中国颅脑创伤诊治的未来

我国颅脑创伤（TBI）的发生率和致死、致残率逐年攀升,已成为一个重大的公共卫生问题。近年来,我国在TBI诊治方面取得长足进步,如建立更多的神经外科重症监护病房、增加脑监测设备的可用性、脑成像技术的发展以及建立以证据为基础的指南,但仍有许多地方需要进一步改进。本文主要围绕我国TBI临床诊治未来发展的具体方向展开述评。     

创伤性进展性后颅窝双侧硬脑膜外血肿一例报道

文章报道1例创伤性进展性后颅窝双侧硬脑膜外血肿病例.伤后1 h首次CT扫描示枕骨线形骨折伴薄层硬脑膜外血肿;于伤后14 h经再次CT检查确诊为后颅窝双侧跨幕上下进展性硬脑膜外血肿并引起梗阻性脑积水.病程中患者仅表现出头痛而无明显异常体征.急诊枕部旁正中切口入路手术清除血肿后,脑积水消失,患者恢复良好.文章结合文献,对该病例的相关问题进行探讨.     

腰穿放液试验在正常压力脑积水病人术前评估中的应用及意义

目的评价腰穿放液试验在正常压力脑积水病人术前评估中的应用价值。方法对2008年6月至2011年3月期间入选的60例正常压力脑积水病人进行前瞻性研究。病人先行腰穿放液试验,5天后行脑室-腹腔分流术。腰穿放液前、放液后24h及分流术后1周分别对病人"三联征"进行定量评估,并通过筛检试验统计方法分析腰穿放液试验预测正常压力脑积水分流手术的有效性。结果腰穿放液试验阳性36例,行分流手术后临床症状改善35例,1例未改善;腰穿放液试验阴性24例,分流术后改善8例,16例未改善。提示分流手术总有效率71.7%;腰穿放液试验对正常压力脑积水分流手术的灵敏度为81.4%,特异度94.1%,阳性预测率97.2%,阴性预测率66.7%。结论正常压力脑积水术前腰穿放液试验阳性者分流手术可望获得良好疗效。     

脑室-腹腔分流术中分流管腹腔端无需特殊处理

Objective To investigate the dynamic changes of peritoneal catheter of ventriculoperitoneal shunt (V- P shunt) prospectively, and to determine simple, effective disposal method of peritoneal catheter. Method From Jan 2007 to Oct 2010, consecutive 40 patients with hydrocephalus were treated by V - P shunt. All patients were operated through puncture of frontal horn of lateral ventricle. And 4 cm straight abdominal incision under xiphoid was made and after shunt system had been connected well, the abdominal catheter was put into peritoneal cavity through 3 mm incision of peritoneum. Head CT scans were regularly made at the 1st, 3rd and 7th day after shunt to determine the intracranial state for all patients, and abdominal X - ray plain films were also obtained to confirm the position of peritoneal catheters at the same time. All the clinical data and results of follow - up were reviewed.Results Dynamic head CT scans showed good results of V - P shunt after surgery in all cases. And abdominal X-ray plain films at the 1st day after operation showed peritoneal catheter was located in pelvic cavity in 31 cases and lower abdominal cavity in 5 cases. At the 3rd day and 7th day after operation, the numbers of peritoneal catheter located in pelvic cavity were 35 and 39 respectively. Among these patients, a large acute subdural hematoma occurred on the same side of V - P shunt at the 5th day after operation. This patient was discharged with GCS 6 as his family refused decompressive craniectomy. The remaining 39 patients were discharged with average hospital - stay time of 11 ± 4 days after shunt. On follow - up, 1patient developed peritoneal infection one year later. After the infection was controlled, he was changed to ventriculo -atrial (V -A) shunt. There was no shunt -related complication occurred on the others during 1 -24 month follow - up periods. Conclusion V - P shunt through small straight incision under xiphoid could reduce surgical injury, shorten the operating time and obtain good Results. Dynamic observation of the location of peritoneal catheter by abdominal X - ray plain film is a simple and practical method. The peritoneal catheter will located in pelvic cavity at the 1st day after shunt in vast majority. There is no special management for peritoneal catheter in V - P shunt in required.     

腰骶部长节段神经鞘瘤一例报道

文章报道1例较少见的腰骶部长节段神经鞘瘤.患者以下肢无力伴尿潴留为主要临床表现,术前腰椎MRI表现为不连续的强化,诊断为腰骶部髓外、硬脊膜内多发性神经鞘瘤.肿瘤经显微手术完整切除,肿瘤长约15 cm.术后患者恢复良好.结合文献,对该病例的相关问题进行探讨.     

皮层电极监测在颅骨缺损合并外伤性癫痫术中的运用

目的 探讨颅骨缺损合并外伤性癫痫的手术方法.方法 回顾性分析11例颅骨缺损合并外伤性癫痫患者的临床资料,术前行神经电生理学和神经影像学检查;术中运用皮层电极监测定位异常放电灶,准确切除癫痫灶,并一期完成颅骨修补术;术后继续使用抗癫痫药物治疗.结果 手术治疗11例合并外伤性癫痫的颅骨缺损患者,颅骨缺损修补术效果满意,经过18个月的随访,术后癫痫治疗有效率达90.9%(10/11).结论 对于颅骨缺损合并外伤性癫痫,在行颅骨修补的同时,运用皮层电极监测定位致癫痫病灶,并准确切除病灶,疗效肯定,可以作为治疗颅骨缺损合并外伤性癫痫患者的常规术式.     

TNF-α反义寡核苷酸对犬颅脑爆炸伤后颅内压的影响

为探讨TNF-α反义寡核苷酸对颅脑爆炸伤后致伤犬颅内压的影响.将18只犬随机分为人工脑脊液组(ACSF)、正义链组和反义链组,利用已建成的颅脑爆炸伤模型装置致伤,伤前经小脑-延髓池分别注入人工脑脊液、TNF-α正义寡核苷酸和TNF-α反义寡核苷酸,比较3组动物脑组织含水量和颅内压的变化.与人工脑脊液组和正义链组相比,伤前经小脑-延髓池脑内局部应用TNF-α反义寡核苷酸组,颅脑爆炸伤后脑组织内含水量明显减少(P<0.05),颅内压明显降低(P<0.05).提示TNF-α反义寡核苷酸可以减轻颅脑爆炸伤后脑水肿,降低颅内压.     

Outcome of 2 284 cases with acute traumatic brain injury

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颅脑创伤后大鼠海马Nav 1.1和Nav 1.2的异常表达

目的 研究大鼠颅脑创伤后Nav 1.1和Nav 1.2的mRNA和蛋白在海马中的表达情况.方法 对成年SD大鼠实施腩液压伤后分别在伤后2,12,24和72 h处死,取伤侧海马行荧光定量PCR和Western blot以及免疫荧光染色等方法检测Nav 1.1和Nav 1.2的mRNA和蛋白表达情况.结果 大鼠脑液压伤后Nav 1.1和Nav 1.2的mRNA表达显著下调(P<0.01),伤后2 h即下调至最低水平,Nav 1.1的蛋白表达在颅脑创伤后显著下调(P<0.01),但伤后72 h时恢复至接近对照组的水平.而颅脑创伤后Nav 1.2的蛋白表达水平与对照组相比,差异无统计学意义(P>0.05).结论 颅脑创伤导致了大鼠海马钠通道α亚单位mRNA和蛋白表达的显著改变,这可能是颅脑创伤后神经元细胞膜上的钠通道功能异常及其诱发的兴奋性毒性作用的分子学基础之一.     

低温对实验型颅脑损伤大鼠免疫功能的影响

目的：研究不同低温状态下实验颅脑损伤大鼠免疫功能的动态变化,方法;采用^3H-TdR掺入法,LDH释放法及流式细胞术分别检测实验型液压颅脑损伤大鼠不同低温处后脾脏T,B淋巴细胞转化功能,NK细胞活性及外周血T细胞亚群的动态变化,结果,与颅脑损伤常温（37℃）组相比,损伤27℃组伤后1天B细胞转化率,NK细胞活性,伤后3天T细胞转化率降低,T细胞亚群CD3细胞伤后1天降低,损伤33℃组伤后1天B细胞转化率降低,伤后3天CD4／CD8升高,结论：（1）27℃低温对实验型颅脑伤大鼠免疫功能有抑制作用,（2）33℃低温不影响实验型颅服损伤大鼠细胞免疫,但对介导体液免疫的B细胞功能有一定的可逆性损害作用。