螺旋CT导向下穿刺治疗颅内血肿

目的：探讨螺旋CT导向下穿刺治疗颅内血肿的临床效果。方法：选择经CT证实并适合穿刺治疗的72例颅内血肿患者，采用螺旋CT扫描下直接准确定位，后经颅骨钻孔、引流及尿激酶溶解术，并进行定期CT随访观察。结果．72例患者均穿刺引流1次成功，操作简单，定位准确性高，损伤小，患者恢复快。结论：螺旋CT导向下穿刺治疗颅内血肿具有简便、安全、有效的优点。     

Severe intracranial and intraspinal subarachnoid hemorrhage after lumbar puncture: a rare case report

The lumbar puncture is considered as a safe routine procedure in widespread clinical use for nearly a century. To the best of our knowledge, intracranial and intraspinal subarachnoid hemorrhage has never been reported as a complication after a lumbar puncture. We presented a case of a 76-year-old woman who fell in a deep coma after a lumbar puncture with diffuse subarachnoid hemorrhage and acute obstructive hydrocephalus on computed tomographic scans. Magnetic resonance imaging studies of the whole spine showed the hematoma spread along the spinal cord upward to the intracranial subarachnoid space. Remarkably, an extravasation of contrast medium presented at the level of L1 through L2, which was subsequently evaluated using the spinal angiography. There was an ongoing bleeding at the terminus of L1 lumbar segmental artery that lay within the spinal cord. Then a transarterial embolization followed and the hemorrhage stopped immediately. This case reminds us that although lumbar puncture is safe and simple, severe potential complication, such as intracranial and intraspinal subarachnoid hematoma, could occur.     

Lumbar puncture complicated by spinal epidural hematoma in a child with leukemia

We report a case of spinal epidural hematoma (SEH) preceded by diagnostic lumbar puncture (LP) in a 5‐year‐old boy with acute lymphoblastic leukemia. MRI confirmed the presence of SEH between T7 and L5 levels, but the patient showed fast recovery during the next hours and conservative management was elected.     

微创颅内血肿清除术的术中及术后并发症分析

目的探讨微创颅内血肿清除术术中及术后并发症的原因及预防措施。方法对200例微创颅内血肿清除术患者的临床资料进行回顾性分析。结果 200例微创颅内血肿清除术患者术中及术后并发症主要有:穿刺针偏离血肿中心5例、穿刺针针尾折断2例、再出血6例、癫痫1例、硬膜外血肿1例、颅内积气8例、钻颅伤口感染6例、颅内感染4例、脑脊液漏5例、血肿分隔引流不畅4例、低颅压2例、脑积水1例、拔除穿刺针时针尾断裂1例。结论对微创颅内血肿清除术术中及术后并发症要有足够的认识,严格掌握手术适应症,精确定位,严格规范手术操作。     

Treatment of Post‐Dural Puncture Headache With Bilateral Greater Occipital Nerve Block

(Headache 2010;50:869‐881) Epidural blood patch is an effective treatment with a low complication rate. It is also an invasive method that can cause permanent neurological sequelae such as early and late back pain, radiculopathy, spinal‐subdural hematoma, spinal‐epiarachnoid hematoma, intrathecal hematoma, arachnoiditis, and infection. We report a case in which a postdural puncture headache resolved within 2 minutes of a greater occipital nerve block, a minimally invasive and easy procedure with a low complication rate. This case report suggests that a greater occipital nerve block may be a successful alternative treatment for patients with post‐dural puncture headache.     

神经干细胞移植治疗外伤性颅内血肿后遗症20例临床疗效分析

目的探讨应用神经干细胞移植治疗外伤性颅内血肿后遗症的临床疗效。方法对20例外伤性颅内血肿后遗症患者行腰椎穿刺蛛网膜下腔注入神经干细胞,并于第1次术前和第4次术后半年进行功能独立性评定（FIM）。结果患者自我料理、括约肌控制、活动和转移、运动、交流、社会认知都有明显改善（P〈0.01）。结论神经干细胞移植可以改善外伤性颅内血肿患者损伤的症状和体征,提高患者生活质量。     

Real time optic nerve sheath diameter measurement during lumbar puncture

Measurement of optic nerve sheath diameter (ONSD) using point of care ultrasound has been used to indirectly assess the intracranial pressure (ICP) particularly in conditions where it is raised. Direct pressure measurements using probes reaching the ventricle system correlated with ONSD using ultrasound. Attempts were made to measure the ONSD pre and post lumbar puncture (LP) after draining cerebrospinal fluid (CSF) as well as post ventricular shunt placement. We report ONSD measurement and demonstrate dynamic changes during LP in a patient with known idiopathic intracranial hypertension (IIH).     

Spontaneous intracranial hypotension--a case report

Positional or orthostatic headache symptoms secondary to intracranial hypotension are usually seen as complications in patients after medical procedures, such as lumbar puncture. We describe a case of spontaneous intracranial hypotension (SIH) in a 43-year-old man without a previous history of headaches. He presented to the Emergency Department (ED) with a new-onset orthostatic headache without any history of recent medical procedure, such as lumbar puncture (LP). The ED evaluation included a normal neurologic examination and normal computed tomography (CT) scan of the brain. An LP showed low opening pressure, elevated protein, 46 RBCs and one lymphocyte. Subsequent evaluation with radionuclide cisternography confirmed a cerebrospinal fluid (CSF) leak in the area of the upper thoracic spine, and treatment with an epidural blood patch dramatically improved his symptoms. SIH is due to CSF leakage, usually in the area of the cervical or upper thoracic spine, often without a clear etiology. Conservative medical management including bed rest, oral hydration and caffeine intake is the usual first line treatment. An epidural blood patch is often a dramatically effective treatment that can be done once the presence and location of the leak is identified. Although mostly benign, this condition occasionally can be associated with the formation of clinically significant subdural fluid collections or hematomas. SIH is an increasingly recognized cause of headache.     

全脑血管造影术后穿刺口血肿的影响因素分析

目的探讨全脑血管造影术后穿刺口血肿影响因素及护理预防策略。方法选择2018年1月—2020年1月医院行全脑血管造影术的患者668例为研究对象,将发生穿刺口血肿的48例患者作为病例组,未发生穿刺口血肿的620例患者作为对照组。收集患者性别、年龄、疾病、穿刺次数等相关资料,采用单因素及多因素Logistic回归分析全脑血管造影术后穿刺口血肿的高危因素。结果单因素分析显示,肥胖、糖尿病、动脉粥样硬化、凝血功能、穿刺次数是导致穿刺口血肿的可疑因素(P<0.05)。多因素Logistic回归分析显示,有肥胖、有糖尿病、有动脉粥样硬化为导致全脑血管造影术后穿刺口血肿的独立危险因素(P<0.05)。结论全脑血管造影术后穿刺口血肿的高危因素包括有肥胖、有糖尿病、有动脉粥样硬化,应针对性的护理贯穿于手术前、中、后全过程,降低穿刺口血肿的发生率。     

以帽状腱膜下血肿为首发表现的慢性髓系白血病一例并文献复习

目的 提高临床医师对以帽状腱膜下巨大血肿合并眶内血肿为首发表现的慢性髓系白血病慢性期（CML-CP）的认识水平。方法 报道1例以帽状腱膜下巨大血肿合并眶内血肿为首发表现的CML患者的诊疗情况,并以“帽状腱膜下血肿”“慢性髓系白血病”（中英文）为检索词,对PubMed、万方数据知识服务平台、维普中文科技期刊数据库、中国生...     

颅内血肿微创穿刺粉碎清除术治疗大量高血压脑出血的临床研究

目的比较颅内血肿微创穿刺粉碎清除术和传统小骨窗开颅手术治疗高血压脑出血的疗效,为大量高血压脑出血寻找理想的治疗方法。方法收集本院自2003年7月至2005年9月手术治疗的65例大量高血压脑出血(出血量在80ml~120ml之间)患者,分为微创穿刺组(34例)和传统开颅手术组(31例),用神经功能缺损评分以及病死率比较两组疗效。结果微创穿刺组有效率、显效率均明显优于传统小骨窗开颅手术组(P<0.05),两组疗效差异有显著意义,而病死率低于传统小骨窗开颅手术组,两组比较差异无显著性。结论颅内血肿微创穿刺粉碎清除术能明显提高有效率,降低致残率,提高患者生存质量。     

数字减影全脑血管造影在脑血管疾病中的应用分析

目的 分析不同类型血管疾病的数字减影全脑血管造影(DSA)的结果,探讨其并发症的防治.方法 对65例脑血管病患者DSA检查结果进行分析,观察病症与血管病变的关系及术中、术后的并发症.结果 65例DSA检查结果显示:颅内外血管异常58例,阳性检出率为89.23%;其中穿刺部位血肿、皮下出血1例、血管痉挛1例、癫痫样发作1例、小脑梗死1例.结论 DSA检查在脑血管的诊断中有重要的应用价值,是一项有创但相对安全可靠的检查方法.     

颅内血肿的简易精确体表定位及微创手术治疗

目的介绍一种简单实用的颅内血肿微创穿刺精确定位及手术方法。方法在头颅CT引导下,以医用齿科砂轮做定位标记,应用颅内血肿粉碎引流器对24例慢性硬膜下血肿、31例高血压性脑出血行微创穿刺血肿清除术。结果慢性硬膜下血肿24例,均痊愈。高血压性脑出血31例,29例有效(93.5%),死亡2例(6.5%)。结论应用简易精确体表定位法行微创穿刺血肿清除术操作简单易行、实用有效、手术时间短、创伤小、适应征宽、并发症少、保全神经功能优势明显。     

脑出血微创血肿抽吸引流术后颅内积气的临床观察

目的:了解脑出血微创血肿抽吸引流术(微创术)后颅内积气的发生情况。方法:接受微创术治疗的脑出血患者134例,术后出现颅内积气的患者为A组(n=97),未出现颅内积气的病例为B组(n=37)。对2组的临床数据进行统计分析。结果:A组中双针穿刺比例、血肿抽吸量及引流量与B组比较差异有统计学意义(P<0.05)。Logistic回归分析表明,双针穿刺是影响术后颅内积气及其严重程度的独立危险因素。结论:脑出血微创血肿抽吸引流术后常出现颅内积气,但对患者预后无显著影响。双针穿刺可能增加术后颅内积气的风险。     

EPs do not accept the strategy of "lumbar puncture first" in subarachnoid hemorrhage

It has been proposed that the workup of suspected subarachnoid hemorrhage should begin with lumbar puncture (LP) rather than computed tomography (CT) scan. We investigated whether EPs would in fact advocate this strategy in an index hypothetical case and in variations of the index case. An eight-question survey was distributed to EM physicians attending national continuing medical education meetings. Questions included whether the responders would advocate "LP first" in the following scenarios: (1) the index case in which the patient's symptoms had been present for more than 12 hours, other diagnoses were very unlikely, the patient was fully insured, and CT scan was available immediately; (2) a case in which the patient is not insured; (3) a case in which the respondent is the patient; and (4) a case in which there is a delay in obtaining a CT scan. Two hundred forty-one of 275 surveys were completed for a response rate of 88%. Given the index scenario, only 22.8% of the respondents would advise patients to have an LP first versus 17.9% if they themselves were the patient (P=.11). Compared with the index scenario, 34.0% of respondents would advise LP first if their patient did not have insurance (P<.0001); a majority, 57.1%, would advise LP first if the CT were delayed (P<.0001). The "LP first" strategy for workup of subarachnoid hemorrhage was rejected by most EM physicians except when the CT scan would entail delay. Compared with the index case, an added number of physicians would advocate this strategy if the patient was uninsured. The ethical implication of advocating a strategy because of financial concerns and that most physicians would not favor for themselves or their patients merits attention.     

CT导向下经皮穿刺术病人并发症的预防和护理

本文对71例CT导引下经皮穿刺术出现的并发症进行归纳和分析，其中颅内血肿微创术并发症5例，胸、腹腔穿刺活检术并发症3例，肝癌射频治疗术并发症2例，总结出做好消毒隔离，预防交叉感染：做好病人呼吸训练；术前准备充分，术后观察细致：落实监护重点，确保操作安全是预防和控制并发症的护理对策。     

经股动脉穿刺行全脑血管造影术后患者穿刺点去除沙袋“十字”加压包扎止血的效果

目的探讨经股动脉行全脑血管造影术后患者穿刺点去除沙袋"十字"加压包扎止血的效果。方法便利抽样法选择2014年1月至2015年3月南京大学医学院附属鼓楼医院神经内科收治的经股动脉穿刺行全脑血管造影术患者153例为研究对象,按入院先后将其分为观察组(78例)和对照组(75例),两组患者术后均严格按照股动脉穿刺点护理要求"十字"加压包扎,对照组患者加用沙袋压迫,观察并比较两组患者术后穿刺点发生皮下血肿及出血的情况。结果观察组和对照组患者术后均无局部皮下血肿发生,两组各有1例患者出现穿刺点出血,差异无统计学意义(P0.05)。结论经股动脉行全脑血管造影术后患者穿刺点去除沙袋"十字"加压包扎,止血效果较好,且有利于提高患者的舒适度。     

Incidence of Traumatic Lumbar Puncture

OBJECTIVE: To determine the incidence of traumatic lumbar puncture (LP). METHODS: A retrospective study was conducted at an urban, university tertiary care referral center with 50000 annual emergency department (ED) visits. The study population included all patients who had cerebrospinal fluid (CSF) samples sent to the laboratory between August 15, 2000, and August 14, 2001. The numbers of red blood cells (RBCs) recorded in the first and last CSF tubes, the location where the LP was performed, and the discharge summary and the discharge diagnoses from the particular visit were obtained. All patients with intracranial pathology and CSF obtained via neurosurgical procedure or fluoroscopic guidance were excluded from the study group. Given no clear definition of traumatic LP in the literature, the incidence of traumatic LP was calculated using a cutoff of greater than 400 RBCs (visual threshold for bloody fluid) and 1000 RBCs (arbitrary threshold selected by other authors) in CSF tube 1. Proportions were compared using chi-square statistics. RESULTS: Seven hundred eighty-six CSF samples were recorded over one year. Twenty-four samples were obtained from patients with intracranial pathology or were obtained via a neurosurgical procedure. Of the remaining 762 CSF samples in the study population, 119 (15.6%) were traumatic using a cutoff of 400 RBCs, and 80 (10.5%) were traumatic, using a cutoff of 1000 RBCs in tube 1. Five hundred three LPs were done in the ED and 259 were attributed to all other locations in the hospital. Using a cutoff of 400 RBCs, the incidence of traumatic LP in the ED was 13.3%, compared with 20% in the rest of the hospital (p < 0.025). Similarly, using a cutoff of 1000 RBCs, the incidence of traumatic LP in the ED was 8.9%, compared with 13.5% in the rest of the hospital (p = 0.1). The incidence of "champagne taps" (defined as zero RBCs in the first and last tubes) in the ED was 34.4%, compared with 24.3% in the rest of the hospital (p < 0.01). CONCLUSIONS: The incidence of traumatic lumbar puncture is approximately 15% using a cutoff of 400 RBCs and 10% using a cutoff of 1000 RBCs. In this study, the rate of traumatic lumbar puncture was significantly less (with a cutoff of 400 RBCs) and the rate of champagne tap was significantly greater for LPs done in the ED compared with the rest of the hospital.     

颅内血肿术后远隔部位迟发血肿再次手术的诊治体会

目的探讨颅内血肿术后远隔部位迟发血肿再次手术的方法。方法急性颅内血肿清除术后其他部位迟发性血肿再次手术患者21例，对其临床资料进行回顾性分析。结果21例中术后良好和中残11例，重残5例，死亡5例。结论早期诊断和及时处理是改善迟发性颅内血肿预后、降低病死率和致残率的关键。     

Cranial burr hole decompression in the emergency department

Presently virtually all patients with acute head trauma are computed tomography (CT) scanned and transferred to a neurosurgical operating room before any surgical intervention. The time required for this, especially if the patient is transferred to another institution, may lead to a significant delay in treatment. In a patient with an expanding intracranial hematoma and evidence of brainstem compromise this delay may produce a worse outcome. Cranial burr hole placement can rapidly, safely, and accurately find and partially decompress most extracerebral intracranial hematomas. A burr hole placed rapidly before CT and transfer could prevent further damage to the brain by an expanding hematoma. The case of a child with a preterminal epidural hematoma whose outcome was excellent because of a burr hole placed in the emergency department (ED) is presented. In light of this case and a complete literature review, it is suggested that more frequent attempts to decompress intracranial hematomas in the ED may be warranted.