颅脑损伤患者颅内压监测正常下意外瞳孔散大

Accidental mydriasis with normal intracranial pressure in craniocerebral trauma patients

目的分析颅脑损伤患者颅内压监测正常情况下，出现突发瞳孔散大病情恶化的原因并验证针对性治疗的有效性。方法回顾性分析2008年6月-2012年3月收治的473例颅脑损伤患者中4例患者在颅内压正常情况下，出现突发意外的瞳孔散大原因，观察针对性治疗后患者病情的变化和监测指标的变化。结果颅内压正常情况下的异常瞳孔散大主要源于经历一定时限的颅内高压后进行充分减压，脑灌注压持续〉110mmHg；或者脑脊液引流过多或颅内压控制过低（〈10mmHg），造成脑灌注压过高；合并出现低血浆渗透压状态和二氧化碳蓄积等因素。4例患者经特定流程治疗后，颅内压正常，脑肿胀好转，病情稳定，瞳孔恢复正常，6个月后随访GOS4分3例，5分1例。结论降低外周血压、控制灌注压、维持高渗性治疗目标、缓解脑水肿能够有效降低颅脑损伤患者颅内压监测正常情况下瞳孔散大的发生率。

Objective To study causes of deterioration of sudden mydriasis in craniocerebral trauma patients with normal intracranial pressure and verify the efficiency of specific treatments. Methods A retrospective analysis was performed on causes of four cases of accidental mydriasis in normal intracranial pressure among 473 cases of craniocerebral trauma treated from June 2008 to March 2012. Changes of patients＇ condition and monitoring indices were observed after specific treatments. Results Abnormal mydriasis with synchronously normal intracranial pressure was largely due to sufficient decompression after a certain period of intracranial hypertension and persistence of brain perfusion pressure to more than 110 mm Hg or due to high cerebral perfusion pressure caused by redundant drainage of eerebrospinal fluid or low intracranial pressure （ 〈 10 mm Hg） , together with factors like low plasma osmotic pressure and carbon dioxide accumulation. The study showed that the intracranial pressure was maintained normal, that the brain swelling took a turn for better, that medical condition were stabilized and that pupil returned to normal in the four cases after treatment with specific protocol. GOS was four points in three cases and five points in one during follow-up at six months postoperatively. Conclusion Incidence of mydriasis with normal intracranial pressure in eraniocerebral trauma patients can be efficiently declined through reduction of peripheral blood pressure, perfusion pressure controlling, hypertonic remedy maintenance and brain edema relief.