侧裂池置管加早期腰大池引流对tSAH后脑血管痉挛的疗效观察
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摘要
目的
本文主要目的是研究颅脑损伤合并外伤性蛛网膜下腔出血(Traumatic subarachnoid hemorrhage, tSAH)术中侧裂池开放置管外引流加术后早期腰大池引流血性脑脊液(Cerebrospinal fluid, CSF)对控制脑血管痉挛(Cerebral Vasospasm, CVS),改善脑缺血、缺氧的临床疗效。为临床治疗以及手术方式方法提供合理有效的依据,提高基层医院中、重度颅脑损伤合并蛛网膜下腔出血时所致脑血管痉挛的治疗效果,以达到减少病患死亡率、改善预后的治疗目的。
方法
以淄博市淄川区医院神经外科自2005年3月至2011年3月期间收治的108例GCS评分为3-12分的中、重度颅脑损伤合并蛛网膜下腔出血患者为研究对象,按照完全随机的方法分为治疗组、观察一组和观察二组。各组患者在性别、年龄、病情等方面没有明显区别。各组患者均行标准大骨瓣开颅血肿清除术,治疗组在术中首先开放侧裂池引流,继而使用无菌生理盐水冲洗血性脑脊液并于侧裂池置管行外引流,术后早期(24小时内)行腰大池持续外引流；观察一组只于术后7天腰大池持续外引流；观察二组,只做侧裂开放引流,不置管外引流,并于术后行间断腰穿治疗。比较三组术后不同时间点的经颅多普勒(Transcranial Doppler, TCD)检查大脑中动脉(middlecerebralartery, MCA)时间平均血液流速变化(Average velocity, Vm)、颅内压(ICP)变化以及术后镜检脑脊液无红细胞的时间点,并且术后随访6个月根据GOS评分评判病患预后。行持续腰大池引流各组均采用电子输液泵控制脑脊液引流速度,以防止引流过度导致低颅压、脑疝危象或者脑脊液倒灌引起的颅内感染,其他神经外科专科治疗在三组中均无明显差异。
结果
1.三组术后主要时间点大脑中动脉(MCA)的时间平均流速(VM)的平均值(cm/s)(x±s)。治疗组的大脑中动脉时间平均流速在各对照点与对照一组、对照二组相比较均明显低,而且在观察周期之内平均VM处于一个较低水平并且无明显起伏,具有明显的统计学意义(均P<0.05)。
2.术后主要时间点颅内压(ICP)平均值的比较(mmH20)(x±s)。各组在相同时间点颅内压变化情况,治疗组与对照一组、对照二组比较均低,而且在观察周期内均处于正常颅内压水平,比较有明显统计学意义(均P<0.05)。
3.术后脑脊液红细胞镜检阴性(d)(x±s)。治疗组较对照一、二组,脑脊液红细胞镜检阴性平均时间明显缩短,具有明显的统计学意义(均P(0.05)。
2.4术后六个月随访：根据GOS预后评分随访结果(例数)(x±s)：治疗组预后良好率为80.5%(29/36),观察一组预后良好率为52.7%(19/36),观察二组预后良好率为63.8%(23/36),治疗组与观察组数据比较有显著差异(均P<0.05)。
2.5三组病人均未出现引流过度导致的低颅压和脑疝危象以及颅内感染出现。
结论
1、开放侧裂池置管引流加早期腰大池持续引流明显加快血性脑脊液的清除速度,有效预防脑血管痉挛。
2、开放侧裂池置管引流加早期腰大池持续引流可明显降低颅内压力,改善颅脑损伤术后脑部血液循环。
3、应用电子输液泵控制脑脊液引流速度,可有效防止因脑脊液引流过快导致的低颅压和脑疝危象发生,以及颅内感染的发生。
Objective:
To investigate therapeutic effect of lumbar drainage of cerebrospinal fluid and remaining a tube in lateral fissure cistern in saving the CVS, improve the Cerebral ischemia and Cerebral hypoxia in the patient of tSAH with Moderate or severe craniocerebral injury. Provide a reasonable and effective basis for the Operation methods and clinical therapeutics. To improve the therapeutic activity of Grassroots hospital in moderate and severe craniocerebral injury complicated with subarachnoid hemorrhage-induced cerebral Vasospasm,to decrease the patient deaths and improve outcomes.
Methods:
The 108 patient with scores of 3-12 on GCS who were admitted to our deparment from match.2005 to match.2011 were analyzed retrospectively.we dividea the 108 patient into three proups in random.there was no Significant differences in the age,sexual distinction and the conditions.the 36 patients as one group(the treatment),Were suffered to lateral fissure cistern external drainage and to lumbar drainage of cerebrospinal fluid(CSF) within 24 hours that after craniotomy;the 36 patients as one group(the NO.1 observation),were suffered to lumbar drainage of cerebrospinal fluid(CSF),the another 36 patients as one group(the NO.2 observation),were suffered to opened lateral fissure.To compared the Vm of the middle cerebral artery that were measured by TCD,Changes of intracranial pressure and the time that the number of red blood cells were lowered to 10×106/L.Postoperative follow-up of 6 months,evaluate Prognosis of the patient under GOS scoring.
There is no obvious exceptions in spedialist treatment differences in three groups.
Results:
1.The Vm of MCA that after craniotomy's main point time in three groups (cm/s) (x±s)。The treament group was slower than the othertwo in the Vm of the MCA, And within the observation period average VM is in a relatively low level and no obvious ups and downs, significant different (P<0.05)。
2. The average of the ICP that after craniotomy's main point time in three groups mmH2o) (x±s)。
The change of the ICP at the same point of the time,, The treament group was lower than the other two's,And during the observation period are in the normal intracranial pressure level, significant different (P<0.05).
2.3The time that Negative microscopic examination of red blood cells in cerebrospinal fluid (d) (x±s):
The average time of the treatment group Average negative microscopic examination of red blood cells in cerebrospinal fluid time significantly reduced than the other groups, significant different (P<0.05)
2.4Postoperative follow-up of 6 months,evaluate Prognosis of the patient under GOS scoring (n) (x±s):
The prognosis good rates of the treatment group was80.5%(29/36), which of the NO.1 Observation was 52.7%(19/36),the NO.2 Observation was 63.8%(23/36), there was significant different in the treatment to the other two's. (P<0.05).
2.5 Three groups of patients and there is no drainage of excessive intracranial hypotension and cerebral hernia caused by crisis and the emergence of intracranial infection.
Conclusion
1、The bloody cerebrospinal fluid was removes quickly by lumbar drainage of cerebrospinal fluid and lateral fissure cistern external drainage, and it gived effective prevention for CVS.
2、The ICP was lowed obviously by lumbar drainage of cerebrospinal fluid and lateral fissure cistern external drainage,and Improved brain blood circulation of the postoperative patients with severe cerebral injury.
3、The mortality and disability rate can be lowed obviously by lumbar drainage of cerebrospinal fluid and lateral fissure cistern external drainage,for its relatively simple operation,,the methods were worth offering to primary hospitals,As well as the occurrence of intracranial infection.
本文主要目的是研究颅脑损伤合并外伤性蛛网膜下腔出血(Traumatic subarachnoid hemorrhage, tSAH)术中侧裂池开放置管外引流加术后早期腰大池引流血性脑脊液(Cerebrospinal fluid, CSF)对控制脑血管痉挛(Cerebral Vasospasm, CVS),改善脑缺血、缺氧的临床疗效。为临床治疗以及手术方式方法提供合理有效的依据,提高基层医院中、重度颅脑损伤合并蛛网膜下腔出血时所致脑血管痉挛的治疗效果,以达到减少病患死亡率、改善预后的治疗目的。
方法
以淄博市淄川区医院神经外科自2005年3月至2011年3月期间收治的108例GCS评分为3-12分的中、重度颅脑损伤合并蛛网膜下腔出血患者为研究对象,按照完全随机的方法分为治疗组、观察一组和观察二组。各组患者在性别、年龄、病情等方面没有明显区别。各组患者均行标准大骨瓣开颅血肿清除术,治疗组在术中首先开放侧裂池引流,继而使用无菌生理盐水冲洗血性脑脊液并于侧裂池置管行外引流,术后早期(24小时内)行腰大池持续外引流；观察一组只于术后7天腰大池持续外引流；观察二组,只做侧裂开放引流,不置管外引流,并于术后行间断腰穿治疗。比较三组术后不同时间点的经颅多普勒(Transcranial Doppler, TCD)检查大脑中动脉(middlecerebralartery, MCA)时间平均血液流速变化(Average velocity, Vm)、颅内压(ICP)变化以及术后镜检脑脊液无红细胞的时间点,并且术后随访6个月根据GOS评分评判病患预后。行持续腰大池引流各组均采用电子输液泵控制脑脊液引流速度,以防止引流过度导致低颅压、脑疝危象或者脑脊液倒灌引起的颅内感染,其他神经外科专科治疗在三组中均无明显差异。
结果
1.三组术后主要时间点大脑中动脉(MCA)的时间平均流速(VM)的平均值(cm/s)(x±s)。治疗组的大脑中动脉时间平均流速在各对照点与对照一组、对照二组相比较均明显低,而且在观察周期之内平均VM处于一个较低水平并且无明显起伏,具有明显的统计学意义(均P<0.05)。
2.术后主要时间点颅内压(ICP)平均值的比较(mmH20)(x±s)。各组在相同时间点颅内压变化情况,治疗组与对照一组、对照二组比较均低,而且在观察周期内均处于正常颅内压水平,比较有明显统计学意义(均P<0.05)。
3.术后脑脊液红细胞镜检阴性(d)(x±s)。治疗组较对照一、二组,脑脊液红细胞镜检阴性平均时间明显缩短,具有明显的统计学意义(均P(0.05)。
2.4术后六个月随访：根据GOS预后评分随访结果(例数)(x±s)：治疗组预后良好率为80.5%(29/36),观察一组预后良好率为52.7%(19/36),观察二组预后良好率为63.8%(23/36),治疗组与观察组数据比较有显著差异(均P<0.05)。
2.5三组病人均未出现引流过度导致的低颅压和脑疝危象以及颅内感染出现。
结论
1、开放侧裂池置管引流加早期腰大池持续引流明显加快血性脑脊液的清除速度,有效预防脑血管痉挛。
2、开放侧裂池置管引流加早期腰大池持续引流可明显降低颅内压力,改善颅脑损伤术后脑部血液循环。
3、应用电子输液泵控制脑脊液引流速度,可有效防止因脑脊液引流过快导致的低颅压和脑疝危象发生,以及颅内感染的发生。
Objective:
To investigate therapeutic effect of lumbar drainage of cerebrospinal fluid and remaining a tube in lateral fissure cistern in saving the CVS, improve the Cerebral ischemia and Cerebral hypoxia in the patient of tSAH with Moderate or severe craniocerebral injury. Provide a reasonable and effective basis for the Operation methods and clinical therapeutics. To improve the therapeutic activity of Grassroots hospital in moderate and severe craniocerebral injury complicated with subarachnoid hemorrhage-induced cerebral Vasospasm,to decrease the patient deaths and improve outcomes.
Methods:
The 108 patient with scores of 3-12 on GCS who were admitted to our deparment from match.2005 to match.2011 were analyzed retrospectively.we dividea the 108 patient into three proups in random.there was no Significant differences in the age,sexual distinction and the conditions.the 36 patients as one group(the treatment),Were suffered to lateral fissure cistern external drainage and to lumbar drainage of cerebrospinal fluid(CSF) within 24 hours that after craniotomy;the 36 patients as one group(the NO.1 observation),were suffered to lumbar drainage of cerebrospinal fluid(CSF),the another 36 patients as one group(the NO.2 observation),were suffered to opened lateral fissure.To compared the Vm of the middle cerebral artery that were measured by TCD,Changes of intracranial pressure and the time that the number of red blood cells were lowered to 10×106/L.Postoperative follow-up of 6 months,evaluate Prognosis of the patient under GOS scoring.
There is no obvious exceptions in spedialist treatment differences in three groups.
Results:
1.The Vm of MCA that after craniotomy's main point time in three groups (cm/s) (x±s)。The treament group was slower than the othertwo in the Vm of the MCA, And within the observation period average VM is in a relatively low level and no obvious ups and downs, significant different (P<0.05)。
2. The average of the ICP that after craniotomy's main point time in three groups mmH2o) (x±s)。
The change of the ICP at the same point of the time,, The treament group was lower than the other two's,And during the observation period are in the normal intracranial pressure level, significant different (P<0.05).
2.3The time that Negative microscopic examination of red blood cells in cerebrospinal fluid (d) (x±s):
The average time of the treatment group Average negative microscopic examination of red blood cells in cerebrospinal fluid time significantly reduced than the other groups, significant different (P<0.05)
2.4Postoperative follow-up of 6 months,evaluate Prognosis of the patient under GOS scoring (n) (x±s):
The prognosis good rates of the treatment group was80.5%(29/36), which of the NO.1 Observation was 52.7%(19/36),the NO.2 Observation was 63.8%(23/36), there was significant different in the treatment to the other two's. (P<0.05).
2.5 Three groups of patients and there is no drainage of excessive intracranial hypotension and cerebral hernia caused by crisis and the emergence of intracranial infection.
Conclusion
1、The bloody cerebrospinal fluid was removes quickly by lumbar drainage of cerebrospinal fluid and lateral fissure cistern external drainage, and it gived effective prevention for CVS.
2、The ICP was lowed obviously by lumbar drainage of cerebrospinal fluid and lateral fissure cistern external drainage,and Improved brain blood circulation of the postoperative patients with severe cerebral injury.
3、The mortality and disability rate can be lowed obviously by lumbar drainage of cerebrospinal fluid and lateral fissure cistern external drainage,for its relatively simple operation,,the methods were worth offering to primary hospitals,As well as the occurrence of intracranial infection.
引文
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1、Taneda M, Kataoka K, Akai F, et al.Traumatic subarach noid hemorrhage as a predictable indicator of delayed ischemicsymptoms [J].Neurosurg,2007,84:762.
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1、Taneda M, Kataoka K, Akai F, et al.Traumatic subarach noid hemorrhage as a predictable indicator of delayed ischemicsymptoms [J].Neurosurg,2007,84:762.
2、徐国政,李国雄,马廉亭,秦尚振,姚国杰,张新元,胡军民,潘力.创伤性蛛网膜下腔出血的相关因素研究[J].创伤外科杂志.2004年,6(6),430-432
3、Dhar R, Diringer MN.The burden of the systemic inflammatory response predicts vasospasm and outcome after subarachnoid hemorrhage [J].Neurocrit Care 2008;8(3):404-12.
4、Walh M, Unterberg A, Baethmann A, et al. Mediators of blood brain barrier dysfunction and formation for vasogenic brain edema [J]. J Cerebral Blood Flow Metab,1988,8:621-634.
5、Nishizawa S, Laher I.Signaling mechanisms in cerebral vasospasm [J]. Trends Cardiovasc Med.2005 Jan:15(1):24-34.
6、郑桃林,阿伟,王桂斌.Rho激酶与蛛网膜下腔出血后脑血管痉挛[J].卒中与神经疾病,2011(2)：125-127.
7、ID JL, DAWSON D, MACRAE IM.Endothelin, cerebral ischaemia and infarction [J].Clin Exp Hypertens:1995,171-2,17(1-2):399-407.
8、dwin AT, Amrani M, Gray CC, et a. Differential effects of endothelin-1 on isolated working rat hearts before and after ischaemia and reperfusion [J].Clin Sci (Lond). 2002,,103Suppl,103(Suppl):189S-193S.
9赵晖,宋钢,夏国道,李宁.外伤性脑血管痉挛与脑脊液内皮素、一氧化氮浓度动态变化的临床研究[J].中华实用诊断与治疗杂志,2009,23(3)：229-231.
10、Immermann M, Seifert V.Endothelin and subarachnoid hemorrhage:an overview [J].Neurosurgery.1998 Oct;43(4):863-875
11、广伟,刘云贺,汪汉民.神经型一氧化氮合酶对脑损伤后神经细胞凋亡的影响[J].实用诊断与治疗杂志,2007(01)：44-46
12、rk JF, Sharp FR.Bilirubin oxidation products (BOXes) and their role in cerebral vasospasm after subarachnoid hemorrhage [J];J Cereb Blood Flow Metab:2006 Oct;26(10):1223-33. Epub 2006 Feb 8.
13、Borel C, Mckee A,Parra A, et al.Possible Role for Vascular Cell Proliferation in Cerebral Vasospasm After Subarachnoid Hemorrhage[J].Stroke,2003,34 (2): 427-433.
14、Pradilla G,Thai Q,Legnani F,er al. Delayed intracranial delivery of a nitric oxide donor from a controlled-release polymer prevents experimental cerebral vasospasm in rabbits[J]. Neurosurgery.2004,55(6):1393-1400.
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20、楚胜华,袁先厚,陈卫国,江普查,吴静,郭国炳.经颅多普勒监测和尼膜同对脑外伤后脑血管痉挛的作用[J].中华创伤杂志,2004年06期：333-335.
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