标准外伤大骨瓣开颅术治疗额颞顶部广泛对冲伤的临床研究

目的 探讨标准外伤大骨瓣开颅术治疗额颞顶部广泛对冲伤的临床应用价值。方法 采用标准外伤大骨瓣开颅术对46例额颞顶部广泛对冲伤患者进行手术治疗，术后3～6个月采用格拉斯哥预后分级标准进行临床疗效的评定，并对并发症进行分析。结果 预后良好22例（47．83％），中度残疾6例（13．04％），莛度残废4例（8．7％），死亡14例（30．43％）。术后主要并发症为迟发性颅内血肿、脑穿通畸形、脑积水、颅骨缺损综合征等。结论 标准外伤大骨瓣开颅术是治疗额颞顶部广泛对冲伤（尤其是单侧）的良好手术方式。     

Computed Tomography Analysis of Head and Spinal Cord Injuries Inflicted by Missiles and Explosives

Cerebral and spinal column computed tomography (CT) was performed in 53 patients wounded during war in the Republic of Croatia from June through December 1992. Of these, 36 (67%) suffered craniocerebral injuries; 10 (18%) sustained facial, neck, and paranasal sinus wounds; and 7 (13%) had vertebral andjor paravertebral lesions. Twenty-five (70%) of the patients with craniocerebral injuries had penetrating wounds with diffuse and multiple, predominantly hemorrhagic lesions of cortical and subcortical structures, with basal ganglia lesions in 15 (43%) and brainstem lesions in 6 (20%). Of the 7 vertebral studies. 4 showed paravertebral tissue damage to the spinal column and cord.     

Missile injuries of the brain: results of less aggressive surgery

Sixty cases of missile injuries (59 males, average age 25 years) were studied over a period of one year. Forty-three patients had suffered splinter injuries, 12 had gunshot wounds and 5 had suffered injuries from improvised explosive devices. The Glasgow coma scale was <5 in 8 patients, 5-8 in 14, 8-12 in 30 and 13-15 in 8 patients. Extensive comminution of skull bones was found in 10 patients. Thirty-five patients had penetration of the skull and the rest had orbito-cranial or facio-cranial wounds. CT scan revealed small hemorrhagic contusion with in-driven bones without mass effect in 15, contusion with mass effect in 36 cases, cortical contusions without in-driven bones (tangential injuries) in 3, distant intracranial contusions in 4, intraventricular hemorrhages in 5, multilobar injuries in 14, and unilobar injury in 40. Fifty-two patients were operated upon at our center, of which 30 were operated within 24 hrs, 10 between 24 to 48 hrs, and 12 between 48 to 72 hrs. Six patients were treated conservatively and 2 underwent only a simple closure of scalp wound. Craniectomy was done in 10 and craniotomy in 42 patients. Two patients developed wound sepsis, one had aspiration pneumonia, one had septicemia and one had deep vein thrombosis while one had post-traumatic hydrocephalus. On follow-up at 6 months, the outcome as per the Glasgow outcome scale was as follows: Good outcome in 42, moderate disability in 7, severe disability in 6 and death of 5 patients. Retained bone fragments were found in 36.3 % on follow-up CT scan but no one had brain abscess.     

汶川地震336例颅脑损伤患者的救治分析

目的 总结和探讨地震发生后一线医院收治的颅脑损伤患者特点及救治经验.方法 将336例地震颅脑损伤患者通过GCS评分法初筛,按伤情程度分为重、中、轻3型,予以药物治疗和医学观察;伤口行止血包扎和清创;复合伤行相关处置;重型颅脑损伤中开颅手术4例,死亡1例.结果 本组病例中,轻型颅脑损伤206例,恢复良好201例;中型颅脑损伤122例,恢复良好11例;重型颅脑损伤8例,恢复良好1例,死亡4例.结论 地震所致颅脑损伤具有致伤机制复杂,合并损伤多,病情变化快的特点,提高一线医院灾害应对能力和应急储备,对于及时抢救危重颅脑损伤患者,提高抢救存活率,最大限度的降低死残率均有着极其重要的现实意义.     

Neurologic recovery after penetrating craniocerebral war injury

From June 1, 1991, until December 31, 1992, 116 patients with penetrating craniocerebral war injuries inflicted at the east Slavonian front were treated at the Osijek University Hospital. There were 26 (22.4%) gunshot wounds and 90 (77.6%) wounds inflicted by explosive devices and projectiles. Four years after the injury, a study of the survivors' condition was carried out. No difference was recorded in the survival rate between the patients with gunshot wounds compared with explosive wounds. Rehabilitation produced good results in the survivors, in the prevention of both acute and chronic complications and permanent damage. Older age, lower Glasgow Coma Scale, and level of consciousness were found to be prognostic indicators of outcome.     

颅脑火器伤临床救治研究

目的研究颅脑火器伤的临床特点,提高诊治水平。方法回顾性总结56例颅脑火器伤患者的临床资料,分析飞射物类型、伤情及处理方式。结果伴颅内异物存留43例,手术全部摘除40例,部分摘除2例,未摘除1例。存活54例,其中恢复良好36例,中残15例,重残2例,植物生存状态1例;死亡2例。8h内和8h以后清创者的恢复良好率分别为82.1%和26.7%,前者明显高于后者,P<0.001。结论颅脑火器伤具有伤情急,创伤、污染重和变化快等特点。正确判断伤情与伤道,尽早彻底清创,选择合适的手术方式和入路取出颅内异物,提高合并伤的警惕性,是提高救治水平的关键。     

170例重型颅脑损伤的临床分析

目的 总结重型颅脑损伤患者的救治方法及经验.方法 对我科收治的170例GCS评分3～8分的重型颅脑损伤患者的临床资料进行回顾性分析.结果 170例患者中标准外伤大骨瓣开颅术治疗135例,不需开颅手术17例,呼吸循环衰竭无法耐受手术治疗18例;按格拉斯哥预后评分法（GOS）评定：存活120例,随访6个月,恢复良好40例,中残20例,重残10例;死亡50例,其中术后死亡17例.结论 重型颅脑损伤患者病情危重、并发症多、病死率高,标准外伤大骨瓣开颅术可有效降低颅内压,解除脑疝,综合治疗可提高存活率.     

高温高湿环境下颅脑火器伤对犬肾脏组织的损害作用

目的研究高温高湿环境下,颅脑火器伤对犬肾脏组织的影响。方法选取杂种犬11只,随机分为高温高湿对照组5只和高温高湿颅脑枪伤组6只,枪伤组使用手枪弹致颅脑火器伤模型。检测体温、呼吸、心率改变,血浆电解质和血气分析及肾脏组织病理学检查。结果高温高湿环境下体温增高,心率、呼吸频率增快,出现低氧血症、低碳酸血症和低钾血症;伤后肾脏组织可见凝固性坏死灶,肾小管上皮细胞内囊泡形成,胞浆内见红染颗粒样变性,肾小管损伤表现。结论高温高湿环境颅脑火器伤对肾脏有病理性损害。     

Gunshot injury to the head and spine.

The principles of management of civilian gunshot wounds (GSWs) to the head and spine have evolved directly from the experience gained in war by military neurosurgeons. The type of craniocerebral wounds being produced in urban gang warfare and suicide at tempts using handguns or rifles at close range vary considerably from the lower velocity fragment injuries which are common in modern warfare. Civilian craniocerebral GSWs are often devastating. The in-hospital mortality for civilians with penetrating craniocerebral injury is 52-95% depending on the proportion of suicide victims in the series. The most important predictive factor is the post-resuscitation Glasgow Coma Score (GCS). Many civilian victims (47%) present with GCS 3-5 and only approximately 8.1% survive. Of these survivors, 1.4% will have nil, mild or moderate disability without surgery and 4.8% with surgery. Higher post-resuscitation GCS is associated with a significantly improved survival: GCS 6-8, 35.6% and GCS 9-15, 90.5%. A selective treatment policy is recommended for the patients with GCS 3-5. There are many clinical and radiological correlates with poor outcome that help the neurosurgeon decide on operative versus supportive treatment. Early aggressive resuscitation, surgery and vigorous control of intracranial pressure offers the best chance of achieving a satisfactory outcome. Spinal GSWs are uncommon and the neurosurgeon should be aware of the principles of management and prognosis. The indication for acute spinal cord decompression is deteriorating neurological status. Steroids are not indicated for these injuries. Neurosurgeons should take an active role in formulating and supporting public policy which aims to reduce possession and usage of firearms and therefore the prevalence of gunshot injuries.     

急性颅脑损伤后血清内源性类洋地黄物质含量变化

目的 探讨颅脑损伤后血清内源性类洋地黄物质（ＥＤＬＳ）含量变化及其机理和临床意义。方法 采用放免法检测６３例急性颅脑外伤患者血清ＥＤＬＳ浓度变化,对其中１９便作动态观测,１６例行手术前后对比,２３例与预后进行相关分析。结果 不同程度脑外伤皇２４小时内血清ＥＬＤＳ均升高,以轻伤组最为典型;随着损伤程度的加剧,少数病例ＥＤＬＳ不变甚至下降,术后或随伤情的恢复,ＥＤＬＳ多同步下降,不同病病理类型的脑损伤     

高原地区(拉萨)颅脑交通伤的特点及救治分析

目的：探讨现代高原交通事故所致颅脑伤的特点及治疗措施。方法：回顾性分析本科近7年间收治的拉萨市交通事故所致颅脑伤656例。其中男性532例，女性124例；平均年龄32．6岁。本组轻型颅脑损伤123例．中型241例，重型292例。结果：汽车交通事故为本组病例颅脑损伤的主要交通事故原因，出租车为肇事高发车群。高发时间在7～9月份。本组手术治疗273例；非手术治疗383例。其中轻型颅脑损伤无一例重残或死亡；中型颅脑损伤重残42例，死亡12例，重残、死亡率为8．2％；重型颅脑损伤重残66例，死亡123例，重残、死亡率为28．8％。结论：(1)拉萨市出租车肇事是造成颅脑交通伤的重要原凶，7～9月为高发时间；(2)高原低氧环境，常致颅脑损伤伤情加重，进展快．特点是伤情重，合并伤多，死亡及致残率高。尽早清除颅内血肿，去大骨瓣减压，亚低温治疗，维持内环境稳定及防治并发症等措施，可改善重型颅脑损伤的预后。     

基层医院颅脑损伤急救模式的探讨

目的 探讨设计基层医院颅脑损伤的急救模式.方法 本院以ICU为依托,神经外科负责,多科协助对颅脑损伤病人由专科医生分类按相应程序进行急救.结果 本病例共1263例,轻型382例,中型443例均治愈、重型及特重型438例,按格拉斯哥预后评分(GOS)评定:恢复良好或中残308例,重残45例,植物生存14例,死亡71例.结论 急诊科院前急救,重型颅脑损伤直接送入ICU,专科医生按急救程序处理,手术由神经外科医生负责,术后送ICU监护有助于重型颅脑损伤的救治.     

256例重型、特重型颅脑外伤后行大骨瓣减压术患者的回顾性分析

目的探讨256例重型、特重型颅脑外伤（TBI）患者行大骨瓣减压的远期治疗效果。 方法单中心回顾性队列研究纳入自2012年7月至2016年12月济南军区总医院神经外科收治256例的因重型、特重型TBI急诊行大骨瓣减压的患者,其中重型（GCS评分6~8分）166例、特重型（GCS评分3~5分）90例,采用标准大骨瓣开颅术,减压窗面积约为12 cm×15 cm左右。术后随访18个月,预后分为良好恢复、中残、重残、植物状态、死亡;其中,良好恢复、中度病残为预后良好者,严重病残和植物状态为预后较差者。 结果恢复良好/中残患者104例（40.61%）,但其规范评估行为、心理表现与心理健康的负担未纳入此次临床评估。重残54例、植物状态38例、死亡60例,共计152例患者预后较差（59.37%）,可判断59.37%的患者存在预后不良。 结论标准外伤大骨瓣减压术是治疗重型TBI脑疝形成的有效方法。发生重型、特重型TBI的患者其临床预后差,表现为死亡、植物生存、功能损伤,需要医学界探索新的治疗策略。     

高温高湿环境下颅脑火器伤对狗心肌组织的损害作用

目的研究高温高湿环境下,颅脑火器伤对犬心肌组织的影响。方法选取杂种狗11只,随机分为高温高湿对照组5只和高温高湿颅脑枪伤组6只,在高温高湿环境下使用手枪弹致颅脑火器伤模型。检测体温、呼吸、心率改变,血液凝血功能和血气分析,伤后心脏组织病理检查。结果伤后心率增快,心肌内出血灶,心肌纤维分离伴纤维间大量红细胞,坏死区心肌细胞存在胞浆红染颗粒;低氧血症、低碳酸血症和凝血因子变化。结论高温高湿环境颅脑火器伤对心肌组织有病理性损害。     

标准大骨瓣开颅减压术在治疗重型颅脑损伤并发脑疝中的应用

目的讨标准大骨瓣开颅减压术治疗重型颅脑损伤并发脑疝的疗效。方法将33例符合手术治疗的重型颅脑损伤并发脑疝的患者行标准大骨瓣开颅减压术,术后随访6~10个月。采用GOS评判预后。结果 33例重型颅脑损伤并发脑疝病人,行标准大骨瓣开颅减压术后,经随访恢复良好15例(45.5%),中残6例(18.2%),重残3例(9.1%),植物生存2例(6.1%),死亡7例(21.2%)。结论标准外伤大骨瓣开颅减压术,具有暴露广泛,颅骨减压窗大,压力容易分散,最大限度地增加有效容积,减压充分,脑疝易复位,能明显降低脑疝病人的死亡率和病残率。     

高温高湿环境下颅脑火器伤对狗肝脏组织的损害作用

目的研究高温高湿环境下,颅脑火器伤对狗肝脏组织的影响。方法选取杂种狗,随机分为高温高湿对照组5只和高温高湿颅脑枪伤组6只,在高温高湿环境下使用手枪弹致颅脑火器伤模型。检测体温、呼吸、心率改变,血液凝血功能和血气分析,伤后肝脏组织病理检查。结果伤后体温增高、心率增快,出现低氧血症、低碳酸血症,凝血因子变化;肝脏肿大、肝窦扩张,其内充有大量红细胞的肝淤血表现。结论高温高湿环境颅脑火器伤对肝脏组织有损害作用。     

Penetrating craniocerebral injury from an underwater fishing harpoon

Weapon injuries other than gunshot wounds or low-velocity stab wounds to the head are extremely rare. We report the case of a 6-year-old girl who sustained a penetrating craniocerebral injury after being accidentally shot with an underwater fishing harpoon. This mechanism of injury seems to share characteristics of both high- and low-velocity projectiles. We discuss the management of this unusual injury in a child, remarking that foreign body removal in these cases must be carried out following the original direction of the projectile trajectory. We review the current literature on craniocerebral injuries caused by similar objects, especially those occurring in children. Received: 18 December 1998     

急性颅脑损伤后的动态心电图变化及分析

目的探讨急性颅脑损伤后心电图改变,了解心肌损害情况。方法入院后即行24h动态心电图描记,1周及2周时复查。结果本组206例急性颅脑损伤患者中,170例出现心电图异常(82.5%),其中重型颅脑损伤组108例(92.3%),中型组51例,轻型组11例(40.7%)。心电图异常主要表现为心肌缺血性改变和心律失常。绝大多数患者心电图改变在2周内随着伤情的好转而恢复正常。结论颅脑损伤可引起心电图异常变化,且其变化与损伤程度呈正相关。心电图改变可反映急性颅脑损伤后心肌损害程度,为临床早期判断伤情提供依据。     

创伤性颅脑损伤行大骨瓣减压术并发脑积水的临床诊疗

目的总结创伤性颅脑损伤（TBI）后大骨瓣减压术后脑积水发生的危险因素与治疗措施。 方法单中心回顾性队列研究济南军区总医院神经外科自2012年7月至2016年12月收治的TBI后行大骨瓣减压术的196例幸存患者的临床资料,根据患者术后5~15 d内的头颅CT或MRI影像资料分为2组：有纵裂积液或/和硬膜下积液为A组（n=81）,无纵裂积液或/和硬膜下积液为B组（n=115）。2组病例复查出现纵裂积液或/和硬膜下积液者给予腰大池持续外引流术及脑室-腹腔分流术（VPS）。 结果随访6个月复查头颅CT或MRI,A组81例患者中57例出现脑积水,发生率70.0%,B组115例患者中仅10例出现脑积水,发生率8.7%。2组患者脑积水发生率差异有统计学意义（χ²=80.35,P<0.05）。A组患者给予5~10 d腰大池持续外引流术,术后未出现脑积水症状的患者24例,有效率42.1%;B组6个月内随访并发脑积水者10例,给予腰大池持续引流4~7 d,拔出引流术管后脑积水复发10例。2组经治疗后共67例脑积水患者行VPS,脑积水影像学表现及患者临床症状（GCS评分增高）改善者62例,有效率92.5%。 结论TBI后行大骨瓣减压术出现纵裂积液或/和硬膜下积液是脑积水发生的因素之一。一旦出现纵裂积液或/和硬膜下积液,则应对患者追踪头颅CT随访,给予积极对症治疗改善临床症状。     

颅脑损伤术中急性脑膨出的临床分析

目的 对颅脑损伤术中急性脑膨出原因和有效防治措施进行探讨.方法 对43例颅脑损伤术中急性脑膨出的临床资料进行同顾性总结.结果 术后死亡24例,存活19例.术后GOS评定:恢复良好5例,中残2例,重残7例,植物生存5例.结论 进展性出血性损伤、急性弥漫性脑肿胀等是造成颅脑损伤术中脑膨出的主要原因,针对不同病因采取相应措施是防治术中出现急性脑膨出的有效措施,提高临床疗效.