大脑中动脉梗死的临床研究
摘要
本文收集了1999年3月～2001年3月两年来大脑中动脉梗死病人102例。男性64例,女性38例,最小年龄20岁,最大年龄85岁,平均53.67岁。发病高峰60岁左右。根据临床表现与CT扫描对照,将本病分为三个类型:(1)主干型;(2)皮层型;(3)深穿型。各型的临床表现不同,主干型意识障碍重、瘫痪程度重、死亡率高。皮层型意识障碍轻,瘫痪程度轻。以脑叶的病变症状为主,如失语、体像障碍、抽搐、精神症状等。深穿型意识清、瘫痪重。
本病的主要病因是栓塞,并且以心源性栓子为多。本组合并心房纤颤47例,心室壁瘤1例、心附壁血栓1例。颈内动脉经多普勒超声发现,动脉硬化8例。动脉粥样硬化斑块脱落栓塞也是常见的病因。
中动脉主干栓塞的急性期治疗尤以脱水为重要,本组51例使用甘油果糖治疗脑水肿,观察效果确切。甘油对脑水肿的降颅压作用持续时间长,在体内代谢作为能量被利用。对肾脏损害小,无反跳现象,效果较好。
手术治疗:本组6例进行去骨瓣减压术治疗,6例病人均发生脑疝,病情危重,经内科保守治疗无效,经手术治疗后有5例存活,至今恢复很好。仅有1例死亡,主要因错过手术的最佳治疗时间。手术适应症:(1)突然意识不清,浅昏迷;(2)出现天幕疝;(3)无脑干损伤症状;(4)最好年龄不超过60岁。
药物治疗:主要是抗感染,肺内感染最多发生,尽早给予足量抗菌素,保持呼吸道通畅。细胞活化剂,神经营养剂应尽早使用。栓塞面积大时早期不适合应用血管扩张剂,容易引起出血性梗塞及脑内盗血现象。总之,大脑中动脉栓塞治疗是比较复杂的,合并症较多,如心衰、肾衰、肺内感染等。相互在治疗上都有矛盾,因
This paper collected 102 consecutive patients with medium sizes artery occlusion from March 1999 through March 2001. The patients were 64 men and 38 women. All were between 20 and 85 years of age, with a mean age of 53.67 years. The onset was commonly around 60 years. The infarct types studied in the patients could be classified into 3 groups based on the clinical features and CT scanning: (1) occlusion of the main medium sizes artery, in which deep coma and serious hemiparalysis were commonly seen and motatity was very high; (2) occlusion of cortical branches, in which main presentation was seizure, mental symptoms, disturbance of body-image and so on; (3) occlusion of deep perforating branches, in which the patients were often conscious, but with serious hemiparalysis. Embolism was considered as a main etiology in the patients. The emboli were commonly from the heart with mitral fibrillation and sometimes from large arteries with atherosclerolic plaques. Treatment for medium sizes artery occlusion in the acute stage was convinced to control cerebral edema. The glvcerol solution which was considered to possess longer action, no toxicity, no rebound phenomenon and provision of energy was used and observed in 51 of the total patients. In fact, it gave rise to a satisfactory effect on the patients in the early period of onset. There were 6 cases in the group who had been received.Decompressing operation when cerebral hernia occurred and could not be reversed by the conservative treatment. Five of them survived. The conservative treatment should also be emphasized, specially on early using antibiotics, keeping a good air pathway,
avoiding using vasodilators to the large-infarct patients in the early period and paying much attention to various complications. The hemorrhagic infarcts were found 29 cases in the group, 29 of them were confirmed by CT scanning. Its mechanisms wereconsidered that sudden occlusion of medium sizes artery caused vascular endothelial cell proliferation, swelling and appearance of pinocytolic vesicles. Venulae were distended and bled.
本病的主要病因是栓塞,并且以心源性栓子为多。本组合并心房纤颤47例,心室壁瘤1例、心附壁血栓1例。颈内动脉经多普勒超声发现,动脉硬化8例。动脉粥样硬化斑块脱落栓塞也是常见的病因。
中动脉主干栓塞的急性期治疗尤以脱水为重要,本组51例使用甘油果糖治疗脑水肿,观察效果确切。甘油对脑水肿的降颅压作用持续时间长,在体内代谢作为能量被利用。对肾脏损害小,无反跳现象,效果较好。
手术治疗:本组6例进行去骨瓣减压术治疗,6例病人均发生脑疝,病情危重,经内科保守治疗无效,经手术治疗后有5例存活,至今恢复很好。仅有1例死亡,主要因错过手术的最佳治疗时间。手术适应症:(1)突然意识不清,浅昏迷;(2)出现天幕疝;(3)无脑干损伤症状;(4)最好年龄不超过60岁。
药物治疗:主要是抗感染,肺内感染最多发生,尽早给予足量抗菌素,保持呼吸道通畅。细胞活化剂,神经营养剂应尽早使用。栓塞面积大时早期不适合应用血管扩张剂,容易引起出血性梗塞及脑内盗血现象。总之,大脑中动脉栓塞治疗是比较复杂的,合并症较多,如心衰、肾衰、肺内感染等。相互在治疗上都有矛盾,因
This paper collected 102 consecutive patients with medium sizes artery occlusion from March 1999 through March 2001. The patients were 64 men and 38 women. All were between 20 and 85 years of age, with a mean age of 53.67 years. The onset was commonly around 60 years. The infarct types studied in the patients could be classified into 3 groups based on the clinical features and CT scanning: (1) occlusion of the main medium sizes artery, in which deep coma and serious hemiparalysis were commonly seen and motatity was very high; (2) occlusion of cortical branches, in which main presentation was seizure, mental symptoms, disturbance of body-image and so on; (3) occlusion of deep perforating branches, in which the patients were often conscious, but with serious hemiparalysis. Embolism was considered as a main etiology in the patients. The emboli were commonly from the heart with mitral fibrillation and sometimes from large arteries with atherosclerolic plaques. Treatment for medium sizes artery occlusion in the acute stage was convinced to control cerebral edema. The glvcerol solution which was considered to possess longer action, no toxicity, no rebound phenomenon and provision of energy was used and observed in 51 of the total patients. In fact, it gave rise to a satisfactory effect on the patients in the early period of onset. There were 6 cases in the group who had been received.Decompressing operation when cerebral hernia occurred and could not be reversed by the conservative treatment. Five of them survived. The conservative treatment should also be emphasized, specially on early using antibiotics, keeping a good air pathway,
avoiding using vasodilators to the large-infarct patients in the early period and paying much attention to various complications. The hemorrhagic infarcts were found 29 cases in the group, 29 of them were confirmed by CT scanning. Its mechanisms wereconsidered that sudden occlusion of medium sizes artery caused vascular endothelial cell proliferation, swelling and appearance of pinocytolic vesicles. Venulae were distended and bled.
引文
[1] 韩仲岩,等.实用脑血管病学.上海科学技术出版社出版,1994,85
[2] 程学林,等.我国脑卒中的地理分布.中华神经外科杂志,1989,5:11-15
[3] 龟因正邦.脑卒中临床诸问题.第19回日本医学总会志,1989,906
[4] 韩仲岩,等.实用脑血管病学.上海科学技术出版社出版,1994,87
[5] 史玉泉,等.实用神经病学.上海科学技术出版社,1994,620
[6] 陈清堂,等.临床神经病学.北京科学技术出版社,2000,198
[7] 陈清堂,等.临床神经病学.北京科学技术出版社,2000,200
[8] Homing CR, et al. Stroke, 1986, 17: 179-185
[9] 神经病学.第四版,人民卫生出版社,2002,134
[10] 神经病学.第四版,人民卫生出版社,2002,136
[11] 吴恩惠.头部CT诊断学.第二版,人民卫生出版社,1984,97
[12] 陈龙华,等.262例脑梗塞CT分析.中风与神经病杂志,1986,3(3):129-132
[13] 黄克维.神经病理学.1987,31-36
[14] 章中春.临床神经解剖学.黑龙江人民出版社,1999,60
[15] 杨洪川.130例幕上梗死的临床和CT.中风与神经疾病杂志,1995,11(3):175-178
[16] 吴恩惠.头部CT诊断学.第二版,人民卫生出版社,1984,130
[17] 韩仲光,等.实用脑血管病学.上海科学出版社,1984,126
[18] Lodder T, et al. Acm Neuro Scand, 1994, 329-325
[19] 韩仲岩,等.实用脑血管病学.上海科学技术出版社,1984,175
[20] 韩仲岩,等.实用脑血管病学.上海科学技术出版社,1984,175
[21] 韩仲岩,等.实用脑血管病学.上海科学技术出版社,1984,175
[22] 韩仲岩,等.实用脑血管病学.上海科学技术出版社,1984,177
[23] 韩仲岩,等.实用脑血管病学.上海科学技术出版社,1984,178
[24] 任安之.脑栓塞的病因及部位探讨.中风与神经疾病杂志,1985,113-116
[2] 程学林,等.我国脑卒中的地理分布.中华神经外科杂志,1989,5:11-15
[3] 龟因正邦.脑卒中临床诸问题.第19回日本医学总会志,1989,906
[4] 韩仲岩,等.实用脑血管病学.上海科学技术出版社出版,1994,87
[5] 史玉泉,等.实用神经病学.上海科学技术出版社,1994,620
[6] 陈清堂,等.临床神经病学.北京科学技术出版社,2000,198
[7] 陈清堂,等.临床神经病学.北京科学技术出版社,2000,200
[8] Homing CR, et al. Stroke, 1986, 17: 179-185
[9] 神经病学.第四版,人民卫生出版社,2002,134
[10] 神经病学.第四版,人民卫生出版社,2002,136
[11] 吴恩惠.头部CT诊断学.第二版,人民卫生出版社,1984,97
[12] 陈龙华,等.262例脑梗塞CT分析.中风与神经病杂志,1986,3(3):129-132
[13] 黄克维.神经病理学.1987,31-36
[14] 章中春.临床神经解剖学.黑龙江人民出版社,1999,60
[15] 杨洪川.130例幕上梗死的临床和CT.中风与神经疾病杂志,1995,11(3):175-178
[16] 吴恩惠.头部CT诊断学.第二版,人民卫生出版社,1984,130
[17] 韩仲光,等.实用脑血管病学.上海科学出版社,1984,126
[18] Lodder T, et al. Acm Neuro Scand, 1994, 329-325
[19] 韩仲岩,等.实用脑血管病学.上海科学技术出版社,1984,175
[20] 韩仲岩,等.实用脑血管病学.上海科学技术出版社,1984,175
[21] 韩仲岩,等.实用脑血管病学.上海科学技术出版社,1984,175
[22] 韩仲岩,等.实用脑血管病学.上海科学技术出版社,1984,177
[23] 韩仲岩,等.实用脑血管病学.上海科学技术出版社,1984,178
[24] 任安之.脑栓塞的病因及部位探讨.中风与神经疾病杂志,1985,113-116