胎脑移植治疗脑性瘫痪21例分析

本文报告采用胎脑移植治疗脑性瘫痪病人２１例，通过术后１￣４年随访，其中疗效优４例，良８例，一般５例，无效４例，无并发症，并对移植作用的可能机制和手术要点进行讨论，主张复合移植。     

细胞移植治疗小儿脑性瘫痪

脑性瘫痪是目前导致儿童神经系统严重瘫痪的主要疾病之一，是由多种原因引起的非进行性中枢性运动障碍。目前尚无特殊治疗，多为支持和对症治疗。随着DNA 的重组技术和细胞生物学的发展，转基因细胞及细胞系移植已成为脑移植研究新的热点。目前关于细胞移植治疗小儿脑性瘫痪的实验研究主要在新生动物缺氧缺血脑损伤后急性期，所用细胞类型主要是干细胞，且取得了一定的进展。研究发现，干细胞移植入脑内后最长可以存活8个月，并能迁移到损伤区并分化为不同表型的神经细胞可部分改善模型动物的神经行为学障碍。然而干细胞移植后分化为目的神经元的比例较小，这也可能是神经改善不理想的主要原因之一。     

神经干细胞移植治疗小儿脑性瘫痪及所存在的问题

脑性瘫痪是儿童时期最常见且终生存在的运动性残疾,目前尚无有效治疗手段,细胞移植和基因治疗技术的飞速发展为治疗此类疾病带来了希望。近两年国内外出现有关神经干细胞移植治疗脑性瘫痪的报道,这给脑性瘫痪的治疗研究提供了新的思路。文章阐述了小儿脑性瘫痪的神经干细胞机制,并回顾近年来国内外关于神经干细胞移植在动物实验及临床中的有效应用,为神经干细胞治疗小儿脑性瘫痪的可行性提供依据。但神经干细胞移植治疗脑性瘫痪还存在一些问题：移植仍然存在免疫排斥反应;如何促进神经干细胞的快速增殖;如何实现神经干细胞的定向诱导分化;如何评价神经干细胞移植以后患儿的改善情况,移植时机,移植量,移植部位,移植方式等一系列问题均有待于基础和临床学科的共同研究和探讨。     

109例脑性瘫痪患儿康复治疗体会

<正>脑性瘫痪(cerebral palsy,CP)是指自受孕开始至婴儿期非进行性脑损伤和发育缺陷所致的综合征,主要表现为运动障碍和姿势异常[1]。脑瘫常并发感觉、知觉、认知、交流、行为紊乱、癫痫、继发性肌与骨骼问题。近年来脑性瘫痪发病率呈上升趋势,受环境、社会压力、围生医学更加发达等多方面因素影响,脑性瘫痪严重影响患儿的生活质量和身心发育状态,同时给家庭、社会都带来极大的负担。小儿脑瘫的病因及发病机制目前不完全清楚,一般认为与产伤、窒息、胆红素脑病及孕早期的病毒感染、早产儿、低体质量儿等有关。通过流行病学调查,明确脑瘫病因,可采取有效的预防措施,     

Effects of deep brain stimulation in dyskinetic cerebral palsy: A meta‐analysis

Secondary dystonia encompasses a heterogeneous group with different etiologies. Cerebral palsy is the most common cause. Pharmacological treatment is often unsatisfactory. There are only limited data on the therapeutic outcomes of deep brain stimulation in dyskinetic cerebral palsy. The published literature regarding deep brain stimulation and secondary dystonia was reviewed in a meta‐analysis to reevaluate the effect on cerebral palsy. The Burke‐Fahn‐Marsden Dystonia Rating Scale movement score was chosen as the primary outcome measure. Outcome over time was evaluated and summarized by mixed‐model repeated‐measures analysis, paired Student t test, and Pearson's correlation coefficient. Twenty articles comprising 68 patients with cerebral palsy undergoing deep brain stimulation assessed by the Burke‐Fahn‐Marsden Dystonia Rating Scale were identified. Most articles were case reports reflecting great variability in the score and duration of follow‐up. The mean Burke‐Fahn‐Marsden Dystonia Rating Scale movement score was 64.94 ± 25.40 preoperatively and dropped to 50.5 ± 26.77 postoperatively, with a mean improvement of 23.6% (P < .001) at a median follow‐up of 12 months. The mean Burke‐Fahn‐Marsden Dystonia Rating Scale disability score was 18.54 ± 6.15 preoperatively and 16.83 ± 6.42 postoperatively, with a mean improvement of 9.2% (P < .001). There was a significant negative correlation between severity of dystonia and clinical outcome (P < .05). Deep brain stimulation can be an effective treatment option for dyskinetic cerebral palsy. In view of the heterogeneous data, a prospective study with a large cohort of patients in a standardized setting with a multidisciplinary approach would be helpful in further evaluating the role of deep brain stimulation in cerebral palsy. © 2013 Movement Disorder Society     

非痉挛型脑瘫的立体定向手术治疗(附16例报告)

目的探讨立体定向核团毁损术及脑深部电刺激术治疗非痉挛型脑瘫的疗效。方法将16例非痉挛型脑瘫病人分成三组：A组为肌张力障碍型，11例；B组为肌张力障碍合并震颤型，3例；C组为共济失调合并震颤型，2例。采用通用DT评分量表（GPS）评估病肢功能。分别采用立体定向核团毁损术及脑深部电刺激术治疗。术后随访1年，评估症状改善情况。结果A组肌张力障碍改善率为0—58．3％，平均17．1％；B组肌张力障碍改善率6．7％～25．0％，震颤改善率66．7％～75．0％；C组共济失调无明显变化，震颤改善率12．5％～25.0％。结论立体定向手术是治疗肌张力障碍型及震颤型脑瘫的可选择手段。     

复合胎脑移植治疗帕金森氏病

本文报告胎脑移植治疗严重帕金森氏病5例。采用脑立体定向技术把胎脑吸附于弹簧载体上植入患者的双侧尾状核及壳核。术后随访时间6～23个月,临床症状获得了显著的改善。其中2位病人在移植后经18-氟-多巴正电子断层扫描显示,移植部位有示踪物摄入。提示多巴胺递质贮存丰富。本文还讨论了临床症状获得好转的可能机制。     

The incidence of prenatal brain injury

Recent epidemiological studies have shown that cerebral palsy is only rarely associated with birth asphyxia and that there may be more important causative factors in the prenatal period. For this reason a series of 165 brains of infants who were stillborn or died in the early neonatal period was examined in order to identify the incidence and nature of prenatal brain damage. Seventeen (44%) of the stillborn infants showed evidence of brain damage thought to be related to circulatory disorders. The most frequent abnormality, widespread ischaemic damage to the white matter of the cerebral hemispheres, occurred in 10 (26%). Criteria for white matter ischaemia were reactive astrocytosis, macrophage infiltration, karyorrhexis and endothelial swelling or reduplication. This abnormality was only seen after 27 weeks gestation. In five (13%) of the stillborn infants, haemorrhage was seen in association with ischaemic damage and in only two (5%) did brain haemorrhage occur in utero without evidence of co-existing ischaemic damage. Of the 90 live-born infants, 12 (16%) of those surviving less than 3 days and three (20%) of 15 infants who lived between 3 and 7 days after birth showed ischaemic damage which was of prenatal origin. The most frequent pathological change in the infants studied was white matter gliosis occurring in infants who survived into or beyond the last trimester. This may interfere with normal myelination by diverting glial stem cells into reactive astrocytes and thus reduce the population of oligodendrocytes available to synthesize myelin and so cause permanent neurological damage.     

标准大骨瓣开颅减压术治疗重型颅脑损伤和大面积脑梗死(附49例报告)

目的探讨标准大骨瓣减压术治疗重型颅脑损伤和大面积脑梗死的临床效果。方法回顾性的分析2006年1月至2011年1月标准大骨瓣开颅减压术治疗的38例重型颅脑损伤和11例大面积脑梗死患者临床资料。结果出院时按GOS分级,38例重型颅脑损伤患者中,GOSⅠ级15例,Ⅱ~Ⅲ级4例,Ⅳ~Ⅴ级19例。11例大面积脑梗死患者中,GOSⅠ级4例,Ⅱ~Ⅲ级1例,Ⅳ~Ⅴ级6例。结论标准大骨瓣减压术是治疗重型颅脑损伤和大面积脑梗塞的有效方法。     

Neuronal migration disorders in cerebral palsy

We retrospectively analyzed 58 autopsy cases of cerebral palsy which were clinically diagnosed at the Aichi Prefecture Colony Hospital. Most of the cases of cerebral palsy had brainweights that were 60–70% of the normal brainweight for their ages. However, approximately 20% of the brains were not small, especially in cases over 20 years of age. The brains of cerebral palsy cases showed wide morphological variation, and were classified into thinned cerebral mantle type (10 cases), hydrocephalus type (three cases) and microgyria-pachygyria type (45 cases). Macroscopic morphometric analysis was performed in the brains of the microgyria-pachygyria type using the coronal whole brain sections through the mammillary bodies stained with Klüver-Barerra (KB) stain, and compared with the brains of four cases of the Fukuyama type congenital muscular dystrophy (FCMD), two cases of lissencephaly, and nine cases of non-neural diseases as controls. The morphometric values of the coronal sections in the cerebral palsy cases showed diminished white matter with more dilatated ventricles compared with the control brains. This tendency was stronger in the brains of spastic cerebral palsy cases than in the brain of athetotic cerebral palsy cases. Cerebral palsy, in terms of the morphological complexity of the cerebrum as determined by the morphometric analysis, was situated between FCMD and lissencephaly. Although microscopic analysis of cerebral palsy brains was limited to 19 cases, there were four brains with heterotopic gray matter, three brains with cortical folding, a sign of cortical dysplasia, and three brains with neuronal cytomegaly. In addition, more than half of the brains showed disorganization of lamination in the cortex with disorientation of neurons. These findings suggest that some cases of cerebral palsy may result from disrupted neuronal migration during cortical development.     

Vojta and Bobath combined treatment for high risk infants with brain damage at early period

BACKGROUND: In the process of early screening and interventions to high risk infants with brain damage, the occasion and choosing methods of interventions and the combined application of different interventions are still at the exploratory phase. OBJECTIVE: To observe the efficacy of early intervention using Vojta and Bobath combined treatment in high risk infants with brain damage, and investigate the effect of early rehabilitation on the prognosis. DESIGN: A randomized controlled comparative observation. SETTING: Daqing Oil Field General Hospital of Heilongjiang Province. PARTICIPANTS: Eighty-four high risk infants younger than 1 year were selected from the Department of Pediatrics, Daqing Oil Field General Hospital of Heilongjiang Province from October 2005 to October 2006, including 52 boys (62%) and 32 girls (38%). The treatment started at the age of 0–3 months in 11 cases (13%), 4–6 months in 28 cases (33%), 7–9 months in 35 cases (42%), and 10–12 months in 10 cases (12%). Infants with at least two of the followings were enrolled, including 7 Vojta abnormal postural reflexes, slow or disorder of motor development, increase of muscular tension, postural abnormality, primary reflection residual and CT/MRI abnormalities. Informed consents were obtained from their guardians. The 84 infants were randomly divided into treatment group (n =42) and control group (n =42). METHODS: All the children were intravenously injected with cerebroprotein hydrolysate injection or cattle encephalon glycoside and ignotin injection, 10 times as a course for 2–5 courses; Besides, the infants in the treatment group also received early rehabilitative training of Vojta and Bobath combined treatment, once a day, 40 minutes per time, 5 times a week followed by a 2-day rest, 1 month as a course, and totally 2–5 courses. The Vojta method was to facilitate the automatic regulation by reflexlocomotion. Bobath method was to inhibit abnormal posture but facilitate the normal one, thus it is also called neurodevelopmental therapy realized by reflex inhibition and facilitation. The rehabilitation was evaluated clinically using Gesell Development Schedules (GDS) after the courses when the infants were 1 year old. GDS included five aspects of adaptive behavior, gross motor, refine motor, speech, individual-social behavior. The developmental quotient (DQ) could be calculated according to their development. DQ=developmental age/actual age×100, < 85 points was taken as abnormal; The higher the DQ value, the better the development. ② Evaluation of efficacy: Cured: Developmental order reached normal or generally normal, abnormal posture disappeared, muscular tension ameliorated, symmetric limbs' motor function, free movement, normal intelligence, powerful reaction, and clear speech. Significant effect: Developmental order tended to normal, abnormal posture disappeared incompletely, muscular tension ameliorated incompletely, transient pause in the flexion and extension of limbs, good reaction, and improved intelligence. Effective: Developmental order improved to a certain degree, muscular tension ameliorated, limbs' motor function and posture improved as compared with before treatment, but still under control, intelligence improved a little. Invalid: No obvious changes before and after treatment. Total significant effective rate=(cured cases+cases of significant effect)/total cases×100%. ③ The enumeration data and measurement data were compared with chi-square test and t test respectively. MAIN OUTCOME MEASURES: Clinical efficacy and GDS results at 1 year old in both groups. RESUTLS: All the 84 infants were involved in the analysis of results. ① Efficacy: The total significant effective rate in the treatment group was higher than that in the control group (93%, 74%, χ2=4.2, P < 0.05). ② Results of GDS evaluation: The DQ values of individual intercourse and social adaptation in the treatment group (93.57±11.23, 95.13±9.32) were higher than those in the control group (88.27±10.18, 90.10±10.67, t =2.267, 2.301, P < 0.05); The DQ values of gross motor, fine motor and speech in the treatment group (90.78±10.20, 98.63±9.23, 93.69±11.31) were higher than those in the control group (84.32±11.33, 87.80±8.61, 85.52±10.61, t =2.746, 5.560, 2.746, P < 0.01). The interventional effects on each functional area were significant, especially the gross motor, fine motor and speech. CONCLUSION: The Vojta and Bobath combined treatment on the basis of drug therapy can improve the general developments of abilities in motor, intelligence, social intercourse, social adaptation and speech of high risk infants with brain damage, also can improve the curative efficacy.     

Vojta and Bobath combined treatment for high ris infants with brain damage at early period

BACKGROUND: In the process of early screening and interventions to high risk infants with brain damage,the occasion and choosing methods of interventions and the combined application of different interventions are still at the exploratory phase.OBJECTIVE: To observe the efficacy of early intervention using Vojta and Bobath combined treatment in high risk infants with brain damage, and investigate the effect of early rehabilitation on the prognosis.DESIGN: A randomized controlled comparative observation.SETTING: Daqing Oil Field General Hospital of Heilongjiang Province.PARTICIPANTS: Eighty-four high risk infants younger than 1 year were selected from the Department of Pediatrics, Daqing Oil Field General Hospital of Heilongjiang Province from October 2005 to October 2006,including 52 boys (62%) and 32 girls (38%). The treatment started at the age of 0 - 3 months in 11 cases (13%), 4 - 6 months in 28 cases (33%), 7 - 9 months in 35 cases (42%), and 10 - 12 months in 10 cases (12%). Infants with at least two of the followings were enrolled, including 7 Vojta abnormal postural reflexes,slow or disorder of motor development, increase of muscular tension, postural abnormality, primary reflection residual and CT/MRI abnormalities. Informed consents were obtained from their guardians. The 84 infants were randomly divided into treatment group (n =42) and control group (n =42).METHODS: All the children were intravenously injected with cerebroprotein hydrolysate injection or cattle encephalon glycoside and ignotin injection, 10 times as a course for 2 - 5 courses; Besides, the infants in the treatment group also received early rehabilitative training of Vojta and Bobath combined treatment, once a day, 40 minutes per time, 5 times a week followed by a 2-day rest, 1 month as a course, and totally 2 - 5 courses. The Vojta method was to facilitate the automatic regulation by reflexlocomotion. Bobath method was to inhibit abnormal posture but facilitate the normal one, thus it is also called neurodevelopmental therapy realized by reflex inhibition and facilitation. The rehabilitation was evaluated clinically using Gesell Development Schedules (GDS) after the courses when the infants were 1 year old. GDS included five aspects of adaptive behavior, gross motor, refine motor, speech, individual-social behavior. The developmental quotient (DQ) could be calculated according to their development. DQ=developmental age/actual age × 100,efficacy: Cured: Developmental order reached normal or generally normal, abnormal posture disappeared,muscular tension ameliorated, symmetric limbs' motor function, free movement, normal intelligence,powerful reaction, and clear speech. Significant effect: Developmental order tended to normal, abnormal posture disappeared incompletely, muscular tension ameliorated incompletely, transient pause in the flexion and extension of limbs, good reaction, and improved intelligence. Effective: Developmental order improved to a certain degree, muscular tension ameliorated, limbs' motor function and posture improved as compared with before treatment, but still under control, intelligence improved a little. Invalid: No obvious changes before and after treatment. Total significant effective rate=(cured cases+cases of significant effect)/total cases respectively.MAIN OUTCOME MEASURES: Clinical efficacy and GDS results at 1 year old in both groups.effective rate in the treatment group was higher than that in the control group (93%, 74%, x2=4.2, P ＜ 0.05).treatment group (93.57±11.23, 95.13±9.32) were higher than those in the control group (88.27± 10.18,90.10±10.67, t =2.267, 2.301, P ＜ 0.05); The DQ values of gross motor, fine motor and speech in the treatment group (90.78± 10.20, 98.63 ±9.23, 93.69± 11.31) were higher than those in the control group (84.32±11.33, 87.80±8.61, 85.52±10.61, t =2.746, 5.560, 2.746, P ＜ 0.01). The interventional effects on each functional area were significant, especially the gross motor, fine motor and speech.CONCLUSION: The Vojta and Bobath combined treatment on the basis of drug therapy can improve the general developments of abilities in motor, intelligence, social intercourse, social adaptation and speech of high risk infants with brain damage, also can improve the curative efficacy.