重度颅脑损伤中枢性低钠血症38例诊治分析

目的探讨重型颅脑损伤病人并发中枢性低钠血症的病因、诊断及治疗。方法回顾性分析重型颅脑损伤后发生中枢性低钠血症病人38例,根据病人的临床表现及实验室指标明确诊断,制定有效的治疗方法。结果10例诊断为抗利尿激素分泌失调综合征(SIADH)的患者经限水治疗,待尿钠降至正常以下再补充钠盐,其中1例在治疗中昏迷程度加深,经补充3%高渗盐水并予呋塞米后缓解,7例病情好转血钠恢复正常,2例死亡。28例诊断为脑性盐耗综合征(CSWS)的患者在积极扩容补液、酌情适量补充3%高渗盐水治疗5～7天后,病情缓解。结论SIADH和CSWS是重型颅脑损伤病人并发中枢性低钠血症的常见病因,两者发病机制及治疗措施不同,对其进行正确诊治能降低颅脑损伤病人的致残率和病死率。     

颅脑创伤后并发低钠血症118例诊疗分析

目的探讨颅脑创伤后并发低钠血症的临床特点及中枢性低钠血症的诊治经验。方法回顾性分析2005年1月至2011年1月我院神经外科收治的118例并发低钠血症的颅脑创伤患者的临床资料,通过临床表现及实验室检查明确诊断,探索有效的治疗方案。结果本组治愈103例(87.3%),死亡15例(12.7%),其中放弃治疗2例,死于各种并发症13例,无低钠血症死亡病例。轻中型、重型及特重型颅脑损伤患者的中重度低钠血症发生率分别为37.0%、54.3%和76.2%(χ2=7.296,p=0.026);三种类型颅脑损伤患者的低钠血症持续时间超过8天的发生率分别为48.1%、50.0%和85.7%(χ2=9.220,p=0.010)。诊断为脑性盐耗综合征(CSWS)22例(18.6%),抗利尿激素不适当分泌综合征(SIADH)7例(5.9%),营养性低钠血症89例(75.5%)。CSWS组和SIADH组中血钠浓度与营养性低钠血症组相比无显著性差异(t=-0.896,p=0.609);血浆ADH及血浆渗透压与营养性低钠血症组相比存在显著性差异(t≥130.31,p0.05)。结论颅脑损伤越重,发生中重度低钠血症可能性越大,低钠血症持续时间越长。CSWS组血浆ADH显著低于营养性低钠血症组,SIADH组血浆ADH显著高于营养性低钠血症组,CSWS组和SIADH组血浆渗透压均低于营养性低钠血症组。CSWS和SIADH是导致颅脑创伤后低钠血症的主要原因,两者在发病机制、临床诊断及治疗方面都存在明显区别。早期诊断,及时明确类型,针对性积极治疗,可有效降低患者致残率和致死率,改善预后。     

中枢性低钠血症的诊断和治疗(附128例报告)

目的探讨中枢性低钠血症的诊断和治疗。方法对我科收治的128例中枢性低钠血症患者的临床资料进行回顾性分析,根据临床症状、实验室检查、中心静脉压确定低钠的程度及类型并进行相应处理。结果128例中枢性低钠血症患者中,脑性盐耗综合征(CSWS)患者92例,占71%(92/128),其中伴随尿崩症(DI)占22%(20/92),抗利尿激素分泌异常综合征(SIADH)患者36例,占29%(36/128),其中伴尿崩症4例,占11%(4/36)。除5例患者因原发性脑干损伤,在伤后6天内死亡,4例自动出院,其余患者的低钠血症得到纠正。结论中枢性低钠血症包括脑性盐耗综合征(CSWS)和抗利尿激素分泌异常综合征(SIADH)两种类型,CSWS患者发病率较SIADH患者高,同时CSWS患者常伴有DI。CSWS和SIADH临床表现相似,而处理原则相反,CSWS的治疗原则是以补盐、补水达到恢复血容量及维持钠的平衡为目的;SIADH的治疗原则是以限制水入量,降低血容量,使血钠恢复正常为目的。     

鞍区肿瘤术后低钠血症的临床研究

目的探讨鞍区肿瘤术后低钠血症的发生规律及其针对不同综合征的治疗方法。方法本组42例鞍区肿瘤患者人院后皆行鞍区肿瘤切除术，对术前及术后的血钠、尿钠、尿比重、中心静脉压等指标进行连续监测，根据诊断标准分辨出抗利尿激素分泌不当综合征（SIADH）及脑性盐耗综合征（CSWS），并根据不同诊断进行相应的治疗，其中CSWS患者分成应用及未应用氢化可的松两组，比较两种不同治疗方法的效果。结果42例患者中11例出现不同程度的低钠血症，其中垂体腺瘤9例，颅咽管瘤2例。符合CSWS的8例，SIADH的3例。SIADH一般发生在手术早期，特别是3d以内，且伴有尿量的减少和尿比重增加；而CSWS出现较晚，一般在3d以后，不伴有尿量的减少和尿比重增加。CSWS的主要处理是钠和水的补充，辅以氢化可的松治疗的效果要好于单纯补充水钠。结论鞍区肿瘤术后CSWS较常见，水钠补充辅以氢化可的松治疗效果较好。     

老年颅脑损伤并发低钠血症病人的临床观察与护理

目的 探讨老年颅脑损伤并发低钠血症病人的观察与护理方法.方法 对71例老年颅脑损伤并发低钠血症病人严密观察意识变化,密切监测尿量及血、尿生化指标等,判定引起低钠血症的原因;早期干预饮食以利纠正低钠血症,并精心护理.结果 诊断为营养性低钠血症59例,经对症处理后血钠基本恢复正常;诊断为抗利尿激素不当分泌综合征(SIADH)3例,脑性盐耗综合征(CSWS)9例,根据不同治疗原则处理后,低钠血症均得到不同程度的纠正.本组存活65例,因原发病或其他合并症过重死亡6例.结论 对老年颅脑损伤并发低钠血症病人进行严密的病情观察与精心护理,可提高治愈率.     

神经外科病人水电解质失衡病因及治疗

目的探讨神经外科病人水电解质失衡的临床特点和处理。方法回顾分析108例我科住院并伴有水电解质紊乱的病人的临床资料,治疗方法和效果。结果46例诊断为中枢性尿崩症（CDU,27例为抗利尿激素分泌不当综合征（SIADH）,20例为脑性盐耗综合征（CSWS）,15例为脑性潴盐综合征。其中101例治愈,另有3例中枢性尿崩症需要长期替代治疗,1例抗利尿激素分泌不当综合征患者死亡,3例CSWS患者需长期高钠饮食以维持正常血钠。结论108例病人中水电解质紊乱原因有：CDI,SIADH,CSWS,脑性潴盐综合征,但无论哪种水电解质紊乱在早期明确诊断后积极治疗,绝大多数患者是可以治愈的。     

中枢性低钠血症临床分析

目的探讨中枢性低钠血症的临床特点。方法回顾性分析28例中枢性低钠血症患者的临床资料。结果 28例患者住院治疗过程中均在原有疾病基础上出现意识状态改变、肢体抽搐及脱水表现;实验室检查:28例患者血钠均<135mmol/L,尿钠均>260 mmol/d;18例诊断为抗利尿激素异常分泌综合征(SIADH),给予限水、利尿治疗;10例诊断为脑性盐耗综合征(CSWS),给予补液、补钠治疗;数日后所有患者血钠、尿钠基本恢复正常,除2例昏迷外,余病情均有好转。结论低血钠、高尿钠及意识状态改变是中枢性低钠血症的临床特征;SIADH以限水治疗为原则;CSWS则以补液、补钠治疗为原则。     

中枢性低钠血症临床分析

目的探讨中枢性低钠血症的临床特点。方法回顾性分析28例中枢性低钠血症患者的临床资料。结果 28例患者住院治疗过程中均在原有疾病基础上出现意识状态改变、肢体抽搐及脱水表现;实验室检查：28例患者血钠均〈135mmol/L,尿钠均〉260 mmol/d;18例诊断为抗利尿激素异常分泌综合征（SIADH）,给予限水、利尿治疗;10例诊断为脑性盐耗综合征（CSWS）,给予补液、补钠治疗;数日后所有患者血钠、尿钠基本恢复正常,除2例昏迷外,余病情均有好转。结论低血钠、高尿钠及意识状态改变是中枢性低钠血症的临床特征;SIADH以限水治疗为原则;CSWS则以补液、补钠治疗为原则。     

鞍区肿瘤术后低钠血症的治疗方法(附51例分析)

目的探讨鞍区肿瘤术后不同性质低钠血症的治疗方法。方法对鞍区肿瘤手术后51例低钠血症按“决补-调整-诊断”的原则进行分级治疗,在治疗过程中鉴别低钠血症的不同类型。结果术后产生一般性低钠血症8例,脑性盐耗综合征（CSWS）39例,抗利尿激素异常分泌综合征（SIADH）4例。本组低钠血症治愈49例。结论在鞍区肿瘤术后的低钠血症中,CSWS占大多数。应根据低钠轻重程度采取不同的补钠方法,必要时采取限水治疗。血浆和白蛋白在低血钠综合征的治疗中起重要作用。     

重度颅脑损伤合并脑性耗盐综合征、抗利尿激素分泌异常综合征的早期临床诊断意义及预后分析

目的探讨重度颅脑损伤合并脑性耗盐综合征、抗利尿激素分泌异常综合征早期诊断的临床意义及预后分析。方法将47例重度颅脑损伤患者按照脑性耗盐(CSWS)、抗利尿激素分泌异常综合征(SIADH)的诊断标准分为CSWS组和SIADH组,比较两组实验室检查并采用Cox风险比例分析预后影响因素。结果 (1)CSWS组在治疗后心钠肽(ANP)、脑钠肽(BNP)降低,与治疗时比较有显著性差异(P<0.05或P<0.01);(2)治疗结束后,CSWS、SIADH患者格拉斯哥预后(GCS)评分3分以下、5分患者明显低于4分组(P<0.05);(4)Cox风险比例模型分析显示,颅底骨折、脑血肿、血渗透压、血钠、皮质醇(HC)、醛固酮(AL)为CSWS、SIADH患者预后危险因素,CSWS与ANP、BNP具有明显的相关性。结论重度颅脑损伤CSWS、SIADH可以通过CVP、ADH以及ANP、BNP变化进行鉴别,同时对预后有重要影响。     

脑卒中造成意识障碍患者的临床特征分析

目的探讨脑卒中出现意识障碍的发生率,发生时间,发病情况,治疗措施以及预后的相关问题。 方法回顾性分析2014年6月至2015年6月隆化县医院神经内外科收治的204例脑卒中所致意识障碍的患者情况。 结果204例出现意识障碍患者中脑出血96例,占47.06%;脑梗死患者108例,占52.94%。在意识障碍与预后的统计中发现,96例出血性卒中意识障碍患者中,长期昏迷30例,死亡12例;108例缺血性卒中意识障碍患者中,长期昏迷12例,死亡4例。 结论意识障碍是脑功能活动障碍最主要的表现,是病情危重的信号,及时正确的治疗可有效降低死亡率及致残率。     

Falls,faints, fits and funny turns

In this practically oriented review, we will outline the clinical approach of patients with falls due to an impairment or loss of consciousness. Following a set of definitions, we describe the salient clinical features of disorders leading to such falls. Among falls caused by true loss of consciousness, we separate the clinical characteristics of syncopal falls (due to reflex syncope, hypovolemia, orthostatic hypotension or cardiac syncope) from falls due to other causes of transient unconsciousness, such as seizures. With respect to falls caused by an apparent loss of consciousness, we discuss the presentation of cataplexy, drop attacks, and psychogenic falls. Particular emphasis will be laid upon crucial features obtained by history taking for distinguishing between the various conditions that cause or mimic a transient loss of consciousness. * This article is based on a lecture presented at the 18^th Meeting of the European Neurological Society” (Ens), Nice (France), 07–11 June 2008.     

Episodic memory and self-awareness in Asperger Syndrome: Analysis of memory narratives

Previous findings from researchers on individuals with Asperger Syndrome (AS) suggest peculiarities of autobiographical memory (AM). They have shown a personal episodic memory deficit in the absence of a personal semantic memory impairment. The primary aim of this study was to explore AM in individuals with AS, and more specifically to investigate the link between episodic memory, self-awareness, and autonoetic consciousness through language analysis. We asked fifteen adults with AS and fifteen age- and IQ-matched controls to recall autobiographical memories from three life periods. Recorded interviews were processed using Alceste software. We found that participants with AS recalled fewer and less-detailed episodic memories than did controls. A content analysis revealed that family-related vocabulary as well as possessive pronouns was significantly less frequent in AS interviews than in those of controls. In conclusion, our results support the hypothesis that a deficiency of episodic memory may be due to poor awareness of the self in social relationships. Reduced use of possessive pronouns may also indicate less self-investment in life experiences, which would in turn impact recall.     

由缺血缺氧性脑病导致的意识障碍患者意识恢复的相关因素分析

目的 探讨由缺血缺氧性脑病导致的意识障碍患者的临床特点及影响意识康复的相关因素。方法 回顾性分析2013年10月至2018年10月在南部战区总医院神经康复一科住院的46例由缺血缺氧性脑病导致慢性意识障碍患者的临床资料,采用二元logistic回归方法对可能影响意识恢复的相关因素进行分析。结果 单因素分析显示植物状态持续时间（P<0.001）、发病至神经康复时间（P=0.001）、（CRS-R）评分（P=0.016）、性别（P=0.034）、阵发性交感神经过度兴奋（P=0.016）、体感诱发电位（P=0.002）和脑电图（P=0.003）与意识恢复相关,差异具有统计学意义（P<0.05）。logistic回归分析显示,植物状态持续时间（OR=1.077,95%CI：1.009~1.148,P=0.025）、阵发性交感神经过度兴奋（OR=15.511,95%CI：1.210~198.833,P=0.035）是意识恢复的独立影响因素。结论 植物状态持续时间过长、阵发性交感神经过度兴奋的出现是影响缺血缺氧性脑病慢性意识障碍患者意识恢复的临床指标。     

Epileptic Seizures and Pseudoseizures from the Viewpoint of the Hierarchy of Consciousness

Summary: Epileptic seizures and pseudoseizures in temporal lobe epilepsies were studied from the viewpoint of the hierarchy of consciousness. Twenty-two patients with temporal lobe epilepsies (TLE) who showed true amnesia or impairment of consciousness developing from the dreamy state, even though their actions and movement continued, were selected among 160 patients with TLE. nine patients with manifested pseudo-seizures, pseudoseizure status, and complex partial seizure status (CPSE) were investigated. Twelve, patients in whom impairment of consciousness followed the dreamy state recognized their own existence and maintained some self-directed consciousness. The other 10 patients with amnesia were aware of their goals. Furthermore, pseudostatus ranged from epileptic seizures during pseudoseizure status to pseudoseizures during status epilepticus (SE). In some cases of CPS, awareness and self-directed consciousness were only partially pseudoseizures, disorders of self-directed consciousness are assumed to influence awareness and arousal.     

Lack of hemispheric dominance for consciousness in acute ischaemic stroke

BACKGROUND: Previous reports have suggested left hemispheric dominance for maintaining consciousness, although there is controversy over this claim. OBJECTIVE: To compare early impairment of level of consciousness between patients with right and left hemispheric stroke. METHODS: Data from 564 patients with ischaemic stroke enrolled in the placebo arm of a trial of a putative neuroprotectant were analysed. All patients had major hemispheric stroke with cortical dysfunction, visual field deficit, and limb weakness, with symptom onset within 12 hours of enrolment. Patients were prospectively evaluated on a predefined scale (1-6; 1 = fully awake, higher scores representing greater impairment) to measure level of consciousness at multiple time points over the initial 24 hours after presentation. The National Institutes of Health (NIH) stroke scale score at presentation and infarct volume at 30 days were determined. RESULTS: Some degree of impairment in level of consciousness was observed in 409 of the 564 patients (73%). Median maximum sedation score was 2 for both right and left hemispheric stroke (p = 0.91). Mean sedation score over 24 hours was 1.5 for both right and left stroke (p = 0.75). There was no difference between level of consciousness scores in right and left stroke at any individual time point during the 24 hour monitoring period. No association between side and impairment in level of consciousness was seen after adjustment for stroke severity and infarct volume. CONCLUSIONS: In contrast to previous reports, there was no evidence for hemispheric dominance for consciousness in the setting of a major hemispheric stroke.     

由缺血缺氧性脑病导致的意识障碍患者意识恢复的相关因素分析

目的探讨由缺血缺氧性脑病导致的意识障碍患者的临床特点及影响意识康复的相关因素。方法回顾性分析2013年10月至2018年10月在南部战区总医院神经康复一科住院的46例由缺血缺氧性脑病导致慢性意识障碍患者的临床资料,采用二元logistic回归方法对可能影响意识恢复的相关因素进行分析。结果单因素分析显示植物状态持续时间(P 0. 001)、发病至神经康复时间(P=0. 001)、(CRS-R)评分(P=0. 016)、性别(P=0. 034)、阵发性交感神经过度兴奋(P=0. 016)、体感诱发电位(P=0. 002)和脑电图(P=0. 003)与意识恢复相关,差异具有统计学意义(P 0. 05)。logistic回归分析显示,植物状态持续时间(OR=1. 077,95%CI:1. 009～1. 148,P=0. 025)、阵发性交感神经过度兴奋(OR=15. 511,95%CI:1. 210～198. 833,P=0. 035)是意识恢复的独立影响因素。结论植物状态持续时间过长、阵发性交感神经过度兴奋的出现是影响缺血缺氧性脑病慢性意识障碍患者意识恢复的临床指标。     

天智颗粒治疗腔隙性梗死所致认知功能障碍的疗效分析

目的观察天智颗粒治疗腔隙性梗死所致认知功能障碍的临床疗效。方法我院神经内科住院的急性腔隙性梗死所致认知功能障碍患者80例,随机分为观察组(40例),对照组(40例)。2组均给予对症治疗,观察组给予口服天智颗粒5g/次,3次/d,共治疗3个月,分别在治疗前后进行蒙特利尔认知评估量表评分(MoCA)。结果治疗组在视空间/执行功能、注意力、抽象能力、延迟回忆及总分方面优于对照组,差异有统计学意义(P0.05)。结论天智颗粒能有效改善腔隙性梗死所致认知功能障碍。     

Varied responses to benzodiazepine treatment in cephalosporin‐related generalized periodic discharges

Although benzodiazepines (BZDs) are used as the first‐line treatment for status epilepticus, previous studies have shown inconsistent responses to BZDs in patients with cephalosporin‐related non‐convulsive status epilepticus. In this study, we investigated nine patients with cephalosporin‐related impaired consciousness and their EEGs all showed generalized periodic discharges (GPDs). One of the patients received repetitive BZD injections without discontinuing cephalosporins, and neither his clinical symptoms nor GPDs on EEG responded to BZDs. Seven of the patients received BZDs after discontinuation of cephalosporins, but only two of them responded immediately to BZD administration. One of the patients did not receive BZDs or antiepileptic drugs, and this patient spontaneously recovered consciousness in one day after cephalosporins were discontinued. The changes in consciousness were reversible in all of the nine patients after cephalosporins were withdrawn. The administration of intravenous BZDs in cases with impairment of consciousness and GPDs secondary to cephalosporins may help in only a small number of patients. Cephalosporin withdrawal is ultimately mandatory in these patients.