2014CNS结核.ppt

CNS Tuberculosis ;引言;病因（病原）;发病机制;临床;结核性脑膜炎———前驱症状;;;结核性脑膜炎——脑脊液检查;;结核性脑膜炎——诊断; We recommend the aids are used to identify the highest risk patients in whom every effort should be made to make a microbiological diagnosis and in whom empiric anti-tuberculosis therapy should be strongly considered (B,II) ;结核性脑膜炎——神经影像;结核性脑膜炎——并发症;What is the best way of diagnosing CNS TB?——Do basic clinical and laboratory features help?;What is the best way of diagnosing CNS TB?Is conventional microbiology useful?;What is the best way of diagnosing CNS TB?——Are nucleic acid amplification techniques useful?;What is the best way of diagnosing CNS TB?——Are other assays helpful?;What is the best way of diagnosing CNS TB?——What is the role of imaging investigations?;结核性脑膜炎——治疗;;;TB耐药4%地区（非洲、亚洲、部分南美较高）采用头2月三联（每日异烟肼+利福平+吡嗪酰胺），7-10个月两联（每日或每周2次异烟肼+利福平）。 全程监测肝酶，谷丙转氨酶明显增高（5次异常），停用异烟肼和利福平，改用乙胺丁醇和链霉素持续至酶恢复正常，再重新开始异烟肼（2周测1次）。多数能耐受异烟肼+乙胺丁醇+吡嗪酰胺+链霉素方案。 妊娠期不用链霉素和吡嗪酰胺，优先考虑异烟肼、乙胺丁醇和利福平。 短疗程也可能有效，2哥对照研究肺外TB：6M疗程发病率/死亡率同长疗程。异烟肼+利福平9月也有95%的有效率，等同于标准的二联三联治疗18-24M。每周2次疗法还有费用低、剂量小、易打理的优点。幼儿TBM大剂量（四联）短疗程（6M）并无明显肝毒作用，复发风险降低1998）。;脑积水TBM患者应考虑外引流，对交通性脑积水办法不多，药物治疗无效时请神经外科会诊，行颅内压监测。 皮质激素能改善中度TBM神经功能预后。能改善儿童TBM生存率和智能状态（不影响脑压和基底节梗塞发生率）。越南成人TBM：皮质激素降低死亡率，但不影响生存者残障程度。地塞米松推荐用于不合并HIV感染的TBM患者，无论年龄和严重程度。第一周0.4mg/kg iv，每周减0.1mg/kg，再每天4mg口服，以后每周减1mg/kg，直至停药。;结核性脑膜炎——耐药;How should CNS tuberculosis be treated?——What is the best anti-tuberculosis drug regimen?;How should CNS tuberculosis be treated?——Do adjunctive corticosteroids improve outcome?;;There is insufficient evidence to recommend routine adjunctive corticosteroids for all patients with tuberculomas without meningitis, or with spinal cord tuberculosis. However, they may be helpful in those patients whose symptoms are not controlled, or are worsening, on anti-tuberculosis therapy, or who have acute spinal cord compression secondary to vertebral tuberculosis (B,II). Similar doses to those used for TBM should be given (B,III). Thalidomide should not be used for t