神经内镜辅助脑室外引流对脑...微循环及血清相关因子的影响_尚彬.pdf

基金项目南充市科技局科技计划项目(编号:18SXHZ0331)神神经经内内镜镜辅辅助助脑脑室室外外引引流流对对脑脑室室出出血血患患者者临临床床疗疗效效、脑脑微微循循环环及及血血清清相相关关因因子子的的影影响响尚 彬,陈华轩,罗 波,张 渊,云德波(四川省南充市中心医院神经外科,四川 南充 637000)摘要 目的 探讨神经内镜辅助脑室外引流(EVD)对脑室出血(IVH)患者的临床疗效、脑微循环及血清相关因子的影响。方法 选择2020 年7 月至2022 年6 月于我院行 EVD 的 IVH 患者86 例,依据随机数字表法分为内镜组与对照组各43例。对照组行 EVD,内镜组在神经内镜辅助下行 EVD。观察两组手术时间、留置引流管时间、术后 1 d 残余血肿量、血肿清除时间、住院时间等围术期指标;两组术前、术后 7 d 血小板计数(PLT)、血小板聚集率(PAG)及纤维蛋白原(Fib)等脑微循环指标;血清轴突生长抑制因子 A(Nogo-A)、正五聚蛋白 3(PTX3)、成纤维细胞生长因子受体-1(FGFR-1)等血清相关因子水平;两组患者神经功能及术后并发症。结果 内镜组手术时间、留置引流管时间、术后 1 d 残余血肿量、血肿清除时间、住院时间等围术期指标均少于对照组(P0.05);术后 7 d,内镜组 PLT、PAG 及 Fib 水平低于对照组(P0.05);血清 Nogo-A、PTX3 水平及NIHSS 评分均低于对照组,FGFR-1 水平均高于对照组(P0.05);内镜组总有效率大于对照组,术后并发症发生率低于对照组(P0.05)。结论 神经内镜辅助 EVD 可提高 IVH 临床疗效,增强脑微循环,改善血清相关因子水平,促进神经功能恢复,术后恢复快,并发症少。关键词 神经内镜;脑室外引流;脑室出血;临床疗效;脑微循环;血清相关因子中图分类号 R743.34;R651 文献标志码 A 文章编号 1672-6170(2023)03-0083-05Effects of neuroendoscopy-assisted external ventricular drainage on clinical efficacy,cerebralmicrocirculation and serum-related factors in patients with intraventricular hemorrhage SHANG Bin,CHEN Hua鄄xuan,LUO Bo,ZHANG Yuan,YUN De鄄bo (Department of Neurosurgery,NanchongCentral Hospital,Nanchong 637000,China)Abstract Objective To investigate the effects of neuroendoscopy-assisted external ventricular drainage(EVD)on clinicalefficacy,cerebral microcirculation and serum-related factors in patients with intraventricular hemorrhage(IVH).Methods A total of86 IVH patients who received EVD in our hospital from July 2020 to June 2022 were selected.The patients were divided into anendoscopy group and a control group according to random number table method,43 in each group.The control group received EVD,and the endoscopy group received neuroendoscopy-assisted EVD.Perioperative indexes such as operation time,catheter retention time,residual hematoma after one day of operation,hematoma clearance time and hospital stay were observed in the two groups.Before andafter 7 days of operation,cerebral microcirculation such as platelet count(PLT),platelet aggregation rate(PAG)and fibrinogen(Fib),and serum related factors such as neurite outgrowth inhibitor-A(Nogo-A),pentamerin 3(PTX3)and fibroblast growth factorreceptor-1(FGFR-1)were observed in the two groups.Neurological function and postoperative complications were also observed in thetwo groups.Results Perioperative indexes such as operation time,catheter retention time,residual hematoma after one day of surgery,hematoma clearance time,and hospital stay time in the endoscopy group were shorter or lower than those in the control group(P0.05).After 7 days of operation,the levels of PLT,PAG and Fib of the endoscopy group were lower than those of the control group(P0.05).After 7 days of operation,the levels of Nogo-A,PTX3 and NIHSS were lower and FGFR-1 level was higher in theendoscopy group than those in the control group(P0.05).The total effective rate of the endoscopy group was higher than that of thecontrol group(P0.05).The incidence of postoperative complications in the endoscopy group was lower than that in the control group(P 9分;本人或家属知情同意者。排除标准:脑血管畸形、颅内动脉瘤及颅内肿瘤导致的 IVH 者;既往颅脑手术者;既往神经系统疾病或神经功能障碍者;出凝血功能异常或使用影响出凝血功能药物者;肝肾功能异常者;依从性差者;合并恶性肿瘤者。其中男 51 例,女 35 例;年龄 48 78 岁(61.85 6.43)岁;病程 1 10 h(3.690.39)h;出血部位:两侧脑室 31 例,侧脑室 25 例,侧脑室及第三脑室 20 例,侧脑室及第三、四脑室 10 例;IVH 类型:原发性 28 例,继发性 58 例。依据随机数字表法将 86例患者分为内镜组与对照组各 43 例,两组基线资料比较差异无统计学意义(P0.05)。见表 1。本研究获南充市中心医院伦理委员会批准(编号:20221220)。表 1 两组基线资料比较项目内镜组(n=43)对照组(n=43)统计量P性别(男/女)24/1927/162=0.42860.5127年龄(岁)61.786.4061.906.46t=0.08650.9312病程(h)3.720.413.670.37t=0.59370.5543出血部位(两侧脑室/侧脑室/侧脑室及第三脑室/侧脑室及第三、四脑室)15/14/8/616/11/12/42=1.59230.6611IVH 类型(原发性/继发性)13/3015/282=0.20940.64731.2 方法 对照组行 EVD。患者局麻,穿刺点选取中线旁约 2.5 cm、冠状缝前约 3 cm 位,与矢状面平行钻孔,深度约 1.5 cm,留置引流管。单侧 IVH行单侧引流,双侧 IVH 行双侧引流。术毕给予尿激酶溶解血栓,以引流管将充分溶解于生理盐水(5ml)的尿激酶(3 万 U)溶液注入脑室,以生理盐水(35 ml)冲管,封管 4 6 h。内镜组在神经内镜辅助下行 EVD。留置引流管及行尿激酶使用方法同对照组,常规置入神经内镜(史托斯神经内镜,型号:28162AUA),将脑室内血肿清除,确保脑脊液循环,电凝止血,然后于神经内镜辅助下引流。1.3 观察指标 观察两组手术时间、留置引流管时间、术后 1 d 残余血肿量、血肿清除时间、住院时间等围术期指标;两组患者术前、术后 7 d 血小板计数(PLT)、血小板聚集率(PAG)及纤维蛋白原(Fib)等脑微循环指标;血清轴突生长抑制因子 A(Nogo-A)、正五聚蛋白 3(PTX3)、成纤维细胞生长因子受体-1(Fibroblast growth factor receptor-1,FGFR-1)等血清相关因子水平。脑微循环指标以全自动凝血分析仪检测;血清相关因子水平以 ELISA 法检测;神经功能以美国国立卫生院神经功能缺损评分(national institutes of health stroke scale,NIHSS)7评价,总分42 分,内容包括视野、凝视、面瘫、意识水平及上下肢运动等 11 项,每项评分 0 2 分,评分越高说明神经功能缺损越严重。疗效评价标准6:基本痊愈:NIHSS 评分较术前降低 91%以上,病残 0 级;显效:NIHSS 评分较术前降低 46%90%,病残 13 级;有效:NIHSS 评分较术前降低 18%45%;无效:NIHSS 评分较术前未见改变或增加。总有效=基本痊愈+显效+有效。观察患者术后并发症。1.4 统计学方法 应用 SPSS 19.0 统计软件分析数据。计量资料以均数标准差描述,组内比较行配对 t 检验,两组间比较行独立样本 t 检验;计数资料以例数(百分率)表示,组间比较行 2检验。检验水准=0.05。2 结果2.1 两组围术期指标比较 内镜组手术时间、留置引流管时间、术后 1 d 残余血肿量、血肿清除时间、住院时间等围术期指标均少于对照组,差异有统计学意义(P0.05);术后 7 d,两组 PLT、PAG 及 Fib 水平均较术前降低,且内镜组指标低于对照组(P0.05);术后7 d,两组血清 Nogo-A、PTX3 水平及 NIHSS 评分均降低,FGFR-1 水平升高(P0.05);且内镜组血清 Nogo-A、PTX3 水平及 NIHSS 评分均低于对照组,FGFR-1水平高于对照组(P0.05)。见表 4。48 实用医院临床杂志 2023 年 5 月第 20 卷第 3 期 表 2 两组围术期指标比较指标内镜组(n=43)对照组(n=43)tP手术时间(min)3.820.415.570.5816.160.00留置引流管时间(d)3.290.354.380.4612.370.00术后 1 d 残余血肿量(ml)5.250.557.360.7614.750.00血肿清除时间(d)5.330.567.980.8317.360.00住院时间(d)13.891.5517.961.9810.610.00表 3 两组脑微循环指标比较指标时间内镜组(n=43)对照组(n=43)tPPLT(109/L)术前387.8641.75383.9441.720.43550.6643术后 7 d163.6219.32a215.9324.07a11.11370.0000PAG(%)术前70.547.2268.967.191.01680.3122术后 7 d47.574.98a56.815.84a7.89450.0000Fib(g/L)术前4.370.464.330.430.41660.6781术后 7 d2.860.31a3.410.37a7.47170.0000a 与术前比较,P0.05表 4 两组血清相关因子及 NIHSS 评分比较指标时间内镜组(n=43)对照组(n=43)tPNogo-A(ng/ml)术前190.8922.43188.7622.350.44110.6603术后 7 d118.4413.49a142.8317.31a7.28780.0000PTX3(ng/ml)术前14.931.6714.891.640.11210.9110术后 7 d8.750.90a9.951.13a5.44710.0000FGFR-1(g/L)术前4.630.494.660.510.27820.7816术后 7 d6.850.70a6.160.64a4.77040.0000NIHSS 评分(分)术前28.583.1028.533.060.07530.9402术后 7 d16.441.86a21.752.39a11.49750.0000a 与术前比较,P0.052.4 两组临床疗效比较 内镜组总有效率明显高于对照组,差异有统计学意义(2=4.389,P 0.05)。见表 5。表 5 两组临床疗效比较 n(%)组别n基本痊愈显效有效无效总有效内镜组4317(39.53)15(34.88)8(18.60)3(6.98)40(93.02)对照组4314(32.56)13(30.23)6(13.95)10(23.26)33(76.74)2.5 两组术后并发症比较 内镜组术后并发症发生率低于对照组(2=8.346,P0.05)。见表 6。表 6 两组术后并发症比较 n(%)组别n脑梗死脑积水感染合计内镜组430(0.00)0(0.00)1(2.33)1(2.33)对照组431(2.33)4(9.30)5(11.63)10(23.26)3 讨论因血肿液化及血肿周围组织产生的不良代谢产物常易导致脑部继发性损伤,发生 IVH 后若不需快速清除脑室血肿,常易导致脑组织不可逆损伤,甚至危及患者生命8。有效的 EVD 是临床治疗IVH 的重要术式,但是否能够达到引流的目的与手术医生的技术息息相关9。EVD 于非直视状态下,不但置管位置易出现失误,给 IVH 患者带来不可避免的脑组织创伤,影响患者神经功能。此外,EVD还存在术后易堵管,并发症发病率高等缺点10。本研究中,内镜组各围术期指标均优于对照组,总有效率高于对照组,说明神经内镜辅助 EVD58 实用医院临床杂志 2023 年 5 月第 20 卷第 3 期 可缩短手术时间,增加引流速度,减少残余血肿量,提高疗效。其原因主要是神经内镜将立体定向与影像导航技术相结合,视野清晰,定位准确,可在避免伤及脑室周围组织的同时快速有效引流血肿12。神经内镜横截面窄,镜身长,且于镜下操作,适用于进出腔隙等狭小部位并完成操作,从而有效避免手术牵拉,降低伤及周围脑组织及脑部血管的风险13。神经内镜可实现直视下放置引流管,提高引流管放置的精确性,提高引流效果,缩短康复时间14。本研究以神经内镜辅助 EVD 不但可快速引流 IVH 患者脑部血肿,还可有效避免手术创伤,达到微创治疗 IVH 的目的。本研究术后 7 d,内镜组 PLT、PAG 及 Fib 水平低于对照组,说明神经内镜辅助 EVD 可有效改善IVH 患者脑微循环。IVH 发生后,随着血肿的不断增大,颅内压也不断升高,脑组织的损伤也不断加重,甚至导致部分神经细胞坏死,损伤及死亡神经细胞可诱导炎症反应,刺激脑血管痉挛或收缩,或者加重血管功能损伤,致使脑微循环紊乱15。本研究以神经内镜辅助 EVD 治疗 IVH,可快速引流血肿,降低颅内压,减轻神经组织及血管损伤,缓解炎症反应,促进神经细胞修复16。此外,以神经内镜辅助 EVD 可有效促进局部血供恢复,改善脑微循环,为神经组织及血管修复提供所需的物质和能量,恢复受损神经组织及血管功能17。内镜组血清 Nogo-A、PTX3 水平及 NIHSS 评分均低于对照组,FGFR-1 水平均高于对照组,说明神经内镜辅助 EVD 可有效抑制 Nogo-A、PTX3 生成,促进分泌 FGFR-1,改善 IVH 患者神经功能。Nogo-A 可经结合其相关受体阻断神经细胞增殖、修复,抑制生长锥功能,促进神经功能损伤。神经组织损伤可促进 Nogo-A 结合其受体,激活下游信号通道,加重线粒体损伤,致使神经细胞凋亡18。研究证明,Nogo-A 水平与脑出血患者神经损伤严重程度正相关,其水平越高,说明患者神经损伤越严重19。PTX3 为炎症损伤标志物,可参与传导炎症信号,促进表达内皮因子形成,促进血栓形成20。PTX3 可经促进生成过氧化低密度脂蛋白诱导炎症反应,加重神经组织及局部血管损伤21。FGFR-1 可经结合其受体参与新生血管及内皮细胞形成或修复。FGFR-1 可诱导细胞增殖,在促进血管形成的同时维持其通透性,改善局部血供,促进神经组织修复22。NIHSS 评分为评价神经功能的重要指标,其结果与神经组织损伤负相关23。本研究以神经内镜辅助EVD 应用于 IVH 的临床治疗,可有效调节 Nogo-A、PTX3、FGFR-1 水平,改善患者神经功能。此外,本研究中,内镜组术后并发症发生率低于对照组,说明神经内镜辅助 EVD 可有效减少术后并发症,具有较高的安全性。综上,神经内镜辅助 EVD 可提高 IVH 临床疗效,增强脑微循环,改善血清相关因子水平,促进神经功能恢复,术后恢复快,并发症少,可推荐于 IVH患者的临床治疗。参考文献1 宋志富,黄学平,甘玉兰,等.侧脑室穿刺置管于三脑室联合尿激酶治疗脑室出血的临床疗效观察J.实用医院临床杂志,2022,19(3):27-30.2 Robles LA,Volovici V.Hypertensive primary intraventricularhemorrhage:a systematic review J.Neurosurg Rev,2022,45(3):2013-2026.3 Al-Kawaz MN,Hanley DF,Ziai W.Advances in TherapeuticApproaches for Spontaneous Intracerebral 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评分、平衡仪指标、步态指标(患侧髋关节活动度、患侧步长、步态周期、步速)均较干预前改善(P0.05),且观察组(除步态周期)明显优于对照组(P0.05),观察组步态周期干预前后差值即进步效果优于对照组(P0.05)。结论 强化髋周肌力训练可进一步改善踝关节骨折患者平衡及步态功能。关键词 踝关节骨折;髋周肌群;平衡;步态中图分类号 R493 文献标志码 A 文章编号 1672-6170(2023)03-0087-05The effects of intensive hip muscle strength training on balance and gait function in patientswith ankle fracture WANG Ming鄄yu1,2,ZHAI Hong鄄wei1,2,LIU Na1,MENG Qing2,BI Ying鄄li2,CHENWei1,2(1.Rehabilitation Department,Xuzhou Central Hospital,Xuzhou Clinical College,Xuzhou MedicalUniversity,Xuzhou 221009,China;2.Rehabilitation Department,The Affiliated Xuzhou RehabilitationHospital,Xuzhou Medical University,Xuzhou 221010,China)Corresponding author CHEN WeiAbstract Objective To investigate the effect of intensive hip muscle strength training on balance and gait function inpatients with ankle fracture.Methods Forty-eight patients with ankle fracture from March 2021 to March 2022 were randomly dividedinto an observation group and a control group,24 in each group.The control group received routine rehabilitation treatment for anklefracture,including recovery of joint range of motion,ankle muscle strength training,balance and gait training and physical factortreatment.Isokinetic hip muscle strength training was further added to the observation group.The treatment time was 6 weeks.Results After treatment,the relative peak moment of isokinetic hip abduction and extension,Tinetti score,balance instrument index and gaitindex(range of motion of the affected hip,length of the affected side,gait cycle and gait speed)of the two groups were improved whencompared to those before treatment(P0.05),and the observation group(except for the gait cycle)was better than the control group(P0.05).The difference of gait cycle before and after intervention,that is,the process effect,in the observation group was betterthan that in the control group(P0.05).Conclusions Intensive hip muscle strength training can further improve the balance and78 实用医院临床杂志 2023 年 5 月第 20 卷第 3 期