动态CT扫描联合TCD检查预测外伤性蛛网膜下腔出血患者预后

目的动态CT扫描联合TCD预测外伤性蛛网膜下腔出血（tSAH）患者预后。方法对155例外伤性蛛网膜下腔出血患者给予动态CT扫描及TCD监测脑血流,6个月后行GOS评分（预后评分）。结果CT扫描tSAH出血量多、Hidjra分型13分以上、出血部位位于颅底大血管周围（外侧裂池、基底池、鞍上池、环池、四叠体池）,合并明显颅内损伤,颅内压较高及TCD监测的大脑中动脉血流明显增快者GOS评分低,预后较差。结论tSAH患者动态CT表现严重、TCD血流增速明显者,预后差。     

重型颅脑损伤术后继发创伤性脑梗死的原因分析

目的 探讨重型颅脑损伤患者术后继发创伤性脑梗死的危险因素及防治措施. 方法 回顾性分析经开颅手术治疗的187例重型颅脑损伤患者的临床资料,根据术后半月内是否出现创伤性脑梗死分为创伤性脑梗死组与无创伤性腩梗死组,对可能造成创伤性脑梗死的因素,如性别、年龄、是否为多发伤、是否出现脑疝、是否合并有创伤性蛛网膜下腔出血等方面,进行统计学分析. 结果 本组187例重型颅脑损伤患者术后继发创伤性脑梗死21例,其中大面积脑梗死8例,非大面积脑梗死13例,创伤性脑梗死发病率11.23％.5例大面积脑梗死颅内压持续增高并形成脑疝再次手术扩大颅骨窗减压术;重型颅脑损伤术后是否出现创伤性脑梗死与性别无关(P＞0.05),与年龄、伤情、多发伤、创伤性蛛网膜下腔出血有关(P＜0.05). 结论 重型颅脑损伤继发创伤性脑梗死与性别无关,与年龄、是否出现脑疝、是否为多发伤、是否合并有创伤性蛛网膜下腔出血有显著相关性;早期诊断和早期综合治疗才能改善患者预后,提高疗效.     

持续腰大池引流治疗外伤性蛛网膜下腔出血

外伤性蛛网膜下腔出血（traumatic subarachnoid hemorrhage,tSAH）是颅脑损伤的一种常见类型,重型颅脑损伤患者蛛网膜下腔出血的发生率为33％～60％。是加重继发性脑损伤的重要因素之一。tSAH并发脑缺血和脑积水与出血量及血液在蛛网膜下腔存在的时间密切相关．尽快清除蛛网膜下腔内的积血是治疗tSAH的关键。     

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。     

重型颅脑损伤并蛛网膜下腔出血术后腰大池持续引流的效果

目的分析重型颅脑损伤并蛛网膜下腔出血术后腰大池持续引流的临床应用价值。方法抽取西平县人民医院2016-01—2017-11间手术治疗的37例重型颅脑损伤并蛛网膜下腔出血患者,术后均给予腰大池持续脑脊液引流术。观察患者蛛网膜下腔积血清除时间。随访6个月,观察治疗后1个月内并发症的发生情况。末次随访依据GOS评分标准对治疗效果进行评价。结果本组患者术后积血清除时间为(7. 59±3. 43) d。治疗后1个月内出现迟发性脑出血1例、脑积水2例、脑梗死2例,并发症发生率为13. 51%。末次随访依据GOS标准,本组良好22例、轻残10例、重残3例、植物生存2例,无死亡病例。结论重型颅脑损伤并蛛网膜下腔出血术后实施腰大池持续引流,清除蛛网膜下腔积血效果可靠,并发症少,可有效提高患者预后效果。     

急性颅脑损伤后进展性出血性损伤危险因素分析

目的探讨急性颅脑损伤后发生进展性出血性损伤危险因素。方法分析274例你和性颅脑外伤患者临床资料,分为进展组86例和非进展组188例,对照分析两组相关因素。结果两组除首次头颅CT时间外,年龄、性别、GCS评分、瞳孔扩大、平均动脉压、合并颅骨折、合并硬膜外血肿、合并脑挫伤、合并蛛网膜下腔出血、双侧伤、首次CT血肿量、两次CT血肿量差之间差异,均有统计学意义(P均<0.05)。GCS<12分、瞳孔扩大、合并脑挫伤、合并蛛网膜下腔出血及首次CT血肿量>10ml为发生进展性出血性损伤的独立危险因素(P均<0.05)。结论急性颅脑损伤患者及时进行头颅CT检查,对血肿量>10ml,GCS评分1<12分、瞳孔扩大及合并脑挫伤和蛛网膜下腔出血患者,应密切观察病情进展,尽早复查头颅CT以及时发现进展性出血性损伤。     

腰椎穿刺脑脊液置换术对颅脑损伤伴蛛网膜下腔出血治疗经验

【摘要】〓目的〓总结腰椎穿刺脑脊液置换术对重型颅脑损伤伴蛛网膜下腔出血的治疗体会。方法〓选取2012年1月~2014年3月间55例重型颅脑损伤伴蛛网膜下腔出血患者接受腰椎穿刺脑脊液置换术作为研究组,另选择同期接受常规救治的该类患者作为对照。对比两组血性脑脊液的清除时间、并发症发生率及临床疗效。结果〓研究组血性脑脊液的清除时间为8.13±1.25 d,对照组为 9.37±1.49 d(P<0.05);研究组脑梗死、脑积水、癫痫发生率分别为0、1.82%、3.64%。对照组分别为9.09%、12.73%、14.55%(P<0.05);研究组患者GOS评定良好率为52.73%,对照组为25.45%(P<0.01);研究组疗效GOS评定重残率、植物生存率及死亡率分别为14.55%、1.82%、0,对照组分别为30.91%、14.55%、7.27%(P<0.05)。结论〓腰椎穿刺脑脊液置换术治疗重型颅脑损伤伴蛛网膜下腔出血可加快血性脑脊液的清除,并降低并发症发生率,同时还能有效的改善预后,临床疗效满意。     

早期限制性液体复苏在重型颅脑损伤合并创伤性失血性休克救治中的应用

目的总结重型颅脑损伤合并刨伤性失血性休克患者早期采用限制性液体复苏的救治经验。方法对2003年1月至2009年12月间收治的91例重型颅脑损伤合并休克患者的临床资料进行回顾性分析,比较常规大量液体复苏和限制性液体复苏的治疗效果。结果重型颅脑损伤合并休克的患者,早期采用限制性液体复苏是合理有效的措施,限制性液体复苏组和常规液体复苏组在入院24小时及1周内的死亡率虽都无显著差异,但限制性液体复苏组1周时的死亡率要更低,出院时限制性液体复苏组预后良好（GOS分级Ⅳ～Ⅴ）的比率则更是显著高于常规液体复苏组。结论早期采用限制性液体复苏可以提高重型颅脑损伤合并创伤性失血性休克患者的救治成功率和远期预后。     

参附注射液治疗外伤性蛛网膜下腔出血后凝血相关因子的变化及其临床意义

目的 探讨参附注射液治疗外伤性蛛网膜下腔出血后患者血液中凝血相关因子的变化规律及其意义. 方法 选取本院收治的外伤性蛛网膜下腔出血患者65例,随机分为治疗组33例与对照组32例,对照组给予常规治疗,治疗组在对照组的基础上加用参附注射液静脉滴注,每日2次,连续用药14天.动态监测患者部分凝血活酶时间(APTT)、凝血酶原时间(PT)、D-二聚体并进行统计学处理. 结果 参附注射液治疗外伤性蛛网膜下腔出血患者的部分凝血活酶时间延长(APTT)、凝血酶原时间(PT)延长、D-二聚体下降. 结论 外伤性蛛网膜下腔出血早期应用参附注射液治疗,可以有效预防外伤性蛛网膜下腔出血患者的血管痉挛,预防颅脑损伤后微血栓的形成,降低脑梗塞风险,改善患者的预后.     

29例重度颅脑损伤继发大面积脑梗死的原因分析

目的分析重度颅脑损伤继发大面积脑梗死的发病机制和预防措施。方法收集252例重度颅脑损伤患者的临床病历,对29例继发大面积脑梗死患者的临床资料进行分析。结果继发大面积脑梗死与重度颅脑损伤患者的性别无关,与年龄、入院GCS评分、蛛网膜下腔出血和颅底骨折等关系密切。结论临床医生应高度重视年龄大、入院GCS评分低、合并蛛网膜下腔出血和颅底骨折等重型颅脑损伤患者的病情变化,采取颅压监测、血性脑脊液引流和科学用药等措施,降低继发大面积脑梗死的发生率,从而改善预后和降低病死率。     

Effect of traumatic subarachnoid haemorrhage on neuropsychological profiles and vocational outcome following moderate or severe traumatic brain injury

OBJECTIVE: Traumatic subarachnoid haemorrhage (tSAH) frequently occurs in moderate or severe traumatic brain injury (TBI) and is related to worse outcome at time of discharge from the acute hospitalization. The current study compared neuropsychological impairment and vocational outcome at 1-year post-injury in patients with and without tSAH. DESIGN: Acute injury, neuroradiological, neuropsychological and vocational data were collected for 100 patients admitted for neurorehabilitation following TBI. RESULTS: Patients with tSAH had significantly worse vocational outcome than patients without tSAH. On neuropsychological measures, patients with tSAH generally performed worse than patients without tSAH across most neurocognitive domains. However, differences in neuropsychological test performance between patients with and without tSAH reached statistical significance on measures of visuospatial processing, verbal reasoning and mood only. CONCLUSION: The presence of tSAH appears to be associated with worse vocational outcome in survivors of moderate or severe TBI. As such, the presence of tSAH appears to have predictive value with respect to outcome following TBI.     

Traumatic subarachnoid hemorrhage on the computerized tomography scan obtained at admission: a multicenter assessment of the accuracy of diagnosis and the potential impact on patient outcome

OBJECT: The goal of this study was fourfold: 1) to determine the incidence of traumatic subarachnoid hemorrhage (tSAH) in patients with traumatic brain injury (TBI); 2) to verify agreement in the diagnosis of tSAH in a multicenter study; 3) to assess the incidence of tSAH on the outcome of the patient; and 4) to establish whether tSAH itself leads to an unfavorable outcome or whether it is a sign of major brain trauma associated with severe posttraumatic lesions. METHODS: Computerized tomography (CT) scans obtained in 169 head-injured patients on admission to 12 Italian intensive care units during a 3-month period were examined. The scans were collected for neuroradiological review and were used for the analysis together with data from a multicenter database (Neurolink). A review committee found a high incidence of tSAH (61%) in patients with TBI and a moderate agreement among centers (K = 0.57). Significant associations were observed between the presence and grading of tSAH and patient outcomes, and between the presence of tSAH and the severity of the CT findings. Logistic regression analysis showed that the presence of tSAH and its grading alone do not assume statistical significance in the prediction of unfavorable outcome. CONCLUSIONS: Traumatic SAH frequently occurs in patients with TBI, but it is difficult to detect and grade. Traumatic SAH is associated with more severe CT findings and a worse patient outcome.     

Traumatic subarachnoid hemorrhage: demographic and clinical study of 750 patients from the European brain injury consortium survey of head injuries

OBJECTIVE: Previous reports identified the presence of traumatic subarachnoid hemorrhage (tSAH) on admission computed tomographic (CT) scans as an independent prognostic factor in worsening outcomes. The mechanism underlying the link between tSAH and prognosis has not been clarified. The aim of this study was to investigate the association between CT evidence of tSAH and outcomes after moderate or severe head injuries. METHODS: In a survey organized by the European Brain Injury Consortium, data on initial severity, treatment, and subsequent outcomes were prospectively collected for 1005 patients with moderate or severe head injuries who were admitted to one of the 67 European neurosurgical units during a 3-month period in 1995. The CT findings were classified according to the Traumatic Coma Data Bank classification system, and the presence or absence of tSAH was recorded separately in the initial CT scan forms. RESULTS: Complete data on early clinical features, CT findings, and outcomes at 6 months were available for 750 patients, of whom 41% exhibited evidence of tSAH on admission CT scans. There was a strong, highly statistically significant association between the presence of tSAH and poor outcomes. In fact, 41% of patients without tSAH achieved the level of good recovery, whereas only 15% of patients with tSAH achieved this outcome. Patients with tSAH were significantly older (median age, 43 yr; standard deviation, 21.1 yr) than those without tSAH (median age, 32 yr; standard deviation, 19.5 yr), and there was a significant tendency for patients with tSAH to exhibit lower Glasgow Coma Scale scores at the time of admission. A logistic regression analysis of favorable/unfavorable outcomes demonstrated that there was still a very strong association between tSAH and outcomes after simultaneous adjustment for age, Glasgow Coma Scale Motor Scores, and admission CT findings (odds ratio, 2.49; 95% confidence interval, 1.74-3.55; P < 0.001). Comparison of the time courses for 164 patients with early (within 14 d after injury) deaths demonstrated very similar patterns, with an early peak and a subsequent decline; there was no evidence of a delayed increase in mortality rates for either group of patients (with or without tSAH). CONCLUSION: These findings for an unselected series of patients confirm previous reports of the adverse prognostic significance of tSAH. The data support the view that death among patients with tSAH is related to the severity of the initial mechanical damage, rather than to the effects of delayed vasospasm and secondary ischemic brain damage.     

Prognostic value of computerized tomography scan characteristics in traumatic brain injury: results from the IMPACT study

Computerized tomography (CT) scanning provides an objective assessment of the structural damage to the brain following traumatic brain injury (TBI). We aimed to describe and quantify the relationship between CT characteristics and 6-month outcome, assessed by the Glasgow Outcome Scale (GOS). Individual patient data from the IMPACT database were available on CT classification (N = 5209), status of basal cisterns ( N = 3861), shift ( N = 4698), traumatic subarachnoid hemorrhage (tSAH) ( N = 7407), and intracranial lesions ( N = 7613). We used binary logistic and proportional odds regression for prognostic analyses. The CT classification was strongly related to outcome, with worst outcome for patients with diffuse injuries in CT class III (swelling; OR 2.50; CI 2.09-3.0) or CT class IV (shift; OR 3.03; CI 2.12-4.35). The prognosis in patients with mass lesions was better for patients with an epidural hematoma (OR 0.64; CI 0.56-0.72) and poorer for an acute subdural hematoma (OR 2.14; CI 1.87-2.45). Partial obliteration of the basal cisterns (OR 2.45; CI 1.88-3.20), tSAH (OR 2.64; CI 2.42-2.89), or midline shift (1-5 mm-OR 1.36; CI 1.09-1.68); >5 mm-OR 2.20; CI 1.64-2.96) were strongly related to poorer outcome. Discrepancies were found between the scoring of basal cisterns/shift and the CT classification, indicating observer variation. These were less marked in studies that had used a central review process. Multivariable analysis indicated that individual CT characteristics added substantially to the prognostic value of the CT classification alone. We conclude that both the CT classification and individual CT characteristics are important predictors of outcome in TBI. For clinical trials, a central review process is advocated to minimize observer variability in CT assessment.     

Effect of AVP on brain edema following traumatic brain injury

Objective: To evaluate plasma arginine vasopressin (AVP) level in patients with traumatic brain injury and investigate the role of AVP in the process of brain edema. Methods: A total of 30 patients with traumatic brain injury were involved in our study. They were divided into two groups by Glasgow Coma Scale: severe traumatic brain injury group (STBI, GCS≤8) and moderate traumatic brain injury group ( MTBI, GCS >8). Samples of venous blood were collected in the morning at rest from 15 healthy volunteers (control group) and within 24 h after traumatic brain injury from these patients for AVP determinations by radioimmunoassay. The severity and duration of the brain edema were estimated by head CT scan. Results: plasma AVP levels (ng/L) were (mean±SD): control, 3. 06±1. 49; MTBI, 38. 12±7. 25; and STBI, 66. 61±17. 10. The plasma level of AVP was significantly increased within 24 h after traumatic brain injury and followed by the reduction of GCS, suggesting the deterioration of cerebral injury (P<0. 01). And the AVP level was correlated with the severity (STBI r =0.919, P < 0.01; MTBI r = 0.724, P < 0.01) and the duration of brain edema (STBI r = 0. 790, P < 0. 01; MTBI r = 0. 712, P<0.01). Conclusions: The plasma AVP level is closely associated with the severity of traumatic brain injury. AVP may play an important role in pathogenesis of brain edema after traumatic brain injury.     

重度颅脑损伤后继发脑积水的早期诊断和治疗

目的:探讨重度颅脑损伤后继发脑积水的早期诊疗方法及愈后。方法:对12例重度颅脑损伤后继发脑积水的患者均一期或二期行脑室—腹腔分流术,10例随访半年～3年。结果:12例术后2周～3月CT复查脑室大小恢复正常。随访10例,生活自理8例,意识及肢体活动好转2例。结论:重度颅脑损伤后继发脑积水是影响愈后的严重并发症,早期确诊和手术治疗是减少其死亡率及致残率的关键。     

经颅多普勒超声检查对重型颅脑损伤预后的判断价值

【摘要】〓目的〓探讨经颅多普勒超声检查(TCD)对重型颅脑损伤患者预后的判断价值。方法〓以2013 年2月至2014年10月在我院进行治疗的62例重型颅脑损伤患者作为病例组,并收集患者受伤后(术后)第1、3、7、14、21 d大脑中动脉的血流数据,以大脑中动脉收缩期血流速度(Vs)、舒张期血流速度(Vd)、博动指数(PI)作为观察指标;将同时期在我院接受TCD检查的健康44名对象作为对照组;将两组数据进行对比。结果〓患者受伤后(术后)第1 d脑血流速度即可发生改变;Vs和Vd值在第7 d降至最低,随后逐级恢复;PI指标则与脑血流速度变化趋势相反;第7 d的Vs是颅脑损伤的一个保护性因素。结论〓通过TCD检测的脑血流速度能反映重型颅脑损伤患者的颅内压力变化及预后情况,对颅脑损伤的治疗具有指导价值。     

Plasma von Willebrand factor levels correlate with clinical outcome of severe traumatic brain injury

Biochemical markers of cellular stress/injury have been proposed to indicate outcome after head injury. The aim of the present study was to determine whether plasma von Willebrand factor (VWF) levels correlate with primary outcome and with clinical variables in severe traumatic brain injury (TBI). Forty-four male patients, victims of severe TBI, were analyzed. Clinical outcome variables of severe TBI comprised survival and neurological assessment using the Glasgow Outcome Scale (GOS) at intensive care unit (ICU) discharge. Computerized tomography (CT) scans were analyzed according to Marshall CT classification. Three consecutive venous blood samples were taken: first sample (11.4 +/- 5.2 h after trauma, mean +/- SD), and 24 h and 7 days later. The result of mean plasma VWF concentration was significantly higher in the TBI group (273 U/dL) than in the control group (107 U/dL; p < 0.001). Severe TBI was associated with a 50% mortality rate. Nonsurvivors presented significantly higher APACHE II scores than survivors (nonsurvivors mean, 18.8; survivors mean, 12.7; p < 0.001), and also presented higher scores in Marshall CT classification (nonsurvivors mean, 4.6; survivors mean, 2.7; p < 0.05). There was a significant positive correlation between plasma levels at second plasma sampling and scores in Marshall CT classification (p < 0.05). The sensitivity of plasma VWF concentration in predicting mortality according to the cut-off of 234 U/dL was 64%, with a specificity of 68%. Therefore, VWF increases following severe TBI may be a marker of unfavorable outcome.     

超声在颅脑损伤术中急性脑膨出时的应用

目的探讨超声检查在重型颅脑损伤开颅术中急性脑膨出时应用价值。方法比较重型颅脑损伤开颅术中出现脑膨出时行床边超声检查组与CT检查组．对比分析两组发现颅内再出血阳性率、开颅手术时间及6月后功能恢复的差异。结果超声检查组与CT检查组在发现颅内再出血阳性率无显著性差异（x2=0．183,P〉0．05）;超声检查组手术时间显著低于CT检查组（x^2=4．861,P〈O．05）;超声检查组术后神经功能恢复显著优于CT检查组（x^2=6．593,P〈O．05）。结论术中超声检查可及时判断急性脑膨出的原因,并为清除颅内血肿实施导向,能避免遗漏血肿、缩短手术时间,对提高手术效果、改善患者预后有重要临床意义。     

单唾液酸四己糖神经节苷脂钠注射液治疗重型颅脑损伤的疗效观察

目的观察单唾液酸四己糖神经节苷脂钠注射液对重型颅脑损伤患者血浆肌酸激酶同工酶BB（CreatinekinaseBB,CK-BB）的动态变化以及临床疗效。方法将60例重型颅脑损伤患者（GCS≤8分）分成两组,观察组30例在常规治疗的基础上加用单唾液酸四己糖神经节苷脂钠注射液治疗,对照组30例采用常规治疗。观察患者血浆CK-BB变化,并两组于伤后6个月按GOS预后评分评定预后,同时比较两组患者的意识好转率。结果观察组患者血浆CK-BB明显低于对照组。观察组恢复良好率（17/30）与对照组（8/30）比较,差异有统计学意义（P〈0.05）。观察组治疗后1个月清醒23例,而对照组l3例,两组清醒率比较,差异有统计学意义（P〈0.01）。两组清醒时间比较,观察组为（14.56±6.56）天,对照组为（20.85±10.92）天。结论单唾液酸四己糖神经节苷脂钠注射液能有效降低重型颅脑损伤患者血浆CK-BB的水平,并且不仅能加速重型颅脑损伤患者清醒,还能促进预后,提高生活质量。单唾液酸四己糖神经节苷脂钠注射液是治疗重型颅脑损伤安全有效的药物,可以广泛地应用于临床。