重型颅脑损伤二次手术原因及效果分析

目的 探讨重型颅脑损伤后二次手术的原因、处理方法及效果。方法回顾分析我院2003．12—2009．12收治的29例重型颅脑损伤行二次手术患者的临床资料。结果根据格拉斯哥预后分级（Glasgow Outcome Scale,COS）评分法,本组29例患者出院时GOS1分（死亡）9例,GOS2分（植物生存）4例,GOS3分（重残）5例,GOS4分（中残）7例,GOS5分（良好）4例。结论二次手术患者多数有多发性损伤、病情危重、致残率及病死率高的原因,掌握手术时机和正确的手术方式,术后严密监测及积极处理复合伤等,可改善患者预后。     

喷他佐辛应用于神经外科开颅手术术后镇痛效果的观察

目的：随机双盲对比观察不同剂量的喷他佐辛用于颅脑术后的镇痛效果及不良反应。方法：择期全麻颅脑手术患者90例（ASAⅠ～Ⅱ）,将其随机分为喷他佐辛90 mg组（Ⅰ组,n=30）、120 mg组（Ⅱ组,n=30）和150 mg组（Ⅲ组,n=30）。术中吸入七氟烷行全身麻醉。根据分组向患者自控镇痛泵（PCA）中注入喷他佐辛,并均以生理盐水稀释到100 ml,设置背景剂量1.5 ml/h,单次剂量0.5 ml,间隔时间15 min。术中缝硬膜时接上电子镇痛泵实行静脉自控镇痛（patient controlled intravenous analgesia,PCIA）。记录术后清醒时、4 h、16～20 h、24 h、40～44 h、48 h、64～68 h、72 h的平均动脉压（MAP）、心率（HR）、呼吸（R）、血氧饱和度（SpO2）、VAS评分、疼痛部位、疼痛性质、PCA累积总量、PCA按压用量、累计按压次数及累计有效按压次数,观察恶心、呕吐、皮肤瘙痒、呼吸抑制、颜面水肿及球结膜水肿的发生情况。结果：Ⅱ、Ⅲ组患者的PCIA按压次数、有效按压次数明显低于Ⅰ组（P〈0.05）。Ⅱ、Ⅲ组患者术后24 h内补救用药的使用例数明显少于Ⅰ组（P〈0.05）。结论：颅脑术后3 d内采用PCA持续泵注喷他佐辛120 mg（平均用量1.79 mg/h）和150 mg（平均用量2.25 mg/h）均能到达满意的术后镇痛效果,而前者的量效比更为合理。     

骨瓣开颅术治疗骑跨横窦的硬膜外血肿24例

目的探讨骨瓣开颅术治疗骑跨横窦硬膜外血肿的手术指征、方法及疗效。方法回顾性分析2003年7月~2011年3月我院神经外科骨瓣开颅术治疗24例骑跨横窦硬膜外血肿患者的临床资料。结果本组24例患者术后3 d复查头部CT示血肿基本清除干净,术区无继发性出血,骨瓣均解剖复位;术后3月进行GOS评分,其中,5分18例,4分4例,3分2例,无死亡及植物生存病例。结论对血肿总量〉30 mL、幕下血肿〉10 mL或血肿量不大但有脑积水、环池受压及四脑室消失的患者应采取积极的手术治疗,应用跨过横窦的骨瓣开颅术方法安全可靠,疗效好。     

Self-drilling anchor screws for dural tenting sutures: technical note

Background

Dural tenting sutures are difficult to place in the case of keyhole surgery and other craniotomies exposing the temporal base and sphenoid ridge because of difficulty in making small drill holes along the bone edge.

Methods

The technical difficulty is solved by using a self-drilling anchor screw. A 4-mm self-drilling titanium screw is fixed loosely to either the cortical surface or the cancellous bone of the bone edge to anchor dural tenting sutures.

Results

The present technique allowed easy placement of dural tenting sutures and efficient epidural hemostasis under the bone edge in more than 100 craniotomies.

Conclusions

The anchor screw technique allows easy placement of dural tenting sutures along the bone edge in the craniotomy with a limited exposure.     

The management of completely resected childhood intracranial ependymoma: the argument for observation only

Introduction  The management of children with completely resected intracranial ependymomas is controversial. We favor deferring adjuvant radiotherapy in low-risk patients, whereas others recommend radiotherapy. Review  This article reviews the available evidence for and against deferring radiotherapy in children with low-risk completely resected childhood ependymomas.     

七氟烷用于癫痫手术麻醉及其对脑电图的影响

目的比较不同呼气末含量七氟烷对开颅手术癫痫及非癫痫患者皮层脑电图的影响。以探讨七氟烷是否适合癫痫手术过程中麻醉的维持,并且确定其最佳麻醉维持剂量。方法24例癫痫患者和15例非癫痫需要开颅手术患者常规麻醉后,切开硬膜后置入皮层电极,分别控制呼气末七氟烷含量0．7,1．0,1．3,1．5MAC,稳定15min后记录皮层脑电图,记录并分析棘波和其它脑波变化。结果癫痫组患者在1．0,1．3MAC七氟烷含量时,棘波数量和导联数与0．7MAC时无明显变化,而1．5MAC棘波频数和导联数明显高于0．7MAC时（P〈0．05）。非癫痫组患者在0．7,1．0,1．3MAC时均无棘波出现,在1．5MAC部分病例出现棘波,且导联弥散。随着七氟烷含量的增加,患者其它脑电波形变化相似,α和β波频率减少,δ波频率增加,而θ波频率变化不明显。结论癫痫患者手术时,如果进行皮层脑电监测,七氟烷含量控制在低于1．3MAC为宜。如果术中脑电监测时,无论是否癫痫患者,七氟烷含量大于1．5MAC均可能影响监测结果。     

The Prediction of Extubation Success of Postoperative Neurosurgical Patients Using Frequency–Tidal Volume Ratios

Background  The process of discontinuing neurological patients from mechanical ventilation is still controversial. The aim of this study was to report the outcome from extubating patients undergoing elective craniotomy and correlate the result with the measured f/V _t ratio. Materials and Methods  In a cohort prospective study, all consecutive patients who required mechanical ventilation for up to 6 h after elective craniotomy were eligible for inclusion in this study. Patients passing daily screening criteria automatically received a spontaneous breathing trial (SBT). Immediately previous to the extubation, the expired minute volume (VE), breathing frequency (f), and tidal volume (V _t) were measured and the breathing frequency-to-tidal volume ratio (f/V _t) was calculated; consciousness level based on Glasgow Coma Scale (GCS) was evaluated at the same time. The extubation was considered a failure when patients needed reintubation within 48 h. Results  Ninety-two patients were extubated and failure occurred in 16%. Despite 15 patients failed extubation just one of them presented the f/V _t score over 105. The best cutoff value for f/V _t observed was 62, but with low specificity (0.53) and negative predictive values (0.29). Area under the ROC curve for the f/V _t was 0.69 ± 0.07 (P = 0.02). Patients who failed the extubation process presented higher incidence of pneumonia (80%), higher need for tracheostomy (33%) and mortality rate of 40%. Conclusion  The f/V _t ratio does not predict extubation failure in patients who have undergone elective craniotomy. Patients who fail extubation present higher incidence of pneumonia, tracheostomy and higher mortality rate.     

重症高血压脑出血治疗方法的探讨

目的探讨对重症高血压性基底节区脑出血更合适的手术方式。方法对出血量50ml以上的高血压性基底节区脑出血患者126例,随机分为3组,分别用穿刺引流术﹙A组﹚、开颅血肿清除术﹙B组﹚及穿刺引流加开颅血肿清除术﹙C组﹚三种手术方式进行治疗,对比3组疗效。结果总有效率A、B、C3组分别为41.46﹪、55.81﹪、85.71﹪,A、B2组之间差异无显著性(P>0.05),C组与A组、C组与B组之间差异均有显著性(P<0.01);病死率A、B、C3组分别为36.59﹪、18.60﹪、9.52﹪,A组与B组、B组与C组、A组与C组之间差异均有显著性﹙P<0.01)。结论重症高血压性基底节区脑出血更适合于用穿刺引流加开颅血肿清除术治疗。     

护理干预对颅脑手术患者并发静脉栓塞的影响

目的 探讨护理干预对颅脑手术并发静脉栓塞患者的临床疗效.方法 选择2008年1月至2009年12月收治的颅脑手术并发静脉栓塞患者42例,随机将患者分为干预组和对照组各21例.2组患者术后均给予常规药物及护理,而干预组则在此基础上给予系统性护理干预,对2组患者的临床疗效及格拉斯哥昏迷评分(GCS)等指标进行对比分析.结果 与对照组相比,干预组患者的痊愈率和总有效率均明显提高,而无效率则明显降低,且GCS评分明显升高.结论 护理干预对颅脑手术并发静脉栓塞患者的功能恢复及预后具有明显的协同作用,是颅脑手术并发静脉栓塞患者不可或缺的辅助疗法之一.     

The role of prophylactic antiepileptic drugs for seizure prophylaxis in meningioma surgery: A systematic review

Meningiomas are the commonest type of primary brain tumours. Whilst most patients are seizure-free prior to surgery, antiepileptic drugs are frequently administered to reduce the risk of developing post-operative seizures. However, evidence to support their efficacy in providing this outcome is sparse. To this end, we performed a systematic review to assess the impact of prophylactic antiepileptic drugs on post-operative epilepsy rates in seizure-naïve patients undergoing craniotomy for resection of meningiomas. The literature search was performed using PubMed for studies published between January 1990 and November 2016. The total number of patients in each study was extracted and divided into cohorts according to administration of prophylactic antiepileptic drugs. Clinical characteristics, study type and post-operative epilepsy rates were recorded. A total of 11 studies involving 1143 patients met the selection criteria. There was no statistically significant difference in the number of patients who developed post-operative epilepsy in the cohort that received prophylactic antiepileptic drugs (20 of 766; 2.6%) and the cohort that did not (10 of 377; 2.7%) (Chi-square test; P = 0.96). A detailed meta-analysis could not be performed due to the insufficiency in data reported. Based on the results of this systematic review, the routine use of antiepileptic drugs for seizure prophylaxis in seizure-naïve patients undergoing meningioma resection could not be substantiated. However, limitations of a systematic review should be considered on interpretation. High quality prospective randomised controlled trials are required to definitively answer this important clinical question.