重型颅脑损伤持续颅内压及脑灌注压监护与预后的关系

对５０例重型颅脑损伤患者进行颅内压（ＩＣＰ）与脑灌注压（ＣＰＰ）连续监测，并根据监测结果及时采取相应的治疗护理措施（监护组）；与５０例未行连续监测，按常规临床观察进行治疗护理的患者（对照组）进行预后比较。结果表明：ＩＣＰ〈２．００ｋＰａ，ＣＰＰ〈９．３３ｋＰａ的患者预后良好；ＩＣＰ〉８．００ｋＰａ，ＣＰＰ〈６．６７ｋＰａ者预后较差。提示：对重型脑损伤患者施行连续ＩＣＰ、ＣＰＰ监护、有利于了解病情变     

持续颅内压监护和脑灌注压监护在重型颅脑损伤中的临床应用

目的探讨持续颅内压（intracranial pressure,ICP）监护和脑灌注压（cerebral perfusionpressure,CPP）监护在重型颅脑损伤患者诊疗中的临床作用。方法临床上采用脑实质内ICP探头置入术,对60例重型颅脑损伤患者进行了持续ICP监护和CPP监护,根据ICP和CPP的变化给予相应治疗。结果根据GOS评分,随访发现预后良好24例（40%）;中残8例（13.3%）,重残4例（6.7%）,植物状态2例（3.3%）,死亡22例（36.7%）。结论持续ICP监护和CPP监护有利于颅脑损伤患者的病情观察,指导脱水药的使用,提高疗效,减少并发症。     

重型颅脑损伤脑监护进展

重型颅脑损伤是目前诊治的重点和难点，而严密观察病情．加强监护，使患者得到良好的治疗和护理．是提高治愈率和降低死亡率的重要措施，近年来有关脑的监测技术的小断发展，可借助仪器对脑代谢等进行精确监测．使得对以控制颅内压（ICP）和／或保持脑灌注压（CPP）为目的的处理更有依据，     

异丙酚和普鲁卡因对颅内压及脑灌注压的影响

目的观察异丙酚、普鲁卡因对颅内压(ICP)和脑灌注压(CPP)的影响。方法25例脑肿瘤病人随机分成异丙酚组(D组)和普鲁卡因组(P组)。局麻下钻孔于颅骨及脑膜间安置SP-2000型颅内压监护仪，连续监测ICP，同时用Colin508连续监测MAP、HR及PETCO2。静注异丙酚2mg／kg后，输注异丙酚100～150pg·kg     

重型颅脑损伤的颅内压监护

我科自1999年2月——2000年7月对18例重型颅脑损伤患行颅内压连续监护，现将监护体会报告如下：     

重型颅脑损伤患者颅内压监护的临床意义

目的探讨重型颅脑损伤患者颅内压(ICP)监护的作用。方法选择40例重型颅脑损伤患者随机分为两组,监护组患者入院或开颅手术后行ICP监护;对照组患者根据常规神经外科治疗,未行ICP监护。结果监护组脱水剂应用时间和剂量均低于对照组。监护组预后优于对照组(P<0.01)。结论对重型颅脑损伤患者行连续性ICP监护,可及时发现颅内继发性病变,有利于指导和及时调整治疗措施,降低并发症,改善预后。     

重型颅脑损伤术后颅内压监护的处理

颅内压增高是引起脑灌注压降低，脑血流量减少的主要原因．并因此导致中枢神经系统功能障碍甚至死亡。本院收集了2007年1月至2008年12月的50例行开颅手术的重型颅脑损伤患者，进行了持续的硬膜下颅内压（ICP）监护，并与其间另外的50例未进行颅内压监护的患者作了比较．现将有关体会报告如下。     

综述：颅脑损伤中脑灌注压的意义

众所周知，创伤性脑损伤后，低脑血流灌注（和脑灌注压（CPP）]是预后不良的重要原因。但尚不明确的是：改变脑血流抑或CPP，是否可以改善临床预后。最初的研究表明，提高CPP是有益的，脑创伤研究协会（Braill Trauma Foundation）将目标值定为70rnrnHg，并编入1996年版指南中。然而，随后的实践显示，达到此目标值并未带来显著的益处，而并发症的发生率却有所上升，因此将此目标值降低为60mmHg。近来，有证据表明，创伤性脑损伤后，脑的自身调节功能被破坏，这样就有学者提出，应对CPP进行个体化的调整。另外，随着先进的神经监测技术的出现，临床医生能够更加准确地观察血流动力学调节措施对脑代谢的影响。但现在仍然缺乏有力的证据支持调控CPP可改善预后这一观点。迄今为止，关于最佳脑灌注压的争论仍在继续。     

体位变化对脑室引流术患者颅内压和平均动脉压及脑灌注压的影响

目的 探讨脑室引流患者的体位变化对平均动脉压、颅内压和脑灌注压的影响.方法 对60例接受过脑室穿刺术并留置脑室引流管患者,监测其抬高床头0°、15°、30°、45°时的颅内压(ICP)和平均动脉压(MAP),再计算出脑灌注压(CPP),比较不同体位状态下患者的MAP、ICP和CPP.结果 ICP随着床头的抬高而显著降低...     

脑灌注压对创伤性脑损伤后急性脑缺血的影响

目的 观察不同脑灌注压(CPP)对创伤性脑损伤后急性脑缺血的影响.方法 实验家兔60只,随机分为正常对照组(无损伤组)、高CPP组(90～110)mm Hg、中CPP组(70～80)mm Hg、低CPP组(50～60)mm Hg、极低CPP组(35～45)mm Hg.采用Feeney's自由落体撞击法建立急性局灶性脑挫裂伤模型,伤后80 min静脉给予升压和降压药物调控血压使CPP达到设计要求,同步进行脑血流、CPP测定,并进行图像分析,且观察不同CPP下颅脑损伤后急性脑缺血动物脑含水量及神经组织超微结构改变.结果 对照组局部脑血流量(rCBF)为156.18±6.22;高CPP组实验组rCBF为140.03±17.32,中CPP组rCBF为100.46±21.37,低CPP组rCBF为86.46±10.30,极低CPP组rCBF为60.36±8.32.对照组脑含水量为(78.21±0.26)%;高CPP组实验组脑含水量为(80.15±0.52)%,中CPP组脑含水量为(80.27±0.36)%,低CPP组脑含水量为(81.18±0.62)%,极低CPP组脑含水量为(81.34±0.83)%.实验组脑组织含水量高于对照组(P<0.01);实验组rCBF较对照组明显降低,差异有统计学意义(P<0.01);高CPP组rCBF明显高于低CPP组及极低CPP组,差异有统计学意义(P<0.01);中CPP组rCBF虽低于对照组及高CPP组,而高于低CPP组及极低CPP组,但组间比较筹异无统计学意义(P>0.05).低CPP组及极低CPP组脑含水量、超微结构较对照组差异有统计学意义(P<0.05).结论 在缺血急性期及时有效地改善脑循环、恢复脑供血是阻止脑缺血发展成为脑组织不可逆损伤的重要环节.     

Outcome prediction in severe traumatic brain injury with transcranial Doppler ultrasonography

ＴＮｅｕｒｏｓｕｒｇｉｃａｌＤｅｐａｒｔｍｅｎｔ,ＳｉｃｈｕａｎＰｒｏｖｉｎｃｉａｌＰｅｏｐｌｅ ｓＨｏｓｐｉｔａｌ 6 10 0 72 ,Ｃｈｉｎａ (ＴａｎＨＢ ,ＦｅｎｇＨＬ ,ＨｕａｎｇＧＦａｎｄＬｉａｏＸＬ)ＮｅｕｒｏｓｕｒｇｉｃａｌＤｅｐａｒｔｍｅｎｔ,ＦｉｒｓｔＵｎｉｖｅｒｓｉｔｙＨｏｓｐｉｔａｌ,ＷｅｓｔＣｈｉｎａＵｎｉｖｅｒｓｉｔｙｏｆＭｅｄｉｃａｌＳｃｉｅｎｃｅｓ 6 10 0 41,Ｃｈｉｎａ (ＧａｏＬＤ)ｒａｕｍａｔｉｃｂｒａｉｎｉｎｊｕｒｙ (ＴＢＩ)ｉｓｏｎｅｏｆｔｈｅｌｅａｄｉｎｇｃａｕｓｅｓｏｆｄｅａ…     

Management of patients with severe traumatic brain injury guided by intraventricular intracranial pressure monitoring: a report of 136 cases

Objective： To evaluate the effect of the treatment modality guided by intraventricular intracranial pressure （ICP） monitoring on patients with severe traumatic brain injury （TBI）. Methods： The clinical data of a group of 136 severely brain-injured patients admitted to Shanghai Neurosurgical Emergency Center from December 2004 to February 2006 were studied. Results： The intraventricular ICP monitor was placed in all the 136 patients via Kocher＇s pathway, Paine＇s pathway or intraoperative opened ventricle. In this series, the probe was placed during the procedure of craniotomy in 98 patients; for other 38 patients, the probe was placed initially to measure or to monitor ICE A stepwise protocol targeting at ICP control （420 mm Hg） and optimal cerebral perfusion pressure （CPP） maintenance （60-90 mm Hg） was deployed.Among them, 76 patients survived with good recovery, 14 with moderate disability, 24 with severe disability, 10 with vegetative state, and 12 died. Complications associated with intraventricular ICP monitoring included hemorrhage and infection. Hemorrhage occurred in 1 patient and infection in 5 patients. There were no unacceptable complications related to ICP monitoring. Conclusions： Ventricular access for 1CP monitoring can be safely and accurately achieved. ICP monitoring via ventriculostomy may facilitate an early and accurate intervention for severely brain-injured patients. The intraventricular ICP monitoring is a low-risk procedure and can yield great benefits for management of patients with severe TBI.     

硫喷妥钠血药浓度对颅内压和脑代谢影响的实验研究

本实验观察和研究了１１只家兔不同硫喷妥钠血药浓度对颅内压和脑代谢的影响。结果表明，在硫喷妥钠血药浓度较低时（≤３６．５ｍｍｏｌ／Ｌ），颅内压降低幅度大于脑灌注压的下降幅度，有利于脑组织的血液灌注；硫喷妥钠血药浓度较高时（≥４８．５９ｍｍｏｌ／Ｌ），虽有较强降低颅内压和脑组织氧耗率的作用，但其降低脑灌压，血压的作用亦较明显，不利于脑组织及其他脏器的血液灌注。     

Transcranial Doppler pulsatility index is not a reliable indicator of intracranial pressure in children with severe traumatic brain injury

BackgroundThe TCD-derived PI has been associated with ICP in adult studies but has not been well investigated in children. We examined the relationship between PI and ICP and CPP in children with severe TBI.MethodsData were prospectively collected from consecutive TCD studies in children with severe TBI undergoing ICP monitoring. Ipsilateral ICP and CPP values were examined with Spearman correlation coefficient (mean values and raw observations), with a GEE, and as binary values (1 and 20 mm Hg, respectively).ResultsThirty-four children underwent 275 TCD studies. There was a weak relationship between mean values of ICP and PI (P = .04, r = 0.36), but not when raw observations (P = .54) or GEE (P = .23) were used. Pulsatility index was 0.76 when ICP was lower than 20 mm Hg and 0.86 when ICP was 20 mm Hg or higher. When PI was 1 or higher, ICP was lower than 20 mm Hg in 62.5% (25 of 40 studies), and when ICP was 20 mm Hg or higher, PI was lower than 1 in 75% (46 of 61 studies). The sensitivity and specificity of a PI threshold of 1 for examining the ICP threshold of 20 mm Hg were 25% and 88%, respectively. The relationship between CPP and PI was stronger (P = .001, r = ?0.41), but there were too few observations below 50 mm Hg to examine PI at this threshold.ConclusionThe absolute value of the PI is not a reliable noninvasive indicator of ICP in children with severe TBI. Further study is required to examine the relationship between PI and a CPP threshold of 50 mm Hg.     

Effect of intracranial pressure and cerebral perfusion pressure on outcome prediction of severe traumatic brain injury

ｒａｕｍａｔｉｃｂｒａｉｎｉｎｊｕｒｙｉｓｏｎｅｏｆｔｈｅｌｅａｄｉｎｇｃａｕｓｅｓｏｆｄｅａｔｈｉｎｔｈｅｉｎｄｕｓｔｒｉａｌｉｚｅｄｗｏｒｌｄａｎｄｃｏｓｔｓｍｏｒｅｔｈａｎｔｅｎｂｉｌｌｉｏｎＵＳｄｏｌｌａｒｓｉｎｔｈｅＰｅｏｐｌｅ ｓＲｅｐｕｂｌｉｃｏｆＣｈｉｎａｅａｃｈｙｅａｒ .Ｆｕｒｔｈｅｒｍｏｒｅ ,ｔｈｏｕｓａｎｄｓｏｆｓｕｒｖｉｖａｌｓａｒｅｌｉｖｉｎｇｗｉｔｈｌｏｎｇ ｔｅｒｍｄｉｓａｂｉｌｉｔｉｅｓｆｒｏｍｔｒａｕｍａｔｉｃｂｒａｉｎｉｎｊｕｒｙ .Ｔｈｅｉｍｐａｃｔｏｆｓｅｃｏ…     

影响重型脑损伤的预后因素

目的 探讨影响重型脑损伤的预后因素。方法 对135例重型颅脑损伤患者进行回顾性分析。结果 保守治疗42例,手术治疗93例,死亡36例,占26.7％,植物生存4例,重残7例,中残13例,良好75例。结论 影响重型颅脑损伤预后的主要因素是原发性脑损伤严重程度、此外还有年龄、入院前抢救方案、严密观察与监测措施、手术指征的掌握和并发症等。     

Standard large trauma craniotomy for severe traumatic brain injury

ThemortalityofsevereTBIisstillhighatpresent.Howtodecreaseitisanimportanttaskthatmanyneurosurgicalresearchersarepayingcloseattentionto .1Acuteintracranialhematomaanddiffusecontusionandlacerationofthebrainwillleadtosuddenstepping upofintracranialpressureandcerebralherniaformationwhichareoneofthemostimportantcausesofdeathinpatientswithsevereTBI.SurgicaldecompressionisacommonmethodtreatingsevereTBI .Accordingtoreports ,SLTCexcelsroutinecraniotomyintreatingsevereTBI ,butdisputesstillexist .2…     

Decompressive craniectomy in pediatric patients with traumatic brain injury with intractable elevated intracranial pressure

Background

Care of pediatric traumatic brain injury (TBI) has placed emphasis on maximizing cerebral perfusion to prevent ischemia and reperfusion injury. A subset of patients with TBI will continue to have refractory intracranial pressure (ICP) elevation despite aggressive therapy including ventriculostomy, pentobarbital coma, hypertonic saline, and diuretics. Decompressive craniectomy (DC) is a controversial treatment of severe TBI. It is our hypothesis that DC can enhance survival and minimize secondary brain injury in this patient subset.

Methods

Patients younger than 20 years treated at a level I regional trauma center between November 2001 and November 2004, who met inclusion criteria for the Brain Trauma Foundation TBI-trac clinical database were included. All patients with a mechanism of injury consistent with TBI and Glasgow Coma Scale score of less than 9 for at least 6 hours after resuscitation and who did not die in the emergency department are entered into a clinical database. Patients who arrived at the study hospital more than 24 hours after injury are excluded.

Results

There were 30 patients with TBI identified. The mean Glasgow Coma Scale score at presentation was 8 with a range of 3 to 13. Six patients underwent DC for intractable elevated ICP. Of 6 patient's postoperative ICP, 5 were less than 20 mm Hg. One patient required a return to the operating room where further débridement of brain was performed. All patients who received a DC survived and were discharged to a TBI rehabilitation facility.

Conclusion

Although this is a small sample, DC should be considered in patients with TBI with refractory elevated ICP. Long-term follow-up of this patient population should consist of neuropsychiatric evaluation in conjunction with measurement of social function.     

有创颅内压监护在重型脑损伤术后的应用

目的探讨有创颅内压监护在重型脑损伤术后的临床应用价值。方法选取2011年1月-2012年9月于我院进行开颅手术及脑室外引流术的重型颅脑损伤患者108例,根据随机原则分为实验组和对照组,每组54例。实验组和对照组患者均采用止血、抗感染、脱水、神经营养等治疗。实验组：使用Codman颅内压监护仪对患者进行硬膜下的颅内压监护。对照组：对患者颅内压不进行检测,仅按照传统方法进行颅内压预测和治疗。结果实验组和对照组相比在甘露醇使用时间及用量、肾功能损害程度和电解质紊乱等并发症的发生率、预后评估等各方面差异有统计学意义（P〈0.05）。结论使用颅内压监护可以明显提高重型颅脑损伤患者的临床疗效,值得推广应用。