亚低温治疗重型颅脑损伤后脑血管痉挛的疗效观察

目的:探讨亚低温对重型颅脑损伤后脑血管痉挛的影响.方法:36例重型颅脑损伤患者(GCS≤8分)随机分为对照组和治疗组各18例.用脑循环动力检测仪检测伤后0,1,3,7,14,21 d的脑循环动力学参数.对照组维持正常体温,治疗组4～8 h将肛温降至33℃左右,维持3～5 d.分析比较2组脑循环动力学参数变化规律和预后不良(GOS<3分)率.同期选择24例正常人检测其脑循环动力学参数,作为正常组.结果:(1)与正常组比较,对照组伤后脑循环动力学参数可划分为4个期,而治疗组仅表现出3个期.对照组和治疗组脑循环动力学参数出现脑血管痉挛变化分别为8例(44.4%)和2例(11.1%),2组比较差异有统计学意义(P<0.05),初步得出脑循环动力学参数诊断外伤性脑血管痉挛的参考值.(2)随防3个月时,对照组预后不良率为61.1%(11/18),治疗组为33.3%(6/18),2组比较差异无统计学意义(P>0.05);随防3年后,对照组预后不良率为55.6%(10/18),治疗组为22.2%(4/18),2组比较差异有统计学意义(P<0.05).结论:亚低温通过稳定重型颅脑损伤后脑循环功能,减少脑血管痉挛发生率,从而改善远期预后.     

探究亚低温脑保护对创伤性颅脑损伤的治疗效果

目的探究亚低温脑保护对创伤性颅脑损伤的治疗效果。方法选取重庆市红十字会医院神经外科收治的创伤性颅脑损伤患者86例,分为两组,其中对照组37例,术后给予患者脱水剂、脑保护剂等常规治疗;试验组49例,在常规治疗的基础上加用亚低温脑保护治疗。比较治疗前后患者血压、水肿带等情况。结果治疗后两组患者的血压、水肿带均有所改善,与对照组相比,试验组的血压、水肿带改善明显,差异有统计学意义(P0.05)。结论亚低温脑保护能降低创伤性颅脑损伤患者的血压,减少患者水肿带,值得临床推广应用。     

Therapeutic hypothermia in traumatic brain injury

Traumatic brain injury is a leading cause of death by trauma in adults in the United States and a major contributor to permanent physical, emotional, and psychological disabilities. Therapeutic hypothermia, defined as cooling of the body to less than 36 degrees C, has been shown to decrease mortality and morbidity and improve long-term outcomes by protecting the brain from secondary brain injury. The most commonly seen benefits of hypothermic temperatures of 32 degrees C to 33 degrees C are a significant reduction in intracranial hypertension and improved cerebral perfusion and oxygenation. Although evidence to date is insufficient to recommend the routine use of therapeutic hypothermia outside of the research setting, therapeutic hypothermia is used in multiple healthcare facilities in the world. The following article will define hypothermia and provide critical information necessary to provide care for the critically ill patient under therapeutic hypothermia. It will define the processes of brain injury and how hypothermia is thought to counteract those to protect the brain. Also included is a review of 2 major randomized, controlled trials of hypothermia for traumatic brain injury that have been instrumental in establishing guidelines and directing further research.     

Depressive symptomatology after mild-to-moderate traumatic brain injury: a comparison of three measures

Measurement of posttraumatic brain injury depression is problematic. Disagreement exists about the best screening measure, and symptoms of brain injury often overlap those of depression. In an outpatient sample of 75 persons, we compared aspects of Criterion A of the Diagnostic and Statistical Manual of Mental Disorders--Fourth Revision, Text Revision (2000), with three depression subscales: the Neurobehavioral Functioning (NFI-D), Profile of Moods State (POMS-D), and Center for Epidemiologic Studies (CES-D). Nearly 40% of this outpatient sample had significant levels of depressive symptoms. All measures were internally consistent, reliable, and highly correlated. For persons with mild-to-moderate traumatic brain injury, the CES-D was the best screening instrument because of its ease in administration, sensitivity in detecting probable major depressive disorders, its established categories of severity, and its comprehensiveness. Further effort in the establishment of depression severity categories using the NFI-D is needed.     

重型颅脑损伤患者开颅术后亚低温治疗作用的研究

目的研究重型颅脑损伤患者开颅术后亚低温治疗的作用。方法80例重型颅脑损伤患者开颅术后被随机分成两组：脑亚低温组（A组）和常温组（B组）。利用亚低温治疗仪,对控制目标温度在脑温33—35℃,亚低温治疗4d后自然复温。具有相似性质病例的B组,使用亚低温外的常规治疗。监测两组病例的生命体征、颅内压、静脉血超氧化物歧化酶（SOD）含量、GOS评分及并发症,进行分析。结果（1）两组在24、48、72h的平均颅内压分别为（23．49±2．38）mmHg、（24．68±1．71）mmHg、（22．51±2．44）mmHg和（25．87±2．18）mmHg、（25．90±1．86）mmHg、（24．57±3．95）mmHg,前者较后者降低（P分别为0．000,0．0130及0．003）;（2）两组在3d和7d的平均SOD含量分别为（533．0±103．4）μg/L、（600．5±82．9）μg/L和（458．7±68．1）μg/L、（497．0±57．3）μg/L,前者较后者明显升高（P=0．000）;（3）1年后两组恢复良好率（GOS评分）分别为70．0％和47．5％,（P=0．041）。两组并发症的发生率（包括肺部感染）分别为57．5％和32．5％（P=0．025）,处理后未见严重后果发生。结论亚低温治疗为重型颅脑损伤患者开颅术后的一种安全有效的治疗措施。     

Effects of therapeutic mild hypothermia on patients with severe traumatic brain injury after craniotomy

PURPOSE: We investigated the effects of therapeutic mild hypothermia on patients with severe traumatic brain injury after craniotomy (TBI). METHODS: Eighty patients with severe TBI after unilateral craniotomy were randomized into a therapeutic hypothermia group with the brain temperature maintained at 33 degrees C to 35 degrees C for 4 days, and a normothermia control group in the intensive care unit. Vital signs, intracranial pressure, serum superoxide dismutase level, Glasgow Outcome Scale scores, and complications were prospectively analyzed. RESULTS: The mean intracranial pressure values of the therapeutic hypothermia group at 24, 48, and 72 hours after injury were much lower than those of the control group (23.49 +/- 2.38, 24.68 +/- 1.71, and 22.51 +/- 2.44 vs 25.87 +/- 2.18, 25.90 +/- 1.86, and 24.57 +/- 3.95 mm Hg; P = .000, .000, and .003, respectively). The mean serum superoxide dismutase levels of the therapeutic hypothermia group at days 3 and 7 were much higher than those of the control group at the same time point (533.0 +/- 103.4 and 600.5 +/- 82.9 vs 458.7 +/- 68.1 and 497.0 +/- 57.3 mug/L, respectively; P = .000). The percentage of favorable neurologic outcome 1 year after injury was 70.0% and 47.5%, respectively (P = .041). Complications, including pulmonary infections (57.5% in the therapeutic hypothermia group vs 32.5% in the control group; P = .025) were managed without severe sequelae. CONCLUSIONS: Therapeutic mild hypothermia provides a promising way in the intensive care unit for patients with severe TBI after craniotomy.     

Cognitive and vocational rehabilitation after mild-to-moderate traumatic brain injury: A randomised controlled trial

BackgroundReturning to work is often a primary rehabilitation goal after traumatic brain injury (TBI). However, the evidence base for treatment options regarding return to work (RTW) and stable work maintenance remains scarce.ObjectiveThis study aimed to examine the effect of a combined cognitive and vocational intervention on work-related outcomes after mild-to-moderate TBI.MethodsIn this study, we compared 6 months of a combined compensatory cognitive training and supported employment (CCT-SE) intervention with 6 months of treatment as usual (TAU) in a randomised controlled trial to examine the effect on time to RTW, work percentage, hours worked per week and work stability. Eligible patients were those with mild-to-moderate TBI who were employed ≥ 50% at the time of injury, 18 to 60 years old and sick-listed ≥ 50% at 8 to 12 weeks after injury due to post-concussion symptoms, assessed by the Rivermead Post Concussion Symptoms Questionnaire. Both treatments were provided at the outpatient TBI department at Oslo University Hospital, and follow-ups were conducted at 3, 6 and 12 months after inclusion.ResultsWe included 116 individuals, 60 randomised to CCT-SE and 56 to TAU. The groups did not differ in characteristics at the 12-month follow-up. Overall, a high proportion had returned to work at 12 months (CCT-SE, 90%; TAU, 84%, P = 0.40), and all except 3 were stably employed after the RTW. However, a significantly higher proportion of participants in the CCT-SE than TAU group had returned to stable employment at 3 months (81% vs. 60%, P = 0.02).ConclusionThese results suggest that the CCT-SE intervention might help patients with mild-to-moderate TBI who are still sick-listed 8 to 12 weeks after injury in an earlier return to stable employment. However, the results should be replicated and a cost-benefit analysis performed before concluding.     

亚低温辅助治疗重型颅脑外伤患者82例

目的探讨亚低温在治疗重型颅脑外伤中的应用价值。方法对连续收治的160例重型颅脑外伤患者,随机分为亚低温治疗组（n=82）和常温组（n=78）,观察两组的治疗效果。结果随访6个月,亚低温组20例轻度残疾、正常生活,24例中残,16例重残,9例植物生存,13例死亡;对照组10例轻度残疾、正常生活,18例中残,16例重残,14例植物生存,20例死亡;两组比较有统计学差异（P〈0．05）,亚低温组的治疗效果优于常温组。结论亚低温有显著的脑保护作用,能降低重型颅脑外伤患者的死残率,改善预后。     

创伤性脑损伤后继发脑萎缩CT动态分析

目的探讨创伤性脑损伤(TBI)后继发的脑容量改变、脑萎缩CT表现特征和治疗效果。方法回顾性分析127例轻中度(GCS≥9)TBI患者伤后1年内动态CT,利用脑容积计算机自动定量检测法,测定脑实质容量分数(VBP)变化,并对29例脑室扩大患者进行脑室-腹腔分流手术。与正常人群29例的CT表现比较。结果TBI组两个时间点患者的VBP变化显著大于对照组,分别为(-5.19±1.78)%和(-1.18±1.62)%,P=0.022。脑萎缩CT表现为脑室扩大而脑室周围无低密度区,脑室扩大分流术前后脑实质容量变化差异无显著性意义(P>0.05)。结论轻中度脑损伤后脑萎缩发生率增高,发生的脑萎缩为全脑性的,手术治疗对脑实质容量和神经功能障碍改善的效果不佳。     

Moderate hypothermia may be detrimental after traumatic brain injury in fentanyl-anesthetized rats

OBJECTIVES: To determine whether transient, moderate hypothermia is beneficial after traumatic brain injury in fentanyl-anesthetized rats. DESIGN: Prospective, randomized study. SETTING: University-based animal research facility. SUBJECTS: Adult male Sprague-Dawley rats. INTERVENTIONS: All rats were intubated, mechanically ventilated, and anesthetized with fentanyl (10 microg/kg intravenous bolus and then 50 microg.kg(-1).hr(-1) infusion). Controlled cortical impact was performed to the left parietal cortex, followed immediately by 1 hr of either normothermia (brain temperature 37 +/- 0.5 degrees C) or hypothermia (brain temperature 32 +/- 0.5 degrees C). Hypothermic rats were rewarmed gradually over 1 hr. Fentanyl anesthesia and mechanical ventilation were continued in both groups until the end of rewarming (2 hrs after traumatic brain injury). MEASUREMENTS AND MAIN RESULTS: Histologic assessment performed 72 hrs after traumatic brain injury was the primary outcome variable. Secondary outcome variables were physiologic variables monitored during the first 2 hrs after traumatic brain injury and plasma catecholamine and serum fentanyl concentrations measured at the end of both hypothermia and rewarming (1 and 2 hrs after traumatic brain injury). Contusion volume was larger in hypothermic vs. normothermic rats (44.3 +/- 4.2 vs. 28.6 +/- 4.0 mm, p <.05), but hippocampal neuronal survival did not differ between groups. Physiologic variables did not differ between groups. Plasma dopamine and norepinephrine concentrations were increased at the end of hypothermia in hypothermic (vs. normothermic) rats (p <.05), indicating that hypothermia augmented the systemic stress response. Similarly, serum fentanyl concentrations were higher in hypothermic (vs. normothermic) rats at the end of both hypothermia and rewarming (p <.05), demonstrating that hypothermia reduced the clearance and/or metabolism of fentanyl. CONCLUSIONS: Moderate hypothermia was detrimental after experimental traumatic brain injury in fentanyl-anesthetized rats. Since treatment with hypothermia has provided reliable benefit in experimental traumatic brain injury with inhalational anesthetics, these results indicate that the choice of anesthesia/analgesia after traumatic brain injury may dramatically influence response to other therapeutic interventions, such as hypothermia. Given that narcotics commonly are administered to patients after severe traumatic brain injury, this study may have clinical implications.     

局灶亚低温对创伤性脑损伤后大鼠脑组织炎症反应的影响

目的 观察创伤性脑损伤后早期应用局灶亚低温治疗对脑组织炎症反应的影响,探讨其治疗创伤性脑损伤的机制.方法 采用自由落体撞击模型,63只雄性Sprague Dawley大鼠随机分为对照组、颅脑外伤组及局灶亚低温组(使用25℃水降温),每组再根据伤后不同生存时间随机分为3个亚组(每组7只).取伤灶脑组织检测髓过氧化物酶(MPO)活性,做细胞间黏附分子-1(ICAM-1)免疫组化染色,光镜下计数ICAM-1阳性血管数.数据的统计采用SPSS 10.0软件行SNK-q检验.结果 局灶亚低温组各时间点伤灶区ICAM-1阳性血管数均明显低于颅脑外伤组相应时间点(P<0.01).局灶亚低温组各时间点MPO活性均明显低于颅脑外伤组相应时问点(P<0.01).结论 局灶亚低温可减少伤灶区ICAM-1的表达及中性粒细胞浸润,这可能是其治疗创伤性脑损伤的机制之一.     

No long-term benefit from hypothermia after severe traumatic brain injury with secondary insult in rats

OBJECTIVES: To evaluate the effect of application of transient, moderate hypothermia on outcome after experimental traumatic brain injury (TBI) with a secondary hypoxemic insult. DESIGN: Prospective, randomized study. SETTING: University-based animal research facility. SUBJECTS: Male Sprague-Dawley rats. INTERVENTIONS: All rats were subjected to severe TBI followed by 30 mins of moderate hypoxemia, associated with mild hypotension. Rats were randomized to three groups: a) normothermia (37 degrees C + 0.5 degrees C); b) immediate hypothermia (32 degrees C +/- 0.5 degrees C initiated after trauma, before hypoxemia); and c) delayed hypothermia (32 degrees C +/- 0.5 degrees C after hypoxemia). The brain temperature was controlled for 4 hrs after TBI and hypoxemia. MEASUREMENTS AND MAIN RESULTS: Animals were evaluated after TBI for motor and cognitive performance using beam balance (days 1-5 after TBI), beam walking (days 1-5 after TBI), and Morris Water Maze (days 14-18 after TBI) assessments. On day 21 after TBI, rats were perfused with paraformaldehyde and brains were histologically evaluated for lesion volume and hippocampal neuron counts. All three groups showed marked deficits in beam balance, beam walking, and Morris Water Maze performance. However, these deficits did not differ between groups. There was no difference in lesion volume between groups. All animals had significant hippocampal neuronal loss on the side ipsilateral to injury, but this loss was similar between groups. CONCLUSIONS: In this rat model of severe TBI with secondary insult, moderate hypothermia for 4 hrs posttrauma failed to improve motor function, cognitive function, lesion volume or hippocampal neuronal survival. Combination therapies may be necessary in this difficult setting.     

Tissue oxygen reactivity and cerebral autoregulation after severe traumatic brain injury

OBJECTIVE: To study the relationship between arterial blood pressure, intracranial pressure, directly measured brain tissue oxygenation (PtiO2), and middle cerebral artery blood flow velocity in severely head-injured patients. DESIGN: Prospective study. SETTING: Neurosurgical intensive care unit.PATIENTS A total of 14 patients with severe head injury. INTERVENTIONS: Pharmacologic blood pressure manipulations using norepinephrine. MEASUREMENTS AND MAIN RESULTS: We assessed the magnitude of PtiO2 related to changes in cerebral perfusion pressure in 12 of the patients. We calculated in all the static rate of regulation, which is an index to describe the change of cerebrovascular resistance, using cerebral artery blood flow velocity in relation to changing cerebral perfusion pressure. Finally, we calculated the rate of change in PtiO2, which quantifies the percentage of change in PtiO2 divided by the percentage of change in cerebral perfusion pressure. It is a new marker for cerebral tissue oxygen regulation based on direct measurement of PtiO2. There was a plateau phase for the cerebral perfusion pressure-PtiO2 relation that was similar to the autoregulatory plateau seen in the relationship between cerebral perfusion pressure and cerebral artery blood flow velocity. The rate of change in PtiO2 demonstrated a significant correlation with the static rate of regulation (R = -.61, <.05). A decrease in intracranial pressure when arterial blood pressure increased from 70 to 90 mm Hg was strongly correlated with static rate of regulation (R =.79, <.001). CONCLUSIONS Cerebral tissue PO2 demonstrates a plateau phase similar to what is known about cerebral blood flow velocity, which suggests a close link between cerebral blood flow and oxygenation. Static cerebral autoregulation is significantly correlated with cerebral tissue oxygen reactivity.     

脑外伤后持续性植物状态的研究现状

持续性植物状态 ( Persistent Vegetative State, PVS) 是指一种持续觉醒而无意识状态 , 目前各国间对 PVS的诊断标准尚未达到统一 . PVS以脑外伤最为多见 , 其主要病理表现为弥漫性轴索损害、脑皮层弥漫性坏死及选择性丘脑坏死 . 正电子发射型计算机断层显像是目前检查 PVS最有意义的方法 . PVS目前没有确切有效的治疗方法 , 脑外伤后 PVS较其他原因的 PVS预后好 .     

头部亚低温干预对大鼠缺血脑组织保护作用的实验研究

目的研究脑缺血后即时亚低温干预对脑缺血损伤的影响。 方法将48只SD大鼠随机分为假手术组（8只）、常温（37～38℃）脑缺血组（8只）和亚低温（33～34℃）脑缺血组（32只）,后者又根据亚低温持续作用时间细分为4个亚组（n=8）。将常温脑缺血组和亚低温脑缺血组大鼠制成全脑缺血20 min、再灌注240 min模型。亚低温脑缺血组大鼠于脑缺血20 min时给予亚低温治疗,4个亚组亚低温持续作用时间分别为30,60,120,240 min。于脑缺血再灌注240 min后检查上述各组大鼠脑组织中一氧化氮（NO）代谢产物亚硝酸盐（NO2）、内皮素-1（ET1）、肿瘤坏死因子-α（TNF-α）和白细胞介素-1β含量;同时对各组大鼠血液中乳酸脱氢酶（LDH）、肌酸激酶（CK）和天门冬氨酸氨基转移酶（AST）及肌酸激酶脑型同工酶（CK-BB）水平进行检测。 结果常温脑缺血组大鼠脑组织中ET1、NO2、TNF-α和IL-1β水平均明显高于假手术组（P<0.01）;亚低温持续作用30 min对脑缺血组织中ET1、NO2、TNF-α和IL-1β含量无明显影响（P&rt;0.05）;亚低温持续作用60～240 min可显著降低脑缺血组织中ET1、NO2、TNF-α和IL-1β水平（P<0.05或0.01）。常温脑缺血组大鼠血液中LDH、AST、CK和CK-BB水平均明显高于假手术组（P<0.01）;亚低温持续作用60～240 min可显著减少脑缺血大鼠血液中LDH、AST、CK和CK-BB含量（P<0.05或0.01）。 结论脑缺血后即时亚低温干预能明显减轻脑缺血损伤,亚低温持续作用时间以超过1 h为宜。     

颅脑损伤术后发生脑梗死的相关高危因素探讨

目的探讨颅脑损伤术后患者发生脑梗死的相关高危因素。方法选取2010年6月至2014年6月收治的颅脑损伤术后的800例患者为研究对象,对患者的年龄、性别、格拉斯哥昏迷评分(GCS)、脑血管痉挛、是否并发脑疝、脑挫裂伤、糖尿病、入院时血压等临床资料进行回顾性分析。采用描述性统计和Logistic回归分析颅脑损伤术后患者发生脑梗死的影响因素。结果 800例临床资料完整的颅脑损伤术后发生脑梗死的患者有45例,发生率为5.63%,死亡2例,病死率为4.44%,年龄、GCS评分、脑血管痉挛、并发脑疝、脑挫裂伤、糖尿病及低血压这7个因素经统计学检验差异有统计学意义(P0.05);经多因素Logistic回归分析发现颅脑损伤术后患者发生脑梗死与低龄、低GCS、低收缩压、脑血管痉挛、并发脑疝、脑损伤类型中的脑挫裂伤、糖尿病及低血压等因素关系密切。结论低龄、低GCS、低收缩压、脑血管痉挛、并发脑疝、脑损伤类型中的脑挫裂伤、糖尿病及低血压等因素可能是颅脑损伤患者术后发生脑梗死的危险因素,需要采取合理措施降低其对患者预后的影响,提高患者的生活质量。     

28例急性颅脑损伤继发大面积创伤性脑梗死的诊治分析

目的探讨28例大面积创伤性脑梗死的致病原因及预后影响因素。方法对28例脑梗死患者中蛛网膜下腔出血(SAH)部位与预后的关系以及梗死部位与预后的关系分别进行分析。结果预后良好14例(50％)，中残3例(10．7％)，重残2例(7．1％)，植物生存1例(3．6％)，死亡8例(28．6％)。SAH位于脑裂池者11例中有7例死亡(63．6％)，占死亡总人数的87．5％。梗死灶位于双额叶或累及视丘下部者死亡4例(占50％)，颞顶叶累及基底节者死亡4例(占50％)。结论SAH位于脑裂池者预后差，梗死部位位于双额叶或双额叶累及视丘下部者、颞顶叶累及基底节者预后差，