陈旧性Denis Ⅱ型骶骨骨折合并骶神经损伤的诊断与治疗

目的：探讨陈旧性Denis Ⅱ型骶骨骨折合并骶神经损伤的诊断及手术方法。方法：取60具骶骨干标本及26具完整骨盆标本，测量S1棘突与S1后孔同位置关系、骶前区血管、骶神经及梨状肌之间关系；对14例陈旧性DenisⅡ型骶骨骨折合并骶神经损伤患者，在常规骨盆X线片，CT，螺旋CT三维重建的同时，又采用显示骶神经全长的骶骨斜冠状位MR扫描，观察神经走向及眦领关系。11例行自行设计的后略骶神经管扩大减压术，3例行非手术治疗。结果：S1棘突于S1后孔中上1/3者占90%，骶前区主要血管有骶外侧动静脉和骶外侧血管、骶正中血管及臀上血管进入骶前孔的分支。血管位于骶丛神经腹侧，骶外侧斑管距离S1前孔大于10mm，S2前孔大于5mm。骶骨斜冠状位MR扫描可以显示骶神经全长及周围眦领关系。骶神经损伤时，发现有神经根走行改变(13例），损伤处神经很周围脂肪消失（11例），神经根管狭窄(10例)。14例均获得随访。随访时间6--12个月。平均7.1个月，术后改善情况，优9例，无变化1例。结论螺旋CT三维重建及骶骨斜冠状位MR扫描对于骶神经损伤的定位及定性诊断有重要价值。后路骶神经管扩大减压术是针对骶神经管、骶前孔处神经损伤的较理想手术方法。     

眼眶动静脉畸形致眼上静脉扩张的影像学表现

目的探讨眼眶动静脉畸形(AVM)致眼上静脉(SOV)扩张的影像学及血管造影表现。设计回顾性病例系列。研究对象6例临床表现与硬脑膜海绵窦瘘(CCF)相似的眼眶AVM患者。方法总结分析所有患者的影像学检查结果,如CT、MRI和选择性脑血管造影。主要指标影像学征象及血流动力学。结果CT和MRI均可显示所有患者的SOV扩张。另外,尚存在眼球突出、AVM畸形血管团等征象。所有6例AVM均位于眼眶内,1例尚合并颅内AVM。所有患者的主要引流静脉均为SOV,动脉包括脑膜中动脉、上颌动脉和眼动脉。结论眼眶AVM可引起与CCF相似的临床和影像学征象,但AVM通常不引起海绵窦膨大,血管造影仍是确诊的必需手段,而无创技术是辅助血管造影进行明确诊断的重要手段。(眼科,2007,16:395-398)     

Horner syndrome

Horner syndrome is an uncommon but important clinical entity, representing interruption of the sympathetic pathway to the eye and face. Horner syndrome is almost always diagnosed clinically, though pharmacological testing can be used to confirm the diagnosis. Imaging modalities such as PET, CT and MRI are important components of work‐up for patients presenting with acquired Horner syndrome. Our patient’s presentation with Horner syndrome unmasked the causative superior sulcus squamous cell carcinoma and a coincidental lower lobe adenocarcinoma. Successful radical treatment of these cancers resulted in complete resolution of the syndrome and disease‐free survival at 18 months. We review the anatomy and pathophysiology underlying this and other causes of Horner syndrome.     

Convergence of occipital nerve and superior sagittal sinus input in the cervical spinal cord of the cat

Co-existence of facial and occipital pain may occur in occipital neuralgia, migraine and cluster headache; suggesting convergence of trigeminal and cervical afferents. Such convergence has been shown in humans and other animals, but the site and extent of this are uncertain. In anaesthetized adult cats, the superior sagittal sinus and occipital nerve were stimulated electrically, and extracellular recordings made in the dorsolateral area of the upper cervical cord using glass-coated tungsten electrodes. Of 49 units in 10 cats, 33 (67%) had input from the superior sagittal sinus and the occipital nerve. Thirteen (27%) had superior sagittal sinus input and 3 (6%) had occipital nerve input. Convergent receptive fields were identified mechanically in 7 units. These experiments in cats show convergent input from occipital nerve and superior sagittal sinus on dorsolateral area units in two-thirds of cases studied. This experimental site of trigeminocervical convergence may relate to referral of pain in occipital neuralgia and other headaches.     

Persistent left superior vena cava draining to left atrium with normal coronary sinus

In embryology, a persistent connection of the left superior vena cava to the left atrium rarely coexists with a coronary sinus. We herein report an unusual case of persistent left superior vena cava terminating in a left atrium with normal coronary sinus, which was revealed at the time of permanent pacemaker implantation after a second operation for recurrent left atrioventricular valve regurgitation. Because this anomaly had gone undiagnosed at the first operation, we were unable to diagnose it prior to the second operation, because the preoperative coronary angiogram clearly demonstrated a coronary sinus that was not dilated. We would have repaired the anomaly using a patch or other procedure had it been diagnosed before the second operation in order to prevent cyanosis or brain complications secondary to right-to-left shunting. One should always be on guard for this rare condition.     

Prostaglandins and CGRP release from cardiac sensory nerves

Summary (1) The possible influence of Prostaglandins (PG) E₁ and I₂ as well as ischaemia, ouabain and bradykinin on the outflow of calcitonin gene-related peptide (CGRP)- and neuropeptide Y (NPY)-like immunoreactivity (LI) from the guinea-pig heart was studied in vitro. (2) Exposure to PGE₁ (10^–5 M), but not PGI₂ (10^–5 M), induced an increased outflow, suggesting release of CGRP-LI. PGE₁ simultaneously increased the contractile force and heart rate while no effects were observed on perfusate volume or outflow of NPY-LI. PGI₂ had no effect on contractile parameters or coronary flow. In separate experiments on capsaicin-pretreated animals, the stimulatory effects of PGE₁ on heart rate and contractile force remained unchanged while no increased CGRP-LI outflow was detectable. (3) Ouabain, bradykinin and reperfusion after total stop-flow ischaemia was associated with an indomethacin-resistant increase in perfusate levels of CGRP-LI but not of NPY-LI. While ouabain markedly increased the contractile force, exposure to bradykinin or ischaemia did not induce any clear-cut changes in contractile force or heart rate. (4) Capsaicin-exposure evoked a markedly increased outflow of CGRP-LI but not of NPY-LI in combination with an increase in heart rate and a decrease in contractile force. Repeated administration of capsaicin induced tachyphylaxis. The stimulatory effects of capsaicin on CGRP-LI outflow and heart rate, but not the negative inotropic effect, did not occur in capsaicin-pretreated animals. (5) It is concluded that PGE₁, but not PGI₂, can activate cardiac capsaicin-sensitive fibres as revealed by increased outflow of CGRP-LI. The cardiostimulatory effects induced by PGE₁ are not related to CGRP release, however. A possible prostaglandin link in the CGRP-LI released by ouabain, bradykinin or ischaemia seems unlikely. Send offprint requests to: A. Franco-Cereceda at the above address     

Early nerve regeneration after Achilles tendon rupture — a prerequisite for healing? A study in the rat

Nerve regeneration during healing of Achilles tendon rupture in the rat was studied by immunohistochemistry including semi-quantitative assessment. Neuronal markers for regenerating and mature fibers, ie., growth associated protein 43 (GAP-43) and protein gene product 9.5 (PGP 9.5), respectively, were analyzed at different time points (1-16 weeks) post-rupture. In the paratenon, both the ruptured and intact contralateral tendon (control) consistently exhibited immunoreactivity to the two neuronal markers. However, in the proper tendinous tissue only the ruptured tendon showed immunoreactivity to GAP-43 and PGP 9.5. This expression was seen already at week 1 post-rupture to reach a peak at week 6 followed by a successive drop till week 16. Also the occurrence of sensory and autonomic fibers according to immunoreactivity for calcitonin gene-related peptide (CGRP) and neuropeptide Y (NPY), respectively, was analyzed. CGRP-positivity was abundantly seen from weeks 2-6 in both perivascular and sprouting free nerve endings in the proper tendon tissue undergoing healing. NPY appeared later, at weeks 6-8 post-rupture around blood vessels mainly located in the surrounding loose connective tissue. Apart from a role in vasoaction (CGRP, vasodilatory; NPY, vasoconstrictory). both neuropeptides have been implicated in fibroblast and endothelial cell proliferation required for angiogenesis. The present study shows that early healing of ruptured tendons is characterized by an orchestrated, temporal appearance of nerve fibers expressing peptides with different actions. The observed pattern of neuronal regeneration and neuropeptide expression may prove to be important for normal connective tissue healing.     

中央沟上段及其邻近沟回的体表定位及其临床意义

目的：探讨在MRI和CT图像上观测中央沟上段及其邻近沟回的特征，进行精确体表定位。方法：30例成人头颅和扫描无颅恼器质性病变10份CT，100份MRI片，在头颅正中欠状面上观测头颅外形和平行于耳眦线平而以上100mm内的前后正巾线的中点及中垂线。在横位图像上观测中央沟上段及其邻近沟回的特征和二维坐标参数。结果：成人头颅近似标准球形。住82％头颅卜平行耳眦线平面的正中点的的投影在垂直耳眦线过外耳道的直线卜，另外18％偏离基线面中垂线小于7mm。上段中央沟在耳眦线平面上70～95mm。84％额上沟与中央前沟相交呈倒T字征，交点住前后中线旁24～27mm，耳眦线平面的中垂线前2～6mm。中央沟上段起点前后中线旁1～15mm，耳眦线平而的中垂线后12～28mm，手结征98％。中央后沟在中央沟之后8～13mm与其平行。结论：每人上段中央沟及其邻近沟回的特征能被MRI精确体表定位。     

Monitoring motor function during resection of tumours in the lower brain stem and fourth ventricle

Objectives Even in the days of modern microsurgery, the removal of a brain stem lesion remains a surgical challenge. Especially when operating on children, the prognosis is directly related to the radicality of the resection; however, a radical resection is often associated with surgical morbidity. Intraoperative neuromonitoring could help to minimise the surgical morbidity, but few studies have been performed to clarify the value of this monitoring. We investigated a prospective series of 21 patients with lesions involving the brain stem for the prognostic value and benefits of neuromonitoring.Methods We performed intraoperative neuromonitoring of cranial nerve function by electromyography (EMG) and motor evoked potential (MEP). The results were correlated with postoperative neurological deficits.Conclusions There is a good correlation between intraoperative neurophysiological events and postoperative neurological deficits in patients with lesions of the brain stem. In general, transient, prolonged, spontaneous activity in EMG is associated with a transient paresis of the respective muscle, whereas a permanent spontaneous activity is associated with a permanent deficit. Intraoperative neuromonitoring reliably predicts postoperative neurological function in patients with tumours of the lower brain stem and fourth ventricle. This neuromonitoring guides the neurosurgeon in the operation and may decrease surgical morbidity. We recommend using monitoring of MEP and EMG of the lower cranial nerves in surgery on all patients with lesions involving the lower brain stem and fourth ventricle.