双侧侧脑室外引流及腰大池输液泵控制持续引流脑脊液净化治疗全脑室铸型出血疗效观察

目的:研究全脑室系统铸型出血的治疗方法,评价其治疗效果。方法:对8例全脑室铸型出血患者采用双侧侧脑室外引流及脑室内灌注尿激酶和腰大池输液泵控制持续引流脑脊液净化治疗。结果:5例存活,3例死亡。5例6个月后随访结果,2例恢复良好,2例轻瘫,1例重瘫。结论:这种综合疗法操作容易,尤其适合于全脑室铸形出血的患者。     

双侧侧脑室外引流及腰大池输液泵控制持续引流

目的:研究全脑室系统铸型出血的治疗方法,评价其治疗效果.方法:对8 例全脑室铸型出血患者采用双侧侧脑室外引流及脑室内灌注尿激酶和腰大池输液泵控制持续引流脑脊液净化治疗.结果:5例存活,3例死亡.5例6个月后随访结果,2 例恢复良好,2例轻瘫,1例重瘫.结论:这种综合疗法操作容易,尤其适合于全脑室铸形出血的患者.     

经侧脑室后角灌洗与侧脑室前角穿刺引流对重症脑室出血疗效的比较研究

目的　探讨治疗脑室出血的有效治疗方法。方法　采用侧脑室后角穿刺引流、大量生理盐水灌洗治疗脑室出血 3 6例 ,并与同期单纯侧脑室前角穿刺引流治疗脑室出血 3 3例进行比较。结果　观察组 3 6例 ,显效 2 4例 ,有效 6例 ,无效 6例 ,死亡 6例 ,死亡率 16 7% ,有效率 83 .3 % ,对照组 3 3例 ,显效 18例 ,有效 1例 ,无效 6例 ,死亡 8例 ,死亡率 2 4.2 % ,有效率 5 7.6%。两组比较具有显著差异 ,P <0 .0 5。结论　侧脑室后角穿刺、灌洗治疗脑室出血简便易行、有效。     

后颅窝小骨窗血肿清除引流联合脑室外引流治疗全脑室铸型出血

 目的 探讨后颅窝小骨窗开颅血肿清除引流联合双侧脑室外引流治疗全脑室铸型出血的疗效。方法 回顾分析我院神经外科高血压全脑室铸型出血80例临床资料,按照随机数字表法分为:实验组(40例)及对照组(40例)。实验组实施后颅窝小骨窗血肿清除引流联合双侧脑室外引流＋尿激酶纤溶治疗,对照组实施传统的双侧脑室外引流＋尿激酶纤溶治疗,分析比较两组患者的预后。结果 实验组患者四脑室、三脑室、侧脑室内血肿术后大部分清除,血肿清除时间实验组平均为(5±2) d,对照组平均为(9±3) d,差异具有统计学意义(P<0.01)。实验组病死率为5％,对照组为22.5％,差异有统计学意义(P<0.01)。术后随访6个月,两组存活患者日常生活能力量表(ADL)对比差异具有统计学意义(P<0.05)。结论 后颅窝小骨窗血肿清除引流联合双侧脑室外引流治疗全脑室铸形出血降低了病死率、改善了预后,是一种安全、有效的治疗方法。     

颅内压监测下脑室外引流治疗重型丘脑出血临床分析

目的探讨脑室型颅内压检测下脑室外引流对重型丘脑出血的治疗效果。方法回顾性分析自2016年6月至2017年6月收治的51例重型丘脑出血患者临床资料,根据治疗方法分为非手术组(n=22)与手术组(n=29)。非手术组采用常规治疗,手术组在非手术组治疗基础上在全身麻醉下行侧脑室型颅内压检测下额角穿刺引流术,血肿破入侧脑室且侧脑室铸型的行双侧侧脑室穿刺引流术。比较两组患者术后病死率、机械通气情况及日常生活活动能力(ADL)分级情况。结果手术组患者病死率13.8%(4/29),明显低于非手术组的40.9%(9/22),两组间比较,差异有统计学意义(P<0.05)。非手术组给予呼吸机辅助通气7例(31.8%),行气管切开5例(22.7%);手术组给予呼吸机辅助通气8例(27.6%),行气管切开6例(20.7%),两组间比较,差异均无统计学意义(P>0.05)。两组患者ADL分级比较,非手术组患者Ⅰ级0例,Ⅱ级3例(13.6%),Ⅲ级3例(13.6%),Ⅳ级4例(18.3%),Ⅴ级3例(13.6%);手术组患者Ⅰ级2例(6.9%),Ⅱ级5例(17.3%),Ⅲ级9例(31.0%),Ⅳ级7例(24.1%),Ⅴ级2例(6.9%),手术组分级优于非手术组,差异有统计学意义(P<0.05)。结论采用颅内压检测下脑室外引流治疗重型丘脑出血可降低患者病死率,改善患者预后。     

小骨窗开颅并侧脑室引流治疗高血压脑出血并脑室铸型

目的总结高血压脑出血合并脑室铸型的手术治疗经验。方法对75例高血压脑出血合并脑室铸型患者行小骨窗开颅合并单侧或双侧侧脑室额角置管外引流手术。结果术后6个月随访,死亡21例;存活54例,其中ADLⅠ～Ⅱ级8例、Ⅲ级10例、Ⅳ～Ⅴ级36例。结论高血压脑出血合并脑室铸型患者行小骨窗开颅合并侧脑室外引流手术可获得良好治疗效果。     

原发性脑室内出血的外科治疗

原发性脑室内出血(PIVH)临床症状严重,多合并意识障碍,其死亡率及致残率均较高。以往多采用保守疗法。我院自1987年10月以来,采用脑室体外引流治疗PIVH5例,获得满意的效果,报告如下。 例1:男性,64岁。因剧烈头痛伴恶心、呕吐4天入院。患高血压病20余年。查体:BP19.95/13.30kPa。神清,伸舌右偏,项强四横指,左侧肢体肌张力V-级,左膝反射活跃,双侧Babinski氏征( )。头颅CT显示:右尾状核头出血,破入脑室。急诊行双侧侧脑室体外引流术,引流出大量血性脑脊液。引流13天,2次尿激酶脑室内灌注,6000u/次。拔管后3次     

脑室及腰大池双向穿刺救治脑室出血

目的:探讨脑室穿刺尿激酶稀释灌洗结合腰大池持续引流对脑室出血治疗方法的临床疗效。方法:对22例诊断明确的脑出血继发脑室出血病人及8例自发性脑室出血病人行脑室穿刺及腰大池穿刺术;术后每天向脑室内缓慢滴入溶有尿激酶4~10万单位的生理盐水约200 ml,腰大池置管持续引流血脑脊液。定期复查头颅CT,术后3~7 d脑室内出血基本清除后拔出脑室外引流管,10 d左右脑脊液基本清亮后拔出腰大池引流管。结果:本组30例患者引流通畅,23例患者术后2~4周意识恢复清醒,3例患者持续昏迷,4例因术后再出血死亡。结论:该方法治疗脑室出血是一种较为简便,损伤较轻,疗效较好,安全可行的治疗措施。     

双侧侧脑室引流治疗脑室内出血效果观察

目的：观察双侧侧脑室引流治疗脑室内出血效果。方法：选择脑室内出血112例,随机分为观察组和对照组各56例。观察组为双侧侧脑室引流,采用穿刺外引流联合尿激酶脑室内灌注,并同时应用腰大池引流术;对照组非手术治疗后,采用腰大池持续引流并行脑脊液置换。观察比较两组日常生活活动能力恢复情况。结果：观察组日常生活活动能力I级恢复率显著高于对照组（P〈O．05）。结论：双侧侧脑室引流治疗脑室内出血效果优于腰大池持续引流并行脑脊液置换。     

丘脑出血破入脑室并脑积水的治疗（附45例）

目的：丘脑出血破入脑室合并脑积水的治疗方法的选择。方法：回顾性分析近5年来收治的45例丘脑出血破入脑室合并脑积水患者治疗方案的临床资料。结果：45例患者经过保守治疗、血肿穿刺（颅骨钻孔血肿穿刺引流术）、脑室外引流、V-P分流术（侧脑室腹腔分流术）等方法治愈37例,占82.22%,自动出院5例,死亡3例。结论：无论是血肿穿刺、脑室外引流、还是V-P分流,都应尽早清除脑室内外积血,恢复脑脊液的循环通畅,改善脑的微循环,这是降低病残率及死亡率,治疗成功的关键。     

CT导向下经皮穿刺硬化治疗胰腺假囊肿

目的 探讨CT引导下经皮穿刺治疗胰腺假囊肿(PPC)的价值。资料与方法 搜集直径3～12cm的PPC24例,CT引导下经皮穿刺引流并注入硬化剂平阳霉素8mg,并根据囊肿大小分为2组。第1组直径3～6cm 16例,第2组直径7～12cm 8例。随访1～3个月,观察治疗效果。结果 24例囊肿消失19例,有效率为79.2％,其中第1组14例,第2组5例,两组对照,P<0.05。结论 CT引导下经皮穿刺治疗PPC是一种安全、有效的方法,特别是对直径小的PPC其治疗效果优于直径大的PPC。     

三步四位一体治疗高血压脑出血破入脑室44例临床疗效分析

目的探讨"三步四位一体"治疗高血压脑出血破入脑室的疗效。方法对44例高血压脑出血破入脑室的患者,通过术前降压、脱水、hemostasis,行颅骨钻孔脑室外引流,术后辅以尿激酶脑室内反复注射,腰椎穿刺置换脑脊液、内科物理及心理行为治疗,观察治疗效果。结果44例患者中,有效率75.0%(33/44);死亡率25.0%(11/44)。按日常生活能力(ADL)Ⅰ级14例;Ⅱ级12例;Ⅲ级4例;Ⅳ级2例;Ⅴ级1例。结论"三步四位一体"治疗高血压脑出血破入脑室可以降低死亡率,提高生活质量。     

CT-guided transthoracic needle biopsy of pulmonary nodules smaller than 20 mm: results with an automated 20-gauge coaxial cutting needle

AIMS: To evaluate the efficacy and the complication rate of CT-guided percutaneous lung biopsy of pulmonary nodules smaller than 20 mm in diameter using a 20-gauge coaxial automated biopsy device. MATERIAL AND METHODS: A prospective study was undertaken of 200 patients who underwent 202 consecutive biopsies of pulmonary nodules, performed with a single type of automated biopsy device. Sixty-seven biopsies of nodules smaller than 20 mm in diameter were performed in 66 patients (group A). One hundred and thirty-five biopsies of lesions of 20 mm or greater in size were performed in 134 patients (group B). Patient characteristics, lesion and procedure variables, the accuracy and complication rates were compared. RESULTS: In group A, the final diagnosis of the nodules was malignant in 47 and benign in 19 cases (prevalence of malignancy 71. 2%). In group B, there were 111 malignant and 21 benign diagnoses (prevalence of malignancy 82.2%). In group A, the sensitivity and specificity for a diagnosis of malignancy were 89.5 and 100%, respectively (positive predictive value 100%, negative predictive value 76%). A specific diagnosis of benignity was obtained in nine out of 19 (47%) biopsies. The pneumothorax rate was 15% (10 patients) of which two (3%) required drainage. CT signs thought to reflect alveolar haemorrhage were noted in 28 (43%) and haemoptysis occurred in five patients (5.9%). In group B, the sensitivity and specificity for a diagnosis of malignancy were 95.5% and 100%, respectively (positive predictive value 100%, negative predictive value 82.7%). A specific diagnosis of benignity was made in 14 cases (58.3%). Complications included pneumothoraces in 22 cases (16.2%) requiring drainage in one (0.7%). Presumed alveolar haemorrhage was recorded in 19 cases (14.1%) and haemoptysis occurred in seven (5. 2%). There were no significant differences between group A and group B, except for alveolar haemorrhage (P < 0.001). CONCLUSION: The accuracy and complication rate of percutaneous CT-guided biopsy of nodules smaller than 20 mm, performed using an automated 20-gauge coaxial biopsy device, are comparable to those for larger lesions.     

Case 56: cor triatriatum dexter

PURPOSE: To assess the effectiveness of a computed tomographic (CT) image-guided transgluteal approach for percutaneous drainage of deep pelvic abscesses as an alternative to surgical drainage. MATERIALS AND METHODS: The medical records of 140 patients who underwent percutaneous CT-guided transgluteal drainage of 154 deep pelvic abscesses were reviewed to determine the origins, location, and size of the abscesses; volume of initial aspirate; organisms identified in fluid culture; duration of catheter drainage; incidence of catheter-related pain and procedure-related complications; and short- and long-term outcomes. The resultant data were analyzed with a Fisher exact test for difference in the incidence of postprocedural catheter-site pain between transpiriformis and infrapiriformis approaches. RESULTS: The origins of the pelvic abscesses included postoperative fluid collection (n = 115), perforating appendicitis (n = 6), diverticulitis (n = 16), tubo-ovarian inflammation (n = 5), Crohn disease (n = 10), and internal bowel fistula due to irradiation (n = 2). The abscesses were 4-12 cm in diameter. The volume of the aspirate was 5-310 mL. Laboratory cultures of the aspirate grew mixed flora, but the organism most frequently isolated was Escherichia coli. Catheters were removed after a mean of 8 days. In 134 (96%) of 140 patients, there was complete resolution of the abscess following transgluteal drainage, without subsequent surgery. In six of 140 (4%) patients, incomplete resolution necessitated subsequent surgery for postoperative fluid collection (n = 3), diverticulitis (n = 2), or perforating appendicitis (n = 1). Complications of transgluteal drainage were rare and included hemorrhage in three (2%) of the 140 patients. There was no procedure-related mortality. A transpiriformis approach was significantly more likely to be associated with postprocedural pain (P <.001) than was an infrapiriformis approach. CONCLUSION: Percutaneous CT-guided transgluteal drainage is a safe and effective alternative to surgery for deep pelvic abscesses. Major complications are rare.     

Mechanical thrombectomy of acute iliofemoral deep vein thrombosis with use of an Arrow-Trerotola percutaneous thrombectomy device

PURPOSE: To evaluate the immediate and 1-year clinical outcomes of mechanical thrombectomy with use of the Arrow-Trerotola percutaneous thrombectomy device (PTD) with or without low-dose urokinase in the treatment of acute iliofemoral deep vein thrombosis (DVT). MATERIALS AND METHODS: Mechanical thrombectomy with the PTD was performed in 25 patients with acute iliofemoral DVT. Thrombolytic therapy with low-dose urokinase was used in all patients without contraindications (n = 20). Other therapies used in combination included inferior vena cava filter insertion (n = 5), sheath aspiration thrombectomy (n = 25), and angioplasty and stent placement (n = 20). RESULTS: Initial technical and clinical success was achieved in all cases. In the 20 patients who had no contraindications to the use of urokinase, the dosage of urokinase did not exceed 1 million IU (range, 360,000-1,000,000 IU; mean, 640,000 IU). The mean time of urokinase infusion was 16 hours (range, 12-20). In five patients who had a contraindication to the use of urokinase, mechanical thrombectomy with the PTD was successful without the use of urokinase. There were no major complications. Primary patency of the stent-implanted common iliac vein segment was achieved at 1 year in 17 of 20 patients (85%). The overall 1-year clinical success rate was 92% (23 of 25 patients). Valvular insufficiency occurred in two patients (8%). CONCLUSION: The PTD is an effective mechanical thrombectomy device in the treatment of acute iliofemoral DVT with or without adjunctive urokinase thrombolysis.     

Weekly prophylactic urokinase instillation in tunneled central venous access devices

PURPOSE: To determine the safety and efficacy of weekly prophylactic urokinase therapy in tunneled central venous access devices (VADs). MATERIALS AND METHODS: A prospective, randomized study was performed in 105 patients who underwent tunneled VAD placement between March 1997 and April 1998. The patients were randomized to receive either twice-daily heparin flushes (14 heparin flushes per week; group A, n = 52) or twice-daily heparin flushes with once-weekly urokinase (UK) instillation (13 heparin flushes, one UK flush per week; group B, n = 53). Patients were followed up by examination and/or interview at 1, 3, and 6 months for signs and symptoms of delayed catheter-related complications. RESULTS: The total number of indwelling catheter-days was similar between groups (5,450 in group A, 5,276 in group B). The total number of infectious complications and fibrin sheaths formed was greater for group A (n = 11; 21.1%) than group B (n = 3; 5.7%) (P = .02). There were no side effects noted from the prophylactic UK administrations. CONCLUSION: Prophylactic UK is advantageous in preventing delayed catheter-related complications.     

下肢深静脉血栓局部溶栓的疗效与影响因素

目的 探讨下肢深静脉血栓局部溶栓治疗的疗效及影响因素。方法 对60例下肢深静脉血栓形成患者,采用经导管血栓局部先团注量灌注尿激酶250000U,然后以125000－150000U／h持续灌注。结果 全组溶栓治疗时间4－76h,平均38h,尿激酶用量750000U－9750000U,平均5150000U,血管再通率88．3％。病程＜4周的急性或亚急性血栓形成患者46例,溶栓后阻塞段血管再通44例（95．7％）。在14例慢性血栓形成患者中,血管再通9例（64．3％）。对残存狭窄＞30％的23例患者,14例行经皮球囊血管成形术（PTA）治疗,9例行PTA及内支架治疗。溶栓术后继续肝素全身抗凝治疗可增强溶栓疗效。6例溶栓前放置下腔静脉过滤器。本组无严重并发症及肺栓塞发生。结论 经导管血栓局部灌注尿激酶是治疗下肢深静脉血栓的安全有效方法,其疗效与多种因素有关。     

Therapeutic alternatives for subacute peripheral arterial occlusion. Comparison by outcome, length of stay, and hospital charges.

Thrombolytic therapy using streptokinase or urokinase has been shown to be a viable alternative to surgical thrombectomy in patients with subacute peripheral arterial occlusion. Urokinase is associated with higher success and lower complication rates than streptokinase, but the cost of urokinase is at least seven times higher. To address questions of utility and effectiveness in the treatment of subacute peripheral arterial occlusions, the authors designed a retrospective study of patients treated either by surgical thrombectomy (n = 70), thrombolysis with streptokinase (n = 19), or thrombolysis with urokinase (n = 22). Outcome of therapy, length of hospital stay, and total hospital charges in the three groups were examined. Treatment successes in the three groups, defined as complete clearing of the occluded segment with patency maintained for 60 days, were 76% for thrombectomy, 32% for streptokinase, and 64% for urokinase. Total duration of hospitalization was 21.1, 21.3, and 11.5 days (P less than .05), respectively. Mean charges for thrombolytic agents were $690 for streptokinase and $6429 for urokinase. Mean total hospital charges, however, were $25,978 for streptokinase, $22,203 for urokinase, and $25,336 for thrombectomy (P = NS). The higher cost of urokinase, then, accounted for the similar total charges, despite the shortened length of stay. These results suggest that urokinase is cost-effective compared to streptokinase for subacute peripheral arterial occlusion. Compared to thrombectomy, thrombolysis with urokinase has a marginally lower patency rate at 60 days, but a significantly shorter length of hospital stay.     

Serial changes on quantitative myocardial perfusion SPECT in patients undergoing revascularization or conservative therapy

BACKGROUND: Little is known about changes of myocardial perfusion in patients undergoing coronary revascularization or medical therapy. The purpose of this observational study was to assess the long-term effects of revascularization or conservative therapy on serial quantitative myocardial perfusion single photon emission computed tomography (SPECT). METHODS AND RESULTS: The study population consisted of 421 patients who underwent serial rest thallium-201/stress technetium-99m sestamibi dual-isotope myocardial perfusion SPECT with at least a 1-year interval between the 2 studies and who had abnormal quantitative scan results on the first stress SPECT. The mean interval between scans was 32.7 +/- 15.9 months. Patients were divided into 3 groups according to stress defect extent: group 1 had small stress defects (4%-10%, n = 145), group 2 had intermediate stress defects (>10%-20%, n = 144), and group 3 had extensive stress defects (>20%, n = 132) at baseline. Forty patients in group 1, 44 in group 2, and 54 in group 3 underwent coronary revascularization between 2 SPECT studies; the others had conservative therapy. In group 3 patients with revascularization, stress defect extent and reversible defect extent were remarkably reduced (14.5% +/- 13.6% and 13.1% +/- 12.5%, respectively; both P <.0001), with greater improvement in those patients reporting increased use of cardiac medications; resting defect extent was slightly reduced (1.9% +/- 6.4%, P <.05). In group 3 patients with conservative therapy, a small reduction in stress defect extent was noted (2.3% +/- 8.3%, P <.05). In group 2, there were modest, similar reductions in reversible defect extent in both the patients with revascularization (2.7% +/- 7.7%, P <.05) and those with conservative therapy (1.8% +/- 7.3%, P <.05), as well as a small but significant reduction in stress defect extent in those with conservative therapy (2.1% +/- 8.2%, P <.05). In group 1 patients, no significant changes in stress, rest, or reversible defect extent were found with either therapy. CONCLUSIONS: The findings of this study show that improvement in quantitative myocardial perfusion abnormalities over time occurs in some patients with either revascularization or conservative therapy and suggest that, in patients with extensive defects, greater improvement may be seen in those who undergo revascularization.