双侧额叶脑挫裂伤迟发性恶化的治疗体会

目的探讨双侧额叶脑挫裂伤迟发性恶化患者的临床特点及治疗方法。方法回顾性分析2008年1月～2012年12月收治的47例双侧额叶脑挫裂伤患者的临床资料。结果12例出现迟发性恶化，平均时间为伤后110h；恶化时，迟发性恶化患者出血和水肿量明显高于未发生恶化的患者（P〈0．05）；发生恶化的12例患者中，5例出现血钠或渗透压下降。发生恶化的12例患者出院后6个月GOS评分：2例死亡，1例中残，9例恢复良好。结论出血少但水肿范围较大、基底池有受压表现的双侧额叶脑挫裂伤容易出现迟发性恶化。一旦出现迟发性恶化，及时手术是关键。     

双侧额叶脑挫裂伤41例手术治疗分析

目的 探讨双侧额叶脑挫裂伤的手术治疗策略.方法 回顾分析41例双额叶脑挫裂伤患者,除脱水等治疗外,尽早手术干预的临床资料.结果 全组41例,恢复良好36例,重残及植物生存3例,死亡2例.结论 双侧额叶脑挫裂伤患者,及时恰当的手术治疗,可降低患者死残率.     

双侧额颞去骨瓣减压治疗广泛性脑挫裂伤并发脑疝的21例体会

目的探讨双侧额颞去骨瓣减压治疗广泛性脑挫裂伤并发脑疝的疗效及手术指征。方法对21例行双侧额颞去骨瓣减压治疗的广泛性脑挫裂伤伴脑疝病例进行回顾性分析。结果根据GOS评分,恢复良好4例,轻残7例,重残4例,植物生存2例,死亡4例。结论双侧额颞去骨瓣减压能有效提高广泛性脑挫裂伤并发脑疝的重型颅脑损伤患者治疗效果。     

双额叶脑挫裂伤并发脑中心疝的临床分析

目的 探讨双额叶脑挫裂伤及并发脑中心疝的临床特点,手术时机和方法.方法 回顾性分析23例双额叶脑挫裂伤并发脑中心疝患者的临床症状、影像学特征、治疗方法及治疗效果.结果 半年随访,根据格拉斯哥预后评分(GOS评分),恢复良好7例,中残7例,重残5例,植物生存2例,死亡2例.结论 双额叶脑挫裂伤患者应密切观察意识,瞳孔,CT影像学变化,及时的双侧开颅减压,以提高治疗效果.     

双侧额叶脑挫裂伤救治体会

目的探讨双侧额叶脑挫裂伤治疗方法及手术时机。方法对31例双侧额叶脑挫裂伤临床资料进行回顾性分析。结果 31例患者中,14例双侧额叶发生大面积脑水肿行双额去骨板减压术,其中9例在未发生枕骨大孔疝时手术治疗,术后1例因脑水肿严重发生枕骨大孔疝而死亡,8例恢复良好;5例发生枕骨大孔疝后手术治疗,术后仍因中枢性呼吸、循环衰竭死亡。结论 双额去骨板减压术是治疗双侧额叶脑挫裂伤积极有效措施,可减少枕骨大孔疝的发生,降低病死率。     

冠状前半颅开颅在对冲性双侧额叶脑挫裂伤中的应用体会

目的：探讨冠状前半颅开颅在对冲性双侧额叶脑挫裂伤中的治疗效果及手术要点。方法回顾性分析12例运用冠状前半颅开颅手术治疗的对冲性双侧额叶脑挫裂伤病例的临床资料。结果术后发生硬膜下积液3例，无其他并发症发生；术后6个月GOS评分：良好3例，轻残4例，重残3例，死亡2例。结论冠状前半颅开颅是治疗对冲性双侧额叶脑挫裂伤的有效术式，把握手术时机、掌握手术要点可提高疗效，降低病死率和致残率。     

急性颅脑创伤后进展性颅内出血的CT表现

目的：探讨急性颅脑创伤后进展性颅内出血（PIH）发生的CT表现与临床价值。方法回顾性分析我院2009-02-2013-09收治的626例急性颅脑创伤患者的临床资料,分析PIH患者与非 PIH患者的CT 表现差异以及PIH发生的危险因素。结果单因素回归分析发现,PIH组与非 PIH组首次CT 表现中颅骨骨折、蛛网膜下腔出血、脑挫裂伤、硬膜外血肿、硬膜下血肿差异有统计学意义（P＜0·05）。多因素回归分析发现,颅骨骨折、蛛网膜下腔出血、脑挫裂伤、硬膜外血肿是影响急性颅脑创伤后进展性颅内出血的独立危险因素（P＜0·05）,蛛网膜下腔出血是最强因素。结论急性颅脑创伤后应尽快进行头颅CT检查,以便尽快确诊PIH及时进行治疗。     

单侧入路大脑镰切开治疗双额叶脑挫裂伤

目的 探讨采用单侧入路大脑镰切开治疗非对称性双额叶脑挫裂伤的手术方法.方法 将我科自2004年3月至2008年3月收治的120例双额叶脑挫裂伤病人分为两组:一组单侧开颅60例;另一组常规双侧开颅60例,两组病人临床基本情况、伤情、伤后至手术时间差异无统计学意义(P＞0.05),所有的病人术前术后都经CT检查证实颅内变化情况.结果 根据伤后6个月GOS预后评分判断预后,两组差异无统计学意义(P＞0.05).单侧组恢复良好48例,重残3例,中残5例,植物生存2例,死亡2例.双侧组恢复良好45例,重残4例,中残6例,植物生存2例,死亡3例.但是手术时间、输血量、住院费用、住院时间、精神障碍、嗅神经损伤单侧组明显优于双侧组(P＜0.01).结论 选择单侧入路大脑镰切开清除双额叶脑挫裂伤、脑内血肿,能明显减少迟发血肿发生,减少因出血水肿造成的大脑镰疝及脑中心疝的发生,但采用此法应严格掌握手术适应证.     

创伤性颅脑损伤后血钠紊乱的危险因素与预后

目的探讨创伤性颅脑损伤发生血钠紊乱的危险因素以及对预后的影响。方法回顾性分析80例中、重型颅脑损伤病例资料。分析血钠紊乱的发生率,外伤性脑损伤后首次CT扫描时的伤情表现和意识状态。结果 36例发生血钠紊乱,20例表现为高钠血症,16例表现为低钠血症。血钠紊乱在硬膜下血肿、脑内血肿和弥散性轴索损伤的病例中发生率更高。弥漫性脑损伤的病例血钠紊乱的发生率比局限性脑挫裂伤组高。结论弥漫性脑损伤病例血钠紊乱的发生率比较高。局限性脑损伤与血钠紊乱的比例并没有相关性。     

甘露醇对双额底脑挫裂伤迟发性脑水肿的影响

目的探讨单纯甘露醇治疗对双侧额叶底脑挫裂伤后迟发性脑水肿形成的影响。方法将87例患者随机分成单纯治疗组及综合治疗组,分析发生迟发性脑水肿病例的相关性。结果在2周后单纯组与综合治疗组迟发性脑水肿的发生比较有显著的统计学差异（P〈0.05）。结论单纯甘露醇治疗双侧额底脑挫裂伤比采用高渗氯化钠等综合治疗措施更易发生迟发性脑水肿。     

Delayed deterioration in patients with traumatic frontal contusions.

The clinical course of 18 head injured patients in whom CT had shown frontal contusions without diffuse brain injury or intracranial haematoma was reviewed. All 10 patients with unilateral frontal contusion made a good recovery. Only two of five patients with limited bilateral frontal contusions made a good recovery. Two of three patients with extensive bilateral frontal contusions deteriorated more than 24 hours after injury, and one died. Delayed deterioration is an important complication of extensive traumatic bifrontal contusions.     

Early and late outcome in head injury patients with radiological evidence of brain damage

This study examined the early and late outcome in head injury patients with focal or multifocal (unilateral or bilateral) brain contusions revealed by computerized tomography (CT) scanning. The outcome was also evaluated in patients hospitalized due to brain concussion. Three months after the injury (the early outcome) 43% of the 86 cases with multifocal contusions on the CT scan were dead. As evaluated by the Glasgow Outcome Scale, all the 57 patients with a focal brain contusion, as well as the 117 cases with brain concussion, made a good recovery or were moderately disabled. The late outcome (1 to 5 years after injury) was evaluated in 78 cases with brain contusion and in 85 cases with brain concussion, and revealed that complaints and impaired adaptive functioning were frequent in both the contusion and concussion group. The occurrence of headache, dizziness and sleep problems did not significantly differ among the various head injury groups. However, focal or multifocal brain contusions on the CT scan increased the frequency of impaired memory, impaired concentration, speech problems, weakness in arms or legs and seizures with loss of consciousness. Cognitive deficits and speech problems were particularly common in patients with a focal contusion in the temporal lobe. The late adaptive and social functioning were most markedly impaired in cases with multifocal bilateral contusions.     

外伤后颅内进展性出血性损伤106例分析

目的探讨颅脑损伤后进展性出血性损伤（PHI）的发生及影响预后的相关因素。方法对2007年颅脑损伤后出现PHI的106例患者的临床资料进行回顾性分析,并与同期无PHI患者进行对照研究。结果颅脑损伤后是否出现PHI与患者的年龄是否超过50岁（P〈0．05）、血浆纤维蛋白原水平是否低于2g／L（P〈0．01）及有无蛛网膜下腔出血（SAH）（P〈0．05）密切相关。PHI患者的预后与年龄是否超过50岁（P〈0．01）、血浆纤维蛋白原水平是否低于2g／L（P〈0．01）、有无SAH（P〈0．01）及入院时的GCS评分（P〈0．01）密切相关。结论PHI最常出现于颅脑伤后12h内,好发于着力点的对冲部位,以额颞部为主,与患者的年龄、血浆纤维蛋白原水平及是否伴有SAH等因素密切相关;其预后与患者的年龄是否超过50岁、入院时GCS评分、血浆纤维蛋白原水平是否低于正常及是否伴有SAH密切相关。     

超薄多层螺旋CT与脑灌注成像在颅脑损伤早期诊断中的对比研究

目的探讨超薄多层螺旋CT和脑灌注成像在急性颅脑外伤(TBI)早期诊断中的临床应用价值。方法收集2010年12月~2012年10月我院收治的200例急性颅脑外伤患者检查资料,均于伤后6 h内行超薄多层螺旋CT(MSCT)和CT脑灌注成像(CTP)检查,全部病例于伤后2~3 d动态复查MSCT明确诊断,将数据进行回顾性分析,采用卡方检验评价。结果在MSCT与CTP这两种检测方法中,CTP在脑挫裂伤、硬膜下血肿和脑内血肿的诊断中优于超薄MSCT(P0.05),并且病灶周围低灌注区域大于超薄MSCT。结论 CTP对于急性颅脑外伤早期和微小损伤的诊断优于超薄MSCT,同时可以反映脑组织的灌注情况,具有可靠的临床价值。     

Temporal lobe contusions on computed tomography are associated with impaired 6-month functional recovery after mild traumatic brain injury: a TRACK-TBI study

ABSTRACT

Introduction: Mild traumatic brain injury (MTBI) can cause persistent functional deficits and healthcare burden. Understanding the association between intracranial contusions and outcome may aid in MTBI treatment and prognosis.

Methods: MTBI patients with Glasgow Coma Scale 13–15 and 6-month outcomes [Glasgow Outcome Scale-Extended (GOSE)], without polytrauma from the prospective TRACK-TBI Pilot study were analyzed. Intracranial contusions on computed tomography (CT) were coded by location. Multivariable regression evaluated associations between intracranial injury type (temporal contusion [TC], frontal contusion, extraaxial [epidural/subdural/subarachnoid], other-intraaxial [intracerebral/intraventricular hemorrhage, axonal injury]) and GOSE. Odds ratios (OR) are reported.

Results: Overall, 260 MTBI subjects were aged 44.4 ± 18.1-years; 67.7% were male. Ninety-seven subjects were CT-positive and 46 had contusions (41.3%–frontal, 30.4%–temporal, 21.7%–frontal + temporal, 2.2% each-parietal/occipital/brainstem); 95.7% had concurrent extraaxial hemorrhage. Mortality was 0% at discharge and 2.3% by 6-months.

GOSE distribution was 2.3%–death, 1.5%–severe disability, 27.7%–moderate disability, 68.5%–good recovery. Forty-six percent of TC-positive subjects suffered moderate disability or worse (GOSE ≤6) and 41.7% were unable to return to baseline work capacity (RTBWC), compared to 29.1%/20.4% for CT-negative and 26.1%/20.9% for CT-positive subjects without TC. On multivariable regression, TC associated with OR = 3.33 (95% CI [1.16–9.60], p = 0.026) for GOSE ≤6, and OR = 4.48 ([1.49–13.51], p = 0.008) for inability to RTBWC.

Conclusions: Parenchymal contusions in MTBI are often accompanied by extraaxial hemorrhage. TCs may be associated with 6-month functional impairment. Their presence on imaging should alert the clinician to the need for heightened surveillance of sequelae complicating RTBWC, with low threshold for referral to services.     

Middle age increases tissue vulnerability and impairs sensorimotor and cognitive recovery following traumatic brain injury in the rat

With increasing age comes an increased risk for sustaining traumatic brain injuries (TBI). However, the effect of age is rarely studied in animal models of TBI. The present study evaluated the effect of increased age on recovery of function following bilateral medial frontal cortex injury. Groups of young (3 months) and middle-aged (14 months) rats received bilateral frontal cortex contusions or sham injuries. The rats were tested on a variety of tests to measure sensorimotor performance (bilateral tactile adhesive removal test), skilled forelimb use (staircase test), and the acquisition of reference and working memory in the Morris water maze. Results indicated that injury produced significant impairments on all behavioral tests compared to sham controls. Middle-aged rats that received cortical contusions were significantly impaired on the bilateral tactile adhesive removal test, acquisition of a reference memory task, and working memory compared to young-injured rats. Histological analysis showed that middle-aged rats developed significantly larger lesion cavities but did not show an increase in the number of glial fibrillary acidic protein (GFAP+) cells compared to young-injured rats. Age alone also significantly impaired function on the bilateral adhesive tactile removal test, skilled forelimb use, the acquisition of a reference memory task, and also increased the number of GFAP+ cells compared to young rats. These results indicate that middle-aged rats respond to brain injury differently than young rats and that age is an important factor to consider in pre-clinical efficacy studies.     

207例重型颅脑损伤合并多发伤的救治分析

目的探讨重型颅脑损伤合并多发伤的临床救治经验。方法选取我科收治的207例重型颅脑创伤合并多发伤患者,回顾性分析其临床资料以及治疗方法,总结重型颅脑创伤合并多发伤的治疗经验以及疗效。结果预后按格拉斯哥结果评分法(GOS评分),恢复良好70例(33.8%),轻残42例(20.2%),重残29例(14%),植物生存10例(4.8%),死亡56例(27.2%)。结论早期诊断,尽早判断伤情,合理把握抢救顺序,及时抢救危及生命的器官损伤,重视术后的综合治疗,则可提高颅脑损伤合并多发伤抢救成功率,减少伤残率和病死率。     

Traumatic isolated intracerebral hemorrhage in children

Among 314 children with craniocerebral injury, 21 were diagnosed as having traumatic, isolated intracerebral hemorrhage (TIICH) by computed tomography (CT) from 1980 to 1986 (basal ganglia, 7; frontal, 8; parietal, 2; frontoparietal, 1; temporoparietal, 1; intraventricular, 1; midbrain, 1). The level of consciousness was assessed according to the Children's Coma Score (CCS) and CT scan was subsequently repeated to evaluate the change in TIICH. The patients were classified into three types according to their clinical courses and CT findings: type I (4 cases), type II (14 cases), and type III (3 cases). Of the 21 cases, conservative treatment was given in 15 and surgical treatment in 6. The outcome showed: good recovery in 1, fair recovery in 7, poor recovery in 2, and death in 2. Type III had a poor prognosis. We discuss the mechanism of the formation of TIICH and speculate that impact to the head caused shear strain in the small perforating vessels and at the junction between white and gray matter which, in turn, caused vascular rupture.     

Diffuse axonal injury due to traumatic brain injury alters inhibition of imitative response tendencies

It is well known that traumatic brain injury particularly affects the frontal lobes. Consequently, patients often suffer from executive dysfunction and behavioral disturbances. Accordingly, our study aimed at investigating patients after traumatic brain injury with two tasks involving different functional processes and structural networks supported by the frontal lobes. Two paradigms were applied: the Stroop color-word task and a task in which subjects had to inhibit imitative response tendencies. We selected a patient group solely with diffuse axonal injury, as this type of injury is homogenous and is correlated with cognitive dysfunction more than focal contusions. To evaluate long-term effects most relevant for rehabilitation, we selected a patient group whose brain injuries dated back several years. Our results show that patients with diffuse axonal injury inhibited imitative responses more successfully than control subjects, whereas executive processes examined with the Stroop task were unaltered. Interestingly, impairments were tightly correlated both with the length of the post-traumatic amnesia predicting outcome in traumatic brain injury and with behavioral disturbances. Impairments in the imitation-inhibition task may indicate alterations in an anterior frontomedian neural network even years after traumatic brain injury.     

外伤性癫痫危险因素的临床分析

目的为外伤性癫痫的早期预防和治疗提供依据。方法回顾性分析356例颅脑损伤病人的临床资料,重点分析外伤性癫痫与颅脑损伤类型,患者年龄、性别以及颅脑损伤严重程度和损伤部位的关系。结果 16岁以下儿童和成人外伤性癫痫发生率分别为16.67%(9/54)和6.62%(20/302),两者相较相差显著(P0.01)。开放性颅脑损伤与闭合性颅脑损伤患者癫痫的发生率分别为29.73%(11/37)和5.64%(18/319),两者相较相差显著(P0.01);脑挫裂伤合并脑内血肿、弥漫性轴索损伤及凹陷性颅骨骨折患者的癫痫发生率分别为16.94%(21/124)、20.51%(8/39)和10.53%(4/38),明显高于CT检查未见颅内明显异常的98例颅脑损伤患者的癫痫发生率1.02%(P0.05)。结论开放性颅脑损伤、脑挫裂伤并脑内血肿、弥漫性轴索损伤、凹陷性颅骨骨折及年龄16岁以下可能是外伤性癫痫的危险因素。