重型颅脑外伤术后并发脑梗塞

目的探讨影响重型颅脑外伤术后并发脑梗塞的相关因素及防治方法。方法总结1990年1月至2002年1月收治的64例颅脑外伤术后并发脑梗塞的临床经验。结果出院时按GOS评价：良好43例，中残10例，曹残6例，植物2例；死亡3例。结论正确认识重型颅脑外伤术后并发脑梗塞的发生原凶、及时手术、术后正确地治疗．可有效地减少和减轻术后脑梗塞的发生，提高生存质量。     

外伤性脑梗死与凝血功能障碍的关系及其对中、重度颅脑损伤患者预后的影响

目的探讨早期（伤后1周）外伤性脑梗死与凝血功能异常的关系,及其对中、重度颅脑损伤患者预后的影响。方法回顾性分析我科收治的218例中、重度颅脑损伤患者的临床资料,记录患者凝血功能各项指标以及入院时GCS评分、弥漫性血管内凝血（DIC）评分;伤后3个月采用GOS评分评估患者预后;使用Logistic回归分析颅脑损伤患者继发外伤性脑梗死的影响因素及凝血功能异常和外伤性脑梗死对患者预后的影响。结果本组患者中27例伤后1周出现外伤性脑梗死;伤后3个月,预后良好（GOS评分4~5分）178例,预后不良（GOS评分1~3分）40例。Logistic回归分析显示血小板计数〈100×109/L、凝血酶原时间延长超过3 s、D-二聚体〉0.4 mg/L、DIC评分≥5分是中、重度颅脑损伤患者继发早期PTCI的独立预测因子（P〈0.05）;同时,它们也是中、重度颅脑损伤患者预后不良的独立预测指标（P〈0.05）。结论监测中重度颅脑外伤患者的凝血功能对于指导治疗及判断预后是帮助。     

急性重型颅脑创伤患者脑组织、血清蛋白质组分析

目的评价急性重度颅脑创伤患者脑组织、血清同时筛选损伤标记物的意义；对比出两种组织之间相同的差异蛋白质，以直接利用血清中的蛋白质来评估颅脑损伤。方法应用表面加强激光解析电离时间飞行质谱技术比较创伤组和对照组皮层组织之间、血清之间蛋白质的差异表达，筛选出血清、脑组织之间相同的差异蛋白质。结果每例患者脑组织、血清之间比较出13—39个相同差异蛋白质峰。创伤组脑组织、血清之间比较出8个相同差异蛋白质峰：m／z3178、m／z3412、m／z4201、m／z4692、m／z8605、m／z8676、m／z9387、m／z9607。结论脑组织、血清同时筛选差异蛋白质，发挥出两种组织各自对比的优势，克服彼此的缺点，为直接利用血清中的差异性蛋白质评估颅脑损伤奠定了实验基础。     

过度通气对重型颅脑创伤病人的脑血流和脑组织氧分压的影响

目的研究过度通气(HV)对重型颅脑创伤(sTBI)病人的颅内压(ICP)、脑血流(CBF)和脑组织氧分压(PbtO2)的影响。方法20例sTBI(GCS3～8分)病人,伤后2～5dICP超过20mmHg时,应用机械通气法使呼气末二氧化碳分压(PetCO2)维持在27～32mmHg之间30min,同时连续监测ICP、CBF和PbtO2。结果所有病人共进行了46次HV,HV可使ICP明显下降(43/46),而CBF和PbtO2对CO2的反应差异较大,其中大部分试验(38/46)CBF和PbtO2明显下降,但仍然保持在各自的缺血阈值(50AU和10mmHg)之上;5次试验CBF和PbtO2下降低于各自的缺血阈值;3次试验ICP无明显变化,CBF轻度升高,而PbtO2下降。结论HV可降低ICP,但有导致或加重脑缺血的危险,应尽量避免早期长时程应用。HV应在CBF持续监测下应用。     

Increased intracranial pressure is associated with the development of acute lung injury following severe traumatic brain injury

Objective

This study investigated the relationship among intracranial pressure (ICP), the development of acute lung injury (ALI) and systemic inflammatory response syndrome (SIRS) following a severe traumatic brain injury (TBI).

Methods

Post-traumatic ICP was continuously monitored for the first week following injury in a series of consecutive patients with isolated severe TBI. The initial ICP and the duration of intracranial hypertension (ICH) were calculated. The risk factors associated with the development of ALI and SIRS were evaluated.

Results

Of the 86 patients enrolled, 22 patients developed ALI and 52 patients developed SIRS during the observation period. The patients with ALI presented with a significantly higher initial ICP (31.3 ± 7.8 mmHg vs. 23.0 ± 8.8 mmHg, p < 0.001) and a longer duration of ICH (16.8 ± 6.5 h vs. 11.9 ± 6.0 h, p = 0.002) than those without ALI. The incidence of both ALI and SIRS increased with increasing initial ICP, and the presence of SIRS was associated with a fourfold increase in the risk of developing ALI (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.2–13.0).

Conclusions

Increased ICP is associated with increased risks of developing ALI and SIRS following severe TBI. Future studies designed to verify the causative relationship between increased ICP and the systemic responses are warranted.     

重型颅脑损伤与继发性脑梗死的预防及治疗

目的分析重型颅脑损伤继发脑梗死的原因，探讨重型颅脑损伤继发脑梗死的预防及治疗。方法回顾我院1996～2004年收治的重型颅脑损伤病人在救治中继发脑梗死的临床特点及预后。结果480例重型颅脑损伤的病人继发脑梗死42例．继发脑梗死的发生率占8．8％，其中成人组432例发生脑梗死34例，占7．9％；儿童组病例48例，发生继发脑梗死8例，占17％。儿童组病例继发脑梗死的例数明显高于成人组。结论重型颅脑损伤病人由于脑损伤的病理生理过程继发脑梗死外，在治疗过程中一些治疗因素也可引发脑梗死。脑梗死的发生加重脑组织的损伤，影响预后。     

重型颅脑损伤术中急性脑膨出治疗体会

目的探讨影响重型颅脑损伤开颅术中急性脑膨出的原因及有效防止措施。方法回顾分析我院2009-01—2010-12收治的12例重型颅脑损伤术中急性脑膨出采取新处理方法的病例资料作为研究组,同时选择2007-01—2008-12收治的9例重型颅脑损伤术中急性脑膨出病例资料作为对照组,分析2组的疗效。结果研究组恢复较好5例,重残5例,死亡2例;对照组恢复较好1例,重残3例,死亡5例。2组比较差异有统计学意义(P<0.05)。结论重型颅脑损伤术中发生急性脑膨出,要排除迟发颅内血肿后采取控制降压、过度换气、脑室引流、切除颞叶脑组织等综合措施,能够明显提高治疗效果,降低致残率和病死率。     

急性重型脑外伤后脑蛋白表达变化的蛋白质组研究

目的应用蛋白质组学技术，研究重型人脑外伤后的脑皮层蛋白质组表达变化的情况。方法提取脑挫伤部位皮层的总蛋白。通过双向电泳，分离蛋白。应用胶内酶切、生物质谱，鉴定由图像分析软件所得出的具有表达差异的蛋白质点。结果在急性期8h内，目前已发现138个蛋白质点，表达水平具有显著性差异变化。在已鉴定出的83个蛋白点中，属于64种蛋白质。依其功能可分为：细胞骨架、代谢反应、核酸蛋白合成与更新、信号传导、氧化应激反应、功能未知等几类。在急性期，大多数差异蛋白表达水平呈波动变化。结论蛋白质组技术作为一个有力的大规模、高通量的分析蛋白质混合物工具，可快速的建立脑蛋白表达谱。在急性期，脑蛋白质表达呈剧烈变化主要为参与细胞代谢反应、结构修复等组织代偿反应。     

Noninvasive selective brain cooling by head and neck cooling is protective in severe traumatic brain injury

Therapeutic hypothermia is a promising treatment for patients with severe traumatic brain injury (TBI). We present here the results of a study in which noninvasive selective brain cooling (SBC) was achieved using a head cap and neckband. Ninety patients with severe TBI were divided into a normothermia control group (n=45) and a SBC group (n=45), whose brain temperature was maintained at 33-35 degrees C for 3 days using a combination of head and neck cooling. At 24, 48 and 72h after injury, the mean intracranial pressure (ICP) values of the patients who underwent SBC were lower than those of the normothermia controls (19.14+/-2.33, 19.72+/-1.73 and 17.29+/-2.07 mmHg, versus 23.41+/-2.51, 20.97+/-1.86, and 20.13+/-1.87 mmHg, respectively, P<0.01). There was a significant difference in the neurological recovery of the two groups at the 6-month follow-up after TBI. Good neurological outcome (Glasgow Outcome Scale score of 4 to 5) rates 6 months after injury were 68.9% for the SBC group, and 46.7% for the control group (P<0.05). There were no complications resulting in severe sequelae. In conclusion, the noninvasive SBC described here is a safe method of administering therapeutic hypothermia, which can reduce ICP and improve prognosis without severe complications in patients with severe TBI.     

Clinicoradiological and therapeutic considerations in severe diffuse traumatic brain injury in children

Forty-one children with severe head injuries and diffuse brain lesions were selected from a consecutive series of 62 children in traumatic coma (21 focal mass lesions) and studied. According to the CT pattern, two main types of intracranial lesions were considered: diffuse axonal injury (DAI) and diffuse brain swelling (DBS). High mortality, due to secondary increases of intracranial pressure (ICP), correlated well with the patterns of severe DBS, absence of perimesencephalic cisterns, and obliteration of the ventricles. However, children with normal CTs, and/or obvious shearing injuries indicative of DAI, had favorable outcomes; there was no mortality if increased ICP was not present. We conclude that although there does not seem to be any routine indications for ICP monitoring in children with pure DAI, early ICP monitoring and aggressive management of increasing ICP should be considered in comatose children with DBS, especially when associated with subarachnoid hemorrage and respiratory or circulatory failure.Presented at the 11th Meeting of the European Society for Paediatric Neurosurgery, Naples 1988     

Rehabilitation and follow-up of children with severe traumatic brain injury

We studied the outcome of 25 patients [12 girls and 13 boys; mean age 13.7 (SD 3.9 years)] with severe traumatic brain injury (TBI). The Glasgow Coma Scale (GCS) score 6 h after the injury was (mean) 4.5 (SD 2.7), and the mean duration of unconsciousness was 15.8 (SD 10.6) days. Being the most severely brain-injured children in the health care region, they were all referred to its only regional pediatric rehabilitation center during 1986–1990. At discharge, 1 patient was healthy, 1 was in a vegetative state and 18 had multiple impairments. Motor problems were present in 22, epilepsy in 7 and speech impairment in 14. It was not possible to assess cognition in 3 of the children, and 15 of the remaining 22 fell in the normal range. At follow up 2–6 years after trauma, all 23 survivors reported at least one sequela, and 21 had multiple sequelae. As many as two-thirds had normal I.Q. and only 3 were non-ambulatory, but behavioral and personality disturbances were so disabling that none of the patients in this group had been able to readjust to a normal life in society after the trauma.     

重型颅脑损伤术中持续脑灌注压监测的意义

目的 探讨重型颅脑损伤(sTBI)患者术中持续脑灌注压(CPP)监测的意义.方法 解放军第一○一医院2009年6月至2011年12月收治的63例sTBI患者根据预后情况分为较好(GOS 4～5分)及较差(GOS 1～3分)两组,对两组患者术中CPP、平均动脉压(MAP)及颅内压(ICP)的变化进行相关性分析.结果 两组间ICP、CPP总体差异有统计学意义(P＜0.05),而两组间MAP总体差异无统计学意义(P＞0.05)；各组内ICP、MAP及CPP在不同时间点变化的差异有统计学意义(P＜0.05)；两组间ICP、MAP及CPP在不同时间点变化的差异有统计学意义(P＜0.05).结论 术中持续CPP监测有助于术者及时判断和处理术中出现的病情变化,对改善sTBI患者的预后可能有着积极的临床意义.     

亚低温对重型颅脑创伤合并急性创伤性凝血病影响的临床研究

目的 研究亚低温对重型颅脑创伤(sTBI)合并急性创伤性凝血病(ATC)患者的影响及其临床意义.方法 83例sTBI合并AT℃患者随机分为亚低温治疗组42例、常规治疗组(对照组)41例.亚低温治疗组均于伤后24h内接受亚低温治疗.分别测量两组患者不同时间点的凝血酶原时间(PT)、部分凝血酶原时间(APTT)、凝血时间(TT)、纤维蛋白原(FIB)及D-二聚体水平,同时监测患者颅内压(ICP)以及生命体征、血气、血电解质及动脉血氧饱和度等,并根据GOS评估法判断预后.结果 亚低温治疗组患者PT、APTT、TT、FIB及D-二聚体与对照组相比差异无统计学意义(P＞0.05),而颅内压明显降低(P＜0.01);生命体征、血气、血电解质、动脉血氧饱和度差异无统计学意义,无严重并发症,病死率低,预后改善明显.结论 亚低温治疗不会增加sTBI合并ATC患者出现凝血障碍及纤溶亢进的风险,并且能有效地降低颅内压,具有肯定的脑保护作用,是一项安全有效的治疗措施.     

儿童外伤性脑梗死的诊断与治疗

目的分析不同类型的外伤性脑梗死患儿的治疗方案,结合文献探讨其发病机制,以提高其治愈率,降低致残率。 方法回顾性分析解放军陆军第八十一集团军医院自2015年1月至2019年12月收治的42例外伤性脑梗死患儿的临床资料。采用头颅CT扫描和MRI诊断儿童外伤性脑梗死,根据不同病情将儿童外伤性脑梗死进行诊断分型,选择不同的治疗方案。腔隙性脑梗死患儿给予钙拮抗剂和神经营养药物治疗,并辅以高压氧、运动康复治疗;局灶型脑梗死、混合型脑梗死患儿除应用钙拮抗剂和神经营养药外,还应用小剂量脱水剂和小剂量激素,并随病情演变随时调整治疗方案;大面积脑梗死的患儿,急诊行去骨瓣减压术,术后给予降颅压、预防并发症等综合治疗。观察患儿的治疗结果及恢复情况。 结果42例外伤性脑梗死患儿中,恢复良好35例（83.3%）,中残4例（9.5%）,重残2例（4.8%）,死亡1例（2.4%）,无植物生存。腔隙性脑梗死的恢复良好率为100%,局灶型脑梗死的恢复良好率为62.5%,混合型脑梗死的恢复良好率为60%,大面积脑梗死的恢复良好率为50%。 结论针对不同类型的脑梗死患儿采用不同的治疗方案,对提高儿童外伤性脑梗死的治疗效果、改善预后意义重大。     

CT测量视神经鞘直径与急性颅脑创伤开颅术后颅内压的相关研究

目的探讨急性重型颅脑创伤患者开颅术后视神经鞘直径(ONSD)与颅内压(ICP)的相互关系,评价ONSD推测ICP变化情况的效能。方法回顾性分析48例急性重型颅脑创伤患者数据,通过重建头部薄层CT来测量球后ONSD,采用有创ICP传感器监测颅内压等临床数据;患者数据按手术类型分类为开颅手术组和单纯ICP组,分别应用线性及Logistic回归分析ONSD与ICP相关性及ONSD的评价效能。结果 48例患者平均ONSD=6.6mm(SD 0.5 4),平均ICP=12mmHg(SD6.5),ONSD与ICP呈明显线性相关性,其中手术组的线性关系更加明显,AUC=0.964,cutoff=7.1 mm,敏感性=100%,特异性=8 9%,P0.0 0 1,ONSD用于推测ICP效能较高,有统计学意义;而ICP组两者间无明显线性相关性。结论急性重症颅脑创伤开颅术后患者ONSD与ICP线性关系明显,可通过ONSD是否大于7.1 mm来推测ICP20 mm Hg,为危急重症患者提供重要的参考意见。     

A longitudinal study of awareness of deficit after moderate to severe traumatic brain injury

Lack of awareness of deficits is a common problem after traumatic brain injury (TBI), and is associated with worse functional outcome and poor compliance with rehabilitation. Little is known, however, about the course of awareness of deficits after TBI. Using a longitudinal design, we examined changes in self-awareness between the subacute stage (about 45 days after injury) and one-year follow-up in a sample of 123 individuals with moderate to severe TBI. Awareness of deficits was operationalised as the discrepancy between patient and family ratings on the Awareness Questionnaire (AQ) and Patient Competency Rating Scale (PCRS). Compared to baseline, awareness was improved at one year, as evidenced by smaller discrepancy scores and stronger correlations between participant and family ratings. Changes in awareness were most pronounced for the behavioural/affective domain and least pronounced for the motor/sensory domain, which showed best agreement at baseline. Even at one year, participants rated themselves as higher functioning than did their relatives. Awareness at baseline and, for the AQ, time to follow commands, significantly predicted awareness at one year. These results suggest that awareness of deficits improves between the subacute and post-acute stages after TBI, and highlight the need for effective interventions for persons with impaired awareness and for flexible timing of rehabilitation efforts.     

重型颅脑损伤并发脑梗死的危险因素分析

目的探讨重型颅脑损伤并发脑梗死的危险因素,为临床诊治提供参考。方法回顾性分析2015年1月至2016年12月收治的符合标准的172例重型颅脑损伤的临床资料,采用多因素Logistic回归分析检验危险因素。结果 172例中,44例并发脑梗死,128例无脑梗死。多因素Logistic回归分析表明脑疝、弥漫性脑肿胀、失血性休克是重型颅脑损伤并发脑梗死的独立危险因素。结论对于伴有脑疝、弥漫性脑肿胀、失血性休克的成人重型颅脑损伤,临床应注意防止脑梗死。     

MRI appearance of a cerebral cavernous malformation in the caudate nucleus before and after chorea onset

Movement disorders associated with cerebral cavernous malformations (CM) are seldom reported, and chorea, in particular, is rarely associated with a CM located in the caudate nucleus. Here we report a 78-year-old female patient with chorea, who presented with choreiform movements due to a CM in the contralateral caudate nucleus. A brain MRI was obtained and compared with that obtained before the onset of chorea. The new images did not reveal further extralesional hemorrhage from the CM when compared with the previous images. The choreiform movements showed spontaneous improvement and then disappeared completely. We reviewed previous reports of patients with chorea associated with a CM, and conclude that CM located in the caudate nucleus can cause chorea.     

Effect of progesterone administration on prognosis of patients with diffuse axonal injury due to severe head trauma

Objective

Severe traumatic brain injury (TBI) has a major role in mortality rate among the other types of trauma. The aim of this clinical study was to assess the effect of progesterone on the improvement of neurologic outcome in patients with acute severe TBI.

Methods

A total of 76 patients who had arrived within 8 h of injury with a Glasgow Coma Score ≤8 were enrolled in the study. In a randomized style 38 received progesterone (1 mg/kg per 12 h for 5 days) and 38 did not.

Results

There was a better recovery rate and GOS score for the patients who were given progesterone than for those in the control group in a 3-months follow-up period (50% vs. 21%); subgroup analysis showed a significant difference in the percentage of favorable outcome between the two groups with GCS of 5–8 (p = 0.03).

Conclusion

The use of progesterone may significantly improve neurologic outcome of patients suffering severe TBI up to 3 months after injury, especially those with 5 ≤ GCS ≤ 8, providing a potential benefit to the treatment of acute severe TBI patients. Considering this drug had no significant side effects, so progesterone could be used in patients with severe TBI as a neuro-protective drug.     

重视对重型颅脑损伤后沉默的30%的研究和治疗

颅脑损伤大多数为轻型伤与中型伤。伤后过程,轻型伤无颅骨骨折者约有0.2%~0.7%的患者加重;有颅骨骨折者3.2%~10%病情转恶化。中型伤有一部分脑挫裂伤患者,数日内出现迟发性颅内血肿。这两类患者如有明显症状,宜住院观察治疗避免发生意外。重型颅脑损伤约占颅脑伤的20%,死亡率很高,是救治的重点。颅脑创伤患者的死亡率下降了50个百分点,具有明显的进步。另外一个有意思的发现是1885~1930年,颅脑创伤死亡率以每10年3个百分点的速度下降,而在1930~1970年期间死亡率无明显增减,1970~1990年出现了死亡率的迅速下降,达到了平均每10年9.2个百分点,而1990~2006年间颅脑创伤死亡率再次出现了平台期,约占病例总数的30%。可以很明显地看到脑外伤死亡率的两次明显下降之后又处在平台期。分析了这种变化趋势背后所采取的救治策略的价值,提出未来应该重视对于救治这沉默的30%颅脑创伤死亡患者的研究和治疗。