局部亚低温联合尼莫地平防治重型颅脑损伤术后脑血管痉挛的疗效研究

Efficacy of brain mild hypothermia combined with nimodipine in prevention of cerebral vasospasm after surgery on patients with severe craniocerebral injury

目的：观察脑部亚低温联合尼莫地平防治重型颅脑损伤患者术后脑血管痉挛（CVS）的疗效及临床预后。方法：入选103例创伤性重型颅脑损伤患者为研究对象，据随机数字表分为观察组（53例）和对照组（50例），对照组患者术后给予局部亚低温（34-35℃）实施脑保护3～5d，观察组在同对照组治疗的基础上24h静脉泵注尼莫地平注射液，起始速率0．5mg／h，最大速率2mg／h，连续14d，其间每日监测大脑中动脉平均血流速度（VMCA），判定CVS严重程度，术后6个月判定颅脑损伤预后。结果：观察组术后的VMCA3d时为（95．8±17．2）mL／s、5d时为（89．5±16．3）mL／s、7d时为（83．7±15．8）mI，／s、14d时为（76．6±10．2）mL／s均明显低于对照组水平，相应为（108．5±21．7）mL／s、（101．2±18．5）mL／s、（92．8±19．7）mL／s、（84．2±13．9）mL／s（P〈0．05）。观察组术后CVS发生率明显低于对照组（15．1％VS32．0％）（x^2=4．114，P=0．043），两组术后CVS的发生程度构成差异显著（Z=-2．150，P=0．032）。观察组住院期间病死率低于对照组（7．5％VS18．0％）（x^2=2．549，P=0．110）；术后6个月，观察组颅脑功能达到良好的比例高于对照组（58．5％VS44．0％），伤残率低于对照组（32．1％VS38．0％），差异均无统计学意义（x^2=2．163，P=0．145；x^2=0．397，P=0．529）。结论：重型颅脑损伤患者术后在实施脑部亚低温支持的基础上，联合静脉泵注尼莫地平注射液，能进一步平抑颅脑损伤后急性高灌注，降低CVS的发生率及严重程度，表现出改善远期预后的趋势。

Objective： To explore the efficacy and prognosis of brain mild hypothermia combined with nimodipine in the prevention of cerebral vasospasm （CVS） after surgery on patients with severe craniocerebral injury. Methods： 103 patients with severe traumatic craniocerebral injury were randomized into the observation group （53 cases） and the control group （50 eases）. The control group were given brain mild hypothermia （34-35 ℃ ） protection for 3-5 days after surgery,and the observation group,in addition to normal treatment were given Nimodipine injection for 14 days, with initial rate： 0.5 mg/h, maximum rate：2.0 mg/h,during which brain artery mean flow velocity （VMCA） and severity of CVS were monitored and 6 months after surgery postoperative prognosis of craniocerebral injury of 2 groups were determined. Results： After surgery the observation group with VMCA 3 d（9.58±17.2） mL/s, 5 d （89. 5±16. 3） mL/s,7 d （83. 7±15. 8） mL/s,14 d （76.6±10.2） mL/s were significantly lower than the control group （108.5±21.7） mL/s,（101.2±18.5） mL/s, （92.8±1.97） mL/s, （84. 2±13. 9） mL/ S （P〈0. 05）. CVS itteidence of the observation group was significantly lower than the control group （15.1% vs 32.0%） （2 =4. l14,P=0. 043）. CVS degrees had significant difference between 2 groups（Z =-2. 150 ,P= 0. 032）. Mortality of the observation group during their hospitalistay in was lower than that of the control group （7.5% vs 18.0%） （x^2 =2. 549,P= 0. 110） ; 6 months later,the ratio of brain function was better in the obseration group than in the control group （58.5 % vs 44.0 % ）, and their disa- bility rate was lower than that in control group （32.1% vs 38.0%）,and the difference had no statistical significance （x^2 =2. 163 ,P= 0. 145 ;x^2 =0. 397 ,P=0. 529）. Conclusion：Based on brain mild hypothermia protection in treatment of patients with severe cranioeerebral injury after surgery,intravenous infusion of Nimodipine injection could further stabilize acute cerebral high perfusion, reduce CVS incidence and severity,and show the trend of improvement in long term prognosis.