去骨瓣减压术在Ⅳ、Ⅴ级动脉瘤破裂患者早期手术后的应用

动脉瘤是常见的脑血管病变之一，多以蛛网膜下腔出血（subarachnoid hemorrhage．SAH）发病，尽管治疗技术不断进步，但动脉瘤破裂患者预后仍然较差，特别是Ⅳ、Ⅴ级动脉瘤患者，虽经积极治疗，预后仍不良，致残率和病死率相当高。如何改善这部分患者预后成为目前研究的热点和难点。随着去骨瓣减压术在重度颅脑损伤、脑梗死等患者中应用产生的良好效果逐渐被认可，     

动脉瘤性与非动脉瘤性蛛网膜下腔出血的比较

目的探讨动脉瘤性和非动脉瘤性蛛网膜下腔出血（SAH）的诊断、治疗和预后的差异.方法对同期发现的非动脉瘤性SAH 16例与动脉瘤性SAH 117例患者的临床表现、入院时意识状况、Hunt and Hess分级以及头颅CT扫描、并发症及预后进行比较和分析.结果非动脉瘤性SAH与非动脉瘤性SAH相比,前者临床症状轻,无局灶性神经体征,16例中仅有2例出现意识障碍（12.5%,2/16）,93.75%（15/16）患者Hunt and Hess分级为Ⅰ、Ⅱ级,Franz量化为（7.2＋3.2）分.结论非动脉瘤性SAH,尤其是非动脉瘤性中脑周围SAH是一种特殊类型的出血模式,临床过程轻微,并发症少,预后良好.     

乳胶垫片在去骨瓣减压手术中的应用

去骨瓣减压术是用于治疗急性幕上颅内血肿和脑挫裂伤、防治恶性颅内高压常用的一种手术方式,而后期在颅骨修补时,由于皮瓣和脑表面往往粘连十分紧密,造成皮瓣剥离困难,并容易造成脑皮层损伤等一系列问题.而我科在去骨瓣减压手术时采用皮瓣下放置乳胶垫片方法,成功解决了上述问题,取得良好效果,现报告如下.     

动脉瘤性蛛网膜下腔出血后脑积水

脑积水是动脉瘤性蛛网膜下腔出血 (ＳＡＨ)后的常见并发症之一 ,对病人的预后有直接的影响 ,本文报告 2 1例动脉瘤性ＳＡＨ后脑积水的治疗。临床资料和治疗方法　　 1.一般资料 :男 9例 ,女 12例 ,年龄 2 2～ 6 6岁 ,平均 4 7 5岁。颈内 后交通动脉瘤 10例 ,前交通动脉瘤 7例 ,大脑中动脉动脉瘤 2例 ,大脑后动脉动脉瘤 2例。ＳＡＨ次数 :1次 2例、 2次 15例、3次 3例、 4次 1例。动脉瘤大小 :0 6～ 1 0ｃｍ 10例、 1 1～ 1 5ｃｍ 7例、 1 6～ 2 5ｃｍ 4例。Ｈｕｎｔ Ｈｅｓｓ分级 :Ⅱ级 3例、Ⅲ级 4例、Ⅳ级 11例、Ⅴ级 3例。临床症状 :…     

宝石CT双低在动脉瘤蛛网膜下腔出血中的应用

目的探讨GE HD750宝石CT能谱技术双低,即低剂量、低辐射在动脉瘤蛛网膜下腔出血中的临床应用。方法选取2015-11—2016-05河南省中医院收治的动脉瘤蛛网膜下腔出血及临床上怀疑脑动脉瘤的患者70例,随机分为双低组和正常组各35例,双低组采用管电压70kVp,对比剂(威视派克,GE)270mgI/mL;正常组采用管电压120kVp,对比剂(碘海醇,GE)350mgI/mL。对2组图像质量进行评价。结果双低组噪声比显著高于正常组(P0.05);2组图像质量、动脉瘤检出率、图像噪声值比较,差异无统计学意义(P0.05)。双低组图像质量分布情况与正常组比较差异无统计学意义(P0.05)。正常组检查时接受的辐射剂量(4.17±0.38)mSv,双低组为(2.60±0.32)mSv,双低组明显低于正常组(t=18.5,P=0.000)。结论扫描条件为管电压70kVp时,使用对比剂(威视派克,270mgI/mL)进行头部CTA检查,能够获得与扫描条件为120kV,使用对比剂(碘海醇,GE,350mgI/mL)相同质量的图像,但使用的对比剂数量更少,也更为安全,而动脉瘤的检出率与常规方法无明显差别。     

脑动脉瘤致蛛网膜下腔出血的脑血管痉挛及早期手术问题

脑动脉瘤破裂引起的蛛网膜下腔出血所致之血管痉挛是外科手术前后最常见和最严重的并发症之一。根据16个国家68个神经外科中心联合研究的资料,在3346例患者中有33.5％血管痉挛是病情恶化和死亡的主要原因。在住院患者中,因血管痉挛导致死亡和病情恶化者占14％。显而易见,血管痉挛引起了包括神经外科在内的临床医师的关注,并提出了包括早期手术在内的防治措施。现将有关问题的研究进展综述如下。     

动脉瘤性蛛网膜下腔出血37例临床分析

1 临床资料 1.1一般资料男9例,女28例,年龄30～77岁,平均54.6岁。Hunt-Hess分级:Ⅰ级3例,Ⅱ级17例,Ⅲ级13例,Ⅳ级3例,Ⅴ级1例。合并动眼神经麻痹10例,脑内血肿和脑积水各5例。SAH诊断依据:突发性剧烈头痛、恶心、呕吐病史,CT示蛛网膜下腔出血或腰穿示血性脑脊液。     

颅脑损伤去骨瓣减压术后慢性脑积水

目的探讨创伤后去骨瓣减压的类型及是否二次手术对脑积水发生的影响。方法回顾性分析387例中、重型颅脑损伤手术病人。结果去骨瓣减压病人脑积水发生率为27.0%,保留骨瓣的病人脑积水发生率为3.8%,双侧开颅、二次手术增大脑积水的发生率,骨瓣距中线距离越近越容易发生脑积水结论去骨瓣减压手术和创伤后脑积水有明确的相关关系,骨瓣相对较大、二次手术及骨瓣距离中线近和脑积水的形成有关。     

微透析监测技术在动脉瘤性蛛网膜下腔出血中的应用

脑微透析技术是一种测定活体脑细胞间液中生化物质变化的新技术。近年来国内外学者应用微透析技术对动脉瘤性蛛网膜下腔出血病人进行连续监测,通过对细胞间液中兴奋性氨基酸、乳酸、葡萄糖、甘油等生化物质代谢变化的检测来研究脑血管痉挛、脑缺血以及延迟性缺血性神经功能障碍(DIND),本文对此进行综述。     

去骨瓣减压术在高血压脑出血手术治疗中的应用

目的探讨去骨瓣减压术治疗高血压脑出血的临床疗效与安全性。方法收集2008-01—2014-06我院行血肿清除术联合去骨瓣减压术治疗的高血压脑出血患者55例作为观察组,同期行单纯血肿清除术治疗者43例作为对照组,比较2组临床疗效。结果观察组优良率为65.5%,显著高于对照组的34.9%;治疗后2组NIHSS评分均显著降低,且观察组显著低于对照组(P0.05);观察组ADL分级显著低于对照组(P0.05)。结论去骨瓣减压术治疗高血压脑出血有利于改善患者的神经功能缺损症状与日常生活活动能力,疗效显著,值得推广应用。     

Ventriculomegaly after decompressive craniectomy with hematoma evacuation for large hemispheric hypertensive intracerebral hemorrhage

Objective

The aim of the present study was to investigate factors associated with the development of ventriculomegaly suggestive of hydrocephalus (VSOH) after decompressive craniectomy with hematoma evacuation for hemispheric hypertensive intracerebral hemorrhage.

Methods

This study focused on 21 patients who underwent decompressive craniectomy with hematoma evacuation for hemispheric hypertensive intracerebral hemorrhage. The patients’ clinical and radiological findings were retrospectively reviewed.

Results

Eleven patients were male and ten were female, with an age range from 22 to 75 years (mean, 56.6 years). The preoperative Glasgow Coma Scale score ranged from 3 to 13 (mean, 6.9). Hematoma volumes ranged from 33.4 to 98.1 ml (mean, 74.2 ml). Hematoma locations were the basal ganglia in 10 patients and the subcortex in 11 patients. The presence of intraventricular hemorrhage was significantly associated with the development of VSOH (P = 0.023). The distance of the decompressive defect to the midline and the presence of meningitis showed a strong trend for association with VSOH (P = 0.051, P = 0.090, respectively).

Conclusion

Careful attention should be paid to the occurrence of VSOH after decompressive craniectomy with hematoma evacuation in intracerebral hemorrhage patients with intraventricular extension, meningitis, and/or a short distance of the decompressive defect to the midline.     

动脉瘤性蛛网膜下腔出血后慢性脑积水的诊治

目的探讨动脉瘤性蛛网膜下腔出血(aSAH)后慢性脑积水的诊断与治疗方法。方法回顾性分析33例经手术治疗的aSAH后慢性脑积水患者的临床资料。结果治疗后随访6月～2年,按GOS评分,恢复良好27例,轻残3例,重残2例,死亡1例。结论慢性脑积水是aSAH后的常见并发症,脑室-腹腔分流术是aSAH后慢性脑积水的有效治疗方法。     

Characteristics and prognostic value of acute catecholamine surge in patients with aneurysmal subarachnoid hemorrhage

Abstract

Objectives: The characteristics of serum catecholamine concentration at the hyper-acute phase of aneurysmal subarachnoid hemorrhage (SAH) and its relationship between patient outcome and delayed vasospasm were investigated.

Methods: Patients with aneurysmal SAH (170) were prospectively studied between August 2008 and June 2011. Baseline demographic data and physiological parameters, including plasma concentrations of adrenaline (AD), noradrenaline (NA), and dopamine (DP) were evaluated for all patients.

Results: On admission, plasma AD, NA, and DP levels were significantly higher in patients with a poor clinical grade on admission (Hunt and Kosnik grade: IV–V), compared to those with a good clinical grade on admission (Hunt and Kosnik grade: I–III). AD showed a markedly high concentration immediately after the onset of SAH and then rapidly decreased. NA levels peaked within 6 hours after onset, then significantly decreased. The increase of DP with time was not significant, but showed a similar trend to that of NA. The level of each catecholamine showed significant mutual correlation.

Our multivariate model demonstrated that age, poor clinical grade at admission, plasma AD and NA levels were good predictors of poor patient outcome [receiver operating characteristic (ROC) area: 0·83]. And that poor clinical grade at admission, Fisher scale, blood sugar level and plasma AD level were good predictors of the development of delayed vasospasm (ROC area: 0·81) (1·3).

Conclusions: The present findings suggest that sympathetic activation in patients in the acute phase of SAH reflects the severity of SAH, and is closely related to the development of delayed vasospasm, leading to the subsequent immune response and inflammatory reactions. Strategies for suppressing catecholamine at the hyper-acute phase may contribute to vasospasm prevention and improve patient outcome.     

Hypertensive intracerebral hematoma after aneurysmal subarachnoid hemorrhage

We report a patient with sequential intracerebral hematoma in bilateral basal ganglia after an aneurysmal subarachnoid hemorrhage. A 55-year-old woman presented with sudden loss of consciousness without a past history of hypertension. Subarachnoid hemorrhage secondary to a ruptured anterior communicating artery aneurysm was seen on initial CT and an intracerebral hematoma was observed in both basal ganglia 3 hours later on a follow-up CT scan. We suggest that delayed intracerebral hematoma may occur due to increased intracranial pressure caused by aneurysmal rupture and discuss the possible mechanisms of this occurrence.     

去骨瓣减压术联合硬脑膜减张缝合术治疗巨大硬脑膜外血肿临床研究

目的探讨去骨瓣减压术联合硬脑膜减张缝合术治疗巨大硬脑膜外血肿临床效果。方法选取78例巨大硬脑膜外血肿患者,分成2组,对照组39例予去骨瓣减压术,观察组39例在对照组基础上联合硬脑膜减张缝合术,观察术后相关指标变化情况。结果观察组预后良好发率高于对照组,重残率、植物生存率低于对照组(P0.05),观察组并发症率(脑积水、脑膨出或脑软化、硬膜下或纵裂积液、脑脊液漏、癫痫、颅内感染)均低于对照组(P0.05)。2组治疗后住院时间、意识恢复时间、出血量、输血发生率比较差异有统计学意义(P0.05)。结论去骨瓣减压术联合硬脑膜减张缝合术能提高巨大硬脑膜外血肿临床效果,降低并发症发生率。     

Multiplexed protein profiling after aneurysmal subarachnoid hemorrhage: Characterization of differential expression patterns in cerebral vasospasm

Cerebral vasospasm is a major contributor to delayed morbidity following aneurysmal subarachnoid hemorrhage. We sought to evaluate differential plasma protein levels across time in patients with aneurysmal subarachnoid hemorrhage to identify potential biomarkers and to better understand the pathogenesis of cerebral vasospasm. Nine female patients with aneurysmal subarachnoid hemorrhage underwent serial analysis of 239 different serum protein levels using quantitative, multiplexed immunoassays (DiscoveryMAP 250+ v2.0, Myriad RBM, Austin, TX, USA) on post-hemorrhage days 0 and 5. A repeated measures analysis of variance determined that mean protein concentration decreased significantly in patients who developed vasospasm versus those who did not for alpha-2-macroglobulin (F [1.00,7.00] = 16.33, p = 0.005), angiogenin (F [1.00,7.00] = 7.65, p = 0.028), apolipoprotein A-IV (F [1.00,7.00] = 6.308, p = 0.040), granulocyte colony-stimulating factor (F [1.00,7.00] = 9.08, p = 0.020), macrophage-stimulating protein (F [1.00,7.00] = 24.21, p = 0.002), tetranectin (F [1.00,7.00] = 5.46, p < 0.039), vascular endothelial growth factor receptor 3 (F [1.00,7.00] = 6.94, p = 0.034), and significantly increased for vitronectin (F [1.00,7.00] = 5.79, p = 0.047). These biomarkers may be of value in detecting cerebral vasospasm, possibly aiding in the identification of patients at high-risk prior to neurological deterioration.     

The 100 most influential publications pertaining to intracranial aneurysms and aneurysmal subarachnoid hemorrhage

The study of intracranial aneurysms has grown at an astounding rate since Sir Charles Symond’s association of hemorrhage within the subarachnoid space to intracranial aneurysms in 1923. These associations led to the first surgical treatment of an intracranial aneurysm with wrapping by Norman Dott in 1931, and shortly thereafter, clip ligation by Walter Dandy in 1938. Surgical outcomes were improved by the introduction of the operative microscope in the 1960s and perioperative care utilizing induced hypertension, hypovolemia, and hemodilution (“HHH therapy”). Recent monumental advancements, such as coil embolization in 1990 by Guglielmi, have continued to advance the field forward. The authors hope to highlight some of the most seminal and influential works. Herein, we utilize the technique of citation analysis to assemble a list of the 100 most influential works pertaining to aneurysmal subarachnoid hemorrhage published between the years 1900 and 2015 to honor these individuals and to provide guidance to current and future researchers in the field. We additionally calculate the effects of author, journal, topic, and study design on the overall influence of publications in this field.     

早期颅骨修补对行去骨瓣减压术的脑损伤及脑出血患者预后的影响研究

目的研究早期颅骨修补对行去骨瓣减压术的脑损伤及脑出血患者的术前术后神经功能缺损评分及并发症的影响。 方法选取深圳市宝安区沙井人民医院神经外科自2016年1月至2018年5月收治的76例行去骨瓣减压术的脑损伤及脑出血患者作为研究对象,采用随机数字表法将入组患者分为早期组（35例）和对照组（41例）,早期组在去骨瓣减压术后4~6周内实施颅骨修补,对照组在术后3~6个月后实施修颅骨修补,对比2组患者术前术后的美国国立卫生研究院卒中量表（NIHSS）评分、术后并发症发生情况以及日常生活能力评分（ADL）和肢体运动功能评分（Fugl-Meyer）。 结果治疗前2组患者的NIHSS评分、ADL评分及Fugl-Meyer评分比较,差异均无统计学意义（P>0.05）。治疗后2组患者的NIHSS评分均显著下降（P<0.05）,且早期组的NIHSS评分显著低于对照组;早期组的ADL评分和Fugl-Meyer评分显著高于对照组（P<0.05）;早期组的并发症发生率显著低于对照组（P<0.05）。 结论颅脑损伤患者实施去骨瓣减压术后,早期实施颅骨修补能够显著改善患者的神经功能缺损状况,并有助于降低术后并发症的发生,对于患者的临床治疗和预后恢复具有积极的影响。     

去骨瓣减压术后的环池改变及其临床意义

目的 探讨环池在去骨瓣减压术后的变化及其临床意义。方法 根据94例患者手术前后CT扫描变化，分析环池变化与临床疗效的关系。结果 环池受压减轻组中62例死亡9例，无改变或加重组中32例死亡19例。结论 去骨瓣减压术后的环池改变对预后有重要意义，动态观察环池的变化是必要的。