本文選題：顱腦創(chuàng)傷 + 經(jīng)顱多普勒�。� 參考：《中南大學(xué)》2013年博士論文

【摘要】：顱腦創(chuàng)傷是神經(jīng)外科常見病和多發(fā)病,特別是中重型顱腦創(chuàng)傷病情兇險,死殘率高,一直神經(jīng)外科的重點和難點。中重型顱腦創(chuàng)傷患者顱內(nèi)壓控制和腦灌注壓維持是搶救成功與否的關(guān)鍵,目前主要采用有創(chuàng)方法監(jiān)測顱內(nèi)壓和腦灌注壓。但是有創(chuàng)顱內(nèi)壓監(jiān)測的風(fēng)險(如感染和顱內(nèi)出血等)以及昂貴的成本費用使臨床應(yīng)用受到限制。隨著微創(chuàng)和無創(chuàng)神經(jīng)外科理念和技術(shù)的發(fā)展,尋求一種有效的無創(chuàng)顱內(nèi)壓和腦灌注壓監(jiān)測方法逐漸受到學(xué)界重視。探討無創(chuàng)監(jiān)測顱腦創(chuàng)傷后腦血流動力學(xué)狀況,評估顱內(nèi)壓、腦灌注壓、腦自動調(diào)節(jié)功能及預(yù)后已受到廣泛關(guān)注。 顱腦創(chuàng)傷所致的腦血管病變(如外傷性頸內(nèi)動脈海綿竇瘺和腦動脈瘤等),早期發(fā)現(xiàn)和早期診斷存在一定困難,因而難以獲得早期治療,以致嚴(yán)重影響向患者預(yù)后。特別是外傷性頸動脈海綿竇瘺的篩查、血管內(nèi)栓塞治療術(shù)中監(jiān)測和術(shù)后隨訪亦是神經(jīng)外科的難題之一。探討無創(chuàng)腦血流動力學(xué)檢測在外傷性腦血管病變的篩查診斷、血管內(nèi)栓塞治療術(shù)中監(jiān)測以及隨訪的實用價值,具有重要的臨床意義。 1982年,挪威學(xué)者Aaslid研制出世界上第一臺經(jīng)顱多普勒超聲儀。從此,無創(chuàng)腦血流動力學(xué)的臨床檢測研究和應(yīng)用進入了新時代。經(jīng)顱多普勒是利用低頻超聲波的良好穿透性,采用低頻超聲探頭經(jīng)特定的顱骨透聲窗,探測顱內(nèi)血管血流動力學(xué)參數(shù)的無創(chuàng)性檢查方法。相比其它腦系方面的檢查其具有無創(chuàng)、便捷、快速、價廉、重復(fù)性強及動態(tài)監(jiān)測的特點。該技術(shù)進入國內(nèi)10余年時間,主要用于檢測病人的腦血管痙攣和腦供血不足等基本應(yīng)用方面,其在神經(jīng)外科的臨床應(yīng)用仍處于探索階段。 本研究旨在采用經(jīng)顱多普勒無創(chuàng)技術(shù)動態(tài)檢測顱腦創(chuàng)傷后腦血流動力學(xué)參數(shù)指標(biāo)和頻譜形態(tài)等變化,并與有創(chuàng)顱內(nèi)壓、腦灌注壓、動脈血壓及腦血管造影等金標(biāo)準(zhǔn)比較,建立無創(chuàng)實時定性定量顱內(nèi)壓、腦灌注壓、腦血流量和腦自動調(diào)節(jié)狀態(tài)的評估方法；探索腦血流動力學(xué)的變化規(guī)律和對預(yù)后的影響,以期為臨床選擇最佳治療時機和方法,指導(dǎo)手術(shù)、血管介入和藥物治療,判斷療效和預(yù)后提供科學(xué)依據(jù),也為將來新的臨床治療方法和藥物選擇提供研究基礎(chǔ)。本研究通過無創(chuàng)檢測技術(shù)進行對照研究,無影響病情的風(fēng)險,亦無倫理隱患存在。研究包括以下四部分。 第一章中重型顱腦創(chuàng)傷后腦血流變化與顱內(nèi)壓和腦灌注壓的相關(guān)性研究 目的探討中重型顱腦創(chuàng)傷后的腦血流動力學(xué)參數(shù)指標(biāo)變化與顱內(nèi)壓和腦灌注壓的相關(guān)關(guān)系。方法采用經(jīng)顱多普勒無創(chuàng)血流檢測技術(shù),前瞻性隨機對照研究62例急性中重型顱腦創(chuàng)傷病人的雙側(cè)大腦中動脈血流動力學(xué)檢測指標(biāo)的有關(guān)參數(shù)和頻譜形態(tài)。檢測腦血流動力學(xué)的參數(shù)指標(biāo)主要包括：收縮期峰值血流速度(Vs)、舒張期低值血流速度(Vd)、平均血流速度(Vm)、搏動指數(shù)(PI)、阻力指數(shù)(RI)；同期采用顱內(nèi)壓監(jiān)護儀和心電監(jiān)護儀持續(xù)監(jiān)測顱內(nèi)壓(ICP)、腦灌注壓(CPP)和平均動脈血壓(MABP)。統(tǒng)計分析腦血流動力學(xué)的有關(guān)參數(shù)指標(biāo)、MABP與ICP、CPP等,分析上述參數(shù)指標(biāo)的相關(guān)關(guān)系和相關(guān)程度。結(jié)果PI、RI與ICP呈正相關(guān)關(guān)系,相關(guān)系數(shù)分別為r=0.898(P0.0001),r=0.812(P0.0001),ICP和CPP與PI、RI、Vd、Vm、MABP多元逐步回歸分析發(fā)現(xiàn)PI與ICP,CPP與PI、MABP關(guān)系最為密切(P0.0001)。結(jié)論無創(chuàng)檢測腦血流動力學(xué)的有關(guān)參數(shù)和頻譜形態(tài)可實時反映中重型顱腦創(chuàng)傷病人的ICP和CPP變化。無創(chuàng)腦血流檢測評估顱內(nèi)壓和腦灌注壓具有無創(chuàng)、便捷、價廉、可重復(fù)性強、易于臨床推廣,可作為神經(jīng)外科臨床顱內(nèi)壓和腦灌注壓監(jiān)測的一種有效方法。 第二章無創(chuàng)腦血流檢測評估中重型顱腦創(chuàng)傷患者預(yù)后的臨床價值研究 目的探討腦血流動力學(xué)的參數(shù)指標(biāo)與預(yù)后評估的參數(shù)指標(biāo)(GCS和GOS)相關(guān)性；探討無創(chuàng)檢測腦血流動力學(xué)有關(guān)參數(shù)指標(biāo)對中重型顱腦創(chuàng)傷病人預(yù)后評估的臨床應(yīng)用價值。方法采用經(jīng)顱多普勒無創(chuàng)檢測72例急性中重型顱腦創(chuàng)傷病人傷后第1、3、7天的雙側(cè)大腦前,大腦中動脈,大腦后動脈和椎基底動脈的血流動力學(xué)參數(shù)指標(biāo)包括：搏動指數(shù)(PI)、阻力指數(shù)(RI)、收縮期峰值血流速度(Vs)、舒張期末血流速度(Vd)和平均血流速度(Vm)。入院后一周動態(tài)記錄病人GCS評分,以及傷后六個月GOS評分。分析Vs、Vd、Vm、PI、RI、GCS評分與傷后六個月GOS預(yù)后評分的關(guān)系。結(jié)果PI和RI與GOS評分呈負(fù)相關(guān)關(guān)系(PI:r=-0.553,P0.0001; RI:r=-0.562,P0.0001)。腦血管痙攣也是影響病人預(yù)后的獨立因素,血管痙攣組與非血管痙攣組的預(yù)后比較有顯著差異(X2=5.98,P0.05),基底動脈血流速度異常是影響病人預(yù)后的重要因素(X2=17.86, P0.01), PI是評估預(yù)后最敏感的指標(biāo),PI1.8提示預(yù)后不良。第三天的GCS評分和EICA-Vm與患者預(yù)后的相關(guān)性最大(P0.0001),相關(guān)系數(shù)R=0.879,確定系數(shù)R2=0.763。結(jié)論無創(chuàng)檢測的腦血流動力學(xué)有關(guān)參數(shù)指標(biāo)是評估中重型顱腦創(chuàng)傷病人預(yù)后的有效方法；腦血管痙攣和基底動脈血流速度異常是影響病人預(yù)后的重要因素。PI是評估預(yù)后最敏感的指標(biāo)。傷后第三天GCS評分和EICA-Vm是評估預(yù)后重要指標(biāo)。 第三章無創(chuàng)腦血流檢測早期評估重型顱腦創(chuàng)傷腦死亡的臨床價值研究 目的探討經(jīng)顱多普勒無創(chuàng)檢測重型顱腦創(chuàng)傷病人腦血流動力學(xué)參數(shù)指標(biāo)診斷腦死亡的臨床價值,以及評估重型顱腦創(chuàng)傷后重度昏迷病人預(yù)后的臨床價值。方法采用經(jīng)顱多普勒無創(chuàng)動態(tài)檢測60例重型顱腦創(chuàng)傷病人(GCS≤8分,持續(xù)時間6小時以上),收集上述病人的大腦前、中、后動脈血流動力學(xué)有關(guān)參數(shù)指標(biāo),以雙側(cè)大腦中動脈(MCA)的血流參數(shù)指標(biāo)和頻譜形態(tài)為主要觀察指標(biāo),同時結(jié)合臨床病情和CT、ICP有關(guān)資料進行對照研究和統(tǒng)計分析。結(jié)果本組重型顱腦創(chuàng)傷后深昏迷病人雙側(cè)大腦中動脈平均血流速度(MCA-Vm)10cm/s,兩條以上的血管出現(xiàn)舒張期反向血流或釘子狀頻譜,血流方向指數(shù)(DFI)0.8,是提示腦死亡的可靠指標(biāo)。顱內(nèi)壓(ICP)60mmHg是腦功能不可逆轉(zhuǎn)的臨界壓力指標(biāo)。結(jié)論無創(chuàng)檢測腦血流動力學(xué)參數(shù)指標(biāo),對于重型顱腦創(chuàng)傷病人腦死亡的初步診斷和重型顱腦創(chuàng)傷深昏迷病人的預(yù)后評估具有較高的準(zhǔn)確性和可靠性。腦死亡的特征性頻譜(RDF和釘子頻譜)早于臨床腦死亡6-12h出現(xiàn),總結(jié)出腦血流監(jiān)測MCA-Vm10cm/s、PI2為可能出現(xiàn)腦死亡的量化指標(biāo)。 第四章無創(chuàng)腦血流檢測在外傷性頸動脈海綿竇瘺診療中的價值研究 目的探討經(jīng)顱多普勒無創(chuàng)腦血流檢測在外傷性頸內(nèi)動脈海綿竇瘺的診斷、血管內(nèi)介入治療術(shù)中監(jiān)測和隨訪的臨床應(yīng)用價值。方法采用經(jīng)顱多普勒無創(chuàng)檢測28例顱腦外傷后合并眼球結(jié)膜充血、突眼、顱內(nèi)血管雜音及其他可疑有頸內(nèi)動脈海綿竇瘺的病人,檢測指標(biāo)參數(shù)包括雙側(cè)大腦中、大腦前、大腦后動脈血流參數(shù),椎基底動脈血流參數(shù),頸內(nèi)動脈顱外段血流參數(shù)。所有病例均經(jīng)數(shù)字減影全腦血管造影(DSA)明確診斷。栓塞術(shù)中經(jīng)顱多普勒持續(xù)監(jiān)測雙側(cè)大腦中動脈血流狀態(tài),統(tǒng)計分析評價栓塞治療過程中腦血流狀態(tài)的變化及血流頻譜的改變,并與DSA檢查結(jié)果對照。另取各種原因進行DSA腦血管造影檢查未見腦血管異常的18例患者經(jīng)顱多普勒無創(chuàng)腦血流檢測的參數(shù)指標(biāo)和頻譜形態(tài)等資料作為對照。結(jié)果無創(chuàng)腦血流檢測發(fā)現(xiàn)頸內(nèi)動脈顱外段的高流速低阻力頻譜,大腦中、前動脈的低流速低阻力頻譜以及眼上靜脈異常頻譜為頸內(nèi)動脈海綿竇瘺的特征性改變,與DSA全腦血管造影對照具有較高的準(zhǔn)確性和特異性�；紓�(cè)EICA-Vm高于健側(cè)EICA-Vm(P0.05),見；患側(cè)EICA-PI低于健側(cè)EICA-PI(P0.05)。術(shù)中無創(chuàng)腦血流監(jiān)測可實時準(zhǔn)確地評估頸內(nèi)動脈海綿竇瘺口栓塞是否成功。無創(chuàng)腦血流檢測診斷TCCF結(jié)果是靈敏度=85.71%,特異度=88.89%,約登指數(shù)=74.60%。栓塞成功后Vm和PI與術(shù)前比較表現(xiàn)為Vm增高和PI升高(P0.01)。結(jié)論經(jīng)顱多普勒無創(chuàng)腦血流檢測是頸內(nèi)動脈海綿竇瘺的臨床初步診斷、介入治療術(shù)中適時效果評估和病例隨訪的有效手段。頸內(nèi)動脈顱外段高流、低阻和大腦中動脈低流、低阻為篩查TCCF的準(zhǔn)確指標(biāo),栓塞術(shù)中大腦中動脈腦血流監(jiān)測是實時評價瘺口栓塞成功的有效方法。(圖22幅,表12個,參考文獻88篇)。
[Abstract]:Craniocerebral trauma is a common and frequently occurring disease in the Department of Neurosurgery, especially the severe head and severe craniocerebral trauma and high death rate. The key and difficult point in the Department of neurosurgery is that the intracranial pressure control and the maintenance of cerebral perfusion pressure in the patients with moderate and severe craniocerebral trauma are the key to rescue success or not, and the main purpose is to use invasive methods to monitor the intracranial pressure and cerebral perfusion pressure. However, the risk of invasive intracranial pressure monitoring (such as infection and intracranial hemorrhage, etc.) and expensive cost costs make clinical applications limited. With the development of the concept and technology of minimally invasive and noninvasive Department of Neurosurgery, the search for an effective noninvasive intracranial pressure and cerebral perfusion pressure monitoring method is gradually valued by the academic community. Assessment of intracranial hemodynamics, intracranial pressure, cerebral perfusion pressure, brain regulation and prognosis have received wide attention.
Early detection and early diagnosis of cerebral vascular lesions (such as traumatic carotid cavernous sinus fistula and cerebral aneurysm) caused by craniocerebral trauma (such as traumatic carotid cavernous sinus fistula and cerebral aneurysm) are difficult to obtain early, so as to seriously affect the prognosis of the patients, especially the screening of traumatic carotid cavernous sinus fistula, monitoring and postoperative intraoperative monitoring of endovascular embolization. Interview is also one of the difficult problems in the Department of neurosurgery. It is of important clinical significance to explore the screening and diagnosis of traumatic cerebral vascular disease, the monitoring of endovascular embolization and the practical value of follow-up.
In 1982, the Norway scholar Aaslid developed the first transcranial Doppler in the world. From then on, the clinical study and application of noninvasive cerebral hemodynamics entered a new era. Transcranial Doppler is a good penetration of low frequency ultrasound, and a low frequency ultrasound probe is used to detect the blood flow power of intracranial vessels. The method of noninvasive examination of the learning parameters has the characteristics of non-invasive, convenient, fast, inexpensive, reproducible and dynamic monitoring compared with other brain systems. This technology has been used for more than 10 years in China and is mainly used to detect the basic application of cerebral vasospasm and cerebral blood supply deficiency in patients, and its clinical application in the Department of Neurosurgery remains still in place. At the exploratory stage.
The aim of this study was to dynamically detect the changes of cerebral hemodynamic parameters and spectrum morphology after craniocerebral trauma by transcranial Doppler noninvasive technique, and to establish noninvasive real-time qualitative and quantitative intracranial pressure, cerebral perfusion pressure, cerebral blood flow and automatic brain regulation compared with the gold standards of traumatic intracranial pressure, cerebral perfusion pressure, arterial blood pressure and cerebral angiography. In order to provide scientific basis for selecting the best treatment opportunity and method, guiding the operation, vascular intervention and drug treatment, judging the curative effect and prognosis, it also provides the basis for the future new clinical treatment and drug selection. A comparative study of noninvasive detection technology has no impact on the risk of illness and no ethical hazard exists. The study includes the following four parts.
The correlation between cerebral blood flow and intracranial pressure and cerebral perfusion pressure after severe traumatic brain injury in Chapter 1
Objective to explore the correlation between the changes of cerebral hemodynamic parameters and intracranial pressure and cerebral perfusion pressure after severe traumatic brain trauma. Methods the transcranial Doppler non-invasive flow detection technique was used to study the parameters of bilateral cerebral artery hemodynamics in 62 patients with acute and severe craniocerebral trauma. Parameters of number and frequency spectrum. The parameters of cerebral hemodynamics were mainly included: peak systolic blood flow velocity (Vs), diastolic low blood flow velocity (Vd), mean blood flow velocity (Vm), pulsatile index (PI), resistance index (RI), intracranial pressure monitor and ECG monitor continuously monitoring intracranial pressure (ICP), cerebral perfusion pressure (CPP) and average. Arterial blood pressure (MABP). Statistical analysis of related parameters of cerebral hemodynamics, MABP and ICP, CPP, and so on. The correlation and correlation of these parameters were analyzed. Results PI, RI and ICP were positively correlated, the correlation coefficients were r=0.898 (P0.0001), r=0.812 (P0.0001), ICP and pluralistic stepwise regression analysis found CP, CPP and PI, MABP is the most closely related (P0.0001). Conclusion the parameters and spectrum form of noninvasive detection of cerebral hemodynamics can reflect the changes of ICP and CPP in patients with severe craniocerebral trauma. Noninvasive cerebral blood flow detection is a noninvasive, convenient, inexpensive, reproducible, and easy to use, and can be used as a nerve. An effective method for monitoring intracranial pressure and cerebral perfusion pressure in surgery.
The second chapter is the clinical value of non-invasive cerebral blood flow in the prognosis of patients with moderate and severe traumatic brain injury.
Objective to explore the correlation between the parameters of cerebral hemodynamics and the parameters of prognostic evaluation (GCS and GOS), and to explore the clinical value of the parameters of noninvasive detection of cerebral hemodynamics to the prognosis evaluation of patients with moderate and severe craniocerebral trauma. Methods 72 cases of acute and severe craniocerebral trauma were detected by transcranial Doppler noninvasive detection. The hemodynamic parameters of the bilateral cerebral anterior brain, middle cerebral artery, posterior cerebral artery and vertebral basilar artery included pulsatile index (PI), resistance index (RI), peak systolic blood flow velocity (Vs), diastolic end flow velocity (Vd) and mean blood flow velocity (Vm). The patients' GCS score was recorded dynamically and six patients after the 1,3,7 day after admission. The relationship between the scores of Vs, Vd, Vm, PI, RI, GCS and the GOS prognosis after six months after injury was analyzed. Results there was a negative correlation between PI and RI and GOS score. Cerebral vasospasm was an independent factor affecting the prognosis of the patients, and there was a significant difference in the prognosis of the vasospasm group and the non vasospasm group (GOS). 98, P0.05), the abnormal flow velocity of basilar artery is an important factor affecting the prognosis of the patients (X2=17.86, P0.01), PI is the most sensitive index to evaluate the prognosis, PI1.8 suggests poor prognosis. The correlation of GCS score and EICA-Vm with the prognosis of patients is the largest (P0.0001), the correlation is R=0.879, determine the coefficient of R2=0.763. conclusion noninvasive brain blood. The parameter index of flow mechanics is an effective method to evaluate the prognosis of patients with severe craniocerebral trauma. Cerebral vasospasm and abnormal velocity of basilar artery blood flow are important factors affecting the prognosis of patients.PI is the most sensitive index to evaluate the prognosis. The third day after injury GCS score and EICA-Vm are important prognostic indicators.
The third chapter is the clinical value of non-invasive cerebral blood flow detection in early assessment of severe traumatic brain injury.
Objective to evaluate the clinical value of cerebral hemodynamic parameters in patients with severe craniocerebral trauma by transcranial Doppler noninvasive detection, and to evaluate the clinical value of the prognosis of severe coma patients after severe craniocerebral trauma. Methods 60 patients with severe craniocerebral trauma were detected by transcranial Doppler noninvasive dynamic test (GCS < 8, duration 6 small. The parameters of the hemodynamic parameters of the anterior, middle and posterior cerebral arteries of the above patients were collected, and the parameters of the blood flow parameters and the spectrum form of the bilateral middle cerebral artery (MCA) were observed as the main indexes, while the clinical condition and the related data of the CT and ICP were compared with the statistical analysis. The mean blood flow velocity (MCA-Vm) of the median cerebral artery (MCA-Vm) 10cm/s, the blood flow of diastolic phase or the nail like spectrum, the blood flow direction index (DFI) 0.8, is a reliable indicator of brain death. The intracranial pressure (ICP) 60mmHg is an irreversible critical pressure index of brain function. Conclusion noninvasive detection of cerebral hemodynamic parameters is a conclusion. The primary diagnosis of brain death in severe craniocerebral trauma patients and the prognosis assessment of severe traumatic brain trauma patients have high accuracy and reliability. The characteristic spectrum of brain death (RDF and nail spectrum) is earlier than that of the clinical brain death 6-12h, and the cerebral blood flow monitoring MCA-Vm10cm/s is summed up, and PI2 is a possible quantification of brain death. Indicators.
The fourth chapter is the value of non-invasive cerebral blood flow in the diagnosis and treatment of traumatic carotid cavernous fistula.
Objective to investigate the clinical value of transcranial Doppler noninvasive cerebral blood flow (TCD) in the diagnosis of traumatic carotid cavernous fistula and the clinical value of monitoring and follow-up during intravascular interventional therapy. Methods 28 cases of craniocerebral trauma were treated with transcranial Doppler, combined with conjunctival congestion, exophthalmos, intracranial vascular murmurs and other suspected internal carotid arteries. The parameters of the cavernous sinus fistula include bilateral brain, precerebrum, posterior cerebral artery blood flow parameters, vertebrobasilar artery blood flow parameters, and extracranial blood flow parameters of the internal carotid artery. All cases are clearly diagnosed by digital subtraction total cerebral angiography (DSA). The changes of cerebral blood flow state and blood flow spectrum in the course of embolization were evaluated by statistical analysis, and the results of the blood flow spectrum were compared with the results of DSA examination. In addition, the parameters of the parameters of the noninvasive cerebral blood flow detection and the spectrum form of the transcranial Doppler non-invasive cerebral blood flow were taken as control in 18 patients with DSA angiography. The high flow velocity and low resistance spectrum of the extracranial segment of the internal carotid artery, the low flow rate of the anterior artery and the abnormal frequency of the superior ophthalmic vein for the cavernous sinus fistula of the internal carotid artery were found to be more accurate and specific than that of the DSA whole brain angiography. The EICA-Vm of the affected side was higher than that of the contralateral EICA-Vm (P 0.05) see, the affected side EICA-PI is lower than the healthy side EICA-PI (P0.05). Noninvasive cerebral blood flow monitoring during the operation can accurately evaluate the success of the carotid cavernous sinus fistula. The TCCF results of non-invasive cerebral blood flow detection are sensitivity =85.71%, specificity =88.89%, Vm and PI after the successful =74.60%. embolism, and the increase of Vm is higher than that of Vm. And PI (P0.01). Conclusion transcranial Doppler non-invasive cerebral blood flow detection is a preliminary clinical diagnosis of cavernous fistula of the internal carotid artery, the effective means of timely evaluation and case follow-up during interventional therapy. The high flow of the extracranial segment of the internal carotid artery, low resistance and low middle cerebral artery flow, low resistance as the accurate index for screening TCCF, the middle cerebral artery in embolization. Cerebral blood flow monitoring is an effective method to evaluate the success of fistula embolization in real time (Fig. 22, table 12, and 88 references).
【學(xué)位授予單位】：中南大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2013
【分類號】：R651.15

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