颅脑外伤后进展性出血性损伤的临床探讨

目的探讨颅脑外伤后进展性出血性损伤的发生机制、诊断和治疗。方法对本院2006年12月至2013年12月收治的98例颅脑外伤后进展性出血性损伤患者进行回顾性分析。结果颅脑外伤后进展性出血性损伤患者占同期收治颅内外伤血肿的10.8%,手术治疗66例,恢复良好42例,中残10例,重残3例,植物生存1例,死亡8例;非手术治疗32例,恢复良好21例,中残3例,重残2例,死亡6例。结论颅脑外伤后进展性出血损伤的发生和多种机制有关,在不可逆性神经损伤发生之前早期诊断出PHI,以及时治疗,可以减少死亡率和致残率。     

脑外伤后进展性脑内血肿28例

目的探讨颅脑外伤后进展性脑内血肿的临床特点,总结其发病机制及诊断治疗方案。方法回顾性分析28例经头颅CT动态观察证实的进展性脑内血肿患者的临床资料。结果按伤后6个月GOS评分作为判断预后标准,非手术组6例恢复均良好（21．4％）,手术组良好14例（50．0％）,中残3例（10．7％）,重残5例（17．9％）。结论颅脑外伤后易出现脑内血肿进展性变化,是多种因素相互持续作用的结果,应进行动态观察和CT复查,根据血肿量和意识变化及时调整治疗方案。     

无中线移位的重型颅脑外伤急性弥漫性脑肿胀的危险因素分析及手术治疗策略

目的 分析无中线移位的重型颅脑外伤急性弥漫性脑肿胀患者的临床危险因素及手术治疗效果.方法收集2011年3月至2012年3月本院收治的60例无中线移位的重型颅脑外伤急性弥漫性脑肿胀患者的临床资料,并收集同期收治的无中线移位的重型颅脑外伤未发生脑肿胀的患者资料纳入研究,分别记录两组患者的年龄、受伤至入院时间、高血压病史以及合并多发伤情况,并分析手术治疗和非手术治疗对于无中线移位的重型颅脑外伤急性弥漫性脑肿胀患者的预后的影响.结果受伤至入院较长、有高血压病史以及合并多发伤是无中线移位的重型颅脑外伤急性弥漫性脑肿胀患者的危险因素,接受手术治疗的患者死亡率较低,差异有统计学意义.结论无中线移位的重型颅脑外伤急性弥漫性脑肿胀的危险因素包括受伤至入院时间、高血压病史以及合并多发伤,积极手术治疗有利于患者预后改善.     

颅脑外伤后进展性出血性损伤与血浆D-二聚体浓度的相关分析

目的揭示血浆D-二聚体浓度对颅脑外伤后进展性出血性损伤的预测价值。方法本研究选取2010年8月至2012年8月,本院收治的颅脑外伤患者和同期健康体检者各168例,采用免疫比浊法测定血浆D-二聚体浓度,采用多因素Logistic回归和ROC曲线分析血浆D-二聚体浓度与进展性出血性损伤的关系。结果行t检验,颅脑外伤患者血浆D-二聚体浓度（1.74±0.85）mg/L较对照组（0.16±0.05）mg/L显著升高（P〈0.001）。45例（26.8%）颅脑外伤患者发生进展性出血性损伤。行t检验,进展性出血性损伤患者血浆D-二聚体浓度（2.62±0.72）mg/L较非进展性出血性损伤患者（1.36±0.67）mg/L显著升高（P〈0.001）。Logistic回归分析显示,血浆D-二聚体浓度（OR=1.220,95%CI=1.109-2.408,P〈0.001）是进展性出血性损伤发生的独立危险因素。ROC曲线分析显示,血浆D-二聚体浓度对进展性出血性损伤发生有显著预测价值（曲线下面积=0.848,95%CI=0.784-0.907,P〈0.001）,且判定血浆D-二聚体浓度大于2.17 mg/L,对预测进展性出血性损伤发生有84.4%的灵敏度和73.2%的特异度。结论血浆D-二聚体浓度与颅脑外伤后进展性出血性损伤的发生密切相关,且具有较高的临床预测价值和指导意义。     

颅脑外伤术后进展性硬脑膜外血肿的早期诊治

目的探讨颅脑外伤术后进展性硬脑膜外血肿（TPEDH）的临床特点和早期诊治方法。方法对34例颅脑外伤术后TPEDH的资料进行回顾性分析，对其临床表现、CT检查结果、治疗结果进行总结。结果本组34例TPEDH中，邻近型8例，远隔型26例；单侧者30例，双侧4例；以颞顶部和枕顶部最多见。主要表现为术后意识障碍无明显好转或者出现新的神经功能障碍表现。再手术33例，32例确认血肿处骨折存在。出院时GOS评分5分12例，4分8例，3分6例，1分8例。结论术后TPEDH多见于冲击部位，早期CT复查有助于及时诊断和改善预后。     

外周血白细胞计数与脑外伤后进展性出血性损伤的相关分析

目的 揭示外周血白细胞计数与脑外伤后进展性出血性损伤的关系.方法选取脑外伤患者142例和同期健康体检者142例,分析外周血白细胞计数对脑外伤后进展性出血性损伤的预测价值.结果经t检验,脑外伤患者外周血白细胞计数（8.1±3.6）×109/L较健康体检者（6.1±2.0）×109/L显著升高（P＜0.01）.本组脑外伤后进展性出血性损伤36例（25.4%）.Logistic回归分析显示,入院时外周血白细胞计数（OR＝2.684,95%CI＝1.501～4.851,P＜0.01）可独立预测脑外伤后进展性出血性损伤.ROC曲线分析显示,外周血白细胞计数可显著预测脑外伤后进展性出血性损伤（曲线下面积＝0.830,95%CI＝0.758～0.888,P＜0.01）,外周血白细胞计数大于10.5×109/L,对预测脑外伤后进展性出血性损伤有69.4%的灵敏度和88.7%的特异度.结论外周血白细胞计数可独立预测脑外伤后进展性出血性损伤.     

颅脑外伤并发脑心综合征原因分析和对策

脑心综合征(cerebro-cardiac svndrome,CCY)是指继发于中枢神经系统损伤后心脏发生心肌梗死、心肌缺血、心律失常等改变.而颅脑外伤是中枢神经系统损伤的主要形式.CCY特点是临床表现多不明显、也不典型,常表现为脑症状和局灶性症状进一步恶化[1].如果观察不仔细,护理和操作不当,将使病情进一步加重,形成恶性循环.因此密切关注颅脑损伤引起的心脏变化,采取积极正确的护理措施,对改善颅脑外伤患者的预后甚为重要.笔者对1996年9月至2002年6月,本院收治的121例颅脑外伤引起脑心综合征患者的诊治经过进行总结,报告如下.     

颅内压及脑电双频指数联合监测在重型颅脑外伤患者术后临床应用中的研究

目的 探讨脑电双频指数及颅内压监测在重型颅脑外伤患者术后意识评测和短期预后评估中的应用价值.方法 采用简单随机抽样法随机选择2014年1月-12月江苏省苏北人民医院神经外科重症监护病房颅脑外伤昏迷患者30例,每8h评价患者的GCS评分,记录患者手术治疗后3d内的GCS评分,记录相同时刻的脑电双频指数值及颅内压值,依据GCS评分将患者分为两组:A组20例(3分≤GCS≤5分),B组10例(5分＜ GCS≤8分),统计两组患者的21 d生存率.采用Kaplan-Meier法和Log-rank检验比较脑电双频指数值和颅内压之间的关系.结果 A组脑电双频指数值为45.3 ±3.8,颅内压值为(18.6±2.8) mmHg,B组脑电双频指数值为32.2 ±8.2,颅内压值为(33.4±4.6) mmHg,A组21d生存率为55％,B组21 d生存率为30％,重型颅脑外伤患者术后脑电双频指数值与昏迷程度呈正相关,与颅内压值呈负相关(r =0.532,P ＜0.05;r =0.521,P ＜0.05).重型颅脑损伤患者,入院时病情越重,患者术后颅内压越高,脑电双频指数值越低,其预后越差.结论 脑电双频指数与颅内压联合监测在评估重型颅脑外伤患者术后昏迷程度及预后方面具有较高的应用价值.     

外伤后急性弥漫性脑肿胀诊疗研究

外伤后急性弥漫性脑肿胀属特重型颅脑损伤,是外伤后脑组织严重损伤的表现,病死率高,预后差.其发病机制及手术治疗的价值目前尚有争议,本文就近年来对此病的研究及治疗进展作一综述.     

颅脑外伤后进展性颅内血肿的诊断和治疗

目的 探讨颅脑损伤后进展性颅内血肿的诊断及治疗.方法 对2006年3月至2008年12月我院收治的78例外伤性进展性颅内血肿患者的临床资料进行回顾性分析.结果 手术治疗49例,保守治疗29例;恢复良好36例,中残21例,重残9例,植物生存1例,死亡11例.结论 对于外伤性进展性颅内血肿患者应密切观察病情变化,动态CT扫描是及时发现血肿变化的重要手段,早期诊断并及时治疗是改善预后的关键.     

创伤性脑损伤后肺损伤的发病机制研究进展

背景 创伤性脑损伤(traumatic brain injury,TBI)患者可能发生肺损伤,严重时甚至发生肺功能障碍.脑与肺通过复杂途径相互联系.发生肺功能障碍的TBI患者病死率增加、 加强治疗病房住院时间延长且神经预后较差.目的 综述TBI后肺损伤的研究进展.内容 讨论TBI后肺损伤的发生特点并综述其潜在机制.趋向 根据具体情况评估TBI患者发生肺损伤的潜在风险,并在其临床症状出现前进行相应干预有助于降低发生TBI后肺损伤的风险.     

Cerebral protection in traumatic brain injury

With advances in the understanding of the pathophysiology of traumatic brain injury, many novel cerebroprotective measures have been developed. Many of them have undergone preclinical trials and have shown promising results, but the results have not translated into clinical benefits. Evidence of these cerebroprotective measures including NMDA‐receptor antagonist, steroids, free radial scavengers, nimodipine, ziconotide, bradykinin receptor antagonist and dexanabinol has been reviewed. Problems encountered in clinical studies of traumatic brain injury are mainly related to the heterogenicity of traumatic brain injury and the design of clinical studies. Given all these difficulties, clear benefit of these measures cannot be shown and an optimum treatment strategy has yet been developed.     

Hypoxic-ischaemic brain injury (HIBI) after cardiopulmonary arrest

Hypoxic-ischaemic brain injury (HIBI) is unfortunately a common complication after cardiopulmonary arrest (CPA) with devastating neurologic complications. Intensive care unit (ICU) management is initially aimed at cardiovascular stabilization and correction of the underlying cause of arrest such as ventricular fibrillation (VF), myocardial infarction from symptomatic coronary artery disease (CAD), or respiratory arrest. Once the patient is stabilized from a cardiac standpoint, growing evidence suggests that therapeutic hypothermia may provide cerebral neuroprotective benefit for VF-related CPA. Practical ICU evaluation and implementation of therapeutic hypothermia is discussed. Evaluation and management of HIBI-related autonomic disturbances or paroxysmal autonomic instability with dystonia (PAID) is discussed. Finally, we review the literature regarding neurological prognostication after cardiac arrest and the tests with highest specificity that can aid in the decision-making process.     

Imaging after brain injury

Head injury remains an important cause of death and disabilityin young adults. This review will discuss the role of structuralimaging using computed tomography (CT) and magnetic resonanceimaging (MRI) and physiological imaging using CT perfusion,¹³¹Xe CT, MRI and spectroscopy (MRS), single photon emissioncomputed tomography, and positron emission tomography (PET)in the assessment, management, and prediction of outcome afterhead injury. CT allows rapid assessment of brain pathology whichensures patients who require urgent surgical intervention receiveappropriate care. Although MRI provides greater spatial resolution,particularly within the posterior fossa and deep white matter,a complete assessment of the burden of injury requires imagingof cerebral physiology. Physiological imaging techniques canonly provide ‘snap shots’ of physiology within theinjured brain, but they can be repeated, and such data can beused to assess the impact of therapeutic interventions. Perfusionimaging based on CT techniques (xenon CT and CT perfusion) canbe implemented easily in most hospital centres, and providequantitative perfusion data in addition to structural images.PET imaging provides unparalleled insights into cerebral physiologyand pathophysiology, but is not widely available and is primarilya research tool. MR technology continues to develop and is becominggenerally available. Using a complex variety of sequences, MRcan provide data concerning both structural and physiologicalderangements. Future developments with such imaging techniquesshould improve understanding of the pathophysiology of braininjury and provide data that should improve management and predictionof functional outcome.     

Psychiatric comorbidity following traumatic brain injury

Primary objective: Survivors of traumatic brain injury (TBI) are at increased risk for development of severe, long-term psychiatric disorders. However, the aetiology of these disorders remains unclear. This article systematically reviews the most current prevalence rates and evidence for causality, in terms of established criteria.

Main outcome and results: Psychiatric syndromes are consistently present at an elevated rate following TBI. Survivors of TBI are particularly susceptible to major depression, generalized anxiety disorder and post-traumatic stress disorder. Evidence for a biological gradient is generally lacking, although this criterion may not be appropriate in the case of TBI. The temporal pattern of onset is variable and reliable critical periods for the post-injury development of a psychiatric disorder remain to be identified; however, individuals appear to remain at risk for years following injury.

Conclusions: Non-organic factors, including pre-morbid personality traits and post-injury psychological reactions to disability and trauma, are implicated in the generation and maintenance of post-TBI psychiatric disorder. There remains insufficient evidence to conclude what role the neuropathological consequences of TBI play in the development of post-TBI psychiatric disorder.     

UFOV performance and driving ability following traumatic brain injury

Primary objective: To investigate the relationship between performance on the Useful Field of View Test (UFOV) and driving performance following traumatic brain injury (TBI).

Participants: Sixty people with TBI referred for driving evaluation.

Measures: Useful Field of View Test, Global Rating Scale and Driver Assessment Scale.

Results: Subject performance diminished as the complexity of the UFOV sub-tests increased. There was a significant relationship between UFOV performance, particularly on the second sub-test, and on-road driving performance. Subject age and Trail Making Test, Part B were also predictive of driving performance.

Conclusions: The UFOV can be used as a screening measure to determine readiness to participate in an on-road driving assessment.     

Clinical treatment of traumatic brain injury complicated by cranial nerve injury

Objective

To discuss the epidemiology, diagnosis and surgical treatment of cranial nerve injury following traumatic brain injury (TBI) for the sake of raising the clinical treatment of this special category of TBI.

Patients and methods

A retrospective analysis was made of 312 patients with cranial nerve injury among 3417 TBI patients, who were admitted for treatment in this hospital.

Results

A total of 312 patients (9.1%) involving either a single nerve or multiple nerves among the 12 pairs of cranial nerves were observed. The extent of nerve injury varied and involved the olfactory nerve (66 cases), optic nerve (78 cases), oculomotor nerve (56 cases), trochlear nerve (8 cases), trigeminal nerve (4 cases), abducent nerve (12 cases), facial nerve (48 cases), acoustic nerve (10 cases), glossopharyngeal nerve (8 cases), vagus nerve (6 cases), accessory nerve (10 cases) and hypoglossal nerve (6 cases). Imaging examination revealed skull fracture in 217 cases, complicated brain contusion in 232 cases, epidural haematoma in 194 cases, subarachnoid haemorrhage in 32 cases, nasal cerebrospinal fluid (CSF) leakage in 76 cases and ear CSF leakage in 8 cases. Of the 312 patients, 46 patients died; the mortality rate associated with low cranial nerve injury was as high as 73.3%. Among the 266 surviving patients, 199 patients received conservative therapy and 67 patients received surgical therapy; the curative rates among these two groups were 61.3% (122 patients) and 86.6% (58 patients), respectively.

Conclusion

TBI-complicated cranial nerve injury is subject to a high incidence rate, a high mortality rate and a high disability rate. Our findings suggest that the chance of recovery may be increased in cases where injuries are amenable to surgical decompression. It is necessary to study all 12 pairs of cranial nerves systematically. Clinically, it is necessary to standardise surgical indications, operation timing, surgical approaches and methods for the treatment of TBI-complicated cranial nerve injury.     

Public attitudes towards survivors of brain injury

Primary objective: To explore the effects of religious identity, gender and socioeconomic status (SES) on public attitudes towards survivors of brain injury. Research design: An independent groups design was used to compare the attitudes of Northern Irish participants. Methods and procedures: The participants were asked to complete a modified form of the Community Attitudes to Mental Illness scale. The new questionnaire replaced the original scales' emphasis on mental illness with that of brain injury. Complete data was available for 179 participants for the religious identity and gender analysis and 124 for gender and SES. Analyses of variance were conducted on these variables. Outcomes and results: Significant differences between male and female attitudes were found along with significant interactions between religious identity and gender and SES and gender. Conclusions: Religious, economic and gender-based divisions in society affect attitudes towards survivors of brain injury.     

Predictors of family system functioning after brain injury

Objectives: To identify predictors of family system functioning after acquired brain injury (ABI).

Research design: Retrospective design.

Methods and procedures: Data on ABI-related impairments, level of awareness, neuropsychological functioning, caregiver strain and family system functioning were extracted from the files of 66 individuals with ABI and 148 family members who had enrolled in a community-based support programme.

Main outcomes and results: Individuals with ABI, mothers, spouses, siblings and the family as a unit reported significant distress in family functioning compared to the norm. Higher caregiver strain and client gender (i.e. female) were predictive of poorer family system functioning. Neither ABI impairments nor neuropsychological variables were correlated with family functioning.

Conclusions: The effects of ABI extend beyond the injured person and primary caregiver. The need for a family systems approach to family intervention after ABI is supported. Implications for practice and future research are discussed.     

Penetrating ballistic-like frontal brain injury caused by a metallic rod

Summary  Penetrating non-missile intracranial injuries caused by metallic foreign bodies are very rare among the civilian population. We present a unique instance of a severe, high-energy, penetrating orbitocranial injury caused by a solid metallic rod that corresponded to the spray valve lever handle of a kitchen sink pre-rinse spray tap, which was fractured and projected at high speed for an unknown reason. To our knowledge, this is the first report of a high-energy, penetrating brain injury caused by such an object. After careful radiological evaluation of the shape and position of the foreign object, a combined right frontal craniotomy and supraorbital osteotomy was performed in order to achieve safe removal of the metal bar. Successful surgical treatment of an orbitocranial injury caused by a similar object has not previously been reported.