破裂脑动脉瘤早期手术者血管痉挛与予后

1981～1989年作者收治破裂脑动脉瘤患者482例,其中,发病一周内手术240例。作者以此为研究对象,分析早期手术后脑血管痉挛与予后的关系。年龄19～74岁,平均51.9岁。男10例,女136例,动脉瘤位于前交通动脉84例,颈内动脉80例,大脑中动脉64例,大脑前动脉9例,基底动脉3例,术前临床轻重程度按GCS计分分为15、14—13、12—7分三组,分别为117例、70例、53例。患者予后按术后六个月统计,分为恢复良好,中度恢复,严重致残,植物生存,死亡五级。根据术后是否发生脑血管痉挛分为三组:无痉挛组(临床无脑血管痉挛症状,CT正常);症状性痉挛组(出现脑血管痉挛症状,CT无低密度区);梗塞组(CT有低密度灶)。以上脑血管痉挛症状和CT低密度灶均除外手术操作,出血水肿等原因所致者。     

显微手术早期治疗破裂的前循环脑动脉瘤

目的旨在进一步提高早期手术治疗破裂的前循环脑动脉瘤的效果。方法回顾性分析早期显微手术治疗的112例破裂前循环脑动脉瘤患者的临床资料。结果112例病人,共125个脑动脉瘤,其中94个行动脉瘤颈夹闭,26个夹闭瘤颈后切除瘤体,另5个动脉瘤予以瘤壁包裹加固术。术后发生症状性脑血管痉挛16例,经积极治疗后,12例逐渐恢复,4例因大片的脑梗死而出现长时间昏迷。全部病例术后平均随访2年10个月,其中恢复良好92例,轻残16例,重残4例,无手术死亡。结论早期手术治疗破裂的脑动脉瘤,不仅可有效地防止再出血的危险,而且有利于脑血管痉挛的防治。术中一旦动脉瘤破裂,可采取暂时性阻断载瘤动脉和控制性低血压,但时间不宜过长。应用罂粟碱溶液冲洗脑池,扩充血容量,提升血压,高度扩张血管对防治脑血管痉挛具有相当好的疗效。     

载瘤动脉临时阻断处理颅内动脉瘤的临床研究

目的 探讨载瘤动脉临时阻断处理动脉瘤继发缺血性脑功能损伤的相关因素。方法 63例颅内动脉瘤夹闭过程中行载瘤动脉临时阻断，术后根据相应部位有无脑功能障碍，CT检查阻断血管供应区有无新鲜梗塞灶为标准判断是否造成缺血性脑损伤，并按有无蛛网膜下腔出血、动脉瘤所在部位、Hunt和Hess分级等进行分组对照。结果 63例载瘤动脉临时阻断时间3-59min，术后共有12例出现缺血性脑损伤表现，其中术前有蛛网膜下腔出血(SAH)者11例，Hunt和Hess分级Ⅲ～V者8例，基底动脉5例、大脑中动脉4例。阻断时间16min以内者均无缺血性脑损伤。结论 载瘤动脉临时阻断继发缺血性脑损伤与阻断部位、阻断时间、阻断方式、侧支循环的个体差异、病人术前状况等因素有关。     

颅内动脉瘤显微夹闭术中临时阻断技术的应用技巧

目的探讨颅内动脉瘤显微夹闭术中载瘤动脉临时阻断技术所致瘤内相关血流动力学变化规律及其应用技巧。方法回顾性分析2014年1月至2018年12月显微夹闭术治疗的55例(55个)颅内动脉瘤的临床资料,总结术中载瘤动脉临时阻断经验。术后24~48 h头颅CT检查临时阻断区有无新发梗死灶作为判断与临时阻断技术相关联的并发症。结果载瘤动脉临时阻断以近端阻断为主,共48例;近、远端同时阻断共7例。术中载瘤动脉阻断时间2~20 min,平均(6.1±2.3)min。持续阻断共43例,间接阻断12例,间接阻断次数2~3次,间隔3~5 min。术后7例出现新发梗死灶,其中后交通动脉动脉瘤3例,大脑中动脉动脉瘤2例,前交通动脉动脉瘤2例。结论颅内动脉瘤显微夹闭术中载瘤动脉临时阻断可造成动脉瘤内明显的血流动力学变化,术后早期继发性梗死灶与临时阻断技术密切相关。     

载瘤动脉临时阻断在颅内动脉瘤术中的应用

目的 探讨颅内动脉瘤手术中载瘤动脉,临时阻断对手术风险的影响。方法 回顾分析112例颅内动脉瘤患者的手术过程及结果,均采用显微外科技术临时阻断栽瘤动脉,显露动脉瘤颈部,清除颅内血肿并对动脉瘤实行手术夹闭。结果 在112例123个动脉瘤中临时阻断载瘤动脉117个,阻断时间最短1.2min,最长15min,平均8．4min,112例患者中1例后交通动脉瘤因动脉硬化较严重夹闭动脉瘤时出现动脉瘤整体脱落,造成载瘤动脉局部缺损行动脉瘤旷治术,术后出行肢体偏瘫;4例出现小缺血病灶,但无明显的神经功能障碍;1例早期手术患者术后因合并严重血管痉挛致脑梗死死亡。结论 载瘤动脉临时阻断有效降低了动脉瘤内的压力,有利于显露动脉瘤颈,夹闭动脉瘤,短时间阻断栽瘤动脉是安全的。     

脑动脉瘤术中干预性载瘤动脉暂时阻断

目的探讨脑动脉瘤术中载瘤动脉暂时阻断的时机和方式。方法１８例脑动脉瘤患者，术中采用干预性载瘤动脉暂时阻断，阻断时间１８～５５ｍｉｎ，平均２７ｍｉｎ，每间隔８～１２ｍｉｎ原位松开阻断夹１０余秒，以防血栓形成，阻断超过３０ｍｉｎ则开放载瘤动脉３～５ｍｉｎ，１０例复合性控制低血压。结果术后再出血死亡１例，出现脑梗塞１例，其余１６例恢复良好。结论干预性载瘤动脉暂时阻断能明显降低动脉瘤术中成熟破裂的发生率，大部分病人能耐受分离瘤颈，夹闭动脉瘤所需时间的阻断     

73例颅内动脉瘤术中破裂的处理体会

目的　探讨动脉瘤术中破裂的对应措施。方法　在控制性低血压下按动脉瘤的解剖特点游离动脉瘤。一旦破裂出血 ,可临时夹闭载瘤动脉 ,或在破裂口处压以涂上医用生物胶的一小块明胶海绵封闭破裂口 ,出血控制后稳妥地夹闭瘤颈。结果　 73例中 6 8例行动脉瘤颈夹闭术。其余 5例 ,分别行囊壁切除动脉修补术、瘤体切除术及颈内动脉血管重建术。治愈率为 93.2 % ,病死率 6 .8%。结论　按动脉瘤的解剖特点游离动脉瘤是控制动脉瘤术中破裂出血的前提 ;有预见性地采用控制性低血压和暂时阻断载瘤动脉或用涂以医用生物胶的小块明胶海绵封闭破裂口是术中控制动脉瘤破裂出血的重要应急措施。     

经翼点锁孔入路显微手术夹闭前循环动脉瘤19例

目的 探讨经翼点锁孔入路手术夹闭前循环动脉瘤的适应证、手术要点及并发症的处理方法.方法 回顾性分析19例动脉瘤患者在显微镜直视下经翼点锁孔入路行动脉瘤夹闭的临床资料.结果 夹闭动脉瘤19例;术中发生动脉瘤破裂3例,予以控制性低血压、临时阻断载瘤动脉及快速吸除积血,重新显露术野后夹闭;脑血管痉挛4例,给予罂粟碱溶液充分冲洗脑池后,脑血管痉挛缓解.术后2例出现脑积水,经行脑室-腹腔分流术后治愈.术后痊愈15例,轻残3例,重残1例.结论 娴熟的显微操作技术、恰当的病例选择、良好的术中显露与并发症的正确处理是经翼点锁孔入路手术夹闭前循环动脉瘤手术成功的关键.     

颅内动脉瘤术中临时阻断载瘤动脉的临床研究

目的探讨颅内动脉瘤手术中载瘤动脉临时阻断后继发脑缺血性脑功能损伤的相关因素。方法128例患者的130个动脉瘤临时阻断载瘤动脉，术后根据相应部位有无脑功能障碍，CT检查阻断血管供应区有无新鲜梗塞灶为标准判断是否造成缺血性脑损伤，并将性别、年龄、有无蛛网膜下腔出血、Hunt-Hess分级、动脉瘤的大小、部位、手术时机、阻断部位、时间、次数、方式、术中破裂、有无高血压、高血糖、载瘤动脉硬化斑块等14种因素进行单因素分析、探讨动脉阻断后可能导致缺血性损伤的原因。结果在130个动脉瘤中，共临时阻断166次，平均每个动脉瘤阻断1.28次，阻断时间为3～45min，平均每个动脉瘤阻断时间约为（9.8±7.8）min，有18例术后出现与载瘤动脉阻断有关新的脑缺血灶（14.06%），单因素分析显示年龄≥60岁、蛛网膜下腔出血、阻断时间≥20min和动脉硬化斑块对术后发生脑缺血具有较高危险性（均P〈0.05）。结论载瘤动脉临时阻断继发缺血性脑损伤与阻断部位、阻断时间、阻断方式、侧支循环的个体差异、病人术前状况等因素有关。阻断时间〈20min，临时载瘤动脉阻断是安全的。     

颅内动脉瘤术后脑血管痉挛发生的相关因素分析

目的探讨颅内动脉瘤术后脑血管痉挛发生的相关因素。方法对30例颅内动脉瘤患者采用经颅多普勒检查诊断脑血管痉挛。结合蛛网膜下腔出血(SAH)Fisher分级、手术时机、术前SAH次数、动脉瘤术中有无破裂等资料进行相关分析。结果蛛网膜下腔积血Fisher分级>Ⅱ级者术后脑血管痉挛发生率(86.7%)明显高于Ⅱ级及以下者(26.7%),P<0.01。Fisher分级与脑血管痉挛的发生明显相关(r=0.3164,P=0.0135);SAH后3周内手术脑血管痉挛发生率(75%)明显高于3周以后手术(20%),P<0.001。术前发生SAH2次以上患者的脑血管痉挛发生率(76.9%)明显高于1次(41.2%),P<0.001。动脉瘤术中有无破裂对脑血管痉挛发生无明显影响。结论(1)动脉瘤术后脑血管痉挛可能是SAH后脑血管痉挛病理过程的延续。(2)SAH后3周内手术是颅内动脉瘤术后脑血管痉挛发生的独立危险因素。(3)早期手术不能降低术后脑血管痉挛的发生率。     

Influence of midazolam premedication on intraoperative EEG signatures in elderly patients

ObjectiveTo investigate the influence of midazolam premedication on the EEG-spectrum before and during general anesthesia in elderly patients.MethodsPatients aged ≥65 years, undergoing elective surgery were included in this prospective observational study. A continuous pre- and intraoperative frontal EEG was recorded in patients who received premedication with midazolam (Mid, n = 15) and patients who did not (noMid, n = 30). Absolute power within the delta (0.5–4 Hz), theta (4–8 Hz), alpha (8–12 Hz), and beta (12–25 Hz) frequency-bands was analyzed in EEG-sections before (pre-induction), and after induction of anesthesia with propofol (post-induction), as well as during general anesthesia with either propofol or volatile-anesthetics (intra-operative).ResultsPre-induction, α-power of Mid patients was lower compared with noMid-patients (α-power: Mid: −10.75 dB vs. noMid: −9.20 dB; p = 0.036). After induction of anesthesia Mid-patients displayed a stronger increase of frontal α-power resulting in higher absolute α-power at post-induction state, (α-power: Mid −3.56 dB vs. noMid: −6.69 dB; p = 0.004), which remained higher intraoperatively (α-power: Mid: −2.12 dB vs. noMid: −6.10 dB; p = 0.024).ConclusionMidazolam premedication alters the intraoperative EEG-spectrum in elderly patients.SignificanceThis finding provides further evidence for the role of GABAergic activation in the induction of elevated, frontal α-power during general anesthesia.Trial Registry NumberNCT02265263. 23 September 2014. Principal investigator: Prof. Dr. med. Claudia Spies. (https://clinicaltrials.gov/ct2/show/NCT02265263).     

不同麻醉方式小骨窗开颅治疗高血压脑出血的临床分析

目的 比较不同麻醉方式下施行小骨窗开颅显微手术治疗高血压脑出血的疗效,探讨其临床应用价值.方法 回顾性分析2010-01-2013-01我科手术治疗的高血压脑出血并成功随访的患者296例,其中171例行局麻,125例行全麻.对比分析两组术后并发症发生率、近期GOS评分、半年后ADL分级等指标.结果 局麻病例术后肺部感染率、应激性溃疡发生率、病死率低于全麻组,再次出血、脑积水发生率以及近期、远期病残率无明显差异.结论 局麻下小骨窗手术治疗高血压脑出血,具有时间短、相对并发症少、节省住院费用等优点,值得临床推广.     

上肢再植过程中应用罗哌卡因微量泵持续输注硬膜外麻醉的评价

背景：不同麻醉和镇痛方法应用于上肢再植术各有优缺点,麻醉效果、生理功能的干扰和对疾病转归的影响是主要评价指标。 目的：探讨微量泵持续输注低浓度罗哌卡因硬膜外麻醉用于上肢(掌、指)再植术的临床效果及安全性。 设计、时间及地点：自身前后对照观察,于2006-06/2008-06在石河子大学医学院第一附属医院麻醉科完成。 对象：石河子大学医学院第一附属医院27例行急诊断肢(掌、指)再植手术的患者27例,男19例,女8例;年龄26~53岁,均符合美国麻醉医师协会(ASA)分级标准Ⅰ~Ⅱ级,且对麻醉和术后镇痛方法知情同意。药物配方：10 g/L罗哌卡因20 mL+生理盐水40 mL,即得3.3 g/L罗哌卡因麻醉药液60 mL。 方法：全组采用颈部硬膜外麻醉。先同时按压∑键和FAST键快速输注8.0~10.0 mL,继而设定5~7 mL/h的速度恒速输注。每隔5 min以针刺法测定麻醉平面,直至达到手术要求开始手术。术中每隔1.0~2.0 h,静脉注射咪唑安定1.0~2.0 mg清醒镇静。术毕更换2 g/L罗哌卡因镇痛液, 4~6 mL/h速度持续输注术后镇痛两三天。 主要观察指标：术中监测心电图、血压、心率、呼吸频率、脉搏氧饱和度,并记录麻醉起效时间、镇痛效果、麻醉平面和运动神经阻滞程度;术后镇痛评分、48 h血压下降、呼吸抑制、恶心呕吐、尿潴留、皮肤瘙痒等不良事件发生率。 结果：27例患者全部进入结果分析。①27例患者均取得满意麻醉效果;目测类比评分0分88.9%,1分7.4%,2分3.7%;麻醉起效时间(15.2±4.3) min;运动神经阻滞轻微,能配合手术要求,术中安静不动。②血压、心率持续输注期间波动轻微;脉搏氧饱和度(98±2)%,高于术前。呼吸频率(16.5±3.6)次/min,较术前缓慢。③术后镇痛效果满意率92.6%。 结论：①微量泵持续输注3.3 g/L罗哌卡因硬膜外麻醉可以安全用于上肢(掌、指)再植术,麻醉效果满意,特别适用于手术时间冗长的复杂再植术。②2 g/L罗哌卡因持续输注便于术后镇痛,镇痛效果确切,不良事件发生率低。     

Percentage of beta 2 band power of quantitative pharmaco-electroencephalography decreases in propofol anesthetized rabbits****★ A dose-dependent analysis

BACKGROUND: Quantitative pharmaco-electroencephalography can be used for studying the dose-effect and time-effect relationships of drugs affecting central nervous system. Therefore, it may become an effective means for monitoring the anesthetic degree of anesthetic drug in the operation. OBJECTIVE: To observe the dose-effect relationship of propofol influencing β2-band power of quantitative pharmaco-electroencephalography in rabbits. DESIGN: A randomized block design. SETTING: Department of Anesthesiology, Xuzhou Medical College. MATERIALS: Thirty-six healthy adult rabbits of either gender, weighing （2.4±0.5）kg, of clean grade, were provided by the Laboratory Animal Center of Xuzhou Medical College. The involved rabbits were randomly divided into 3 groups with 12 in each by table of random digit: high-dose propofol group, moderate-dose propofol group, and low-dose propofol group. The protocol was carried out in accordance with animal ethics guidelines for the use and care of animals. METHODS: This study was carried out in the Department of Anesthesiology, Xuzhou Medical College between August 1999 and April 2000. Rabbits in the high-dose propofol group, moderate-dose propofol group, and low-dose propofol group were injected with 10, 5 and 2.5 mg/kg propofol (ZENECA Company, British, Batch No. 032000), respectively. Before and after intravenous administration of propofol, percentage of β2-band power of quantitative pharmaco-electroencephalography was measured, and the latent and persistent periods when rabbit righting reflex disappeared were observed by quantitative pharmaco-electroencephalography and power spectrum analysis. MAIN OUTCOME MEASURES: ①Percentage of β2-band power of quantitative pharmaco-electroencephalography. ②Latent period and persistent period of abolition of righting reflex of rabbits. RESULTS: Thirty-six rabbits were involved in the final analysis. ①Effect of propofol on righting reflex of rabbits: Righting reflex disappeared within 1 minute after the rabbits being intravenously injected with propofol. The higher dose, the shorter latent period (r =–0.94, P < 0.01), and the longer persistent period (r =0.79, P < 0.01). Both latent period and persistent period had good correlation with propofol dose. ② Effect of propofol on the percentage of β2-band power of quantitative pharmaco-electroencephalography: In the low-dose propofol group, no significant changes in the percentage of β2-band power of quantitative pharmaco-electroencephalography existed between before and after administration within 30 minutes (P > 0.05). In the moderate-dose propofol group, the percentage of β2-band power of quantitative pharmaco-electroencephalography in each brain region except for left and right frontal areas was significantly decreased within 30 s to 5 minutes (P < 0.05), and recovered to the level before administration 10 minutes later. In the high-dose propofol group, the percentage of β2-band power of quantitative pharmaco-electroencephalography in each brain region was significantly decreased from 20 s to 5 minutes after administration (P < 0.05–0.01), and that was gradually recovered to the level before administration 5 to 10 minutes after administration. This tendency was basically the same as the changes of latent period and persistent period. CONCLUSION: Propofol decreases the percentage of β2-band power of quantitative pharmaco- electroencephalography in dose-dependent manner. It indicates that β2-band power might become one of indexes for reflecting the anesthetic degree of propofol.     

椎管内麻醉后暂时性神经病学综合征的治疗分析

目的 探讨椎管内麻醉所致暂时性神经病学综合征的治疗方法.方法 将本院2006-10-2013-04发生的椎管内麻醉所致暂时性神经病学综合征患者90例随机分成2组,对照组和观察组各45例.对照组不进行任何干预,观察组静脉注射恩再适.比较2组症状消失时间,治疗前后视觉模拟评分（visual analogue scale,VAS）痛觉评分差异及疗效差异.结果 治疗7 d后,观察组患者显效率和总有效率均显著高于对照组,而无效率则显著低于对照组（P＜0.05）.观察组患者症状消失时间显著短于对照组（P＜0.05）;治疗后第1、3、7天观察组VAS评分均显著低于对照组（P＜0.05）.结论 采用恩再适治疗暂时性神经病学综合征,促进症状尽快消失并减轻患者的疼痛感,能有效提高疾病的改善率.     

癫痫手术的麻醉

随着麻醉技术和脑电图术中监测的发展，目前大多数癫痫手术都在全身麻醉下进行，但是因为麻醉医生不但要处理患的各种生理和心理问题，还要选择合适的麻醉药以减少对术中脑电监测的影响，所以癫痫手术的麻醉是对麻醉医生的一个挑战。本综述了癫痫手术的麻醉原则，围术期处理和麻醉药的选择，主要讨论了各种常用的全身麻醉药、阿片类镇痛药和肌肉松弛药对癫痫病人的影响。     

Percutaneous Neuromodulation of the Brachial Plexus and Sciatic Nerve for the Treatment of Acute Pain Following Surgery: Secondary Outcomes From a Multicenter,Randomized, Controlled Pilot Study

ObjectivesWe recently reported that percutaneous peripheral nerve stimulation (PNS or “neuromodulation”) decreased pain and opioid consumption within the first two weeks following ambulatory surgery. However, the anatomic lead locations were combined for the analysis, and benefits for each location remain unknown. We therefore now report the effects of percutaneous PNS for brachial plexus and sciatic nerve leads separately.Materials and MethodsBefore surgery, leads were implanted percutaneously to target the brachial plexus (N = 21) for rotator cuff repair or sciatic nerve (N = 40) for foot/ankle surgery, followed by a single injection of local anesthetic. Postoperatively, subjects were randomized in a double masked fashion to 14 days of electrical stimulation (N = 30) or sham/placebo (N = 31) using an external pulse generator. The primary outcome of interest was opioid consumption and pain scores evaluated jointly. Thus, stimulation was deemed effective if superior on either outcome and at least noninferior on the other.ResultsFor brachial plexus leads, during the first seven postoperative days pain measured with the numeric rating scale in participants given active stimulation was a median [interquartile range] of 0.8 [0.5, 1.6] versus 3.2 [2.7, 3.5] in patients given sham (p < 0.001). For this same group, opioid consumption in participants given active stimulation was 10 mg [5, 20] versus 71 mg [35, 125] in patients given sham (p = 0.043). For sciatic nerve leads, pain scores for the active treatment group were 0.7 [0, 1.4] versus 2.8 [1.6, 4.6] in patients given sham (p < 0.001). During this same period, participants given active stimulation consumed 5 mg [0, 30] of opioids versus 40 mg [20, 105] in patients given sham (p = 0.004). Treatment effects did not differ statistically between the two locations.ConclusionsAmbulatory percutaneous PNS of both the brachial plexus and sciatic nerve is an effective treatment for acute pain free of systemic side effects following painful orthopedic surgery.     

Phase changes induced by ketamine in the vertical vestibulo-ocular reflex in the rabbit

The effect of ketamine has been tested on the phase of the vertical vestibulo-ocular reflex of rabbits sinusoidally oscillated at various frequencies. A significant phase lag, predominantly affecting the macular component of the reflex, was observed. This action resembles that induced by Nembutal in the same preparation. A specific action of ketamine on synaptic transmission is suggested. Erroneous phase relationship between natural stimuli and responses can be obtained in experiments employing ketamine.     

Anesthetic management of the pregnant patient for endovascular coiling of an unruptured intracranial aneurysm

Diagnosis of an intracranial aneurysm during pregnancy is a rare event requiring multidisciplinary care for successful management. The knowledge base for the anesthesiologist involves principles of both obstetric and neuroanesthesia, as well as critical care. This article reports such a case and discusses the relevant pathophysiology, along with details of the perioperative management by the anesthesiology team.     

神经外科手术期间体感诱发电位变化的研究

目的　研究神经外科手术期间体感诱发电位 (SEP)的变化 ,以期为麻醉和手术处理提供依据 ,评估疗效 ,判断预后。方法　对 17例神经外科手术患者于术前、麻醉、术始、术中、术毕和术后六个时程连续监测SEP ,探讨全麻及手术操作对SEP的影响。结果　麻醉后SEP潜伏期延长 5 .96 %,波幅下降 2 4 .0 0 %,未出现波形消失者 ;SEP可监测手术中脑缺血及脊髓功能的变化。结论　麻醉期间脑电活动受到抑制 ,SEP出现潜伏期延长和波幅下降 ,未出现波形消失者 ;SEP可用于手术操作的监测 ,尤其是涉及躯体感觉传导通路的手术