本文選題：垂體瘤卒中 + 急診手術(shù)　； 參考：《西南醫(yī)科大學》2017年碩士論文

【摘要】：目的:探究術(shù)前清晨8:00血清皮質(zhì)醇水平處于正常范圍內(nèi)的臨床型垂體瘤卒中患者使用糖皮質(zhì)激素治療的療效與安全性。方法:回顧性分析從2007年1月至2016年7月入住我院神經(jīng)外科的符合納入條件的43例臨床型垂體瘤卒中患者的病歷資料及影像資料,將其按照入院后是否使用糖皮質(zhì)激素治療分成使用糖皮質(zhì)激素治療組(觀察組)和未使用糖皮質(zhì)激素治療組(對照組),43例患者均行手術(shù)治療,觀察組術(shù)前、術(shù)后一周都使用激素治療,統(tǒng)計分析兩組患者臨床癥狀、手術(shù)全切率、術(shù)后癥狀改善、術(shù)后內(nèi)分泌改善情況、平均住院時間、術(shù)后病理類型、術(shù)后第3天、術(shù)后第7天的血清皮質(zhì)醇水平變化情況、低鈉血癥及尿崩的發(fā)生情況,進而分析急診手術(shù)效果,糖皮質(zhì)激素治療的療效。結(jié)果:(1)43例患者中突發(fā)頭昏頭痛37例,占86.05%;視物模糊29例,占67.44%;惡心、嘔吐23例,占53.49%;有急性失明5例,占11.62%;泌乳、閉經(jīng)3例,占6.97%;肢端肥大2例,占4.65%;3例患者查體頸項強直,克氏征陽性,腦膜刺激征表現(xiàn),占6.97%;發(fā)生偏癱2例,占4.65%。(2)急診手術(shù)治療,其中行經(jīng)鼻蝶竇顯微鏡下切除術(shù)患者39例,行開顱切除術(shù)患者4例,術(shù)后腫瘤全切41例,全切率為95.35%,次全切患者2例,次全切率為4.65%。其中觀察組18例患者,全切17例,次全切1例,對照組25例患者,全切24例,次全切1例,p0.05,差異無統(tǒng)計學意義。(3)術(shù)后患者頭昏頭痛癥狀較術(shù)前明顯緩解33例,其中觀察組16例,對照組17例,未見明顯改善觀察組1例,對照組2例,觀察組中1例患者加重,p0.05,差異無統(tǒng)計學意義;兩組患者視力模糊、惡心、嘔吐均有所緩解;5例急性失明患者中有3例完全緩解,2例明顯改善。(4)術(shù)后內(nèi)分泌癥狀改善情況,垂體泌乳素觀察組正常16例,低于正常2例,對照組正常18例,低于正常7例,p0.05,差異無統(tǒng)計學意義;生長激素觀察組正常14例,低于正常4例,對照組正常19例,低于正常6例,p0.05,差異無統(tǒng)計學意義;ft3、ft4觀察組正常16例,降低2例,對照組正常14例,降低11例,p0.05,差異無統(tǒng)計學意義。(5)術(shù)后平均住院時間,觀察組(13.21±5.78)天,對照組(13.71±4.93)天,p0.05,差異無統(tǒng)計學意義。(6)術(shù)后病理報告示無功能性腺瘤19例,促性腺激素腺瘤11例,垂體泌乳素(prl)腺瘤5例,生長激素腺瘤(gh)3例,混合腺瘤3例,acth型腺瘤1例,tsh腺瘤1例。(7)術(shù)后血清皮質(zhì)醇水平變化情況,兩組患者在術(shù)后第三天清晨8:00血清皮質(zhì)醇水平分別為(13.89±6.53)ug/dl、(9.46±3.66)ug/dl,p0.05,差異有統(tǒng)計學意義;兩組患者在術(shù)后第七天清晨8:00血清皮質(zhì)醇水平分別為(13.19±4.64)ug/dl、(8.78±2.20)ug/dl,p0.05,差異有統(tǒng)計學意義。(8)術(shù)后皮質(zhì)醇低于4ug/dl,觀察組0人,對照組3人,p0.05,差異無統(tǒng)計學意義。(9)術(shù)后發(fā)生一過性尿崩觀察組3人,對照組6人,p0.05,差異無統(tǒng)計學意義。(10)術(shù)后發(fā)生低鈉血癥(低于135mmol/l)觀察組3人,對照5人,p0.05,差異無統(tǒng)計學意義。(11)術(shù)后一月兩組患者皮質(zhì)醇水平分別為(9.01±4.51)ug/dl、(8.93±4.27)ug/dl,p0.05,差異無統(tǒng)計學意義;術(shù)后三月皮質(zhì)醇分別為(9.34±3.87)ug/dl、(8.72±4.09)ug/dl,p0.05,差異無統(tǒng)計學意義。(12)術(shù)后3例皮質(zhì)醇低于4ug/dl患者中有2例患者皮質(zhì)醇逐漸恢復,不需長期替代治療,僅有1例患者長期口服激素替代治療。結(jié)論:1.糖皮質(zhì)激素替代治療僅有利于維持患者血清皮質(zhì)醇水平,但對患者術(shù)后恢復及術(shù)后并發(fā)癥的預防無明顯作用。因此術(shù)前皮質(zhì)醇水平在正常范圍內(nèi)的臨床型垂體瘤卒中患者可在嚴密監(jiān)測血清皮質(zhì)醇水平的情況下不使用糖皮質(zhì)激素替代治療,但由于本研究納入病例數(shù)少,臨床個體差異,術(shù)前皮質(zhì)醇在正常范圍內(nèi)的臨床垂體瘤卒中患者是否需使用糖皮質(zhì)激素治療仍有待進一步研究。2.手術(shù)切除術(shù)后,患者殘留垂體腺功能有一定恢復,可不使用激素替代治療,功能未得到恢復患者可在密切監(jiān)測垂體功能前提下使用激素替代治療。3.臨床型垂體瘤卒中患者入院后積極完善相關(guān)術(shù)前檢查,急診行手術(shù)治療對患者的臨床癥狀、體征均有明顯的改善,經(jīng)鼻蝶鞍區(qū)占位切除術(shù)手術(shù)全切率高、術(shù)后并發(fā)癥少、對患者損傷較小,是目前垂體瘤卒中的首選手術(shù)治療方式。4.垂體瘤卒中發(fā)病率的高低,無功能性腺瘤促性腺激素腺瘤垂體泌乳素(PRL)腺瘤生長激素腺瘤(GH)混合腺瘤ACTH型腺瘤、TSH腺瘤。
[Abstract]:Objective: To explore the efficacy and safety of glucocorticoid therapy for clinical pituitary tumor stroke patients at 8:00 before 8:00 in the morning. Methods: a retrospective analysis of the medical records of 43 patients with clinical pituitary apoplexy from January 2007 to July 2016. The material and image data were divided into the treatment group (observation group) and the unused glucocorticoid treatment group (control group) in the treatment group (observation group) and unused glucocorticoid treatment group (control group) in accordance with the use of glucocorticoid after admission. 43 patients were treated with surgical treatment. The observation group was treated with irritable treatment in the first week of the operation. The clinical symptoms of the two groups were analyzed and the operation was completely cut. Rate, postoperative symptoms improvement, postoperative endocrine improvement, average hospitalization time, postoperative pathological type, third days after operation, changes in serum cortisol level, hyponatremia and diabetes insipidus at seventh days after operation, and then analyzed the effect of emergency operation and glucocorticoid treatment. Results: (1) 37 cases of sudden dizziness and headache in 43 patients. Accounting for 86.05%, 29 cases, 67.44%, 23 cases of nausea and vomiting, 53.49%, 5 cases of acute blindness, 11.62%, lactation, amenorrhea 3, 6.97%, 2 acromegaly, 4.65%, and 3 cases of neck rigidity, Kirschner's sign, meningeal irritation, accounting for 6.97%; 4.65%. emergency surgery, which took the transnasal butterfly Dou Xian There were 39 cases of microendoscopic resection, 4 cases of craniotomy, 41 cases of total resection of tumor after operation, total resection rate of 95.35%, and 2 cases of subtotal resection. The subtotal resection rate was 4.65%. in the observation group of 18 cases, total resection in 17 cases, subtotal resection in 1 cases, and 25 patients in the control group, 24 cases of total resection, total resection of 1 cases, and the difference was not statistically significant. (3) postoperative head FATP. The pain symptoms were significantly relieved in 33 cases, including 16 in the observation group and 17 in the control group, with no obvious improvement in the observation group, 1 in the observation group, 2 in the control group and 1 in the observation group, P0.05, with no statistically significant difference; the two groups were relieved of blurred vision, nausea and vomiting in the two group; 3 patients in 5 cases were completely relieved and 2 cases improved significantly (4). After the improvement of endocrine symptoms, 16 cases in the pituitary prolactin observation group were normal, 2 cases were lower than normal and 18 cases in the control group, 18 cases were normal, 7 cases were lower than normal, P0.05, the difference was not statistically significant; the growth hormone observation group was normal 14 cases, lower than normal 4 cases, normal 19 cases in the control group, lower than the normal 6 cases, and the difference was not statistically significant; FT3, FT4 observation group was normal 16 For example, 2 cases were reduced and 14 cases in the control group were normal, 11 cases decreased, P0.05, the difference was not statistically significant. (5) the average hospitalization time after operation, the observation group (13.21 + 5.78) days, the control group (13.71 + 4.93) days, the difference was not statistically significant. (6) 19 cases of reactive power adenomas, 11 cases of gonadotropin adenoma and 5 cases of pituitary prolactin (PRL) adenoma after operation were reported. 3 cases of long hormone adenoma (GH), 3 cases of mixed adenoma, 1 cases of ACTH type adenoma, 1 cases of TSH adenoma. (7) the change of serum cortisol level after operation. The serum cortisol level was (13.89 + 6.53) ug/dl (9.46 + 3.66) ug/dl, P0.05, respectively, at 8:00 postoperatively at the early morning after the operation, and the difference was statistically significant; the patients in the two group were at 8:00 in the morning after the operation. The level of cortisol was (13.19 + 4.64) ug/dl, (8.78 + 2.20) ug/dl, P0.05, and the difference was statistically significant. (8) the cortisol was lower than 4ug/dl, 0 in the observation group, 3 in the control group, and P0.05, with no statistical significance. (9) there was 3 in the observation group of diabetes insipidus, 6 in the control group and P0.05 in the control group. (10) there was low sodium blood after operation. There were 3 people in the observation group (lower than 135mmol/l), 5 people and P0.05, the difference was not statistically significant. (11) the level of cortisol was (9.01 + 4.51) ug/dl, (8.93 + 4.27) ug/dl, P0.05, respectively, and the cortisol was (9.34 + 3.87) ug/dl, (8.72 + 4.09) ug/dl, P0.05, P0.05, no statistical significance after the operation. After 3 cases of cortisol lower than 4ug/dl, 2 patients with cortisol gradually recovered, without long-term replacement therapy, only 1 patients had long-term oral hormone replacement therapy. Conclusion: 1. glucocorticoid replacement therapy is only beneficial to maintain the patient's serum cortisol level, but it has no obvious effect on postoperative recovery and postoperative complications. Clinical pituitary apoplexy patients with normal cortisol levels can not use corticosteroid replacement therapy if the serum cortisol level is closely monitored. However, due to the small number of cases in this study and the difference in the clinical individual, whether the patients with pituitary tumor stroke need to use sugar before the operation of cortisol in the normal range. Corticosteroid therapy still needs further study of.2. resection. The residual pituitary gland function of the patients is restored, and hormone replacement therapy is not used. The patients who have not recovered function can use hormone replacement therapy under the premise of close monitoring of pituitary function to treat.3. clinical pituitary tumor stroke patients after admission. The clinical symptoms and signs of the patients were obviously improved, the total resection rate was high, the postoperative complications were less and the patients were less injured. It was the first choice of surgical treatment for pituitary tumor stroke, the incidence of.4. pituitary apoplexy, no functional adenomatous adenomatous adenomatous adenomatous adenoma. Prolactin (PRL) adenoma growth hormone adenoma (GH) mixed adenoma type ACTH adenoma, TSH adenoma.
【學位授予單位】：西南醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R736.4

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