神经内镜在脑外科的临床应用

目的 探讨神经内镜在颅内疾病临床治疗中的作用。方法 应用神经内镜治疗颅内疾病患者315例,其中单纯神经内镜手术219例,内镜辅助的显微神经外科手术72例,内镜控制的显微神经外科手术24例。结果 单纯神经内镜手术的219例中201例（91．8％）有效;内镜辅助手术的72例,术中均明显改善暴露,减少正常神经组织的牵拉,降低手术并发症;内镜控制手术的24例中,21例（87．5％）取得满意治疗结果。本组病例无严重并发症。结论 内镜用于神经外科,使手术更加微创化,疗效明显,副损伤及并发症发生率明显降低。     

神经内镜辅助锁孔手术治疗颅内动脉瘤

目的 探讨神经内镜辅助下的锁孔手术治疗颅内动脉瘤的手术效果。方法 对14例颅内动脉瘤行动脉瘤夹闭术。经眉弓或翼点锁孔开颅，手术显微镜下初步暴露动脉瘤，置入神经内镜，观察动脉瘤颈及其周围结构的局部解剖，动脉瘤夹夹闭，再次置入神经内镜了解夹闭情况。结果 14例患者均无手术并发症，未出现新的神经系统症状与体征，全部恢复良好出院。结论 应用神经内镜辅助下的锁孔手术治疗颅内动脉瘤，可充分暴露动脉瘤及周围结构的局部解剖结构，手术创伤小，手术时间缩短，手术效果明显提高。     

脑血管

重组腺病毒载体介导外源基因转移至痉挛脑血管的研究；中低温停循环技术在复杂头颈部血管病变中的脑保护作用；去骨瓣减压术治疗大面积脑梗死100例；影响破裂大脑中动脉瘤手术预后因素的分析；以动静脉瘘为主的脑动静脉畸形的栓塞治疗；内镜辅助下经外侧裂手术治疗基底节区高血压性脑出血的临床疗效观察；神经内镜辅助下显微神经外科“锁孔”手术治疗前循环动脉瘤(综述)；颅内动脉瘤术后低血压反应的危险因素分析；3D-CTA在颅内动脉瘤诊治中的应用；创伤性颈动脉海绵窦瘘介入治疗的临床效果影响因素分析；锁孔手术治疗基底节区脑出血的术式评价；血管内栓塞辅助显微手术治疗复杂难治性脑动静脉畸形。     

神经内镜辅助锁孔显微外科治疗颅内胆质瘤

目的 探讨神经内镜辅助锁孔显微神经外科治疗颅内胆质瘤的方法和意义。方法 应用神经内镜辅助锁孔显微神经外科技术治疗颅内胆质瘤16例。以MRI显示的肿瘤核心部位选择锁孔入路，在手术显微镜下尽可能切除可见的肿瘤部分，再辅助使用神经内镜寻找残余的肿瘤并切除。结果 在常规显微神经外科切除肿瘤后，应用神经内镜探查，13例仍能发现残余肿瘤，在内镜下进一步切除；3例无残余肿瘤；肿瘤全切除14例，次全切除2例。15例手术后2周内原有症状明显缓解或恢复，1例发生了无菌性脑膜炎，经治疗2周后痊愈。无术后脑积水及继发性颅内出血。术后3～12个月随访10例，9例痊愈，1例存在三叉神经痛，需药物治疗。结论 神经内镜辅助锁孔显微神经外科治疗颅内胆质瘤，尤其是生长广泛的巨大胆质瘤，有助于提高颅内肿瘤全切率，减少手术创伤，降低术后并发症。     

多技术联合应用于颅内巨大动脉瘤的显微外科治疗

目的 探讨神经电生理监测、术中超声、术中荧光造影、神经内镜多技术联合应用于颅内巨大动脉瘤的显微外科手术治疗的临床效果。方法 回顾性分析显微手术治疗颅内巨大动脉瘤17例的临床资料。术前采用3D-CTA、MRI和DSA,充分评估动脉瘤的位置、大小和形状。术中应用神经电生理监测评价动脉瘤夹闭前、后的神经功能保留和损害程度;通过微血管多普勒超声的定性和定量分析联合术中荧光造影评定动脉瘤和周围邻近血管的血液流速及通畅度;神经内镜观察动脉瘤区的局部解剖,辨认重要的穿支血管、瘤颈结构和动脉瘤夹情况。手术在手术显微镜下操作,采用载瘤动脉控制性技术、瘤颈成形技术、动脉瘤内减压和切除技术、多瘤夹夹闭技术和血管痉挛保护技术等进行联合治疗。 结果 在多技术联合监测下,显微外科手术成功夹闭巨大动脉瘤17个,术后恢复良好15例,出现轻偏瘫1例,重度偏瘫l例,无死亡病例。DSA复查示瘤颈夹闭完全,载瘤动脉通畅。远期随访仍在进行中。 结论 多技术联合显微手术技术,能有效提高颅内巨大动脉瘤的手术疗效。     

眶上锁孔入路显微手术治疗前循环动脉瘤

目的 探讨眶上锁孔人路、神经内镜辅助显微手术治疗前循环动脉瘤的手术方法。方法 对12例前循环动脉瘤患者,依据手术前诊断性影像资料,制订个体化手术计划;手术行眉部皮肤切口,于眶上作直径2cm左右骨窗开颅,采用内镜辅助的显微外科技术夹闭动脉瘤。结果 12例5种不同类型动脉瘤患者经该方法治愈,其中1例患者术中动脉瘤破裂,经阻断载瘤动脉12min,妥善分离动脉瘤后,在内镜辅助下准确夹闭瘤颈,术后对侧肢体有暂时性轻瘫,经治疗1周后肌力恢复正常。本组病例均未出现与手术人路相关的并发症。结论 采用眶上锁孔入路、内镜辅助的显微外科技术治疗前循环动脉瘤,是一种安全、微侵袭和有效的途径。     

内窥镜辅助的显微神经外科手术

目的 探讨内窥镜辅助显微神经外科的临床应用价值。方法 在包括颅内肿瘤、囊性病变、颅内动脉瘤、神经－血管压迫综合征、血肿及脑积水的３７例颅脑病变患者手术中使用神经内窥镜,分析内窥镜与显微手术配合的过程（包括对脑组织、颅神经的暴露与保护,手术视野,手术时间等多方面）。结果 颅脑肿瘤组１５例,１３例肿瘤全切,肿瘤全切率高,并发症少,其中桥脑小脑角肿瘤１１例,在肿瘤全切下面神经均得以保留;神经－血管压迫综     

显微手术和介入治疗急性期颅内动脉瘤破裂的对比性研究

目的 比较显微外科手术和血管内介入治疗急性期颅内动脉瘤破裂的疗效和相关并发症。方法 82例破裂性颅内动脉瘤，均在蛛网膜下腔出血急性期(72h以内)行外科治疗，其中行显微手术瘤颈夹闭40例，血管内电解可脱性弹簧圈栓塞治疗42例。对两组疗效和并发症进行对比分析。结果 显微手术组，完全夹闭率92．5％，手术相关并发症4例，死亡2例。弹簧圈栓塞组，完全闭塞率71．4％，栓塞组相关并发症6例，死亡1例。在前循环动脉瘤中，栓塞组完全闭塞率与手术组完全夹闭率相比较，显微手术组结果优于栓塞组。临床随访6个月，两者预后良好者均达95．0％。结论 显微瘤颈夹闭术和血管内栓寒治疗均是颅内动脉瘤治疗的有效方法。     

球囊辅助下ONYX栓塞大型脑动脉瘤

颅内动脉瘤是神经外科常见疾病．其破裂出血的病死率很高．达25％-60％，死亡的主要原因为出血及早期并发症。目前显微神经外科直接手术治疗大型（10～25mm）和巨大型（〉25mm）脑动脉瘤虽可治愈部分患者，但手术难度大．病残率和病死率均较高。以往对此类颅内动脉瘤应用微弹簧圈如电解脱弹簧圈（GDC）等进行血管内治疗，由于瘤腔难以致密填塞、手术后弹簧圈被压缩和瘤内存在血栓等因素，因此疗效较差、复发率高。球囊辅助下ONYX可以致密填塞动脉瘤腔，保留载瘤动脉，重建损伤的动脉血管壁，因此对治疗大型和巨大型脑动脉瘤有较大的优越性。     

显微手术辅以内镜切除大型听神经瘤

目的 探讨神经内镜辅助的显微神经外科手术治疗大型听神经瘤的临床意义和手术方法。方法 16例大型听神经瘤，均施行患侧枕下乙状窦后入路显微手术切除，同时辅以神经内镜配合。结果 肿瘤全切除13例，次全切除者3例。面神经保留14例，短期并发症4例。所有患者神经功能均有不同程度的恢复。结论 神经内镜辅助显微手术切除大型听神经瘤，具有微创及提高肿瘤全切除率等优点。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.