Clinical neuroprotection and secondary neuronal injury mechanisms

Cerebral injury is a common cause of severe morbidity and mortality and is frequently encountered by anaesthetists and intensive care physicians in clinical practice. Insults may arise from a variety of medical and surgical conditions, including stroke, subarachnoid haemorrhage, central nervous system infection, epilepsy, post cardiac arrest, and traumatic brain injury (TBI). Although the primary damage to brain tissue may be irreversible, aggressive early treatment may limit the ensuing secondary brain injury and reduce the risk of severe disability or death. Neuroprotection involves physiological, pharmacological and surgical interventions, initiated before the onset of ischaemia that can modify the cascade of events that lead to permanent cell damage when left unchecked.     

Factors predictive of fatality in massive middle cerebral artery territory infarction and clinical experience of decompressive hemicraniectomy

To determine the factors predictive of fatality in massive middle cerebral artery (MCA) territory infarction and outcome of decompressive hemicraniectomy, 62 patients who were retrospectively verified with first event massive MCA infarctions were enrolled in this study. Amongst them, 21 received decompressive hemicraniectomy during hospitalization. Clinical data between early and late hemicraniectomy groups were also compared. Significant deterioration occurred in 40 cases, 21 of whom received decompressive hemicraniectomy. The other 19 received conservative treatment. The mortality rate of these 40 cases between decompressive hemicraniectomy and conservative treatment was 29% (six of 21) and 42% (eight of 19), respectively. Factors that predicted fatalities in our massive MCA infarction patients with or without decompressive hemicraniectomy were total scores of baseline GCS at the time of admission, associated with coronary artery diseases, and significant deterioration during hospitalization. This study confirms the lifesaving procedure of hemicraniectomy that prevents death in patients deteriorating because of cerebral edema after infarction, although it may produce severe disability with an unacceptably poor quality of life in survival. Despite high mortality and morbidity, decompressive hemicraniectomy to prevent cerebral herniation when significant deterioration is demonstrated are essential for maximizing the potential for survival.     

特大骨瓣减压治疗特重型颅脑损伤

目的评估实施特大骨瓣减压术治疗特重型颅脑损伤的手术适应证及疗效。方法对50例特重型颅脑损伤患者均实施了特大骨瓣减压术。结果按格拉斯哥预后评分(GOS)：恢复0例，良好2例，中残8例，重残21例，植物生存6例，死亡13例。37例存活者出院后随访1-4年，再次GOS评定：恢复2例，良好5例，中残10例，重残10例，植物生存3例，死亡7例。共死亡20例，总死亡率40％。结论对特重型颅脑损伤实施特大骨瓣减压术是挽救该类垂危病人的首选办法。在严格掌握手术适应证的同时，确定、实施适当手术方案，并减张缝合修复硬膜．是值得提倡的手术措施，辅以术后常规治疗，可明显提高疗效。     

改良去骨瓣减压术与传统外伤大骨瓣减压术治疗重型颅脑损伤的效果评价

目的分析改良去骨瓣减压术与传统外伤大骨瓣减压术治疗重型颅脑损伤的效果。方法80例重型颅脑损伤患者,随机分为对照组与观察组,各40例。对照组实施传统外伤大骨瓣减压术,观察组实施改良去骨瓣减压术。比较两组手术出血量、手术总耗时、住院时间、治疗前后患者生活质量水平。结果观察组手术出血量(95.21±15.26)ml、手术总耗时(56.21±5.21)min及住院时间(14.21±1.25)d均低于对照组的(126.78±21.78)ml、(74.44±12.66)min及(21.55±1.26)d,差异均具有统计学意义(P<0.05)。治疗后,观察组生理机能、生理职能、躯体疼痛、一般健康、精力、社会功能、精神健康、主观健康评分分别为(95.57±3.72)、(95.17±3.47)、(95.73±3.76)、(95.73±3.52)、(95.16±3.92)、(95.21±3.61)、(95.57±3.21)、(95.21±3.21)分,均高于对照组的(84.21±2.81)、(84.24±0.14)、(84.77±0.11)、(84.52±0.82)、(84.72±0.61)、(84.85±0.83)、(84.21±2.81)、(84.52±0.12)分,差异均具有统计学意义(P<0.05)。观察组恢复良好率为52.5%高于对照组的30.0%,差异具有统计学意义(P<0.05)。观察组并发症发生率为5.00%低于对照组的20.00%,差异具有统计学意义(P<0.05)。结论改良去骨瓣减压术与传统外伤大骨瓣减压术治疗重型颅脑损伤的效果比较,前者的效果更好,创伤更轻,可更好改善患者生活质量,减少并发症。     

标准大骨瓣减压术与常规骨瓣开颅术治疗重型颅脑损伤疗效对比

目的：探讨标准大骨瓣减压术与常规骨瓣开颅术治疗重型颅脑损伤的临床疗效。方法选自2013年1月～2014年9月我院收治的重型颅脑损伤患者102例，将其随机分成2组，分别命名为观察组和对照组。观察组患者给予标准大骨瓣减压术进行治疗，对照组患者给予常规骨瓣开颅术进行治疗。结果观察组患者术后6天颅内压及术后30天神经缺损评分低于对照组患者。结论标准大骨瓣减压术治疗重型颅脑损伤临床疗效显著。     

大面积脑梗死的手术治疗分析（附16例报告）

目的 探讨大面积脑梗死的手术指征、手术方法及治疗效果。方法 对2003年4月至今本院手术治疗的16例大面积脑梗死患者的临床资料进行回顾性分析。结果 本组16例，死亡1例，在随访的12例患者中，9例恢复满意。3例大面积小脑梗死的患者，2例在住院期间恢复良好，未遗留明显的神经功能障碍，1例遗留轻微的共济失调。结论 去骨瓣减压术不仅可明显降低大面积脑梗死患者的病死率，而且可以获得较好的功能预后。对高度怀疑脑梗死的患者，应及时行MR检查，以便得到更积极的治疗。     

去骨瓣减压术治疗大面积脑梗死的有效性研究

目的 探讨去骨瓣减压术治疗大面积脑梗死的有效性.方法 回顾性分析65例大面积脑梗死患者,根据患者手术时机的不同分为Ⅰa组14例(患者出现颞叶沟回疝时行去骨瓣减压术),Ⅰb组12例(患者出现早期意识改变和/或中线偏移≥10mm时行去骨瓣减压术);相对应同期内科保守治疗患者分为Ⅱa组20例(患者病程中出现颞叶沟回疝),Ⅱb组19例(患者病程中未出现颞叶沟回疝).将4组患者配为3对,Ⅰa对Ⅱa;Ⅰb对Ⅱb;Ⅰa对Ⅰb,观测其30d时死亡率、治疗前及治疗后30d神经功能缺损程度.结果 在病程不同阶段给予去骨瓣减压术与保守治疗相比均可明显降低死亡率(P＜0.05),但脑疝时手术与早期手术死亡率无显著性差异(P＞0.05).脑疝时行去骨瓣减压术与发生过脑疝而行保守治疗的患者在30d时神经功能缺损程度无显著性差异(P＞0.05),而早期手术患者比保守治疗及脑疝时手术患者在30d时神经功能缺损程度存在显著性差异(P＜0.05).结论 去骨瓣减压术可明显降低大面积脑梗死患者死亡率,早期手术可改善病人的临床神经功能.     

Clinical neuroprotection and secondary neuronal injury mechanisms

Multiple disease processes can ultimately lead to cerebral injury, a common cause of both severe morbidity and mortality in patients of all age groups. Cerebral injury is seen in a variety of both medical and surgical conditions, including stroke, subarachnoid haemorrhage, central nervous system infection, epilepsy, post cardiac arrest and, of course, traumatic brain injury.Although the primary damage to brain tissue may be irreversible, aggressive early physiological, pharmacological and surgical interventions may limit the ensuing secondary brain injury caused by ongoing ischaemia, and reduce the risk of severe disability or death.     

A new classification for spinal epidural hematoma following microendoscopic decompressive laminotomy: A prospective clinical and magnetic resonance imaging study of 245 patients

ObjectiveThe aim of this study was to develop a new radiological classification system for postoperative spinal epidural hematoma (SEH) using magnetic resonance imaging (MRI) and to determine the correlation of this classification system with clinical and radiological outcomes.MethodsThis prospective study included a total of 245 consecutive patients (126 females, 119 males; mean age=72 years; age range=39–91 years) with single level spinal stenosis who were treated by microendoscopic decompressive laminotomy (MEDL). MRI was performed for all patients 24 hours postoperatively and at 12 months. SHEs were categorized into four grades using our new MRI-based classification system based on the measurement of dural sac area: Grade A, small hematoma with a round shape; grade B, small hematoma that show no round shape; grade C, moderate hematoma; grade D: severe hematoma. Patients were then divided into four groups according to their hematoma grades, Group A, 107 patients with grade A hematomas; group B, 47 with grade B; group C, 67 with grade C; group D, 24 with grade D. Also, patients who had neurological deterioration or who pain resistant to medical treatment were treated surgically, and those were assigned to group H+(14 patients). The study, therefore, contained five groups. Clinical evaluation was done using Japanese Orthopaedic Association (JOA) score preoperatively and at 12 months postoperatively.ResultsNo significant difference existed among groups in the preoperative median measurement of the dural sac area, which were 0.90 cm2 in group A, 0.80 cm2 in group B, 0.70 cm2 in group C, 1.1 cm2 in group D, and 0.80 cm2 in group H+ (p=0.076). At the postoperative 12-month measurement, no significant difference was noted among groups A (2.05 cm2), B (1.80 cm2 ), and H+ (1.90cm2) (A vs B: p=0.891, A vs H+: p=0.089, B vs H +: p=0.933). The measurements were greater in groups A and B than in groups C and D (p<0.05). Also, larger dural sac areas were determined in group H+ (1.90cm2) compared to Groups C (1.80 cm2) and D (1.60 cm2) but the difference reached no statistical significance (p=0.078). In preoperative JOA scores, there were no significant differences among groups (p>0.05). At 12-month JOA scores, no significant difference was observed between groups A and B (p=0.061) and between groups C and D (p=0.511). The scores were higher in groups A and B than in groups C and D (p<0.05).ConclusionIt seems that the narrower the preoperative dural sac area, the better the clinical symptoms of the patients with SEHs based on our new MRI-based classification system. This classification may be useful to predict the clinical status of these patients at one-year follow-up.Level of EvidenceLevel IV, Diagnostic study     

Abdominal compartment syndrome

Abdominal compartment syndrome (ACS) is a devastating condition for the critically unwell patient. Initially described as solely affecting surgical patients, ACS is now also recognized in the medical intensive care setting. Without prompt and definitive treatment mortality rates approach 70% as multi-organ failure develops. Over the past decade our understanding, recognition and management of ACS has evolved. The World Society of Abdominal Compartment Syndrome published updated guidelines in 2012 to draw consensus and improve patient outcomes. ACS is the end sequela of raised intra-abdominal pressure (IAP), defined as a sustained IAP >20 mmHg with or without an abdominal perfusion pressure <60 mmHg and associated with new organ dysfunction. Intravesical measuring of IAP is the gold standard diagnostic technique. Surgical decompressive laparotomy and open abdomen with temporary abdominal closure measures is the definitive treatment. This article summarizes the updated consensus definitions, pathophysiology, diagnostic investigation and management to help the junior surgical trainee faced with ACS.