The influence of hyperthermia on intracranial pressure,cerebral oximetry and cerebral metabolism in traumatic brain injury

Background: Hyperthermia is a common secondary insult in traumatic brain injury (TBI). The aim was to evaluate the relationship between hyperthermia and intracranial pressure (ICP), and if intracranial compliance and cerebral blood flow (CBF) pressure autoregulation affected that relationship. The relationships between hyperthermia and cerebral oximetry (B_tipO₂) and cerebral metabolism were also studied.

Methods: A computerized multimodality monitoring system was used for data collection at the neurointensive care unit. Demographic and monitoring data (temperature, ICP, blood pressure, microdialysis, B_tipO₂) were analyzed from 87 consecutive TBI patients. ICP amplitude was used as measure of compliance, and CBF pressure autoregulation status was calculated using collected blood pressure and ICP values. Mixed models and comparison between groups were used.

Results: The influence of hyperthermia on intracranial dynamics (ICP, brain energy metabolism, and B_tipO₂) was small, but individual differences were seen. Linear mixed models showed that hyperthermia raises ICP slightly more when temperature increases in the groups with low compliance and impaired CBF pressure autoregulation. There was also a tendency (not statistically significant) for increased B_tipO₂, and for increased pyruvate and lactate, with higher temperature, while the lactate/pyruvate ratio and glucose were stable.

Conclusions: The major finding was that the effects of hyperthermia on intracranial dynamics (ICP, brain energy metabolism, and B_tipO₂) were not extensive in general, but there were exceptional cases. Hyperthermia treatment has many side effects, so it is desirable to identify cases in which hyperthermia is dangerous. Information from multimodality monitoring may be used to guide treatment in individual patients.     

非占位病变颅内压增高的诊断与处理

报道１６４例非占位病变颅内压增高的诊断与临床处理经验。     

Analysis of 164 patients with non-space-occupying intracranial hypertension

Ａｎａｌｙｓｉｓｏｆ１６４ｐａｔｉｅｎｔｓｗｉｔｈｎｏｎ－ｓｐａｃｅ－ｏｃｃｕｐｙｉｎｇｉｎｔｒａｃｒａｎｉａｌｈｙｐｅｒｔｅｎｓｉｏｎ￥（章翔）（费舟）（张志文）（张剑宁）（刘卫平）（付洛安）（李安民）（易声禹）（付相平）ＺｈａｎｇＸｉａｎｇ，Ｆｅ...     

Subacute Inclusion Encephalitis: A Clinical and Pathological Review

Subacute inclusion encephalitis has been reported most frequently from Western Europe; only 16 cases have been described in North America. During the past eight years the authors have encountered 14 cases in the Toronto area, and histological confirmation has been obtained in seven of these.

The disease most often presents as a combination of progressive personality and intellectual deterioration combined with myoclonic seizures or drop attacks and focal neurological deficits, although extrapyramidal symptoms or evidence of raised intracranial pressure may also occur.

At the time of the initial presentation the EEG was characteristic in only nine of the 14 cases, but a first-zone rise in the colloidal gold curve was present in all cases in which it was carried out.

From the pathological features of the disease, as described, and its absence of familial occurrence, it is concluded that a viral origin is most probable, although its rarity and predilection for a particular age group are unusual.

     

A clinical, pneumoencephalographic and radioisotopic study of normal-pressure communicating hydrocephalus

Human serum albumin labelled with iodine-133 or technetium-99^m was injected by the lumbar or cisternal route into patients suspected of having communicating hydrocephalus, and scintigrams were performed up to 24 hours after injection.

The CSF isotope studies were shown to be a valuable adjunct to clinical examination and pneumoencephalography in the diagnosis of hydrocephalus. This was especially true in suspected cases of “normal”-pressure hydrocephalus where there may be considerable uncertainty as to which patients with normal pressure and enlarged ventricles will benefit from a shunting procedure. The CSF isotope study provides useful information to the clinician in differentiating patients with symptomatic hydrocephalus from the larger group with dementia, cerebral atrophy and hydrocephalus ex vacuo.

     

颅内压监测在丘脑出血破入脑室治疗中的应用

目的探讨颅内压监测在丘脑出血破入脑室治疗中的作用。方法收集62例丘脑出血破入脑室患者的临床资料,比较应用颅内压监测组与未应用颅内压监测组患者的再出血率及预后。结果颅内压监测组在病死率、预后均优于无颅内压监测组,在导致重度残疾率和再出血率均低于无颅内压监测组。结论在丘脑出血破入脑室的患者应用颅内压监护可以更加直观、更准确地了解患者颅内压力的变化情况,可以更加及时地调整治疗方案,进而降低了病死率,改善了患者的预,是理想的监测和治疗方法。     

Advances in the Understanding and Treatment of Head Injury

The author describes his personal involvement in head injury prevention and management over the past 40 years. He reviews the evolution of knowledge concerning the role of increased intracranial pressure, and considers the importance of cerebral vasoparalysis in the production of signs and symptoms following head injury, and the development of methods of recording intracranial pressure continuously, over hours and days.

The development of an experimental compression model has led to a fuller understanding of edema of the brain and has provided a means of studying, by light and electron microscopy, the histological changes that result from edema. More recently, analyses of biochemical changes and disturbed membrane function have opened up a new avenue of potential treatment. Moreover, it is now clear that cerebral vascular dilatation and abrupt pressure increase can be produced in the monkey, in over 50% of cases, by lesions in the dorsomedial nucleus of the hypothalamus. Similar lesions may occur in the human and this suggests other therapeutic approaches. There is, then, a genuine hope of a breakthrough in the management of head injuries.

     

咪唑安定诱导和普鲁卡因静脉复合麻醉对颅内压及脑灌注压的影响

研究比较异丙酚与咪唑安定在高颅内压患者的麻醉诱导，并用普鲁卡因静脉复合维持麻醉，对平均动脉压（ＭＡＰ），颅内压（ＩＣＰ），脑灌注压（ＣＰＰ），心率（ＨＲ）的影响。２６例ＡＳＡＩ～Ⅱ级颅内肿瘤切除术患者依次序为异丙酚组（Ｐ组，ｎ＝１０），咪唑安定组（Ｍ组，ｎ＝１６）。结果表明异丙酚和咪唑安定在诱导中都有一过性循环功能抑制，但能维持脑的自身调节功能，有明显降低颅内压作用（Ｐ〉０．０５或Ｐ〈０．０１）Ｐ     

MAGNETIC RESONANCE IMAGING IN INTRACRANIAL TUBERCULOSIS

Tuberculosis (TB) is still a major cause of serious illness in many parts of the world. Intracranially, TB manifests itself variably as meningitis, tuberculoma and tubercular abscess [1]. Although its appearance on MR is not absolutely specific, it is important in the proper clinical setting to recognize the range of possible patterns that can be observed on images [2]. Magnetic Resonance Imaging (MRI) has emerged as a quality imaging tool aiding in the diagnostic evaluation of intracranial TB variably displaying meningeal, parenchymal, osseous and craniovertebral lesions. The MRI characteristics of 18 cases of intracranial TB were reviewed. Results: Multiple lesions occured with a slightly higher incidence at 61%. In all, 11 patients (61%) presented with meningitis. Meningeal lesions without parenchymal or vascular involvement were seen in 16% of cases. 2 patients had extension of enhancing exudates into the spinal subarachnoid spaces. While 6 patients had focal intra-axial tuberculomas, representing 33% cases, 3 patients presented with infarcts. 1 patient presented with haemorrhagic infarct at right middle cerebral artery territory while two other showed multiple small infarcts. Hydrocephalus was identified in 4 patients and epidural lesions were noted in 2 cases. MRI should be considered as the imaging modality of choice for patients with suspected intracranial TB.KEY WORDS: Intracranial tuberculosis, Magnetic resonance imaging, Tubercular meningitis     

发热对颅内压影响的实验研究

通过对24只家兔的动物实验,探讨了全身发热对颅内压的影响。实验分为3组:正常颅压组、高颅压模型组及抑制发热组。结果表明:发热可使颅内压明显升高,高颅爪模型组颅内爪升高的幅度更大。提示临床上对高颅压患者应尽量避免发热,一旦发热,应采取积极的降温措施,高热吋在降温的同时应给于甘露醇等脱水药物以防颅内压上升到蜲账健     

Isolation and Controlled Perfusion of the Canine Brain

Experiments were carried out to evaluate the adequacy of internal carotid perfusion of the isolated canine brain and the application of a perfusion apparatus which was designed to facilitate environmental control for the isolated functioning organ. Anatomic considerations and the surgical isolation of the cerebral vasculature are presented in detail. Intact animals were used to provide physiologic arterial blood which was pumped under pressure control to six brains which were maintained at simulated low, normal and high intracranial pressures. Good electrocortical activity has been preserved for up to eight hours in the preparation.

The methods provide a useful model for the future investigation of cerebral circulation, metabolism and function under normal and various pathophysiologic conditions.

     

特发性颅内压增高的研究进展

特发性颅内压增高也称做假性脑瘤,是一种以无明确原因的颅内压升高为特点的临床综合征。此类患者的神经影像学检查和脑脊液分析正常,但颅内压增高及其相关症状和体征却存在,如果延误治疗,可能会导致患者并发严重的视觉障碍。目前临床上对该病的认识产生了一些新的观点。本文主要综述特发性颅内高压的病理机制、诊断及治疗的研究进展。     

Studies in Osteoarthritis of the Hip: Part IV, * Biomechanics and clinical considerations

Present knowledge of hip biomechanics supports the contention that the stresses imposed on the hip on the side of the longer leg are greater than normal; those on the short side are comparably reduced. Indirect measurements by various authors have demonstrated greater stress on the hip if the pelvis is adducted, a persistent and chronic condition of the hip joint on the side of a long leg. Furthermore the pressure on the acetabulum will be displaced laterally in these circumstances. The consistent pattern of degeneration in unilateral superolateral O A hip is what would be expected if the consequences of leg-length disparity were as described. Leg-length inequality may be a major contributing factor in the development of unilateral degenerative disease of the hip of this type.

A clinical method of estimating leg-length disparity is described. Clinical findings in patients support the hypothesis that hip stress is increased on the side of a longer leg.

     

自发性低颅内压综合征20例分析

目的探讨自发性低颅内压综合征(SIH)的临床表现、脑脊液、影像学的改变,诊治及预后,提高对本病的认识。方法对20例自发性低颅内压综合征患者的临床资料进行回顾性分析。结果 20例患者均有体位性头痛,卧位时缓解或消失,腰穿压力均<0.588 kPa(60 mm H2O),其中8例呈血性CSF,蛋白增高。6例白细胞升高。17例行头CT检查正常,1例硬膜下积液,1例硬膜下血肿,1例脑室变小。MRI检查7例显示弥漫性硬脑膜增厚强化。结论 SIH患者以体位性头痛为主要症状,脑脊液压力<60 mm H2O。治疗以补充生理盐水为主,疗效不佳时可给予激素及鞘内注入生理盐水。一般预后良好。认识自发性低颅内压综合征的临床表现、脑脊液、影像学的改变至关重要。注意与颅内高压、蛛网膜下腔出血,原发性、肥厚性硬脑膜炎等鉴别。     

高颅压型脑囊虫病的临床研究

目的 探索高颅压型脑囊虫病临床治疗的有效方法。方法 选择住院的156例高颅压患为临床治疗观察对象。根据病人的具体情况选择联合应用阿苯达唑、吡喹酮，以不同的抗囊方法及剂量进行治疗，一般3～5个疗程，每个疗程间隔2～3个月。结果 对于绦虫现症病人15例，全部驱下绦虫，驱虫率100．00％；伴有皮下结节50例，疗后均消失，消失率为100．00％。脑神经症状疗后有明显改善，93例癫痫治疗后86例未再发作。疗后脑CT复查，其中56例颅内未见异常，原CT病灶已吸收；有95例可见散在钙化灶，5例除钙化灶外，仍可见有低密度灶，但较原片明显减少；10例行脑脊液分流术，侧脑室及三脑室已基本恢复正常。结论 联合应用阿苯达唑、吡喹酮剂量递增疗法是抗囊虫治疗的有效方法；密切观察病情，及时恰当地对症治疗是保障病人安全和抗囊虫治疗顺利实施的重要措施。     

Management of Flavobacterium meningitis in the neonates: experience with 18 consecutive cases

18 neonates with bacteriologically confirmed Flavobacterium meningitis and ventriculitis were treated with various antibiotic regimens, including the use of intraventricular antibiotics. During the course of treatment, four patients died. 8/14 patients developed progressive hydrocephalus which required insertion of ventriculo-peritoneal shunts. The remainder 6/14 patients had normal ventricles or only mild ventriculomegaly. 5/8 patients with progressive hydrocephalus and 5/6 patients with normal or mildly dilated ventricles were followed up for at least 24 months. 4/5 of the patients with progressive hydrocephalus had severe bilateral hearing loss and delayed milestones. All the 5 patients with normal or mildly dilated ventricles had normal hearing although 2 of them had gross motor delay due to spastic paraplegia. Patients with progressive hydrocephalus received effective antibiotic treatment more than 8 days after the onset of infection while those with normal or mildly dilated ventricles within 8 days of infection. Onset of ventricular dilatation was associated with ventriculitis. Daily ultrasound scanning of the ventricles in the early stage helped to determine the need for early instillation of intraventricular antibiotics. Combined use of intravenous rifampicin, moxalactam and piperacillin showed promise as an effective antibiotic regimen in treating patients with normal or mildly dilated ventricles. Once significant ventriculomegaly has occurred, concomitant intravenous and intraventricular administration of antibiotics, to which the organisms were sensitive, was necessary to eradicate the infection.     

Usefulness of exploratory burr holes in the management of severe head injury

The authors performed burr hole exploration for the diagnosis of intracranial haematomas in 110 consecutive patients with severe head injury. Burr hole revealed extra-axial mass lesions in 61 patients and 49 patients had negative exploration. Post-mortem study showed that only a very few clots were missed by routine burr holes. The study indicated that diagnostic burr hole exploration was a sensitive method for detecting extracerebral mass lesions in centres where CT scanning facilities were not available.     

颅内肿瘤66例分析

随着医疗仪器的进步,颅内肿瘤的诊断率逐年提高,检出率逐年增加。尽管颅内肿瘤的发病率与患病率均较低,然而颅内肿瘤对人体危害是严重的。尤其是胶质瘤:切除率和远期存活率都不能令人满意。因此必需进一步提高对颅内肿瘤的诊断和治疗水平。现将我院1984年10月至1987年5月,2年又9个月所收治的颅内肿瘤加以分析。     

脑出血急性期血压变化对颅内压的影响及调控

目的探讨脑出血急性期血压变化对颅内压的影响及调控。方法选取我院2008年10月～2011年11月收治的脑出血患者41例。监测患者收缩压、舒张压、颅内压的变化情况。结果患者收缩压、舒张压、颅内压均先升高后再降低,最终趋于稳定。结论脑出血患者的治疗关键在于颅内压的控制,对脑出血急性期血压进行有效调控可以降低脑出血的病死率,提高治愈率,具有重要的临床意义。     

Sudden, Severe Mitral Insufficiency

Five male patients with sudden, severe mitral insufficiency due solely to ruptured chordae tendineae or papillary muscle had an abrupt onset of symptoms of left and right heart failure and the sudden appearance of a harsh, widely propagated apical pansystolic murmur. None had a history of rheumatic fever. All were in sinus rhythm and had but mild left atrial and ventricular enlargement. Giant left atrial “v” waves were characteristic and exceeded pulmonary artery pressure in two instances.

In contrast, when ruptured chordae tendineae were superimposed on chronic rheumatic mitral insufficiency, females predominated and there was a long history of disability. Atrial fibrillation, less elevation of left atrial pressure, and marked left atrial and ventricular enlargement were characteristic. These latter patients closely resembled patients with chronic rheumatic mitral insufficiency alone.

It is concluded that the syndrome of sudden, severe mitral insufficiency develops if ruptured chordae tendineae occur on a previously normal or insignificantly diseased mitral valve. If ruptured chordae tendineae are superimposed on chronic rheumatic mitral insufficiency, the syndrome resembles that seen in the latter alone.