无创监测颅脑创伤后脑血流动力学变化的临床应用价值研究

发布时间：2018-06-03 17:35

本文选题：颅脑创伤 + 经颅多普勒　；参考：《中南大学》2013年博士论文

【摘要】：颅脑创伤是神经外科常见病和多发病,特别是中重型颅脑创伤病情凶险,死残率高,一直神经外科的重点和难点。中重型颅脑创伤患者颅内压控制和脑灌注压维持是抢救成功与否的关键,目前主要采用有创方法监测颅内压和脑灌注压。但是有创颅内压监测的风险(如感染和颅内出血等)以及昂贵的成本费用使临床应用受到限制。随着微创和无创神经外科理念和技术的发展,寻求一种有效的无创颅内压和脑灌注压监测方法逐渐受到学界重视。探讨无创监测颅脑创伤后脑血流动力学状况,评估颅内压、脑灌注压、脑自动调节功能及预后已受到广泛关注。颅脑创伤所致的脑血管病变(如外伤性颈内动脉海绵窦瘘和脑动脉瘤等),早期发现和早期诊断存在一定困难,因而难以获得早期治疗,以致严重影响向患者预后。特别是外伤性颈动脉海绵窦瘘的筛查、血管内栓塞治疗术中监测和术后随访亦是神经外科的难题之一。探讨无创脑血流动力学检测在外伤性脑血管病变的筛查诊断、血管内栓塞治疗术中监测以及随访的实用价值,具有重要的临床意义。 1982年,挪威学者Aaslid研制出世界上第一台经颅多普勒超声仪。从此,无创脑血流动力学的临床检测研究和应用进入了新时代。经颅多普勒是利用低频超声波的良好穿透性,采用低频超声探头经特定的颅骨透声窗,探测颅内血管血流动力学参数的无创性检查方法。相比其它脑系方面的检查其具有无创、便捷、快速、价廉、重复性强及动态监测的特点。该技术进入国内10余年时间,主要用于检测病人的脑血管痉挛和脑供血不足等基本应用方面,其在神经外科的临床应用仍处于探索阶段。本研究旨在采用经颅多普勒无创技术动态检测颅脑创伤后脑血流动力学参数指标和频谱形态等变化,并与有创颅内压、脑灌注压、动脉血压及脑血管造影等金标准比较,建立无创实时定性定量颅内压、脑灌注压、脑血流量和脑自动调节状态的评估方法；探索脑血流动力学的变化规律和对预后的影响,以期为临床选择最佳治疗时机和方法,指导手术、血管介入和药物治疗,判断疗效和预后提供科学依据,也为将来新的临床治疗方法和药物选择提供研究基础。本研究通过无创检测技术进行对照研究,无影响病情的风险,亦无伦理隐患存在。研究包括以下四部分。第一章中重型颅脑创伤后脑血流变化与颅内压和脑灌注压的相关性研究目的探讨中重型颅脑创伤后的脑血流动力学参数指标变化与颅内压和脑灌注压的相关关系。方法采用经颅多普勒无创血流检测技术,前瞻性随机对照研究62例急性中重型颅脑创伤病人的双侧大脑中动脉血流动力学检测指标的有关参数和频谱形态。检测脑血流动力学的参数指标主要包括：收缩期峰值血流速度(Vs)、舒张期低值血流速度(Vd)、平均血流速度(Vm)、搏动指数(PI)、阻力指数(RI)；同期采用颅内压监护仪和心电监护仪持续监测颅内压(ICP)、脑灌注压(CPP)和平均动脉血压(MABP)。统计分析脑血流动力学的有关参数指标、MABP与ICP、CPP等,分析上述参数指标的相关关系和相关程度。结果PI、RI与ICP呈正相关关系,相关系数分别为r=0.898(P0.0001),r=0.812(P0.0001),ICP和CPP与PI、RI、Vd、Vm、MABP多元逐步回归分析发现PI与ICP,CPP与PI、MABP关系最为密切(P0.0001)。结论无创检测脑血流动力学的有关参数和频谱形态可实时反映中重型颅脑创伤病人的ICP和CPP变化。无创脑血流检测评估颅内压和脑灌注压具有无创、便捷、价廉、可重复性强、易于临床推广,可作为神经外科临床颅内压和脑灌注压监测的一种有效方法。第二章无创脑血流检测评估中重型颅脑创伤患者预后的临床价值研究目的探讨脑血流动力学的参数指标与预后评估的参数指标(GCS和GOS)相关性；探讨无创检测脑血流动力学有关参数指标对中重型颅脑创伤病人预后评估的临床应用价值。方法采用经颅多普勒无创检测72例急性中重型颅脑创伤病人伤后第1、3、7天的双侧大脑前,大脑中动脉,大脑后动脉和椎基底动脉的血流动力学参数指标包括：搏动指数(PI)、阻力指数(RI)、收缩期峰值血流速度(Vs)、舒张期末血流速度(Vd)和平均血流速度(Vm)。入院后一周动态记录病人GCS评分,以及伤后六个月GOS评分。分析Vs、Vd、Vm、PI、RI、GCS评分与伤后六个月GOS预后评分的关系。结果PI和RI与GOS评分呈负相关关系(PI:r=-0.553,P0.0001; RI:r=-0.562,P0.0001)。脑血管痉挛也是影响病人预后的独立因素,血管痉挛组与非血管痉挛组的预后比较有显著差异(X2=5.98,P0.05),基底动脉血流速度异常是影响病人预后的重要因素(X2=17.86, P0.01), PI是评估预后最敏感的指标,PI1.8提示预后不良。第三天的GCS评分和EICA-Vm与患者预后的相关性最大(P0.0001),相关系数R=0.879,确定系数R2=0.763。结论无创检测的脑血流动力学有关参数指标是评估中重型颅脑创伤病人预后的有效方法；脑血管痉挛和基底动脉血流速度异常是影响病人预后的重要因素。PI是评估预后最敏感的指标。伤后第三天GCS评分和EICA-Vm是评估预后重要指标。第三章无创脑血流检测早期评估重型颅脑创伤脑死亡的临床价值研究目的探讨经颅多普勒无创检测重型颅脑创伤病人脑血流动力学参数指标诊断脑死亡的临床价值,以及评估重型颅脑创伤后重度昏迷病人预后的临床价值。方法采用经颅多普勒无创动态检测60例重型颅脑创伤病人(GCS≤8分,持续时间6小时以上),收集上述病人的大脑前、中、后动脉血流动力学有关参数指标,以双侧大脑中动脉(MCA)的血流参数指标和频谱形态为主要观察指标,同时结合临床病情和CT、ICP有关资料进行对照研究和统计分析。结果本组重型颅脑创伤后深昏迷病人双侧大脑中动脉平均血流速度(MCA-Vm)10cm/s,两条以上的血管出现舒张期反向血流或钉子状频谱,血流方向指数(DFI)0.8,是提示脑死亡的可靠指标。颅内压(ICP)60mmHg是脑功能不可逆转的临界压力指标。结论无创检测脑血流动力学参数指标,对于重型颅脑创伤病人脑死亡的初步诊断和重型颅脑创伤深昏迷病人的预后评估具有较高的准确性和可靠性。脑死亡的特征性频谱(RDF和钉子频谱)早于临床脑死亡6-12h出现,总结出脑血流监测MCA-Vm10cm/s、PI2为可能出现脑死亡的量化指标。第四章无创脑血流检测在外伤性颈动脉海绵窦瘘诊疗中的价值研究目的探讨经颅多普勒无创脑血流检测在外伤性颈内动脉海绵窦瘘的诊断、血管内介入治疗术中监测和随访的临床应用价值。方法采用经颅多普勒无创检测28例颅脑外伤后合并眼球结膜充血、突眼、颅内血管杂音及其他可疑有颈内动脉海绵窦瘘的病人,检测指标参数包括双侧大脑中、大脑前、大脑后动脉血流参数,椎基底动脉血流参数,颈内动脉颅外段血流参数。所有病例均经数字减影全脑血管造影(DSA)明确诊断。栓塞术中经颅多普勒持续监测双侧大脑中动脉血流状态,统计分析评价栓塞治疗过程中脑血流状态的变化及血流频谱的改变,并与DSA检查结果对照。另取各种原因进行DSA脑血管造影检查未见脑血管异常的18例患者经颅多普勒无创脑血流检测的参数指标和频谱形态等资料作为对照。结果无创脑血流检测发现颈内动脉颅外段的高流速低阻力频谱,大脑中、前动脉的低流速低阻力频谱以及眼上静脉异常频谱为颈内动脉海绵窦瘘的特征性改变,与DSA全脑血管造影对照具有较高的准确性和特异性。患侧EICA-Vm高于健侧EICA-Vm(P0.05),见；患侧EICA-PI低于健侧EICA-PI(P0.05)。术中无创脑血流监测可实时准确地评估颈内动脉海绵窦瘘口栓塞是否成功。无创脑血流检测诊断TCCF结果是灵敏度=85.71%,特异度=88.89%,约登指数=74.60%。栓塞成功后Vm和PI与术前比较表现为Vm增高和PI升高(P0.01)。结论经颅多普勒无创脑血流检测是颈内动脉海绵窦瘘的临床初步诊断、介入治疗术中适时效果评估和病例随访的有效手段。颈内动脉颅外段高流、低阻和大脑中动脉低流、低阻为筛查TCCF的准确指标,栓塞术中大脑中动脉脑血流监测是实时评价瘘口栓塞成功的有效方法。(图22幅,表12个,参考文献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).
【学位授予单位】：中南大学
【学位级别】：博士
【学位授予年份】：2013
【分类号】：R651.15

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