病人无任何并发症,无死亡。结论　伽玛刀是治疗三叉神经痛安全和有效的治疗方法。     

松果体区肿瘤的伽玛刀治疗

使用立体定向伽玛刀治疗松果体区肿瘤３３例，肿瘤直径（Ｘ＋Ｙ＋Ｚ／３）１０．０～４５．５ｍｍ；平均２３．５ｍｍ；体积０．４～３５．４ｃｍ３，平均１２．１ｃｍ３；肿瘤边缘剂量１４～２０Ｇｙ，平均１５．２±１．７Ｇｙ；中心剂量２５．０～４２．８Ｇｙ，平均３７．３±６．９Ｇｙ；影像定位仪为１．５ＴＭＲ。随访３～１２个月。初步结果表明：病人的临床症状体证明显好转，９个月后肿瘤生长控制率，即治疗有效率为９６．２％，显效率９２．３％，无严重并发症发生。提示γ－刀可作为松果体区肿瘤的有效治疗方法。     

三叉神经痛伽玛刀治疗（附30例分析）

介绍伽玛刀治疗三叉神经痛３０例。方法：采用１．５ＴＭＢ影像。Ｇａｍｍａ－Ｐｌａｎ定位和治疗计划，γ－刀治疗。治疗靶点在三叉神经感觉根桥脑进入区，用４ｍｍ准真器，最大剂量７２－８０Ｇｙ，５０％等剂量线限定靶点，颅底肿瘤１２－１５Ｇｙ治疗。结果：随访３－２４个月。疼痛１００％缓解占６０％，疼痛缓解〉９０％占２３．３％，疼痛缓解〉５０％占６．３３％，总有效率８９．７％，２例无效，１例５个月后复发。无效和     

伽玛刀治疗脑胶质瘤临床疗效的随访分析

伽玛刀治疗脑胶质瘤效果尚无定论 ,本文通过对 4 1例伽玛刀治疗脑胶质瘤的病例进行随访分析 ,认为伽玛刀可以做为治疗脑胶质瘤的一种重要手段。临床资料从 1995年 1月至 2 0 0 0年 4月 ,本中心对 4 1例脑胶质瘤实施了伽玛刀治疗并进行随访 ,全部病例经病理证实。最长随访时间 5年 ,最短 3个月 ,平均 1 5年。其中男性 2 6例 ,女性 15例。最大年龄65岁 ,最小仅 7岁 ,平均 37岁。Ｋａｒｎｏｆｓｋｙ评分最高 90分 ,最低 30分 ,平均 58分。肿瘤最大直径4 2ｃｍ ,最小 0 8ｃｍ ,平均 2 3ｃｍ。周边剂量最大2 0Ｇｙ ,最小 6Ｇｙ ,平均 13Ｇｙ。…     

脉络膜黑色素瘤的X—刀治疗

目的探讨Ｘ－刀治疗脉络膜黑色素瘤的疗效及照射剂量。方法采用６０％～８０％等剂量曲线覆盖靶区,肿瘤边界最小剂量１８．４～２７Ｇｙ,平均３７．９Ｇｙ。治疗脉络膜黑色素瘤９例。结果平均随访１８．７个月。眼球保留率８８．９％（８／９）。治疗后１年计算机层摄影（ＣＴ）、磁共振成像（ＭＲＩ）检查结果示：肿瘤消失１例,缩小４例,无变化３例,进展１例。肿瘤周边剂量≤２０Ｇｙ组有效率为２５％（１／４）比＞２０Ｇｙ组     

伽玛刀在松果体区肿瘤治疗中的应用

的探讨伽玛刀对松果体区肿瘤治疗的有效性。方法２５例共３１个病灶,治疗前肿瘤平均体积为５４ｃｍ３（００９２～２９３ｃｍ３）;ＫＰＳ平均为７９２３分（５０～１００分）;射点数１～８个（平均４２个）;周边剂量１０～２２５Ｇｙ（平均１４８６Ｇｙ）;周边剂量曲线３０％～９０％（平均４３９％）;中心剂量１４４４～５６２５Ｇｙ（平均３６１８Ｇｙ）。结果１９个月内有１４例获得随访,平均随访期为５５个月,治疗后平均肿瘤体积缩小至４４ｃｍ３（０～２６７ｃｍ３）。治疗后肿瘤体积缩小者临床症状有明显好转或改善,ＫＰＳ平均为８６９２分（５０～１００分）。结论定位诊断明确的松果体区占位病变,如果其体积在伽玛刀治疗的允许范围内,首选伽玛刀治疗是明智的,可获得良好的预后。     

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.