颅脑外伤去骨瓣减压术后并发脑积水的预测模型建立与验证

目的基于临床资料建立并验证创伤性颅脑损伤（TBI）去骨瓣减压（DC）术后并发脑积水（PTH）的预测模型。 方法选取解放军联勤保障部队第九〇四医院神经外科自2010年1月至2019年12月诊治的符合纳入条件的451例TBI患者,随访6个月后根据PTH诊断标准分为PTH组（127例）和无PTH组（324例）,分析与之可能相关的15项因素。采用最小绝对收缩和选择算子（LASSO）回归降低数据维度和筛选预测因子。纳入多因素Logistic回归分析后建立预测模型并制作列线图,受试者工作特征曲线（ROC）和校准曲线用于检测模型的区分度和拟合优度,决策曲线分析（DCA）评价模型的临床适用性。 结果LASSO回归筛选出5个预测因子并用于构成模型。经过验证,模型的ROC曲线下面积为0.762。校准曲线显示预测概率与实际概率有很好的一致性。DCA表明模型在一定范围内的临床适用性。 结论本研究建立一个PTH的预测模型,具有良好的区分度、拟合优度和临床适用性,有利于高危患者的识别和针对性随访干预。     

639例重型颅脑损伤患者生存预测分析

目的 建立一个关于重型颅脑损伤患者生存的简单、方便、准确率高的预测模型.方法 采用分类和回归树(classification and regression tree,CART)分析方法,选择8个预后因子,对639例重型颅脑损伤患者的预后进行分析,预后以外伤后6个月生存或死亡为标准.结果 GCS评分是最好的预测因子,血糖、瞳孔情况是强有力的预测因子,头颅CT表现、年龄是有效的预测因子,白细胞计数也对预后产生有意义的影响.CART中的所有变量都与预后相关,预测生存的准确率达91.4%.结论 CART预测模型能较好地预测重型颅脑损伤患者的生存,是简单有效、准确率高的预测方法.     

重型颅脑损伤长期意识障碍患者MRI表现与预后的关系

目的 探讨重型颅脑损伤长期意识障碍患者磁共振成像(MRI)表现与预后的关系.方法 收集珠江医院神经外科自2003年1月至2008年8月收治的66例重型颅脑损伤后意识障碍超过2周的患者的头部MRI资料,统计MRI横断位扫描T2WI像中脑干、丘脑、基底前脑、胼胝体、大脑皮层下及大脑皮层等区域的异常信号表现,以颅脑损伤后6个月患者是否清醒分为清醒组与非清醒组,运用Logistic回归分析计算患者头部MRI中的损伤灶位置与清醒与否的OR值,明确对预后有影响的独立危险因素.结果 头颅MRI中脑干腹侧及背侧、双侧基底前脑、双侧丘脑、胼胝体、双侧大脑额叶区域损伤和未损伤患者在清醒组与非清醒组间比较差异有统计学意义(P<0.05).Logistic回归分析显示脑干背侧损伤、丘脑右侧损伤、胼胝体损伤是影响预后的独立危险因素.结论 MRI表现可较客观、准确地反映脑损伤程度和预测患者的预后,脑干中上段背侧、胼胝体、丘脑有损伤灶的患者预示着难以清醒.     

改良CT图像评分对重型颅脑损伤昏迷患者预后评估的临床价值

目的 探讨改良CT图像评分对重型颅脑损伤昏迷患者预后评估的作用. 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6月至2011年9月收治的90例重型颅脑损伤昏迷患者的临床资料,根据预后分为清醒组和昏迷组.应用改良CT图像评分法对患者的CT图像进行评分,并分析其与患者病情严重程度及预后的关系. 结果 昏迷组患者的改良CT图像评分明显高于清醒组,差异有统计学意义(P＜0.05).GCS评分3～5分组患者改良CT图像评分明显高于6～8分组,差异有统计学意义(P＜0.05); Spearman相关分析显示患者改良CT图像评分与GCS评分呈负相关关系(r=-0.790,P=0.000). 结论 改良CT图像评分有助于评估患者病情、预后及指导临床诊治,具有良好的临床应用价值.     

重型颅脑损伤后并发脑积水的危险因素分析

目的探讨重型颅脑损伤去大骨瓣减压术后并发脑积水的相关危险因素。方法回顾性分析2012年3月至2015年7月去大骨瓣减压术治疗的104例重型颅脑损伤的临床资料。采用多因素Logistic回归分析检验脑积水的危险因素。结果出院后随访9个月,104例中,发生脑积水24例(23.08%),未发生脑积水80例(76.92%)。多因素Logistic回归分析显示,年龄≥50岁、脑室出血、昏迷、硬膜下血肿、入院时GCS评分3~5分、骨窗面积≥120 cm2、双侧去骨瓣减压术是重型颅脑损伤去骨瓣减压术后并发脑积水的独立危险因素(P0.05),而早期颅骨缺损修补术却可以减少脑积水的发生率(P0.05)。结论重型颅脑损伤去大骨瓣减压术后并发脑积水的危险因素众多,包括高龄、脑室出血、昏迷、硬膜下血肿、骨窗面积、双侧去骨瓣减压术、未行早期颅骨缺损修补术等,临床应给予相应措施以减少脑积水的发生率。     

重型颅脑损伤患者早期呼吸困难治疗体会

目的探讨重型颅脑损伤早期呼吸困难的诊断及治疗。方法回顾性分析1998年6月至2010年5月收治的261例重型颅脑损伤患者的临床资料。结果伤后早期出现呼吸困难70例,其中呼吸道阻塞48例,中枢性呼吸困难8例,胸部外伤致呼吸困难5例,贫血性呼吸困难2例,上颈段脊髓损伤致呼吸困难1例,多种因素致呼吸困难6例;伤后2周清醒15例,昏迷28例,死亡27例;191例无呼吸困难患者中,伤后2周清醒102例,昏迷25例,死亡64例。48例呼吸道阻塞致呼吸困难患者中,18例行气管切开术,伤后2周清醒3例,昏迷9例,死亡6例;30例未行气管切开术的患者中,伤后2周清醒4例,昏迷14例,死亡12例。结论呼吸道阻塞是导致重型颅脑损伤患者呼吸困难的主要原因,早期救治可有效改善患者预后。     

颅脑损伤患者临床死亡预测:一项基于机器学习的主成分分析-逻辑回归模型

目的探索主成分分析(principal component analysis,PCA)-逻辑回归模型在颅脑损伤患者临床死亡预测建模中的应用,以及影响临床预后的病理生理模式和重要风险因素。方法收集2011—2017年四川省人民医院创伤中心数据库符合研究标准的108例颅脑损伤患者的临床资料,建立PCA-逻辑回归模型,应用ROC评估模型预测效果,验证死亡结局模型的预测效能。结果 PCA-逻辑回归模型分析结果显示,影响患者死亡结局的分别为第1、第8、第11及12主成分。计算出的指标系数对应的临床指标与措施具有较大影响力的因素,分别为开放性颅脑损伤、凝血改变、气管切开、脑干伤、血肿量、感染性并发症、糖皮质激素、肠内营养时间及舒张压。经ROC曲线评估PCA-逻辑回归模型,死亡结局模型具有较高的预测效能(灵敏度:92. 3%,特异度:93. 7%,AUC:0. 983)。结论 PCA-逻辑回归分析方法可以有效地挖掘颅脑损伤患者伤后的临床变量,建立其临床死亡预测模型。严重颅脑损伤后出现的血流灌注不足可能是影响患者生存的重要病理生理模式。     

重型颅脑损伤术中急性脑膨出情况及其影响因素分析

目的探讨重型颅脑损伤术中急性脑膨出的影响因素。方法回顾性分析2012-02—2014-08我院收治的重型颅脑损伤患者140例的临床资料,观察急性脑膨出的发生情况,采用二分类Logistic回归分析探讨重型颅脑损伤术中急性脑膨出的影响因素。结果 140例重型颅脑损伤患者中,术中出现急性脑膨出52例,发生率为37.1%;多因素分析发现,年龄50岁、昏迷≥48h、凝血功能异常是重型颅脑损伤术中急性脑膨出的危险因素(P0.05)。结论重型颅脑损伤术中急性脑膨出发病率较高,且其致病原因较多,应做好术前、术中预防,同时加强年轻、昏迷时间长和凝血功能异常患者的监视,以减少急性脑膨出的发生。     

品管圈对降低颅脑损伤昏迷患者误吸发生率的效果分析

正重型颅脑损伤患者意识障碍时间长,且常存在不同程度的吞咽功能障碍。研究显示,早期鼻饲饮食不仅能保证重型颅脑损伤患者的营养摄入,且能促进重型颅脑损伤昏迷患者的苏醒、有利于改善重型颅脑损伤患者的预后[1-2]。误吸是昏迷患者鼻饲过程中较严重的并发症之一,发生率为10%[~70%3],严重者可导致患者窒息死亡。因此,对重型颅脑损伤昏迷鼻饲患者采取规范、系统的护理干预,降低误吸发     

重型颅脑损伤并发脑梗死的危险因素分析

目的探讨重型颅脑损伤并发脑梗死的危险因素,为临床诊治提供参考。方法回顾性分析2015年1月至2016年12月收治的符合标准的172例重型颅脑损伤的临床资料,采用多因素Logistic回归分析检验危险因素。结果 172例中,44例并发脑梗死,128例无脑梗死。多因素Logistic回归分析表明脑疝、弥漫性脑肿胀、失血性休克是重型颅脑损伤并发脑梗死的独立危险因素。结论对于伴有脑疝、弥漫性脑肿胀、失血性休克的成人重型颅脑损伤,临床应注意防止脑梗死。     

Epilepsy and anomalies of neuronal migration: MRI and clinical aspects

Neuronal migration disorders are the result of disturbed brain development. In such disorders, neurons are abnormally located. In diagnosing these conditions, magnetic resonance imaging is superior to any other imaging technique. This enables us to improve our knowledge of the clinical correlates of neuronal migration. With reference to migrational disorder, a retrospective study of all 303 patients with epileptic seizures referred for magnetic resonance imaging during a 3-year period was performed, 13 patients (aged 12-41, mean age 27) were identified. They represent 4.3% of the entire study group. Of the patients with known epilepsy, 6.7% and of the mentally retarded, 13.7% had migrational disorders. Four patients had schizencephaly as the dominant finding, one was classified as hemimegalencephaly, 2 had isolated heterotopias, and 6 had localized pachy- and/or poly-microgyria. The clinical pictures are complex. Ectopias of grey matter are recognised foci of epilepsy, but from an epileptological and a clinical viewpoint little attention has been given to these disorders. The present study shows that malmigration is not rare in epilepsy patients, especially not in the mentally retarded.     

Hepatic Considerations in the Use of Antiepileptic Drugs

Summary: Virtually all of the major antiepileptic drugs (AEDs) can cause hepatotoxicity, although fatal hepatic reactions are rare. The mechanisms, incidences, and risk profiles for such reactions differ from drug to drug. With carbamazepine and phenytoin, hepatotoxicity may be due to drug hypersensitivity. Although the profiles of patients at risk have not been well-defined for these two antiepileptic drugs, it would appear from reports in the literature that older adolescents and adults are at higher risk than children of developing serious or fatal hepatotoxicity. Once hepatotoxicity develops, mortality rates are 10–38% with phenytoin and 25% for carbamazepine. The risk profile for valproate fatal hepatotoxicity has been more clearly defined. Those at primary risk of fatal hepatic dysfunction are children under the age of 2 years who are receiving multiple anticonvulsants and also have significant medical problems in addition to severe epilepsy. The risk is considerably lower for patients over the age of 2 years on valproate monotherapy. In contrast to the risk profile with other AEDs, adults receiving valproate as monotherapy have the lowest risk of hepatotoxicity. Fatal hepatic dysfunction coincident with valproate may be the result of aberrant drug metabolism. Concomitant use of AEDs that induce microsomal P450 enzymes (e.g., phenytoin and phenobarbital) may enhance the production of a toxic metabolite, and hence the greater risk of hepatotoxicity with polypharmacy.     

Vascular Malformations and Epilepsy: Clinical Considerations and Basic Mechanisms

Summary: Vascular malformations (VMs) are associated with epilepsy. The natural history of the various VMs, clinical presentation, and tendency to provoke epilepsy determine treatment strategies. Investigations have probed the mechanisms of epileptogenesis associated with these lesions. Electrophysiologic changes are associated with epileptogenic cortex adjacent to VMs. Putative pathophysiologic mechanisms of epileptogenesis include neuronal cell loss, glial proliferation and abnormal glial physiology, altered neurotransmitter levels, free radical formation, and aberrant second messenger physiology.     

Classification of methods in transcranial Electrical Stimulation (tES) and evolving strategy from historical approaches to contemporary innovations

Transcranial Electrical Stimulation (tES) encompasses all methods of non-invasive current application to the brain used in research and clinical practice. We present the first comprehensive and technical review, explaining the evolution of tES in both terminology and dosage over the past 100 years of research to present day. Current transcranial Pulsed Current Stimulation (tPCS) approaches such as Cranial Electrotherapy Stimulation (CES) descended from Electrosleep (ES) through Cranial Electro-stimulation Therapy (CET), Transcerebral Electrotherapy (TCET), and NeuroElectric Therapy (NET) while others like Transcutaneous Cranial Electrical Stimulation (TCES) descended from Electroanesthesia (EA) through Limoge, and Interferential Stimulation. Prior to a contemporary resurgence in interest, variations of transcranial Direct Current Stimulation were explored intermittently, including Polarizing current, Galvanic Vestibular Stimulation (GVS), and Transcranial Micropolarization. The development of these approaches alongside Electroconvulsive Therapy (ECT) and pharmacological developments are considered. Both the roots and unique features of contemporary approaches such as transcranial Alternating Current Stimulation (tACS) and transcranial Random Noise Stimulation (tRNS) are discussed. Trends and incremental developments in electrode montage and waveform spanning decades are presented leading to the present day. Commercial devices, seminal conferences, and regulatory decisions are noted. We conclude with six rules on how increasing medical and technological sophistication may now be leveraged for broader success and adoption of tES.     

Carbamazepine Efficacy and Utilization in Children

Summary: Carbamazepine is effective for preventing partial and generalized tonic-clonic seizures in children. Although absence epilepsies are more common in children than adults, an estimated 80% of children with epilepsy have seizure types or epilepsies that are potentially responsive to carbamazepine. The differential diagnosis of ictal staring is an especially important issue in children because absence and atypical absence seizures are more prevalent in children than adults. Age-related pharmacokinetic differences and drug interactions are major considerations in children. On average, children have higher clearance rates of carbamazepine, shorter half-lives, and higher ratios of carbamazepine-10, 11-epoxide to carbamazepine than adults. In addition, children with severe epilepsy are more likely to require multiple-drug therapy, which can lead to complex drug interactions. When carbamazepine is administered along with valproate, drug protein binding interactions can cause intermittent side effects.     

Neonatal Seizures: Problems in Diagnosis and Classification

Summary: The clinical identification of neonatal seizures is critical for the recognition of brain dysfunction; however, diagnosis is often difficult because of the poorly organized and varied nature of these behaviors. Current classification systems are limited in their ability to communicate motor, autonomic, and electroencephalo-graphic features of seizures precisely and to provide a basis for uniform effective diagnosis, therapy, and determination of prognosis. Recent investigations of neonates, utilizing bedside electroencephalographic/polygraphic/ video monitoring techniques, have provided the basis for improved diagnosis and classification of seizures in the newborn. These studies have demonstrated that not all clinical phenomena currently considered to be seizures require electrocortical epileptiform activity for their initiation or elaboration. In addition, the specific clinical character of the phenomena considered to be seizures, the clinical state of the infant, and the character of the EEG indicate the probable pathophysiological mechanisms involved and suggest probable etiologies, prognosis, and therapy. Similarities between animal models that demonstrate reflex physiology and neonates with motor automatisms and tonic posturing suggest that these clinical behaviors may not be epileptic in origin but, rather, primitive movements of progression and posture mediated by brainstem mechanisms. Although not all clinical behaviors currently considered to be neonatal seizures may have similar pathophysiological mechanisms, they are clinically significant because they all indicate brain dysfunction.     

Valproate Monotherapy in the Management of Generalized and Partial Seizures

Summary: For decades, therapeutic tradition has promoted the concept of polypharmacy in the management of epilepsy. In recent years, however, studies have shown that, for most patients, monotherapy can provide comparable or better seizure control than administration of multiple anticonvulsants, while diminishing the potential for adverse reactions, drug interactions, and poor compliance. Valproate is an important monotherapeutic agent that is highly effective in the control of idiopathic primary and secondarily generalized epilepsies, and partial seizures that do not generalize. Comparative studies have found that valproate is at least as effective as phenytoin and carbamazepine in the treatment of generalized and partial seizures. Given the similar efficacy, other factors such as pharmacokinetics and side effects may therefore determine anticonvulsant selection for monotherapy.     

Un nouveau cadre conceptuel de travail pour la psychiatrie

In an attempt to place psychiatric thinking and the training of future psychiatrists more centrally into the context of modern biology, the author outlines the beginnings of a new intellectual framework for psychiatry that derives from current biological thinking about the relationship of mind to brain. The purpose of this framework is twofold. First, it is designed to emphasize that the professional requirements for future psychiatrists will demand a greater knowledge of the structure and functioning of the brain than is currently available in most training programs. Second, it is designed to illustrate that the unique domain which psychiatry occupies within academic medicine, the analysis of the interaction between social and biological determinants of behavior, can best be studied by also having a full understanding of the biological components of behavior.