重型颅脑损伤早期CT脑池改变与预后

我院自1998．6～2000．10收治重型颅脑损伤70例,对伤后首次CT资料及临床表现进行分析,观察GCS记分,脑干周围池形态的变化(CES)与预后关系。现分析报告如下。     

重型颅脑损伤持续颅内压及脑灌注压监护与预后的关系

对５０例重型颅脑损伤患者进行颅内压（ＩＣＰ）与脑灌注压（ＣＰＰ）连续监测，并根据监测结果及时采取相应的治疗护理措施（监护组）；与５０例未行连续监测，按常规临床观察进行治疗护理的患者（对照组）进行预后比较。结果表明：ＩＣＰ〈２．００ｋＰａ，ＣＰＰ〈９．３３ｋＰａ的患者预后良好；ＩＣＰ〉８．００ｋＰａ，ＣＰＰ〈６．６７ｋＰａ者预后较差。提示：对重型脑损伤患者施行连续ＩＣＰ、ＣＰＰ监护、有利于了解病情变     

动态脑电图监测重型颅脑损伤的临床应用

目的　探讨重型颅脑损伤患者的动态脑电图 (AEEG)表现与临床的关系和意义。方法　对过去 2年间 6 4例重型颅脑损伤患者进行了 AEEG监测和回顾性分析。结果　 6 4例患者的AEEG均为异常 ,轻度异常 17例存活 (病死率 0 % ) ,中度异常 2 6例中死亡 2例 (病死率 7.7% ) ,重度异常 2 1例中死亡 12例 (5 7.1% )。AEEG改变以广泛性慢波异常为主 ,并且颅脑损伤程度越重 ,AEEG异常越明显 ,表现为频率越慢 ,波幅越低甚至呈平坦波改变 ,预后也越差。AEEG监测还可检出痫样波的发作情况 ,据此帮助临床调整用药。结论　分析重症颅脑损伤患者的 AEEG表现对判断病情和预后、诊断脑死亡以及指导临床用药有较大的意义     

重型颅脑损伤后高血糖反应与预后的关系

目的探讨重型颅脑伤后病人高血糖反应与GCS评分及预后的相互关系,探索应用胰岛素治疗高血糖反应对预后的影响.方法分析我科自1995年5月～2000年12月收治重型颅脑损伤病人(GCS评分≤8分)126例,其中,GCS3～4分36例,GCS5～6分42例,GCS7～8分 48例,每例均测定伤后24 h空腹血糖浓度,并随机分成胰岛素治疗组(63例)和非胰岛素治疗组(63例),其余相关治疗措施相同.结果颅脑损伤后24 h空腹血糖水平显著高于正常值(P＜0.05),与损伤程度呈显著相关(P＜0.05),与病人的预后呈显著相关(P＜0.05).按GCS预后评分,胰岛素治疗组GCS 4～5分(痊愈或轻残)29例(46.03%),GCS 2～3分(重残或植物生存)18例(28.57%),GCS1分( 死亡 )16例(25.39%);非胰岛素治疗组GCS 4～5分30例(47.62%),GCS 2～3分15例(23.81%) ,GCS 1分18例(28.57%). 二组病人的预后无显著差异(P＞0.05).结论重型颅脑伤患者伤后24 h空腹血糖测定有助于了解颅脑损伤的严重程度,有助于估计病人的预后;加用胰岛素治疗高血糖反应对预后的转归无显著效果.     

颅内压及脑电双频指数联合监测在重型颅脑外伤患者术后临床应用中的研究

目的 探讨脑电双频指数及颅内压监测在重型颅脑外伤患者术后意识评测和短期预后评估中的应用价值.方法 采用简单随机抽样法随机选择2014年1月-12月江苏省苏北人民医院神经外科重症监护病房颅脑外伤昏迷患者30例,每8h评价患者的GCS评分,记录患者手术治疗后3d内的GCS评分,记录相同时刻的脑电双频指数值及颅内压值,依据GCS评分将患者分为两组:A组20例(3分≤GCS≤5分),B组10例(5分＜ GCS≤8分),统计两组患者的21 d生存率.采用Kaplan-Meier法和Log-rank检验比较脑电双频指数值和颅内压之间的关系.结果 A组脑电双频指数值为45.3 ±3.8,颅内压值为(18.6±2.8) mmHg,B组脑电双频指数值为32.2 ±8.2,颅内压值为(33.4±4.6) mmHg,A组21d生存率为55％,B组21 d生存率为30％,重型颅脑外伤患者术后脑电双频指数值与昏迷程度呈正相关,与颅内压值呈负相关(r =0.532,P ＜0.05;r =0.521,P ＜0.05).重型颅脑损伤患者,入院时病情越重,患者术后颅内压越高,脑电双频指数值越低,其预后越差.结论 脑电双频指数与颅内压联合监测在评估重型颅脑外伤患者术后昏迷程度及预后方面具有较高的应用价值.     

血糖水平与重型颅脑损伤时病情及预后的关系

目的了解血糖水平与重型颅脑损伤时病情及预后的关系。方法对收治的87例重型颅脑损伤患者于脑外伤后24小时内及伤后1、3、5、7、10、14天进行血糖测定。结果人院后24小时内血糖水平与其预后有明显的相关性（P〈0．01）。结论对颅脑外伤后高血糖进行迅速有效的控制,对病人的预后有十分重要的意义。     

重型颅脑损伤患者继发转氨酶异常与预后关系分析

目的探讨重型颅脑损伤后继发转氨酶异常与预后关系。方法对117例重型颅脑损伤患者抽血检查谷丙转氨酶（AIJT）、谷草转氨酶（AST），按化验结果分为转氨酶升高组和转氨酶正常组。转氨酶升高组包括ALT〉50U／L和（或）AST〉50U／L。分析两组间GOS预后良好率和死亡率区别；同时比较转氨酶升高组中不同GOS预后评分的ALT、AST水平。结果转氨酶升高组预后良好率低于转氨酶正常组（x2=4．71，P〈0．05），而死亡率高于转氨酶正常组（x2=5．42，P〈0．05）。转氨酶升高组中ALT、AST水平与GOS预后明显相关，且转氨酶水平越高，预后越差。结论重型颅脑损伤常致转氨酶异常，转氨酶升高水平与预后密切相关，监测及保护肝功能有利改善患者预后。     

重型颅脑损伤患者气管切开时机的选择及其对预后的影响

目的 探讨重型颅脑损伤患者气管切开时机，并分析其对预后的影响。方法 回顾性分析74例行气管切开术的重型颅脑损伤患者的临床资料，根据气管切开时间的不同，将患者分为两组：早期气管切开组（测定组）和非早期气管切开组（对照组），分别计算两组患者1周后的GCS评分变化，低氧血症、肺部感染和死亡的发生率，评价患者预后。本文所有数据用SPSS 11．0软件包完成统计。结果 测定组患者1周后的GCS评分明显高于对照组，两者差异有显著性（t=2．292，P〈0．05）；测定组低氧血症、肺部感染发生率及死亡率明显低于对照组，差异具有显著性（P〈0．05）。结论 正确把握气管切开的适应证，及早行气管切开对于保持呼吸道通畅及肺呼吸功能有积极作用。能够明显改善患者的预后，在重型颅脑损伤的救治中具有重要意义。     

31例重型颅脑损伤术中急性脑膨出的防治

重型颅脑损伤开颅术中急性脑膨出较为常见，由于病情危重．若处理不当．往往预后不良．死亡率很高。本文回顾自1998年1月至2005年9月本院收录的31例术中出现急性脑膨出的重型颅脑损伤患者的临床资料．分析其形成原因并探讨防治措施．     

早期使用胰岛素泵治疗重型颅脑损伤高血糖反应对患者预后的影响

目的观察早期使用胰岛素泵治疗重型颅脑损伤高血糖反应对患者预后的影响。方法测定重型颅脑损伤患者入院时的血糖，随机分成胰岛素泵治疗组和常规胰岛素强化治疗组，观察1个月后的疗效。结果重型颅脑损伤后血糖水平显著升高，其与格拉斯哥昏迷记分（GCS），预后差异有高度统计学意义（P〈0．01），胰岛素泵治疗组预后与对照组相比差异有高度统计学意义（P〈0．01）。结论测定血糖有助于了解颅脑损伤的严重程度，估计患者的预后，用胰岛素泵治疗重型颅脑损伤高血糖反应能改善患者预后。     

Topognostic and prognostic evaluation of traumatic facial nerve injuries

If and when to intervene during the course of a traumatic facial palsy depends on the immediacy of the palsy, signs and symptoms of an associated temporal bone fracture, function of the various facial branches, and the results of electrical stimulation. Some facial nerve tests will be more valuable than others in a given case. The following is a philosophy of management that has proven useful to the author in the management of facial palsies of traumatic causes.     

Relationship between intracranial pressure monitoring and outcomes in severe traumatic brain injury patients

Intracranial pressure (ICP) monitoring is recommended in patients with a severe traumatic brain injury (TBI) and an abnormal computed tomography (CT) scan. However, there is contradicting evidence about whether ICP monitoring improves outcome. The purpose of this study was to examine the relationship between ICP monitoring and outcomes in patients with severe TBI. From February 2001 to December 2008, a total of 477 consecutive adult (> or =18 years) patients with severe TBI were included retrospectively in the study. Patients who underwent ICP monitoring (n=52) were compared with those who did not (n=425). The primary outcome was hospital mortality. Secondary outcomes were ICU mortality, mechanical ventilation duration, the need for tracheostomy, and ICU and hospital length of stay (LOS). After adjustment for multiple potential confounding factors, ICP monitoring was not associated with significant difference in hospital or ICU mortality (odds ratio [OR] = 1.71, 95% confidence interval [CI] = 0.79 to 3.70, P = 0.17; OR = 1.01, 95% CI = 0.41 to 2.45, P = 0.99, respectively). ICP monitoring was associated with a significant increase in mechanical ventilation duration (coefficient = 5.66, 95% CI = 3.45 to 7.88, P < 0.0001), need for tracheostomy (OR = 2.02, 95% CI = 1.02 to 4.03, P = 0.04), and ICU LOS (coefficient = 5.62, 95% CI = 3.27 to 7.98, P < 0.0001), with no significant difference in hospital LOS (coefficient = 8.32, 95% CI = -82.6 to 99.25, P = 0.86). Stratified by the Glasgow Coma Scale score, ICP monitoring was associated with a significant increase in hospital mortality in the group of patients with Glasgow Coma Scale 7 to 8 (adjusted OR = 12.89, 95% CI = 3.14 to 52.95, P = 0.0004). In patients with severe TBI, ICP monitoring was not associated with reduced hospital mortality, however with a significant increase in mechanical ventilation duration, need for tracheostomy, and ICU LOS.     

The prognostic reliability of the Glasgow coma score in traumatic brain injuries: evaluation of MRI data

Purpose

To clarify the predictive power of the Glasgow coma score (GCS) after traumatic brain injury (TBI) and in the context of brain stem lesions.

Methods

In 143 patients who had suffered severe TBI, the GCS was correlated to brain damage as visualized by cranial magnetic resonance imaging (MRI). This technique evaluates the damage to the brain stem in particular. The Brussels coma score (BCS) was also used.

Results

The GCS was not significantly correlated to brain stem lesions when it was only scored at the time of admission. When MRI was not used later on, the GCS showed a poor ability to predict the outcome. After 24 h, and on the day of MRI screening, the GCS was significantly correlated with two parameters: outcome (the higher the GCS, the better the outcome) and the frequency of patients without injuries to the brainstem in MRI (the higher the GCS, the higher this frequency). These correlations were much more evident when the BCS was used. The prognostic power of the GCS was found to vary over time; for example: a GCS of 3 at admission was associated with a favorable prognosis; a GCS of 4 signified a poor prognosis, irrespective of the time point at which the GCS was scored; and the prognostic power of a GCS of 5 deteriorated from the day of the MRI onwards, whereas the prognostic power of a GCS of 6 or 7 varied little over time.

Conclusions

We only recommend the use of the GCS for prognostic evaluation in a multidimensional model. Study protocols should contain additional brain stem function parameters (BCS, pupil condition, MRI).     

Correlation between Glasgow coma scale and Jugular venous oxygen saturation in severe traumatic brain injury

BackgroundGlasgow Coma Scale (GCS) remains a key measure in neurological assessment after head injury and in most studies classification of the severity of the trauma is still based on the admission GCS.The aim of the workThe aim of the work was to correlate between Jugular venous oxygen saturation (Sjvo2) with GCS in cases with severe traumatic brain injury.Patients and methodsA 44 patients met the inclusion criteria, were included in the present study. They were selected from the neurosurgical and intensive care units at Al-Azhar University hospital during the period from June 2010 till June 2012. All therapeutic interventions were performed in accordance with Guidelines for the Management of Severe Traumatic Brain Injury. The following variables were collected: patients’ demographics, Sjvo2, ICP, MAP, CPP and GCS. All pressures were monitored invasively and with identical transducers connected to monitors, and expressed numerically in mmHg. Measurements were always performed at 8.00 a.m. At the same time, patients were neurologically examined and these data were expressed as GCS score.ResultsThere was statistically significant increase of GCS, MAP, CPP, Sjvo2 and Extended Glasgow Outcome Scale (GOSE) and decrease of ICP in survived in comparison to non-survived cases. In survived cases, there was positive significant correlation between Sjvo2 and GCS, MAP, CPP and GOSE, while there was significant negative correlation with ICT. On the other hand, in non-survived cases, there was only positive moderate, significant correlation between Sjvo2 and GCS. Running simple linear regression analysis, only GCS and Sjvo2 can predict mortality in studied cases.ConclusionResults of the present study proved that, Sjvo2 is proportionally correlated with GCS and both can predict the prognosis of severe traumatic injury.     

脊柱脊髓损伤合并重型颅脑损伤的早期诊治体会

目的：探讨早期诊治脊柱、脊髓损伤合并重型颅脑损伤病例，降低伤残率、死亡率的有效措施。方法：回顾性分析本院45例患者，及采取的相应诊断治疗措施。结果：临床治愈26例，好转14例，死亡5例。结论：骨科、神经外科和急诊科医生必须给予足够的重视，早期正确检查、及早诊断和有效治疗至关重要，常规行头部和脊柱脊髓影像学检查十分必要，进一步可采取CT三维重建、MRI等检查，提高早期诊断率，对降低伤残与死亡率有着十分重要的临床意义。     

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。     

Glutamate in traumatic brain injuries

During the past years, studies dealing with the pathophysiology of brain injuries have focused on certain agents that seem to be particularly involved in secondary brain lesions. Of them, some amino acids, and particularly glutamate, appears to deserve special attention. We discuss the role of glutamate neurotransmitters, review glutamate metabolism and actions, and then review in the pertinent literature devoted to the role of glutamate in the onset of brain injuries secondary to head trauma.