Studies on postoperative neurological complications, particularly cognitive dysfunction(文献分享)
α7-nAChR在围术期神经认知功能障碍中的研究进展
α7-nAChR 在围术期神经认知功能障碍中的研究进展佳木斯大学附属第一医院 154000摘要：围术期神经认知功能障碍(PND)是指在是全身麻醉和手术后中枢神经系统并发症，常见的临床表现是健忘、信息处理能力的减退、精力下降和焦虑以及认知能力障碍等，但其具体发生机理尚不清楚。
但目前大量科学研究已经证实，由麻醉和手术所引起的中枢神经系统发炎反应,及其后小胶质细胞的活化可能参与了PND的产生发展过程。
烟碱型乙酰胆碱受体家族中的α7烟碱型乙酰胆碱受体(α7-nAChR)已被证明在中枢神经系统疾病中起到了积极功能。
本文将就α7-nAChR在PND中的研究进展作一综述，将有助于研究围手术期神经认知障碍的防治并探讨其危险因素和干预措施，对于减轻围术期神经认知功能障碍有非常重要的影响。
关键词：围术期神经认知功能障碍；α7烟碱型乙酰胆碱受体；胆碱能抗炎通路Abstract: perioperative neurocognitive impairment (PND) refers to the complications of central nervous system after general anesthesia and surgery. The common clinical manifestations are amnesia, decreased information processing ability, decreased energy, anxiety and cognitive impairment, but its specific mechanism is not clear. However, a large number of scientific studies have confirmed that the central nervous system inflammatory response caused by anesthesia and surgery and the subsequent activation of microglia may be involved in the production and development of PND. In nicotinic acetylcholine receptor family α Nicotinic acetylcholine receptor（α 7-nachr) has been proved to play a positive role in central nervous system diseases.This article will α A review of the research progress of 7-nachr in PND will help to study the prevention and treatment of perioperative neurocognitive impairment and explore its risk factors and intervention measures, which has a very important impact on reducing perioperative neurocognitive impairment.Key words: perioperative neurocognitive impairment; α 7 nicotinic acetylcholine receptor; cholinergic anti-inflammatory pathway1围术期神经认知障碍1.1概念围术期神经认知障碍(perioperative neurocognitive disorders,PND)是全身麻醉和手术后常见的并发症之一，表现为记忆功能受损、信息处理能力下降、精神衰退和焦虑。
右美托咪定联合舒芬太尼对脑出血患者术后炎性应激反应及神经和认知功能的影响
ｄｏｉ:１０.３９６９/ｊ.ｉｓｓｎ.１００２－７３８６.２０１９.０７.００１论著右美托咪定联合舒芬太尼对脑出血患者术后炎性应激反应及神经和认知功能的影响郭庆夺㊀杨秋影㊀马美娜㊀王旭鹏㊀于红㊀吴春玲㊀李睿作者单位:０６１００１㊀河北省沧州市中心医院麻醉科㊀㊀ʌ摘要ɔ㊀目的㊀观察右美托咪定联合舒芬太尼对脑出血患者术后炎性应激反应㊁神经功能和认知功能的影响ꎮ方法㊀选取２０１６年３月至２０１８年３月诊治的脑出血患者１２０例ꎬ随机分为对照组和观察组ꎬ每组６０例ꎮ对照组给予丙泊酚联合舒芬太尼麻醉方案ꎬ观察组给予右美托咪定联合舒芬太尼麻醉方案ꎮ观察２组麻醉诱导前(Ｔ０)㊁插管时(Ｔ１)㊁切皮时(Ｔ２)㊁拔管时(Ｔ３)㊁拔管后(Ｔ４)各时间点应激反应指标[平均动脉压(ＭＡＰ)㊁心率(ＨＲ)㊁皮质醇]ꎻ比较２组术前㊁术后２４ｈ血清炎性因子[白介素６(ＩＬ￣６)㊁白介素１０(ＩＬ￣１０)㊁超敏Ｃ￣反应蛋白(ｈｓ￣ＣＲＰ)㊁肿瘤坏死因子α(ＴＮＦ￣α)]㊁外周血Ｔｏｌｌ样受体２(ＴＬＲ２)㊁ＴＬＲ４表达及神经功能[神经元特异性烯醇酶(ＮＳＥ)㊁胶质纤维酸性蛋白(ＧＦＡＰ)㊁Ｔａｕ蛋白(Ｔａｕ)]㊁认知功能[简易智力状态检查量表(ＭＭＳＥ)和蒙特利尔认知评估量表(ＭｏＣＡ)]变化ꎮ结果㊀Ｔ０时２组ＭＡＰ㊁ＨＲ㊁皮质醇比较差异无统计学意义(Ｐ>０.０５)ꎻ与Ｔ０时比较ꎬＴ１~Ｔ４时对照组ＭＡＰ㊁ＨＲ㊁皮质醇显著升高ꎬ观察组ＭＡＰ㊁ＨＲ㊁皮质醇低于同期对照组(Ｐ<０.０５)ꎮ术前２组血清ＩＬ￣６㊁ＩＬ￣１０㊁ｈｓ￣ＣＲＰ㊁ＴＮＦ￣α㊁ＭＤＡ㊁ＳＯＤ㊁外周血ＴＬＲ２㊁ＴＬＲ４表达及ＮＳＥ㊁ＧＦＡＰ㊁Ｔａｕ㊁ＭＭＳＥ评分㊁ＭｏＣＡ评分比较差异无统计学意义(Ｐ>０.０５)ꎮ术后２４ｈ２组血清ＩＬ￣６㊁ＩＬ￣１０㊁ｈｓ￣ＣＲＰ㊁ＴＮＦ￣α㊁ＭＤＡ㊁外周血ＴＬＲ２㊁ＴＬＲ４表达及ＭＭＳＥ评分㊁ＭｏＣＡ评分均较治疗前显著升高ꎬＮＳＥ㊁ＧＦＡＰ㊁Ｔａｕ㊁ＳＯＤ均较治疗前显著降低ꎬ差异有统计学意义(Ｐ<０.０５)ꎬ且观察组血清ＩＬ￣６㊁ｈｓ￣ＣＲＰ㊁ＴＮＦ￣α㊁ＭＤＡ㊁外周血ＴＬＲ２㊁ＴＬＲ４表达及ＮＳＥ㊁ＧＦＡＰ㊁Ｔａｕ低于对照组ꎬＩＬ￣１０㊁ＳＯＤ㊁ＭＭＳＥ评分㊁ＭｏＣＡ评分高于对照组(Ｐ<０.０５)ꎮ结论㊀右美托咪定联合舒芬太尼麻醉用于脑出血患者术中能够通过降低ＴＬＲ２㊁ＴＬＲ４表达减轻术后炎性应激反应ꎬ促进患者神经功能和认知功能的恢复ꎮʌ关键词ɔ㊀右美托咪定ꎻ舒芬太尼ꎻ脑出血ꎻ炎性应激反应ꎻ神经功能ꎻ认知功能ʌ中图分类号ɔ㊀Ｒ７４３.３４㊀㊀ʌ文献标识码ɔ㊀Ａ㊀㊀ʌ文章编号ɔ㊀１００２－７３８６(２０１９)０７－０９６５－０６Ｅｆｆｅｃｔｓｏｆｄｅｘｍｅｄｅｔｏｍｉｄｉｎｅｃｏｍｂｉｎｅｄｗｉｔｈｓｕｆｅｎｔａｎｉｌｏｎｐｏｓｔｏｐｅｒａｔｉｖｅｉｎｆｌａｍｍａｔｏｒｙｓｔｒｅｓｓｒｅｓｐｏｎｓｅａｎｄｎｅｕｒｏｌｏｇｉｃａｌｆｕｎｃｔｉｏｎａｓｗｅｌｌａｓｃｏｇｎｉｔｉｖｅｆｕｎｃｔｉｏｎｉｎｐａｔｉｅｎｔｓｗｉｔｈｉｎｔｒａｃｅｒｅｂｒａｌｈｅｍｏｒｒｈａｇｅ㊀ＧＵＯＱｉｎｇｄｕｏꎬＹＡＮＧＱｉｕｙｉｎｇꎬＭＡＭｅｉｎａꎬｅｔａｌ.ＤｅｐａｒｔｍｅｎｔｏｆＡｎｅｓｔｈｅｓｉａꎬＣａｎｇｚｈｏｕＣｅｎｔｒａｌＨｏｓｐｉｔａｌꎬＨｅｂｅｉꎬＣａｎｇｚｈｏｕ０６１００１ꎬＣｈｉｎａʌＡｂｓｔｒａｃｔɔ㊀Ｏｂｊｅｃｔｉｖｅ㊀Ｔｏｏｂｓｅｒｖｅｔｈｅｅｆｆｅｃｔｓｏｆｄｅｘｍｅｄｅｔｏｍｉｄｉｎｅｃｏｍｂｉｎｅｄｗｉｔｈｓｕｆｅｎｔａｎｉｌｏｎｐｏｓｔｏｐｅｒａｔｉｖｅｉｎｆｌａｍｍａｔｏｒｙｓｔｒｅｓｓｒｅｓｐｏｎｓｅａｎｄｎｅｕｒｏｌｏｇｉｃａｌｆｕｎｃｔｉｏｎａｓｗｅｌｌａｓｃｏｇｎｉｔｉｖｅｆｕｎｃｔｉｏｎｉｎｐａｔｉｅｎｔｓｗｉｔｈｉｎｔｒａｃｅｒｅｂｒａｌｈｅｍｏｒｒｈａｇｅ.Ｍｅｔｈｏｄｓ㊀Ａｔｏｔａｌｏｆ１２０ｐａｔｉｅｎｔｓｗｉｔｈｉｎｔｒａｃｅｒｅｂｒａｌｈｅｍｏｒｒｈａｇｅｗｈｏｗｅｒｅａｄｍｉｔｔｅｄａｎｄｔｒｅａｔｅｄｉｎｏｕｒｈｏｓｐｉｔａｌｆｒｏｍＭａｒ２０１６ｔｏＭａｒ２０１８ｗｅｒｅｅｎｒｏｌｌｅｄｉｎｔｈｅｓｔｕｄｙ.Ｔｈｅｓｅｐａｔｉｅｎｔｓｗｅｒｅｒａｎｄｏｍｌｙｄｉｖｉｄｅｄｉｎｔｏｃｏｎｔｒｏｌｇｒｏｕｐ(ｎ＝６０)ａｎｄｏｂｓｅｒｖａｔｉｏｎｇｒｏｕｐ(ｎ＝６０).Ｔｈｅｐａｔｉｅｎｔｓｉｎｃｏｎｔｒｏｌｇｒｏｕｐｗｅｒｅｔｒｅａｔｅｄｂｙｐｒｏｐｏｆｏｌｃｏｍｂｉｎｅｄｗｉｔｈｓｕｆｅｎｔａｎｉｌａｎｅｓｔｈｅｓｉａꎬｈｏｗｅｖｅｒꎬｔｈｅｐａｔｉｅｎｔｓｉｎｏｂｓｅｒｖａｔｉｏｎｇｒｏｕｐｗｅｒｅｔｒｅａｔｅｄｂｙｄｅｘｍｅｄｅｔｏｍｉｄｉｎｅｃｏｍｂｉｎｅｄｗｉｔｈｓｕｆｅｎｔａｎｉｌａｎｅｓｔｈｅｓｉａ.Ｔｈｅｓｔｒｅｅｓｓｒｅａｃｔｉｏｎｓｉｎｄｅｘｅｓｗｅｒｅｏｂｓｅｒｖｅｄａｎｄｃｏｍｐａｒｅｄｂｅｔｗｅｅｎｔｈｅｔｗｏｇｒｏｕｐｓｂｅｆｏｒｅａｎｅｓｔｈｅｓｉａｉｎｄｕｃｔｉｏｎ(Ｔ０)ꎬｔｒａｃｈｅａｌｉｎｔｕｂａｔｉｏｎ(Ｔ１)ꎬｃｕｔｔｉｎｇｓｋｉｎ(Ｔ２)ꎬｄｕｒｉｎｇｅｘｔｕｂａｔｉｏｎ(Ｔ３)ａｎｄａｆｔｅｒｅｘｔｕｂａｔｉｏｎ(Ｔ４).ＴｈｅｓｅｒｕｍｌｅｖｅｌｓｏｆＩＬ￣６ꎬＩＬ￣１０ꎬｈｓ￣ＣＲＰꎬＴＮＦ￣αꎬａｎｄｔｈｅｅｘｐｒｅｓｓｉｏｎｌｅｖｅｌｓｏｆＴＬＲ２ꎬＴＬＲ４ꎬＮＳＥꎬＧＦＡＰꎬＴａｕꎬａｓｗｅｌｌａｓＭＭＳＥｓｃｏｒｅｓꎬＭｏＣＡｓｃｏｒｅｓｂｅｆｏｒｅｓｕｒｇｅｒｙａｎｄａｔ２４ｈａｆｔｅｒｓｕｒｇｅｒｙｗｅｒｅｏｂｓｅｒｖｅｄａｎｄｃｏｍｐａｒｅｄｂｅｔｗｅｅｎｔｈｅｔｗｏｇｒｏｕｐｓ.Ｒｅｓｕｌｔｓ㊀ＴｈｅｒｅｗｅｒｅｎｏｓｉｇｎｉｆｉｃａｎｔｄｉｆｆｅｒｅｎｃｅｓｉｎｔｈｅｌｅｖｅｌｓｏｆＭＡＰꎬＨＲａｎｄｃｏｒｔｉｓｏｌａｔＴ０ｂｅｔｗｅｅｎｔｈｅｔｗｏｇｒｏｕｐｓ(Ｐ>０.０５).ＴｈｅｌｅｖｅｌｓｏｆＭＡＰꎬＨＲａｎｄｃｏｒｔｉｓｏｌａｔＴ１~Ｔ４ｉｎｃｏｎｔｒｏｌｇｒｏｕｐｗｅｒｅｓｉｇｎｉｆｉｃａｎｔｌｙｈｉｇｈｅｒｔｈａｎｔｈｏｓｅａｔＴ０ꎬｍｏｒｅｏｖｅｒꎬｔｈｅｌｅｖｅｌｓｏｆＭＡＰꎬＨＲａｎｄｃｏｒｔｉｓｏｌｉｎｏｂｓｅｒｖａｔｉｏｎｇｒｏｕｐｗｅｒｅｓｉｇｎｉｆｉｃａｎｔｌｙｌｏｗｅｒｔｈａｎｔｈｏｓｅｉｎｃｏｎｔｒｏｌｇｒｏｕｐ(Ｐ<０.０５).ＢｅｆｏｒｅｓｕｒｇｅｒｙꎬｔｈｅｒｅｗｅｒｅｎｏｓｉｇｎｉｆｉｃａｎｔｄｉｆｆｅｒｅｎｃｅｓｉｎｔｈｅｓｅｒｕｍｌｅｖｅｌｓｏｆＩＬ￣６ꎬＩＬ￣１０ꎬｈｓ￣ＣＲＰꎬＴＮＦ￣αꎬＭＤＡꎬＳＯＤꎬｔｈｅｅｘｐｒｅｓｓｉｏｎｓｏｆＴＬＲ２ꎬＴＬＲ４ꎬＮＳＥꎬＧＦＡＰꎬＴａｕꎬＭＭＳＥｓｃｏｒｅｓａｎｄＭｏＣＡｓｃｏｒｅｓｂｅｔｗｅｅｎｔｈｅｔｗｏｇｒｏｕｐｓ(Ｐ>０.０５).ＡｆｔｅｒｓｕｒｇｅｒｙꎬｔｈｅｓｅｒｕｍｌｅｖｅｌｓｏｆＩＬ￣６ꎬＩＬ￣１０ꎬｈｓ￣ＣＲＰꎬＴＮＦ￣αꎬＭＤＡꎬｔｈｅｅｘｐｒｅｓｓｉｏｎｌｅｖｅｌｓｏｆＴＬＲ２ꎬＴＬＲ４ꎬａｎｄＭＭＳＥｓｃｏｒｅｓａｎｄＭｏＣＡｓｃｏｒｅｓｗｅｒｅｓｉｇｎｉｆｉｃａｎｔｌｙｉｎｃｒｅａｓｅｄａｔ２４ｈａｆｔｅｒｓｕｒｇｅｒｙｉｎｂｏｔｈｇｒｏｕｐｓꎬｈｏｗｅｖｅｒꎬｔｈｅｌｅｖｅｌｓｏｆＮＳＥꎬＧＦＡＰꎬＴａｕꎬＳＯＤｗｅｒｅｓｉｇｎｉｆｉｃａｎｔｌｙｄｅｃｒｅａｓｅｄａｔ２４ｈａｆｔｅｒｓｕｒｇｅｒｙｉｎｂｏｔｈｇｒｏｕｐｓ(Ｐ<０.０５).ＭｏｒｅｏｖｅｒｔｈｅｌｅｖｅｌｓｏｆＩＬ￣６ꎬｈｓ￣ＣＲＰꎬＴＮＦ￣αꎬＭＤＡꎬｔｈｅｅｘｐｒｅｓｓｉｏｎｌｅｖｅｌｓｏｆＴＬＲ２ꎬＴＬＲ４ꎬＮＳＥꎬＧＦＡＰꎬＴａｕａｔ２４ｈａｆｔｅｒｓｕｒｇｅｒｙｉｎｏｂｓｅｒｖａｔｉｏｎｇｒｏｕｐｗｅｒｅｓｉｇｎｉｆｉｃａｎｔｌｙｌｏｗｅｒｔｈａｎｔｈｏｓｅｉｎｃｏｎｔｒｏｌｇｒｏｕｐꎬａｎｄｔｈｅｌｅｖｅｌｓｏｆＩＬ￣１０ꎬＳＯＤꎬＭＭＳＥｓｃｏｒｅｓａｎｄＭｏＣＡｓｃｏｒｅｓａｔ２４ｈａｆｔｅｒｓｕｒｇｅｒｙｉｎｏｂｓｅｒｖａｔｉｏｎｇｒｏｕｐｗｅｒｅｓｉｇｎｉｆｉｃａｎｔｌｙｈｉｇｈｅｒｔｈａｎｔｈｏｓｅｉｎｃｏｎｔｒｏｌｇｒｏｕｐ(Ｐ<０.０５).Ｃｏｎｃｌｕｓｉｏｎ㊀Ｄｅｘｍｅｄｅｔｏｍｉｄｉｎｅｃｏｍｂｉｎｅｄｗｉｔｈｓｕｆｅｎｔａｎｉｌａｎｅｓｔｈｅｓｉａｃａｎｒｅｄｕｃｅｐｏｓｔｏｐｅｒａｔｉｖｅｉｎｆｌａｍｍａｔｏｒｙｓｔｒｅｓｓｒｅｓｐｏｎｓｅｉｎｐａｔｉｅｎｔｓｗｉｔｈｉｎｔｒａｃｅｒｅｂｒａｌｈｅｍｏｒｒｈａｇｅꎬｗｈｉｃｈｃａｎｄｏｗｎ￣ｒｅｇｕｌａｔｅｔｈｅｅｘｐｒｅｓｓｉｏｎｌｅｖｅｌｓｏｆＴＬＲ２ａｎｄＴＬＲ４ꎬｓｏａｓｔｏｐｒｏｍｏｔｅｔｈｅｒｅｃｏｖｅｒｙｏｆｔｈｅｎｅｕｒｏｌｏｇｉｃａｌｆｕｎｃｔｉｏｎａｎｄｃｏｇｎｉｔｉｖｅｆｕｎｃｔｉｏｎｏｆｐａｔｉｅｎｔｓ.ʌＫｅｙｗｏｒｄｓɔ㊀ｄｅｘｍｅｄｅｔｏｍｉｄｉｎｅꎻｓｕｆｅｎｔａｎｉｌꎻｉｎｔｒａｃｅｒｅｂｒａｌｈｅｍｏｒｒｈａｇｅꎻｉｎｆｌａｍｍａｔｏｒｙｓｔｒｅｓｓｒｅｓｐｏｎｓｅꎻｎｅｕｒｏｌｏｇｉｃａｌｆｕｎｃｔｉｏｎꎻｃｏｇｎｉｔｉｖｅｆｕｎｃｔｉｏｎ㊀㊀脑出血是多发于中老年人群的常见心脑血管疾病之一ꎬ具有起病急㊁病情进展快㊁死亡率和致残率高的特点ꎮ采用外科手术清除颅内血肿是目前治疗脑出血的首选方案ꎬ能够有效清除血肿ꎬ降低颅内压ꎬ并促进神经功能恢复[１ꎬ２]ꎮ但手术操作㊁药物麻醉及气管内插管易导致围术期炎性应激反应ꎬ从而造成脑损伤和认知功能障碍ꎬ不利于患者预后[３]ꎮ因此ꎬ术中给予合理的麻醉干预减轻炎性应激反应对于保护脑功能ꎬ改善患者预后至关重要ꎮ本研究观察了右美托咪定联合舒芬太尼对脑出血患者术后炎性应激反应㊁神经功能和认知功能的影响ꎬ旨在为临床寻找理想的麻醉方案提供理论依据ꎮ１㊀资料与方法１.１㊀一般资料㊀选取２０１６年３月至２０１８年３月我院收治的脑出血患者１２０例ꎬ随机分为对照组和观察组ꎬ每组６０例ꎮ２组年龄㊁性别比㊁出血部位㊁基础疾病等一般资料比较差异无统计学意义(Ｐ>０.０５)ꎬ具有可比性ꎮ见表１ꎮ表１㊀２组一般资料比较ｎ＝６０组别性别(例ꎬ男/女)年龄(岁ꎬ ｘʃｓ)出血部位(例)壳核丘脑脑叶基础疾病(例)高血压高血脂对照组３６/２４５８.２３ʃ５.１４３３１８９４０２０观察组３４/２６５７.６９ʃ５.２０３０１８１２３８２２１.２㊀纳入及排除标准㊀纳入标准:(１)患者均经头颅ＣＴ或ＭＲＩ检查确诊为脑出血ꎬ且均为首次发作ꎬ发病至入院时间<２４ｈꎻ(２)入院时ＧＣＳ评分为５~８分ꎻ(３)所有患者签署知情同意书ꎬ且临床资料完整ꎮ排除标准:(１)合并心㊁肝㊁肺㊁肾等重要脏器功能障碍者ꎻ(２)依从性差者ꎻ(３)血液系统㊁神经系统疾病患者ꎮ１.３㊀治疗方法㊀２组患者术前均监测呼吸㊁心率㊁血压等生命体征变化ꎬ肌内注射０.５ｍｇ阿托品和静脉推注０.４~０.８μｇ/ｋｇ舒芬太尼ꎬ对照组１ｍｉｎ前静脉滴注６ｍｇ ｋｇ－１ ｈ－１丙泊酚ꎬ观察组１０ｍｉｎ前静脉滴注０.５μｇ ｋｇ－１ ｈ－１右美托咪定维持麻醉至手术结束ꎮ术中根据患者心率㊁血压变化调整麻醉药物用量ꎮ１.４㊀观察指标㊀观察２组患者在麻醉诱导前(Ｔ０)㊁插管时(Ｔ１)㊁切皮时(Ｔ２)㊁拔管时(Ｔ３)㊁拔管后(Ｔ４)的应激反应指标[平均动脉压(ＭＡＰ)㊁心率(ＨＲ)㊁皮质醇]变化ꎻ比较２组术前㊁术后２４ｈ血清炎性因子[白介素６(ＩＬ￣６)㊁白介素１０(ＩＬ￣１０)㊁超敏Ｃ￣反应蛋白(ｈｓ￣ＣＲＰ)㊁肿瘤坏死因子α(ＴＮＦ￣α)]㊁外周血Ｔｏｌｌ样受体２(ＴＬＲ２)㊁ＴＬＲ４表达及神经功能[神经元特异性烯醇酶(ＮＳＥ)㊁胶质纤维酸性蛋白(ＧＦＡＰ)㊁Ｔａｕ蛋白(Ｔａｕ)]㊁认知功能[简易智力状态检查量表(ＭＭＳＥ)和蒙特利尔认知评估量表(ＭｏＣＡ)]的变化ꎮ１.５㊀检测方法１.５.１㊀血流动力学指标:观察２组Ｔ０㊁Ｔ１㊁Ｔ２㊁Ｔ３㊁Ｔ４时ＭＡＰ㊁ＨＲꎬ抽取静脉血３ｍｌꎬ测定血浆皮质醇浓度ꎮ１.５.２㊀标本制备:分别于术前及术后２４ｈ抽取患者清晨空腹静脉血５ｍｌꎬ３０００ｒ/ｍｉｎ离心１０ｍｉｎꎬ分离血清ꎬ－２０ħ保存备用ꎮ１.５.３㊀炎性因子㊁氧化应激和神经功能:采用双抗体夹心酶联免疫(ＥＬＩＳＡ)试剂盒测定血清ＩＬ￣６㊁ＩＬ￣１０㊁ｈｓ￣ＣＲＰ㊁ＴＮＦ￣α㊁ＳＯＤ㊁ＭＤＡ㊁ＮＳＥ㊁ＧＦＡＰ㊁Ｔａｕꎮ１.５.４㊀认知功能:采用ＭＭＳＥ评分和ＭｏＣＡ评分评估患者认知功能ꎬ分值越高表示患者认知功能越好ꎮ１.６㊀统计学分析㊀应用ＳＰＳＳ２０.０统计软件ꎬ计量资料以 ｘʃｓ表示ꎬ计数资料采用χ２检验ꎬＰ<０.０５为差异有统计学意义ꎮ２㊀结果２.１㊀２组血流动力学指标比较㊀Ｔ０时２组ＭＡＰ㊁ＨＲ㊁皮质醇比较差异无统计学意义(Ｐ>０.０５)ꎻ与Ｔ０时比较ꎬＴ１~Ｔ４时对照组ＭＡＰ㊁ＨＲ㊁皮质醇显著升高ꎬ观察组ＭＡＰ㊁ＨＲ㊁皮质醇低于同期对照组(Ｐ<０.０５)ꎮ见表２ꎮ２.２㊀２组血清炎性因子比较㊀术前２组血清ＩＬ￣６㊁ＩＬ￣１０㊁ｈｓ￣ＣＲＰ㊁ＴＮＦ￣α比较差异无统计学意义(Ｐ>０.０５)ꎮ术后２４ｈ２组血清ＩＬ￣６㊁ＩＬ￣１０㊁ｈｓ￣ＣＲＰ㊁ＴＮＦ￣α均较术前显著升高ꎬ差异有统计学意义(Ｐ<０.０５)ꎬ且观察组血清ＩＬ￣６㊁ｈｓ￣ＣＲＰ㊁ＴＮＦ￣α低于对照组ꎬＩＬ￣１０高于对照组(Ｐ<０.０５)ꎮ见表３ꎬ图１ꎮ２.３㊀２组外周血ＴＬＲ２㊁ＴＬＲ４表达比较㊀术前２组外周血ＴＬＲ２㊁ＴＬＲ４表达比较差异无统计学意义(Ｐ>０.０５)ꎮ术后２４ｈ２组外周血ＴＬＲ２㊁ＴＬＲ４表达均较术前显著升高ꎬ差异有统计学意义(Ｐ<０.０５)ꎬ且观察组外周血ＴＬＲ２㊁ＴＬＲ４表达低于对照组(Ｐ<０.０５)ꎮ见表２㊀２组血流动力学指标比较ｎ＝６０ꎬ ｘʃｓ㊀组别Ｔ０Ｔ１Ｔ２Ｔ３Ｔ４对照组㊀ＭＡＰ(ｍｍＨｇ)９８.７６ʃ８.４３１３２.８９ʃ７.６２∗１３４.９０ʃ８.１１∗１３２.４１ʃ９.２９∗１３３.５６ʃ９.６３∗㊀ＨＲ(次/ｍｉｎ)６８.７９ʃ６.３１８４.０４ʃ４.６５∗８５.６８ʃ６.８０∗８３.８９ʃ４.９０∗８５.８９ʃ４.２２∗㊀皮质醇(ｎｇ/ｍｌ)８２.４５ʃ６.８９９３.６６ʃ６.２３∗９８.２３ʃ７.３１∗１０９.６７ʃ１０.４３∗１１５.２３ʃ１２.５６∗观察组㊀ＭＡＰ(ｍｍＨｇ)９７.９８ʃ１０.４４１１４.３３ʃ６.９６＃１１５.０２ʃ８.５３＃１１４.７７ʃ９.５４＃１１３.５１ʃ７.９３＃㊀ＨＲ(次/ｍｉｎ)６７.８１ʃ６.２４７３.６９ʃ４.３５＃７３.５１ʃ６.２４＃７０.９５ʃ４.４２＃７１.０７ʃ４.６７＃㊀皮质醇(ｎｇ/ｍｌ)８６.７８ʃ７.３２８０.６９ʃ５.２２＃８３.０４ʃ７.６５＃８６.３２ʃ８.１１＃８９.４９ʃ９.７７＃㊀㊀注:与Ｔ０时比较ꎬ∗Ｐ<０.０５ꎻ与对照组比较ꎬ＃Ｐ<０.０５表３㊀２组血清炎性因子比较ｎ＝６０ꎬ ｘʃｓ㊀组别ＩＬ￣６(μｇ/Ｌ)ＩＬ￣１０(μｇ/Ｌ)ｈｓ￣ＣＲＰ(ｍｇ/Ｌ)ＴＮＦ￣α(μｇ/Ｌ)对照组㊀术前２.３４ʃ０.１５２８.２７ʃ２.５７１０.６６ʃ１.１２１.８６ʃ０.１３㊀术后２４ｈ８.６１ʃ０.５９∗５０.９６ʃ４.８３∗２０.８５ʃ２.３２∗４.１７ʃ０.２２∗观察组㊀术前２.３１ʃ０.１６２６.９６ʃ２.６６１１.２８ʃ１.０９１.９０ʃ０.１５㊀术后２４ｈ５.００ʃ０.３４∗＃９７.４４ʃ８.７０∗＃１５.９９ʃ１.７６∗＃２.８０ʃ０.１８∗＃㊀㊀注:与术前比较ꎬ∗Ｐ<０.０５ꎻ与对照组比较ꎬ＃Ｐ<０.０５㊀㊀注:与术前比较ꎬ Ｐ<０.０５ꎻ与对照组比较ꎬһＰ<０.０５图１㊀ＥＬＩＳＡ检测血清炎性因子表４ꎬ图２ꎮ２.４㊀２组血清氧化应激指标比较㊀术前２组血清ＭＤＡ㊁ＳＯＤ比较差异无统计学意义(Ｐ>０.０５)ꎮ术后２４ｈ２组血清ＭＤＡ均较术前显著升高ꎬＳＯＤ均较术前显著降低ꎬ差异有统计学意义(Ｐ<０.０５)ꎬ且观察组血清ＭＤＡ低于对照组ꎬＳＯＤ高于对照组(Ｐ<０.０５)ꎮ见表５ꎬ图３ꎮ表４㊀２组外周血ＴＬＲ２、ＴＬＲ４表达比较ｎ＝６０ꎬ％ꎬ ｘʃｓ㊀组别ＴＬＲ２ＴＬＲ４对照组㊀术前７.９７ʃ０.６８１８.６６ʃ２.３４㊀术后２４ｈ１０.６８ʃ１.１２∗２７.９０ʃ３.２２∗观察组㊀术前８.０３ʃ０.７４１９.３２ʃ２.５０㊀术后２４ｈ８.９５ʃ０.７８∗＃２３.００ʃ２.９８∗＃㊀㊀注:与术前比较ꎬ∗Ｐ<０.０５ꎻ与对照组比较ꎬ＃Ｐ<０.０５注:与术前比较ꎬ∗Ｐ<０.０５ꎻ与对照组比较ꎬ＃Ｐ<０.０５图２㊀流式细胞术检测外周血ＴＬＲ２㊁ＴＬＲ４表达表５㊀２组血清氧化应激指标比较ｎ＝６０ꎬ ｘʃｓ㊀组别ＭＤＡ(μｍｏｌ/Ｌ)ＳＯＤ(Ｕ/Ｌ)对照组㊀术前３.８２ʃ０.３６９９.６５ʃ８.３４㊀术后２４ｈ８.７７ʃ０.６９∗５０.００ʃ４.３３∗观察组㊀术前３.８６ʃ０.３８１０２.１２ʃ９.２０㊀术后２４ｈ６.２４ʃ０.５３∗＃７８.５４ʃ５.４２∗＃㊀㊀注:与术前比较ꎬ∗Ｐ<０.０５ꎻ与对照组比较ꎬ＃Ｐ<０.０５２.５㊀２组神经功能比较㊀术前２组血清ＮＳＥ㊁ＧＦＡＰ㊁Ｔａｕ比较差异无统计学意义(Ｐ>０.０５)ꎮ术后２４ｈ２组血清ＮＳＥ㊁ＧＦＡＰ㊁Ｔａｕ均较术前显著降低ꎬ差异有统计学意义(Ｐ<０.０５)ꎬ且观察组血清ＮＳＥ㊁ＧＦＡＰ㊁Ｔａｕ低于对照组(Ｐ<０.０５)ꎮ见表６ꎬ图４ꎮ注:与术前比较ꎬ∗Ｐ<０.０５ꎻ与对照组比较ꎬ＃Ｐ<０.０５图３㊀ＥＬＩＳＡ检测血清氧化应激指标表６㊀２组神经功能比较ｎ＝６０ꎬ ｘʃｓ㊀组别ＮＳＥ(μｇ/Ｌ)ＧＦＡＰ(ｎｇ/Ｌ)Ｔａｕ(ｎｇ/Ｌ)对照组㊀术前６７.１３ʃ５.２２１.４０ʃ０.１７１２.８４ʃ１.３３㊀术后２４ｈ４９.７５ʃ３.８０∗０.８３ʃ０.１１∗７.４２ʃ０.４６∗观察组㊀术前６４.８９ʃ４.７８１.３７ʃ０.１９１３.２５ʃ１.４１㊀术后２４ｈ２３.６６ʃ２.６２∗＃０.４４ʃ０.０５∗＃３.６８ʃ０.３９∗＃㊀㊀注:与术前比较ꎬ∗Ｐ<０.０５ꎻ与对照组比较ꎬ＃Ｐ<０.０５㊀㊀注:与术前比较ꎬ∗Ｐ<０.０５ꎻ与对照组比较ꎬ＃Ｐ<０.０５图４㊀ＥＬＩＳＡ检测血清神经功能指标２.６㊀２组认知功能比较㊀术前２组ＭＭＳＥ评分㊁ＭｏＣＡ评分比较差异无统计学意义(Ｐ>０.０５)ꎮ术后２４ｈ２组ＭＭＳＥ评分㊁ＭｏＣＡ评分均较术前显著升高ꎬ差异有统计学意义(Ｐ<０.０５)ꎬ且观察组ＭＭＳＥ评分㊁ＭｏＣＡ评分高于对照组(Ｐ<０.０５)ꎮ见表７ꎮ表７㊀２组认知功能比较ｎ＝６０ꎬ分ꎬ ｘʃｓ㊀组别ＭＭＳＥ评分ＭｏＣＡ评分对照组㊀术前１２.７５ʃ１.３６９.８２ʃ０.７８㊀术后２４ｈ１５.８３ʃ１.７９∗１２.６９ʃ１.１７∗观察组㊀术前１３.１１ʃ１.３２１０.０７ʃ１.１２㊀术后２４ｈ１９.４４ʃ２.０１∗＃１５.９８ʃ１.８５∗＃㊀㊀注:与术前比较ꎬ∗Ｐ<０.０５ꎻ与对照组比较ꎬ＃Ｐ<０.０５３㊀讨论㊀㊀脑出血是神经科常见急危重症ꎬ该病是由于非外伤性脑血管破裂引起的颅内出血现象ꎬ可直接损害脑组织并导致周围脑组织产生脑缺血或脑水肿ꎬ患者主要表现为头晕头痛㊁恶心呕吐㊁意识障碍㊁偏瘫等神经系统受损症状体征[４ꎬ５]ꎮ目前ꎬ手术治疗是脑出血的首选治疗方案ꎮ但外科手术在清除血肿㊁降低颅内压的同时不仅有可能损伤脑组织ꎬ在术中麻醉药物和气管内插管等强烈刺激下机体也会出现一系列炎性应激反应ꎬ导致心率加快㊁血压升高ꎬ累及呼吸和循环系统ꎬ严重者甚至危及患者生命[６ꎬ７]ꎮ因此ꎬ如何控制或减轻术中炎性应激反应对于维持血流动力学稳定ꎬ保证手术顺利进行ꎬ改善患者预后具有重要的临床意义ꎮ㊀㊀研究认为ꎬ麻醉与术中炎性应激反应及患者预后密切相关ꎮ丙泊酚是目前常用于麻醉诱导和维持的新型麻醉药物ꎬ具有起效快㊁作用时间短㊁安全毒副反应少等优点ꎬ不仅能够有效抑制中枢神经发挥镇痛镇静作用ꎬ还能够减轻脑水肿ꎬ降低颅内压ꎬ从而发挥脑保护作用[８]ꎮ研究证实ꎬ抑制炎性反应㊁降低钙超载㊁清除氧自由基是丙泊酚发挥脑保护作用的主要机制[９ꎬ１０]ꎮ目前ꎬ丙泊酚联合芬太尼是临床常用的麻醉方案ꎬ不仅能够增强丙泊酚的麻醉作用ꎬ还能减少不良反应发生[１１]ꎮ然而ꎬ有报道提出丙泊酚对心血管系统具有抑制作用ꎬ容易产生血压下降㊁呼吸抑制和负性肌力等作用ꎮ右美托咪定是一种新型α２肾上腺素受体激动剂ꎬ不仅能够抑制突触前膜分泌去甲肾上腺素ꎬ还能降低交感神经活性ꎬ从而产生镇痛㊁抑制应激反应等作用[１２ꎬ１３]ꎮ临床研究表明ꎬ麻醉诱导期㊁维持期和苏醒期单独使用右美托咪定或与其他麻醉药物合用能够有效维持开颅手术患者血流动力学稳定ꎬ患者苏醒质量高ꎬ且拔管引起的心率加快㊁血压升高等不良反应发生率明显降低[１４]ꎮ本研究中ꎬ术后２４ｈ对照组ＭＡＰ㊁ＨＲ㊁皮质醇均发生明显变化ꎬ而观察组术后２４ｈＭＡＰ㊁ＨＲ㊁皮质醇变化不明显ꎬ说明右美托咪定能够有效维持脑出血患者术后血流动力学的稳定ꎬ效果优于丙泊酚麻醉ꎮ㊀㊀研究显示ꎬ手术创伤会导致术后出现严重的炎性应激反应ꎬ其中ＩＬ￣６㊁ｈｓ￣ＣＲＰ㊁ＴＮＦ￣α等多种促炎因子水平显著升高ꎬ不仅产生神经毒性ꎬ也加重了神经功能损伤和认知功能障碍ꎮＩＬ￣１０是机体重要的抗炎因子ꎬ能够减轻炎性反应ꎬ抑制炎性因子释放ꎮＴＬＲ２㊁ＴＬＲ４是ＴＬＲｓ家族的重要成员ꎬ通过激活ＮＦ￣κＢ炎症信号通路诱导炎性因子的大量释放和炎性反应加剧[１５]ꎮ此外ꎬ脑出血时由于血肿压迫造成周围正常脑组织缺血缺氧ꎬ这会导致氧自由基和氧化防御之间平衡的破坏ꎬ从而引起氧化应激损伤ꎮＭＤＡ是脂质过氧化产物ꎬ其含量表示细胞膜受氧自由基损伤的严重程度ꎮＳＯＤ是机体重要的抗氧化物质ꎬ能够清除氧自由基ꎬ减轻氧化应激损伤[１６]ꎮ本研究以血清ＩＬ￣６㊁ＩＬ￣１０㊁ｈｓ￣ＣＲＰ㊁ＴＮＦ￣α㊁ＭＤＡ㊁ＳＯＤ及ＴＬＲ２㊁ＴＬＲ４表达为指标ꎬ观察右美托咪定联合舒芬太尼对脑出血患者术后炎性反应和氧化应激指标的影响ꎮ结果表明ꎬ术后２４ｈ观察组血清ＩＬ￣６㊁ｈｓ￣ＣＲＰ㊁ＴＮＦ￣α㊁ＭＤＡ及ＴＬＲ２㊁ＴＬＲ４表达低于对照组ꎬＩＬ￣１０㊁ＳＯＤ高于对照组ꎬ说明右美托咪定可能通过降低ＴＬＲ２㊁ＴＬＲ４表达抑制了ＴＬＲ/ＮＦ￣κＢ炎症信号通路的激活和炎性因子的释放ꎬ减轻氧化应激损伤ꎬ效果优于丙泊酚麻醉ꎮ㊀㊀脑出血发生后颅内血肿可造成病灶周围脑组织功能和血脑屏障功能异常ꎬ并释放大量神经损伤因子进入血液循环[１７]ꎮＮＳＥ是存在于神经组织和神经内分泌组织的一种细胞因子ꎬ正常情况下血液㊁脑脊液中ＮＳＥ含量极低ꎬ当脑组织损伤或功能异常时ＮＳＥ可透过血脑屏障入血[１８]ꎮＧＦＡＰ是星形胶质细胞分泌的一种酸性蛋白ꎬ脑组织损伤时ＧＦＡＰ从胶质细胞中溢出进入血液循环ꎮＴａｕ是存在于神经元轴突中的一种磷蛋白ꎬ神经元病变时血液中Ｔａｕ水平升高[１９]ꎮ本研究发现ꎬ术后２４ｈ２组血清ＮＳＥ㊁ＧＦＡＰ㊁Ｔａｕ均较治疗前显著降低ꎬ且观察组血清ＮＳＥ㊁ＧＦＡＰ㊁Ｔａｕ低于对照组ꎬ说明手术治疗脑出血能够有效清除颅内血肿ꎬ促进神经功能恢复ꎬ且使用右美托咪定麻醉较丙泊酚麻醉更能降低神经损伤因子的释放ꎬ保护脑组织ꎮ认知功能障碍是脑出血术后常见并发症ꎬ对患者预后产生不利影响ꎮ本研究结果显示ꎬ术后２４ｈ２组ＭＭＳＥ评分㊁ＭｏＣＡ评分均较治疗前显著升高ꎬ且观察组ＭＭＳＥ评分㊁ＭｏＣＡ评分高于对照组ꎬ说明右美托咪定麻醉对脑出血术后认知功能具有明显保护作用ꎬ效果优于丙泊酚麻醉ꎮ㊀㊀综上所述ꎬ右美托咪定联合舒芬太尼麻醉用于脑出血患者术中疗效显著ꎬ能够更好的维持血流动力学稳定ꎬ并通过降低ＴＬＲ２㊁ＴＬＲ４表达减轻术后炎性应激反应ꎬ从而促进患者神经功能和认知功能的恢复ꎬ其效果优于丙泊酚麻醉ꎮ参考文献１㊀ＷａｎｇＸꎬＷａｎｇＪꎬＺｈａｏＨꎬｅｔａｌ.Ｃｌｉｎｉｃａｌａｎａｌｙｓｉｓａｎｄｔｒｅａｔｍｅｎｔｏｆｓｙｍｐｔｏｍａｔｉｃｉｎｔｒａｃｒａｎｉａｌｈｅｍｏｒｒｈａｇｅａｆｔｅｒｄｅｅｐｂｒａｉｎｓｔｉｍｕｌａｔｉｏｎｓｕｒｇｅｒｙ.ＢｒＪＮｅｕｒｏｓｕｒｇꎬ２０１７ꎬ１:２１７￣２２２.２㊀刘宏浩ꎬ王少雄ꎬ黄程ꎬ等.不同手术时机治疗高血压脑出血的对比分析研究.重庆医学ꎬ２０１４ꎬ４３:２９２５￣２９２７.３㊀ＹｏｕＳꎬＷａｎｇＸꎬＬｉｎｄｌｅｙＲＩꎬｅｔａｌ.ＥａｒｌｙＣｏｇｎｉｔｉｖｅＩｍｐａｉｒｍｅｎｔａｆｔｅｒＩｎｔｒａｃｅｒｅｂｒａｌＨｅｍｏｒｒｈａｇｅｉｎｔｈｅＩＮＴＥＲＡＣＴ１Ｓｔｕｄｙ.ＣｅｒｅｂｒｏｖａｓｃＤｉｓꎬ２０１７ꎬ４４:３２０￣３２４.４㊀周萍.丙泊酚与咪达唑仑在急性脑出血手术中的麻醉效果对比研究.中国卫生标准管理ꎬ２０１５ꎬ６:３７￣３８.５㊀宋大勇ꎬ赵军ꎬ张宁ꎬ等.不同手术方式治疗老年早期基底节区高血压脑出血患者疗效及预后随访.中华老年医学杂志ꎬ２０１７ꎬ３６:７４２￣７４５.６㊀李洋.脑外科急诊手术麻醉药物的对比研究.浙江创伤外科ꎬ２０１６ꎬ２１:１７４￣１７５.７㊀ＢｉｌｇｉＭꎬＴｅｋｅｌｉｏｇｌｕＵＹꎬＳｉｔＭꎬｅｔａｌ.Ｃｏｍｐａｒｉｓｏｎｏｆｔｈｅｅｆｆｅｃｔｓｏｆｂｉｓｐｅｃｔｒａｌｉｎｄｅｘ￣ｃｏｎｔｒｏｌｌｅｄｕｓｅｏｆｒｅｍｉｆｅｎｔａｎｉｌｏｎｐｒｏｐｏｆｏｌｃｏｎｓｕｍｐｔｉｏｎａｎｄｐａｔｉｅｎｔｃｏｍｆｏｒｔｉｎｐａｔｉｅｎｔｓｕｎｄｅｒｇｏｉｎｇｃｏｌｏｎｏｓｃｏｐｙ.ＡｃｔａＧａｓｔｒｏｅｎｔｅ￣ｒｏｌＢｅｌｇꎬ２０１５ꎬ７８:３１４￣３１８.８㊀ＨａｙｔｕｒａｌＣꎬＡｙｄｉｎｌｉＢꎬＤｅｍｉｒＢꎬｅｔａｌ.Ｃｏｍｐａｒｉｓｏｎｏｆｐｒｏｐｏｆｏｌꎬｐｒｏｐｏｆｏｌ￣ｒｅｍｉｆｅｎｔａｎｉｌꎬａｎｄｐｒｏｐｏｆｏｌ￣ｆｅｎｔａｎｙｌａｄｍｉｎｉｓｔｒａｔｉｏｎｓｗｉｔｈｅａｃｈｏｔｈｅｒｕｓｅｄｆｏｒｔｈｅｓｅｄａｔｉｏｎｏｆｐａｔｉｅｎｔｓｔｏｕｎｄｅｒｇｏＥＲＣＰ.ＢｉｏｍｅｄＲｅｓＩｎｔꎬ２０１５ꎬ２０１５:４６５４６５.９㊀刘艳ꎬ夏洁ꎬ彭宗军ꎬ等.丙泊酚麻醉对颅脑外伤患者氧化应激㊁神经功能及炎症因子水平的影响.海南医学院学报ꎬ２０１７ꎬ２３:３４７１￣３４７４.１０㊀郑勇ꎬ张建伟.脑外伤术中靶控输注丙泊酚围术期护理干预效果分析.中国药业ꎬ２０１５ꎬ２４:１３７￣１３８.１１㊀ＬｅｅＳＨꎬＫｉｍＪＤꎬＰａｒｋＳＡꎬｅｔａｌ.Ｅｆｆｅｃｔｓｏｆμ￣ｏｐｉｏｉｄｒｅｃｅｐｔｏｒｇｅｎｅｐｏｌｙｍｏｒｐｈｉｓｍｏｎｐｏｓｔｏｐｅｒａｔｉｖｅｎａｕｓｅａａｎｄｖｏｍｉｔｉｎｇｉｎｐａｔｉｅｎｔｓｕｎｄｅｒｇ￣ｏｉｎｇｇｅｎｅｒａｌａｎｅｓｔｈｅｓｉａｗｉｔｈｒｅｍｉｆｅｎｔａｎｉｌ:ｄｏｕｂｌｅｂｌｉｎｄｅｄｒａｎｄｏｍｉｚｅｄｔｒｉａｌ.ＪＫｏｒｅａｎＭｅｄＳｃｉꎬ２０１５ꎬ３０:６５１￣６５７.１２㊀ＴａｎｇＱꎬＷｕＸꎬＷｅｎｇＷꎬｅｔａｌ.Ｔｈｅｐｒｅｖｅｎｔｉｖｅｅｆｆｅｃｔｏｆｄｅｘｍｅｄｅｔｏｍｉｄｉｎｅｏｎｐａｒｏｘｙｓｍａｌｓｙｍｐａｔｈｅｔｉｃｈｙｐｅｒａｃｔｉｖｉｔｙｉｎｓｅｖｅｒｅｔｒａｕｍａｔｉｃｂｒａｉｎｉｎｊｕｒｙｐａｔｉｅｎｔｓｗｈｏｈａｖｅｕｎｄｅｒｇｏｎｅｓｕｒｇｅｒｙ:ａｒｅｔｒｏｓｐｅｃｔｉｖｅｓｔｕｄｙ.ＰｅｅｒＪꎬ２０１７ꎬ５:ｅ２９８６.１３㊀ＬｉＪꎬＸｉｏｎｇＭꎬＮａｄａｖａｌｕｒｕＰＲꎬｅｔａｌ.ＤｅｘｍｅｄｅｔｏｍｉｄｉｎｅＡｔｔｅｎｕａｔｅｓＮｅｕｒ￣ｏｔｏｘｉｃｉｔｙＩｎｄｕｃｅｄｂｙＰｒｅｎａｔａｌＰｒｏｐｏｆｏｌＥｘｐｏｓｕｒｅ.ＪｏｕｒｎａｌｏｆＮｅｕｒｏｓｕｒｇｉ￣ｃａｌＡｎｅｓｔｈｅｓｉｏｌｏｇｙꎬ２０１６ꎬ２８:５１.１４㊀杨自娟ꎬ张兴安.右美托咪定的临床应用研究.中国药物与临床ꎬ２０１３ꎬ１３:１８９￣１９１.１５㊀ＲａｍｓｔｅａｄＡＧꎬＲｏｂｉｓｏｎＡꎬＢｌａｃｋｗｅｌｌＡꎬｅｔａｌ.ＲｏｌｅｓｏｆＴｏｌｌ￣ＬｉｋｅＲｅｃｅｐｔｏｒ２(ＴＬＲ２)ꎬＴＬＲ４ꎬａｎｄＭｙＤ８８ｄｕｒｉｎｇＰｕｌｍｏｎａｒｙＣｏｘｉｅｌｌａｂｕｒｎｅｔｉｉＩｎｆｅｃｔｉｏｎ.Ｉｎｆｅｃｔｉｏｎａｎｄｉｍｍｕｎｉｔｙꎬ２０１６ꎬ８４:９４０￣９４９.１６㊀Ｓｈｏｕ￣ＳｈｉＷꎬＴｉｎｇ￣ＴｉｎｇＳꎬＪｉ￣ＳｈｕｎＮꎬｅｔａｌ.ＰｒｅｃｌｉｎｉｃａｌｅｆｆｉｃａｃｙｏｆＤｅｘｍｅｄｅｔｏｍｉｄｉｎｅｏｎｓｐｉｎａｌｃｏｒｄｉｎｊｕｒｙｐｒｏｖｏｋｅｄｏｘｉｄａｔｉｖｅｒｅｎａｌｄａｍａｇｅ.ＲｅｎＦａｉｌꎬ２０１５ꎬ３７:１１９０￣１１９７.１７㊀ＫｅＷꎬＬｉＬꎬＦｅｉＸꎬｅｔａｌ.Ｎｅｒｖｅｇｒｏｔｈｆａｃｔｏｒｐｒｏｔｅｃｔｓｔｈｅｉｓｃｈｅｍｉｃｈｅａｒｔｖｉａａｔｔｅｎｕａｔｉｏｎｏｆｔｈｅｅｎｄｏｐｌａｓｍｉｃｒｅｔｉｃｕｌｕｎｓｔｒｅｓｓｉｎｄｕｃｅｄａｐｏｐｔｏｓｉｓｂｙａｃｔｉｖａｔｉｏｎｏｆｐｈｏｓｐｈａｔｉｄｙｌｉｎｏｓｉｔｏｌ３￣ｋｉｎａｓｅ.ＩｎｔｅｒｎａｔｉｏｎａｌＪｏｕｒｎａｌｏｆＭｅｄｉｃａｌＳｃｉｅｎｃｅｓꎬ２０１５ꎬ１２:８３￣９０.１８㊀ＳａｈｕＳꎬＮａｇＤＳꎬＳｗａｉｎＡꎬｅｔａｌ.Ｂｉｏｃｈｅｍｉｃａｌｃｈａｎｇｅｓｉｎｔｈｅｉｎｊｕｒｅｄｂｒａｉｎ.ＷｏｒｌｄＪＢｉｏｌＣｈｅｍꎬ２０１７ꎬ８:２１￣３１.１９㊀刘霞ꎬ秦雪.胶质纤维酸性蛋白的生物学特性及临床研究进展.国际检验医学杂志ꎬ２０１５ꎬ１８:２７１６￣２７１７.(收稿日期:２０１８－０８－２０)。
综合护理对微创脑出血手术患者术后神经功能恢复及生活质量的影响探讨
SYSTEMS MEDICINE系统医学DOI:10.19368/ki.2096-1782.2021.20.187综合护理对微创脑出血手术患者术后神经功能恢复及生活质量的影响探讨陈利莉,谭晓洁徐州医科大学附属医院神经外科,江苏徐州221000[摘要]目的探讨综合护理对脑出血微创手术患者神经功能恢复和生活质量的影响。
方法从2018年7月—2019年6月该院收治的脑出血微创手术患者中选取90例,数表法随机分成两组:对照组、研究组,每组45例,分别实施常规护理、综合护理干预。
比较两组护理满意度,评估神经功能恢复情况和生活质量。
结果研究组护理满意率(95.56%)明显高于对照组(80.00%),差异有统计学意义(χ2=5.074,P=0.024)。
两组患者干预前的NIHSS 评分、Barthel 指数接近,差异无统计学意义(P>0.05);干预后研究组评分结果为(12.60±2.55)分和(82.53±4.62)分,优于对照组的(15.33±3.08)分和(80.37±4.25)分,差异有统计学意义(t=4.579、2.308,P=0.001、0.023)。
患者干预前的QOL 评分接近,差异无统计学意义(P>0.05);干预后研究组躯体、心理、社会3个领域的评分为(52.17±2.26)分、(48.20±2.79)分和(53.08±3.61)分,均高于对照组的(49.83±2.37)分、(45.72±2.46)分和(50.27±3.40)分,差异有统计学意义(t=4.793、4.472、3.801,P=0.001)。
结论脑出血微创手术患者实施综合护理,能进一步改善神经功能、提高生活质量和护理满意度,具有推广价值。
[关键词]脑出血;微创手术;综合护理;满意度;神经功能;生活质量[中图分类号]R47[文献标识码]A[文章编号]2096-1782(2021)10(b)-0187-04The Effect of Comprehensive Nursing Care on Postoperative Neurological Function Recovery and Quality of Life in Patients with Minimally Invasive Cerebral Hemorrhage SurgeryCHEN Lili,TAN Xiaojie Department of Neurosurgery,Affiliated Hospital of Xuzhou Medical University,Xuzhou,Jiangsu Province,221000China[Abstract]Objective To explore the effect of comprehensive nursing care on the recovery of neurological function andquality of life in patients with minimally invasive surgery for cerebral hemorrhage.Methods From July 2018to June 2019,90patients with minimally invasive cerebral hemorrhage surgery were selected in the hospital,and the number table method was randomly divided into two groups:the control group and the study group,45cases in each group,and routine procedures,comprehensive nursing intervention were pared nursing satisfaction,evaluated the recovery of neurological function and quality of life.Results The nursing satisfaction rate of the study group (95.56%)was significantly higher than that of the control group (80.00%),and the difference was statistically significant (χ2=5.074,P=0.024).The NIHSS score and Barthel index of the two groups of patients before intervention were similar,and the difference was not statistically significant (P>0.05);the scores of the study group after intervention were (12.60±2.55)points and (82.53±4.62)points,which were better than those of the control group (15.33±3.08)points and (80.37±4.25)points,the difference was statistically significant(t =4.579,2.308,P =0.001,0.023).The QOL scores of thepatients before the intervention were similar,and the difference was not statistically significant(P>0.05);after theintervention,the scores of the three areas of physical,psychological,and social in the study group were (52.17±2.26)points,(48.20±2.79)points,and (53.08±3.61)points,all higher than the (49.83±2.37)points,(45.72±2.46)points and(50.27±3.40)points of the control group,the difference was statistically significant (t=4.793,4.472,3.801,P=0.001).Conclusion Comprehensive nursing for patients withminimallyinvasivesurgeryforcerebralhemorrhage can further improve neurological function,[作者简介]陈利莉(1985-),女,本科,主管护师,研究方向为神经外科护理。
桡骨远端关节内粉碎性骨折内外联合固定的手术疗效
桡骨远端关节内粉碎性骨折内外联合固定的手术疗效（作者:___________单位: ___________邮编: ___________）作者：李健，肖斌，赵洪普，高梁斌，范震波【摘要】［目的］评价经伤椎椎弓根钉固定结合经椎弓根植骨治疗胸腰椎爆裂骨折的临床疗效，探讨其适应证。
［方法］对30例胸腰椎爆裂骨折患者实施经伤椎椎弓根钉固定结合经椎弓根植骨术治疗，其中男22例，女8例，年龄18～64岁。
30例均为单一椎体损伤。
术前伤椎前缘高度平均35％，脊柱后凸角（Cobb角）26°，椎管正中矢状径55％，神经功能按Frankel分级：A级4例，B级8例，C级5例，D级6例，E级7例。
［结果］术后随访6～30个月，30例患者术后疼痛明显缓解（VAS评分改善），术后伤椎前缘平均高度恢复到97％，脊柱后凸角（Cobb′s角）为3.5°，椎管正中矢状径恢复到92％，手术前后差异显著（P＜0.05）。
术后神经功能恢复情况：A 级2例，B级2例，C级5例，D级5例，E级16例。
术后骨折均获得复位，无1例发生内固定断裂、松动、矫正丢失等并发症。
［结论］经伤椎椎弓根钉固定结合经椎弓根植骨术能让骨折获得满意复位，重建椎体高度，增强脊柱的抗压稳定性，减少内固定因应力过大造成的断钉、矫正丢失等并发症，是一种治疗胸腰椎爆裂骨折的有效方法。
【关键词】胸腰椎损伤；爆裂骨折；椎弓根钉；经椎弓根；植骨术Abstract：［Objective］To investigate curative effect for thoracolumbar burst fractures by the method of vertebral pedicle screw fixation applied in the with transpedicular bone graft,and consider its indications.［Method］Thirty cases of thoracolumbar burst fractures were treated by vertebral pedicle screw fixation combining transpedicular bone graft.Among them 22 were male and 8 were famale,age ranged 18-64.All of cases were single segment fractures.The average height of anterior border was 35% before the operation,the average of Cobb’s angle was 26°,the percentage of midsagital diameter was 55%.According to Frankel’s neurological function classification,preoperative neurological function was Grade A in 4 cases,B in 8,C in 5,D in 6,E in 7.［Result］All cases were followed up for 6 to 30 months.All patients’pain relieved distinctly,the average height anterior border was increased to 97%,the average of Cobb’s angle was 3.5°,the percentage of midsagital diameter was 92% postoperatively,showing significant difference（P＜0.05）before and after operation.The postoperativeneurological function was improved: Grade A in 2 cases,Grade B in 2,Grade C in 5,Grade D in 5,Grade E in 16.All the fracture were reduced and the internal fixation didn’t loose and break,and there was no lost of correction and other complications.［Conclusion］Vertebral pedicle screw fixation with transpedicular bone graft can not only reduce verbebral fracture satisfactorily,increasing the stability of spine,but also decrease the possibility of breaking nail and correction loss.Therefore it is an effective method of treating thoracolumbar burst fractures.Key words：thoracolumbar injury; burst fractures；pedicle screw; transpedicular；bone graft目前，经后路伤椎上、下相邻椎弓根螺钉内固定术仍为临床上治疗胸腰椎爆裂骨折的传统术式，但该术式存在椎体高度复位不佳，失败率较高［1］等不足。
贝前列素钠片治疗脑小血管病患者临床研究
·13JOURNAL OF RARE AND UNCOMMON DISEASES, OCT. 2023,Vol.30, No.10, Total No.171【第一作者】王 阔，男，住院医师，主要研究方向：神经外科临床研究。
E-mail：***************【通讯作者】王 阔·论著·神经内镜下经额锁孔入路对基底节区脑出血患者神经功能恢复及安全性研究 王 阔* 武树超 魏志玄 谢宗新 王 博南阳医学高等专科学校第一附属医院(河南 南阳 473000)【摘要】目的 探究神经内镜下经额锁孔入路对基底节区脑出血患者神经功能恢复及安全性的影响。
方法 选择本院2020年3月~2022年3月收治的102例基底节区脑出血患者，按手术方式不同设为49例对照组(显微镜下经颞锁孔入路)与53例研究组(神经内镜下经额锁孔入路)。
比较两组手术效果、血肿清除率、神经功能(GCS评分)、日常生活能力(MBI评分)及并发症情况。
结果 两组住院时间及血肿清除率相比无差异(P >0.05)；研究组手术时间比对照组短，术中出血量比对照组少(P <0.05)；两组术后神经纤维束各向异性值、相对各向异性值均比术前高，且研究组比对照组高(P <0.05)；两组术后GCS评分、MBI评分均比术前高，且研究组术后GCS评分比对照组高(P <0.05)；两组再出血、脑梗死等并发症发生率相比无差异(P >0.05)。
结论 神经内镜下经额锁孔入路治疗基底节区脑出血安全有效，可明显减少患者术中出血，促进其神经功能恢复。
【关键词】基底节区脑出血；神经内镜；锁孔入路；神经功能【中图分类号】R722.15+1【文献标识码】A DOI:10.3969/j.issn.1009-3257.2023.10.006Neuroendoscopic Transfrontal Keyhole Approach for Neurological Function Recovery and Safety in Patients with Basal Ganglia Cerebral Hemorrhage WaNg Kuo *, WU Shu-chao, Wei Zhi-xuan, Xie Zong-xin, WaNg Bo.The First affiliated hospital of Nanyang Medical College, Nanyang 473000, henan Province, China abstract: objective To investigate the effect of neuroendoscopic transfrontal keyhole approach on neurological function recovery and safety in patients with basal ganglia cerebral hemorrhage. Methods a total of 102 patients with basal ganglia cerebral hemorrhage admitted to our hospital from March 2020 to March 2022 were selected and divided into control group (n = 49) and study group (n = 53) according to different surgical methods. The operation effect, hematoma clearance rate, neurological function (gCS score), ability of daily living (MBi score) and complications were compared between the two groups. Results There was no difference in the length of hospital stay and hematoma clearance rate between the two groups (P >0.05). The operation time of the study group was shorter than that of the control group, and the intraoperative blood loss was less than that of the control group (P <0.05). The anisotropy value and relative anisotropy value of nerve fiber bundle after operation in the two groups were higher than those before operation, and the study group was higher than the control group (P <0.05). The postoperative gCS score and MBi score of the two groups were higher than those before operation, and the postoperative gCS score of the study group was higher than that of the control group (P <0.05). There was no difference in the incidence of complications such as rebleeding and cerebral infarction between the two groups (P >0.05). Conclusion Neuroendoscopic transfrontal keyhole approach is safe and effective in the treatment of basal ganglia cerebral hemorrhage, which can significantly reduce intraoperative bleeding and promote the recovery of neurological function.Keywords: Basal Ganglia Cerebral Hemorrhage; Neuroendoscopy; Keyhole Approach; Nerve Function 基底节区作为脑出血最常见位置，此处脑出血极易造成严重神经损害，引发颅内高压等多种并发症，甚至脑疝，严重威胁患者生命安全[1]。
颅骨修补手术室安排流程
颅骨修补手术室安排流程英文回答：Preoperative Planning for Cranioplasty Surgery.Preoperative planning for cranioplasty surgery involves a thorough assessment of the patient's medical history, physical examination, and imaging studies. The following steps are typically involved in the preoperative planning process:1. Medical History: The patient's medical history is reviewed to identify any potential risk factors for surgery, such as diabetes, heart disease, or bleeding disorders.2. Physical Examination: A physical examination is performed to assess the patient's overall health and to evaluate the surgical site.3. Imaging Studies: Imaging studies, such as computedtomography (CT) or magnetic resonance imaging (MRI), are used to evaluate the size and location of the skull defect, as well as to assess the underlying brain tissue.4. Surgical Planning: The surgical team develops a surgical plan based on the patient's individual needs. This plan includes the type of cranioplasty procedure to be performed, the materials to be used, and the expected length of surgery.5. Patient Education: The patient is educated about the surgery, including the risks and benefits, and is given instructions on how to prepare for surgery.6. Informed Consent: The patient signs an informed consent form indicating that they understand the surgery and agree to proceed with the procedure.Perioperative Management.Perioperative management involves the care of the patient before, during, and after surgery. This includes:1. Preoperative Preparation: The patient is preparedfor surgery by shaving the surgical site and administering antibiotics.2. Intraoperative Management: During surgery, the surgical team monitors the patient's vital signs and administers anesthesia. The skull defect is repaired using the chosen materials and technique.3. Postoperative Care: After surgery, the patient is monitored for complications and is given pain medication as needed. The surgical site is dressed and the patient is gradually mobilized.Follow-Up Care.Follow-up care is essential to ensure that the patient is recovering well and that the surgical site is healing properly. Follow-up appointments typically include:1. Wound Care: The surgical site is inspected andcleaned at follow-up appointments.2. Imaging Studies: Imaging studies may be repeated to assess the healing of the skull defect.3. Neurological Examination: A neurological examination is performed to assess the patient's neurological status.4. Rehabilitation: The patient may be referred to rehabilitation to help them regain their strength and function.中文回答：颅骨修补术术前准备流程。
手术室护理指南英语电子版
手术室护理指南英语电子版Perioperative Nursing Guidelines for the Operating Room. Introduction.The operating room (OR) is a specialized environment where surgical procedures are performed. Perioperative nurses play a vital role in ensuring the safety and well-being of patients undergoing surgery. These guidelines provide comprehensive instructions for perioperativenursing care, encompassing preoperative, intraoperative,and postoperative phases.Preoperative Phase.Patient Education and Assessment.Educate patients about the surgical procedure, anesthesia, and postoperative expectations.Obtain a thorough medical history, including allergies, current medications, and any previous surgeries.Assess patients' physical and psychological status, including vital signs, pain levels, and anxiety.Review preoperative orders and ensure compliance.Preoperative Preparation.Verify patient identity and surgical site.Remove jewelry, clothing, and any other potential hazards.Administer preoperative medications as ordered.Insert an intravenous (IV) line and monitor vital signs.Position the patient on the operating table accordingto the surgical procedure.Maintain a sterile field and ensure proper positioning of equipment.Intraoperative Phase.Circulating Nurse.Monitor the sterile field and ensure adherence to sterile technique.Manage supplies, equipment, and instruments.Assist the surgeon with procedural needs, such as retracting tissues or administering medications.Provide technical support to the surgical team and maintain a safe and efficient environment.Scrub Nurse.Prepare and pass sterile instruments and supplies tothe surgeon.Anticipate the surgeon's needs and maintain a well-organized instrument table.Maintain a sterile field and assist with wound closure.Document surgical procedures and any significant events.Anesthesia Care.Monitor the patient's vital signs, including heart rate, blood pressure, and oxygen saturation.Administer anesthesia and monitor the patient's response.Manage airway and ventilation during surgery.Provide pain management and sedation as needed.Postoperative Phase.Post-Anesthesia Care Unit (PACU)。
C3椎板切除与微型钛板固定成形颈椎后路单开门术后颈椎活动度及曲度的比较
《中国组织工程研究》 Chinese Journal of Tissue Engineering Research·研究原著·陈育岳，男，1982年生，广东省汕头市人，汉族，硕士，主治医师，主要从事脊柱外科相关疾病的研究。
通讯作者：马向阳，教授，主任医师，博士后，博士生导师，中国人民解放军南部战区总医院骨科，广东省广州市 510010文献标识码:A投稿日期：2019-09-07 送审日期：2019-09-10 采用日期：2019-10-31 在线日期：2019-12-03Chen Yuyue, Master, Attending physician, Department of Orthopedics, General Hospital of Southern Theater Command of PLA, Guangzhou 510010, Guangdong Province, ChinaCorresponding author: Ma Xiangyang, Professor, Chief physician, MD, Doctoral supervisor, Department of Orthopedics, General Hospital of Southern Theater Command of PLA, Guangzhou 510010, Guangdong Province, ChinaC 3椎板切除与微型钛板固定成形颈椎后路单开门术后 颈椎活动度及曲度的比较陈育岳，邹小宝，马向阳，王宾宾，杨浩志，葛 苏，张 双，倪 菱，夏 虹，吴增晖(中国人民解放军南部战区总医院骨科，广东省广州市 510010)DOI:10.3969/j.issn.2095-4344.2542 ORCID: 0000-0002-182-0745(陈育岳)文章快速阅读：文题释义：后路单开门手术：该术式可扩大颈椎椎管，使得颈脊髓向后方漂移，从而解除脊髓压迫，缓解神经功能障碍症状，是治疗多节段脊髓型颈椎病、发育性颈椎管狭窄、后纵韧带骨化等疾病的最常用手术方式。
buerger病和冠心病
case-2(Case Reports in Medicine,2013)
A 52-year-old patient, heavy smoker with hypertension and COPD, has been sufering from thromboangiitis obliterans(TAO) for the last 25 years. Within the frame of symptomatic treatment of TAO, lumbar sympathectomy was followed by spinal cord stimulator.His amputation history is impressive as it includes right lower limb amputation, at the level below knee; epicondylar amputation of the left extremity; amputations of the left index, of the right middle inger, and of the right little finger. His vascular history includes 60% stenosis of the right internal carotid artery, abdominal aortic aneurysm (43 mm),40% stenosis of the left renal artery, and a signiicant degree of stenosis of the iliac vessels (40% on the left and 60% on the right). Pulses were absent from the femoral, the radial, and ulnar arteries, on both sides. The patient had never stopped smoking.
英文病历
Case 17: Suprasellar meningioma鞍上脑膜瘤A 59-year-old woman presented to us with a few years history of decreased vision. She had an outside CT scan showing an enhancing lesion in the suprasellar area. The neurological examination was positive for severely decreased vision in both eyes, left more then right. There was primary optic atrophy in the left eye. MRI scans confirmed the CT findings, showing an enhancing lesion in the suprasellarregion.Through a bifrontalcraniot-omy a suprasellar tumor originating from the tuberculumsellae enveloping the supraclmoid ICA and both optic nerves and extending Into the sellaturcica was completely removed. The postoperative course was uncomplicated with improvement of vision on the right. Postoperative CT showed complete tumor removal.Case 18: Tuberculumsellae-planumsphenoidale meningioma鞍结节蝶骨平台脑膜瘤A 58-year-old man was diagnosed as having a predominantly intracranial meningioma en plaque of the anterior skull base in the midline area,extending from the tuberculumsellae and pla-numsphenoidale to the crista galli. The tumor was exposed in-tradurally through a right frontal craniotomy. The compressed right optic nerve and internal carotid artery were identified and freed from tumor. Then the optic chiasm and left optic nerve?completely encased by tumor, were freed by piecemeal removal of the neoplasm. Residual tumor on the tuberculumsellae and portions of the planumsphenoidale were removed with the diamond burr. The bone defect was closed in two layers with lyoph-ilizeddura and a galealpericranial flap.Case 19: Meningioma of the left optic sheath左视神经鞘脑膜瘤A 33-year-old woman had a 7-year history of progressive vis-eterioration culminating in amaurosis. Axial CT scans with oblique reconstruction showed a dense tumorlike swelling along the course of the optic nerve.The presence of amaurosis despite the small tumor size implied that optic nerve function had been damaged by mfiltrative growth. The tumor was approached through a right frontotemporal osteoplastic craniotomy with ex-tradural exposure of the orbital roof. The orbital roof was removed microsurgically with the diamond burr, and the optic canal was unroofed. The tumor was exposed by incising the dural cuff around the optic nerve.The nerve and surrounding tumor were resected with adequate margins posteriorly and also close to the globe. Salvage of the optic nerve was impossible due to inftl-trative growth.Case 20: Clivus meningioma斜坡脑膜瘤A 63-year-old women came to our attention with a 2-year history of double vision when looking to right. Neurological examination disclosed a right abducens paresis and a left hemipare-sis, worse in the arm. Audiogram showed a 50dB hearing loss between 1. 5 and 3 kHz on the right. CT and MRI scans demonstrated a right prepontineextraxial mass at the level of the middle pons. The patient was operated on in the semisiting position with the head tilted 30° to the right and slightly flexed. A lateral suboccipitalcraniectomy was used to expose the right cerebellar hemisphere flush to the petrous pyramid. The dura v/as opened just medial to the sigmoid sinus,and cerebrospinal fluid was drained from the lateral cerebellomedullary cistern. After medial retraction of the cerebellar hemisphere and visual exploration of the lower cerebellopontlne cistern it was evident that the lower cranial nerves (IX-XI) as well as the YE-VB complex were mildly displaced posteriorly by the prepontlne mass. Nerve V was pos-terosuperiorly displaced. The tumor was completely removed working around the nerve W-VB complex. During tumor removal the auditory evoked potentials were permanently lost? and nerve VB was consequently cut, making tumor removal somewhat easier. The tumor originated from the dural entrance of nerve VI which was,both proximally and distally to this point, totally engulfed by tumor.It was possible to remove the tumor completely, preserving the VI function. In addition to loss of the nerve VIII function, the postoperative neurological examination showed decreased hemiparesis and improvement of the abducens function, which returned to normal in 6 months.Case 21: A recurrent inferior clivalmeningioma (with far lateral approach)复发性斜坡下段脑膜瘤（远外侧入路）A 28-year-old female had neuro-fibromatosis type II. She had 11 operations before presenting to our institution with increasing problems of gait and the development of moderate n-paresis. Diagnostic studies demonstrated a clivalmeningiorna compressing and shifting the medulla and upper cervical.two previous attempts to resect the tumor from the stand-n-iidhne, posterior fossa craniectomy, C1-C2 lammectomy approach had been made. At the last operation, damage to the vertebral artery had caused extensive hemorrhage and required packing with muslin to control.This case is a good example of the need to evaluate whether the previous approach offered the best exposure to the tumor. The midline approach does not offer adequate midline exposure of the tumor. Associated neural structures can be injured when they are retracted during this approach. The use of muslin and the associated scarring illustrate complications that can change or increase the difficulty of a reoperatton. The patient also had a previous postoperative pseudo-meningocele. Direct closure was attempted but failed. It eventually required a lumboperitoneal shunt.The displacement of the brain stem and upper cervical cord to the right mandated an approach from the left. The far-lateral transcondylar approach offered a fresh exposure to the tumor. The patient was placed in the modified park bench position. An inverted hockey stick incision incorporated the previous midline incision but circled laterally to the mastoid tip.The scalp flap was dissected from the scar tissue in the midline and reflected posterolaterally to expose the left side of the previous operative approach. This maneuver provided access to the lateral posterior fossa. The posterior fossa craniectomy was expanded laterally to the occipital condyle and through the inferior mastoid region. The posterolateral condyle and the lateral mass of Cl were drilled away.Only remnants of dura were in the previous operative site, but clean dura was found along the lateral aspect of the expanded bony exposure. The intact dura was open and reflected laterally. Under the operating microscope, the lower cranial nerves were identified from the jugular foramen and the hypoglossal canal and traced toward the brain stem. The vertebral artery and cranialnerves were carefully microdissected from the scar tissue. The hard, calcified mass of muslin encasing the vertebral artery was dissected free from the vertebral artery and brain stem and removed. The tumor was therefore exposed without retracting the brain stem. This maneuver was important because the brain stem had extensive arachnoid scarring. Retraction without removal of these adhesions could have damaged the brain stem.For complete tumor excision, these adhesions were taken down with sharp dissection, and the dentate ligaments of the upper cervical cord were cut to allow mobilization.Once mobilized and fully exposed, the tumor was removed completely to prevent the recurrence of a pseudomeningocele.afascial graft was used to close the operative site. Nonetheless, a pseudomeningocele recurred and required a ventricular peritoneal shunt. The lumbar peritoneal shunt system did not function properly because of extensive neurofibromas of the caudaequina. Postoperatlvely, the patient's quadriparesis improved and she had no new neurologic deficits.Case 22: Petroclival meningioma岩斜脑膜瘤A 49-year-old female presented with a 1-year history of stag-g and poor balance, a several year history of occasional nau-sea and vomiting, and a 10-15-year history of night terrors and sleep-walking. Several years prior to her admission, she was medically treated for trigeminal neuralgia on the left side, which sided without recurrence. Her neurological exam was significant for left cerebellar signs,as well as a positive Rhomberg with the patient falling to the left. An audlogram showed bilateral high-frequency hearing loss.Both CT and MRI demonstrated a large petroclival tumor with extensions through the tentorial hiatus. A cerebral arteriogram showed that the sinuses were patent. Using the petrosal approach, we gained access to and totally removed the meningioma. Her postoperative course was uneventful with the patient neurologically intact aside from the cerebellar signs present preoperatlvely, which gradually resolved over 1 month. On follow-up after 2 weeks?the patient demonstrated a large CSF collection under the skin flap.This was successfully treated with spinal drainage. There has been no sign of tumor recurrence after 4 years of follow-up.Case 23: Petroclival middle fossa meningioma岩斜中颅窝脑膜瘤This 45-year-old woman was evaluated 8 years previously for Meniere's disease. She presented now with a complete hearing loss on the left and vertigo. CT and MRI scans revealed a tumor involving the petrous ridge, tentorium, and the middle cranial fossa on soft tissue windows, and the petrous bone. During an initial operation, meningioma was removed from the posterior and middle fossae. Residual tumor was present in the internal auditory canal, the petrous bone, Meckel’s cave, and the clivalduraa-round CN VI. During a second operation 9 days later, a subtotal piecemeal petrosectomy with theremoval of all residual tumor was Ⅶwas tumor encased in the intracanalicular, labyrinthine, and tympanic segments. Resection of the epineurium allowed the nerve to be preserved. The patient sustained a temporary palsy of CNs V[ and Vttpostoperatively.The patient developed a necrosis of the posterior edge of the very thin scalp flap. This required debridement and a trapezius muscle rotation flap. The abducens palsy resolved quickly, and the facial nerve palsy improved over 5 months, eventually with House grade n function. No tumor recurrence was noted a year later.Case 24 Trigeminal meningioma三叉神经脑膜瘤A 56-year-old woman presented with a 3-year history of decreased hearing and a 2-month history of unsteady gait and trouble in swallowing. Neurological examination was positive for mildly decreased sensation over the left face, decreased hearing, decreased DC-XI nerve function,and positive cerebellar tests. CT scans showed a 5-cm tumor in the cerebellopontine angle with severe degree of cerebellar-brainstem edema. At surgery, by suboc-cipitalcramectomy, a tumor originating from the posterior fossa opening of MeckeFs cave, displacing the nerve VH complex orsally and the cranial nerves DC-XI caudally was completely re-°ved. Nerve V was invaded by tumor and had to be sacrificed. Du to difficulties in waking up from the anesthesia a CT scan was obtained, which showed a cerebellar blood clot in the area of preoperative swelling, compressing the IV ventricle with hydrocephalus. The hematoma was removed, and the patient was discharged 3 months after the operation.。
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EDITORIALStudiesonpostoperativeneurologicalcomplications,particularlycognitivedysfunction
ShigeruSaito
Received:15June2013/Accepted:8July2013ÓJapaneseSocietyofAnesthesiologists2013
KeywordsPostoperativecognitivedysfunctionÁPostoperativecognitivedeclineÁNeurologicalcomplicationÁStrokeÁCardiopulmonarybypass
Postoperativerespiratoryandcirculatorycomplicationsareincreasinglysuccessfullymanagedbyadvancedmedicaltechnologies.However,preventionofcentralnervoussystem(CNS)complicationsisnotassuccessful.Thistrendseemstobemoreapparentindevelopedcountries,wheremostpatientsundergoingsurgeriesareelderlypeo-plewithcoexistingdiseases.Forexample,neuropsycho-logicaldysfunctionaftercardiopulmonarybypass(CPB)hasbeenreportedinmorethanhalfofpatientsduringtheearlypostoperativeperiod[1].Manyoriginalreportsandreviewarticlesregardingthistopichavebeenpublishedinthisjournal.Inparticular,cognitivedysfunctionsfollowingcardiacandorthopedicsurgeryareoftendiscussed.Cerebralinfarctioncanbefatalorcancauseseveredisabilities.Hence,thiscomplicationisthemostseriouscentralneurologicalcomplicationaftersurgery.Fortu-nately,however,theincidenceofseverecasesisnotveryhigh,theoverallstrokerateinananalysisoflargecohortsreportedlybeingapproximately1–2%[1,2].However,theincidenceofminorneurologicalcomplicationsfollowingmajorsurgeriesisquitehigh,withcognitivedysfunctionbeingfarmorecommonthanstroke[2].Althoughthesearecategorizedas‘‘clinicallyminorcomplications,’’theyare
capableofinterferingwiththelifeofpatientspostoperatively.Thereiswidevariationamongthereportedrateofcognitivedysfunctionaftermajorsurgery[1,2].Intheimmediatepostoperativeperiod,theincidencerangesashighas80–90%,whichmeansthatalmostallpatientsexperiencecognitiveabnormalitiesaftermajorsurgery.However,atseveralmonthsafterthesurgery,theinci-dencedecreasestolessthanhalfofthepatients,furtherdecreasingtoaroundone-fourthofpatientsat1yearafterthesurgery.Althoughitmaybetruethatmostoftheearlycognitivelossistransient,multiplelongitudinalstudiesdemonstratedthat,insomecases,itpersistsforseveralyearsaftersurgery,especiallyaftercardiacsur-gery[3].Theincidenceoflong-lastingneurologicalsymptomsseemsnottobenegligible.Minorneurologicalinjuries,suchascognitivedysfunctions,donotnecessar-ilyincreasethenumberofbedriddenpatientsasseenafterstroke.However,theextremelyhighincidencecomparedtostrokemakestheseinjuriesextremelyproblematic,intermsofthesocialimpact,suchasqualityoflifeofanagedpopulationandeconomicburdenonhealthcareresources.Amongthevariouspostoperativecognitivedysfunc-tions,postoperativecognitivedecline(POCD)representstrivialcognitivedysfunction[2].Afterasurgicalproce-dure,patientsfrequentlycomplainofmemorylossandlackofconcentration.SymptomsofsuchsubtlecognitiveabnormalitiesexperiencedafteranoperationaredescribedasPOCD.Althoughminorsymptomsarenotnoticeabletootherpeople,thepatientsthemselvescansensetheappar-entabnormalities.Minorcognitivedysfunctionitselfisnotlifethreatening,andthesubtledifferencesincognitiveperformanceareextremelydifficulttomeasure.Forthisreason,thetrueprevalenceofPOCDisuncertain.
S.Saito(&)DepartmentofAnesthesiology,GunmaUniversityGraduateSchoolofMedicine,3-39-22Showa-machi,Maebashi371-8511,Japane-mail:shigerus@showa.gunma-u.ac.jp
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JAnesthDOI10.1007/s00540-013-1674-9Asanunignorablefactforanesthesiologists,patientsoftenattributethesesymptomstointraoperativeanesthesiamanagement[2].However,thereislittleevidencethatPOCDiscausedbyanesthesiamanagement,includinggeneralanesthesia.SeveralclinicalstudiesdemonstratedthattheanesthetictechniqueisnotadeterminantofPOCD[2,4].Furthermore,theriskofPOCDisreportedtobesimilarafterbothgeneralandregionalanesthesia.Therearemanyreportsdescribingtherelationshipbetweenthetypeofoperationandtheincidenceofneu-rologicalcomplications.Postoperativecognitivedysfunc-tions,whichareapparentevenwithoutneuropsychologicaltesting,arereportedmostfrequentlyaftercardiacandhipreplacementsurgery[5–7].Thistrendisconsistentamongclinicalreports.Inthesecases,neurologicaldysfunctionprobablyreflectsmicroembolicbraininjury.Theincidenceafterthoracicsurgeryandabdominalsurgeryhasalsobeenreportedinthisjournal[8,9].Apartfromthenatureofthesurgicalprocedure,advancedageisanotherimportantriskfactorforpostop-erativecognitivedysfunction[1,2].Althoughcognitivedysfunctionisalsoseeninpediatriccasesaftersurgeries,thosedysfunctionsseeninyoungerchildrenshouldnotbeconsideredtogetherwithgeriatriccases[10].Developingandmaturebrainsbehavedifferentlywhenfacedwithclinicalinsults.Becauseadvancesinsurgicaltechnologieshaveallowedinvasivesurgeriestobeperformedonaprogressivelyolderandsickerpopulation,theseolderand/orsickerpopulationsareconsideredtobeatparticularriskforcerebralinjuryduringsurgery[11].Alongwiththeeffectofaging,coexistingdiseasesandpreoperativeconditionshaveasignificantimpactonpost-operativeneurologicalfunctions.Preexistingneurologicaldisordersanddepressivetendencieshavebeenreportedtocorrelatewithpostoperativecognitivedysfunction[12,13].Diabeteshasbeenrepeatedlydiscussedinthisjournalasacommonpreoperativedisorderthatisrelatedtopostoper-ativecondition[13,14].Itiswidelyknownthatthepres-enceofdiabetesmellitusisariskfactorforstrokeandcognitivedysfunctionaftercardiacsurgery[5,11].Onepossiblemechanismforthemorefrequentoccurrenceofpostoperativecognitivechangesindiabeticpatientsisreportedlytheirabnormalcerebralautoregulationduringcardiopulmonarybypass[14].ReducedcerebrovascularCO2reactivityindiabeticpatientsmightbeoneoftheriskfactorsforpostoperativecognitivedysfunctionaftercoro-naryarterybypassgraftsurgery.Metabolicsyndrome,whichisconsideredtobeaprecursorofseverallifestyle-relateddiseases,suchasdiabetes,hypertension,andcoro-naryarterydiseases,isalsoreportedtobeariskfactorforpostoperativecognitivedysfunction[15].Severalrecentoriginalarticlesinthisjournalhavedis-cussedthevariousmechanismsofpostoperativecognitivedysfunctions.Asmentionedearlier,embolizationofpar-ticulateandgaseousmaterialintothecerebralmicrovas-culature,resultinginfocalareasofcerebralischemia,hasbeenbeststudied,especiallyincardiacandorthopediccases[2,3].Theseetiologiesproposeischemiaanditssequelaetobeimportantpathophysiologicalevents.How-ever,clinicalandexperimentaldatahavealsoproposedothermechanismsforcognitivedysfunction.Forexample,cerebralaswellassystemicinflammatoryeffectscanbeinducedduringcardiopulmonarybypass,leadingtoinjury,bothdirectlyandindirectly,tobraincells[16].Inaddition,cerebraledemadocumentedbypostoperativemagneticresonanceimaging(MRI)hasalsobeendemonstratedinpatientsundergoinggastrointestinalsurgeries[17].Ahyperthermicresponseoccursintheearlypostoperativeperiodfollowingcardiacsurgery,whichhasbeenlinkedtocognitivedecline6weeksaftercardiacsurgery[3].Severalbiomarkershavealsobeenproposedasbeingeffectiveinpredictinganddiagnosingpostoperativeneurologicalsequelae[6,7].Furthermore,althoughthereisnosolidscientificevidenceforthis,geneticvariations,suchasapolipoproteingenotype,havebeenreportedtoaffectboththesusceptibilitytoinjuryaswellastheabilitytorecoverfollowinginjury[18,19].Consideringthattherearenumerousdescriptionsregardingthegeneticandepi-geneticetiologiesofneurologicalandcirculatorydisorders,itisnotsurprisingthatpostoperativecognitivedysfunctionhasalsobeenlinkedtoageneticbackground.Comparedtoepidemiologicalandetiologicaldescrip-tions,studiesonthetreatmentofpostoperativecognitivedysfunctionsareverylimited.However,theeffectsofaminophyllineoncognitiverecoveryaftergeneralanes-thesiawerereportedina2011issueofthisjournal[20].Althoughthearticleonlydiscussedimmediatepostopera-tivesymptoms,furtherstudieswithasimilarapproachcouldhelptacklethiswidelyobservedclinicalproblem.Newmanetal.[21]reportedthatdeterioratedcognitivefunctionwasobservedinmorethanhalfofpatientsaftercardiacsurgeryintheir5-yearfollowup,andthatthelowercognitivefunctionscoreswereassociatedwithpoorergen-eralhealthandalessproductiveworkingstatus.Inouyeetal.estimatedthateachyearcognitiveimpairmentcomplicateshospitalstaysformorethan2.3millionolderpeople,involvesmorethan17.5millioninpatientdays,andaccountsformorethan$4billionofMedicareexpendituresintheUnitedStates.Substantialadditionalcostsaccrueafterdis-chargefromthehospital,becauseoftheincreasedneedforinstitutionalization,rehabilitation,andhomecare[22].Physicians’attentionmustgointoimprovementinbrainprotectionandqualityoflife.Amultidisciplinaryapproachmustbedevelopedtominimizetheadverseaffectsofoper-ationoncognitivefunctionbecausedeteriorationincogni-tivefunctionhasadversesocietalconsequences.