颅内破裂动脉瘤手术时机的选择

目的探讨颅内破裂动脉瘤不同手术时机与临床预后的关系.方法回顾性分析121例前循环动脉瘤,其中延期手术夹闭97例,早期24例,采用不同的统计方法分析不同手术时机对预后的影响.结果早期手术夹闭24例中除1例V级患者于术后3d死亡和1例Ⅲ级患者于术后2月因颅内感染死亡外,余22例均获得优或良疗效;平均住院18.2d,无1例再出血,延期手术的97例平均住院时间是前者的2倍,14例发生再出血.结论早期显微外科治疗颅内破裂动脉瘤,尤其对Hunt&HessI～Ⅲ级患者,有利于缩短住院时间,降低保守治疗期间再出血的危险性,而对于Ⅳ～V级脑肿胀患者,早期手术的困难程度相应增加.     

Pressure Transfer Between Intracranial and Cochlear Fluids in Patients With Meniere's Disease

Objectives: To elucidate the pressure transfer between intracranial and labyrinthine fluids in patients with well‐defined unilateral Meniere's disease. Study Design: Eleven patients previously exposed to hypobaric pressure agreed to be investigated further with the tympanic membrane displacement (TMD) technique. TMD was used to indirectly analyze perilymph pressure changes as the result of changes in body position. Methods: Repeated measurements for both the diseased and the healthy ears were made with the patients supine and then in a sitting position. The TMD parameters for the maximum inward displacement, the Vi, and the mean volume displacement, the Vm, were calculated and compared. Results: The paired comparison showed statistically significant larger Vi values for both ears in the supine position. A similar tendency was observed for the Vm value. This difference of the Vi was significantly larger for the diseased ear compared with the currently healthy ear. The results were compared to the audiometric and electrocochleographic results previously obtained on the same patients when they were subjected to hypobaric pressure. Patients who experienced the largest differences in hearing level thresholds in the lower frequencies also showed the greatest differences in TMD values as the result of postural changes. Conclusions: Despite the limited number, the statistically supported results suggest a relation between the efficiency of the routes of pressure transfer and the observed effect of hypobaric exposure. The results also indicate that for the patients tested, the routes of communication are more effective in the diseased ear than in the healthy ear—a condition that may relate to the pathogeneses of Meniere's disease.     

Noninvasive three-dimensional computed tomographic angiography in preoperative detection of intracranial arteriovenous malformations

Ｃｏｎｖｅｎｔｉｏｎａｌｉｎｔｒａ ａｒｔｅｒｉａｌｄｉｇｉｔａｌｓｕｂｔｒａｃｔｉｏｎａｎｇｉｏｇｒａｐｈｙ (ＤＳＡ)ｕｓｅｄｔｏｂｅｒｅｇａｒｄｅｄａｓｔｈｅｇｏｌｄｓｔａｎｄａｒｄｆｏｒｄｉａｇｎｏｓｉｓｏｆｉｎｔｒａｃｒａｎｉａｌａｒｔｅｒｉｏｖｅｎｏｕｓｍａｌｆｏｒｍａｔｉｏｎｓ(ＡＶＭｓ) Ｒｅｃｅｎｔｌｙ ,ｎｅｗｔｅｃｈｎｉｑｕｅｓｏｆｎｅｕｒｏｉｍａｇｉｎｇａｎｄｃｏｍｐｕｔｅｒａｓｓｉｓｔｅｄｔｈｒｅｅ ｄｉｍｅｎｓｉｏｎａｌｒｅｃｏｎｓｔｒｕｃｔｉｏｎｍａｋｅｉｔｐｏｓｓｉｂｌｅ…     

新生儿窒息与相关疾病心肌酶活性的变化

目的为了探讨新生儿窒息合并新生儿缺氧缺血性脑病(HIE)、新生儿颅内出血和新生儿肺炎时血清肌酸激酶及其同功酶(CK、CK-MB)、乳酸脱氢酶(LDH)、α-羟丁酸(α-HBDH)的活性变化及之间关系.方法新生儿窒息32例,其中合并新生儿肺炎15例,合并HIE、新生儿颅内出血17例,分别测定血清中CK、CK-MB、LDH、α-HBDH的活性,并做对比分析.结果两组间CK值合并HIE和新生儿颅内出血组高于合并新生儿肺炎组(P＜0.05),有显著差异,其它心肌酶无显著差异.结论心肌酶活性的增高与HIE、新生儿颅内出血疾病本身无直接关系,其活性增高可能是新生儿窒息的结果.有脑损伤史的患儿CK值增高可能是其同功酶CK-BB活性增高所致.     

Pharmacokinetics and boron uptake of BSH (Na2B12H11SH) in patients with intracranial tumors

We evaluated retrospectively the pharmacokinetics and boron uptakeof BSH (mercaptoundecahydrododecarborate) for Boron Neutron Capture Therapy(BNCT) in 123 patients undergoing craniotomy for intracranialtumors. The pharmacokinetics revealed that BSH could moveeasily from blood to the peripheral organs; itwas retained there and elimination was very slow.BSH after intra-arterial infusion (IA) was found tomove into the peripheral organs more easily thanafter intra-venous (IV) infusion.In patients with malignant glioma, the average valuesof boron concentration in tumor and the tumorto blood ratio (T/B ratio) after IA infusionwere 26.8 ± 19.5 g/g (range, 6.1–104.7 g/g)and 1.77 ± 1.30 (range, 0.47–6.65) respectively. Onthe other hand, after IV infusion the valueswere 20.9 ± 12.2 g/g (range, 7.0–39.7 g/g)and 1.30 ± 0.65 (range, 0.61–2.94) respectively. Thedifferences are not statistically significant. Boron uptake inmalignant glioma was about three times higher thanlow grade glioma. We found a good correlationbetween boron uptake and time interval from BSHinfusion, and 15–20 hours after BSH infusion theboron concentration in tumor was above 20 g/g¹⁰B in 69% of the malignant glioma patients;T/B ratio was above one in 75%, andabove two in 44% of them.We recommend intra-venous infusion of BSH clinically sinceit is safer, and results in sufficient boronconcentration in tumor, and the planned irradiation mightbe optimal around 15–20 hours after the BSHinfusion for treating malignant glioma.     

Effects of intravenous nitroglycerin combined with dopamine on intracranial pressure and cerebral arteriovenous oxygen difference in patients with acute subarachnoid haemorrhage

Summary The effects of intravenous nitroglycerin (NTG) combined with dopamine on intracranial pressure (ICP) and cerebral arteriovenous oxygen difference (AVDO₂) were studied in 11 patients with acute subarachnoid haemorrhage (SAH). The study was performed on Days 1 to 3 of SAH after aneurysmal clipping. Treatment consisted of an intravenous drip infusion of NTG in increasing incremental doses of 0.5, 1.0, 1.5, 2.0, and 2.5 g/kg/min at one-hour intervals. Dopamine (5 to 10 g/kg/min) was also given concurrently to maintain systemic blood pressure. ICP values before NTG administration ranged from 7 to 24 mmHg (mean, 11.91±5.30 mmHg). ICP began to increase immediately after the adminisration of NTG 0.5 g/kg/min and peaked at 14.64±5.93 mmHg 10 minutes after onset of infusion. Thereafter, ICP gradually returned to pretreatment levels. Increasing the dose of NTG failed to induce further significant rises in ICP. Mean AVDO₂ before NTG administration was 4.69±0.62 ml/dl. This parameter showed no significant change during NTG infusion, although cerebral perfusion pressure decreased to between 75% to 94% of the control value after NTG administration. These results indicate that continuous NTG infusion combined with dopamine does not have adverse effects on ICP (the ICP increase is minimal and transient) and may even have beneficial effects on CBF in patients with acute SAH.     

Correlation between the degree of contrast enhancement and the volume of peritumoral edema in meningiomas and malignant gliomas

Peritumoral edema and contrast enhancement of brain tumors are both thought to be due to breakdown of the blood-brain barrier (BBB); however, the exact mechanism by which these two phenomena occur and whether there is a quantitative or etiological relationship is not known. Our purpose was to determine whether the relationship between the breakdown of the BBB, defined radiologically as the degree of contrast enhancement, and the volume of surrounding edema is different for high-grade gliomas and meningiomas. We analyzed 13 meningiomas and 23 gliomas. A direct linear relationship between the degree of contrast enhancement (dC) and volume of peritumoral edema (V) with a high correlation coefficient (R = 0.66, P = 0.0006) was established for gliomas. A mathematical relationship between dC and V could not be established for meningioma. The findings for gliomas offer indirect radiological evidence that the defect in the BBB which causes edema is quantitatively and etiologically related to the defect in the BBB responsible for contrast enhancement. For meningiomas, the lack of a relationship between dC and V implies either that the mechanisms responsible for formation of edema and contrast enhancement are fundamentally different or that a physical barrier in certain meningiomas limits propagation of edema into the adjacent white matter. Received: 4 March 1999 Accepted: 18 March 1999     

Noninvasive assessment of the elastance and reserve capacity of the craniovertebral contents via flow velocity measurements in the straight sinus by TCD during body tilting test.

Invasive recording of intracranial pressure (ICP) changes during cerebrospinal fluid (CSF) infusion-drainage tests have been used to estimate elastance and reserve capacity of craniovertebral contents. The increase in ICP and its pulse-related oscillations lead to "cuff constriction" of cerebral veins. The purpose of this study is noninvasive assessment of elastance and reserve capacity of craniovertebral contents (RCCC) by measurement of flow velocity (FV) in the straight sinus by transcranial Doppler (TCD) during body tilt tests, which cause changes in ICP. The study was performed in 14 healthy volunteers (age 12-49 y, 6 men) and 32 patients with Intracranial Hypertension (IH) (Benign Intracranial Hypertension, n = 14; Brain Tumors, n = 18). The straight sinus was insonated through the occipital window during body tilt tests (BTT). Tilt table position was changed gradually from head up (+75 degrees) to head down (-45 degrees). It was established that systolic flow velocity and amplitude of FV pulsations (Amp) in horizontal position in patients is usually higher than in healthy volunteers. We found that reserve capacity of craniovertebral contents in patients with IH was usually exhausted. Elastance in patients was usually significantly higher than in healthy volunteers. Evaluation of cerebral venous circulation during body tilt tests clearly differs between the patients with IH and the healthy volunteers. The degree of this difference depends on the localization and character of the pathologic process.     

CO2 and indomethacin vasoreactivity in patients with head injury

Summary The purpose of this study was to compare the effect of hyper-ventilation and indomethacin on cerebral circulation, metabolism and pressures in patients with acute severe head injury in order to see if indomethacin may act supplementary to hyperventilation. Fourteen severely head injured patients entered the study. Intracranial pressure (ICP), mean arterial blood pressure (MABP) and cerebral perfusion pressure (CPP) were monitored continuously. Within the first four days after the trauma the CO₂ and indomethacin vasoreactivities were studied by measurements of cerebral blood flow (CBF) (Cerebrograph 10a, intravenous¹³³Xe technique) and arterio-venous difference of oxygen (AVdO₂). Ischaemia was evaluated from changes in CBF, saturation of oxygen in the jugular bulb (SvjO₂), lactate and lactate/oxygen index (LOI). Data are presented as medians and ranges, results are significant unless otherwise indicated. Before intervention ICP was well controlled (14.8 (9–24) mmHg) and basic CBF level was 39.1 (21.6–75.0) ml/100 g/min). The arterio-venous oxygen differences were generally decreased (AVdO₂ = 4.3 (1.8–8.1) ml/100 ml) indicating moderate luxury perfusion. Levels of CMRO₂ were decreased (1.54 (0.7–3.2) ml/100 g/min) as well.Duringhyperventilation (APaCO₂ = 0.88 (0.62–1.55) kPa) CBF decreased with 11.8 (–33.4–29.7) %/kPa and ICP decreased with 3.8 (0–10) mmHg. AVdO₂ increased 34.0 (4.0–139.2) %/kPa, MABP was unchanged, CMRO₂ and CPP increased (CPP = 3.9 (–10–20) mmHg). AVD (lactate) and LOI were unchanged. No correlations between CBF responses to hypocapnia and outcomes were observed.An i.v. bolus dose ofindomethacin (30 mg) decreased CBF 14.7 (–16.7–57.4) % and ICP decreased 4.3 (–1–17) mmHg. AVdO₂ increased 27.8 (–40.0–66.7)%, MABP (MABP = 4.9 (–2–21) mmHg) and CPP (CPP = 8.7 (3–29) mmHg) increased while CMRO₂ was unchanged. No changes in AVd (lactate) and LOI indicating cerebral ischaemia were found.Compared to hyperventilation (changes per 1 kPa, at PaCO₂ level = 4.05 kPa) the changes in MABP, CPP and CBF were significantly greater after indomethacin, while the changes in AVdO₂, ICP, SvjO₂, and LOI were of the same order of magnitude.Nocorrelation between relative reactivities to indomethacin and CO₂, evaluated from changes in CBF and AVdO₂, or between the decrease in ICP after the two procedures were found. Thus, some patients reacted to indomethacin but not to hyperventilation, and vice versa.These results suggest that indomethacin and hyperventilation might act independently, or in a complementary fashion in the treatment of patients with severe head injury.