【作者】 陈卓；

【导师】 赵丛海；

【作者基本信息】 吉林大学 ， 外科学， 2012， 硕士

【摘要】 目的:结合吉林大学中日联谊医院神经外一科实际，探讨颅内压监测在神经重症患者中应用的临床效果。方法:收集并总结吉林大学中日联谊医院神经外一科2011年9月至2012年2月安置颅内压监测的4例神经重症患者临床资料，其中男性3例，女性1例，年龄35-74岁，平均61.5岁。高血压脑出血1例，重度颅脑损伤1例，颅内动脉瘤破裂2例。根据GCS评分，12-14分1例，9-11分3例。颅脑损伤患者安置硬膜下颅内压监测；高血压脑出血行血肿腔引流并于对侧脑室行颅内压监测、脑室外引流；1例颅内动脉瘤破裂患者急性期安置脑室内颅内压监测并行脑室外引流术，12天后行颅内动脉瘤夹闭术；1例颅内动脉瘤破裂患者急性期行介入栓塞术，术后安置脑室内颅内压监测以及脑室外引流术。应用美国强生公司生产的Codman颅内压监护仪记录患者的颅内压，并且观察患者的GCS评分、平均动脉压、住院期间治疗情况以及并发症等。根据监测结果调整颅内压，维持有效颅内灌注压。对于难以控制的颅内高压，需要结合患者的临床症状、影像学变化决定是否手术干预。治疗3个月后随访,应用Barther指数分级法对患者日常生活能力(ADL)评定,将评定标准分为五级: Ⅰ级为100分,生活完全自理,完全恢复社会生活;Ⅱ级为60~99分,生活基本自理,部分恢复社会生活或可独立进行家庭生活; Ⅲ级为40~59分,生活需要帮助但可扶持行走; Ⅳ级为20~39分,生活明显依赖,卧床但神志清醒; Ⅴ级为20分以下,生活完全依赖,植物人状态。结果:4例患者颅内压均增高，1例轻度增高，3例重度增高。2例重度增高患者通过加大脱水药物剂量或者调整脑室外引流高度，颅内压逐渐下降至15mmHg以下，停用脱水治疗。1例重度增高患者颅内压进行性增高，复查头部CT显示脑水肿明显，中线移位，遂急诊行脑血肿清除术、去骨瓣减压术。2例颅内动脉瘤破裂患者早期脑积水，拔除脑室引流管后复查CT显示脑积水明显缓解，3个月后轻度脑积水无症状继续观察。1例脑实质内颅内压监测、3例脑室内监测颅内压探头放置天数3-8天，持续监测颅内压＜15mmHg24小时后拔管。Barther指数分级：Ⅱ级1例，Ⅲ级2例，Ⅴ级1例。4例患者均未发生颅内感染以及与安置颅内压探头相关出血。结论:通过此4例病人监测过程及结果，结合文献可得出下列结论：1、颅内压监测并不只适用于GCS＜8分的神经重症患者，对于那些GCS9-12分却有恶化倾向的患者，也是监测的指征。2、根据颅内压监测数值调整脱水药物剂量较为安全、可靠，可避免脱水药物的过度使用。3、颅内压持续＞40mmHg将严重危及生命，保守治疗无效的情况下需积极行去骨瓣减压术，对于颅内压大于60mmHg的患者，无论是否手术，死亡率几乎为100%。4、对神经重症患者应用颅内压监测，可在临床症状出现前发现迟发性血肿，及时了解脑水肿情况，对于评估患者预后有较好的意义。更多还原

【Abstract】 Objective: to analysis of clinical effect of intracranial pressure monitoring in patientswith severe nerveMethods:we collection summary of the clinical data of the four cases in our hospitalfrom September2011to February2012use of intracranial pressure monitoring in patientswith neurological intensive, including3males and1female, age35-74years, mean61.5years. Hypertensive intracerebral hemorrhage1case，severe traumatic brain injury1case,2cases of ruptured intracranial aneurysm. One case of GCS score of12-14(mild coma),9-11(moderate coma) in three cases. In4cases,1patient with severe traumatic brain injury usesubdural intracranial pressure monitoring, conservative treatment;1case of hypertensiveintracerebral hemorrhage use intraventricular intracranial pressure monitoring andventricular drainage, and acute phase of patients with ruptured intracranial aneurysm useintraventricular intracranial pressure monitoring and ventricular drainage, after12days wesurgery intracranial aneurysm.1case of acute aneurysms underwent coiling, then useintracranial pressure monitoring and ventricular drainage. We applicated of the U.SJohnson’s Codman Intracranial Pressure Monitor to record the patient’s intracranial pressureand then recorded the patient’s GCS score, mean arterial pressure during hospitalization,treatment, and complications. According to monitoring results to reduce intracranial pressure,to maintain effective intracranial perfusion pressure, and combined with the clinicalsymptoms and imaging changes to decide whether surgical intervention. Follow-up threemonths after the treatment, we applicated Barther Index classification of patients toassessment activities of daily living (ADL), evaluation standard is divided into five levels: Ilevel of100points, patients can completely take care of themselves, fully restored social life;II level60~99points, their lives can basic take care of themselves, the partial restoration ofsocial life or family life can be carried out independently; III level for40to59, living needhelp but with others support walking; IV level of20to39，living is significantly dependenton others, on the bed but conscious; Ⅴgrade of20points or less, life is totally dependent onothers or the vegetative state..Results:4patients were increased intracranial pressure, one cases of slightly elevated, three cases of severe increased, the increased severe in two cases by increasing thedehydration of the dose or adjust ventricular drainage height gradually to below15mmHg,and then stop the dehydration treatment. Patients with intracranial pressure increased reviewof head CT showed obvious cerebral edema, midline shift, craniotomy to remove thehematoma and decompressive craniectomy surgery. Two cases of hydrocephalus patientsbefore and after removal of the ventricular drainage tube CT scan showed hydrocephalusapparent ease, three months after mild hydrocephalus asymptomatic continue to observe.One cases of subdural intracranial pressure monitoring, three cases of intraventricularcatheter guardianship placement days3-8days, intracranial pressure <15mmHg andsustained24hours after extubation. Barther index classification: Ⅰgrade1cases,2cases ofgrade Ⅲ, Ⅴ grade1cases.Four cases the placement of intracranial pressure probes were nointracranial infection.Conclusions: By four cases of patient monitoring process and results, and literature canbe drawn the following conclusions:1, intracranial pressure monitoring does not only applyto the of GCS <8patients with neurological intensive, for those GCS912points there isdeterioration in patients with a tendency toalso monitored indications.2, dehydrated drugdose adjustment based on intracranial pressure monitoring values and more reliable, toavoid dehydration excessive use of drugs.3, the intracranial pressure continued to>40mmHg would seriously endanger the life line conservative therapy need to activelydecompressive craniectomy in patients with intracranial pressure greater than60mmHg,whether or not surgery, the mortality rate is almost100%.4, nerves in patients with severeintracranial pressure monitoring clear surgical indications, delayed hematoma can be foundbefore the onset of clinical symptoms, and to keep abreast of brain edema, have a bettersense for the assessment of prognosis.更多还原