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神经可塑性和大脑连接组:让·塔莱拉克的思考能给现代精神外科带来什么?

Neuroplasticity and the brain connectome: what can Jean Talairach's reflections bring to modern psychosurgery?

机构信息

Department of Neurosurgery, Neurology and Neurosurgery Hospital Pierre Wertheimer, Hospices Civils de Lyon.

Inserm U1127, CNRS U7225, Université Pierre et Marie Curie (UPMC-Paris 6), Paris.

出版信息

Neurosurg Focus. 2017 Sep;43(3):E11. doi: 10.3171/2017.6.FOCUS17251.


DOI:10.3171/2017.6.FOCUS17251
PMID:28859565
Abstract

Contrary to common psychosurgical practice in the 1950s, Dr. Jean Talairach had the intuition, based on clinical experience, that the brain connectome and neuroplasticity had a role to play in psychosurgery. Due to the remarkable progress of pharmacology at that time and to the technical limits of neurosurgery, these concepts were not put into practice. Currently, these concepts are being confirmed by modern techniques such as neuroimaging and computational neurosciences, and could pave the way for therapeutic innovation in psychiatry. Psychosurgery commonly uses a localizationist approach, based on the idea that a lesion to a specific area is responsible for a deficit opposite to its function. To psychosurgeons such as Walter Freeman, who performed extensive lesions causing apparently inevitable deficit, Talairach answered with clinical data: complex psychic functions cannot be described that simply, because the same lesion does not provoke the same deficit in different patients. Moreover, cognitive impairment did not always follow efficacious psychosurgery. Talairach suggested that selectively destructing part of a network could open the door to a new organization, and that early psychotherapy could encourage this psychoplasticity. Talairach did not have the opportunity to put these concepts into practice in psychiatric diseases because of the sudden availability of neuroleptics, but connectomics and neuroplasticity gave rise to major advances in intraparenchymal neurosurgery, from epilepsy to low-grade glioma. In psychiatry, alongside long-standing theories implicating focal lesions and diffuse pathological processes, neuroimaging techniques are currently being developed. In mentally healthy individuals, combining diffusion tensor imaging with functional MRI, magnetoencephalography, and electroencephalography allows the determination of a comprehensive map of neural connections in the brain on many spatial scales, the so-called connectome. Ultimately, global neurocomputational models could predict physiological activity, behavior, and subjective feeling, and describe neuropsychiatric disorders. Connectomic studies comparing psychiatric patients with controls have already confirmed the early intuitions of Talairach. As a striking example, massive dysconnectivity has been found in schizophrenia, leading some authors to propose a "dysconnection hypothesis." Alterations of the connectome have also been demonstrated in obsessive-compulsive disorder and depression. Furthermore, normalization of the functional dysconnectivity has been observed following clinical improvement in several therapeutic interventions, from psychotherapy to pharmacological treatments. Provided that mental disorders result from abnormal structural or functional wiring, targeted psychosurgery would require that one be able: 1) to identify the pathological network involved in a given patient; 2) to use neurostimulation to safely create a reversible and durable alteration, mimicking a lesion, in a network compatible with neuroplasticity; and 3) to predict which functional lesion would result in adapted neuronal plasticity and/or to guide neuronal plasticity to promote recovery. All these conditions, already suggested by Talairach, could now be achievable considering modern biomarkers and surgical progress.

摘要

与 20 世纪 50 年代常见的精神外科实践相反,Jean Talairach 博士根据临床经验直觉地认为,大脑连接组和神经可塑性在精神外科中发挥作用。由于当时药理学的显著进步和神经外科的技术限制,这些概念并未付诸实践。目前,这些概念正在被神经影像学和计算神经科学等现代技术所证实,并可能为精神病学的治疗创新铺平道路。精神外科通常采用定位主义方法,基于这样一种观点,即特定区域的病变会导致与其功能相反的缺陷。对于像 Walter Freeman 这样进行广泛病变导致明显不可避免的缺陷的精神外科医生,Talairach 用临床数据回答说:复杂的心理功能不能如此简单地描述,因为同一病变不会在不同患者中引起相同的缺陷。此外,认知障碍并不总是伴随着有效的精神外科手术。Talairach 认为,选择性地破坏部分网络可能会为新的组织打开大门,早期心理治疗可以鼓励这种神经可塑性。由于神经安定药的突然出现,Talairach 没有机会将这些概念应用于精神疾病,但连接组学和神经可塑性为脑内神经外科的重大进展提供了契机,从癫痫到低级别胶质瘤。在精神病学中,除了长期以来涉及局灶性病变和弥漫性病理过程的理论外,神经影像学技术也在不断发展。在心理健康的个体中,将弥散张量成像与功能磁共振成像、脑磁图和脑电图相结合,可以在许多空间尺度上确定大脑中神经连接的全面图谱,即所谓的连接组。最终,全局神经计算模型可以预测生理活动、行为和主观感受,并描述神经精神障碍。将连接组学研究与对照精神病患者进行比较已经证实了 Talairach 的早期直觉。作为一个引人注目的例子,精神分裂症中发现了大量的连接中断,这导致一些作者提出了“连接中断假说”。在强迫症和抑郁症中也发现了连接组的改变。此外,在几种治疗干预措施(从心理治疗到药物治疗)后,临床改善后,功能性连接的正常化也得到了观察。假设精神障碍是由异常的结构或功能布线引起的,那么有针对性的精神外科手术需要:1)能够识别出特定患者中涉及的病理性网络;2)使用神经刺激安全地创建一个可逆和持久的改变,模拟病变,在一个与神经可塑性兼容的网络中;3)预测功能性病变将导致适应性神经元可塑性,或者指导神经元可塑性以促进恢复。所有这些条件,已经由 Talairach 提出,现在考虑到现代生物标志物和手术进展,都有可能实现。

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引用本文的文献

[1]
Electromagnetic Brain Stimulation in Patients With Disorders of Consciousness.

Front Neurosci. 2019-3-18

[2]
[Brain stimulation for the selective treatment of schizophrenia symptom domains : Non-invasive and invasive concepts].

Nervenarzt. 2019-1

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