老年高血压性脑出血相关预后影响因素回顾性分析

目的：回顾性分析高血压性脑出血患者影响预后的各因素之间的关系的相关性,以及各因素对脑出血患者预后的影响。方法：回顾性分析我院2009年1月-2012年7月间接受治疗的老年高血压性脑出血患者147例,其中男：86例,女：61例;年龄60．83岁,平均（69．6±5．7）岁;高血压病程8-23年,平均（9．7±1．6）年。分析老年高血压性脑出血患者发病至就诊时间、入院就诊时的临床表现、患者的意识状态、出血位置及出血量、语言功能障碍、肢体运动功能障碍,以及患者的预后转归等因素与预后的相关性。结果：老年高血压性脑出血治疗后,总有效率为67．7％;在诸多预后因素中：意识状态、出血量、出血位置,以及是否破入脑室等因素与预后具有相关性,具有统计学意义（P〈0．05）。结论：老年高血压性脑出血的预后与意识状态、出血量、出血位置相关,根据临床症状对脑出血患者采取积极的治疗措施,对脑出血患者的预后有重要的意义。     

心房颤动对不同时间窗内急性缺血性脑卒中患者静脉溶栓疗效的对比研究

目的:探讨与对比心房颤动对不同时间窗内急性缺血性脑卒中患者静脉溶栓疗效的影响。方法:选择2014年8月到2016年5月在我院进行诊治的急性缺血性脑卒中患者98例,其中卒中前已诊断心房颤动定义为慢性心房颤动组(n=50),入院后诊断心房颤动者为新发心房颤动组(n=48);两组都给予重组组织型纤溶酶原激活剂(rt-PA)静脉溶栓治疗,记录两组预后情况。结果:两组患者的性别、年龄、时间窗、合并疾病、血糖与甘油三酯含量对比无明显差异(P0.05)。慢性心房颤动组与新发心房颤动组的有效率分别为94.0%和95.8%,组间比较差异无统计学意义(P0.05)。慢性心房颤动组与新发心房颤动组治疗后的m RS评分分别为6.22±1.83分和6.29±1.45分,都明显低于治疗前的9.24±1.31分和9.19±1.52分(P0.05),组间对比无明显差异(P0.05)。慢性心房颤动组的症状性脑出血与非症状性脑出血发生率分别为4.0%和2.0%,都明显低于新发心房颤动组的14.6%和12.5%(P0.05)。结论:发病4.5h之内静脉溶栓急性缺血性脑卒中是安全有效的,新发心房颤动不影响患者静脉溶栓后的神经功能结局,但是会增加症状性脑出血与非症状性脑出血,需要加强预防性管理。     

CEREBRAL COMPLICATIONS INCURRED DURING PREGNANCY AND THE PUERPERIUM

In a statistical study of maternal mortality cases in Franklin County, Ohio, with a total of 170 deaths in a ten-year period (1948-1957), there were 36 fatal cases with cerebral complications of various types. Intracranial hemorrhage was the cause of death in 17 cases; subarachnoid hemorrhage in eight; intracerebral hemorrhage in eight and subdural hemorrhage in one case. There were nine cases of intracranial tumor with fatality. In a miscellaneous group of ten “cerebral deaths” infectious processes were the cause in eight cases, including tuberculous meningitis, purulent meningitis, brain abscess, acute (cerebromedullary) poliomyelitis, “viral” encephalitis, toxoplasmosis and tetanus.In a smaller clinical (nonfatal) group with cerebral complications occurring during pregnancy and the puerperium, two patients with subarachnoid hemorrhages made spontaneous recovery. A diagnosis of intracerebral hemorrhage was made in three instances, in two of which operation was done and evacuation of blood clots was accomplished. One patient recovered spontaneously from a minimal hemorrhage.Five other persons had cerebral thrombosis, three in the third month of pregnancy and two in the immediate puerperium. All recovered, with some residual deficits.Three patients with intracranial tumor were successfully treated surgically but with disappointing results ultimately (one case each of cerebellar medulloblastoma, cerebral astrocytoma and supratentorial meningioma).Only when the obstetrician, neurologist and the neurosurgeon are fully aware of the signs, symptoms, and many times the rapid course of these cerebral complications of pregnancy, can there be any material lowering of the morbidity and mortality. Emphasis should be placed on the early investigation of all neurological complaints during pregnancy and the puerperium, with immediate institution of an aggressive diagnostic and therapeutic regimen.     

Is severe pulmonary hypertension a contraindication for orthotopic heart transplantation? Not any more

Pulmonary hypertension (PH) unresponsive to pharmacological intervention is considered a contraindication for orthotopic heart transplantation (OHTX) due to risk of postoperative right-heart failure. In this prospective study, we describe our experience with a treatment strategy of improving severe PH in heart transplant candidates by means of ventricular assist device (VAD) implantation and subsequent OHTX. In 11 heart transplantation candidates with severe PH unresponsive to pharmacological intervention we implanted VAD with the aim of achieving PH to values acceptable for OHTX. In all patients we observed significant drop in pulmonary pressures, PVR and TPG (p < 0.001 for all) 3 months after VAD implantation to values sufficient to allow OHTX. Seven patients underwent transplantation (mean duration of support 216 days) while none of patients suffered right-side heart failure in postoperative period. Two patients died after transplantation and five patients are living in very good condition with a mean duration of 286 days after OHTX. In our opinion, severe PH is not a contraindication for orthotopic heart transplantation any more.     

幕上高血压脑出血小骨窗开颅术后C 反应蛋白及TNF-α 的变化及对转 归影响的临床分析

目的:探索幕上高血压脑出血术前及小骨窗开颅术后C反应蛋白(CRP)及肿瘤坏死因子α(TNF-α)的变化与病情的关系及对患者临床预后的预测价值。方法:38例诊断为幕上高血压脑出血的患者,在明确手术指征后行小骨窗开颅术,于术前,术后第1天,第7天,第14天监测患者的CRP及TNF-α的水平;并同时测定格拉斯哥昏迷评分(GSS)。另设30例作为正常对照病例,一次性抽取静脉血进行CRP及TNF-α进行检测。结果:①术前脑出血患者血中CRP与TNF-α的水平显著高于正常对照组;②术后CRP与TNF-α的水平仍继续上升,术后第7天显著下降;③CRP及TNF-α的水平与GCS评分密切相关。结论:CRP与TNF-α的水平可反映脑出血患者的病情,对病情转归有预测意义。     

Dysphagia in acute stroke.

A prospective study was undertaken to define the incidence, duration, and consequences of dysphagia in an unselected group of 91 consecutive patients who had suffered acute stroke. The site of the present lesion and of any previous stroke was determined clinically and was confirmed by computed tomography of the brain or necropsy in 40 cases. Of 41 patients who had dysphagia on admission, 37 had had a stroke in one cerebral hemisphere. Only seven patients showed evidence of lesions in both hemispheres. Nineteen of 22 patients who survived a stroke in a hemisphere regained their ability to swallow within 14 days. Dysphagia in patients who had had a stroke in a cerebral hemisphere was associated in this study with a higher incidence of chest infections, dehydration, and death.     

CX3CR1 Signaling on Monocytes Is Dispensable after Intracerebral Hemorrhage

Intracerebral hemorrhage is a subset of stroke for which there is no specific treatment. The Ly6C^hi CCR2⁺ monocytes have been shown to contribute to acute injury after intracerebral hemorrhage. The other murine monocyte subset expresses CX3CR1 and lower Ly6C levels, and contributes to repair in other disease models. We hypothesized that the Ly6C^lo CX3CR1⁺ monocytes would contribute to recovery after intracerebral hemorrhage. Intracerebral hemorrhage was modeled by blood injection in WT and CX3CR1-null bone marrow chimeras. Neurological outcomes and leukocyte recruitment were quantified at various time points. Functional outcomes were equal at 1, 3, 7, and 14 days after intracerebral hemorrhage in both genotypes. No differences were observed in leukocyte recruitment between genotypes on either 3 or 7 days after intracerebral hemorrhage. A few hundred Ly6C^lo monocytes were found in the ipsilateral hemisphere in each genotype and they did not change over time. Peripherally derived CX3CR1⁺ monocytes were observed in the perihematomal brain 7 and 14 days after intracerebral hemorrhage. Our data suggests CX3CR1 signaling on monocytes does not play an influential role in acute injury or functional recovery after intracerebral hemorrhage and therefore CX3CR1 is not a therapeutic target to improve outcome after intracerebral hemorrhage.     

Allogeneic bone marrow stromal cell transplantation after cerebral hemorrhage achieves cell transdifferentiation and modulates endogenous neurogenesis

Background aimsWhen a severe neurologic lesion occurs as a consequence of intracerebral hemorrhage (ICH), there is no effective treatment available for improving the outcome. However, cell therapy has opened new perspectives on reducing neurologic sequels subsequent to this diseaseMethodsIn this study, ICH was induced by stereotactic injection of 0.5 U collagenase type IV in the striatum of adult Wistar rats, and 2 h later a group of animals (n = 48) was subjected to intracerebral injection of 2 × 10⁶ allogeneic bone marrow stromal cells (BMSC), while a control group (n = 48) received saline only. Eight animals from each group were killed at 48 h, 72 h, 7 days, 14 days, 21 days and 28 days. At these time-points, endogenous neurogenesis and survival of transplanted BMSC were studied.ResultsOur findings show that after allogeneic BMSC transplantation, donor cells can survive in the brain tissue expressing neuronal and astroglial markers. Furthermore, BMSC transplantation enhances endogenous neurogenesis and inhibits apoptosis of newborn neural cells.ConclusionsAlthough these results should be extrapolated to human disease with caution, it is obvious that cell therapy using allogeneic BMSC transplantation offers great promise for developing novel and efficacious strategies in patients suffering ICH.     

微创手术联合早期针灸治疗高血压脑出血的临床研究

目的:探究微创手术联合早期针灸治疗高血压脑出血的临床疗效。方法:采用随机数字表法将本院2012年3月到2014年3月住院治疗的63例高血压脑出血患者分为研究组(34例)和对照组(29例),研究组给予微创手术与早期针灸(拔除引流管后第2~4天)治疗,对照组给予微创手术与常规针灸(拔除引流管后2周)治疗,分别于治疗前、针灸治疗后第2周和第4周对所有患者进行神经功能缺损及日常生活活动能力判定,对比两组疗效。结果:治疗第2周、4周后,两组神经功能缺损评分在逐渐下降(P0.05),而日常生活活动能力评分在逐渐上升(P0.05),且研究组治疗2周、4周后的神经功能缺损评分均低于对照组(P0.05),日常生活活动能力评分均高于对照组(P0.05);研究组的总有效率为91.2%,显著高于对照组的62.1%(P0.05)。结论:微创手术联合早期针灸治疗可显著改善高血压脑出血患者的神经功能及活动能力,临床疗效显著,且疗效优于微创手术联合常规针灸治疗。     

应激性高血糖与急性自发性脑出血患者术后并发症和早期预后的相关性研究

目的:探讨应激性高血糖与自发性脑出血患者术后并发症及早期预后的关系。方法:回顾性分析我院收治的自发性脑出血患者358例,根据入院时血糖水平、糖化血红蛋白(HbAlc)及既往有无糖尿病史分为血糖正常组(96例)、应激性高血糖组(107例)及糖尿病组(155例),记录和比较各组入院时的血糖、格拉斯哥昏迷评分(GCS)、平均出血量及入院后30 d时各组的术后并发症发生情况、格拉斯哥预后评分(GOS)的差异。结果:糖尿病组入院时血糖水平、平均出血量、重型患者所占比率、脑出血破入脑室、颅内再出血、颅内感染、肺部感染、尿路感染及上消化道出血发生率、GOS分级植物状态或死亡发生率均明显高于应激性高血糖组(P0.05),GOS分级良好率低于应激性高血糖组(P0.05);而应激性高血糖组入院时血糖水平、平均出血量、重型患者所占比率、脑出血破入脑室、颅内再出血发生率、GOS分级植物状态或死亡发生率均明显高于血糖正常组(P0.05)。结论:自发性脑出血患者入院时应激性高血糖与患者的病情显著相关,可加重急性脑出血的不良预后。     

Atrial Pacing to Control Heart Rate and Rhythm in Acute Cardiac Conditions

Increasing the heart rate by a bedside atrial pacing technique was successfully utilized to treat serious cardiac arrhythmia or failure in 13 patients. Nine of these had ventricular arrhythmia refractory to drugs. Seven had evidence of sinus node depression or disease since their sinus pacemaker was below 70 beats per minute under decompensated conditions. In five, coronary artery disease was associated with the bradycardia and in two, digitalis toxicity was related to depression of the intrinsic pacemaker rate. Two patients in the coronary group required implantation of a permanent demand ventricular pacemaker. Hemodynamic studies were performed in seven patients. Only one patient had no increase in cardiac output with pacing rates above his resting rate. The other six patients showed an increase in cardiac output from 22 to 81% at paced rates between 70 and 125/minute. The duration of pacing ranged from one hour to 14 days and averaged five days.     

A Survey of Cardiac Infarctions: Hospital Experience

A study of patients with cardiac infarction, treated in hospital between 1950 and 1954 and followed up to the present, is reported. One hundred and forty-two patients suffered 169 attacks. In 95 attacks, the patients received anticoagulant therapy, with 15 acute deaths. Fifty-six were not so treated; among these there were 21 deaths. The rate of survival was best in younger patients with their first episode of infarction, without preexisting hypertension, cardiac failure, or systolic blood pressure persistently below 100. Angina preceding infarction disappeared in one-half of the subjects after the episode; half the survivors suffered recurrent myocardial infarction within five years. Moderate hypertension had no effect upon immediate or 10-year survival. No patient received long-term anticoagulant therapy. Of the survivors of acute infarction, 16 died in the first year after the acute attack, nine in the second year, nine in the third, six in the fourth and five in the fifth. At the end of five years, 51 subjects had survived 60 episodes. At the end of 10 years, 43 living patients had sustained 45 myocardial infarctions.     

重组组织型纤溶酶原激活剂静脉溶栓治疗发病4.5小时内急性脑梗死近期疗效的回顾性研究

目的:研究发病4.5小时内的急性脑梗死患者早期应用重组组织型纤溶酶原激活剂(rt-PA)静脉溶栓治疗的临床效果。方法:回顾性分析2018年07月1日到2020年10月31日我院神经内科收治的发病在4.5小时内的652例急性脑梗死患者的临床资料,其中使用rt-PA静脉溶栓治疗的患者285例为溶栓组,未溶栓仅使用抗血小板聚集、他汀类降脂、脑保护等常规治疗的患者367例为对照组。记录两组患者治疗前及治疗后24小时、7天、14天的美国国立卫生研究院卒中量表(NIHSS)评分和治疗3个月后的改良Rankin量表(mRS)评分。对于有吞咽障碍的患者,收集洼田饮水试验结果。统计两组患者出血情况和死亡率。结果:溶栓组治疗后24小时、7天、14天的NIHSS评分以及治疗后3个月的mRS评分改善明显,与对照组相比,差异有统计学意义(P<0.05);对于有吞咽障碍的患者,溶栓组的治疗有效率高于对照组(P<0.05);溶栓组轻微出血的概率大于对照组(P<0.05);两组在症状性及致死性脑出血方面的差异无统计学意义(P>0.05);溶栓后大量及致死性脑出血部位多在梗死的中心区、出血量多大于10 mL,患者临床NIHSS评分≥24分。溶栓组死亡率较对照组下降(P<0.05)。结论:发病4.5小时内的急性脑梗死患者接受rt-PA静脉溶栓治疗的近期治疗效果良好,轻微出血风险较高,但是死亡率下降。临床神经功能缺损重、NIHSS评分≥24分、出血风险大的患者预后不良,不推荐溶栓治疗。     

人骨髓间充质干细胞移植对食蟹猴脑出血模型损伤的修复作用

目的观察人骨髓间充质干细胞（human mesenchymal stem cells,hMSCs）移植4周和8周后,对食蟹猴脑出血模型脑组织损伤的修复作用。方法在脑定位仪定位下,通过自体血注入法制成食蟹猴脑出血模型,并将其随机分为高剂量治疗组、低剂量治疗组和模型组,分别在脑出血部位附近注入高、低密度的hMSCs和生理盐水。应用整体病理切片扫描、HE染色及免疫组织化学的方法观察hMSCs移植治疗食蟹猴脑出血4周和8周后脑损伤部位的病理变化。结果脑出血模型组可见脑出血损伤部位脑组织大面积变性坏死,多量吞噬含铁血黄素的泡沫细胞增生,周围少许肉芽组织增生伴局部纤维组织形成。hMSCs治疗组,整体切片扫描结果提示,与模型组相比,hMSCs低剂量及高剂量治疗组均可见脑组织变性坏死范围减小,且低剂量治疗组略好于高剂量治疗组;HE染色可见大脑注射部位局部脑组织变性坏死、吞噬含铁血黄素的泡沫细胞增生,周围肉芽组织增生伴局部纤维组织形成。免疫组化发现治疗组出血区内可见神经巢蛋白（Nestin）阳性细胞内散在分布,而在模型组中呈阴性表达。结论hMSCs可促进食蟹猴脑出血脑组织损伤的修复,且治疗效果可能与治疗剂量有一定相关性。     

Acute coronary syndromes following abrupt cessation of oral propranolol therapy.

Abrupt cessation of oral propranolol therapy was followed by 15 acute coronary events in 14 patients with severe angina who had been receiving propranolol in daily doses of 80 to 400 mg for periods of 7 days to 6 years. Propranolol had been stopped 1 to 14 days before each acute event because of angiographic study (seven patients), increasing symptoms (three), acute coronary insufficiency (one), asymptomatic bradycardia (one), elective surgery (one) and unknown reasons (two). Before abrupt cessation of propranolol treatment anginal symptoms had been stable in six instances but had increased in the other nine. Cessation was followed by rapid progression of symptoms prior to 11 of the 15 acute events. There were six acute transmural myocardial infarctions with three deaths, three intramural myocardial infarctions, one with ventricular fibrillation, and six episodes of acute coronary insufficiency, Unstable angina followed nine of the events and responded to propranolol therapy (160 to 320 mg/d) in eight instances. Three other patients underwent aortocoronary bypass surgery; perioperative acute myocardial infarction occurred in two. These data suggest that in a minority of patients abrupt cessation of propranolol may be hazardous, particularly in severe or unstable disease. Cessation or propranolol therapy in such patients should be gradual and closely observed. Recurrent symptoms respond to reinstitution of propranolol therapy.     

Long-term survival after orthotopic and heterotopic cardiac transplantation.

Five long-term survivors of heart transplantation were reinvestigated. Two patients had undergone orthotopic heart transplantation over 11 and 9 years earlier and constitute two of the world''s longest-surviving patients after this procedure. Three patients had undergone heterotopic heart transplantation (one left heart bypass alone and two biventricular bypass) four to six years earlier. Four of the five patients had had only one or no documented acute rejection episodes. Three had been given blood transfusions. None had had particularly good tissue matching in relation to the donor on HLA typing. All five patients were leading full and active lives. At review two patients had significant coronary artery disease, one severe, presumably due to chronic immune-complex deposition. Heart transplantation remains a major undertaking, but it can offer the patient many years of good-quality life.     

Neurologic complications of lightning injuries.

Over the past ten years, we have cared for 13 patients who suffered serious neurologic complications after being struck by lightning. The spectrum of neurologic lesions includes the entire neuraxis from the cerebral hemispheres to the peripheral nerves. We describe these various neurologic disorders with regard to the site of the lesion, severity of the deficit, and the outcome. Damage to the nervous system can be a serious problem for patients struck by lightning. Fatalities are associated with hypoxic encephalopathy in patients who suffered cardiac arrests. Patients with spinal cord lesions are likely to have permanent sequelae and paralysis. New technology for detecting lightning with wideband magnetic direction finders is useful in establishing lightning-flash densities in each state. Florida and the Gulf Coast states have the highest densities. Colorado and the Rocky Mountain states have the next highest.     

Traumatic Intracranial Hemorrhage Correlates with Preinjury Brain Atrophy,but Not with Antithrombotic Agent Use: A Retrospective Study

Background

The impact of antithrombotic agents (warfarin, clopidogrel, ASA) on traumatic brain injury outcomes is highly controversial. Although cerebral atrophy is speculated as a risk for acute intracranial hemorrhage, there is no objective literature evidence.

Materials and Methods

This is a retrospective, consecutive investigation of patients with signs of external head trauma and age ≥60 years. Outcomes were correlated with antithrombotic-agent status, coagulation test results, admission neurologic function, and CT-based cerebral atrophy dimensions.

Results

Of 198 consecutive patients, 36% were antithrombotic-negative and 64% antithrombotic-positive. ASA patients had higher arachidonic acid inhibition (p = 0.04) and warfarin patients had higher INR (p<0.001), compared to antithrombotic-negative patients. Antithrombotic-positive intracranial hemorrhage rate (38.9%) was similar to the antithrombotic-negative rate (31.9%; p = 0.3285). Coagulopathy was not present on the ten standard coagulation, thromboelastography, and platelet mapping tests with intracranial hemorrhage and results were similar to those without hemorrhage (p≥0.1354). Hemorrhagic-neurologic complication (intracranial hemorrhage progression, need for craniotomy, neurologic deterioration, or death) rates were similar for antithrombotic-negative (6.9%) and antithrombotic-positive (8.7%; p = 0.6574) patients. The hemorrhagic-neurologic complication rate was increased when admission major neurologic dysfunction was present (63.2% versus 2.2%; RR = 28.3; p<0.001). Age correlated inversely with brain parenchymal width (p<0.001) and positively with lateral ventricular width (p = 0.047) and cortical atrophy (p<0.001). Intracranial hemorrhage correlated with cortical atrophy (p<0.001) and ventricular width (p<0.001).

Conclusions

Intracranial hemorrhage is not associated with antithrombotic agent use. Intracranial hemorrhage patients have no demonstrable coagulopathy. The association of preinjury brain atrophy with acute intracranial hemorrhage is a novel finding. Contrary to antithrombotic agent status, admission neurologic abnormality is a predictor of adverse post-admission outcomes. Study findings indicate that effective hemostasis is maintained with antithrombotic therapy.     

In-hospital cerebrovascular complications following orthotopic liver transplantation: A retrospective study

Background

Cerebrovascular complications are severe events following orthotopic liver transplantation (OLT). This study aimed to observe the clinical and neuroimaging features and possible risk factors of in-hospital cerebrovascular complications in the patients who underwent OLT.

Patients and methods

We retrospectively reviewed 337 consecutive patients who underwent 358 OLTs. Cerebrovascular complications were determined by clinical and neuroimaging manifestations, and the possible risk factors were analyzed in the patients with intracranial hemorrhage.

Results

Ten of 337 (3.0%) patients developed in-hospital cerebrovascular complications (8 cases experienced intracranial hemorrhage and 2 cases had cerebral infarction), and 6 of them died. The clinical presentations were similar to common stroke, but with rapid deterioration at early stage. The hematomas on brain CT scan were massive, irregular, multifocal and diffuse, and most of them were located at brain lobes and might enlarge or rebleed. Infarcts presented lacunar and multifocal lesions in basal gangliar but with possible hemorrhagic transformation. The patients with intracranial hemorrhage had older age and a more frequency of systemic infection than non-intracranial hemorrhage patients. (P = 0.011 and 0.029, respectively).

Conclusion

Posttransplant cerebrovascular complications have severe impact on outcome of the patients who received OLT. Older age and systemic infection may be the possible risk factors of in-hospital intracranial hemorrhage following OLT.     

骨髓间质干细胞移植治疗大鼠脑出血模型的实验研究

目的：研究大鼠骨髓间质干细胞（Mscs）移植治疗脑出血的可行性。方法：分离MSCs后,连续传代培养、扩增,Brdu标记的MSCs通过颈动脉、侧脑室2种途径移植入脑出血大鼠模型体内,采用爬行计分法评估神经功能的恢复程度,并观察脑部Brdu阳性细胞的分布。结果：通过侧脑室、颈动脉移植后大鼠神经功能改善,明显优于对照组（P〈0．05）;经颈动脉注射组较经侧脑室注射组爬杆实验评分低（P〈0．05）。移植的MSCs主要迁移到出血灶、大脑皮层、海马区等处。结论：MSCs移植对脑出血具有保护作用,而经颈动脉给药疗效优于经侧脑室给药。