保守治疗颅脑损伤患者出现颅内迟发性血肿38例临床分析

<正>颅脑损伤患者首次颅脑CT检查颅内未及明显异常或仅见颅骨骨折、脑挫伤、蛛网膜下腔出血,而住院3天内颅脑CT复查见颅内迟发性血肿,该类患者目     

颅脑损伤患者Rotterdam评分与术后挫伤性脑出血扩大的相关研究

目的探讨重型颅脑损伤患者Rotterdam头颅CT评分与去骨瓣减压术后挫伤性脑出血扩大的关系,明确挫伤性脑出血增加量与预后的关系。方法 212例行单侧去骨瓣减压术的颅脑损伤患者进入研究,记录年龄,GCS评分,瞳孔,实验室检查和最初的、术前最近的、术后首次的头颅CT数据。预后指标:外伤后6个月GOS评分。结果最初头颅CT的Rotterdam评分与去骨瓣减压术后的挫伤性脑出血是否扩大及血肿增加量相关。Rotterdam评分与死亡率和预后相关。去骨瓣减压术后挫伤性脑出血增加量与死亡率和预后相关。结论重型颅脑损伤患者最初的Rotterdam头颅CT评分可以预测去骨瓣减压术后脑挫伤出血扩大的风险,且与预后相关。     

颅脑外伤后进展性出血损伤的临床特点及预后分析

目的了解急性颅脑外伤患者进展性出血损伤的临床特点,并分析其相关危险因素及对预后的影响。方法回顾分析316例急性颅脑外伤患者,根据入院24小时内复查的头颅CT结果分为进展性出血损伤组和非进展性出血损伤组,对两组患者既往病史、临床特点及动态头颅CT结果进行对比分析。结果超过30%的急性颅脑外伤患者发生进展性出血损伤,进展性出血损伤患者在饮酒史、入院时GCS评分及出血部位方面与非进展性出血损伤患者相比存在显著差异,伤后距首次头颅CT及首次复查头颅CT的时间越短,进展性出血损伤的发生率越高,并且进展性出血损伤患者并发症发生率高,住院时间长,预后差。结论急性颅脑外伤患者在受伤早期发生进展性出血损伤概率较高,发病时病情轻重、出血部位及既往饮酒情况对早期进展性出血损伤有重要影响,进展性出血损伤在急性颅脑外伤患者预后的评估中起重要作用,可作为患者预后的预测指标。     

脑外伤后进展性出血性损伤的发生率及其危险因素分析

目的调查脑外伤后进展性出血性损伤的发生率,分析其发生的危险因素。方法回顾性分析2009年6月至2011年6月本院收治的168例脑外伤患者。收集年龄、性别、入院时间、入院时GCS评分、蛛网膜下腔出血、中线移位、环池形态、瞳孔散大、急诊手术、首次CT时间、创伤严重程度评分和APACHEⅡ评分等资料。计算脑外伤后进展性出血性损伤的发生率,采用非条件多因素Logistic回归分析确定脑外伤后进展性出血性损伤发生的危险因素。结果 63例(37.5%)脑外伤患者发生进展性出血性损伤。多因素Logistic回归分析显示,蛛网膜下腔出血(OR=12.421,95%CI=1.263～42.715,P=0.001)和首次CT时间(OR=0.421,95%CI=0.263～0.715,P=0.002)是脑外伤后进展性出血性损伤发生的独立危险因素。结论脑外伤后进展性出血性损伤发生率较高,外伤性蛛网膜下腔出血和短时间内完成首次CT检查是脑外伤后进展性出血性损伤的独立危险因素。     

重度颅脑损伤继发大面积脑梗塞

笔者在近几年来重度颅脑损伤治疗中,发现一部分病人出现脑梗塞,有些是大面积梗塞。这类病人伤情危重,预后差。现将笔者遇到的24例临床特点及治疗结果,报告如下。1临床资料1.1一般资料:本组男性17例,女性7例;年龄38～81岁,平均60岁。脑挫裂伤合并脑内血肿18例,其中额颞叶挫伤伴血肿7例,颞顶叶挫伤伴血肿6例,双颞叶脑内血肿伴颅底骨折2例,顶枕叶挫伤伴血肿3例,巨大硬膜下血肿6例,血肿量在80ml以上。GCS计分均在6分以下,均出现脑疝征状,脉搏、呼吸、血压出现库兴氏征改变。入院时均行头颅CT扫描检查。发现脑梗塞灶2例,头颅CT复查脑梗塞灶4小…     

外伤性蛛网膜下腔出血对重型颅脑损伤患者Marshall CT分级预后的影响

目的研究外伤性蛛网膜下腔出血是否影响颅脑损伤患者Marshall CT分级的预后。方法收集本院2008年2月至2008年12月间共66例重型颅脑损伤患者,按照Marshall CT分级分为弥漫性损伤组和局灶性损伤组,分析外伤性蛛网膜下腔出血的发生率及对其预后的影响。结果66例重型颅脑损伤的患者中,合并外伤性蛛网膜下腔出血的发生率高达77．27％,并且预后较差。根据Marshall CT分级,弥漫性损伤组中,伤后6个月GOS评分合并蛛网膜下腔出血者平均为3．00,不合并者为4．25;局灶性损伤组中,伤后6个月GOS评分合并蛛网膜下腔出血者平均为1．91,不合并者为3．00,鼹者有统计学差异（P〈0．05）。结论外伤性蛛网膜下腔出血在重型颅脑损伤患者中极为常见,并且影响Marshall CT分级的预后。     

轻中度创伤性脑损伤后发生进展性出血性损伤的危险因素分析

目的探讨轻中度[格拉斯哥昏迷量表(Glasgow coma scale,GCS)≥9]创伤性脑损伤(traumatic brain injury,TBI)后发生进展性出血损伤(progressive hemorrhagic injury,PHI)的相关危险因素。方法回顾性分析2013年9月~2015年8月132例轻中度TBI患者颅内出血进展情况,41例(31.1%)进展为PHI(PHI组)。单因素分析包括性别、年龄、受伤原因、损伤类型、瞳孔大小、瞳孔对光反应、入院时高血压(收缩压≥140 mm Hg)、受伤到首次CT检查时间、血肿部位、血肿类型、是否合并脑挫裂伤、是否合并蛛网膜下腔出血,以及入院首次凝血功能指标、血糖、血常规、肾功能,出院时格拉斯哥预后评分(Glasgow outcome scale,GOS),并应用logistic回归进行多因素分析。结果单因素分析显示年龄、损伤类型、入院时高血压、合并脑挫裂伤、合并蛛网膜下腔出血、D-二聚体、红细胞计数、血糖和出院GOS评分的差异有统计学意义(P0.05)。多因素分析显示入院时高血压(OR=2.417,P=0.045),合并脑挫裂伤(OR=2.792,P=0.017)和D-二聚体≥6500μg/L(OR=4.968,P=0.000)是独立危险因素。结论轻中度TBI患者若存在入院时高血压、合并脑挫裂伤和较高水平D-二聚体(≥6500μg/L)更易发生PHI,需要加强监测。     

脑外伤患者82例心电图分析

本文回顾８２例颅脑外伤患者心电图改变，并分析了颅脑外伤严重程度与其心电图改变的关系。现报告如下。资料和方法１．临床资料：按照格拉斯哥评分及头颅CT诊断，８２例病例均为重度颅脑损伤。受检者男６７例，女１５例；年龄１７～６５岁，平均３４．５岁。多为青壮年，既往无心脏病史。８２例重度颅脑外伤中，脑干挫伤１７例，脑内血肿伴蛛网膜下腔出血８例，颅底骨折伴硬膜下血肿１３例，弥漫性脑组织挫伤颅骨骨折伴广泛脑挫伤５例，脑室出血伴脑挫伤１４例，颅骨骨折伴硬膜下血肿、脑内血肿１２例，脑挫伤１３例。２．检测方法：８２…     

重型颅脑损伤并发急性肾衰竭的抢救

<正> 重型颅脑损伤并发急性肾衰竭(acute renal failure,ARF)在临床中较为常见,早期易被漏诊或疏忽,使病情加重,救治困难,死亡率较高。我科自1996年3月～2002年3月收治重型颅脑损伤患者中,其中并发ARF31例,现总结如下。 1 临床资料 1.1 一般资料:男21例,女10例;年龄33～68岁,平均48.3岁;车祸伤18例,坠落伤8例,钝器伤5例;头颅CT示颅内血肿15例,脑挫裂伤10例,蛛网膜下腔出血6例;合并四肢     

颅脑损伤继发外伤后脑梗死的危险因素分析

目的探讨颅脑损伤继发外伤后脑梗死的危险因素。方法对1028例颅脑损伤患者的性别、年龄、伤后血压、脑损伤类型、是否并发脑疝、是否合并糖尿病、是否手术等相关因素与外伤后脑梗死的关系进行回顾性分析。结果继发外伤性脑梗死者61例，其中年龄、低血压或休克、蛛网膜下腔出血、脑挫裂伤、硬膜下血肿、并发脑疝、合并糖尿病等因素与外伤性脑梗死关系密切（P〈0．05）。结论年龄、低血压或休克、蛛网膜下腔出血、脑挫裂伤、硬膜下血肿、并发脑疝、合并糖尿病等因素是颅脑损伤继发外伤后脑梗死的危险因素。     

Diffuse axonal injury and early intracranial sequelae in severe head injury.

The importance of diffuse axonal injury (DAI) and early intracranial sequelae was studied in 107 patients with diffuse and focal brain injuries. Comprehensive neuropathological study was also undertaken in 24 fatal patients. The mortality rate was clearly the highest in traumatic subarachnoid hemorrhage, followed by acute subdural hematoma, cerebral contusion with delayed hematoma formation, traumatic intracerebral hematoma, diffuse cerebral swelling, DAI with classical features, and finally nearly normal on computed tomographic scans. The mean flow velocities in the middle cerebral artery recorded by transcranial Doppler ultrasound were variable in diffuse brain injury, but commonly decreased on the hematoma side depending on increased intracranial pressure and decreased cerebral perfusion pressure in focal brain injury. Deep-seated hemorrhagic lesions did not expand in diffuse brain injury, but sizable hematoma developed within 24 hours in focal brain injury. The platelet count was significantly lower in patients with poor outcomes in focal brain injury. Histological evidence of classical DAI was found in eight (50%) of 16 cases with focal brain injury. DAI of varying severity is the common subjacent lesion in patients with severe head injury, but the final outcome varies greatly with different lesion types.     

Post-operative expansion of hemorrhagic contusions after unilateral decompressive hemicraniectomy in severe traumatic brain injury

Decompressive hemicraniectomy is commonly performed in patients with traumatic brain injury (TBI) with diffuse brain swelling or refractory raised intracranial pressure. Expansion of hemorrhagic contusions in TBI patients is common, but its frequency following decompressive hemicraniectomy has not been well established. The aim of this retrospective study was to determine the rate of hemorrhagic contusion expansion following unilateral hemicraniectomy in severe TBI, to identify factors associated with contusion expansion, and to examine whether contusion expansion is associated with worsened clinical outcomes. Computed tomography (CT) scans of 40 consecutive patients with non-penetrating TBI who underwent decompressive hemicraniectomy were analyzed. Hemorrhagic contusion volumes were measured on initial, last pre-operative, and first post-operative CT scans. Mortality and 6-month Glasgow Outcome Scale (GOS) score were recorded. Hemorrhagic contusions of any size were present on the initial head CT scan in 48% of patients, but hemorrhagic contusions with a total volume of >5 cc were present in only 10%. New or expanded hemorrhagic contusions of >or=5 cc were observed after hemicraniectomy in 58% of patients. The mean volume of increased hemorrhage among these patients was 37.1+/-36.3 cc. The Rotterdam CT score on the initial head CT was strongly associated with the occurrence and the total volume of expanded hemorrhagic contusions following decompressive hemicraniectomy. Expanded hemorrhagic contusion volume greater than 20 cc after hemicraniectomy was strongly associated with mortality and poor 6-month GOS even after controlling for age and initial Glasgow Coma Scale (GCS) score. Expansion of hemorrhagic contusions is common after decompressive hemicraniectomy following severe TBI. The volume of hemorrhagic contusion expansion following hemicraniectomy is strongly associated with mortality and poor outcome. Severity of initial CT findings may predict the risk of contusion expansion following hemicraniectomy, thereby identifying a subgroup of patients who might benefit from therapies aimed at augmenting the coagulation system.     

外伤性迟发性颅内血肿临床特点及首次CT的影像学特征分析

目的分析外伤性迟发性颅内血肿临床特点及首次CT影像学特征,早期诊断外伤性迟发性颅内血肿,提高疗效。方法回顾性分析我院2005年至2009年经CT证实的外伤性迟发性颅内血肿患者的临床资料,总结临床特点和首次CT影像学特征。结果迟发性血肿多发生在伤后3d内,额颞部好发,老年人容易发生,进行性的意识水平下降或出现新的神经系统体征往往意味着迟发性血肿;首次CT发现头皮血肿、颅骨骨折、气颅、脑挫伤、蛛网膜下腔出血、外侧裂血肿等预警征象时,要警惕迟发性血肿的发生。结论如果首次CT扫描有头皮血肿、颅骨骨折、脑挫伤、蛛网膜下腔出血、外侧裂血肿者,或颅内血肿成功清除后,但临床症状和特征未改善甚至加重者,进行性的意识水平下降者,伤后应将头部CT动态扫描作为常规检查,做到早期诊断、及时治疗。     

重型颅脑外伤性脑梗死的发生率及其危险因素分析

目的调查重型颅脑外伤性脑梗死的发生率,分析其发生的危险因素。方法回顾性分析208例重型颅脑外伤患者,收集年龄、性别、入院时间、入院时GCS评分、蛛网膜下腔出血、中线移位、环池形态、脑疝、急诊手术、创伤严重程度评分和APACHEⅡ评分等资料,计算重型颅脑外伤性脑梗死的发生率,采用多因素分析确定重型颅脑外伤性脑梗死发生的危险因素。结果 31例(14.9%)重型颅脑外伤患者发生外伤性脑梗死。多因素分析显示,脑疝(OR=6.421,95%CI=2.312～22.517,P=0.001)和GCS评分(OR=0.422,95%CI=0.233～0.851,P=0.002)是重型颅脑外伤并发脑梗死的独立危险因素。结论重型颅脑外伤性脑梗死的发生率较高,伤情和并发脑疝是重型颅脑外伤性脑梗死发生的独立危险因素。     

Progressive hemorrhage after head trauma: predictors and consequences of the evolving injury.

OBJECT: Progressive intracranial hemorrhage after head injury is often observed on serial computerized tomography (CT) scans but its significance is uncertain. In this study, patients in whom two CT scans were obtained within 24 hours of injury were analyzed to determine the incidence, risk factors, and clinical significance of progressive hemorrhagic injury (PHI). METHODS: The diagnosis of PHI was determined by comparing the first and second CT scans and was categorized as epidural hematoma (EDH), subdural hematoma (SDH), intraparenchymal contusion or hematoma (IPCH), or subarachnoid hemorrhage (SAH). Potential risk factors, the daily mean intracranial pressure (ICP), and cerebral perfusion pressure were analyzed. In a cohort of 142 patients (mean age 34 +/- 14 years; median Glasgow Coma Scale score of 8, range 3-15; male/female ratio 4.3: 1), the mean time from injury to first CT scan was 2 +/- 1.6 hours and between first and second CT scans was 6.9 +/- 3.6 hours. A PHI was found in 42.3% of patients overall and in 48.6% of patients who underwent scanning within 2 hours of injury. Of the 60 patients with PHI, 87% underwent their first CT scan within 2 hours of injury and in only one with PHI was the first CT scan obtained more than 6 hours postinjury. The likelihood of PHI for a given lesion was 51% for IPCH, 22% for EDH, 17% for SAH, and 11% for SDH. Of the 46 patients who underwent craniotomy for hematoma evacuation, 24% did so after the second CT scan because of findings of PHI. Logistic regression was used to identify male sex (p = 0.01), older age (p = 0.01), time from injury to first CT scan (p = 0.02), and initial partial thromboplastin time (PTT) (p = 0.02) as the best predictors of PHI. The percentage of patients with mean daily ICP greater than 20 mm Hg was higher in those with PHI compared with those without PHI. The 6-month postinjury outcome was similar in the two patient groups. CONCLUSIONS: Early progressive hemorrhage occurs in almost 50% of head-injured patients who undergo CT scanning within 2 hours of injury, it occurs most frequently in cerebral contusions, and it is associated with ICP elevations. Male sex, older age, time from injury to first CT scan, and PTT appear to be key determinants of PHI. Early repeated CT scanning is indicated in patients with nonsurgically treated hemorrhage revealed on the first CT scan.     

Acute spontaneous subdural hematoma of arterial origin

BACKGROUND: Acute subdural hematoma is usually associated with cerebral contusion or laceration of the bridging veins following a head injury. However, several cases of acute subdural hematoma without head injury (acute spontaneous subdural hematoma) have been reported. METHODS: Among 162 cases of acute subdural hematoma admitted to our departments between 1996 and 2003, we repoort eight cases of acute spontaneous subdural hematoma. These cases fulfilled the following criteria. 1) Head injury was either trivial or absent. 2) Neither aneurysm nor arteriovenous malformation was apparent. 3) CT scan revealed neither brain contusion nor traumatic subarachnoid hemorrhage. 4) At operation, laceration of the cortical artery was observed. In this article, we describe the clinical feature (age, sex, Glasgow Coma Scale [GCS] Score on admission, past history, CT appearance, and outcome) associated with this condition. RESULTS: Patients ranged in age from 68 to 85 years (average 74.8 years), and were comprised of 3 males and 5 females. Previous medical history included cerebral infarction in 6 of the 8 patients and myocardial infarction in 1 patient. These seven patients were taking antiplatelet manifestation. GCS on admission ranged from 4 to 13. Five of the 7 patients on antiplatelet medication had secondary insults, such as hypoxia. On CT, hematoma thickness ranged from 13.2mm to 42.5mm (average 22.6mm), and midline shift ranged from 10.0mm to 24.0mm (average 16.5mm). Neurological outcome evaluated using the Glasgow Outcome Scale was as follows, good recovery n = 2, moderate disability n = 2, severe disability n = 3, persistent vegetative state n = 1. CONCLUSION: The mechanism of acute spontaneous subdural hematoma is influenced by the presence of pre-existing cerebrovascular disease and by the use of antiplatelet agents. In such cases, the possibility of cortical arterial bleeding should be taken into account, and craniotomy should be performed.     

重型颅脑损伤后高血糖的临床意义分析

目的探讨重型颅脑损伤（SBI）后高血糖的临床意义。方法回顾性收集了128例重型闭合性颅脑损伤（GCS≤8分）患者的临床资料,应用统计学方法分析不同颅脑损伤损伤类型、入院时GCS水平、瞳孔光反应、近期预后与术后24小时内血糖水平的关系。颅脑损伤类型分为硬膜外血肿、硬膜下血肿、脑内血肿/脑挫裂伤3组;入院时GCS水平分成3-4分组、5-6分组、7-8分组;瞳孔对光反应情况分成双侧瞳孔光反应存在、单侧瞳孔光反应消失、双侧瞳孔光反应消失3组。近期预后分为预后良好和预后不良2组。结果重型颅脑损伤组血糖水平明显高于中型颅脑损伤组（P〈0.05）,3-4分组血糖水平（16.11±2.85）mmol/L明显高于7-8分组（12.33±2.23）mmol/L和5-6分组（14.11±2.85）mmol/L,而5-6分组血糖水平也明显高于7-8分组,各组间差异均有统计学意义（P〈0.05）;双侧瞳孔光反应消失组术后24小时内血糖水平（19.29±3.87）mmol/L,明显高于双侧瞳孔光反应存在组（15.69±2.83）mmol/L和单侧瞳孔光反应消失组（17.84±3.89）mmol/L,单侧瞳孔光反应消失组血糖水平明显高于双侧瞳孔光反应存在组,各组间差异均有统计学意义（P〈0.05）;预后不良组术后24小时内血糖水平明显高于预后良好组（P〈0.05）。血糖16.7mmol/L组的预后明显差于≤16.7mmol/L组（P〈0.05）。结论重型颅脑损伤后血糖水平明显增高。颅脑损伤伤情越重,血糖水平越高。高血糖是严重影响重型颅脑损伤预后的重要指标。     

对冲性颅脑损伤双侧血肿的手术策略

【摘要】〓目的〓探讨对冲性颅脑损伤所导致的颅内双侧血肿的手术策略,以提高此类患者的预后。方法〓回顾分析我院颅脑创伤中心2011年10月至2014年10月由同一术者手术治疗的97例对冲性颅脑损伤患者的病例资料,根据术前头CT所示,将患者分为三型,Ⅰ型:着力侧硬膜外血肿为主(20例),Ⅱ型:着力侧硬膜外血肿量与对冲侧血肿量(硬膜下血肿或者脑挫裂伤伴实质内血肿)相当(29例),Ⅲ型:对冲侧血肿(硬膜下血肿或者脑挫裂伤伴实质内血肿)为主(48例)。对上述三型患者采取针对性的手术治疗。结果〓Ⅰ型患者主要先行着力侧的硬膜外血肿手术处理,对冲侧根据术前(达到手术指征同期手术)及术后(复查CT,血肿增多达到手术指征即手术,未增多则行颅压监护)情况决定是否手术;Ⅱ型患者术前双侧血肿未达手术指征根据GCS评分及瞳孔决定是否手术,达到手术指征则行同期双侧血肿清除;Ⅲ型患者先行着力侧钻孔引流,再行对冲侧血肿清除,术中使用超声检查着力侧血肿决定进一步治疗。根据GOS评分判断患者预后,其中预后良好45例,轻度残疾22例,重度残疾11例,植物生存11例,死亡8例。结论〓对冲性颅脑损伤双侧血肿患者根据术前头CT血肿分型采取针对性的手术策略,可以取得较好的预后。