创伤性脑损伤研究新进展

创伤性脑损伤(TBI)病情进展迅速、预后险恶,给临床救治工作带来极大困难,已成为现代急危重症医学面临的突出难题。除了特殊情况下必要的手术干预外,有关TBI的临床处置措施、无创和有创监测模式等近年来有了新的认识。本文重点阐述了TBI的监测和治疗现状,通过对TBI病理生理机制的深入了解,在发病不同环节采取针对性和精准化策略...     

Nutritional therapy in traumatic brain injury : Update 2012

Severe traumatic brain injury ranks among the most common causes of death in young adults in western countries. Severe traumatic brain injury is typically followed by a pronounced pathophysiological cascade that accounts for many deaths. The aim of intensive care medicine after traumatic brain injury is to minimize and to control the consequences of this potentially fatal cascade. The avoidance of hypoxemia, arterial hypotension, intracranial hypertension, hyperthermia, hyperglycemia, hypoglycemia and thromboembolic complications is essential in preventing this cascade. The effect of nutrition has been rather underestimated as a means of improving the outcome after traumatic brain injury. Nutrition should be started within the first 24?h after trauma. Enteral, wherever applicable, should be the route of administration of nutrition. Enteral administration of the whole calculated calorie requirement on day 1 after trauma, if possible, lowers the infection and overall complication rates. The present review gives an update of a practical approach to nutrition in traumatic brain injury.     

Update of neuropathology and neurological recovery after traumatic brain injury

This review focuses on the potential for traumatic brain injury to evoke both focal and diffuse changes within the brain parenchyma, while considering the cellular constituents involved and the subcellular perturbations that contribute to their dysfunction. New insight is provided on the pathobiology of traumatically induced cell body injury and diffuse axonal damage. The consequences of axonal damage in terms of subsequent deafferentation and any potential retrograde cell death and atrophy are addressed. The regional and global metabolic sequelae are also considered. This detailed presentation of the neuropathological consequences of traumatic brain injury is used to set the stage for better appreciating the neurological recovery occurring after traumatic injury. Although the pathological and clinical effects of focal and diffuse damage are usually intermingled, the different clinical manifestations of recovery patterns associated with focal versus diffuse injuries are presented. The recognizable patterns of recovery, involving unconsciousness, posttraumatic confusion/amnesia, and postconfusional restoration, that typically occur across the full spectrum of diffuse injury are described, recognizing that the patient's long-term recovery may involve more idiosyncratic combinations of dysfunction. The review highlights the relationship of focal lesions to localizing syndromes that may be embedded in the evolving natural history of diffuse pathology. It is noted that injuries with primarily focal pathology do not necessarily follow a comparable pattern of recovery with distinct phases. Potential linkages of these recovery patterns to the known neuropathological sequelae of injury and various reparative mechanisms are considered and it is proposed that potential biological markers and newer imaging technologies will better define these linkages.     

Amantadine treatment following traumatic brain injury in children

Primary objective: The focus of this paper is to review the current literature on the use of amandatine in children who have sustained a head injury.

Main outcomes and results: A MEDLINE search was conducted and yielded five papers. They were composed of prospective, retrospective and case study designs. Dosage use and side effect profiles were consistent with expected norms. Efficacy was measures primarily by alertness and arousal and positive results were found for all studies on these dimensions. Behavioural and cognitive measures of outcome yielded mixed results.

Conclusions: The studies reviewed for this paper suggest that amantadine is clinically beneficial for children who have sustained head injuries. Double blind placebo controlled trials with larger sample sizes are needed to further substantiate these findings.     

Psychiatric treatment outcome following traumatic brain injury

The relationship between self-reported history of traumatic brain injury (TBI) and psychiatric treatment outcome was investigated. TBI was hypothesized to be frequent, associated with cognitive deficits on neuropsychological testing, and less amenable to standard psychiatric treatment. Subjects were 42 psychiatric patients with a self-reported history of TBI and 25 psychiatricpatients with no TBI history. Subjects received approximately 2 weeks of inpatient psychiatric treatment. Subjects received neuropsychological testing and completed the Brief Symptom Inventory weekly. TBI was frequent (66% of subjects); multiple injuries were common. Neuropsychological performance was generally average in both groups with few group differences. Subjects, on average, reported significantly decreased psychiatric symtoms on discharge. However, the TBI group appeared to improve less than the control group; group status was a significant predictor of treatment outcome. Implications of results for assessment and treatment of psychiatric disorders in patients with a history of TBI are discussed.     

Differential treatment of focal traumatic brain injury]

On the basis of observation of 65 patients with focal traumatic injury to the brain (hematoma of mater encephali was noted in 24, intracerebral--in 27, a focus of type III brain contusion--in 24, type IV--in 11, multiple hematomas and foci on contusion-crush--in 21), the criteria for their non-surgical treatment have been substantiated. Choice of a method for the treatment depends on the sizes of a hematoma, focus of contusion-crush, location of an injury, degree of its influence on the brain structures (deformation, shift), value of intracerebral pressure, dynamics of the clinico-roentgenologic symptoms.     

提高创伤性颅脑损伤诊治水平

创伤性颅脑损伤（traumitic brian injury,TBI）是世界性的多发疾病、常见疾病,也是死亡率、致残率最高疾病之一,严重危害人们健康。随着我国经济的迅速增长,交通愈加发展,TBI的发生逐渐增多,我们神经外科医生用智慧和双手把许多危重患者从死亡线救了回来,并重新走上工作岗位。但在TBI患者救治方面仍有进一步提高的空间和潜力,更好地造福于人类。     

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.     

Incidence and treatment of visual dysfunction in traumatic brain injury

The incidence of visual dysfunction and effectiveness of visual exercises in acute traumatically brain injured inpatients in a rehabilitation programme were studied. Vision evaluation norms were established on 23 hospital staff. The evaluation was then administered to 51 inpatients within days after admission. An additional 21 patients were unable to participate, usually due to decreased cognition or agitation. Thirty of 51 (59%) scored impaired in one or more of the following: pursuits, saccades, ocular posturing, stereopsis, extra-ocular movements, and near/far eso-exotropia. For patients having dysfunction in pursuits or saccades, a 2-week baseline was followed by vision exercises. During the baseline interval patients were evaluated by an optometrist to verify therapists' findings. Six patients who participated in several weeks of treatment were evaluated at 2-week intervals by an independent rater. Progress is graphically illustrated. Conclusions were that the suitability of an inpatient vision programme, from our experience, is questionable. However, an initial evaluation proved valuable for informing staff of patients' visual status and for referral to an optometrist/ophthalmologist for further treatment.     

Bromocriptine in traumatic brain injury

The authors report the case of a 63-year-old patient with severe traumatic brain injury (TBI) associated with Parkinson's syndrome, whose performances were dramatically improved by bromocriptine therapy, with an improvement of the scores, not only on tests evaluating motor functions but also on tests evaluating the patient's cognitive functions. However, no improvement was observed with levodopa.     

Neuromonitoring in traumatic brain injury

Current approaches to monitoring in severe traumatic brain injury (TBI) include a wide array of modalities, providing insight into pressure parameters, oxygenation, perfusion, electrophysiology and metabolism of the brain. The intent of "multimodality monitoring" is to obtain a better understanding of what is going on within the brain of an individual patient in order to target treatment more appropriately. In this review we highlight the current status of neuromonitoring for TBI with a specific focus on how advanced analysis and integration of these parameters may be used to implement more personalized treatment approaches. In particular, combining information from different parameters and performing dynamic testing offers the potential to better understand the pathophysiological mechanisms active in the brain of a particular patient. Rather than persisting in a standardized "one size fits all" approach to therapy or continuing down the separate tracts of goal directed therapy, we suggest to think more in terms of "individualized therapeutic strategies" more focused on the specific requirements of each patient. Given the considerable data overload in multimodality monitoring and the complexity in interpretation of signals from multiple sources, specific attention needs to be directed to data processing and user-friendly displays. Intense collaboration and interaction between clinicians, basic researchers, IT-experts, nurses and industry will be required to further advance the fields towards more personalized approaches.     

Hypertension in traumatic brain injury

The incidence and natural history of hypertension associated with traumatic brain injury were studied using a cohort of 80 patients discharged from a brain-injury rehabilitation centre. Although a significant incidence (15%) of hypertension is documented in traumatic brain-injured patients, the problem appears transient for most patients. Nonetheless, hypertension after brain injury merits treatment while it is an ongoing process for the anticipated few patients in whom it might persist.     

Severe traumatic brain injury

Traumatic brain injury is a leading cause of morbidity and mortality, especially under 45 years of age. The primary brain injury occurs at the moment of trauma and is defined by the direct damage to tissue. In contrast, secondary brain injury develops over time and is accessible to therapeutic interventions. Patients with severe traumatic brain injury have to be transferred to a specialized trauma centre in order to perform appropriate diagnostic and therapeutic procedures. These include surgical management of lesions (e.g. haematoma evacuation) as well as specific neurointensive care. Neurointensive care medicine principles such as treatment of increased intracranial pressure and advanced invasive neuromonitoring of brain tissue have to be followed.     

Recurrent traumatic brain injury

This article reviews, analyses and provides commentary on the most recent literature concerning recurrent traumatic brain injury (RTBI) case histories. It is revealed that a significant proportion of TBI sufferers survive and recover most of the functions of daily living. However, relatively little is known about the epidemiology, effects, or causes of a new phenomenon: recurrent TBI.