Factors affecting outcome of intracerebral hemorrhage in patients undergoing chronic hemodialysis

To date, despite a markedly high incidence of intracerebral hemorrhage (ICH) in patients with end-stage renal disease, only few studies have focused on factors that affect patient's prognosis. To elucidate these factors, we retrospectively investigated 22 consecutive patients who had chronic renal failure, were maintained by hemodialysis (HD), had suffered from ICH, and were hospitalized and treated in our institute from 2006 to 2008. Hematoma volume, blood pressure on admission, blood pressure 3 days after ICH onset, and neurological deterioration significantly affected patient mortality. Progression of neurological symptoms during HD was observed often in patients with hematoma of more than 60 mL or in patients with pontine hemorrhages. Age, gender, duration of HD, anti-platelet or anticoagulant therapies, or maximal dose of nicardipine did not affect patient's prognosis. Based on this study we conclude that controlling blood pressure on admission and within 3 days after onset of ICH may be the most important factor that would improve patient's prognosis. Further, special care might be required for patients with large hematomas (more than 60 mL) or those with brainstem hemorrhages, because progression of neurological symptoms occurs often in such patients.     

Prediction of evolution toward brain death upon admission to ICU in comatose patients with spontaneous intracerebral hemorrhage using simple signs

The aim of the study was to identify the predictors of brain death (BD) upon admission to the intensive care unit (ICU) of comatose patients with spontaneous intracerebral hemorrhage (ICH). Patients admitted in our ICU from 2002 to 2010 for spontaneous ICH and placed under mechanical ventilation were retrospectively analyzed. Of the 72 patients, 49% evolved to BD, 39% died after withdrawal of life support, and 12% were discharged alive. The most discriminating characteristics to predict BD were included in two models; Model 1 contained ≥3 abolished brainstem responses [adjusted odds ratios (OR) = 8.4 (2.4, 29.1)] and the swirl sign on the baseline CT‐scan [adjusted OR = 5.0 (1.6, 15.9)] and Model 2 addressed the abolition of corneal reflexes [unilateral/bilateral: adjusted OR = 4.2 (0.9, 20.1)/8.8 (2.4, 32.3)] and the swirl sign on the baseline CT‐scan [adjusted OR = 6.2 (1.9, 20.0)]. Two scores predicting BD were created (sensitivity: 0.89 and 0.88, specificity: 0.68 and 0.65). Risk of evolution toward BD was classified as low (corneal reflexes present and no swirl sign), high (≥1 corneal reflexes abolished and swirl sign), and intermediate. Simple signs at ICU admission can predict BD in comatose patients with ICH and could increase the potential for organ donation.     

Supratentorial pressures: Part II: Intracerebral pulse waves

Intracerebral pulse waves were recorded in cat and monkey while intracranial pressure (ICP) manipulations were performed. The intracerebral pulse waves appeared comparable to cerebrospinal fluid (CSF) pulsations. The wave forms were divided into multiple smaller waves, designated P₁ to P₄. The P₁ component was primarily of arterial origin and was accentuated by increasing ICP unrelated to increased venous pressure, most commonly from a mass lesion. Bilateral carotid occlusion resulted in decreased amplitude of P₇. Venous hypertension from jugular venous or sagittal sinus occlusion, on the other hand, accentuated waves P₂ and P₃ more than P₇. This is consistent with a Starling resistor model of the cerebral venous system in which mass lesions may compress low-pressure veins and accentuate the arterial pressure-dependent P₁ wave, whereas venous hypertension causes increased prominence of the later P₂ and P₃ waves.     

超早期强化降压对脑出血血肿扩大、血浆基质金属蛋白酶-9及神经功能的影响

目的  探讨超早期强化降压治疗对基底节区脑出血血肿扩大、血浆基质金属蛋白酶（MMP）-9、脑水肿和神经功能的影响。方法  前瞻性纳入发病4 h内的脑出血患者134例,随机分为两组,强化降压组（67例）完成3次颅脑CT检查的患者为60例,普通降压组（67例）完成3次颅脑CT检查的患者为62例。分别在开始治疗后的1 h内采用静脉点滴降压药物使收缩压控制在130～140 mmHg、160～180 mmHg,并维持24 h。于治疗前、后进行美国国立卫生院神经功能缺损（NIHSS）评分、改良Rankin量表（mRS）评分、血浆MMP-9水平测定、颅脑CT检查,计算血肿量、血肿扩大例数和水肿量,进行组间比较。结果  治疗后14 d强化降压组NIHSS评分明显低于普通降压组（P <0.05）,治疗后90 d强化降压组评分为中重度残疾或死亡患者的比例明显低于普通降压组（P <0.05）。强化降压组治疗后24 h血肿量、血肿扩大患者比例明显小于普通降压组（均P <0.05）。强化降压组治疗后5 d水肿量、血浆MMP-9水平明显低于普通降压组（均P <0.05）。结论  基底节区脑出血患者超早期强化降压治疗能够减少血肿扩大、降低血浆MMP-9水平、减轻脑水肿,进而改善患者的神经功能。

     

乌拉地尔与硝普钠对高血压脑出血降压效果的对比研究

目的 比较乌拉地尔及硝普钠对高血压脑出血患者急性期降压作用及预后的影响。方法 将高血压脑出血患者根据用药情况分为乌拉地尔组及硝普钠组。硝普钠组患者予以注射用硝普钠治疗,治疗初始剂量为0.5～1.0 μg/（kg·min）;乌拉地尔组患者予以乌拉地尔注射液治疗。比较两组用药后血压变化、心率变化、血肿大小变化及神经功能评分的差异。结果 两组患者在分别用药10、20、30、60、120 min后,使用乌拉地尔组患者平均收缩压及平均舒张压高于使用硝普钠组患者,组间差异具有统计学意义（P<0.05）,在分别用药240 min后,两组患者的平均收缩压及平均舒张压差异无统计学意义。在分别用药10、20、30、60、120、240 min后,乌拉地尔组患者的平均心率低于硝普钠组患者的平均心率,组间差异具有统计学意义（P<0.05）。在分别用药24、72 h后,两组患者的血肿大小差异无统计学意义。1个月后,两组患者的神经功能评分具有显著差异（P<0.05）。结论 乌拉地尔能有效控制高血压脑出血患者急性期血压,且其神经功能保护作用较硝普钠显著。     

Challenges in management of a giant left ventricular pseudoaneurysm complicated by intracerebral hemorrhage

Urgent surgery is generally indicated for left ventricular (LV) pseudoaneurysms, especially for large or expanding lesions. However, management of pseudoaneurysms complicated by acute intracerebral hemorrhage is controversial. This case of a giant LV pseudoaneurysm followed a successful postoperative course after 4 weeks of conservative management followed by surgical repair and may suggest a safe and efficient management.     

浅谈高血压性脑出血急性期患者的护理

目的探讨高血压性脑出血急性期患者的临床护理。方法选择2012年1月至2013年8月之间我院收治的105例高血压性脑出血患者,在急性期对其进行护理,包括密切观察病情变化、引流管护理、预防并发症,另外还要进行出院指导。结果 105例高血压性脑出血患者中治愈45例,肌力处于4⁵级;好转51例,肌力处于15级;好转51例,肌力处于1³级;自动出院5例;死亡4例。结论加强对高血压性脑出血急性期患者的护理,可以降低病死率,获得较好的临床效果,提高患者生活质量。     

不同麻醉方式小骨窗开颅治疗高血压脑出血的临床分析

目的 比较不同麻醉方式下施行小骨窗开颅显微手术治疗高血压脑出血的疗效,探讨其临床应用价值.方法 回顾性分析2010-01-2013-01我科手术治疗的高血压脑出血并成功随访的患者296例,其中171例行局麻,125例行全麻.对比分析两组术后并发症发生率、近期GOS评分、半年后ADL分级等指标.结果 局麻病例术后肺部感染率、应激性溃疡发生率、病死率低于全麻组,再次出血、脑积水发生率以及近期、远期病残率无明显差异.结论 局麻下小骨窗手术治疗高血压脑出血,具有时间短、相对并发症少、节省住院费用等优点,值得临床推广.     

立体定向软通道微创血肿穿刺外引流术治疗高血压脑出血的临床研究

目的探讨立体定向软通道微创血肿穿刺外引流术治疗高血压脑出血的临床疗效。方法 56例高血压脑出血患者被随机分为对照组(开颅血肿清除术)和观察组(微创血肿穿刺外引流术)各28例,根据神经功能缺损程度评分标准,对两组神经功能缺损程度评分、临床疗效、并发症、生存率,进行观察和比较。结果与对照组相比,观察组术后3个月和术后9个月神经功能缺损评分明显降低,治疗总有效率、生存率均显著升高,并发症发生率显著降低,P<0.05。结论对于高血压脑出血患者,立体定向软通道微创血肿穿刺外引流术治疗能够明显提高临床疗效,降低并发症的发生率,有利于提高患者预后的生活质量。