植物人昏迷促醒.ppt

高颈段脊髓电刺激术高颈段脊髓电刺激术促醒昏迷促醒昏迷中国武警脑科医院董月青 昏昏 迷迷n n急性颅脑损伤的救治已经取得了明显的进步，但是还有相当一部分患者发展为长期昏迷状态。在美国闭合性颅脑损伤出院后存在长期昏迷的占14%,至少有10万到25万成人长期昏迷患者，6千至1万儿童长期昏迷患者。n n常规综合治疗效果欠佳。Adamides AA.ANZ J,Surg 2006Adamides AA.ANZ J,Surg 2006急性脑损伤的流程急性脑损伤的流程急性脑损伤昏迷闭锁综合征植物状态慢性昏迷（少见）脑死亡最小意识状态精神紊乱状态生活自理状态永久植物状态死亡不同意识障碍的觉醒和认知状态不同意识障碍的觉醒和认知状态脊髓电刺激脊髓电刺激n n脊髓电刺激术是将电极植入到脊髓椎管内，以脉冲电刺激脊髓治疗疾病的方法。最初应用于顽固性疼痛的治疗。随着研究的深入目前应用范围越来越广，如心绞痛、脑瘫、外周缺血性疾病，昏迷。Percutaneous Lead Kit 128911131034675141213124567891314312101119Surgical Lead Kit电生理调控组电生理调控组SCSSCS的组成的组成延伸延伸导线和和电极极刺激器刺激器/电池池电源源传导线电极触点触点+3 2 1 3 2 1 0 0刺激点刺激点+,+,“PolesPoles”27所谓脊髓神经电刺激：所谓脊髓神经电刺激：蛛网膜下腔刺激蛛网膜下腔刺激硬膜下刺激硬膜下刺激硬膜外电刺激硬膜外电刺激临床上多用硬膜外电刺激临床上多用硬膜外电刺激脊髓神经电刺激方法Dorsal column stimulation（DCS)for persistent vegetative staten n长期昏迷患者（颅脑创伤、缺血缺氧性脑病、脑血管意外等）。n n改变患者脑血流、电生理和神经递质。术前检查和机制术前检查和机制n n术前意识的评估术前意识的评估n n术前术前2mm2mm层层CTCT的三个维度的三个维度的扫描，的扫描，PETPET，评估患者，评估患者大脑的结构和功能。大脑的结构和功能。n nTheThe indicationindication included included young age,history of brain young age,history of brain trauma,evidence of brain trauma,evidence of brain atrophy with no other major atrophy with no other major lesions and CBF values prior lesions and CBF values prior to DCS of 20 ml/100 g/min to DCS of 20 ml/100 g/min or higheror higherStimulation n n如果没有手术并发症，术后3-7天开始刺激。头颅和躯干分别选择不同的极性。n n 参数：amplitude of 2.03.0V,rate of 70 Hz,and pulse width of 120 msec，循环模式15-minute stimulation and 15-minute resting，白天刺激，夜间关闭模式。机制机制n n1、增加了脑血流n n2、影响脑内神经递质，如儿茶酚胺的代谢n n3、脊髓背侧柱的刺激，激活了脑干网状结构，中缝核，丘脑腹后核，甚至上传到大脑皮层随随 访访n nAppearance of reactions to orders(understanding of intention),Appearance of reactions to orders(understanding of intention),speech,and appearance of swallowing movement(oral ingestion)speech,and appearance of swallowing movement(oral ingestion)are judged are judged ExcellentExcellent.n nAppearance of these means recovery from the vegetative state.Appearance of these means recovery from the vegetative state.Changes in expression and emotion(joy and anger,feelings)in Changes in expression and emotion(joy and anger,feelings)in response to stimulation,awakening,appearance of sleep rhythm,response to stimulation,awakening,appearance of sleep rhythm,and appearance of pursuit and gazeare judged as and appearance of pursuit and gazeare judged as PositivePositive.n nAppearance of these changes compared to the condition before Appearance of these changes compared to the condition before DCS is recognized by the medical staff and patientDCS is recognized by the medical staff and patient s family and it s family and it is judged as is judged as PositivePositive.Based on these criteria,we evaluated the.Based on these criteria,we evaluated the effect effect 1 1 2 years after2 years after initiation of electrical stimulation.initiation of electrical stimulation.外科电极植入外科电极植入显显 露露n n暴露相应位置的脊髓段n n用咬骨钳摘除部分目标脊板的下沿与下一脊板的上沿，暴露脊板间空隙切切 开开n n夹起黄韧带的中线n n在黄韧带上打开一个小窗口植植 入入n n暴露硬脑膜并把空白电极以小角度伸入硬膜外腔n n将外科电极植入并准备测试n n更加微创，更加安全。更加微创，更加安全。颅脑创伤颅脑创伤脑电图脑电图体感诱发电位体感诱发电位日常监测日常监测术后复查术后复查术后术后1个月个月术后术后2个月个月弥漫性轴索损伤弥漫性轴索损伤本周5手术，今天上午调试颅脑创伤颅脑创伤术前术前3月月30日日4月月8日日4月月22日（分流）日（分流）术后复查术后复查术后术后3个月，伤后个月，伤后6个月个月n n患者已经拔除了气管患者已经拔除了气管插管和鼻饲进食管，插管和鼻饲进食管，能够经口自己进食。能够经口自己进食。术后术后3个月，伤后个月，伤后6个月个月n n图中的我拿出患者家图中的我拿出患者家中的相册，患者在给中的相册，患者在给我一一指出患者的父我一一指出患者的父亲、母亲、自己的妻亲、母亲、自己的妻子和孩子。还特别一子和孩子。还特别一一指出自己孩子。患一指出自己孩子。患者能说出者能说出“妈妈，还妈妈，还要吃饭要吃饭”等表达自己等表达自己思想的言语。思想的言语。术后随访、调控术后随访、调控n n我们的电生理调试医我们的电生理调试医生，专门对患者进行生，专门对患者进行重新调试。重新调试。术后术后9个月复查个月复查术后术后9个月复查个月复查缺血缺氧脑病缺血缺氧脑病10月15日11月15日1月4日分流分流3月22日术前和术后术前和术后PET-CT比较比较术前和术后术前和术后2个月比较个月比较术前术前术后术后2个月个月术前和术后术前和术后2个月个月术前术前术后术后2月月术后术后2个月个月只要是点滴阳光照耀的地方只要是点滴阳光照耀的地方 生命就会灿烂！生命就会灿烂！谢谢 谢！谢！昏迷中心网站：www.cuxing.org39健康网博客：董博士的神经外科空间