额叶脑挫裂伤恶化的危险因素分析

目的 探讨不同类型外伤性额叶脑挫裂伤恶化的危险因素,首次CT表现能否预示恶化发生的风险.方法 回顾性分析36例没有弥散性脑损伤或颅内血肿而CT表现额叶脑挫裂伤的头部外伤病例.分析额叶脑挫裂伤类型（根据CT扫描结果）,格拉斯哥昏迷评分（GCS）,病情恶化的时间和预后（GOS）.结果 20例单侧额叶脑挫裂伤的病例都恢复良好;10例局限性双侧额叶脑挫裂伤仅5例恢复良好;6例广泛性双侧额叶脑挫裂伤中的4例伤后24h病情仍恶化,其中1例死亡.结论 脑水肿尤其延迟效应是额叶脑挫裂伤恶化的主要危险因素.首次CT扫描所示脑挫裂伤的类型可以用来预示恶化发生的风险,双侧广泛性额叶脑挫裂伤恶化的危险性很高.     

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.     

双额叶脑挫裂伤的治疗策略选择

目的探讨双额叶脑挫裂伤患者的临床治疗策略。方法回顾性分析山西医科大学第一医院近10年来收治的59例双额叶脑挫裂伤患者的临床资料,按其伤后水肿高峰期GCS评分将患者分为轻、中和重型,测量各患者水肿高峰期头颅CT中脑挫裂伤灶体积和双侧脑室前夹角,分析各组患者GCS评分与影像学结果的相关性。中、重型患者按其入院后是否行手术治疗,又分为手术治疗组和保守治疗组,比较两组患者在住院时间、并发症发生情况、早、远期预后和远期认知功能等情况。结果 59例双额叶脑挫裂伤患者中轻型20例,中型26例,重型13例,Pearson相关性分析显示各组患者GCS评分与影像学表现呈中度负相关;中、重型组中保守治疗21例,手术治疗18例,保守组仅1例(4. 76%)重残,并伴认知功能障碍;手术组3例(16. 67%)植物生存,7例(38. 89%)重残,12例(66. 67%)伴不同程度认知障碍;两组患者在早、远期预后及认知功能方面差异有统计学意义(P 0. 05),在并发症及住院时间无统计学差异(P 0. 05)。结论(1)双额叶脑挫裂伤患者的GCS评分与其影像学评价指标中度相关,当二者间不完全一致时,治疗策略选择应以GCS评分为准,兼顾影像学改变。(2)手术治疗组患者总体预后及认知功能差,所以严格把控双额叶脑挫裂伤患者的手术指征,对于保留患者的认知功能、减少不良预后具有重大意义。     

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.     

THE CONTUSION INDEX: A REAPPRAISAL IN HUMAN AND EXPERIMENTAL NON-MISSILE HEAD INJURY

A previously described method of quantifying cerebral contusions in man (the contusion index) caused by non-missile head injury has been modified and applied to a larger series of cases, and used to assess contusions in experimental head injuries. The initial findings in man have been confirmed, viz. that contusions are most severe in the frontal and temporal lobes; that contusions may be entirely absent in a patient dying as a result of a head injury; that there is no correlation between the severity of contusions and the nature of the injury; that the concept of contrecoup must continue to be questioned; that contusions are more severe in patients who have a fracture of the skull in comparison to those who do not; that contusions are more severe in patients who do not experience a lucid interval than in those who do; and that contusions are less severe in patients with diffuse axonal injury than in those who do not have diffuse axonal injury. The distribution of contusions in subhuman primates is similar to that seen in man, and they occur more frequently with short duration than with long duration acceleration.     

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.     

Dramatic neurobehavioral disorder in two cases following bilateral anteromedial frontal lobe injury: Delayed psychosis and marked change in personality

Abstract

This paper describes two cases of closed head injury causing bilateral frontal lobe contusions that resulted in enduring changes in self-control, perception, mood and cognition. In the first case the primary feature was delayed-onset psychosis. In the second case the patient developed mood lability, poor impulse control, a dramatic change in personality and impaired cognition. Midline, anterior frontal regions were most severely affected In both cases. The diagnostic evaluation and the clinical course are described. The neuropsychiatric syndromes are discussed with reference to lesion location and the literature on the neurobehavioral sequelae of closed head injury.     

Improved behavioral outcomes after progesterone administration in aged male rats with traumatic brain injury

Twenty-month-old male Fischer 344 rats with bilateral contusions of the frontal cortex (n=8/group) or sham operations received 16 mg/kg of progesterone or vehicle at 1 and 6 h post-injury, then once every 24 h for the next seven days, with tapering of the dose over the final two treatments. The rats' behavioral recovery was then evaluated on tests of locomotor activity and Morris water maze learning. All rats were sacrificed 21 days post-TBI and brains were perfused and cryoprotected for necrotic cavity measurements. The injury produced significant impairments in activity and spatial learning compared to sham controls. The progesterone-treated rats had better functional outcomes than vehicle-treated rats with similar cortical injuries. The neurosteroid treatment did not affect the size of the necrotic cavity.     

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.     

TUNEL-positive staining of surface contusions after fatal head injury in man

In frontal lobe contusions obtained post mortem from 18 patients who survived between 6 h and 10 days after head injury, DNA fragmentation associated with either apoptotic and/or necrotic cell death was identified by the terminal deoxynucleotidyl transferase-mediated biotinylated deoxyuridine triphosphate nick end labelling (TUNEL) histochemical technique. Additional histological techniques were also used to identify regional and temporal patterns of tissue damage. TUNEL-positive cells were present in both the grey and white matter of the contusion, where they peaked in number between 25 and 48 h, and were still identifiable at 10 days post injury. Fewer TUNEL-positive cells were observed in grey than in white matter; and most TUNEL-positive neurons in the grey matter demonstrated the morphological features of necrosis. However, the morphology of some TUNEL-stained neurons, and of TUNEL-stained oligodendroglia and macrophages in white matter was suggestive of apoptosis. Apoptosis was not seen in age- and sex-matched controls, none of whom had died from intracranial pathology or had pre-existing neurological disease. These findings suggest that multiple cell types in frontal lobe contusions exhibit DNA fragmentation and that both necrosis and apoptosis are likely to contribute to post-traumatic pathology. These findings provide further evidence that the observations made in animal models of traumatic brain injury have fidelity with clinical head injury. Received: 25 November 1999 / Revised: 3 February 2000 / Accepted: 9 February 2000     

双额叶挫裂伤患者病情恶化的临床及影像学危险因素及手术干预效果分析

目的 探讨双额叶挫裂伤后病情恶化的临床与影像学相关危险因素以及手术干预的效果。方法 选择2014年4月-2017年4月于本院就诊的84例双额叶挫裂伤患者,分析病情恶化和病情稳定患者临床和影像学检查的差异,多因素Logistics回归分析引起病情恶化的相关独立危险因素。对病情恶化患者采取手术干预,并比较病情恶化组和病情稳定组患者的预后差异。结果 病情恶化组的年龄、多处受伤比例、入院时ICP和D-二聚体水平较高,入院时GCS较低(P<0.05); 病情恶化组的挫裂伤体积、中线移位距离和合并双侧血肿、颅骨骨折的比例显著高于病情稳定组(P<0.05)。多因素Logistics回归分析显示,入院时低GCS评分、高ICP,挫裂伤体积、中线移位和合并颅骨骨折是双额叶挫裂伤患者病情恶化的独立危险因素。病情恶化组术后与病情稳定组的1年病死率(8.70% vs. 5.26%,P>0.05)和预后不良率(23.68% vs. 28.26%,P>0.05)无明显差异。结论 入院时低GCS评分、高ICP,挫裂伤体积、中线移位和合并颅骨骨折是双额叶挫裂伤患者病情恶化的独立危险因素; 对高危患者进行手术干预,可以改善患者预后。     

Language after bilateral cerebral infarctions: role of the minor hemisphere in speech

Language was studied in four patients with bilateral cerebral infarctions. Bilateral destruction of the third frontal gyri did not necessarily produce the severely limited language output characteristic of global or severe Broca aphasia; for Broca aphasia to occur, there must be extensive frontoparietal damage in the dominant cerebral hemisphere. Thus, the marked recovery of language after lesions limited to the dominant third frontal gyrus is mediated by adjacent areas of the dominant hemisphere, and not by the nondominant third frontal gyrus. The nondominant hemisphere nevertheless has a limited capacity to produce oral speech after extensive damage to the dominant hemisphere and may play an appreciable, although still subsidiary, role in normal articulation. The central gyri and rolandic operculum may be more essential than the third frontal gyri for well-articulated speech.     

Norepinephrine and traumatic brain injury: a possible role in post-traumatic edema

Unilateral cerebral contusion is associated with an early (30 min) increase in norepinephrine (NE) turnover followed by a later (6–24 h) depression of turnover which is bilateral and widespread throughout the brain. Blockade of NE function during the first few hours after traumatic brain injury (TBI) impedes subsequent recovery of function without enlarging the size of the lesion. The current studies were carried out to characterize further the timing of the switch from increased to decreased NE turnover and to investigate the pathogenesis of the delayed recovery of function associated with blocking NE function. Adult male rats had unilateral somatosensory cortex contusions made with a 5 mm diameter impact piston. They were killed after 2 h and their brains analyzed for NE turnover by HPLC with electrochemical detection. In general, NE turnover (the ratio of 3-methoxy-4-hyroxyphenylglycol to NE levels) had returned to sham-lesion control levels in most brain regions by 2 h after either left or right sided contusions. The only exceptions were a persistent 87% increase at the lesion site after right-sided contusions and 22% and 32% increases in the contralateral cerebellum after right- and left-sided contusions, respectively. Blockade of α₁-adrenoceptors by treatment with prazosin (3 mg/ kg, i.p.) 30 min prior to TBI produced edema in the striatum and hippocampus at 24 h which was not seen saline-treated rats nor in rats where NE reuptake was blocked with desmethylimipramine (DMI; 10 mg/kg, i.p.). DMI increased edema at the lesion site at 24 h, however. These data suggest that the early increase in NE release following unilateral cerebral contusion is protective and that this may act to stabilize the blood–brain barrier in areas adjacent to the injury site. Drugs that interfere with this enhanced noradrenergic function might enhance the damage caused by TBI.     

Widespread and lateralized effects of acute traumatic brain injury on norepinephrine turnover in the rat brain

Norepinephrine (NE) has been implicated in recovery of function following traumatic brain injury (TBI). While bilateral decreases in brain NE turnover occur at 6–24 h after TBI, it is unknown what effects unilateral TBI might have on brain NE turnover over the first few minutes after injury. Here male Sprague-Dawley rats had unilateral contusions of either the right or left somatosensory cortex produced by an air driven piston. At 30min after TBI, brain NE turnover was assessed by measuring the ratio of 3-methoxy-4-hydroxyphenylglycol (MHPG) to NE levels in various brain regions. Both right and left TBI produced 32–103% increases in NE turnover at the injury site and in the ipsilateral cerebral cortex surrounding, rostral and caudal to the injury as compared to the contralateral, uninjured site or to the homologous sites in uninjured controls. NE turnover was also altered selectively in some brain areas not affected by right TBI. Left TBI decreased NE turnover by 29% in the frontal cortex contralateral to the injury and by 24% bilaterally in the hypothalamus while increasing locus coeruleus NE turnover by 72% compared to uninjured controls. Thus, unilateral cortical TBI produced predominantly ipsilateral increases in cortical NE turnover but variable, bilateral changes in NE turnover in subcortical areas which were dependent upon the side of injury. These subcortical differences may explain some of the lateralized effects of cortical injury on post-injury behavior.     

老年人额叶脑挫裂伤微创手术治疗临床分析

目的总结老年人额叶脑挫裂伤行微创手术治疗的经验。方法对我科自2000年至2005年底收治的31例老年人额叶脑挫裂伤病人在3～7d保守治疗后,行经皮微创穿刺碎吸血肿及坏死脑组织手术处理。结果临床死亡一例,其余病例经随访半年以上,按GOS评分分为恢复良好20例,中残10例,无重残病例。结论对老年人额叶脑挫裂伤的治疗在加强监护,病情相对稳定的情况下,保守治疗3～7d后行经皮锥颅微创穿刺碎吸术治疗,可促使患者早日康复,减少并发症的发生,提高生存率及生存质量。     

Relationships between measured cognitive ability and reported psychosocial activity after bilateral frontal lobe injury: An 18‐year follow‐up

This case study illustrates a well‐established paradox often seen after serious frontal injury. Some individuals have little or no neurological abnormality, perform well on cognitive tests, and display an apparently “normal” social appearance, yet have serious, if subtle, neurobehavioural disability that prevents reliable and efficient performance in a number of daily activities. In this case study, we report the psychosocial progress of a young man who suffered serious bilateral frontal injury in a road traffic accident at the age of 20 years. He made a good neurological recovery and relatively few cognitive deficits were recorded. His performance on a range of neuropsychological tests, including specialist tests of “frontal function”, was mainly in the above average or superior range. In contrast, observations of his functional activities revealed a number of dysexecutive problems that had an adverse impact on his life. Changes in his personality and social behaviour, reflecting a number of “frontal” characteristics, only marginally improved as a result of post‐acute neuropsychological rehabilitation. He did not receive long‐term professional support but, with the passage of time and continued support from his family, he has married and manages to maintain a basic level of social integration, but not one commensurate with his pre‐accident potential. Problems of planning, organisation, initiative, and self‐awareness that were not recognised early in his recovery, and are not evident from neuropsychological assessment, remain as major obstacles to full social independence.     

Distractibility following simultaneous bilateral lesions of the superior colliculus or medial frontal cortex in the rat

Hooded rats with bilateral lesions of the superior colliculus or medial frontal cortex were compared with controls for locomotor guidance in shuttling back and forth between goal-doors at two opposite ends of a large arena. Colliculectomized rats accomplished this with great accuracy. When flashing distractor lights were introduced midway down the runway, frontal corticals and controls were severely disrupted but colliculars continued to run normally. This result was obtained both when all training occurred postoperatively (Experiment 1) and when runway performance had been stabilized preoperatively (Experiment 2), thus after a long or short postoperative recovery interval. The results offer support for previous studies with rats which have demonstrated sensory 'neglect' but good locomotor guidance after collicular ablation. Frontal corticals differed from controls only in terms of their elevated rate of repeat door-pressing upon postoperative resumption of testing in Experiment 2. Despite the similarity between effects reported elsewhere of collicular and frontal lesions made unilaterally, bilateral deficits clearly demonstrable after collicular ablation were absent here after frontal lesions. The results imply that the functional responsibilities of superior colliculus and frontal cortex in the rat are separable; at least, they have different rates of functional recovery.     

MRI findings and Axis I and II psychiatric disorders after traumatic brain injury: a 30-year retrospective follow-up study

We studied the association between psychiatric disorders and the presence and location of traumatic lesions on magnetic resonance imaging (MRI) in 58 patients, on average, 30 years after traumatic brain injury. Axis I psychiatric disorders that had begun after the injury were assessed with the Schedules for Clinical Assessment in Neuropsychiatry (version 2.1), and Axis II disorders with the Structured Clinical Interview for DSM-III-R Personality Disorders. A 1.5-Tesla MRI scanner was used. One-third of the subjects had traumatic lesions visible on MRI. Only three psychiatric disorders, that is, delusional disorder, dementia, and the disinhibited type of organic personality syndrome, were significantly more common in subjects with contusions. Concerning the location of contusions, organic personality syndrome and its disinhibited subtype were associated with frontal lesions, and major depression was, surprisingly, inversely associated with temporal lesions. These results, which should be interpreted with caution due to the limited size of the study group, suggest that the majority of psychiatric disorders after traumatic brain injury are not closely related to the specific location or even the presence of contusions detectable with post-acute MRI.     

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.     

额叶内侧面损伤的临床特点及救治

目的 总结17例额叶内侧面损伤的临床特点及救治经验。方法 对我科1999年7月至2003年4月收治的额叶内侧面损伤患者进行回顾性分析。结果 手术治疗1例，恢复良好，保守治疗16例，其中恢复良好12例，中残2例，死亡2例，全组死亡率11．77％。结论 额叶内侧面损伤一般意识障碍较轻，但易直接发生枕骨大孔疝，严密观察病情及动态CT检查，颅内压监测，不拘泥传统手术指征，及时抓住手术时机，可有效降低致残率及死亡率。