颅脑损伤患者术中出现急性脑膨出的预后及影响因素分析

目的探讨颅脑损伤患者术中出现急性脑膨出的预后及影响因素。方法对112例开颅术中出现急性脑膨出颅脑损伤患者的临床及随访资料进行回顾性分析,以Glasgow预后评分(GOS)将112例患者分为观察组和对照组,其中GOS1~3分为对照组、4~5分为观察组。对可能影响患者预后的12项因素年龄、凝血指标、血糖、多发伤、术前颅内压、术前瞳孔、术前Glasgow评分(GCS)、脑膨出原因、是否再次手术、术后颅内压、术后瞳孔、术后GCS等,采用分类变量多因素Logistic回归分析进行研究。结果 112例患者中22例(19.6%)预后良好,90例(80.4%)预后不良。年龄、手术前后颅内压、脑膨出原因、术后GCS与术中出现急性脑膨出颅脑损伤患者的预后密切相关(P0.05)。结论术中出现急性脑膨出颅脑损伤患者总体预后差,年龄、手术前后颅内压、脑膨出原因、术后GCS可作为判断预后的重要指标。     

局部亚低温对颅脑损伤患者去骨瓣减压术后脑膨出并发症的影响

目的 探讨局部亚低温对颅脑损伤患者去骨瓣减压术后脑膨出并发症的控制作用.方法 选取行去骨瓣减压术治疗的重型颅脑损伤患者86例,术后给予常规治疗32例,在常规治疗的基础上加用局部亚低温辅助治疗54例.术后12 h亚低温治疗前对患者行格拉斯哥昏迷评分(GCS),检测颅内压(ICP)、脑灌注压(CPP)及血氧饱和度(SaO2).术后7d判定患者脑膨出情况并再次检测ICP及CPP. 结果常规治疗组与局部亚低温治疗组在年龄、性别、受伤至手术时间分布、亚低温治疗前GCS评分、ICP、CPP及SaO2方面的差异均无统计学意义(P＞0.05).术后7 d亚低温治疗组患者脑膨出发生率、脑膨出程度及ICP均低于常规治疗组,CPP高于常规治疗组,差异均有统计学意义(P＜0.05). 结论 去骨瓣减压术后进行局部亚低温治疗有助于提高CPP、降低ICP,并且减少脑膨出的发生率和脑膨出程度,有利于脑损伤患者功能恢复.     

颅脑损伤手术中急性脑膨出的形成原因初步探讨

目的探究颅脑损伤手术中急性脑膨出的形成原因及影响因素,提出有效防治措施。方法选取2014年1月至2016年1月我院神经外科实施开颅手术的颅脑损伤患者130例,根据术中是否发生急性脑膨出分为观察组(发生急性脑膨出)和对照组(未发生急性脑膨出)。收集患者的临床资料,通过单因素卡方检验和多因素Logistic回归分析总结颅脑损伤患者术中发生急性脑膨出的影响因素。结果 40例患者术中发生急性脑膨出,发生率为30.8%。经单因素卡方检验,两组患者性别比、年龄、致伤原因、有无脑脊液漏以及合并多发伤情况差异均无统计学意义(P0.05);观察组入院后首次格拉斯哥昏迷评分(glasgow coma scale,GCS)8分、受伤至手术时间3 h、合并手术远隔部位颅骨骨折、合并迟发性外伤性颅内血肿(delayed traumatic intracranial hematoma,DTIH)以及合并外伤性弥漫性脑肿胀(post-traumatic acute diffuse brain swelling,PADBS)的比例均高于对照组,差异均有统计学意义(P0.05)。经多因素Logistic回归分析,入院后首次GCS评分低、受伤至手术时间短以及合并手术远隔部位颅骨骨折、DTIH和PADBS均为颅脑损伤患者术中发生急性脑膨出的危险因素。结论颅脑损伤患者手术过程中发生急性脑膨出的几率较高,且与入院后首次GCS评分、受伤至手术时间以及合并手术远隔部位颅骨骨折、DTIH和PADBS情况相关,术前应对患者发生急性脑膨出的风险进行综合评估。     

外伤后急性弥漫性脑肿胀术中急性脑膨出相关危险因素分析

目的探讨外伤后急性弥漫性脑肿胀PADBS术中急性脑膨出相关危险因素。 方法对厦门大学附属中山医院神经外科自2010年1月至2015年12月收治的58例PADBS开颅减压术中发生急性脑膨出（病例组）与47例同期术中未发生脑膨出（对照组）患者的性别,年龄,受伤至手术时间,减速性颅脑损伤,合并多发伤,颅脑CT血肿厚度,脑疝,术前GCS评分,术中低血压,手术方式进行病例对照研究,通过Logistic多因素回归分析术中急性脑膨出相关危险因素。 结果Logistic多因素回归分析显示减速性颅脑损伤,术前GCS评分,脑疝,术中低血压与PADBS术中急性脑膨出发生密切相关。 结论减速性颅脑损伤,术前GCS评分,脑疝,术中低血压是PADBS发生术中急性脑膨出的独立危险因素,术前准确评估伤情及术中积极控制可降低PADBS术中急性脑膨出发生风险。     

颅内压监测下去骨瓣减压术患者预后的分析

目的探讨重型颅脑创伤患者在持续颅内压(ICP)监测下行单侧去骨瓣减压术预后相关因素分析。方法收集我科2015年1月至2016年1月期间收治的16例重型颅脑损伤去骨瓣减压术的临床资料,分析术前瞳孔直径及GCS评分、受伤-开颅间隔、改良CT计分及持续ICP及其对预后的影响,预后以6个月内GOS评分判断。结果预后良好组(GOS 4~5分)7例,预后不良组(GOS 1~3分)9例。两组间在术前改良CT计分、初始ICP、关颅缝皮后ICP、术后24hICP、术前GCS评分、术前瞳孔直径、受伤-开颅间隔时间等方面差异具有统计学意义。结论术前改良CT计分、持续ICP监测在去骨瓣减压术患者中有助于及时发现问题,可指导治疗和评估预后。评估去骨瓣减压术患者预后,ICP优于改良CT计分、瞳孔变化、GCS评分,ICP与预后存在负相关;改良CT计分可反应ICP水平;二者具有重要的临床应用价值。     

迟发性硬脑膜外血肿所致的术中急性脑膨出

目的 分析急性颅脑损伤后开颅血肿清除术中急性脑膨出的原因。方法 对发生于近5年内开颅血肿清除术中发生的急性脑膨出患者进行统计,总结其中迟发性硬脑膜外血肿发生情况。结果 5年中发生于颅脑损伤后开颅血肿清除术中的急性脑膨出患者75例,其中迟发性外伤性硬脑膜外血肿25例(25/75),占同期外伤性硬脑膜外血肿的5.1％。死亡6例,死亡率为24％(6/25)。结论 颅脑损伤后减压术中出现原因不明的颅内压增高、脑膨出时,应首先排除迟发性硬脑膜外血肿的可能,以防漏诊,延误治疗。     

影响重型颅脑损伤患者大骨瓣减压术后预后的多因素分析

目的分析重型颅脑损伤(severe craniocerebral injury,sTBI)患者大骨瓣减压(decompressivecraniectomy,DC)术后的预后及相关因素。方法回顾分析121例DC术后患者的临床资料。出院1个月后,根据格拉斯哥预后评分(Glasgow outcome scale,GOS)分为预后不良组(n=72)和预后良好组(n=49),比较两组患者的年龄、性别、受伤至手术时间、入院时格拉斯哥昏迷评分(Glasgow coma scale,GCS)、瞳孔变化、术前中线移位、术前基底池形态、术前血糖等因素,Logistic多元回归分析影响预后的相关因素。结果单因素分析表明两组间受伤至手术时间、入院时GCS评分、瞳孔变化、术前中线移位、术前基地池形态和术前血糖差异有统计学意义(P<0.05);采用Logistic回归分析上述因素,影响预后的相关因素分别为入院时GCS评分、瞳孔变化、术前中线移位、术前基地池形态、受伤至手术时间和术前血糖。结论sTBI患者DC术后的预后与入院时GCS评分、术前中线移位、术前基地池形态、瞳孔变化、受伤至手术时间和术前血糖等因素有关。     

重型颅脑损伤急性脑膨出术中死亡1例并相关文献复习

目的探讨重型颅脑损伤术中急性脑膨出的原因及防治对策。方法分析1例典型的重型颅脑损伤术中急性脑膨出患者的临床资料,并复习关于术中急性脑膨出形成原因及防治的文献。结果本例患者开颅术中发生急性脑膨出,在术中死亡。结论迟发性颅内血肿、弥漫性脑肿胀及大面积脑梗死是术中形成急性脑膨出的主要原因,术前正确评估及术中采取相应的对策可有效防治急性脑膨出,提高患者的生存率。     

持续颅内压监测指导重型颅脑损伤开颅术后甘露醇的应用

目的探讨持续动态颅内压(ICP)监测指导重型颅脑损伤(sTBI)患者行开颅脑血肿清除术和(或)去骨瓣减压术后甘露醇使用的临床价值。方法对20例sTBI开颅术后患者行持续ICP监测,根据ICP数值作个体化甘露醇脱水降颅压,并与同期未行ICP监测的21例开颅术后患者的甘露醇应用时间和计量、术后并发症、预后进行比较。结果监测组甘露醇使用时间及计量较对照组低,监测组术后总并发症(迟发性脑血肿、大面积脑梗塞、弥漫性脑肿胀、电解质紊乱、急性肾功能损害)发生率较对照组低;监测组GOS预后评分优于对照组。结论持续动态ICP监测能及时反应sTBI开颅术后ICP的变化,通过个体化精准降颅压治疗有效控制ICP,维持脑灌注压,减少甘露醇的使用,减少术后并发症的发生,改善sTBI患者预后和生存率。     

重型颅脑损伤的颅内压与预后及其在大骨瓣减压术中的变化

目的探讨重型颅脑损伤患者颅内压(ICP)与预后的关系,以及大骨瓣减压术中ICP的变化。方法回顾性分析58例重型颅脑损伤患者大骨瓣减压术前、术中和术后的ICP值。术后6个月时评估患者的预后,对术前不同ICP患者的预后进行比较。结果本组患者在大骨瓣减压术前、骨瓣去除后、硬脑膜切开后、血肿清除后和关颅后的平均ICP,分别为(45.48±10.09)mm Hg、(29.84±5.21)mm Hg、(8.86±3.78)mm Hg、(10.15±4.12)mm Hg和(11.41±5.26)mm Hg。减压术前ICP60 mm Hg患者的预后不良率和术中急性脑膨出发生率均显著高于ICP40 mm Hg和40~60 mm Hg的患者(均P0.05)。减压术中大骨瓣去除后和硬脑膜切开后的ICP均较术前明显下降(均P0.05)。结论重型颅脑损伤后ICP明显增高患者的预后较差,应警惕患者术中发生急性脑膨出。大骨瓣减压的同时充分切开硬脑膜能最大程度地降低ICP。     

Evidence for effectiveness of botulinum toxin for hyperhidrosis

Summary Hyperhidrosis refers to excessive and uncontrollable sweating beyond that is required to return body temperature to normal. Although a broad spectrum of treatment modalities are available including topical and systemic therapies, iontophoresis, and surgical interventions, their efficacy are usually short-term or are associated with unacceptable side effects. Recently, chemodenervation using botulinum toxin has emerged as a safe and effective treatment for both primary palmar and axillary hyperhidrosis in several clinical trials. In this article, we utilized the scale developed by the Therapeutics and Technology Assessment (TTA) subcommittee of the American Academy of Neurology evaluating current evidence supporting the use of botulinum toxin for the treatment of primary focal hyperhidrosis. As a result, there is a strong evidence to support the efficacy of botulinum toxin type A in axillary (Level A evidence) and palmar (Level B evidence) hyperhidrosis. Correspondence: Roongroj Bhidayasiri, MRCP (UK), Chulalongkorn Comprehensive Movement Disorders Center, Division of Neurology, Chulalongkorn University Hospital, Bangkok 10330, Thailand     

Strategies for the Development of Drugs for Pharmacoresistant Epilepsies

Summary: Presently, most strategies for development of antiepileptic drugs (AEDs) center around seizure models that are known to respond to presently marketed AEDs. These strategies do not take into account that epilepsy can be a progressive disease. Moreover, region-specific aspects of ep-ileptogenesis are rarely considered when new AEDs are developed. Seizures in the temporal lobe are often difficult to treat. Animal studies on various seizure models in the hippocampus and the entorhinal cortex (EC) suggest that these structures do not a priori produce seizures that are difficult to treat. However, seizure-like events in the EC tend to progress to a state of status epilepticus-like activity that cannot be suppressed by presently marketed AEDs. Loss of 7-aminobutyric acid (GABA)ergic neurotransmission and increased excitatory synaptic coupling seem to cooperate for induction of this state. Epilepsy induced alterations in the interaction between the EC and the hippocampus may lead to alterations that facilitate precipitation of seizures. Because of the recurrent interaction between the hippocampus and the EC, these seizures may reach an intensity that is no longer controllable by presently available AEDs. Ontogenetic alterations of the circuitry between the EC and the hippocampus. seizure-induced stabilization of synaptic connections over-expressed during ontogenesis, seizure-induced lesions and subsequent rearrangements of internal cell properties, and synaptic arrangements and kindling-like alterations of nerve cell and glial behavior may all be involved in the generation of a neuronal aggregate whose balance between inhibitory and excitatory processes becomes readily disturbed. Strategies for the development of AEDs treating such seizures should suppress hyperactivity and prevent progression of epilepto-genesis. AEDs directed against seizures may be effective if they can be given in sufficient concentrations to suppress very intense local seizures.     

Evidence for the effectiveness of botulinum toxin for sialorrhoea

Summary Sialorrhoea is a common symptom in many neurological disorders. Recently, botulinum toxin has been introduced as a treatment for sialorrhoea, and in this paper, we review the evidence for its effectiveness. The publications on the topic were searched and reviewed independently by two authors using the scale developed by the Therapeutics and Technology Assessment subcommittee for the American Academy of Neurology. All papers identified in our search fulfilled were evaluated, and classified into 1 of the 4 levels of evidence. According to this scheme, the effectiveness of botulinum toxin A in the treatment of sialorrhoea is considered established (level A). Botulinum toxin B is considered probably effective in the treatment of sialorrhoea (level B). Correspondence: Daniel D. Truong, The Parkinson’s and Movement Disorder Institute, 9940 Talbert Ave., Fountain Valley, CA 92708, USA     

Considerations for Intentional Use of Self-Disclosure for Family Therapists

One of the most debated ethical issues in psychotherapy is that of therapist self-disclosure. In this article, relevant marriage and family therapy literature on therapist self-disclosure will be presented. The influence of practice setting, particularly in training clinics and private practice, on therapist self-disclosure is discussed. A distinction is drawn between intentional and spontaneous self-disclosure. Risks for excessive self-disclosure become amplified in private practice, whereas training clinics are more likely to discourage the use of self-disclosure as a clinical technique. Literature presented is intended to demonstrate that advanced training settings and advanced practice settings hold disparate positions on the issue of self-disclosure. This gap between advanced training and advanced practice may leave therapists open to ethical vulnerabilities. Recommended steps toward intentional and ethical practice are presented.     

Use of conivaptan for management of hyponatremia following surgery for Cushing's disease

Background

Hyponatremia due to syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a common osmoregulatory complication following surgery for Cushing's disease. Conventional management includes water restriction and sodium repletion, however this regimen does not address the underlying pathophysiology of excessive vasopressin production. Vaptans are arginine vasopressin receptor antagonists shown to be effective in correcting water excess in other disease states of euvolemic and hypervolemic hyponatremia. The use of these agents has not been reported in Cushing's patients.

Methods

We retrospectively studied Cushing's patients at our institution with post-surgical hyponatremia (Na < 130 mEq/L) treated with and without conivaptan between 2005 and 2011. We report rates of serum sodium normalization and compare length-of-stay (LOS) between the groups.

Results

Hyponatremia developed in six of 98 patients (6.1%) undergoing resection of ACTH-positive pituitary adenomas. Three patients received conivaptan and fluid restriction ± sodium supplementation, and three received conventional therapy alone. The rate of serum sodium normalization with conivaptan was 5.8 ± 2.3 mEq/L/20 mg IV bolus given every 24 h. All patients receiving conivaptan were discharged with normal serum sodium values and no instances of rapid overcorrection occurred. A trend toward longer LOS occurred in patients treated with conivaptan (4.6 ± 0.3 days, mean ± SE) versus conventional therapy alone (1.6 ± 0.3 days).

Conclusions

Conivaptan is a potentially useful treatment option for hyponatremia in the setting of Cushing's disease patients after pituitary surgery.