颅内高压的治疗
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摘要
颅内压(Intracranial Pressure, ICP)是颅腔内容物对颅腔壁所产生的压力。它是由脑组织、脑血流和脑脊液三部分组成,正常颅内压应小于10mmHg。颅内压增高是神经科危重症病人的重要表现。它可以由一系列神经系统和非神经系统疾病引起,例如颅脑外伤、卒中、肿瘤、瑞夷综合征,肝昏迷或其他的病理情况。有效地降低颅内压能够防止脑疝形成及脑功能衰竭,抢救生命。常用方法包括避免各种可导致颅内压增高的因素,临床发现颅内压增高时,应对症处理。可通过改变患者的体位、降低体温、镇静和通气疗法控制颅内压进一步增高。药物治疗主要有应用镇静药物、减少脑脊液分泌的药物和渗透性脱水剂,其它如巴比妥盐、过度通气(paCO2<25 mmHg)、亚低温和去骨瓣减压术均可考虑。
Intracranial pressure (ICP) is the pressure exerted by cranial contents on the dural envelope. It comprises the partial pressures of brain, blood and cerebrospinal fluid (CSF). Normal intracranial pressure is somewhere below 10mmHg. Intracranial hypertension is a common neurologic complication in critically ill patients; it is the common pathway in the presentation of many neurologic and non-neurologic disorders,such as traumatic brain injury, stroke, neoplasm,Reye's syndrome, hepatic coma, or other pathologies. Effective management of intracranial hypertension involves meticulous avoidance of factors that precipitate or aggravate increased intracranial pressure. When intracranial pressure becomes elevated, treatment is indicated. ICP may be controlled by correcting the patient's position, temperature, sedation or ventilation. Medical management of increased intracranial pressure should include sedation, drainage of cerebrospinal fluid, and osmotherapy with either mannitol or other drugs.Futher management includes barbiturate coma, 'forced hyperventilation' (paCO2<25mmHg), hypothermia, or decompressive craniectomy should be considered.
Intracranial pressure (ICP) is the pressure exerted by cranial contents on the dural envelope. It comprises the partial pressures of brain, blood and cerebrospinal fluid (CSF). Normal intracranial pressure is somewhere below 10mmHg. Intracranial hypertension is a common neurologic complication in critically ill patients; it is the common pathway in the presentation of many neurologic and non-neurologic disorders,such as traumatic brain injury, stroke, neoplasm,Reye's syndrome, hepatic coma, or other pathologies. Effective management of intracranial hypertension involves meticulous avoidance of factors that precipitate or aggravate increased intracranial pressure. When intracranial pressure becomes elevated, treatment is indicated. ICP may be controlled by correcting the patient's position, temperature, sedation or ventilation. Medical management of increased intracranial pressure should include sedation, drainage of cerebrospinal fluid, and osmotherapy with either mannitol or other drugs.Futher management includes barbiturate coma, 'forced hyperventilation' (paCO2<25mmHg), hypothermia, or decompressive craniectomy should be considered.
引文
1 Leonardo Rangel-Castillo, MD, Shankar Gopinath,MD, and Claudia S-Robertson, MD. Management of Intracranial Hypertension , Neurol Clin, 2008, 26(2): 521-541
2 Jantzen JP. Prevention and treatment of intracranial hypertension, BestPract Res Clin Anaesthesiol, 2007, 21(4): 517-538
3 Chen HI, Malhotra NR, Heuer GG. Barbiturate infusion for intractable intracranial hypertension and its effect on brain oxygenation, Neurosurgery, 2008, 63(5): 880-7
4 Rangel-Castilla L, Gopinath S, Robertson CS. Management of intracranial hypertension, Neurol Clin, 2008, 26(2): 521-41
5 Frank JI. Large hemispheric infarction, deterio ration, and intracranial p ressure, Neurology, 1995, 4(5): 1286-1290
6 Miller JD, Sullivan HG. Severe intracranial hypertension, Int Anesthesiol Clin, 1979, 17: 19–75
7 Stiefel MF, Heuer GG, Smith MJ. Cerebral oxygenation following decompressive hemicraniectomy for the treatment of refractory intracranial hypertension, J Neurosurg, 2004, 101: 241–7
8 Polin RS, Shaffrey ME, Bogaev CA. Decompressive bifrontal craniectomy in the treatment of severe refractory posttraumatic cerebral edema, Neurosurgery, 1997, 41: 84–92
9 Sahuquillo J, Arikan F. Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury, Cochrane Database Syst Rev, 2006, CD003983
10 Sakowitz -O-W, Stover -J-F; Sarrafzadeh A-S. Effects of mannitol bolus administration on intracranial pressure, cerebral extracellular metabolites, and tissue oxygenation in severely head-injured patients, J-Trauma, 2007 , 62(2): 292-8
11 Scalea -T-M, Bochicchio -G-V, Habashi–N, Increased intra-abdominal, intrathoracic, and intracranial pressure after severe brain injury: multiple compartment syndrome., J-Trauma, 2007, 62(3): 647-56
12 Johnston I, Paterson A. Benign intracranial hypertension, Diagnosis and prognosis, Brain, 1974, 97(2): 289–300
13 Wilkinson HA. Intracranial pressure, Neurological Surgery, 1990, 661-695
14 Narayan PK. Intracranial pressure, Neurosurg , 1994, 81(6): 810
15 Wilkison HA. Intracranial Pressure. NeurologicalSurgery, 1990, 1661-663
16 Dorman HR. Mannitol-induced acute renal failure, Medicine Baltinore, 1990, 69(3): 612
17 Jantzen JP. Prevention and treatment of intracranial hypertension, Best Pract Res Clin Anaesthesiol, 2007, 21(4): 517-38
18 Mayer SA, Dennis LJ. Management of increased intracranial pressure, Neurologist, 1998, 4: 2-12
19 Himmelseher S. Hypertonic saline solutions for treatment of intracranial Hypertension, Curr Opin Anaesthesiol, 2007, 20(5): 414-426
20李维平,黄国栋,王建中.重型颅脑损伤患者甘露醇、速尿和白蛋白降颅压作用的临床观察,中华神经医学杂志, 2005, 19(4): 377-379
21齐波,苏殿三,王祥瑞.高渗盐溶液治疗颅内高压的研究进展,实用医学杂志, 2009, 25(13): 2015-2017
22王维治,富羽弘.颅内高压症的监测和治疗进展,中风与神经疾病杂志, 2000, 1217(6): 374-375
23雷鹏.重型颅脑创伤治疗中颅骨去骨瓣减压术的应用及注意事项,创伤外科杂志, 2008, 10(1): 92-94
24于广杰,王朝晖.脑外伤后顽固性颅内高压的综合治疗,青岛医药卫生, 1996, 28(6): 19
25陈朝生.甘露醇诱发急性肾功能衰竭,中国实用内科杂志, 1994, 10 (14): 612
26曾红科,王华东.高渗盐水治疗急性脑血管病治疗颅内高压的临床和病理生理研究,中国病理生理杂志, 2005, 21(8): 1663
27崔岩.甘油果糖注射液与甘露醇联合应用治疗脑出血62例疗效观察,中国临床医药研究杂志, 2004, 11(7): 12281
28杨树源,岳勇,李庆彬.甘油果糖注射液降低颅内压的临床观察,中华神经外科杂志, 1994, 9(10)
1吴江,贾建平,崔丽英.神经病学,人民卫生出版社, 2005, 341-343
2王维治.神经病学,人民卫生出版社, 2004, 151～156
3陈平,陈辰昊.老年人蛛网膜下腔出76例临床分析,中风与神经疾病杂志, 2004 , 21(2): 181～181
4 Broderick J P, Brott TG,Duldner J E. Initial and recurrent bleeding are the major causesof death following subarachnoid hemorrhage, Stroke , 1994, 25: 1342
5 Eisenberg HM, Gary HE, Aldreich EF. Initial CTfindlings in 753 patients with severe head injury, A report from NIH traumatic coma data band, Neurosurg, 1990, 73(5): 688
6 Kakarieka A. Traumatic subarachnoid hemorrhage, BerlinSpringer -Verlag , 1997: 96
7 Longstreth WT, Nelson LM , Koep sell TD. Cigarette smoking, alcoho l use, and subarachnoid hemorrhage, Stroke, 1992, 23: 124221249.
8江基尧,朱诚.外伤性蛛网膜下腔出血,国外医学神经病学神经外科学分册, 1998, 25 (5): 255
9马荣,郑晓琳,蔡涛.原发性蛛网膜下腔出血放射影像诊断的价值分析,中华放射医学与防护杂志, 2005 25(3): 2872289
10周敬初.原发性蛛网膜下腔出258例临床分析,临床荟萃, 2000, 9: 391
11高宗恩,苏克江,冯兰玲.动脉瘤性蛛网膜下腔出血的治疗,国际脑血管病杂志, 2006, 14(7): 552
12赵家壁,段昌琦.蛛网膜下腔出血诊断若干问题的讨论,中华神经科杂志, 1997, 30(2): 241
13宋东林,石进,吕强.蛛网膜下腔出血脑脊液检查的意义,中国神经精神疾病杂志, 1995, 21(1): 221
2 Jantzen JP. Prevention and treatment of intracranial hypertension, BestPract Res Clin Anaesthesiol, 2007, 21(4): 517-538
3 Chen HI, Malhotra NR, Heuer GG. Barbiturate infusion for intractable intracranial hypertension and its effect on brain oxygenation, Neurosurgery, 2008, 63(5): 880-7
4 Rangel-Castilla L, Gopinath S, Robertson CS. Management of intracranial hypertension, Neurol Clin, 2008, 26(2): 521-41
5 Frank JI. Large hemispheric infarction, deterio ration, and intracranial p ressure, Neurology, 1995, 4(5): 1286-1290
6 Miller JD, Sullivan HG. Severe intracranial hypertension, Int Anesthesiol Clin, 1979, 17: 19–75
7 Stiefel MF, Heuer GG, Smith MJ. Cerebral oxygenation following decompressive hemicraniectomy for the treatment of refractory intracranial hypertension, J Neurosurg, 2004, 101: 241–7
8 Polin RS, Shaffrey ME, Bogaev CA. Decompressive bifrontal craniectomy in the treatment of severe refractory posttraumatic cerebral edema, Neurosurgery, 1997, 41: 84–92
9 Sahuquillo J, Arikan F. Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury, Cochrane Database Syst Rev, 2006, CD003983
10 Sakowitz -O-W, Stover -J-F; Sarrafzadeh A-S. Effects of mannitol bolus administration on intracranial pressure, cerebral extracellular metabolites, and tissue oxygenation in severely head-injured patients, J-Trauma, 2007 , 62(2): 292-8
11 Scalea -T-M, Bochicchio -G-V, Habashi–N, Increased intra-abdominal, intrathoracic, and intracranial pressure after severe brain injury: multiple compartment syndrome., J-Trauma, 2007, 62(3): 647-56
12 Johnston I, Paterson A. Benign intracranial hypertension, Diagnosis and prognosis, Brain, 1974, 97(2): 289–300
13 Wilkinson HA. Intracranial pressure, Neurological Surgery, 1990, 661-695
14 Narayan PK. Intracranial pressure, Neurosurg , 1994, 81(6): 810
15 Wilkison HA. Intracranial Pressure. NeurologicalSurgery, 1990, 1661-663
16 Dorman HR. Mannitol-induced acute renal failure, Medicine Baltinore, 1990, 69(3): 612
17 Jantzen JP. Prevention and treatment of intracranial hypertension, Best Pract Res Clin Anaesthesiol, 2007, 21(4): 517-38
18 Mayer SA, Dennis LJ. Management of increased intracranial pressure, Neurologist, 1998, 4: 2-12
19 Himmelseher S. Hypertonic saline solutions for treatment of intracranial Hypertension, Curr Opin Anaesthesiol, 2007, 20(5): 414-426
20李维平,黄国栋,王建中.重型颅脑损伤患者甘露醇、速尿和白蛋白降颅压作用的临床观察,中华神经医学杂志, 2005, 19(4): 377-379
21齐波,苏殿三,王祥瑞.高渗盐溶液治疗颅内高压的研究进展,实用医学杂志, 2009, 25(13): 2015-2017
22王维治,富羽弘.颅内高压症的监测和治疗进展,中风与神经疾病杂志, 2000, 1217(6): 374-375
23雷鹏.重型颅脑创伤治疗中颅骨去骨瓣减压术的应用及注意事项,创伤外科杂志, 2008, 10(1): 92-94
24于广杰,王朝晖.脑外伤后顽固性颅内高压的综合治疗,青岛医药卫生, 1996, 28(6): 19
25陈朝生.甘露醇诱发急性肾功能衰竭,中国实用内科杂志, 1994, 10 (14): 612
26曾红科,王华东.高渗盐水治疗急性脑血管病治疗颅内高压的临床和病理生理研究,中国病理生理杂志, 2005, 21(8): 1663
27崔岩.甘油果糖注射液与甘露醇联合应用治疗脑出血62例疗效观察,中国临床医药研究杂志, 2004, 11(7): 12281
28杨树源,岳勇,李庆彬.甘油果糖注射液降低颅内压的临床观察,中华神经外科杂志, 1994, 9(10)
1吴江,贾建平,崔丽英.神经病学,人民卫生出版社, 2005, 341-343
2王维治.神经病学,人民卫生出版社, 2004, 151～156
3陈平,陈辰昊.老年人蛛网膜下腔出76例临床分析,中风与神经疾病杂志, 2004 , 21(2): 181～181
4 Broderick J P, Brott TG,Duldner J E. Initial and recurrent bleeding are the major causesof death following subarachnoid hemorrhage, Stroke , 1994, 25: 1342
5 Eisenberg HM, Gary HE, Aldreich EF. Initial CTfindlings in 753 patients with severe head injury, A report from NIH traumatic coma data band, Neurosurg, 1990, 73(5): 688
6 Kakarieka A. Traumatic subarachnoid hemorrhage, BerlinSpringer -Verlag , 1997: 96
7 Longstreth WT, Nelson LM , Koep sell TD. Cigarette smoking, alcoho l use, and subarachnoid hemorrhage, Stroke, 1992, 23: 124221249.
8江基尧,朱诚.外伤性蛛网膜下腔出血,国外医学神经病学神经外科学分册, 1998, 25 (5): 255
9马荣,郑晓琳,蔡涛.原发性蛛网膜下腔出血放射影像诊断的价值分析,中华放射医学与防护杂志, 2005 25(3): 2872289
10周敬初.原发性蛛网膜下腔出258例临床分析,临床荟萃, 2000, 9: 391
11高宗恩,苏克江,冯兰玲.动脉瘤性蛛网膜下腔出血的治疗,国际脑血管病杂志, 2006, 14(7): 552
12赵家壁,段昌琦.蛛网膜下腔出血诊断若干问题的讨论,中华神经科杂志, 1997, 30(2): 241
13宋东林,石进,吕强.蛛网膜下腔出血脑脊液检查的意义,中国神经精神疾病杂志, 1995, 21(1): 221
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