脑脊液置换治疗蛛网膜下腔出血

蛛网膜下腔出血（subarachnoid hemorrhage，SAH）是指各种原因出血血液流人蛛网膜下腔的统称。临床上可分为自发性与外伤性两大类，自发性又分为原发性与继发性两种。由各种原因引起软脑膜血管破裂血液流入蛛网膜下腔者称原发性蛛网膜下腔出血；因脑实质内出血血液穿破脑组织流入蛛网膜下腔者称继发性蛛网膜下腔出血。SAH是加重继发性脑损害的重要因素。如何加速蛛网膜下腔血液的廓清，减轻继发性脑损害，多年来一直是神经外科学者关注的热点，近年来，脑脊液置换技术越来越多地应用于临床，方法多种多样，均取得了良好的治疗效果，现收集我科2003—2007年期间采用脑脊液置换治疗SAH79例的资料，进行研究和分析，并报告如下。     

脑脊液置换疗法治疗蛛网膜下腔出血40例疗效观察

我院自2005年12月至2008年12月采用脑脊液置换疗法治疗原发性蛛网膜下腔出血病人40例,取得满意疗效.现分析报告如下.     

24例蛛网膜下腔出血脑脊液置换疗效观察

对２４例ＳＡＨ采用ＣＳＦ置换结合常规治疗。共置换９６例次，平均每例４次。全部患者置换后头痛等症状均明显好转，未出现与腰椎穿刺直接相关的严重并发症。认为只要病例选择合适，放ＣＳＦ速度缓慢，尚属安全。ＣＳＦ置换仍不失为ＳＡＨ的治疗措施之一。     

脑脊液置换术治疗蛛网膜下出血160例疗效观察

目的 观察脑脊液置换术治疗蛛网膜下腔出血(以下简称SAH)的疗效.方法 诊断成立后即行脑脊液置换术隔日1次,共置换3～5次,每次腰穿放出血性脑脊液5～10ml,以等量生理盐水进行缓慢置换,间隔5min再放出血性脑脊液5～10ml,以等量生理盐水进行置换,再间隔5min放出血性脑脊液5～10ml,以等量生理盐水进行置换,加地塞米松5mg鞘内注射.结果 160例经置换脑脊液后头痛能迅速缓解,平均为4.6d,而对照组150例头痛缓解时间平均为13.2d,P>0.05.脑血管痉挛致脑梗死的发生,置换组0例,而对照20例,置换组无脑积水的病例发生,而对照组发生脑积水25例.结论 应用脑脊液置换术治疗SAH是一种缓解头痛,减少脑血管痉挛、梗阻性脑积水的有效方法.     

脑脊液置换治疗蛛网膜下腔出血36例临床分析

我们对我院2004年2月-2005年6月收治的72例经腰穿、头CT确诊为蛛网膜下腔出血的患者随机分为两组，分别进行了脑脊液置换和常规治疗对比，现将结果报告如下：     

脑脊液置换在蛛网膜下腔出血中的应用

我科于2007～2008在常规治疗的基础上,同时应用腰穿脑脊液置换配合椎管内注入地塞米松治疗原发性蛛网膜下腔出血40例,取得满意疗效,现报告如下.     

脑脊液置换术治疗蛛网膜下腔出血58例护理

蛛网膜下腔出血(SAH)是神经内科常见病,具有病死率高,致残率低的特点[1-2]。其病死率高主要是因为起其并发症多。我科于1999年8月至2004年11月对58例蛛网膜下腔出血病人,在常规应用甘露醇和抗纤溶药物的同时,应用脑脊液置换术治疗,取得了很好疗效。现报告如下。1资料与方法1·1临床资料本组58例病人,其中男48例,女10例。年龄45~78岁,平均52岁。入选病例均按中华医学会第四界脑血管病会议确定的诊断标准,并全部经头部CT扫描证实确诊SAH。1·2治疗方法本组所有病例均采取传统的止血、脱水降颅压、口服尼莫地平和对症支持治疗,同时行脑脊液…     

脑脊液置换术治疗蛛网膜下腔出血25例体会

目的研究脑脊液置换术治疗蛛网膜下腔出血的临床疗效,探讨最佳方法。方法对我院收治的25例蛛网膜下腔出血(SAH)的病例行脑脊液置换术治疗,每次放脑脊液10ml,再注入等量的0.9%氯化钠溶液,反复进行3～5次,一次置换脑脊液30～50ml,并观察临床疗效。结果3次置换内头痛完全消失22例(88%),2例死于再出血,1例死于脑血管痉挛,但其头痛程度均有明显的减轻。结论腰穿脑脊液置换术是一种相对安全且效果较好的治疗方法,能够很好且及时地防治蛛网膜下腔出血并发症,如脑血管痉挛、再出血,也可以有效防止阻塞性脑积水、化学性脑膜炎、下丘脑功能紊乱等病理过程的发生。     

原发性蛛网膜下腔出血再出血31例临床分析

目的：探讨蛛网膜下腔出血（SAH）并发再出血的危险因素，为防治该病提供参考。方法：回顾分析SAH再出血31例临床资料。结果：SAH再出血好发于第2、3周，末次腰穿术后4d-7d，且大部分病例无明显诱因。CT显示积血阳性、脑表面有凝血块或颅底池及脑室积血发生率较高，预后较差。结论：SAH病例某些临床特点及早期CT表现对再出血预测有一定的临床意义，据此进行防治。     

Serial lumbar puncture reduces cerebrospinal fluid (CSF) infection during removal of hemorrhagic CSF in aneurysmal subarachnoid hemorrhage after endovascular coiling

The present study aimed to compare the complications and clinical outcomes of serial lumbar puncture (LP) and lumbar cerebrospinal fluid (CSF) drainage (LD) of patients with aneurysmal subarachnoid hemorrhage and provide more evidence to guide clinical management. In this retrospective study, 41 and 39 aneurysmal subarachnoid hemorrhage patients were enrolled in the LP and LD group, respectively. Clinical outcomes, including CSF infection, intracerebral hemorrhage, vasospasm, hydrocephalus, death, length of stay, duration of drainage and the Glasgow Outcome Scale score were compared between the two groups. By comparing with the LP group, the LD group showed a significantly higher rate of CSF infection (P = 0.029) and shorter duration of drainage (P < 0.001). Both groups displayed similar rates of vasospasm, hydrocephalus, intracerebral hemorrhage, the Glasgow Outcome Scale score one month after endovascular coiling and length of stay (P > 0.05, respectively). In conclusion, both LD and serial LP are effective methods in the treatment of aneurysmal subarachnoid hemorrhage; besides, serial LP can reduce the incidence of CSF infection in draining hemorrhagic CSF in aneurysmal subarachnoid hemorrhage after endovascular coiling.     

术前腰大池外引流对经鼻蝶垂体腺瘤切除术中脑脊液漏的防治作用

目的：探讨术前腰大池外引流对经鼻蝶垂体腺瘤患者术中脑脊液漏的防治作用。方法回顾性分析2012年1月—2013年11月郑州大学第一附属医院神经外科行经鼻蝶垂体腺瘤切除术的194例患者的临床资料,其中54例患者术前行腰大池外引流（引流组),140例患者术前未行腰大池外引流（对照组)。两组患者性别、年龄、肿瘤类型、Wilson分级等一般资料差异均无统计学意义（P值均>0．05),具有可比性。对比2组术中脑脊液漏的发生情况。结果194例患者均顺利完成手术。引流组54例,除1例无脑脊液流出者,其余患者术中引流脑脊液40~80 mL;术中发生脑脊液漏3例（5．6%),常规给予修补鞍底+腰大池外引流,术后均未再发生脑脊液漏;术后发生脑脊液漏2例（3．7%),1例行腰大池外引流、1例予修补鞍底+腰大池外引流,均治愈。对照组140例,术中发生脑脊液漏54例（38．6%),常规给予修补鞍底+术后腰大池外引流治疗,49例痊愈,5例术后再次发生脑脊液漏;术后共发生脑脊液漏7例（5．0%),1例行腰大池持续外引流、6例再次手术行脑脊液漏修补+腰大池外引流,均痊愈。两组患者术中脑脊液漏发生率比较,引流组术中脑脊液漏发生率明显低于对照组,差异有统计学意义（χ2=20．473,P<0．01)。结论术中鞍膈及蛛网膜的直接或间接损伤可能是经鼻蝶垂体腺瘤患者术中发生脑脊液漏的原因。经鼻蝶垂体腺瘤切除术术前行腰大池外引流,术中腰大池外引流释放脑脊液可降低蛛网膜张力,减少鞍膈和蛛网膜的直接或间接损伤,进而降低术中脑脊液漏的发生率。     

Metabolites from cerebrospinal fluid in aneurysmal subarachnoid haemorrhage correlate with vasospasm and clinical outcome: a pattern-recognition 1H NMR study

Following subarachnoid haemorrhage the most significant complication is sustained cerebral vascular contraction (vasospasm), which may result in terminal brain damage from cerebral infarction. Despite this, the biochemical cause of vasospasm remains poorly understood. In this study, the global high-concentration metabolite composition of CSF has been correlated with patient outcome after subarachnoid haemorrhage using multivariate statistics and 1H NMR spectroscopy. In total, 16 patients with aneurysmal subarachnoid haemorrhage (aSAH) were compared with 16 control patients who required a procedure where CSF was obtained but did not have aSAH. Multivariate statistics readily distinguished the aSAH group from the heterogeneous control group, even when only those controls with blood contamination in the CSF were used. Using principal components analysis and orthogonal signal correction, vasospasm was correlated to the concentrations of lactate, glucose and glutamine. These pattern recognition models of the NMR data also predicted Glasgow Coma Score (54% within +/- 1 of the actual score on a scale of 1-15 for the whole patient group), Hunt and Hess SAH severity score (88% within +/- 1 of the actual score on a scale of 1-5 for the aSAH group) and cognitive outcome scores (78% within +/- 3 of the actual score on a 100% scale for the whole patient group). Thus, the approach allowed the prediction of outcome as well as confirming the presence of aSAH.     

82例蛛网膜下腔出血的脑电图与临床

分析８２例蛛网膜下腔出血（ＳＡＨ）患者的脑电图（ＥＥＧ）所见及与临床的关系。ＳＡＨ的ＥＥＧ异常率８３％，异常ＥＥＧ主要有三种形式：以普遍性改变为主（６６％）；广泛性异常伴局灶慢波；局灶性改变。ＥＥＧ中、重度异常以病后２４ｈ～１０天居多（８９％）。ＥＥＧ异常与高血压及腰穿压力增高之间无明显相关性（Ｐ＞０．０５），而与意识障碍及预后明显相关（Ｐ＜０．０５），提示ＥＥＧ可作为判断预后的指标之一。另外ＥＥＧ限局性异常与ＣＴ病灶和脑血管造影也有一定关系。     

Prevalence of transthoracic echocardiographic abnormalities in patients with ischemic stroke,intracerebral hemorrhage,and subarachnoid hemorrhage

Introduction

This study investigated the prevalence of transthoracic echocardiographic abnormalities in patients with ischemic stroke (IS), subarachnoid hemorrhage (SAH), and intracerebral hemorrhage (ICH) in sinus rhythm.

Material and methods

The patients included 120 with IS, 30 with SAH, and 41 with ICH. All diagnoses were confirmed by magnetic resonance imaging or brain computed tomography. Two-dimensional echocardiograms were taken at the time stroke was diagnosed. All echocardiograms were interpreted by an experienced echocardiographer.

Results

Of 120 IS patients, 1 (1%) had a left ventricular (LV) thrombus, 1 (1%) had mitral valve vegetations, 30 (25%) had LV hypertrophy, 26 (22%) had abnormal LV ejection fraction, 4 (3%) had mitral valve prolapse, 33 (28%) had mitral annular calcium (MAC), 40 (33%) had aortic valve calcium (AVC), 3 (3%) had a bioprosthetic aortic valve, 10 (8%) had aortic stenosis (AS), 6 (5%) had atrial septal aneurysm, 2 (2%) had patent foramen ovale, and 40 (33%) had no abnormalities. Of 30 SAH patients, 5 (17%) had LV hypertrophy, 1 (3%) had abnormal LV ejection fraction, 1 (3%) had AS, 4 (13%) had MAC, 5 (17%) had AVC, and 20 (67%) had no abnormalities. Of 41 ICH patients, 9 (22%) had LVH, 1 (2%) had abnormal LV ejection fraction, 1 (3%) had AS, 6 (15%) had MAC, 8 (20%) had AVC, and 22 (54%) had no abnormalities.

Conclusions

Transthoracic echocardiographic abnormalities are more prevalent in patients with IS than in patients with SAH or ICH.     

CT评价腰大池引流减少蛛网膜下腔出血的研究

目的 探讨腰大池引流对蛛网膜下腔出血患者的有效性和安全性.方法 选择蛛网膜下腔出血患者44例,19例行腰大池引流设为引流组,25例未行脑脊液引流或仅行单独的脑室外引流设为对照组.分析2组患者新发脑梗塞的发生率及引流组的并发症.结果 CT影像比较表明,引流组新发脑梗塞的发生率(5％)少于对照组(32％),其差异具有统计学意义(P＜0.05);脑积水的发生率2组无区别,腰大池引流组并发症很少且可进行良好的控制.结论 严格掌握适应症和正确操作,腰大池引流具有较少的并发症和良好的安全性,可有效减少蛛网膜下腔出血患者脑血管痉挛及其相关梗塞.     

自发性蛛网膜下腔出血后脑血管痉挛节律特征的研究

目的：探讨分析自发性蛛网膜下腔出血后脑血管痉挛的生物节律特征。方法：选取87例经头颅CT、CTA、DSA及脑血管彩超确诊为蛛网膜下腔出血并发脑血管痉挛患者,在自然光暗循环条件下利用经颅多普勒（TranscranialDopplor,TcD）对患者大脑中动脉平均血流速度（Vm）进行24小时以上连续监测后判断分析24小时12个时间段的发病时间特征。结果：8：00点和20：OO点两个时间点的大脑中动脉平均血流速度较其他时间点有显著性差异．流速显著较快（p〈0．05）,脑血管痉挛的节律变化特征呈“双峰”表现。结论：自发性蛛网膜下腔出血后脑血管痉挛时间具有典型的近日节律特征,其发病高峰期位于每目的8：00点及20：00点。     

Learning deficits after experimental subarachnoid hemorrhage in rats

About 50% of subarachnoid hemorrhage (SAH) survivors have cognitive or neurobehavioral dysfunction. The mechanisms are not known. This study characterized behavioral deficits in a rat SAH model, and correlated these changes with histological alterations. SAH was induced by injection of 0.3 ml blood into the prechiasmatic cistern. Cognitive and memory changes were investigated in the Morris water maze. Neuronal cell death was evaluated by fluoro-jade and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining. Vasospasm was assessed on cross-sections of middle and anterior cerebral arteries. Microthromboemboli were quantified by fibrinogen staining. Escape latency and swimming distance were significantly increased in rats with SAH as compared to controls (P<0.05–0.001). SAH rats tended to do poorly on accuracy in spatial and working memory tests. SAH rats had a significantly higher number of fluoro-jade and TUNEL positive neurons in CA1 and CA3 of the hippocampus, cerebral cortex and Purkinje cells in the cerebellum (P<0.05–0.001). The number of microthromboemboli in the cortex and cerebellum were significantly higher after SAH than in controls (P<0.05–0.001). Cognitive deficits were induced by SAH in rats. There was a significant increase in apoptotic neurons in all regions of brain examined. However, cell death in the hippocampus was not sufficient to cause the neurobehavioral deficits observed in the Morris water maze. This suggests that other factors such as dysfunction of neurotransmission or plasticity in hippocampal pathways might contribute to the impairments.     

Lumbar puncture: anatomical review of a clinical skill

The safe and successful performance of a lumbar puncture demands a working and specific knowledge of anatomy. Misunderstanding of anatomy may result in failure or complications. This review attempts to aid understanding of the anatomical framework, pitfalls, and complications of lumbar puncture. It includes special reference to 3D relationships, functional and imaging anatomy, and normal variation. Lumbar puncture is carried out for diagnostic and therapeutic purposes. Epidural and spinal anesthesia, for example, are common in obstetric practice and involve the same technique as diagnostic lumbar puncture except that the needle tip is placed in the epidural space in the former. The procedure is by no means innocuous and anatomical pitfalls include inability to find the correct entry site and lack of awareness of structures in relation to the advancing needle. Headache is the most common complication and it is important to avoid traumatic and dry taps, herniation syndromes, and injury to the conus medullaris. With a thorough knowledge of the contraindications, regional anatomy and rationale of the technique, and adequate prior skills practice, a lumbar puncture can be carried out safely and successfully.