颅脑损伤致双瞳孔散大病人的手术方法探讨

特重型颅脑损伤并颞叶钩回疝继发脑干损伤，双瞳孔散大GCS3～5分的病人，是当今颅脑损伤治疗的重点和难点。我科从1998年1月至2002年12月收治特重型颅脑损伤并脑疝双瞳孔散大病人32例，现将其手术方法改进及临床救治效果总结如下。     

术前双侧瞳孔散大颅脑损伤病人的救治经验

目的总结术前双侧瞳孔散大颅脑损伤病人的救治经验。方法对84例术前双侧瞳孔散大颅脑损伤病人的临床资料进行回顾性分析。结果84例病人中死亡41例（48．8％），存活43例（51．2％），其中植物生存7例，重残12例，中残11例，良好13例。患者瞳孔散大的时间、血肿的类型及急性脑膨出后行迟发性血肿清除与否均与患者的预后密切相关。结论①缩短脑组织受压时间，尽早清除血肿；②充分减压；③后期综合治疗措施的运用是治疗该病的三个关键措施。     

术前双侧瞳孔散大颅脑损伤病人救治经验

目的总结24例术前伴有双侧瞳孔散大颅脑损伤病人的救治体会。方法对24例术前双侧瞳孔散大颅脑损伤病人的临床资料进行回顾性分析。结果 24例术前伴有双侧瞳孔散大颅脑损伤病人中死亡8例,存活16例,其中良好4例,中残4例,重残3例,植物生存5例。结论尽早气管插管,通过绿色通道尽早手术清除血肿、大骨瓣减压前预减压,术后尽早气管切开呼吸机辅助呼吸,维持内环境稳定,积极防治并发症等方法能提高救治双侧瞳孔散大颅脑损伤病人成功率。     

特重型颅脑损伤早期救治体会

目的总结特重型颅脑损伤致脑疝病人的治疗经验。方法对2000年6月至2007年6月间我院46例特重型颅脑损伤致脑疝病人的临床救治经过进行回顾性分析。结果46例病人中，存活21例。根据GOS评分，良好9例，中残4例，重残5例，植物生存3例，死亡25例。结论畅通气道、抗休克等有效的抢救措施可为手术成功创造条件。对脑挫裂伤合并颅内血肿的双瞳孔散大患者，应严格把握手术时机和手术适应证；对单纯硬膜外血肿所导致的双瞳孔散大者，治疗的关键是争取尽早手术。     

《中国临床神经外科杂志》2003年第8卷文题索引

颅脑损伤142例脑干损伤病人临床分 孙希炎江基尧(1)5768例高频喷射通气与颅内压关系分 周宏秦飚秦为民(5)349TCD对重型颅脑损伤预后判断价值的临床研 谭海斌冯海龙黄光富等(1)8伴颅盖骨折的颅脑损伤的手术指 陈善常会民林永青等(3)228伴双侧瞳孔散大颅脑损伤病人的救治经 万金中袁先厚丁斌等(2)114标准外伤大骨瓣开颅术治疗额颞顶广泛对冲伤疗效分 沈良军江基尧(5)384波兰人造颅骨临床应用及手术方法探 张曙光宋奎勤徐丽(5)3…     

颅脑损伤双侧瞳孔散大病人的救治体会

颅脑损伤双侧瞳孔散大病人的救治体会雷万生，吴明，朱炯明，陈文郁，祝斐，谢联斌我院自１９８９年１０月至１９９４年１０月共收治颅脑损伤双侧瞳孔散大病人５０例，占同期脑疝病人的１５．２％，现报告如下。临床资料与结果男３９例，女１１例。年龄３～７９岁，平均年...     

去骨板减压术治疗的重型颅脑损伤出院时预后的影响因素

目的 探讨重型颅脑损伤去骨瓣减压术后出院时预后的影响因素。方法 回顾性分析2014年5月至2019年5月收治的150例重型颅脑损伤的临床资料,均行去骨板减压术治疗。出院时,根据GOS评分评估预后,4~5分为预后良好,1~3分为预后不良。采用多因素logistic回归分析检验预后影响因素。结果 150例中,出院时预后良好39例,预后不良111例。多因素logistic回归分析结果显示,入院时APACHEⅡ评分低、无瞳孔散大及入院时GCS评分较高及气管切开术是预后良好的独立评估指标（P<0.05）。结论 重型颅脑损伤病人预后影响因素很多,对于入院时APACHEⅡ评分较高、瞳孔散大、入院GCS评分较低的病人,应及早采取措施干预,以改善病人预后;另外,重型颅脑损伤建议尽早进行气管切开术     

重型颅脑损伤伴休克患者的救治

目的 总结重型颅脑损伤并休克患者的救治经验，分析其休克发生的原因及机理。方法 对我院1997年1月～2003年1月收治的68例重型颅脑损伤伴休克患者进行回顾性分析。对病人严密监护，及时进行手术，抗休克及其他综合治疗。结果 本组68例病人31例存活，37例死亡，死亡率为54．41％。结论 早期迅速查明休克原因，正确早期治疗尤为重要。绝不能把重度休克病人的意识障碍简单地归结于颅脑损伤，更不能把血压下降归结于高颅内压危象、继发性脑干损伤，而延误治疗。     

急性中-重型颅脑损伤患者瞳孔曲线变化观测的临床应用

目的通过观察中-重型急性颅脑损伤病人的瞳孔曲线变化规律,总结其在疾病的观察与判断、掌握手术时机、预后评估中的作用。方法回顾分析101例中-重型颅脑损伤病人的临床资料,绘制出动态的瞳孔变化规律和演变情况的曲线图。结果28例在脑疝前期经临床积极手术治疗,干预了脑疝的发生,取得了良好效果;16例脑疝晚期患者虽经及时抢救治疗,但无效而死亡;11例就诊较晚,入院时有一侧或双侧瞳孔散大给予单次大剂量脱水药物后,瞳孔回缩,然后经紧急手术,仍遗留有偏瘫、失语等后遗症;单纯颅内血肿和单侧瞳孔散大病例均恢复良好。结论瞳孔曲线用于颅脑损伤的监护是一种简便易行和便于普及的方法,特别适合基层医院。     

双侧瞳孔散大颅脑损伤患者45例手术治疗体会

颅脑损伤后双侧瞳孔散大的患者致残率和病死率都很高,是颅脑损伤治疗中的难点。我科自2009年1月至2010年11月共收治双侧瞳孔散大的颅脑损伤患者58例,其中45例行手术治疗,本文将其救治经验及疗效进行分析,现报告如下。一、对象与方法1.一般资料:本组男37例,女8例,男女之比为4.61。     

重型颅脑损伤合并寰枢椎半脱位的诊断与治疗

目的探讨重型颅脑损伤合并寰枢椎半脱位的诊断和治疗方法。方法重型颅脑损伤137例患者中合并寰枢椎半脱位者17例。每例患者均行颅脑和寰枢椎CT扫描，必要时加做寰枢椎CT三维重建或MRI检查。在积极治疗颅脑损伤同时，均予以颈同固定制动、颌枕吊带或颅环弓牵引治疗。结果17例重型颅脑损伤合并寰枢椎半脱位患者经治疗后12例神志转清，5例植物生存。2例有脊髓损伤者完全恢复。无1例因寰枢椎半脱位而导致呼吸骤停或猝死，CT复查寰枢椎结构恢复正常。结论对重型颅脑损伤患者在颅脑伤诊治的同时，应常规行寰枢椎CT检查，以明确诊断，早期治疗，能有效预防并发症，改善预后。     

An Unusual Cause of Fixed Dilated Pupils After Cardiac Surgery

Background  The presence of fixed, dilated pupils after cardiac surgery is an ominous sign, typically indicating severe diffuse hypoxic-ischemic brain injury. Rarely, however, this finding can be seen as a result of focal midbrain ischemia. It is important to differentiate between these syndromes, as the latter might be amenable to acute stroke treatments, and because they affect consciousness very differently. Case  A 46-year-old man with diffuse atherosclerosis underwent coronary artery bypass grafting and closure of an incidentally discovered patent foramen ovale. He underwent neurologic evaluation on post-operative day 6 because he was not speaking and appeared to have a new right hemiparesis. Eye movements, pupillary, and lid function were all normal at this time. MRI showed multiple posterior circulation infarcts, involving both cerebral peduncles. On post-operative day 12, he became unresponsive, quadriplegic, and had bilaterally fixed, dilated pupils. CT showed low attenuation in nearly the entirety of both cerebral peduncles. Discussion  Midbrain infarction is rare. Bilateral midbrain infarction is even rarer and typically presents as locked-in syndrome with preservation of pupillary function and at least vertical eye movements. In our review of the literature, we found only three other cases of midbrain infarction associated with bilateral mydriasis. As in our case, these characteristically involved the anteromedial midbrain bilaterally. Conclusions  Fixed, dilated pupils after cardiac surgery can rarely be caused by bilateral anteromedial midbrain infarctions. It is important to differentiate this from the much more common diffuse hypoxic-ischemic injury.     

Long term outcome in patients with severe head injury and bilateral fixed dilated pupils

Patients with severe head injury with bilateral dilated unreactive pupils are considered to have a grave prognosis. Hence proper planning and aggressive management becomes mandatory for achieving good results. We present the outcome of consecutive 166 patients with severe head injury, admitted between January 1996 and December 2000 and analysed retrospectively. All the patients had an initial GCS of 8 or less and post resuscitation bilateral dilated unreactive pupils. Our aim was to analyze the long term outcome in these patients and identify the other significant prognostic factors. Of the 166 patients, 42 (25.30%) had a functional outcome (good recovery in 10.24%, moderate disability in 15.06%), and 124 (74.69%) had a poor outcome (death in 58.43% and severe disability in 16.26% of cases). There were 45 patients with polytrauma and 24 of these patients (53.33%) succumbed to the injuries. Obliteration of the basal cisterns and contusion were the common CT scan findings. Factors adversely affecting the survival included age of the patient, polytrauma with shock, initial GCS of 3 or 4, and compression of the basal cisterns on the initial CT scans. At follow up, most of the patients with a functional outcome showed a significant improvement in their motor function but continued to have neuro-behavioral and cognitive deficits.     

中重型颅脑损伤后进展性出血性损伤危险因素的Logistic回归分析

目的 探讨中重型颅脑损伤后进展性出血性损伤(PHI)的相关危险因素,为其早期诊治和有效预防提供依据.方法 选取湖南省长沙市中医医院神经外科自2007年8月至2009年2月收治的颅脑损伤患者262例(发生PHI 125例,未发生PHI 137例),多因素Logistic回归分析患者的年龄、性别、出血部位、出血类型、瞳孔情况、入院时收缩压、伤后至首次CT时间、GCS评分、受伤机制、首次CT和第2次CT的间隔时间、大剂量应用甘露醇、血小板计数(PLT)、凝血酶原时间(PT)、活化部分凝血酶原时间(APTT)对PHI发生的影响.结果 单因素分析显示年龄、出血类型、伤后至首次CT时间、GCS评分、PLT、PT、APTT对PHI发生的影响具有统计学意义(P＜0.05).多因素Logistic回归分析显示伤后至首次CT时间、GCS评分、PLT是PHI发生的独立危险因素,OR值分别为3.5448、3.0975、2.2361.结论 对于首次CT检查时间较早、GCS评分低、PLT较低的中重型颅脑损伤患者,要警惕PHI的发生,及时行正规的动态CT复查,提高PHI的诊断和救治成功率.     

Delayed emergence from anesthesia associated with absent brainstem reflexes following suboccipital craniotomy

One of the most feared complications after intracranial surgery is development of acute intracranial pathology, which may result in hypoperfusion and brain injury. Thus, early neurological assessment, performed in the operating room immediately after emergence from anesthesia, is a practice that may contribute to timely diagnosis of neurosurgical complications. Failure to awake after general anesthesia precludes conductance of neurological assessment. We report a patient who failed to emerge from anesthesia after suboccipital craniotomy and had absent brain-stem reflexes with fixed and dilated pupils consistent with severe brain injury. Approximately 60 minutes after termination of surgery, the patient suddenly woke up. After the fact, we discovered that the neurosurgeon performed a generous field block with bupivacaine along the neck incision line. We presume that our patient's failure to awaken was caused by paralysis of brain-stem caused by migration of bupivacaine from the site of the injection.     

重型颅脑损伤术中急性脑膨出应对措施

目的探讨重型颅脑损伤手术中急性脑膨出的机理与处理措施。方法回顾性分析58例在颅脑手术过程中发生脑膨出的重型颅脑损伤患者临床资料,影像学资料及应对措施,采用标准大骨瓣减压、过度通气、咬除颅底骨质、阶梯性减压、及时复查颅脑CT等综合措施。结果术后随访三月按GOS评定预后恢复良好19例、轻残11例、重残11例、植物生存5例、死亡12例。迟发性血肿(63.8%),弥漫性脑肿胀(27.6%)及脑梗死(8.6%)是重型颅脑损伤手术中急性脑膨出的主要原因。结论对重型颅脑损伤手术中急性脑膨出的患者要正确判断,区别原因采取相应的措施。     

颅脑损伤后顽固性脑膨出的原因及处理

目的：探讨颅脑损伤后顽固性脑膨出的原因及处理方法。方法：对25例颅脑损伤后顽固性脑膨出患的诊治经过作回顾性分析。结果：25例患，19例治愈，6例死亡。结论：颅脑损伤后顽固性脑膨出的原因是在水颅骨缺损的基础上同时合并有颅内感染或严重脑水肿，脑积水等引起的颅内压增高，有效运用药物和采取措施减轻脑水肿，解除脑积水，预防和控制感染以降低颅内压是解决颅脑损伤后顽固性脑膨出的有效方法。     

Tonic pupils with acute ophthalmoplegic polyneuritis

Two patients with the symmetrical ophthalmoplegic variant of acute idiopathic polyneuritis (Fisher's syndrome) developed bilateral dilated pupils with cholinergic supersensitivity and light-near dissociation (tonic pupils), indicating involvement of the postganglionic parasympathetic neuron within the orbit. Supranuclear eye movement dysfunction also was present, indicated by relative levator sparing in both patients and by preservation of Bell's phenomenon in 1 patient despite paralysis of voluntary upward gaze. The lesions that produce the eye signs of ophthalmoplegic polyneuritis are not necessarily restricted to the cranial nerve trunks. The present cases support a relationship between the ophthalmoplegic variant of the Guillain-Barré syndrome and acute postinfectious encephalomyelitis (brainstem encephalitis) on the one hand, and idiopathic autonomic neuropathies such as the Holmes-Adie syndrome and pandysautonomia on the other.