爆炸冲击波对家兔颈部大血管损伤机制研究

目的 探讨头颈部爆炸冲击波对颈部大血管的损伤机制，为临床救治头颈部爆炸伤患者、预防并减少并发症提供理论依据。方法 将炸药球置于家兔颈部不同距离处引爆，模拟头颈部爆炸伤。家兔颈部皮肤表面及血管深面放置压力传感器用以记录冲击波压力变化；用光镜以及扫描电镜观察颈部大血管损伤情况。结暴爆炸后，家兔颈部软组织受到冲击波的直接作用而损伤，大血管壁也受到冲击波的间接作用而损伤：内皮变性、脱落，中膜断裂，血细胞进人中膜层等，为爆炸伤后假性动脉瘤的形成提供理论依据；颈部大血管内在不同时刻发现血栓形成，颈总动脉内以血小板聚集而成的微血栓为主，而颈外静脉可发生血栓堵塞管腔现象。结论 颈部爆炸伤时，冲击波致伤颈部大血管，颈外静脉损伤易于形成血栓，甚至堵塞管腔；颈动脉损伤形成微血栓，并可能继发假性动脉瘤。为临床救治爆炸伤伤员提供一定的理论依据。     

医源性心脏大血管损伤的外科处理

目的 总结各类心胸外科手术中医源性心脏大血管损伤(ICVI)28例的救治体会，探讨其产生的原因及对症采取的措施。方法 大多数病例采用手指按压后用无损伤垫片针褥式缝合，如无法直接缝合止血，即用手指按压出血处，然后迅速做供血插管及肝素化措施，建立体外循环，再予止血。结果 28例在术中采用各种止血方法均获得成功，后因l例肾缺血时间过长并发急性肾衰而死亡(死亡率3．57％)，其他病人均康复出院。结论 ICVI造成的原因很大一部分是术者操作不良及手术经验不足而引起，另一部分是组织粘连紧密或晚期癌肿浸润而引起，采用不同的止血方法，特别是褥式垫片缝合及Prolene线连续缝合或附加止血辅助物可以使手术获得成功，必要时尽早建立心肺体外转流技术，但关键是在术中预防此类合并症的发生。     

心脏大血管创伤的诊断与处理

目的：探讨心脏大血管创伤后的急诊和外科处理。方法：回顾性分析我科1954年6月－2002年7月收治的46例心脏大血管损伤后急救处理和后遗症的病例资料，其中：穿透性损伤18例，闭合性损伤14例和医源性损伤14例；心脏穿破17例，瓣膜破损11例，心脏异物8例，假性动脉瘤和动脉静瘘8例，右心室动脉瘤和室间隔缺损、心包缩窄和右下肺弹头各1例。结果：44例经手术治疗痊愈出院，死亡2例。1例左心房撕裂后大出血导致心脏停搏，抢救无效死亡。另1例外伤引起弓降部假性动脉瘤，手术时出血死亡。结论：及时诊断、紧急手术，后遗症择期手术需在体外循环准备下手术，心脏异物需在食道超声探头监测下施行手术。     

胸部大血管刃器伤急诊外科治疗

目的 总结胸部大血管刃器伤的抢救体会，以改善治疗效果。方法 对15例胸部大血管刃器伤及其合并伤的早期诊断、控制出血、损伤血管修复原则和要点等进行临床分析。结果 15例患者中治愈11例，4例死亡。结论 胸部大血管刃器伤早期诊断、快速术前准备、快捷的手术入路、有效的心肺复苏、及时控制出血及正确缝合止血技术等是提高胸部大血管刃器伤抢救成功率的关键。     

改良冀点入路消除急性颞部创伤性颅内血肿

目的：探索颞部急性损伤性颅内血肿的手术入路和颅外减压的方式。方法：采用改良冀点入路清除颞部急性损伤性颅内血肿３７例，其中２６例用游离的骨膜或颞肌筋膜减张缝合硬脑膜。结果：恢复良好３２例（８６％），重度残废１例，死亡４例。结论：改良冀点入路显露颞叶底面及中颅底良好，用于颞部损伤性颅内血肿手术优于常规颞瓣开颅术；硬脑膜减张缝合简单易行，不影响颅外减压效果且克服了硬脑膜不缝合的弊端。     

15例颈部大血管损伤患者的诊治

1990年 2月— 2 0 0 2年 3月 ,我院共收治颈部大血管损伤 15例 ,现就其诊治经验与教训总结如下。1　临床资料1.1　病例 :15例患者中男 13例 ,女 2例 ;年龄 2 0～ 6 5岁 ,平均 (41.0± 1.8)岁 ;开放性损伤 11例 ,闭合性损伤 4例 ;刀刺伤 7例 ,交通事故中玻璃割伤 4例 ,飞梭击伤 4例 ;均为单侧颈部大血管损伤 ,其中颈内静脉损伤 7例 ,颈内动脉损伤 3例 ,颈总动脉损伤 4例 ,颈内静脉伴颈总动脉损伤 1例 ;合并臂丛神经损伤1例 ,伴食管损伤 1例 ,合并脾破裂 1例 ,血肿压迫致气管移位 2例 ;入院时合并失血性休克 13例 ,血压为 0～ 5 0 / 0～30 mm …     

腹部大血管刀刺伤的诊治体会(附8例分析)

目的：探讨腹部大血管刀刺伤的诊断、治疗。方法：对8例腹腔大动脉刀刺伤的治疗方法进行分析。结果：成功救治7例，死亡例。结论：积极抗休克，并紧急剖腹止血，是腹部大血管刀刺伤病人救治的关键。     

腹部大血管损伤的诊断和治疗(附36例报告)

目的:探讨腹部大血管损伤的诊断和治疗,提高救治水平.方法:回顾性总结分析1990年1月～2003年1月发生的36例腹部大血管损伤的临床资料.其中开放性损伤26例,闭合性损伤7例,医源性损伤3例.结果:存活27例,死亡9例,死亡率为25.0%.主要死亡原因为失血性休克.结论:判断伤情,有效复苏,控制休克,紧急剖腹止血是抢救成功的关键.     

以神经系统为首发临床表现的多发伤50例延误诊断分析

在同一致病因素下，使两个或两个以上解剖部位或脏器受到严重损伤，其中有一处是危及生命的或合并休克。因此，凡具有以下两条或两条以上的均可诊断多发性创伤。①颅脑外伤：颅骨骨折、颅内血肿、脑挫伤或裂伤、领面部骨折；②颈部损伤：大血管损伤或颈椎损伤；③胸部损伤：多发肋骨骨折、血气胸、心、肺、气管、纵膈、横膈和大血管损伤；④腹部损伤：腹腔内实质、空腔脏器损伤、出血、后腹膜血肿⑤脊柱骨折伴有神经损伤⑥骨盆骨折伴有休克.     

8例心脏及大血管损伤的急救处理

８例心脏及大血管损伤的急救处理朱学诚心脏及大血管损伤患者病情危重，需要迅速有效地急救处理，否则迅速导致死亡。１９６４～１９９３年共抢救成功８例心脏大血管损伤患者，报告如下。１临床资料１．１病例：８例中男７例，女１例；年龄５～３６岁。其中穿透性损伤６例...     

Chronic fusiform extracranial vertebral artery aneurysm with recurrent posterior circulation emboli: Case report and review of the literature

We report a case of a 64-year-old man with a fusiform right extracranial vertebral artery aneurysm, spanning over half the extra-cranial V2 (foraminal) segment, presenting with recurrent multi-focal posterior circulation embolic ischaemic stroke. The patient was treated with endovascular embolisation of the right vertebral artery to prevent further thrombo-embolic events. Distal and proximal occlusion of the aneurysmal vertebral artery was performed with a micro-vascular plug with partial aneurysm sack embolisation to aid thrombosis and reduce the risk of recanalisation. Two months post procedure MR angiography confirmed successful aneurysm occlusion with no post-procedural complication. The patient returned to his normal independent life. Endovascular treatment with vessel sacrifice is an effective treatment with low morbidity and we believe the MVP device to be a efficacious option in the vertebral artery.     

外周血管穿刺后并发症的多普勒超声观察

目的：分析动／静脉穿刺后的常见并发症包括血肿、假性动脉瘤、动静脉瘘的超声特征。方法：多普勒超声观察２０例在动脉或静脉穿刺后出现血管杂音或／和肿块者,分析肿块的内部回声状态以及与邻近血管的关系,肿块内血流状态,动静脉管壁的完整性及血流关系。结果：５例单纯血肿,肿块内无流动性血流;１１例假性动脉瘤,动脉壁有破口,肿块内有流动性血流;５例动静脉瘘,在静脉内检出动脉性血流或在瘘口处双期连续性分流。结论：超     

Delayed aneurysm rupture due to residual blood flow at the inflow zone of the intracranial paraclinoid internal carotid aneurysm treated with the Pipeline embolization device: Histopathological investigation

Cerebral aneurysm rupture is a serious complication that can occur after flow diverter (FD) placement, but the underlying mechanisms remain unclear. We encountered a case in which direct stress on the aneurysm wall caused by residual blood flow at the inflow zone near the neck during the process of thrombosis after FD placement appeared associated with aneurysm rupture. The patient was a 67-year-old woman with progressive optic nerve compression symptoms caused by a large intracranial paraclinoid internal carotid aneurysm. The patient had undergone treatment with a Pipeline embolization device (PED) with satisfactory adherence between the PED and vessel wall. Surgery was completed without complications, and optic nerve compression symptoms improved immediately after treatment. Postoperative clinical course was satisfactory, but the patient suddenly died 34 days postoperatively. Autopsy confirmed the presence of subarachnoid hemorrhage caused by rupture of the internal carotid aneurysm that had been treated with PED. Although the majority of the aneurysm lumen including the outflow zone was thrombosed, a non-thrombosed area was observed at the inflow zone. Perforation was evident in the aneurysm wall at the inflow zone near the neck, and this particular area of aneurysm wall was not covered in thrombus. Macrophage infiltration was not seen on immunohistochemical studies of the aneurysm wall near the perforation. A hemodynamically unstable period during the process of complete thrombosis of the aneurysm lumen after FD placement may be suggested, and blood pressure management and appropriate management with antiplatelet therapy may be important.     

兔眼视网膜静脉阻塞模型的建立

目的；探讨建立兔眼视网膜静脉阻塞模型的方法。方法：用氩激光光凝封闭兔视网膜颞侧静脉，行眼底照像及荧光造影均证实静脉阻塞模型形成。形成后2h，1d，3周，4周处死家兔，摘除眼球，行光镜和电镜观察。结果：FFA显示击射处血管完全阻塞。光镜和电镜下显示缺血、水肿、血栓形成等典型的病理学改变。结论：用氩激光光凝兔眼视网膜静脉可导致视网膜静脉血管变细，血流中断，血栓形成。该方法可为临床研究视网膜静脉阻塞提供可靠的动物模型。     

64排螺旋CT用于体部动脉性病变的诊断

目的:评价64排螺旋CT血管造影(64-MDCTA)及重建技术在体部动脉(除冠状动脉外)性病变诊断中的临床应用价值。方法:102例患者(包括颈、椎动脉19例、肺动脉5例、胸腹主动脉及其分支49例,双下肢动脉29例)行64-MDCTA检查,采用准直0.625mm,层厚0.625mm,间隔0.5~0.625mm。应用多平面重建(multiple planar reconstruction,MPR),曲面重建(curved planar reconstruction,CPR),最大密度投影(maxi mumintensity projection,MIP),容积显示技术(volume renderingtechnique,VRT)以及血管分析(vessel analysis,VA)软件进行图像重建及分析。结果:102例体部动脉病变中,CTA显示:颈动脉钙化斑块伴狭窄10例,颈动脉体瘤3例,颈总动脉假性动脉瘤1例,颈动脉鞘内神经源性肿瘤伴血管推移1例,椎动脉狭窄1例,椎动脉瘤1例,正常颈动脉2例,肺动脉栓塞4例,正常肺动脉1例,马凡氏综合征2例,大血管转位1例,胸、腹主动脉瘤15例,假性动脉瘤3例,夹层动脉瘤11例,夹层动脉瘤术后随访8例,脾动脉瘤1例,肾动脉斑块、狭窄2例,右肾动脉狭窄支架术后随访1例,腹主动脉瘤术后随访2例,椎体骨质增生压迫腹主动脉1例,正常主动脉1例,正常腋动脉1例,髂动脉瘤3例,股髂动脉血栓、闭塞4例,双下肢动脉硬化性闭塞症14例,下肢血管动静脉瘘3例,下肢动脉术后随访4例,正常双下肢动脉1例。以上几种重建技术均能显示病变发生部位、大小、形态、范围,对病变可从不同角度观察,VRT能三维立体显示病变,MPR、CPR、MIP均能显示血栓、钙化,MPR、CPR、VA能显示动脉管腔及支架腔内情况。102例中63例经手术或DSA证实。结论:64-MDCT能够全面清晰显示体部动脉病变,为患者提供快速及有效、可靠的诊断手段,对临床诊断、治疗具有重要指导意义。     

Head and neck neurovascular trauma: Clinical and angiographic correlation

A retrospective review of all angiograms done for craniocervical trauma, over an eight-year period at Groote Schuur Hospital identified 61 patients out of 823 angiographically studied who had extradural vascular injury and required endovascular treatment. Multiple lesions were identified in nine (14,8%) patients and associated injuries were found in 23 patients (37%). The mechanism of injury was blunt in nine (14.8%) patients and penetrating in 52 (85.2%). There was a statistically significant correlation between the presenting clinical feature and the underlying angiographic lesion. Patients with active bleeding were more likely to have a vessel laceration, an expanding hematoma was associated with false aneurysm and a pulsatile mass with arteriovenous fistula. Endovascular treatment with emphasis on vessel occlusion rather than preservation was successful in all cases except one which required surgical vessel ligation.     

氦-氖激光血管内照射治疗脑梗塞35例观察及护理体会

目的:总结氦-氖激光血管内照射治疗脑梗塞患者的护理方法。方法:选择与激光针规格相匹配的静脉穿刺留置针,取前臂肘正中静脉或贵要静脉进行氦-氖激光治疗。结果:本组治愈8例,显效12例,有效14例,无效1例,有效率为97.1%。结论:氦-氖激光血管内照射配合药物治疗脑梗塞,可缩短疗程,减轻患者痛苦,且疗效显著,操作简单,无副作用。     

三维对比增强MRA容积再现重建在颈部动脉狭窄中的诊断价值

目的分析三维对比增强MRA(3D CE-MRA)容积再现(VR)重建对颈部动脉狭窄的诊断价值。方法选择经DSA证实的颈部动脉狭窄28例,采用三维容积超快速多期动态增强扫描序列(Propeller LAVA)行颈部3D CE MRA检查,将原始图像在Adw4.3工作站上行最大强度投影(MIP)及VR血管重建,以DSA作为标准进行对照。结果28例共44支。动脉闭塞7例11支,其中单侧颈内动脉1支,双侧椎动脉4例8支,单侧椎动脉2支。动脉狭窄21例33支血管(轻度18支、中度10支、重度5支),其中单侧颈内动脉1支,双侧椎动脉12例24支,单侧椎动脉5支,单侧锁骨下动脉3支。44支病变血管VR所见与DSA表现基本一致,所有轻中度狭窄、闭塞血管MIP与DSA表现一致,重度狭窄1例相符,总符合率90.9%。4例重度狭窄血管中,MIP将左椎动脉重度狭窄显示管腔闭塞1支,管腔闭塞后侧支血管显示不清1支,狭窄段形态显示不清2支。结论颈部动脉VR重建可避开静脉干扰,血管显示更直观,反映的是血管真实信息。     

微创腔内隔绝术治疗降主动脉病变

目的总结微创腔内隔绝术治疗降主动脉病变的经验及近中期效果。方法分析总结本院2004年4月至2008年11月行腔内隔绝术27例患者的临床资料,其中急性Stanford“B”型夹层分离16例,降主动脉假性动脉瘤11例（包括5例外伤性降主动脉假性动脉瘤、5例降主动脉穿透性溃疡及1例感染性降主动脉假性动脉瘤）。结果26例患者手术获得成功,1例外伤性降主动脉完全断裂患者,因导丝无法进入升主动脉真腔,微创手术失败,转开胸手术行降主动脉替换。腔内隔绝术成功26例,术后降主动脉破口均立刻消失,真腔扩大。术后早期死亡1例（于术后2周死于胃溃疡大出血）;发生Ⅰ型内漏2例,Ⅱ型内漏1例;无术后截瘫、感染、远端血管损伤栓塞等并发症。腔内隔绝术成功26例患者中25例治愈出院。术后随访1个月～4年,覆膜支架通畅,无移位,真腔扩大,假腔缩小或消失。术后3个月CT复查,2例Ⅰ型内漏中1例内漏完全消失,1例内漏减轻（继续随访中）,1例Ⅱ型内漏无变化。结论腔内隔绝术治疗Stanford“B”型夹层动脉瘤及降主动脉假性动脉瘤创伤小,安全可靠,近中期疗效确切。     

Internal carotid artery aneurysm repair requiring skull base resection: a case study.

A 51-year-old man with a history of hypertension and smoking with an internal carotid artery (ICA) aneurysm was a referral from an outside hospital. He had a history remarkable for headaches for 6 months refractory to conventional therapy, but no stroke, transient ischemic attack, seizure activity, or neck pain. Arteriogram revealed a right ICA aneurysm at the level of the skull base with no accessible cervical ICA distal to the aneurysm. The petrous and intracranial ICA were normal. A team approach to repair was undertaken with a skull base resection and ICA exposure by head and neck surgeons and vascular reconstruction with vein graft from common carotid to petrous portion of ICA by vascular surgeons. A small right parietal infarction was noted in the postoperative period and became a focus of seizure activity. Anti-seizure medication was successful and transient upper-extremity weakness cleared. Transient dysfunction of cranial nerves VII and IX developed. The complex nature of the operation required expertise from different surgical specialties, and the postoperative complication mandated medical specialty and extensive inpatient and outpatient physical, occupational, and speech therapies ICA aneurysms of the skull base are uncommon. Historic treatment involved either ligation with a high risk of stroke or bypass to intracranial artery because direct repair was difficult. With a skilled team approach, direct repair as described is effective. This article focuses on the complexity of the surgical procedure, perioperative care, outcome of surgical intervention, and a multidisciplinary approach to the care of the patient undergoing ICA aneurysm repair requiring skull base resection.