创伤性大脑前动脉瘤的早期诊断和治疗

目的探讨早期诊断和治疗创伤性大脑前动脉瘤的临床意义。方法回顾性分析9例创伤性大脑前动脉瘤患者的临床资料,分析其受伤机制、临床表现及头颅CT或MRI的特征性表现。患者早期行CTA或DSA检查,早期手术治疗,术后随访,并进行格拉斯哥预后量表(GOS)评分。结果 9例患者的动脉瘤均位于大脑前动脉分支,7例患者在动脉瘤破裂之前行手术治疗,2例患者在动脉瘤破裂后手术治疗。随访12个月,7例患者GOS评分5分,1例患者GOS评分4分,1例患者GOS评分3分。术后复查CTA,均无复发。结论对于高度怀疑创伤性大脑前动脉瘤的患者,应早期行CTA或DSA检查,早诊断、早治疗,手术治疗是其有效的治疗方法。     

三维CT血管造影术在颅内动脉瘤破裂早期诊治中的价值(附348例报告)

目的评价三维CT血管造影术（3D-CTA）在颅内动脉瘤破裂早期诊断和治疗中的临床应用价值。方法对419例自发性蛛网膜下腔出血病例全部行3D-CTA检查，其中阴性病例再行DSA检查，对确诊为颅内动脉瘤的病例行显微外科手术或介入治疗。结果345例经3D-CTA检查阳性中检出动脉瘤365个，75例阴性病例中DSA证实仅有3例漏诊。348例动脉瘤患者共检测出动脉瘤368个，术中见动脉瘤位置及瘤体、瘤颈和周围解剖结构的关系与术前3D-CTA显示一致。术后病人3D-CTA随访，与术前比较，动脉瘤均夹闭完全、确实。结论3D-CTA是一种方便、可靠、快捷的诊断方法，可以作为颅内动脉瘤破裂诊治的首选影像检查。并且在术中及术后复查随访研究方面也具有重要的临床应用价值。     

DSA检查和介入治疗在蛛网膜下腔出血应用的临床体会

目的探讨DSA检查及介入治疗在蛛网膜下腔出血(subarachnoid hemorrhage,SAH)病人的病因诊断和治疗中的应用。方法回顾性分析我院45例常规行3D-DSA的SAH病例,其中31例同步行3D-CTA检查,28例接受颅内动脉瘤的介入治疗。比较DSA与CTA在上述患者中的颅内动脉瘤的检出情况,比较DSA与CTA对SAH病人病因诊断的优缺点;并探讨介入治疗在SAH合并颅内动脉瘤病例治疗中的优缺点。结果在动脉瘤检出率方面DSA与CTA比较,两者无统计学差异(P>0.05);在显示的动脉瘤大小,形状,动脉瘤瘤颈显示情况及其与载瘤动脉的关系方面,DSA检查患者在介入治疗过程证实明显优于CTA检查;28例行弹簧圈栓塞介入治疗的预后明显优于16例行内科保守治疗患者的预后(P<0.05)。结论在SAH的病因诊断中DSA优于CTA检查,但CTA不失为一种良好的动脉瘤筛选手段,DSA检查对要求进一步行病因治疗的患者是不可替代的;动脉瘤弹簧圈栓塞治疗SAH合并动脉瘤是安全有效的,可明显减少动脉瘤再破裂出血,改善预后。     

20例椎动脉夹层病例的临床研究

目的 探讨椎动脉夹层的临床特点和诊断及治疗.方法 应用回顾性分析20例椎动脉夹层患者的临床表现结合辅助检查进行分析.结果 本组椎动脉颅内段夹层12例,颅外段夹层动脉瘤8例.8例行椎动脉支架治疗,2例支架合并栓塞术,其中1例在栓塞后造成Wallenberg综合征.2例行动脉瘤夹闭,2例椎动脉闭塞未治疗,6例行抗凝治疗后复查夹层消失.结论 对突发后枕部剧烈持续性疼痛或伴有后循环系统梗塞的中青年患者,需高度怀疑椎动脉夹层,应尽早行DSA检查,以便早期诊断和治疗.     

颅内动脉瘤破裂伴颅内血肿的诊断与显微手术治疗

目的探讨颅内动脉瘤破裂伴发颅内血肿的诊断和显微手术治疗效果。方法回顾性分析13例颅内动脉瘤破裂伴发颅内血肿患者的临床资料。术前5例患者进行了DSA检查,3例患者进行了CT血管造影检查,5例进行了头部CT检查（4例经术中证实为动脉瘤,1例术后经DSA证实为动脉瘤）。其中大脑中动脉动脉瘤5例,前交通动脉动脉瘤4例,后交通动脉动脉瘤3例,骈周动脉动脉瘤1例。结果 13例患者中有12例行开颅动脉瘤夹闭及血肿清除术;1例仅行血肿清除术,术后行血管内栓塞治疗。所有患者术后随访3个月,根据GOS分级,Ⅰ级3例,Ⅱ级4例,Ⅲ级3例,Ⅳ级1例,Ⅴ级2例。结论颅内动脉瘤破裂伴颅内血肿需尽早行DSA或CT血管造影检查明确诊断;治疗方式应首选开颅动脉瘤夹闭＋血肿清除术。     

创伤性颅内动脉瘤的诊断和治疗

目的 报告创伤性颅内动脉瘤诊断与治疗方法.方法 8例创伤性颅内动脉瘤患者,5例开颅手术夹闭,2例行血管内栓塞治疗,1例保守治疗.结果 术后DSA检查,载瘤动脉6例通畅,1例颈内动脉被球囊闭塞.6例术后均无新的神经系统症状,1例出现右侧肢体肌力减退.预后4例良好,2例轻残,2例中等残疾.结论 创伤性颅内动脉瘤主要表现为脑外伤后出现迟发性蛛网膜下腔出血、脑内出血及其引起的不明原因的神经功能障碍.开颅手术和血管内治疗是有效的治疗方法.     

破裂大脑中动脉动脉瘤的显微手术治疗

目的探讨破裂大脑中动脉动脉瘤的诊断、显微手术治疗及其疗效。方法回顾性分析显微手术治疗的70例破裂大脑中动脉动脉瘤患者的临床资料。64例患者术前进行了头颅3D-CTA或/和DSA检查,6例仅行头颅CT检查。结果 70例患者中,67例行动脉瘤夹闭术,3例行动脉瘤包裹术。术后随访3月～2年,按GOS评分,5分57例,4分5例,3分5例,2分1例,1分2例;60例患者行3D-CTA或/和DSA复查,未见动脉瘤复发,其中1例行包裹术的患者动脉瘤无明显增大。结论破裂大脑中动脉动脉瘤应尽早采取显微手术治疗,以有效改善预后;术中多普勒超声的使用能为手术提供帮助。     

感染性颅内动脉瘤的诊治分析

目的 探讨感染性颅内动脉瘤的诊治方法。方法 回顾性分析2008~2013年收治的8例感染性颅内动脉瘤的临床资料。结果 8例患者行头颅CT证实有颅内出血;1例行CTA检查,7例行DSA检查;动脉瘤位于大脑后动脉P3段1例,大脑后动脉P4段4例,大脑中动脉M5段2例,大脑前动脉A4段1例。3例行开颅手术;4例行血管内介入栓塞;1例因载瘤动脉太细,未行血管内栓塞治疗,给予保守治疗。所有病例均恢复良好,无死亡病例;1例遗留左侧肢体偏瘫,其余7例出院时均无神经功能缺失。术后随访3~6个月均未见复发。结论 感染性颅内动脉瘤是一种特殊类型的动脉瘤,应根据患者全身情况及颅内动脉瘤类型进行个体化治疗。     

创伤性颅内动脉瘤的临床诊疗

创伤性颅内动脉瘤虽然不属于脑外伤的常见并发症,但发病隐匿的特点使其成为颅脑损伤患者延期死亡重要原因之一。创伤性颅内动脉瘤在伤后2~3周内破裂风险极高,可能在外伤后突发颅内出血、蛛网膜下腔出血或鼻、眼部大出血,所以怀疑创伤性动脉瘤的外伤患者需早期行颅内血管检查。创伤性颅内动脉瘤以假性动脉瘤为主,缺少完整的血管壁与瘤颈,其临床处理也与自发性动脉瘤有所不同。除了开颅手术治疗之外,单纯弹簧圈填塞、支架辅助弹簧圈栓塞、覆膜支架及血流导向装置等技术手段都已被学者应用于治疗创伤性颅内动脉瘤。本文针对创伤性颅内动脉瘤的危险因素、分类及发病机制、治疗手段做一综述,同时分享2例创伤性与医源性颅内动脉瘤患者的诊治经验。     

颅内多发动脉瘤的治疗

目的探讨颅内多发动脉瘤的诊断、手术时机和治疗方法。方法 48例颅内多发动脉瘤患者共有105个动脉瘤,均进行了3D-CTA或/和脑DSA检查,41例患者采用开颅手术或/和血管内栓塞治疗,7例患者放弃治疗。一次性手术一侧开颅29例,一次性手术双侧开颅1例,分次手术4例,一次性血管内栓塞4例,开颅手术+血管内栓塞3例。结果 41例患者共成功夹闭或血管内栓塞治疗91个动脉瘤,其中39例随访3月~5年,无再出血症状发生,1例开颅夹闭加包裹术的患者出院后4年包裹的动脉瘤再次破裂出血死亡,1例夹闭一侧动脉瘤的患者出院后2年对侧动脉瘤破裂出血,再次入院手术治疗后康复。39例患者随访时进行GOS评分,5分30例,4分4例,3分3例,2分1例,1分1例。35例患者经3D-CTA或/和DSA复查,未见动脉瘤新生或再通。7例放弃治疗的患者随访3月~2年,未破裂的动脉瘤患者4例,其中2例发生破裂出血死亡,破裂的动脉瘤患者3例均发生再次破裂出血死亡。结论 CT、3D-CTA的应用能为颅内多发动脉瘤的诊断及术后复查提供有效的帮助,DSA仍是颅内多发动脉瘤诊断的金标准,对颅内多发动脉瘤的患者应尽早采取开颅手术或血管内栓塞治疗,能有效改善预后。     

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.     

Anticonvulsant Drugs and Cognitive Function: A Review of the Literature

Summary: Alterations of cognitive function are separate from disturbances of behavior seen in association with epilepsy. The nature of the cognitive disability may to a certain extent depend on the seizure type. Partial seizures, mainly derived from a temporal lobe focus, impair memory tasks, while generalized seizures seem to have more effect on attentional abilities. A number of studies, reviewed in this paper, suggest that anticonvulsant drugs further impair cognitive function. Maximal impairments are seen in patients receiving polytherapy: rationalization of polytherapy improves cognitive abilities. Studies in children and adults have allowed differentiation of the effects of various commonly used antiepileptic agents. Maximal cognitive deficits are seen with. phenytoin, while phenobarbital and sodium valproate induce moderate disturbances, and carbamazepine seems relatively free from such toxicity. Further research is needed on the interrelationship between types of seizure disorders, types of anticonvulsant medications, and cognitive function.