可逆性后部白质脑病2例临床分析

目的 探讨可逆性后部白质性脑病综合征（reversible posterior leukoencephalopathy syndrome，RPLS）的病因、临床表现、影像学特征及治疗。方法 分析2例可逆性后部白质脑病综合征患者的临床资料，并复习文献。结果 2例患者均有头痛、视物不清、头部MRI检查示T2高信号，其中1例伴有癫发作，经治疗患者的临床表现及影像学均很快好转。结论 可逆性后部白质脑病综合征的临床表现无特异性，经对症处理后临床及影像学表现均很快好转。     

连续脑电监测评价重症脑血管病人预后的研究

目的探讨急性重症脑血管病患者的EEG分级与预后的关系,以及长程脑电监测评价脑功能损伤程度和预后的准确率。方法选择神经内科重症监护室中格拉斯哥昏迷评分(GCS)<8分的急性重症脑血管病患者41例,利用床边中央神经监护系统记录连续脑电图,确定急性重症脑血管病患者的EEG分级,每次行脑电监测前都进行格拉斯哥昏迷评分。结果41例重症脑血管病患者的连续脑电图全部异常,发生癫样活动的患者8例(19.5%),病死率37.5%,其中非痉挛性癫(nonconvulsive sei-zures,NCS)发生率17.1%,痉挛性癫的发生率2.4%。连续脑电图分级分成2组进行卡方检验,2组预后的差别显著;GCS评分和EEG分级与预后有关,GCS评分综合预后判断准确率78.4%,EEG分级综合预后判断准确率79.2%。结论连续脑电图分级与预后显著相关,非痉挛性癫的发生率19.5%,远高于痉挛性癫(2.4%);连续EEG动态监测和分级判断可以准确、客观地评价和预测重症脑血管疾病脑功能损伤的预后。     

大剂量丙种球蛋白治疗重症病毒性脑炎的护理体会

我科自2007年来应用大剂量丙种球蛋白治疗重症病毒性脑炎10例,经过精心诊治和护理,取得满意疗效,现将护理体会总结报告如下。1资料与方法1.1一般资料本组10例患者中男6例,女4例;年龄5～68岁;临床表现均有高热、意识障碍(嗜睡3例,昏睡4例,昏迷3例),发作癫6例,经脑电图、脑脊液、脑CT和或MRI等各项检查排除其他炎症性脑病,达到重症脑炎诊断标准[1]。     

影响小儿重症病毒性脑炎预后的相关危险因素分析

目的观察小儿重症病毒性脑炎的临床特点,探讨影响其预后的危险因素,为临床早期识别重症病毒性脑炎,指导临床治疗及预防提供理论依据。方法选取2012-09—2015-09在我院儿科及重症监护病房住院并首次确诊为重症病毒性脑炎的151例患儿为研究对象。对所有入组患儿进行定期随访,回顾分析入组患者的临床及辅助检查资料。并应用Lo-gistic回归模型分析影响重症病毒性脑炎患儿预后的危险因素。结果重症病毒性脑炎患儿预后良好率为56.2%,预后不良率为43.8%。预后良好组与预后不良组性别、年龄、住院时间、有无发热、意识障碍、合并低钠血症、低钾血症、CSF白细胞数、CSF蛋白量组间比较差异均无统计学意义(P0.05);预后良好组发热时间、惊厥及惊厥时间、意识障碍时间显著短于预后不良组,意识障碍程度Glasgow评分显著低于预后不良组,其组间比较差异均具有统计学意义(P0.05);预后良好组脑电图异常、头颅MRI异常情况所占比例低于预后不良组,差异均具有统计学意义(P0.05)。Logistic回归分析显示发热时间、惊厥时间、意识障碍及意识障碍时间、意识障碍程度、脑电图异常、头颅MRI异常可增加重症病毒性脑炎患儿预后不良的发生风险,是影响重症病毒性脑炎患儿预后的危险因素。其风险比分别为2.59、5.62、2.68、4.59、4.97、11.59、9.74。结论发热时间、惊厥时间、意识障碍及意识障碍时间、意识障碍程度、脑电图异常、头颅MRI异常可增加重症病毒性脑炎患儿预后不良的发生风险,是影响重症病毒性脑炎患儿预后的危险因素。     

丙泊酚联合亚低温治疗重症单纯疱疹病毒性脑炎的疗效观察

临床研究发现格拉斯哥昏迷量表评分(GCS)<6分的单纯疱疹病毒性脑炎(HSE)患者病死率高达50%,幸存者也常留有严重后遗症.2006年3月～2007年7月我科收治GCS评分<6分且合并癫(癎)持续状态的HSE患者4例,予以丙泊酚联合亚低温治疗,现将结果报告如下.     

小儿肺炎并发急性中毒性脑病救治体会

2011-01—2012-12我院重症监护病房共收治小儿肺炎引起的中毒性脑病患儿92例,现将救治情况分析如下。1临床资料1.1一般资料选择2011-01—2012-12我院儿童重症监护室诊断为肺炎合并急性中毒性脑病患儿92例。诊断根据患儿临床表现、体格检查、X线胸片、血气分析、脑脊液检查、脑电图、头颅CT结果等[1]。男53例,女39例;年龄1个月～1岁59例(64.1%),>1～2岁23例(25%),>2～3岁8例(8.7%),>3～5岁2例(2.2%)。除肺部症状外,高热86例,嗜睡76例,双眼上翻29例,双眼凝视10例,烦躁不安6     

可逆性后部白质脑病综合征临床探讨

目的探讨可逆性后部由质性脑病综合征（RPLS）的病因、临床表现、影像学特征及治疗。方法总结分析8例可逆性后部白质脑病综合征患者的发病原因、临床症状、影像学检查特点、治疗及预后。结果8例患者经针对病因治疗（如降压、止痉、停止使用免疫抑制药物、化疗药、停止放疗、控制肺部感染）及酌情使用甘露醇、呋噻米等脱水降颅压药物,症状与体征恢复至发病前6例,基本消失2例。结论可逆性后部白质脑病综合征是一种有特征临床和影像学检查表现的临床综合征,及时就诊、尽早治疗,一般预后良好。     

可逆性后部白质脑病综合征1例报告并文献复习

目的：探讨可逆性后部白质脑病的常见病因、发病机制、临床表现、诊断及治疗措施。方法对1例产褥期可逆性后部白质脑病综合征患者的诊疗经过进行分析。结果患者有中枢神经系统症状、体征,结合相关检查结果,采用脱水、营养神经、对症支持治疗,预后良好。结论可逆性后部白质脑病综合征是一种由多种原因引起的以神经系统异常为主要表现的临床综合征。常见的病因有恶性高血压、妊娠子痫、各类严重肾脏疾病、免疫抑制剂及细胞毒药物、自身免疫病的治疗等。急性或亚急性起病,临床表现多种多样,常见的有头痛、痫性发作、视觉障碍、意识障碍及精神异常等。临床诊断主要依据其典型的影像学改变,大多数影像学改变为可逆性,预后良好。     

Kojewnikow综合征12例报告

目的 研究Kojenikow综合征的病因、临床特征、脑电图及影像学改变。方法 对12例Kojenikow综合征患者进行临床、脑电图及影像学观察。结果 Kojenikow综合征有局限性持续性肌肉抽搐和单纯部分运动性癫痫持续发作2个基本特征,病因以病毒性脑炎最多见,其他为脑膜脑炎、脑质瘤、脑囊虫病、脑梗死、糖尿病及隐源性癫痫。并发现其病灶分布以分水岭区为多见。结论 Kojenikow综合征分2型,综合分析临床、脑电图及影像学检查结果,有助于提高本病的诊断率并发现病因。大部分患者抗癫痫治疗效果较差,预后不良。     

卒中样低血糖脑病

目的提高对低血糖脑病的认识,降低误诊率。方法回顾性总结分析15例以卒中起病的低血糖脑病的临床资料。结果14例入院诊断为“大面积脑梗死或脑干梗死”,1例诊断为“昏迷原因待诊,病毒性脑炎可疑”的患者,均给以相应治疗无明显疗效后急查血糖示偏低而确诊。确诊后给予推注高渗葡萄糖和持续静点葡萄糖后,大部分患者有立竿见影的效果。结论出现卒中后常规急诊测血糖,极早诊断和治疗低血糖脑病,能最大限度降低患者中枢神经系统不可逆性损害的发生。     

Persistent but reversible coma in encephalitis

Introduction: Nontraumatic coma in adults has a poor prognosis, and late recovery of consciousness is unlikely. Functional recovery is usually extremely poor. However, a few nontraumatic comatose patients have shown late recovery of both awareness and function. Methods: A retrospective survey was conducted by reviewing the medical records of all inpatients to our department during the 1990s. Patients with persistent but reversible nontraumatic coma were identified according to the following criteria: (a) deep coma with a Glasgow Coma Scale (GCS) score of 7 or less on admission; (b) nontraumatic cause; (c) persistence of unconsciousness for longer than 1 month; and (d) subsequent recovery of GCS (total) to normal. The clinical spectrum of patients meeting these criteria was evaluated. Results: Six patients (ages 16–75 years) met the criteria. Viral encephalitis was diagnosed in five (two with herpes simplex virus, two with cytomegalovirus, and one with Epstein-Barr virus or cytomegalovirus). Two young female patients with encephalitis manifested extremely protracted coma persisting for 3 and 18 months, respectively. Complications included nonconvulsive status epilepticus in two patients and relative overdose of clonazepam in one patient. Conclusion: Recognition of the clinical spectrum of persistent but reversible nontraumatic coma is important.     

Digital video-electroencephalographic monitoring in the neurological-neurosurgical intensive care unit: clinical features and outcome

BACKGROUND: Prolonged electroencephalographic (EEG) recordings in the neurological-neurosurgical intensive care unit (NICU) may be performed in patients with status epilepticus, repetitive seizure activity, or an encephalopathy with or without seizures. The electroclinical correlation and neurological outcome of patients undergoing digital video-EEG monitoring (DVEEG) in the NICU has not been determined. OBJECTIVES: To evaluate the clinical utility and prognostic importance of the DVEEG in the NICU. METHODS: We retrospectively evaluated 105 patients who underwent DVEEG in the NICU at the Mayo Clinic, Rochester, Minn, between January 1, 1994, and July 31, 2001. All patients had a routine EEG recording performed prior to DVEEG. RESULTS: The mean age of the patients at the time of the DVEEG was 54 years (age range, 16-88 years). The mean duration of the DVEEG was 2.9 days (range, 1-17 days). Forty-four patients (42%) had a severe encephalopathy (Glasgow Coma Scale score, <8) at the time of the DVEEG. Forty-five patients (42.8%) had generalized convulsive status epilepticus, 19 patients (18.1%) had nonconvulsive status epilepticus, and 7 patients (6.7%) had epilepsia partialis continua. The mean duration of follow-up was 7 months (range, 1-54 months). The outcome in 84 patients included death in 38 patients, severe neurological deficits, that is, bed bound and needs support for activities of daily living, in 6 patients, and a vegetative state in 3 patients. Fifteen individuals had no neurological impairment during follow-up. Refractory status epilepticus (P<.003), hypoxic-ischemic encephalopathy (P<.004), and multiple cerebral infarcts (P<.003) were the factors associated with increased mortality in univariate analysis. With multivariate logistic regression analysis only the presence of multiple strokes (P<.03; odds ratio, 5.62) was predictive of mortality. CONCLUSIONS: Continuous EEG monitoring is essential in the diagnosis and treatment of refractory status epilepticus or an encephalopathy with seizures in the NICU. A minority of these patients, however, experienced a favorable neurological outcome.     

Nontraumatic coma. Glasgow coma score and coma etiology as predictors of 2-week outcome

In 1987 and 1988, we carried out a prospective study of patients older than 10 years with nontraumatic coma in the intensive care units of Columbia-Presbyterian Medical Center, New York, NY. Of 188 patients with Glasgow Coma Scale (GCS) determinations within 72 hours, 61% were dead or in persistent coma by 2 weeks from onset. Age, sex, and ethnicity did not influence outcome. The 2-week outcome for patients with initial GCS of 3 to 5 was 14.8% awake; 85.2% were dead or in persistent coma. For the GCS 6 to 8 group, 53.1% were awake and 46.9% were dead or in persistent coma. Hypoxic or ischemic coma had the worst 2-week outcome (79% dead or comatose); coma caused by metabolic disease or sepsis (68%), focal cerebral lesions (66%), and general cerebral diseases (55%) were intermediate, while drug-induced coma had a favorable outcome (27% dead or comatose). The independent predictors of 2-week outcome were the first GCS and drug-induced coma. The predicted probability of waking at 2 weeks was eight times better for drug-induced coma than other causes when GCS was held constant. Patients with an initial GCS score of 6 to 8 were seven times more likely to waken than those with a score of 3 to 5. The motor subscore alone was a significant independent predictor of 2-week outcome. Modification of coma score to include etiology may give more accurate predictions of 2-week outcome after nontraumatic coma.     

P300 auditory event-related potentials in nontraumatic coma. Association with Glasgow Coma Score and awakening.

Auditory event-related potentials (ERPs) were performed in 20 patients with nontraumatic coma to determine the presence of a P300 ERP in coma and its association with the Glasgow Coma Score and awakening (Glasgow Outcome Score, > or = 3). A standard "oddball" paradigm was used: frequent tone, 1 kHz; rare tone, 2 kHz and 4 Hz; probability, 20%. The Glasgow Coma Score was determined concurrently with the P300 ERP. Thirty percent (6/20) of the comatose patients had a P300 ERP. The mean Glasgow Coma Score was significantly higher for those with a P300 ERP. Eighty-three percent (5/6) of those with a P300 ERP awoke. Presence of a P300 ERP was associated significantly with awakening, but absence of a P300 ERP did not preclude it.     

Vigilance scoring in children with acquired brain injury: Vienna Vigilance Score in comparison with usual coma scales

An instrument in neurologic rehabilitation for the assessment of a person's clarity of consciousness must fulfill the need to provide the rehabilitation team with some information regarding the structuring of the rehabilitation process. The Vienna Vigilance Score is oriented toward cooperation within the rehabilitation team with the specific advantage of focus on the subject status of the patient on the basis of the dialogue. It does not use painful stimuli and is oriented toward the next developmental step of the rehabilitation process. The first extensive application of the Vienna Vigilance Score was carried out in a 3-year study of 38 children and adolescents. We report the comparison with other coma scales (Glasgow Coma Scale, Children's Coma Score, and Modified Glasgow Coma Scale) on 24 children and adolescents (1.4-16.8 years of age). The results showed satisfying statistical parameters: measuring range comparable with other scales; a Kendall tau correlation of .59 on both the Modified Glasgow Coma Scale and the Children's Coma Scale and of .66 on the Glasgow Coma Scale; a Spearman's rank order correlation of .70 to both the Modified Glasgow Coma Scale and the Children's Coma Scale and of .78 on the Glasgow Coma Scale. By accepting the Glasgow Coma Scale as a gold standard for classification of the level of coma, we can confirm satisfactory measuring qualities for the Vienna Vigilance Score.     

Outcome of children with traumatic brain injury in rural Malaysia.

Malaysia had the second highest crude accident rate in the world until 1998. Most children who were involved in these road traffic accidents required intensive neurosurgical care management. We report a prospective study on 36 paediatric neurotrauma patients in rural North East West Malaysia who underwent uniform intensive therapy and were subsequently followed up over a period of 2 years. The modified paediatric Glasgow Coma Scale with support of the revised Wechlser Intelligence Scale for children was used to test the outcome of these children over a period of two years. All patients were managed aggressively in our intensive care as well as our high dependency units. Our results indicate that improvement in outcome is seen after a six month period. Midline shift, duration of coma and duration of transport were found to be significant variables associated with bad outcome. Other variables i.e. age, sex, Glasgow Coma Scale on admission and on site, and lesions of the dominant lobe were not found to be associated with good outcome in these patients.     

分子吸附再循环系统在肝衰竭并肝性脑病治疗中的应用

目的：探讨分子吸附再循环系统在肝衰竭并肝性脑病治疗中的临床应用效果。方法将我院收治的68例肝功能衰竭并肝性脑病患者,随机分为对照组和观察组。对照组采用保肝、营养支持治疗、维持水、电解质平衡等综合治疗。观察组在对照组的基础上,加用分子吸附再循环系统治疗。比较2组的治疗效果,治疗前后肝功能改善情况及治疗过程中不良反应发生情况。结果2组治疗前总胆红素、血氨、PT A （凝血酶原活动度）、Glasgow 昏迷评分差异无统计学意义（ P＞0.05）。观察组治疗3 d后总胆红素、血氨显著低于对照组,差异有统计学意义（P＜0.05）。观察组治疗后PTA、Glasgow 昏迷评分显著高于对照组,差异有统计学意义（P＜0.05）。观察组治疗3 d后,总有效率显著高于对照组,差异有统计学意义（P＜0.05）。观察组治疗3 d后肝性脑病清醒率,显著高于对照组（P＜0.05）。2组治疗过程中均未见严重不良反应发生。结论在综合治疗的基础上加用M A RS治疗,肝功能改善显著,肝性脑病清醒率高,不良反应少,值得临床推广应用。     

Wessex Head Injury Matrix and Glasgow/Glasgow-Liege Coma Scale: A Validation and Comparison Study

The Wessex Head Injury Matrix (WHIM) is an assessment tool designed for use during and immediately after coma. The aim of this study was (1) to test a French adaptation of the WHIM, (2) to compare the WHIM to the Glasgow Coma Scale (GCS) and its extension, the Glasgow-Liège Coma Scale (GLS), and (3) to confirm the sequence of emergence of behaviours. The three scales were used to assess 23 patients admitted to an intensive care unit with a GCS score equal to or less than 8 for at least 1 hour, longitudinally. Results indicated that the WHIM had good concurrent validity with the GCS and GLS, good inter-rater agreement, and excellent test-retest reliability. The WHIM is more appropriate and sensitive than the GCS and the GLS for the period of emerging from coma and immediately afterwards, whereas the GLS is more appropriate than the WHIM for the deepest phase of coma, as it also assesses brainstem reflexes. Furthermore, analysis of our data confirmed the ordering of the 66 items of the WHIM as a function of sequence of recovery from coma, as suggested by its authors.     

高血糖-弥漫性轴索损伤患者神经损伤严重度和预后的指示剂

目的研究外伤性弥漫性轴索损伤患者高血糖与预后的关系。方法前瞻性对 118例中、重型外伤性弥漫性轴索损伤患者进行研究, 监测入院时、入院后 3 d、7 d 和两周时的神经元特异性烯醇化酶(NSE)、血糖、GCS, 于出院时和三个月后作 GOS 预后评分, 分析血糖水平与损伤严重度和神经功能预后的关系。结果死亡患者入院时血糖水平显著高于存活患者 (260mg/dLvs 130 mg/dL,P<0.005)。入院时血糖≥260 mg/dL 的患者均死亡。结论弥漫性轴索损伤常发生应激反应性早期高血糖, 它是损伤严重度的指示剂和可靠的预后预测指标。     

高血压脑出血患者预后相关因素分析

目的 研究急性高血压脑出血患者90d预后的相关因素,为临床治疗提供指导。方法 本研究是一项前瞻性队列研究,在2006年1月至2007年10月,共连续入选发病3h之内的自发性高血压脑出血患者73例。患者入院时收集人口学资料、既往病史、实验室检查,在基线（发病3h之内）,24±3h,72±3h进行颅脑计算机断层扫描（computed tomography,CT）,获取影像学资料,并在上述时间点及发病90d进行神经功能评分：美国国立卫生院卒中评分（National Institutes of Health Stroke Scale,NIHSS）,格拉斯哥昏迷评分（Glasgow Coma Scale,GCS）,改良的Rankin评分（modified Rankin Scale,mRS）。结果 对73例发病3h之内的高血压脑出血患者研究发现：发病3h之内乳酸脱氢酶（P＝0.026）、纤维蛋白原（P=0.012）、血沉（P=0.001）、肌酐（P=0.036）、基线水平GCS（P=0.001）和NIHSS评分（P=0.002）、住院期间发生感染（P=0.001）、手术（P=0.014）、血肿大小（P<0.01）、绝对水肿大小（P<0.01）、发病24h血肿扩大（P＝0.002）、出血破入脑室系统（P＝0.001）、影像学具有占位效应（P＝0.003）与患者90d mRS临床结局具有相关性。结论 高血压脑出血患者感染、手术、所观测时间点血肿体积、绝对水肿体积、发病24h血肿扩大、出血破入脑室系统、影像学具有占位效应、基线的乳酸脱氢酶、纤维蛋白原、血沉、肌酐、基线水平GCS和NIHSS评分与患者90d临床结局具有相关性,控制这些因素有可能改善预后。