重型颅脑创伤长期意识障碍患者清醒预测的MRI分级研究

目的 探讨MRI对重型颅腩创伤后长期意识障碍患者清醒预测的分级标准.方法 记录66例重型TBI意识障碍超过2周患者的MRI表现,以MRI的表现分为3级:Ⅰ级:仅有大脑半球的损伤;Ⅱ级:丘脑、胼胝体的损伤,伴或不伴有I级的损伤灶,包括:Ⅱa级(单侧丘脑的损伤)和Ⅱb级(胼胝体、双侧丘脑的损伤);Ⅲ级:脑干背外侧的损伤,伴或小伴有Ⅰ级和(或)Ⅱ级的损伤灶.预后以颅脑创伤后6个月患者是否清醒为标准.结果 MRI分级与清醒的概率有显著相关性,Pearson相关系数-0.722(P＜0.05),分级越高,预后越差;Ⅱb级、Ⅲ级作为预后不良的指标,判断的敏感性为85.7%,特异性为87.5%,准确率为86.4%,错误率为13.6%;ROC曲线下面积为0.89,95%可信区间为(0.808,0.978).结论 MRI分级可客观、准确地反映颅脑创伤程度和清醒的概率.     

应用MRI分级预测颅脑损伤长期意识障碍患者的清醒时间及预后

目的 探讨颅脑损伤长期意识障碍患者MRI分级与清醒时间及预后的关系.方法 收集珠江医院神经外科自2003年至2008年收治的66例重型颅脑损伤后意识障碍超过2周的患者,记录患者颅脑MRI表现并进行分级;记录所有清醒患者损伤后清醒时间;预后以患者伤后6个月时GOS评分进行判别.结果 患者预后(GOS评分)与MRI分级存在联系,分级越高者,预后越差;MRI对预后的预测准确率为83.33%.MRI分级为Ⅰ级和Ⅱa级的清醒患者的平均清醒时间为(8.00±4.10)周,MRI分级为Ⅱb级和Ⅲ级的清醒患者的平均清醒时间为(22.67±23.66)周.结论 颅脑损伤长期意识障碍患者的头颅MRI分级与患者的清醒时间及预后有关,应用MRI分级可客观、准确的预测患者的预后.     

CT中脑背侧脑池出血对原发性脑干损伤的早期诊断价值

目的 分析颅脑外伤急诊CT中脑背侧脑池出血的表现,探讨其对临床原发性脑干损伤的早期诊断价值.方法 回顾性分析52例颅脑外伤患者临床表现及影像学资料,并依据GCS评分分为轻、中、重及特重型.所有患者均在伤后48 h内接受CT检查,CT采用常规程序扫描.MRI检查则根据病情变化在伤后1周内完成,采用自旋回波T1WI、T2WI序列.结果 所有病例的CT表现均与MRI的T1WI、T2WI序列行比较研究,其中39例颅脑损伤患者的急诊CT有中脑背侧环池或四叠体池出血表现,合并弥漫性脑肿胀19例,脑实质出血灶单发或多发点状出血灶11例,直径小于2 cm;37例MRI检查存在不同程度的脑干组织损伤表现.结论 重型和特重型颅脑外伤(GCS<9分)伤后早期CT的中脑背侧脑池出血表现高度提示原发性脑干损伤可能,对提高原发性脑干损伤早期诊断水平具有重要的参考价值.     

Fahr病的临床和CT特征

目的探讨Fahr病的临床及CT特征。方法回顾性分析本院收治的5例患者的临床资料。结果该病主要表现为智力障碍、语言障碍、癫痫间、共济失调、椎体外系异常,头部CT示双侧基底节对称性钙化,并可有大脑皮层、小脑、丘脑、脑干等多处钙化灶。结论 Fahr病的临床表现多样,双侧基底节对称性钙化可能是其特征性CT表现。     

重型颅脑损伤术后患者预后现状和影响因素分析

目的 探讨重型颅脑损伤术后患者预后现状和影响因素.方法 查阅重型颅脑损伤术后患者相关文献制定自编问卷,应用于2010-07-2012-07在我院脑外科住院治疗的69例重型颅脑损伤术后患者进行临床资料的收集,根据患者格拉斯哥预后评分将其分为A组和B组,采用描述性统计和二分类Logistic回归分析重型颅脑损伤术后患者预后现状和影响因素.结果 本研究入选的69例患者中预后良好率18.84%,预后不良率81.16%,多因素Logistic回归分析发现：凝血功能异常、S-100蛋白水平高、神经元特异性烯醇化酶水平高、脑干损伤和术后出现并发症是重型颅脑损伤术后影响患者预后的危险因素,而术后康复训练到位是影响重型颅脑损伤术后患者预后的保护因素.结论 重型颅脑损伤术后患者预后总体欠佳,受多方面因素的影响,应针对性采取干预措施来提高患者预后,并加强康复训练改善患者预后.     

意识障碍的神经电生理检查

清醒的意识状态依赖于大脑皮质、脑干和丘脑的非特异性上行性激活系统的正常功能来维持。颅脑外伤后，由于广泛的轴索损害使皮层和皮层下失去联络，非特异性上行性激活系统上传的冲动，无法进入广泛的大脑皮层，或者幕上病损压迫丘脑和上脑干的网状结构，以及直接引起的脑干损伤，均可以引起颅脑外伤患者发生意识障碍，意识障碍是颅脑外伤后最常见的症状，亦是最棘手的治疗难点。     

弥漫性轴索损伤

弥漫性轴索损伤(DAI)属于闭合性原发弥漫性脑损伤。是由于头部成角、加(减)速运动或旋转性暴力出现弥漫性轴索扭曲、肿胀、断裂及皮髓质交界区穿行血管中断所致。好发于皮髓质交界区、胼胝体、尾状核、丘脑、内囊及中脑被盖的背外侧。其病理变化包括:(1)广泛性轴索损害,累及大脑、脑干和小脑的白质和大脑深部核质,包括中线旁皮质下白质、胼胝体、穹窿柱、内囊、基底节及丘脑、齿状核背侧小脑叶、皮质脊髓束、内侧丘脑系、内侧纵束等。(2)胼胝体局限性出血灶。(3)上脑干背外     

重型颅脑损伤昏迷患者的清醒预测模型

目的 探讨早期预测评估重型颅脑损伤昏迷患者清醒概率的方法,开发预测清醒概率的模型. 方法 回顾性分析南方医科大学附属花都医院神经外科自2010年5月至2012年7月间收治的263例重型颅脑损伤昏迷患者的临床资料,多分类Logistic回归分析与患者清醒预后相关的多种因素,并建立预测清醒概率的模型. 结果 多分类Logistic回归显示年龄、入院时瞳孔对光反射、运动格拉斯哥评分(mGCS)、CT示脑干是否受压,治疗后的睁眼时间和脑缺血体积百分比均为重型颅脑损伤昏迷患者清醒的独立预测因子,Pearson残差评估显示预测模型的拟合效果较佳. 结论 本预测模型有较好的拟合效果,所需预测因子的数据易于获得,普遍适用于基层医院,对重型颅脑损伤昏迷患者早期的临床决策有重要参考价值.     

重型颅脑损伤后缄默症23例报告

目的 探讨重型颅脑损伤后缄默症的影像学特点.方法 回顾性分析我院2001年6月至2007年6月收治呶23例重型颅脑损伤后缄默症患者,均于脑外伤后24 h到10 d内行常规MR成像、流动衰减反转恢复序列(FLAIR)及弥散加权成像(DWI),分析发生部位与缄默的相关性.结果 23例缄默症中,发现病灶203个,依次为大脑半球皮层下脑白质区占56.7%;基底节占5.4%;胼胝体占25.1%,丘脑占6.4%;脑干占2.5%,小脑占3.9%.症状多于2～3周后恢复.结论 重型颅脑外伤后缄默症与胼胝体损伤或齿状核-丘脑-皮质通路有关,持续时间在2周左右,其预后较好.     

5个CADASIL家族的核磁共振改变特点

目的　分析来自5个CADASIL家族中8名患者的核磁共振(MRI)表现,总结病变不同时期的MRI变化规律及其诊断价值。方法　研究对象为经过超微病理和Notch3基因检查确诊的5个CADASIL家族中的8个患者,均在成年早期发病,主要表现为反复发作的缺血性卒中和进行性痴呆。对先证者1及其母亲、先证者2及其哥哥、姐姐,先证者3、4和5 ,总计8名患者进行了头部MRI检查,其中4名进行了MRI血管成像检查。结果　8名患者的头部MRI均显示多发腔隙性脑梗死,病灶主要分布在基底节、丘脑和脑室旁白质,6例患者出现了外囊梗死,4例出现了胼胝体梗死,3例出现了脑桥梗死。所有8例患者均存在双侧大脑半球多灶性或弥漫性白质疏松,1例患者MRI确诊1年后随访显示多灶性白质病变进展为弥漫性损害,5例患者出现了双侧颞极等T1 长T2 信号。4例患者的头部MRI血管成像检查未见异常。结论　基底节、丘脑和脑室旁白质是CADASIL腔隙性脑梗死的好发部位,外囊和胼胝体梗死以及双侧颞极长T2 信号对本病具有较高的诊断价值。脑干受累可以出现在病程早期,而白质病灶分布形式的变化可以反映病情的进展。     

低血糖脑病的影像学特征

目的探讨低血糖脑病的影像学特征。方法回顾性分析7例低血糖脑病患者的核磁共振资料。结果低血糖脑损害有高度的区域选择性,可不对称。主要累及大脑皮层、海马、基底节和胼胝体压部,甚至皮层下白质;MRI表现为等或稍长T1、长T2信号,DWI呈高信号,伴ADC值降低,部分病变可逆;MRS示病变区乳酸峰无明显变化。结论低血糖脑损害有很强的区域选择性、可不对称;DWI对病变更敏感;大脑皮层和基底节区受累者预后不佳,侵犯胼胝体压部者预后好。     

Differentiation of mechanism and prognosis of traumatic brain stem lesions detected by magnetic resonance imaging in the acute stage

We retrospectively evaluated the MRI from 17 patients with primary brain stem injury obtained in the acute stage. Clinical and radiological findings were analyzed in these 17 patients. T2-weighted imaging proved to be most sensitive and specific for the diagnosis of primary brain stem injury. We found two patterns of brain stem injury. The good prognosis group showed ventral brain stem lesions or dorsal superficial brain stem lesions. On the other hand the poor prognosis group showed deep dorsal brain stem lesions. These acute stage findings are seen only temporally in many cases so that it is most important to examine MRI findings in the acute stage to evaluate the prognosis of the patient. MRI was valuable in predicting the outcome. The possible mechanism of brain stem injury in patients with head injury is briefly discussed.     

Boomerang Sign on MRI

Introduction

Altered mental status and more subtle cognitive and personality changes after traumatic brain injury (TBI) are pervasive problems in patients who survive initial injury. MRI is not necessarily part of the diagnostic evaluation of these patients.

Methods

Case report with relevant image and review of the literature.

Results

Injury to the corpus callosum is commonly described in traumatic brain injury; however, extensive lesions in the splenium are not well described. This image shows an important pattern of brain injury and demonstrates a common clinical syndrome seen in patients with corpus callosum pathology.

Conclusion

Injury to the splenium of the corpus callosum due to trauma may be extensive and can cause significant neurologic deficits. MRI is important in the diagnostic evaluation of patients with cognitive changes after TBI.     

The added prognostic value of magnetic resonance imaging in traumatic brain injury: The importance of traumatic axonal injury when performing ordinal logistic regression

Background and purposeThis study was performed to investigate the prognostic value of traumatic axonal injury (TAI) in severe head trauma.MethodsWe attempted to determine whether any MR imaging findings of TAI could be related to prognosis in 264 patients with severe head trauma. We performed an ordinal logistic regression, adjusted for the prognostic factors according to the IMPACT studies, adding each MR feature related to prognosis one at a time. A new prognostic model was described by adding these MR features to the classic prognostic factors. The model was externally validated in a prospective series. Harrel's c-statistic and ordinal c-index (ORC) were calculated to measure its predictive accuracy.ResultsWe found 178 patients with TAI lesions. Lesions in the basal ganglia/thalamus, corpus callosum (CC) and brain stem were associated with poor outcome (P < 0.01). The highest OR was for TAI lesions in the splenium (OR: 2.6) and brain stem dorsal lesions (OR: 3.1). We only found significant differences in outcome between haemorrhagic and non-haemorrhagic TAI lesions in the subgroup of patients with white matter and basal ganglia/thalamus lesions (P = 0.01). We obtained a superior discriminatory capacity by adding these MR findings to the previous prognostic model (Harrel's c-statistic 0.72 and ORC 0.7) in a prospective series of 93 patients.ConclusionsThe prognostic model including MR findings maintained a superior discriminatory capacity than that obtained for the model with the classic prognostic factors alone.     

Traumatic brain injury and atrophy of the cingulate gyrus

The medial surface areas of the cingulate gyrus (CG) and other midline structures (corpus callosum, thalamus, lateral ventricle) were examined in 27 traumatically brain injured (TBI) and 12 age- and gender-matched control subjects from an established TBI data base. Significant atrophy, primarily in the posterior CG, was found in TBI patients. Degree of atrophy was related to severity of injury. TBI subjects also had significantly reduced corpus callosum and thalamic cross-sectional surface areas with associated increased lateral ventricular volume, as well as reduced brain volume and increased ventricle-to-brain ratio. Despite significant atrophy of the posterior CG, neuropsychological performance was not related to changes in CG cross-sectional surface area in the TBI subjects. This apparent discrepancy is discussed.     

胼胝体病变-肝豆状核变性的少见脑部影像学表现

目的研究肝豆状核变性患者胼胝体病变及其临床价值。方法收集3例肝豆状核变性患者的临床及影像资料,参照2001年第八届莱比锡肝豆状核变性国际会议制定的诊断评分系统评分。利用磁共振成像(MRI)技术检查胼胝体压部病变。结果 3例患者均存在胼胝体压部病变,但均无胼胝体病变所致的失连接综合征表现。头颅MRI技术提示3例患者胼胝体病变主要为长T2异常信号、FLAIR像稍高信号,其中1例DWI呈高信号。出现胼胝体病变的3例肝豆状核变性患者均病情较重、脑部损伤弥漫(尾状核、壳核、苍白球、丘脑、中脑及桥脑)。结论胼胝体病变为肝豆状核变性患者少见的影像学表现,若在有典型基底节病变的同时还伴有胼胝体病变则高度支持肝豆状核变性的诊断。胼胝体病变也提示患者病情较重、脑部损伤弥漫,预后相对较差。     

Unexpected Recovery of Function After Severe Traumatic Brain Injury: The Limits of Early Neuroimaging-Based Outcome Prediction

Background

Prognostication in the early stage of traumatic coma is a common challenge in the neuro-intensive care unit. We report the unexpected recovery of functional milestones (i.e., consciousness, communication, and community reintegration) in a 19-year-old man who sustained a severe traumatic brain injury. The early magnetic resonance imaging (MRI) findings, at the time, suggested a poor prognosis.

Methods

During the first year of the patient’s recovery, MRI with diffusion tensor imaging and T2*-weighted imaging was performed on day 8 (coma), day 44 (minimally conscious state), day 198 (post-traumatic confusional state), and day 366 (community reintegration). Mean apparent diffusion coefficient (ADC) and fractional anisotropy values in the corpus callosum, cerebral hemispheric white matter, and thalamus were compared with clinical assessments using the Disability Rating Scale (DRS).

Results

Extensive diffusion restriction in the corpus callosum and bihemispheric white matter was observed on day 8, with ADC values in a range typically associated with neurotoxic injury (230–400 × 10^?6 mm²/s). T2*-weighted MRI revealed widespread hemorrhagic axonal injury in the cerebral hemispheres, corpus callosum, and brainstem. Despite the presence of severe axonal injury on early MRI, the patient regained the ability to communicate and perform activities of daily living independently at 1 year post-injury (DRS = 8).

Conclusions

MRI data should be interpreted with caution when prognosticating for patients in traumatic coma. Recovery of consciousness and community reintegration are possible even when extensive traumatic axonal injury is demonstrated by early MRI.     

低血糖脑病的临床及脑部磁共振特征

目的探讨低血糖脑病的临床及脑部磁共振特征。方法回顾分析69例低血糖昏迷患者的临床、脑磁共振（MRI）成像资料。结果低血糖昏迷诱因较为复杂,常见的为进食减少、腹泻、上呼吸道感染、降糖药物应用不当等。临床表现复杂多样,除意识障碍外,还可表现为偏瘫、四肢瘫、凝视麻痹等,多数伴有Babinski征。69例患者中有18例出现脑MRIDWI异常高信号病灶,病灶主要累及海马、基底节、大脑皮质以及皮质下白质,多为对称性损害。3个月后随访,不伴有脑部MRI损害的患者预后良好率明显高于伴有脑部MRI损害的患者（94．12％对22．22％;P=0．0011）。伴有脑部MRI损害者有10例患者预后不良,其中9例（90％）发生于皮质受累患者。结论低血糖脑病临床表现不具有特异性,对于昏迷患者,应当考虑到低血糖的可能。降糖药物应用不当为低血糖脑病的主要诱发因素。脑部MRI要优于脑部CT检查,其中DWI序列对于检测低血糖所致的脑部损害有着非常重要的意义。皮质受累者预后不良。     

A case of postural and kinetic tremor caused by diffuse axonal injury]

We reported a 25-year-old woman with postural and kinetic tremor caused by diffuse axonal injury. The patient demonstrated consciousness disturbance, left oculomotor palsy and tetraparesis because of an automobile accident. T2-weighted and FLAIR MRI showed features of diffuse axonal injury. Hyperintense lesions appeared in the corpus callosum, fornix, dorsal portion of midbrain, right cerebral peduncle, and bilateral internal capsules. About 3 weeks later, head tremor and left hemiparesis appeared with improvement of consciousness. Administration of trihexyphenidyl decreased the tremor. Ten weeks after the accident, a coarse tremor in the head and right upper extremity developed after withdrawal of trihexyphenidyl. Tremor in the right upper limb predominantly occurred while maintaining an upright posture and with intended movements. Re-administration of trihexyphenidyl decreased the tremors. The dentatothalamic pathway is one of the lesions responsible for posttraumatic tremor. Our patient demonstrated lesions of diffuse axonal injury involving the dentatothalamic pathway. We considered that these lesions were associated with postural and kinetic tremor in our case. The tremor occurred at least 3 weeks after the accident. This finding suggested that the tremor was caused by transsynaptic alternations of thalamus or the extrapyramidal system secondary to involvement of the dentatothalamic pathway.