重型颅脑损伤术中急性脑膨出救治经验总结的论文.docVIP

　　重型颅脑损伤术中急性脑膨出救治经验总结的论文 　　【摘要】 目的 总结重型颅脑损伤术中急性脑膨出救治的经验。方法 回顾性分析大坪医院自1997年7月～2007年1月37例术中出现急性脑膨出的重型颅脑损伤患者的临床资料。结果 ct复查示迟发性颅内血肿26例，弥漫性脑肿胀7例，挫裂伤脑水肿2例;另2例未行ct复查原因不清。对侧钻孔确认后直接开颅7例，手术过程中复查ct后手术5例，关颅后复查ct再手术20例，未复查切除脑叶者2例。死亡7例，包括4例弥漫性脑肿胀患者。伤后半年gos评估，植物生存1例，重残3例，中残6例，良好20例。结论术中出现脑膨出时，首先考虑对侧迟发性颅内血肿可能，对侧可疑部位钻孔探查手术，或快速ct复查，明确诊断后再次手术。梯度减压开颅、异丙酚麻醉、控制性低血压及去骨瓣减压是防治弥漫性脑肿胀的救治措施。 　　【关键词】 颅脑损伤; 脑膨出;颅内血肿;脑肿胀 　　management of intraoperative acute encephalocele during clot evacuation in severe brain injury 　　xu lunshan,xu minhui,chen guangxin,et al. 　　(department of neurosurgery,institute of surgery research，daping hospital，third mililtary medical university， 　　chongqing 400042,china) 　　abstract： objective to summarize the causes and strategies of management of intraoperative acute encephalocele in severe brain injury.methods during a tenyear period(july 1997jan 2007),the clinical diagnosis,operative events,and ct findings in 37 cases suffering from acute open brain herniation ong ,26 suffered from delayed intracranial hematomas,7 from acute diffuse brain s delayed onset of massive oedema around the contusion.a contralateral craniectomy ed after trepanation ed before scalp closure,2 undery oderately disabled,3 severely disabled,1 survived as persistent vegetative state,and 7 died.conclusion intraoperative acute encephalocele is mainly caused by delayed intracranial hematomas.it should be effectively treated by early craniotomy after diagnosis by emergency ct scan,or trepanation according to the skull fracture immediately.the ictus due to acute brain seasures,including gradient depressive craniectomy,controlled hypotension and propofol infusion to cut doatoma;brain smhg和薄层硬膜下血肿伴弥漫性脑挫裂伤、中线移位gt;5mm者是术中发生急性脑膨出的预警信号[6，7]。治疗措施包括确认气管内插管和头部的位置正确、过度通气、巴比妥钠、硫喷妥钠、甘露醇与速尿联合强力脱水、控制性低血压及行去骨瓣减压术等。但过度通气没有直接证据证明可改善术中急性脑膨出，且存在因减少正常脑组织的血流量而影响脑氧供，所以一般仅短暂应用。巴比妥钠和硫喷妥钠虽广泛应用，但并不能明显改善脑肿胀，且可致延迟苏醒、免疫抑制和电解质紊乱。异丙酚可降低脑代谢率和脑血流量，进而减低颅内压和平均动脉压，还兼具神经保护作用与谷氨酸受体拮抗剂和γ氨基丁酸受体激动剂作用，可防治非外伤性术中脑膨出[8]，值得进一步实践总结。标准去骨瓣减压可使80%病