血管狭窄支架置入术治疗缺血性脑血管病的随访研究

目的 探讨头颈部血管狭窄支架置入术对缺血性脑血管病防治的有效性及安全性.方法 选择符合本研究设计的2008年8月～2012年3月在西安交通大学第二附属医院神经内科住院、接受全脑血管造影术且行血管内支架置入术的122例患者作为研究对象.观察:(1)靶病变血管病变的分布情况、支架置入成功率;(2)脑梗死患者术前及术后1个月临床神经功能缺失评分(NIHSS),术后3个月时改良Rankin评分(mRS);(3)随访期间用药依从性、脑血管病复发率及其他并发症的发生情况.结果 (1)不同年龄段靶病变血管的分布不同,青年组以颅内血管病变为主,中老年组以颅外血管病变为主;支架置入手术成功率为92.62％;围手术期严重并发症发生9例(7.38％),其中死亡5例(4.10％).(2)76例围手术期后生存的脑梗死患者,术前及术后1个月NIHSS有统计学差异(P＜0.01);术后3个月mRS≤2分者63例(82.89％).(3)终末随访时正规服药者73例(65.77％);随访期间发生缺血性脑血管病17例(13.93％),共发生支架再狭窄10例(8.20％);总死亡及植物状态10例(8.20％),支架手术相关性死亡及植物状态6例(4.92％).结论 支架置入术对缺血性脑血管病的近期和远期治疗安全有效.定期门诊检查,可以提高患者术后用药的依从性.     

症状性基底动脉狭窄支架置入术后血清MMP-9与围手术期缺血性脑血管事件的关系

目的 探讨血清基质金属蛋白酶-9(MMP-9)与症状性基底动脉狭窄支架置入术后围手术期缺血性脑血管事件的关系.方法 测定42例基底动脉支架置入患者术后1d的外周血中血清MMP-9的水平,同时观察围手术期缺血性脑血管事件的发生情况.结果 共有4例出现围手术期缺血性脑血管事件.血清MMP-9在围手术期出现缺血性脑血管事件者中高于未出现者(1106.71±237.21ng/ml vs 636.87.47±133.51ng/ml,P＜0.01).结论 症状性基底动脉狭窄支架置入术后的MMP-9水平可能与围手术期缺血性脑血管事件危险增加有一定的相关性.     

椎动脉支架置入术对脑血管反应性的影响

目的探讨椎动脉支架置入术对脑血管反应性(CVR)的影响及与CVR之间的关系。方法选择行椎动脉支架置入术的卒中患者27例为手术组,选择同期非卒中患者38例为对照组。经颅多普勒(TCD)结合二氧化碳吸入试验检测手术前、术后3d及术后3个月CVR的变化,DSA造影明确卒中血管狭窄分级,并结合相关数据分析。结果手术组术前CVR明显低于对照组,术后3dCVR较术前明显提高,差异有统计学意义(P0.05)。术前CVR与脑血管狭窄分级呈正相关(r=0.587,P0.05),脑血管狭窄分级中度与重度之间术前CVR比较差异有统计学意义(P0.05),重度与次全闭塞之间术前比较差异无统计学意义(P0.05)。术后3dCVR改善幅度与术前CVR呈负相关(r=-0.750,P0.05),与脑血管狭窄等级亦呈负相关(r=-0.610,P0.05)。术后3d和术后3个月CVR比较差异无统计学意义(P0.05)。结论椎动脉支架置入术能有效改善患者CVR。     

弓上颅外动脉支架置入术后再狭窄危险因素研究

目的弓上动脉支架置入术已经成为治疗头颈部动脉重度狭窄的主要方法,本研究探讨弓上动脉支架置入术后支架内再狭窄的独立危险因素以及不同血管支架内再狭窄率的不同原因。方法回顾性分析2017年10月至2019年3月行弓上动脉支架置入术219例患者的临床资料。术后复查头颈部CTA或全脑血管造影术(DSA)判定有无支架内再狭窄,依据是否存在支架内狭窄分为再狭窄组与非狭窄组,对比分析两组的术前基线资料和术后临床数据。采用多因素Logistic回归分析支架内再狭窄的独立危险因素。结果 219例患者置入支架共计265枚:颈动脉127枚、椎动脉138枚。随访(15.2±4.5)个月,265枚支架中,颈动脉出现再狭窄8/127枚(6.3%),椎动脉出现再狭窄24/138枚(17.4%)。多因素Logistic回归分析发现病变血管直径(OR=1.738, 95%CI:1.294～2.336, P0.001),吸烟史(OR=3.575, 95%CI:1.042～12.258,P=0.043),糖尿病史(OR=2.561, 95%CI:1.474～4.448, P=0.001),残余狭窄(OR=1.225, 95%CI:1.081～1.390, P=0.002)是不同部位动脉支架置入术后支架内再狭窄的独立危险因素。结论颈动脉支架置入术后再狭窄率较椎动脉低,血管直径与支架术后再狭窄呈负相关关系,且是引起不同血管再狭窄率不同的原因,应用药物洗脱支架治疗椎动脉狭窄是减少支架置入术后再狭窄的有效方法。     

急性颅内前循环脑梗死患者机械取栓术后应用阿加曲班的安全性和有效性观察研究

目的 观察急性颅内前循环脑梗死患者机械取栓术(MT)后应用阿加曲班的安全性及有效性。方法 选取2020年1月至2021年9月收治的84例急性颅内前循环脑梗死后实施MT的患者,随机分为阿加曲班组(42例)和对照组(42例)。对照组患者在MT后给予标准化治疗,阿加曲班组在MT后常规标准化治疗基础上加用阿加曲班。比较两组患者美国国立卫生研究院卒中量表(NIHSS)评分、改良Rankin量表(mRS)评分,血管再闭塞率,以及出血、死亡等不良事件发生率。结果 阿加曲班组患者7 d、90 d的NIHSS评分和90 d mRS评分均优于对照组,两组间比较(P<0.05)。同时阿加曲班组的血管再闭塞率明显低于对照组(P<0.05),而颅内出血、脑梗死出血转化等并发症两组间比较差异无显著性(P>0.05)。结论 阿加曲班可以显著改善急性颅内前循环脑梗死患者MT后神经功能缺损症状,降低再闭塞率,提高3个月生活能力,同时不增加出血、死亡等不良事件风险。     

颈内动脉狭窄支架置入术后支架内再狭窄的相关危险因素分析

目的分析颈内动脉分叉处狭窄支架置入术(CAS)后支架内再狭窄的发生情况及相关因素,为临床预防CAS术后支架内再狭窄提供参考。方法分析行颈内动脉分叉处狭窄支架置入术的174例患者的病例资料,按原始治疗部位复发狭窄程度>50%为再狭窄,将病例分成再狭窄组(13例)和无再狭窄组(161例)。分析两组患者的性别、血压、高脂血症、血糖、是否吸烟、术后抗聚抗凝药物应用依从性与再狭窄的关系;t检验分析年龄、术前狭窄程度与再狭窄的关系。结果单因素分析显示:高龄、高血压、高血糖、高脂血症、吸烟、术后抗聚抗凝药物应用依从性差、术前狭窄率高、多个危险因素是CAS后支架内再狭窄的影响因素;Logistic回归分析显示:吸烟、高血压、高血糖、高脂血症是CAS后支架内再狭窄的独立危险因素。结论吸烟、高血压、高血糖、高脂血症是颈内动脉狭窄支架术后再狭窄的独立危险因素。     

杂交支架用于重度颈动脉狭窄治疗的研究

目的 研究杂交支架治疗重度颈动脉狭窄的疗效和安全性.方法 使用杂交支架对21例缺血性脑血管病合并重度颈动脉狭窄患者进行颈动脉支架成形术.术后观察血管狭窄程度及不良反应,随访6个月观察脑血管事件的发生.结果 所有患者均顺利完成手术,共置入支架23枚.术后脑血管造影示颈动脉狭窄程度均≤20％.术中出现颈动脉窦综合征5例,血管痉挛2例,支架远端血管栓塞1例,经治疗均恢复.术后6个月时,患者均未发生与手术侧颈动脉相关的脑血管事件.结论 颈动脉杂交支架治疗重度颈动脉狭窄效果显著,能减少脑血管事件的发生,且比较安全.     

症状性椎基底动脉狭窄患者支架置入术后再狭窄相关因素分析

目的 探讨症状性椎基底动脉(VBA)狭窄患者支架置入术后再狭窄与临床因素的关系. 方法收集我院36例症状性VBA狭窄且行支架置入术患者的临床资料,以经颅多普勒(TCD)、彩色多普勒超声(CDI)、数字减影血管造影(DSA)随访支架置入术后的再狭窄率.选择了脑梗死易患因素、靶病变长度、靶病变部位等11项观察指标,分析上述各种临床因素与再狭窄的相关性,对有、无相关危险因素再狭窄率采用卡方检验. 结果 36例患者有40处狭窄,置入支架40枚,平均随访时间为(16.5±15.4)个月(3个月～3年),TCD、CDI随访30例,DSA随访6例,8例(8/36,22.2%)出现＞50%的再狭窄.再狭窄组病人合并有糖尿病史比例较无再狭窄组明显增多(分别为62.5%、32.1%,P＜0.05);再狭窄组椎动脉开口病变比例明显高于无再狭窄组(分别为62.5%、39.3%,P＜0.05);再狭窄组的靶病变≥10mm明显高于无再狭窄组(分别为50.0%、28.6%,P＜0.05).结论 症状性椎基底动脉狭窄支架置入术患者合并糖尿病、椎动脉开口病变及靶病变长度可能是术后再狭窄的预测因素.     

症状性颅内动脉狭窄的支架治疗

目的探讨Wingspan支架治疗症状性颅内动脉狭窄的安全性、可行性和临床疗效。方法应用Wingspan支架治疗90例症状性颅内动脉狭窄患者,观察其手术技术成功率、围手术期并发症,以及术后6个月时脑血管造影显示的支架内再狭窄率。结果 90例患者手术技术成功率约为98.92%(92/93)。术前平均狭窄率为(83.42±9.53)%,术后残余狭窄率为(21.82±9.86)%,手术前后比较差异具有统计学意义(t=3.280,P=0.002)。共5例发生围手术期并发症,约占5.56%(5/90),3例死亡;术后6个月时再狭窄发生率约为19.10%(17/89)。结论 Wingspan支架植入术治疗症状性颅内动脉狭窄具有较高的手术技术成功率、较低的手术并发症及较好的近期疗效,尚待进一步观察患者远期疗效。     

颈动脉血管成形支架置入术对脑血管储备能力的影响

目的探讨颈动脉血管成形支架置入术对脑血管储备能力的影响。方法60例颈内动脉狭窄≥70％的患者接受颈动脉血管成形支架置入术,在术前、术后30d进行经颅多普勒检查,通过屏气试验测定脑血管储备能力。结果所有患者均成功置入支架,围手术期无手术相关的并发症,术后30d手术侧脑血管储备能力从术前18．3％提高至30．3oA（P〈0．05）,对侧从手术前28．6％提高至31．6％（P〉0．05）。结论颈动脉狭窄是导致脑血管储备能力下降的原因之一,颈动脉血管成形支架置入术显著提高脑血管储备能力。     

Diagnostic Difficulties and Treatment Implications

Summary: Differentiation between types of epileptic seizures has been aided in recent years by the introduction of intensive neurodiagnostic techniques and the development of increasingly detailed classification systems. Paradoxically, these developments have not simplified the task of matching the appropriate antiepileptic drug to a particular seizure type. It is reasonable to assume that anticonvulsant drugs will have different effects on different types of seizures, but faulty, circular reasoning can enter the picture if one also assumes that responses of seizures to different drugs signify different seizure types. There are several examples of differential diagnoses that can fall prey to this problem, including the diagnosis between partial seizures with secondary generalization and generalized tonic-clonic seizures, and the diagnosis between complex partial seizures and absence seizures with automatisms, among others. Considerations of etiology in future classification systems can further complicate the problem: should one then choose an anticonvulsant drug on the basis of individual seizure type or on the basis of the type of epilepsy? Ramifications of this issue extend even to the drug approval process. Official sanction is not given for use of a drug for a seizure type not included in the original efficacy studies, even if later scientific evidence shows that seizure type to be related to a type that is included. New trials must be undertaken. These problems arise from how we choose to classify seizures.     

Cognitive Dysfunction Associated with Antiepileptic Drug Therapy

Summary: Epilepsy is frequently associated with cognitive dysfunction. However, the reasons for this correlation are unclear. Possible influential factors include patient age; duration, frequency, etiology, and type of seizures; hereditary factors; psychosocial issues; and antiepileptic drug (AED) therapy. Whereas many of these factors are beyond the physician's control, AED therapy is one element that can be addressed in treatment decisions by recognizing the potential cognitive effects of particular AEDs. For example, phenobarbital impairs memory and concentration; phenytoin affects attention, problem solving ability, and performance of visuomotor tasks. In contrast, carbamazepine may affect concentration, while valproate would appear to have minimal effects on cognition. Moreover, cognitive effects of AEDs are amplified with coadministration of multiple anticonvulsants (polytherapy). A review of studies on the cognitive effects of monotherapy with AEDs, as opposed to those of polytherapy, provides evidence that drug-related cognitive dysfunction can be reversed if patients are switched to a simpler therapeutic regimen. Future research should be directed toward developing reliable measures for assessing and monitoring cognition, and understanding the particular cognitive side effects of each AED. Physicians also need to revise their opinions about which side effects are "tolerable" for epileptic patients.     

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.     

Carbamazepine Efficacy in Adults With Partial and Generalized Tonic-Clonic Seizures

Summary: Carbamazepine and phenytoin are drugs of choice in initial monotherapy for adult partial and secondarily generalized tonic-clonic seizures. These designations reflect the results of the Veterans Administration Epilepsy Cooperative Study Group of 1985. An earlier comparative study of carbamazepine and phenytoin by Ramsay and associates found both drugs equally effective in controlling new-onset seizures. Among the advantages of carbamazepine is that it causes relatively few cognitive and dysmorphic side effects. Its disadvantages are its unavailability in parenteral formulation and its metabolic autoinduction. The latter must be compensated for by planned dosage increases to maintain therapeutic plasma steady-state levels during the first 2 or 3 months of treatment. Carbamazepine is judged a drug of choice in the treatment of these secondarily generalized tonic-clonic seizures, and the drug of choice in children, adolescents, and women susceptible to the dysmorphic side effects associated with other anticonvulsant agents.     

Etiologic and Preventive Aspects of Epilepsy in the Child–Bridging the Gap Between Laboratory and Clinic

Summary: Four broad categories of basic phenomena are pertinent to developing ways to prevent epilepsy. These include mechanisms of epileptogenesis, ictal initiation and temporary entrainment by the seizure discharge of normally functioning brain, seizure propagation, and control mechanisms that function both to restrain the cascade of epileptic events culminating in a seizure and to arrest the epileptic event and restore the interictal state. In newborns and children, hypoxia-ischemia is a major factor leading to epileptogenesis, and several schemes are proposed to classify, quantify, and prevent hypoxic-ischemic encephalopathy. Control mechanisms must be better understood in order to develop prophylactic recommendations for epilepsy, and an experimental model of "kindling antagonism" may increase our understanding of these. Programs of prevention of seizures in children will evolve only if basic researchers and clinicians work productively together to develop an adequate understanding of factors important in epileptogenesis and antiepileptogenic control mechanisms.     

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.     

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.     

Predisposing and Causative Factors in Childhood Epilepsy

Summary: We review information from large studies of defined populations, examining the role of known factors and especially of prenatal and perinatal factors in contributing to nonfebrile seizure disorders of early childhood. We depend especially, but not exclusively, on the recently completed analyses from the Collaborative Perinatal Project of the National Institute of Neurological and Communicative Disorders and Stroke, the NCPP. About 4% of children in the NCPP who had at least one non-febrile nonsymptomatic seizure by the age of 7 years had a previous seizure during acute neurologic illness, such as meningitis or during the acute illness after trauma. Many such seizures should potentially be preventable. Of children with seizures, 10% had had a neonatal seizure and 13% had had a febrile seizure. Among the hundreds of prenatal and perinatal factors explored as predictors of childhood seizure disorders, the principal predictors identified were congenital malformations of the fetus, cerebral and noncerebral; family history of certain neurologic disorders; and neonatal seizures. In agreement with the British National Child Development Study, labor and delivery factors in the NCPP appeared to contribute very little to childhood seizure disorders. Maldevelopment, rather than damage at birth to an initially intact nervous system, appeared to be the more common mechanism. Most seizure disorders of early childhood remained unexplained by the large set of prenatal and perinatal characteristics examined.     

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.