背景:新近研究表明,急性期各种原因蛛网膜下腔出血所致脑血管痉挛的脑保护措施中,轻度低温的作用受到特别重视,并推荐临床应用.但多限于实验研究和动脉瘤出血,做临床研究亚低温可能对重型颅脑损伤的脑血管痉挛期有重要影响.目的:以脑循环动力学指标变化观察亚低温对重型颅脑损伤后脑血管痉挛期的脑保护作用.设计:随机对照实验.单位:解放军第十六医院神经外科和解放军第一军医大学珠江医院全军神经医学研究所.对象:选择1997-07/1999-08解放军第一军医大学珠江医院全军神经医学研究所收治36例重型颅脑损伤患者随机分为对照组和治疗组,每组18例.同期筛选出24例正常人检测其脑循环动力学指标,作为正常组,所有被试对象均自愿参加本实验.方法:对照组和治疗组均给予抗炎、止血、限液、脱水、支持、高压氧等治疗.对照组维持正常体温,治疗组4～8 h内将肛温降至33℃左右,维持3～5 d.监测项目:①伤灶脑水肿体积:每例患者伤后当天(0),1,3,7,14,21 d各行1次CT检查,计算伤灶脑水肿体积.②脑循环动力学指标:于伤后当天(0,未治疗前),1,3,7,10,14,21天每例患者各检测1次,其中最低血流速度和最低血流量是反映检测点远端脑血管供血状态和血流量的指标,脑血管阻力反映脑微循环通畅程度的指标,动态阻力反映脑血管自动调节功能.评估标准:伤后1周按格拉斯哥昏迷评分判定意识恢复情况,3个月后按格拉斯哥预后评分评定预后良好和预后不良(5分良好,4分中残,3分重残,2分植物状态,1分死亡).4分以上为预后良好.主要观察指标:①对照组和治疗组动态脑循环动力学指标和脑血管痉挛发生率.②对照组和治疗组动态伤灶脑水肿体积.③对照组和治疗组伤后1周意识恢复情况和预后情况.结果:36例重型颅脑损伤患者全部进入结果分析.①与正常组比较,对照组伤后脑循环动力学指标可划分为4个期,即低灌注期(0 d)、高灌注期(1～3 d)、脑血管痉挛期(4～14 d)、好转期(＞ 15d);而治疗组仅表现出3个期,即低灌注期(0 d)、好转期(1～3d)、恢复期(＞ 4 d),未出现高灌注期.对照组和治疗组脑循环动力学指标出现脑血管痉挛变化者分别是8例和2例(P＜0.05).②伤灶脑水肿体积:对照组在伤后第14天最大(140.9±22.95)cm3,治疗组在伤后第3天最大(95.83±14.97)cm3,在伤后第14天治疗组比对照组减少42%(P＜0.05).③伤后1周内转清醒率:对照组为22.2%(4/18),治疗组为55.6%(10/18)(P＜0.05);预后良好率:对照组为38.9%(7/18),治疗组为66.7%(12/18).结论:亚低温通过稳定重型颅脑损伤后脑循环功能,尤其是能平抑重型颅脑损伤后急性高灌注,降低脑血管痉挛发生率,从而明显减少伤灶脑水肿体积,改善预后.
揹景:新近研究錶明,急性期各種原因蛛網膜下腔齣血所緻腦血管痙攣的腦保護措施中,輕度低溫的作用受到特彆重視,併推薦臨床應用.但多限于實驗研究和動脈瘤齣血,做臨床研究亞低溫可能對重型顱腦損傷的腦血管痙攣期有重要影響.目的:以腦循環動力學指標變化觀察亞低溫對重型顱腦損傷後腦血管痙攣期的腦保護作用.設計:隨機對照實驗.單位:解放軍第十六醫院神經外科和解放軍第一軍醫大學珠江醫院全軍神經醫學研究所.對象:選擇1997-07/1999-08解放軍第一軍醫大學珠江醫院全軍神經醫學研究所收治36例重型顱腦損傷患者隨機分為對照組和治療組,每組18例.同期篩選齣24例正常人檢測其腦循環動力學指標,作為正常組,所有被試對象均自願參加本實驗.方法:對照組和治療組均給予抗炎、止血、限液、脫水、支持、高壓氧等治療.對照組維持正常體溫,治療組4～8 h內將肛溫降至33℃左右,維持3～5 d.鑑測項目:①傷竈腦水腫體積:每例患者傷後噹天(0),1,3,7,14,21 d各行1次CT檢查,計算傷竈腦水腫體積.②腦循環動力學指標:于傷後噹天(0,未治療前),1,3,7,10,14,21天每例患者各檢測1次,其中最低血流速度和最低血流量是反映檢測點遠耑腦血管供血狀態和血流量的指標,腦血管阻力反映腦微循環通暢程度的指標,動態阻力反映腦血管自動調節功能.評估標準:傷後1週按格拉斯哥昏迷評分判定意識恢複情況,3箇月後按格拉斯哥預後評分評定預後良好和預後不良(5分良好,4分中殘,3分重殘,2分植物狀態,1分死亡).4分以上為預後良好.主要觀察指標:①對照組和治療組動態腦循環動力學指標和腦血管痙攣髮生率.②對照組和治療組動態傷竈腦水腫體積.③對照組和治療組傷後1週意識恢複情況和預後情況.結果:36例重型顱腦損傷患者全部進入結果分析.①與正常組比較,對照組傷後腦循環動力學指標可劃分為4箇期,即低灌註期(0 d)、高灌註期(1～3 d)、腦血管痙攣期(4～14 d)、好轉期(＞ 15d);而治療組僅錶現齣3箇期,即低灌註期(0 d)、好轉期(1～3d)、恢複期(＞ 4 d),未齣現高灌註期.對照組和治療組腦循環動力學指標齣現腦血管痙攣變化者分彆是8例和2例(P＜0.05).②傷竈腦水腫體積:對照組在傷後第14天最大(140.9±22.95)cm3,治療組在傷後第3天最大(95.83±14.97)cm3,在傷後第14天治療組比對照組減少42%(P＜0.05).③傷後1週內轉清醒率:對照組為22.2%(4/18),治療組為55.6%(10/18)(P＜0.05);預後良好率:對照組為38.9%(7/18),治療組為66.7%(12/18).結論:亞低溫通過穩定重型顱腦損傷後腦循環功能,尤其是能平抑重型顱腦損傷後急性高灌註,降低腦血管痙攣髮生率,從而明顯減少傷竈腦水腫體積,改善預後.
배경:신근연구표명,급성기각충원인주망막하강출혈소치뇌혈관경련적뇌보호조시중,경도저온적작용수도특별중시,병추천림상응용.단다한우실험연구화동맥류출혈,주림상연구아저온가능대중형로뇌손상적뇌혈관경련기유중요영향.목적:이뇌순배동역학지표변화관찰아저온대중형로뇌손상후뇌혈관경련기적뇌보호작용.설계:수궤대조실험.단위:해방군제십륙의원신경외과화해방군제일군의대학주강의원전군신경의학연구소.대상:선택1997-07/1999-08해방군제일군의대학주강의원전군신경의학연구소수치36례중형로뇌손상환자수궤분위대조조화치료조,매조18례.동기사선출24례정상인검측기뇌순배동역학지표,작위정상조,소유피시대상균자원삼가본실험.방법:대조조화치료조균급여항염、지혈、한액、탈수、지지、고압양등치료.대조조유지정상체온,치료조4～8 h내장항온강지33℃좌우,유지3～5 d.감측항목:①상조뇌수종체적:매례환자상후당천(0),1,3,7,14,21 d각행1차CT검사,계산상조뇌수종체적.②뇌순배동역학지표:우상후당천(0,미치료전),1,3,7,10,14,21천매례환자각검측1차,기중최저혈류속도화최저혈류량시반영검측점원단뇌혈관공혈상태화혈류량적지표,뇌혈관조력반영뇌미순배통창정도적지표,동태조력반영뇌혈관자동조절공능.평고표준:상후1주안격랍사가혼미평분판정의식회복정황,3개월후안격랍사가예후평분평정예후량호화예후불량(5분량호,4분중잔,3분중잔,2분식물상태,1분사망).4분이상위예후량호.주요관찰지표:①대조조화치료조동태뇌순배동역학지표화뇌혈관경련발생솔.②대조조화치료조동태상조뇌수종체적.③대조조화치료조상후1주의식회복정황화예후정황.결과:36례중형로뇌손상환자전부진입결과분석.①여정상조비교,대조조상후뇌순배동역학지표가화분위4개기,즉저관주기(0 d)、고관주기(1～3 d)、뇌혈관경련기(4～14 d)、호전기(＞ 15d);이치료조부표현출3개기,즉저관주기(0 d)、호전기(1～3d)、회복기(＞ 4 d),미출현고관주기.대조조화치료조뇌순배동역학지표출현뇌혈관경련변화자분별시8례화2례(P＜0.05).②상조뇌수종체적:대조조재상후제14천최대(140.9±22.95)cm3,치료조재상후제3천최대(95.83±14.97)cm3,재상후제14천치료조비대조조감소42%(P＜0.05).③상후1주내전청성솔:대조조위22.2%(4/18),치료조위55.6%(10/18)(P＜0.05);예후량호솔:대조조위38.9%(7/18),치료조위66.7%(12/18).결론:아저온통과은정중형로뇌손상후뇌순배공능,우기시능평억중형로뇌손상후급성고관주,강저뇌혈관경련발생솔,종이명현감소상조뇌수종체적,개선예후.
BACKGROUND: It is indicated in latest research that in cerebral protective measures of cerebral vasospasm induced by subarachnoid hemorrhage due to various factors in acute stage, mild hypothermia has been drawn the attention specially and it has been recommended in clinical practice. But such therapy is generally limited in experimental research and aneurysm hemorrhage, the clinical research on subhypothermia probably provides important influence on cerebral vasospasm in severe craniocerebral injury.OBJECTIVE: Based on cerebral vascular hemodynamical indexes (CVDI),the cerebral protection of subhypothermia was observed on cerebral vasospasm in severe craniocerebral injury.DESIGN: Randomized controlled experiment.SETTING: Department of Neurological Surgery of No.16 Hospital of Chinese PLA and General Military Institute of Neurological Medical Science in Zhujiang Hospital Affiliated to First Military Medical University of Chinese PLA.PARTICIPANTS: Totally 36 cases of severe craniocerebral injury were selected in General Military Institute of Neurological Medical Science in Zhujiang Hospital Affiliated to First Military Medical University of Chinese PLA from July 1997 to August 1999, which were randomized into the control and treatment group, 18 cases in each one. At same period, 24 cases with normal CVDI were screened and taken as normal group. All of receptors participated in the experiment in volunteer.METHODS: In both the control and treatment group, the treatment was applied with anti-inflammation, stopping bleeding, fluid limitation, dehydration, supporting, hyperbaric oxygen, etc. In the control, the normal body temperature was maintained and in treatment group, anus temperature was dropped to about 33 ℃ in 4 hours to 8 hours, which was maintained for 3-test was given on the day of injury (0), on the 1st, 3rd, 7th, 14th and 21st days assay was done on the day of injury (0), on the 1st, 3rd, 7th, 14th and 21st days successively, in which, minimum blood velocity (Vmin) and minimum blood flow (Qmin) reflect blood supply of distal cerebral vessel and blood flow.Cerebral vessel resistance (CVR) reflects smooth degree of cerebral microcirculation. Dynamical resistance (DR) reflects auto-regulation of cerebral vessel. Criteria of evaluation: Recovery state of consciousness was justified according to Glasgow Coma Scale (GCS) in 1 week after injury. The outcomes were evaluated according to Glasgow outcome scale (GOS) in 3 months (5 score: good, 4 score: moderate handicapped, 3 score: severely handicapped, 2 score: vegetative state and 1 score: death). The case over 4 score indicated good outcome.ery of consciousness and outcomes in 1 week after injury in the control and treatment group.RESULTS: Totally 36 cases of severe craniocerebral injury entered result phases after injury in the control, named hypoperfusion phase (0 day), hyperperfusion phase (1-3 days), cerebral vasospasm phase (4-14 days) and improving phase (＞15 days). In treatment group, 3 phases were manifested,named hypoperfusion phase (0 day), improving phase (1-3 days) and recovery phase (＞ 4 days), without hyperperfusion phase. Eight cases and 2 cases of cerebral vasospasmodic changes in CVDI presented in the control in focus: The maximum volume (140.9±22.95) cm3 was on the 14th day after injury in the control and that (95.83-±14.97) cm3 was on the 3rd day in treatment group. On the 14th day after injury, the volume in treatment group in 1 week after injury: It was 22.2% (4/18) in the control and 55.6%(10/18) (P ＜ 0.05) in treatment group. Improving outcome rate: It was 38.9% (7/18) and 66.7% (12/18) in treatment group.CONCLUSION: Subhypothermia reduces incidence of cerebral vasospasm by stabilizing cerebral circulation after severe craniocerebral injury, especially by inhibiting acute hyperperfusion after the injury so that the volume of cerebral edema in focus is lessened remarkably and the prognosis is improved.
