标准大骨瓣减压术治疗大面积脑梗死临床体会

目的 探讨标准大骨瓣减压术治疗大面积脑梗死两种不同方法的疗效以及影响其疗效的因素。方法 对大面积脑梗死患者随机分组部分行标准大骨瓣减压颞肌黏覆术，另一部分行标准大骨瓣减压硬膜扩大减张缝合术，术后分析其疗效，并分析GCS评分和梗死面积同患者疗效的关系。结果 35例中是否行颞肌黏覆术对其疗效无明显差别，GCS评分低，梗死面积大的患者疗效差。结论 标准大骨瓣减压术是治疗大面积脑梗死的有效方法，硬膜扩大减张缝合术优于颞肌黏覆术，判断大面积脑梗死术后疗效基本因素为患者术前GCS评分和梗死范围。     

乳突后小骨窗开颅骨片复位显微手术切除大型桥小脑角肿瘤

目的 探讨大型桥小脑角肿瘤经乳突后小骨窗开颅、骨片复位的手术方法 及其治疗效果.方法 18例大型桥小脑角肿瘤(听神经鞘瘤13例,脑膜瘤3例,胆脂瘤2例)均采用单侧乳突后小骨窗开颅,应用显微神经外科技术进行肿瘤切除,必要时磨开内听道,术中行脑干听觉诱发电位(BAEP)、体感诱发电位(SEP)和面神经功能监测,肿瘤切除后严密缝合硬脑膜,骨片复位.结果 肿瘤全切除17例、次全切除1例.全组患者的面神经均得到了解剖保留.无手术死亡.术后复查MRI示17例肿瘤全切除者未见有肿瘤残留,1例听神经鞘瘤行次全切除者于内听道内可见少许肿瘤组织残留,术后3个月行伽玛刀治疗.术后有10例遗留轻度面瘫(口角稍有歪斜,眼睑闭合良好),均为大型听神经鞘瘤患者,余患者无脑神经功能障碍,恢复良好.结论乳突后小骨窗开颅术适用于不同大小的桥小脑角肿瘤,严格按显微神经外科技术操作,结合术中BAEP,SEP和面神经功能监测,均可做到肿瘤全切除,并能有效地保护肿瘤周围的重要神经结构及其功能.严密缝合硬脑膜和骨片复位可消除局部皮下积液.     

神经外科颅内感染危险因素的病例对照研究

目的回顾分析神经外科颅脑手术后发生颅内感染的危险因素，为临床预防和控制颅内感染提供依据。方法对2006年1-8月神经外科颅脑手术后38例发生颅内感染和68例未发生颅内感染病例的一般资料、基础疾病、主要诊断、手术情况、抗菌药物应用情况、侵入性操作、住院时间及手术人员等因素进行统计分析。结果单因素分析结果显示，两组病例在主要诊断、手术入路方式、入住重症监护室、手术持续时间、住院时间、留置导尿、H2受体阻滞剂（包括质子泵抑制剂）应用、手术人员等方面有统计学差异（均P＜0.05）；进一步通过多因素Logistic回归分析发现，手术持续时间和手术人员是颅脑手术后发生颅内感染的独立危险因素。结论颅脑手术后发生颅内感染与手术持续时间和手术人员的手术技巧及其无菌观念有关。     

Plasma levobupivacaine concentrations following scalp block in patients undergoing awake craniotomy

Background. Levobupivacaine is an effective local anaestheticagent for nerve blockade with less systemic toxicity than racemicbupivacaine. The safety and efficacy of levobupivacaine forscalp blockade during awake craniotomy have not been addressedpreviously. Methods. Serial arterial plasma levobupivacaine concentrationsfollowing scalp blockade were measured to 2 h in 10 patientsbooked for awake craniotomy for epilepsy or tumour surgery.Bilateral scalp blockade providing surgical anaesthesia wasachieved with a mean dose of 177 mg (2.5 mg kg^–1, range1.6–3.2 mg kg^–1) of levobupivacaine (0.5%, 5 mgml^–1) with epinephrine (5 µg ml^–1) added immediatelybefore the block insertion. Results. The maximum measured plasma levobupivacaine concentrationwas 1.58 (0.44) µg ml^–1 [mean (SD)] with a meantime to peak plasma concentration of 12 (4) min. There wereno episodes in any of the 10 patients of symptoms or signs suggestiveof either CNS or CVS toxicity. Conclusions. This study demonstrated a relatively rapid riseof plasma levobupivacaine concentration without evidence ofcardiovascular or central nervous system sequelae in a samplepopulation of patients who may be particularly prone to perioperativeseizures.     

Comparison of propofol/remifentanil and sevoflurane/remifentanil for maintenance of anaesthesia for elective intracranial surgery

Background. Propofol and sevoflurane are suitable agents formaintenance of anaesthesia during neurosurgical procedures.We have prospectively compared these agents in combination withthe short-acting opioid, remifentanil. Methods. Fifty unpremedicated patients undergoing elective craniotomyreceived remifentanil 1 µg kg^–1 followed by an infusioncommencing at 0.5 µg kg^–1 min^–1 reducing to0.25 µg kg^–1 min^–1 after craniotomy. Anaesthesiawas induced with propofol, and maintained with either a target-controlledinfusion of propofol, minimum target 2 µg ml^–1 orsevoflurane, initial concentration 2%_ET. Episodes of mean arterialpressure (MAP) more than 100 mm Hg or less than 60 mm Hg formore than 1 min were defined as hypertensive or hypotensiveevents, respectively. A surgical assessment of operating conditionsand times to spontaneous respiration, extubation, obey commandsand eye opening were recorded. Drug acquisition costs were calculated. Results. Twenty-four and twenty-six patients were assigned topropofol (Group P) and sevoflurane anaesthesia (Group S), respectively.The number of hypertensive events was comparable, whilst morehypotensive events were observed in Group S than in Group P(P=0.053, chi-squared test). As rescue therapy, more labetolol[45 (33) vs 76 (58) mg, P=0.073] and ephedrine [4.80 (2.21)vs 9.78 (5.59) mg, P=0.020] were used in Group S. Between groupdifferences in recovery times were small and clinically unimportant.The combined hourly acquisition costs of hypnotic, analgesic,and vasoactive drugs appeared to be lower in patients maintainedwith sevoflurane than with propofol. Conclusion. Propofol/remifentanil and sevoflurane/remifentanilboth provided satisfactory anaesthesia for intracranial surgery.     

Hodgkin's disease primarily localized to the brain

Summary A case of primary Hodgkin's paragranuloma of the brain is described. The benignancy of the lesion is shown both by the microscopical appearance and by the clinical course of the disease. It seems that this is the first case of intracranial Hodgkin's paragranuloma to be described, and that all forms of the disease can affect the brain. The possible origin of the tumour is discussed.     

Frontal sinus complications after frontal craniotomy

OBJECTIVES: To review frontal sinus complications following frontal craniotomy and to describe management strategies. STUDY DESIGN: Retrospective review. METHODS: Retrospective review was made of six patients who had undergone frontal craniotomy and subsequently developed frontal sinus complications. Demographic data, indication for craniotomy, type of reconstruction, average time to development of complications, presenting symptoms, diagnosis, surgical management, follow-up, and outcomes were reported. RESULTS: Complications included unilateral frontal sinus mucoceles in four patients, bilateral frontal sinus mucoceles in one patient, and bilateral frontal sinus mucopyoceles with upper-eyelid abscess in one patient. The average time to presentation of symptoms and development of complications following frontal craniotomy was 14.8 years (range, 1-39 y). Headaches were the most common presenting complaint. All patients underwent endoscopic mucocele marsupialization as part of their management. After an average follow-up period of 9 months, no recurrences were found and no complications occurred. CONCLUSION: A small number of patients develop otolaryngological complications, most commonly, frontal mucoceles, following frontal craniotomy. A high level of suspicion and long-term surveillance are needed to monitor for their occurrence. Endoscopic marsupialization may provide an effective, safe means for management.     

新配穴法针刺麻醉在幕上脑深部及重要功能区手术中的应用

目的总结新配穴法针刺麻醉在幕上脑深部及重要功能区手术中的应用经验。方法将针刺穴位由原来的近节段取穴及手术周围取穴,调整为循经远近配穴法(即新配穴法),对23例幕上脑深部及重要功能区病变的脑肿瘤等患者进行开颅手术。结果23例患者均获得手术成功,其中达Ⅰ级甲为82．6％。在中央前后回和语言中枢等这些重要功能区病变的手术中较好地防止了对其功能的误伤。结论新配穴法针刺麻醉在幕上脑深部及重要功能区开颅手术中效果满意。在监测手术对周围正常脑功能的影响,避免对其误伤方面具有独特的优点。     

Applying circular posterior-hinged craniotomy to malignant cerebral edemas

Malignant brain edemas are often fatal, regardless of whether they are treated conservatively with sedation, blood pressure management, mannitol-therapy, hyperventilation and hypothermia, or non-conservatively with routine trepanation. Unfortunately, temporal trepanation may result in significant brain damage through herniation of the cerebrum at the edges of the trepanation openings. In one case of a 26-year-old male with severe head injury, a circular posterior-hinged craniotomy (CPHC) was performed after an ineffective unitemporal trepanation for evacuation of an acute subdural hematoma. This ultimately successful operation prompted experimental and morphologic investigations on a new surgical procedure for lowering intracranial pressure (ICP). In 12 of 15 human cadavers, an experimentally ICP was lowered by a CPHC with between 9-21 mm of frontal elevation of the calvaria. Using computer simulation, the frontal elevations of the calvaria were "virtually" performed on 3D reconstructions from CT scans of skulls, and the intracranial volume gained was measured with a computer software program. The volume increase of the cranial cavity showed a relatively constant relation to the cranial capacity and was increased by 6.0% (+/-0.4%) or 78 cm(3) with a 10 mm elevation and by 12.4% (+/-0.7%) or 160 cm(3) with a 20 mm elevation. There were no significant differences with skulls of different ages or ethnic origin; however, a significant effect of gender (F = 7.074; P < or = 0.013) on the gained volume in percent of the cranial capacity for the 20 mm elevation was observed. This difference can be explained by the inverse relationship between volume increase and cranial capacity (r = -0.507; P < or = 0.004).     

Evolution of pediatric epilepsy surgery program over 2000–2017: Improvement of care?

PurposeWe assessed trends in spectrum of candidates, diagnostic algorithm, therapeutic approach and outcome of a pediatric epilepsy surgery program between 2000 and 2017.MethodsAll pediatric patients who underwent curative epilepsy surgery in Motol Epilepsy Center during selected period (n = 233) were included in the study and divided into two groups according to time of the surgery (developing program 2000–2010: n = 86, established program 2011–2017: n = 147). Differences in presurgical, surgical and outcome variables between the groups were statistically analyzed.ResultsA total of 264 resections or hemispheric disconnections were performed (including 31 reoperations). In the later epoch median age of candidates decreased. Median duration of disease shortened in patients with temporal lobe epilepsy. Number of patients with non-localizing MRI findings (subtle or multiple lesions) rose, as well as those with epileptogenic zone adjacent to eloquent cortex. There was a trend towards one-step procedures guided by multimodal neuroimaging and intraoperative electrophysiology; long-term invasive EEG was performed in fewer patients. Subdural electrodes for long-term invasive monitoring were almost completely replaced by stereo-EEG. The number of focal resections and hemispherotomies rose over time. Surgeries were more often regarded complete. Histopathological findings of resected tissue documented developing spectrum of candidates. 82.0% of all children were seizure-free two years after surgery; major complications occurred in 4.6% procedures; both groups did not significantly differ in these parameters.ConclusionIn the established pediatric epilepsy surgery program, our patients underwent epilepsy surgery at younger age and suffered from more complex structural pathology. Outcomes and including complication rate remained stable.