颅内压监测下阶梯式减压在重型颅脑损伤患者术中的应用

目的 探讨颅内压监测下阶梯式减压在重型颅脑损伤患者术中的应用效果。方法 选取2019年3月至2020年6月开封市中心医院收治的58例重型颅脑损伤患者作为研究对象,根据治疗方法将其分为观察组（29例）与对照组（29例）。观察组患者行颅内压监测下阶梯式减压术治疗,对照组患者行传统大骨瓣减压术治疗,对比两组患者格拉斯哥昏迷指数（GCS）评分变化情况、术后并发症（急性脑膨出、迟发脑血肿、术后脑梗死等）发生情况及死亡率。结果 术后1个月,观察组患者GCS评分为（10.67±2.19）分,明显高于对照组患者的（8.66±1.88）分（t=3.750,P＜0.001）;观察组患者术后出现急性脑膨出2例、术后脑梗死1例,并发症发生率为10.34%,对照组患者术后出现急性脑膨出5例、迟发脑血肿1例、术后脑梗死3例,并发症发生率为31.03%,两组间差异无统计学意义（χ2=3.783,P=0.052）;观察组患者中死亡6例,死亡率为20.69%,对照组患者中死亡12例,死亡率为41.38%,两组间差异无统计学意义（χ2=2.900,P=0.089）。结论 颅内压监测下阶梯式减压相对于传统大骨瓣减压而言,可明显促进患者意识恢复,提高患者预后。     

基层特重型颅脑损伤的治疗策略

目的：探讨手术治疗特重型颅脑损伤患者的临床治疗策略。方法分析经2005～2013年手术治疗的77例重型颅脑损伤患者的手术方式及综合治疗情况。结果65例存活,生存率为84％;死亡12例,死亡率为16％;恢复良好40例,恢复良好率为51％。结论对于手术治疗特重型颅脑损伤病例,选择恰当的手术方式,合理的手术操作技能,以及有效的术后处理,对提高其生存率、生存质量有良好作用。     

创伤性脑中心疝的临床诊治分析

对42例创伤性脑中心疝患者的临床资料进行回顾性分析。42例均进行手术治疗,根据格拉斯哥预后评分(GOS)评价临床治疗效果,瞳孔散大前手术26例中,良好13例,中残7例,重残3例,植物生存1例,死亡2例;瞳孔散大后手术16例中,死亡8例,植物生存3例,重残3例,中残2例。应仔细认真分析患者临床表现及影像学动态观察结果,做出早期预判、诊断和及时处理;患者能否在间脑期得到积极的治疗,是降低致残率和死亡率的关键。     

多发伤合并腹部损伤延迟诊断导致腹腔室隔综合征的诊治分析

目的分析多发伤合并腹部损伤延迟诊断导致腹腔室隔综合征(ACS)9例的临床特点,总结其诊治经验,并提出预防方法。方法收集2002年10月~2009年6月我科收治的9例多发伤合并腹部损伤延迟诊断导致腹腔室隔综合征患者的临床资料,分析其延迟诊断的可能原因、临床治疗和预防措施。结果9例均为多发伤,均于伤后3~11天转来我院就诊后腹部损伤得到明确诊断并手术治疗。最常见致伤原因为道路交通事故,其次为高处坠落。9例中,2例为胰腺损伤,3例十二指肠损伤,1例腹膜后结肠损伤,3例小肠损伤。9例中4例死亡,死亡率44.4%。存活患者术后均出现并发症,并发症发生率100%。结论提高对多发伤合并腹部损伤的警惕、动态监测腹部症状和体征的变化,及时诊断和处理腹部创伤有助于减少创伤后腹腔室隔综合征的发生。根据患者损伤情况,选择恰当的个体化手术方案有助于降低创伤后腹腔室隔综合征的并发症和死亡率。     

高原地区高血压脑出血规范化外科治疗探讨-附216例手术分析

目的:探讨高原地区高血压脑出血规范化外科治疗的手术方式。方法:根据患者脑出血部位及GCS分级选择不同的手术方式观察治疗结果及预后。结果:手术216例,存活151例,放弃治疗17例,死亡48例,死亡率22.2%。结果:规范化外科治疗是降低高血压脑出血患者死亡率、改善其生存质量的重要途径。     

多发伤合并脂肪栓塞综合征的临床特点和诊治分析

目的分析多发伤患者脂肪栓塞综合征(FES)的临床特点,总结其诊治经验。方法收集2007年1月～2012年6月我科收治多发伤5 074例患者临床资料,有25例在创伤后继发FES。结合本组患者临床资料,分析其发病特点、诊断和治疗方法。结果 25例均为多发伤,损伤严重程度(ISS)≥16,FES发生率0.49%,脂肪栓塞症状伤后平均43.68h。所有患者给与积极有效的治疗措施,其中治愈12例,明显好转后转当地医院治疗7例,植物状态1例,放弃治疗1例,死亡4例,死亡率为16%。结论在多发伤中,FES发生率低但死亡率高,关键是对FES的早期诊断和及时处理创伤后长骨骨折。选择积极有效的综合治疗,改善创伤后FES患者的预后。     

内窥镜辅助经外侧裂-岛叶入路显微外科手术治疗基底节区高血压脑出血研究

目的探讨使用神经内窥镜辅助下经外侧裂-岛叶入路显微外科手术治疗基底节区高血压脑出血的疗效。方法回顾分析2008年1月～2011年12月我院12例高血压基底节区脑内血肿患者的资料,患者均在急性期接受神经内窥镜辅助下经外侧裂-岛叶入路显微手术治疗。结果术后即刻复查CT示9例血肿基本清除,3例清除约80%,其中2例出现了术后少量迟发出血,均保守治疗成功。随访6个月时GOS评分：恢复良好8例,轻度残疾2例,重度残疾2例,无植物生存及死亡病例。结论经外侧裂-岛叶入路显微外科手术治疗基底节区高血压脑出血具有微创的特点,内窥镜辅助下能有效清除脑内血肿,并减少了颞叶皮层及血管的损伤,有益于改善患者的预后。     

创伤后腹腔室隔综合征的诊治分析

目的 分析创伤后腹腔窜室隔综合征(ACS)的临床特点,总结其诊治经验.方法 收集2000年8月-2008年3月我科收治的17例创伤后ACS临床资料,分析其发病高危因素、临床分型和治疗措施.结果 17例创伤后ACS患者中,6例因胰腺和(或)十二指肠损伤延迟诊断而引起.根据病变部位分型,17例中9例为腹腔型,8例为腹膜后型.17例均行剖腹手术治疗,4例死亡,死亡率23.5%.结论 及时处理腹部创伤、减少漏诊、选择适当的休克复苏措施有助于减少创伤后ACS的发生.根据患者损伤情况ACS分型,选择恰当的个体化手术方案有助于降低创伤后ACS的并发症和死亡率.     

高原地区高血压脑出血规范化外科治疗探讨一附216例手术分析

目的：探讨高原地区高血压脑出血规范化外科治疗的手术方式。方法：根据患者脑出血部位及GCS分级选择不同的手术方式观察治疗结果及预后。结果：手术216例，存活151例，放弃治疗17例，死亡48例，死亡率22．2％。结果：规范化外科治疗是降低高血压脑出血患者死亡率、改善其生存质量的重要途径。     

双额颞部开颅减压治疗弥漫性脑肿胀双侧脑疝

目的探讨双额颞部扩大翼点入路开颅减压治疗弥漫性脑肿胀致双侧脑疝的临床价值。方法将我院2010年1月至2014年6月收治的74例弥漫性脑肿胀患者随机分为对照组和观察组。其中对照组38例,行双侧额颞部传统"?"形入路开颅减压术。观察组36例,行双侧额颞部扩大翼点入路开颅减压术。比较两组患者的术中术后并发症、手术时间、死亡率及格拉斯哥分级(GOS)评分。结果观察组的术中术后并发症、住院时间、死亡率、致残率,均明显低于对照组,差异均有统计学意义(P<0.05)。结论双侧额颞部扩大翼点入路开颅减压手术能有效降低术中脑膨出及术后脑梗死,缩短手术时间,降低死亡率及致残率,提高生存质量,临床疗效确切。     

Prognostic value of hyperattenuating middle cerebral artery sign at CT in cerebral infarction

PURPOSE: To assess the prognostic value of hyperattenuating middle cerebral artery sign at CT in acute cerebral infarction. MATERIALS AND METHODS: Ninety-two patients with acute cerebral infarction in the sylvian area were retrospectively reviewed. All patients underwent unenhanced CT 12-24 hours after the onset of symptoms and follow-up CT within 48-72 hours. Initial CT scans were evaluated by consensus by three radiologists to confirm or exclude the presence of hyperattenuating middle cerebral artery sign. History, cardiovascular risk factors and neurological impairment at discharge (mean 25 days) were recorded for each patient. The degree of disability was graded 0 (no disability) to 6 (death). Patients were divided into two groups: patients without (group A) and patients with (group B) hyperattenuating middle cerebral artery sign. A logistic regression analysis was performed to compare the two groups. Results were correlated with cardiovascular risk factors. Kaplan-Meier survival curves were calculated for each group. RESULTS: Hyperattenuating middle cerebral artery sign was present in 18 patients (19.6%) (group B). The percentage of neurological deficits was significantly higher in group B than in group A (p<0.05). Sixteen (88.9%) of the 18 patients in group B had a poor prognostic index (score 3 - 6) with a significantly higher percent difference (41.6%, p<0.05) than patients of group A. Within 10 days of admission, 3 patients (16.7%) died in group A and 6 (8.1%) in group B. However, no significant differences were observed in the Kaplan-Meier survival curves. No correlation with cardiovascular risk factors was observed. CONCLUSIONS: Besides having an important diagnostic value, hyperattenuating middle cerebral artery sign is a reliable predictor of prognosis in terms of disability rather than mortality, as it reflect the larger extension of infarction.     

联合应用尿激酶和前列腺素E1治疗脑梗死的临床研究

 目的研究探索联合溶栓剂尿激酶(Urokinase,UK)和前列腺素E1(Protaglandin E1,PGE1)对急性脑梗死患者进行静脉溶栓的临床疗效观察.方法将急性脑梗死患者,随机分为联合用药组(46例)和单一用药组(37例)进行溶栓治疗,联合用药组应用UK和PGE1进行治疗,单一用药组应用UK进行治疗.结果联合用药组临床有效率为93.4%,明显高于常规单一用药组(87%).PGE1能增强UK的溶栓效果,两组结果相比,总有效率有显著差异(P＜0.05).两组均未发生大量脑出血及严重其他部位出血.结论静脉内联合应用UK和PGE1,对急性脑梗死患者能降低病死率、致残率,可减少并发症的发生率,是一种疗效好、不良反应少且安全可靠的溶栓方法.     

高压氧综合治疗急性脑梗死一年期内疗效分析

目的 探讨脑梗死急性期行高压氧治疗对患者1年内神经功能恢复的影响.方法 急性脑梗死患者192例分为高压氧组和非高压氧组,分别于治疗前、治疗20 d、3个月、6个月、12个月时进行神经功能缺损评分对比.根据治疗前神经功能缺损评分,每组患者冉被分为轻、中、重3个亚组进行分析.结果 (1)神经功能缺损轻型组:治疗后各评分时间高压氧组均较非高压氧组有显著改善(P<0.01或P<0.05).(2)神经功能缺损中型组:高压氧20 d组、12个月组较同期非高压氧组有明显改善,差异有统计学意义(P<0.05).(3)神经功能缺损重型组:高压氧6个月组、12个月组较同期非高压氧组有明显改善,差异有统计学意义(P<0.05).(4)高压氧组1年死亡率较非高压氧组有明显降低,差异有统计学意义(P<0.01).高压氧组1年复发率较非高压氧组有明显降低,差异有统计学意义(P<0.05).结论 脑梗死患者急性期行高压氧治疗不仪可以改善患者急性期神经缺损,而且在1年内仍可使患者受益,改善神经功能,降低死亡率及复发率.     

Post-traumatic cerebral infarction. Neuroimaging findings, etiology and outcome

Purpose: To assess the radiological characteristics of post-traumatic cerebral infarctions (PTCIs), the etiology and site of infarction, and to provide neuroimaging indicators of a poor clinical outcome.Material and Methods: A retrospective study of 16 patients with the neuroimaging-based diagnosis of PTCI was carried out. All CT, MR examinations, cerebral angiograms and medical records of the patients were reviewed.Results: Infarcts were diagnosed in the territory of the posterior cerebral artery in 9 patients, in the middle cerebral artery in 5, in the anterior cerebral artery in 3, lenticulostriate-thalamoperforating in 2, vertebrobasilar in 3, and cortical infarcts in 2 patients. Neuroimaging studies suggested focal mass effect and/or acquired intracranial herniations as the cause of infarction in 13/16 patients (81.2%). In 3/16 patients (18.8%), PTCI was due to vascular injury of which 2 were angiographically documented (carotid artery dissection). Eight of the 16 patients in this study died or were left in a persistent vegetative state. Patients with associated subdural hematoma, brain swelling/edema and traumatic subarachnoid hemorrhage (tSAH) exhibited the worst outcome.Conclusion: Gross mechanical shift of the brain and herniation across the falx and/or tentorium accounted for infarction in a majority of cases in our study. The overall death rate was 43.8% and this result suggests that PTCI is an indication of a poor clinical outcome, especially among patients with associated subdural hematoma, brain swelling/edema and tSAH.     

Safety and efficacy of delayed intraarterial urokinase therapy with mechanical clot disruption for thromboembolic stroke.

PURPOSETo evaluate safety and efficacy of delayed intraarterial urokinase therapy with mechanical disruption of clot to treat thromboembolic stroke.METHODSThirteen patients with cerebral thrombolic disease (10 carotid territory, 3 basilar territory) were treated with catheter-directed intraarterial urokinase therapy with mechanical disruption of the clots. All patients were excluded from a 6-hour multicenter thrombolytic trial by either time, recent surgery, age, seizure, or myocardial infarction. Time elapsed before treatment ranged from 3.5 to 48 hours (12 +/- 13 hours), with 200,000 to 900,000 U of urokinase used.RESULTSTen patients had successful vessel recanalization, confirmed by repeat angiography. Cases with distal branch vessel occlusions were less likely to recanalize. Asymptomatic hemorrhagic conversion occurred in 2 patients on repeat scans. Both acute neurologic and functional outcomes were assessed with significant improvement occurring in 9 (69%) of 13 patients at 48 hours (greater than four-point change on the National Institutes of Health scale) and in 100% of 3-month survivors. All patients who improved had normal initial CT scans.CONCLUSIONSIntraarterial cerebral thrombolysis with mechanical disruption of clot seems to be a useful therapy in selected stroke cases even after 6 hours.     

64层螺旋CT脑灌注成像评价急性脑梗死溶栓前后脑血流动力学改变

目的探讨64层螺旋CT脑灌注成像(CTP)在评价急性脑梗死溶栓疗效中的应用价值。资料与方法20例急性脑梗死患者于发病3~10h行常规CT平扫和CTP检查,其中16例行静脉溶栓、4例行动脉溶栓治疗。溶栓后2~7天复查CT平扫和CTP。对溶栓治疗前后病变区的脑血流量(CBF)、脑血容量(CBV)和达峰时间(TTP)进行定性和定量比较分析。结果20例中5例头颅CT平扫发现早期脑梗死征象,15例常规CT平扫未发现异常,CTP均发现与临床症状对应的脑灌注异常区,表现为CBF、CBV降低,TTP延迟。溶栓后15例脑灌注异常范围缩小,CBF和CBV增加,TTP缩短;3例脑灌注异常区范围扩大,CBF、CBV进一步降低,TTP延迟更加显著;2例出现局部过度灌注。统计学分析结果显示溶栓治疗后多数患者脑灌注情况明显改善,缺血边缘区CBF和TTP与溶栓前差异有统计学意义(P<0.05),缺血中心区CBF和CBV与溶栓前差异无统计学意义(P>0.05)。结论脑CTP检查能够观察溶栓治疗前后脑血流动力学指标的变化,为评价急性脑梗死患者的溶栓疗效提供重要依据。     

Outcome of stroke patients without angiographically revealed arterial occlusion within four hours of symptom onset

BACKGROUND AND PURPOSE: Follow-up imaging data from stroke patients without angiographically apparent arterial occlusions at symptom onset are lacking. We reviewed our Emergency Management of Stroke (EMS) trial experience to determine the clinical and imaging outcomes of patients with ischemic stroke who showed no arterial occlusion on angiograms obtained within 4 hours of symptom onset. METHODS: All patients in this report were participants in the EMS trial that was designed to address the safety and potential efficacy of combined IV and intraarterial thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) in patients with acute ischemic stroke. RESULTS: Thirty-five patients were randomized to receive either IV rt-PA (n = 17) or placebo (n = 18), followed by cerebral angiography. No symptomatic arterial occlusion was evident in 10 (29%) of the 34 patients. Eight (80%) of 10 patients without angiographically apparent clot within 4 hours of symptom onset had a new cerebral infarction confirmed on follow-up brain imaging. The median 72-hour infarction volume was 2.4 cc (range, 1-30 cc). Four of the 10 "no-clot" patients had a favorable 3-month outcome as assessed by Barthel Index (score, 95 or 100) and modified Rankin Scale (score, 0 or 1). The six remaining patients had 3-month Rankin Scale scores of 1 (Barthel of 90), 2, 3, 4, or 5. CONCLUSION: Acute ischemic stroke patients with a neurologic deficit but a negative angiogram during the first 4 hours after symptom onset usually develop image-documented cerebral infarction, and approximately half suffer from long-term functional disability. The two most likely explanations for negative angiograms are very early irreversible ischemic damage despite recanalization or ongoing ischemia secondary to clot in non-visible penetrating arterioles or in the microvasculature.     

老年心脏重症患者主动脉内球囊反搏术的应用及预后分析

目的探讨老年心脏重症患者主动脉内球囊反搏术（intra-aortic balloon pumpI,ABP）治疗的应用、临床预后及并发症。方法回顾性分析我院老年病房接受IABP治疗的48例患者的临床资料。将患者分为死亡组及存活组,分析治疗效果的相关因素及并发症。结果接受IABP治疗患者总病死率39.6%;存活组再血管化成功率为62.1%,明显高于死亡组26.3%;而有陈旧性心梗病史率低于死亡组（P〈0.01）。总并发症率16.7%,以出血最常见。此外,多因素Logistic回归分析,结果表明陈旧性心梗史、心源性休克与院内病死率正相关,而成功再血管化则与其负相关。结论老年人心源性休克、陈旧性心梗史及成功再血管化是影响老年人心血管重症接受IABP治疗院内病死率的重要因素。     

The role of CT and DSA in cranial sino-venous occlusion

Twenty-three patients with a clinical and a radiological diagnosis of cranial sino-venous occlusion (CSO) were randomly assembled and selectively studied in a retrospective manner. Eleven instances were related to the presence of a meningioma and 12 were not. Patients in the meningioma group were older and had a better prognosis than the patients in the nonmeningioma group, but angiography was still necessary in all those with meningioma to diagnose CSO, whereas computed tomography (CT) was most helpful in permitting the diagnosis in the nonmeningioma group. The most frequent CT abnormality seen in this latter group was the "delta" or empty triangle sign (75% of scans), followed by cerebral edema (42%) and venous infarction (33%). One patient had a normal scan. The recent availability of intravenous digital subtraction angiography has helped confirm the diagnosis in a faster, safer and more reliable way. Careful interpretation of CT, especially in patients with CSO unrelated to meningioma, may result in decreased morbidity and mortality as a result of earlier diagnosis and treatment.     

头部低温治疗大面积脑梗死的效果研究

目的　观察头部低温治疗大面积脑梗死的效果。方法　 61例LCI病人 ,随机分为两组。观察组 3 1例 ,在脱水、抗凝、扩容、对症等治疗的同时将患者头部置于颅脑降温治疗仪 (HTI)头盔内密闭 ,进行头部低温治疗。对照组 3 0例 ,除不用HTI外 ,其它治疗方法同治疗组。以两组治疗 7d后梗死体积 ,病死率 ,生存者预后NDS ,ADL为观察指标。结果　两组比较 ,观察组治疗 7d后梗死体积较对照组明显缩小 (P <0 .0 1) ;对照组病死率较高 (P <0 .0 5 ) ;生存者预后NDS ,ADL观察组较对照组明显减少或降低 (P <0 .0 5 )。结论　头部低温可使LCI梗死体积缩小、提高生存者的预后生活质量、降低病死率