近年来,国外许多研究发现:在药物治疗效果不满意的癫痫病人中,20—30%的病人实际上并不是癫痫却被误诊为癫痫多年。这些病人几乎都经过多次脑电图甚至长时脑电图检查。造成这种误诊的主要原因是对脑电图的误判。也就是将原本正常变异的脑电波形误认为“癫痫波”或“异常放电”,而导致错误的诊断。 如此高的误诊率使许多病人在长期背负沉重的精神负担的同时还承受着药物副作用对身体造成的伤害。 因此,对①病人服用抗癫痫药物疗效不理想,②发作诱因与众不同,例如发作诱因是“情绪”“疼痛”时,③具有“癔病气质”的病人,应该审视诊断的正确性。 用同时记录病人发作表现和脑电变化的视频脑电图记录下病人的癫痫发作,并进行仔细分析通常可以做出正确的鉴别诊断,但目前尚做不到100%。
患有蛛网膜囊肿合并癫痫的病人及家属通常都会认为:这个囊肿就是导致癫痫发作的原因,治愈这个囊肿就能根除癫痫发作。 因为蛛网膜囊肿常常是病人的唯一异常发现,根据一般医学规律,许多医生也会持有这种观点。 但近10余年来的许多临床资料显示:癫痫灶恰好位于囊肿邻近部位的病人只占这类病人中的不足20%。80%以上的病人,癫痫灶远离囊肿。例如,颞叶蛛网膜囊肿的病人,其癫痫灶却在额叶、顶叶、甚至位于对侧大脑半球。对这类病人,单纯治疗囊肿显然不能有效控制癫痫发作,必需找到远离部位的癫痫灶并将其切除。 蛛网膜囊肿的发生原因,目前尚不完全清楚。虽然有几种学说,但都不能完全解释许多临床现象。因此,对上述看似违背一般医学规律的现象还没有被公认的解释。
当自己的亲人出现癫痫发作时,家人多半会极度担心。特别是年幼的孩子出现癫痫发作,家长更是忧虑重重,不顾一切的四处求医问药。实际上,9%的人在一生中会出现一次癫痫发作,或通俗地说:出现一次肢体抽搐的症状。这一次肢体抽搐的发生原因多种多样,比如头部外伤、中枢神经系统感染、脑出血、脑血栓、中毒性疾病和代谢性疾病,以及突然戒酒、戒药等,甚至是一些难以查清的原因。通常癫痫发作出现于上述疾病发生后的一周以内,一周后即不再发作,所以,不需要长期服用抗癫痫药物。严格地讲,只有一次肢体抽搐不能诊断为癫痫病,只能称之为“癫痫发作”。总之,第一次或只有一次癫痫发作的人,不必过分担心,更不必服用抗癫痫药物。有些癫痫病人,虽然是反复发作,但只在夜间发作(通常是在刚入睡或接近睡醒的时段发作)。如果每次发作的持续时间仅1—2分钟,发作不频繁,也可以不服用抗癫痫药。因为,癫痫对病人的最大危害是发作时可能发生的外伤性意外,以及在公众面前发作所引发的心理障碍。而夜间发作,既不会发生外伤性意外又不被公众所知也不影响正常工作。虽然服用抗癫痫药会使发作减轻,但一旦开始服用抗癫痫药即需要长期服用,随便停药常常会导致癫痫发作加重甚至引发能危及生命的癫痫发作持续状态。而抗癫痫药几乎都有许多副作用,长期服用会对身体造成损害。权衡利弊,这类病人以不服药为宜。有些儿童病人,虽然反复出现癫痫发作,但智力发育正常,脑核磁共振等影像学检查正常。这类病人有可能是“良性癫痫”,通常青春期之后发作自然停止。如果发作不频繁也可以不服用抗癫痫药物。
患者:2009年10月20日发生抽搐两次间隔3小时,每次2-3分钟,抽搐时两眼上翻,双手紧握,牙紧闭,孩子的父亲一岁二个月时发病过,半年内每月发一次,之后在没发过,现在都33了。 只抽两次还没开始治 要做哪些检查才能确诊。 化验、检查结果:在贵州省医学院做24小时脑电图,结果是轻微癫痫。在贵州省毕节市做CT,抽血化验都是正常的青岛海慈医院西医神经外科于广杰:建议参考文章:http://yuguangjie.haodf.com/wenzhang/98525.htm患者:于大夫您好: 您建议的参考文章我已看了,看后心里放心了很多,我小孩10月20号那天发作过(只有两次),到现在没有发作过,作24小时的脑电图结果(清醒:监护过程中,患儿较安静,但背景活动节律欠规整,Θ及低波幅β节律均可见,Θ节律Θ节律3.57-7.14Hz,44-94μV。活动中,节律无明显改变。 睡眠期以宽大的,波幅较高的Θ及δ波。Θ节律4.35-5.56Hz,125-208μV,δ节律2.70-3.33Hz,157-218μV. 在监护过程的各个时间段(患儿均为睡眠中)均可见单发或阵发(持续2-3秒)的波幅高的尖、尖慢波。全头均可见,有时现为右侧明显) 我现在就是想问一下,如果今后我小孩都不会发作,那她算不算是正常的,我们也不用太担心呢?还有我想把她的检查报告上传给您,请您帮我们看看像她这种情况的严重吗。还要不要吃药。谢谢您了!!青岛海慈医院西医神经外科于广杰:最好将脑电图传过来。很难依据脑电图报告做出判断。另外,1-2岁孩子睡眠中出现的尖慢波常常是正常的。患者:于大夫您好! 脑电图已传过来,您看了吗?如果您看了我可以向您咨询几个问题吗? 1.像她这样的还要吃药吗?医生开了笨巴妥片,副作用大吗? 2.还要进一步检查吗? 3.像她这样的能痊愈吗?青岛海慈医院西医神经外科于广杰:脑电图没传上来。患者:于医生您好 我已传脑电图 的图像,请问您收到了吗。就在发表对话的右下侧,如果收不到。请您发您的邮箱给我好吗? 一个很感谢您的患者 谢谢青岛海慈医院西医神经外科于广杰:在我的页面上看不到你传的脑电图。传到我的邮箱吧:guangjie_yu@hotmail.com患者:您好,我发了到您的,请问您收到了吗青岛海慈医院西医神经外科于广杰: 收到并看了你孩子的脑电图。虽然脑电图中确实有阵发性尖波,但背景波很好。这意味着孩子大脑发育正常,至少没有明显结构性病变。结合孩子爸爸小时候的类似病史,你孩子有可能也是特发性癫痫,就是说,有可能像她爸爸一样,属于良性癫痫,也就是可以自愈的癫痫。建议你服用一段时间的药物后,如果发作停止,可以在医生的指导下提早减停药。患者:于医生您好! 非常感谢您能在百忙中抽时间给我回复,您的回复给了我们一家希望,我的小孩就发过那么一次,到现在都没发过,所以我们没有给她用药,毕竟药对她是有副作用的,我们想在观察观察,如果在有一次发作就给她用药,我想问一下医生,如果我小孩一直不发作的话是不是意昧着她好了呢,我们现在不给她用药的做法可取吗? 谢谢您!!!!青岛海慈医院西医神经外科于广杰:我赞成你暂时不给孩子用药的决定。如果孩子不再发作,特别是至青春期仍无发作,就意味着完全自愈。患者:太感谢您了.您真是位好医生,
患者:大夫, 您好, 我咨询以下问题: 我爸爸76岁,因车祸颅左侧受外伤,左侧开颅后,一直昏迷,现在已经有两个月了,好象有时能清醒会微笑.但一个月以来,每天都有38度多的高烧,而且一定要用肛门栓降温药才能把体温降下, 身体其他部分有异常的是: 1. 臀部因久卧床出现两个绿豆大小的小脓泡已破,正用碘敷杀菌后用生鸡蛋壳内皮贴患处, 这样处理有没有问题? 2.肺部有痰,经常侧身拍背,能咳出痰,但发现呼吸困难时,体温就会迅速上升到38度多,甚至39度. 开颅后住院治疗一个月后,汤到嘴里知道咽下,头部伤口恢复很好, 回家后挂抗生素,能量合剂和甘露醇及小黄牛血清药水, 挂了一个星期,因经常出现39度多的高烧,而且去掉颅骨的头皮处由手术后凸出来,现在已下凹,所以就停止了挂上述药水,后两天体温最高就在37度8处, 现在又每天出现一至两次38度多高烧 1.我不知道为何体温升的怎么这样快(10分钟内)? 如何控制体温 2.臀部绿豆大小的小脓泡用碘敷杀菌后用生鸡蛋壳内皮,贴患处, 这样处理有没有问题?如不好,能否建议该怎样做? 化验、检查结果: 1.血液检查: 有贫血. 注:手术时有补血800ml 2.CT显示,出院时,颅内肿块已变小很多,但受伤的左脑有大面积的灶化区域青岛海慈医院西医神经外科于广杰: 这种情况常见于病人不能自己吃饭,或不能咀嚼而只能吃稀粥样的饭菜的时候,由于家属喂饭时速度过快,或姿势不太合适,导致病人吃饭时发生呛咳,也就是误将食物吞咽入气管内,导致气管和肺部感染。纠正方法:喂饭时让病人半坐位或侧卧位,不要将饭直接倒入病人口内深部,而是放入嘴的侧方或舌头上,让病人自己慢慢吞咽。如果出现发烧,咳黄痰,通常需要使用抗生素治疗。患者:大夫,我父亲的CT 我已经上传了. 按照CT的图片看,不知我父亲还能清醒吗? 现在还在昏迷中,已经两个月了. 谢谢您在帮忙中给我的回复患者:CT片子是出院那天拍的青岛海慈医院西医神经外科于广杰: 对病人的预后判断,需要依据病人手术前状态、术前CT、术中所见以及术后治疗情况综合分析判断。依据单纯一张CT是无法作出判断的。不过,根据国外的研究资料:脑外伤病人,80%的功能康复在伤后1年半内完成。也就是说,如果病人在伤后1年半内仍不清醒,或某项功能比如偏瘫、语言障碍等仍未恢复,一年半以后能够恢复的可能性仅为20%。
患者:09年11月15日汽车在高速行驶时,车被撞,当时积了保险绳。但右头前部重撞车窗两下,肿起.颈部也拉伤,都没有出血. 现头部肿块未消,还很大,头有时有点晕血块摸上去有疼感,颈部也有疼感,不太严重 能出现迟发性的脑出血吗?据说,有的脑部疾病和过去的头被重撞有关,我们应该怎样预防这种情况出现!多少时间去检查为好,做什么检查好 化验、检查结果:CT没有异常,脑中线居中 最后一次就诊的医院:上海第八人民医院青岛海慈医院西医神经外科于广杰: “头部肿块”可能是头皮血肿。头皮血肿通常都会自行吸收,一般不需要进行处理,但较大的血肿,吸收时间可能很长,就有发生血肿腔感染的可能,最好将血肿腔的血液抽出一部分或大部分,以加快血肿的吸收速度。“迟发性血肿”一般分为两种,一种是脑内迟发性血肿,通常出现于伤后数天内。另一种是“慢性硬膜下血肿"多出现于伤后3周至3个月期间,半年之后出现的很少。迟发血肿必然导致病人出现不同程度的症状体征,比如,头疼逐渐加重,或一侧肢体逐渐无力等。有这些症状出现就应及时找医生检查,期间没有固定的复查时间。患者:谢谢于大夫:你的回复对我的家人很重要,我们会及时注意的,还有一个问题,我们一直还有顾虑,就是你说的慢性硬膜下出血,怕这个慢性的硬膜下出血,会在一年或数年后才发现,那就糟了,我家邻居的小孩从滑梯上滑下来,CT拍出来没有问题,但一年后就死了,医院的医生说,和那次头被摔了有关,可能小孩不会表达,耽误了治疗,,也有的我们也是听说的,过了十几年才发现。 这种情况可能是万一 ,但落在我们个体身上却是100%的悲剧。所以我们还想对这方面的知识多了解一些,出现不对的症状,就马上到医院,这样的警惕性是否要保持数年以上。谢谢你再次給我们答复好吗?青岛海慈医院西医神经外科于广杰:脑外伤后数年后出现出血症状,这种情况太罕见。我没有听说过,也没有发现有文献记载。但伤后3周以上出现出血症状的病人属慢性血肿。他们都有一个共同的特点就是发展缓慢。也就是说,只要不过分大意,都有机会得到治疗,不应当发生死亡或严重后遗症。患者:谢谢于大夫:你打消了我家的顾虑,也让我们提高了警惕,我们不会大意的,有症状就会去看病,但也不会顾虑重重了,我们不懂医学常识,能得到咨询,真的很高兴。也感到亲切。
本文发表于《英国神经外科杂志》—《British Journal of Neurosurgery 》2009,23(6),606-611.本文已被SCI收录Prolonged drainage reduces the recurrence of chronic subdural hematomaGuang Jie Yu, M.D.1, Chong Zhen Han3, Ming Zhang2, Han Ting Zhuang,M.D.1,Yong Gang Jiang, M.D.1Department of Neurosurgery, Qingdao HaiCi Hospital, P.R.ChinaAbstractBackground: Recurrence of chronic subdural hematoma (CSH) is a significant problem in neurosurgical practice. Various risk factors associated with patient’s characteristics and the pathogenesis of CSH have been investigated in many studies, but controversial findings are not uncommon. Therefore we made a retrospectively investigation focusing mainly on the factors associated with surgical techniques. in order to find out the factors which may affect the recurrence rate of CSH.Methods: The medical records of 97 consecutive patients with 121 CSHs, who were treated with burr-hole craniostomy and continuous drainage, were retrospectively reviewed. The relationships between the recurrence rate and some factors associated with surgery, such as location of burr-hole, thickness of residual hematoma, location of drainage catheter, intracapsular air postsurgery, duration of drainage were investigated. Results: The average recurrence rate was 6.6% in this whole series. For patients with less than three days of drainage, the recurrence rate was16.3%, whereas for those with 3 and more days of drainage, the recurrence rate was only 1.3%. The duration of drainage significantly related to recurrence rate. In addition, a higher recurrence rate seemed to be associated with more intracapsular air postsurgery, but it did not reach statistically significant level in this study. Prolonged duration of drainage did not increase the frequency of infection in this series.Conclusion: We found in this study that the duration of drainage play an important role in the treatment of CSH and three full days of drainage seems to be necessary, especially for patients of 60 years and over. We presumed that it takes at least 3 days of drainage for outer membrane of CSH to get the restoration of a normal balance between coagulation and fibrinolysis after surgery, which is necessary for termination of the vicious cycle and resolution of the hematoma.Key words: Chronic subdural hematoma, duration of drainage, operation, recurrenceIntroductionChronic subdural hematoma (CSH) is one of the most common diseases in neurosurgical practice. Burr-hole craniotomy with closed-system drainage (BCD) has been widely accepted as the optimum method for treating CSH1,2 However, there are still a significant number of patients with hematoma recurrence after BCD treatment, with a recurrence rate ranging from 3% to 21.5%1-10 Various risk factors associated with patients characteristics and the pathogenesis of CSH, such as age, sex, alcohol abuse, bleeding tendency, brain atrophy, neurological status, and CT features, have been investigated in many studies, but controversial findings are not uncommon.5-7,11-20 It seems that none of the above factors is critically correlated to the recurrence of CSH. However, the factors associated with surgical techniques have not been fully investigated. We therefore conducted a retrospectively investigation mainly on the factors associated with surgical techniques, in order to identify the key factors that may affect the recurrence rate of CSH. Material and Methods100 patients with CSH were treated with burr-hole craniotomy and closed-system drainage at our hospital from January 1997 to June 2008. The medical records of the 100 patients were retrospectively reviewed. Two patients who died in hospital during treatment and one infant who was treated with a series of subdural aspirations were excluded from the study. Recurrence of CSH was defined as reaccumulation of hematoma within the postoperative hematoma cavity and the reappearance of CSH symptoms postoperatively. The diagnosis was made by Computed Topographic scans (CT). The association between recurrence and patient-specific risk factors such as alcohol abuse and bleeding tendency were compared. A patient was considered to have a bleeding tendency if he/she had any abnormalities in blood examination for Fibrinogen, activated partial thromboplastin time (APTT), prothrombin time (PT), platelet. The single burr-hole surgery under local anesthesia was performed in hemisphere. The location of burr hole was defined as anterior or posterior based on its position in front of or behind the imaginary midline between forehead and occiput. After burr-hole craniotomy with a diameter of 15 mm and opening the dura mater, a subdural catheter was carefully placed in all directions and the subdural compartments were irrigated repeatedly with saline solution until clarification. Then, the catheter was assigned for placement with tip toward either the frontal or occipital region as drainage catheter. After the skin was closed, the catheter was connected hermetically to a bag which was replaced with a new one everyday. The drainage catheter was removed when ①the affected brain got fairly well re-expansion, ② or the drainage ceased. Patients had been kept in bed until the drains were removed. Prophylactic antibiotics therapy was administered after surgery for three days intravenously, then continued by oral until the next day of the drainage removed if no infectious complications was observed. The wound was disinfected daily if the drainage lasted for more than 2 days, and was covered with povidone iodine saturated gauzes if any infectious symptoms developed. The drainage outlet was sutured upon removal of drainage catheter.By the routine, patients underwent postoperative brain CT scanning 1 or 2 days after operation. Some patients, but not all of them, took CT before the drain removed. Another CT scanning was made before discharged, and 1-2 following-up CT scans were taken in the first three months as outpatients. Based on the postoperative CT, residual intracapsular air were characterized into categories: ①No or Small: in which there was no residual intracapsular air or only a small amount of air without cerebral compression; ②Moderate: in which there was a moderate amount of air with compression of cerebral surface; ③Large: in which there was a large amount of air with cerebral midline shift. The thickness of residual hematoma was the maximum width of subdural fluid on the postoperative CT. The duration of drainage was calculated from the time when the patient got back to ward after operation to the time when the catheter was removed according to medical record. We first divided the patients into two groups, the recurrent and nonrecurrent CSH groups, and found that the duration of drainage was significant difference. Then, all the patients in the series were divided into three groups based on the duration of drainage: 1) less than 3 days(<72 hours);2),3-4 days (72-119 hours); and 3) 5 days or longer (≥120 hours). The relationships among the rate of recurrence, patient’s age, and the duration of drainage were analyzed.. We used chi-square test to analyze frequency and ANOVA (analysis of variance) to compare means with the SPSS 13.0 software. P<0.05 was considered to be significant.ResultsThis study consisted of 97 patients with 121 of CSH, including 15 females, 82 males; 73 patients with unilateral hematomas (26 cases in the right, 47 cases in the left), and 24 patients with bilateral hematomas. The age ranged from 14 to 93 years , with an average of 67 years old. There was only one patient under 20 years of age, and 3 cases under 30 years of age who all had normal CT image except for CSH. No patient with intracranial hypotension, shunt operations or cerebrospinal fluid overdrainage was found in this group.Table 1:Comparing risk factors between patients of recurrence and of nonrecurrenceRisk factorsNo. RecurrenceNo. NonrecurrenceP valueSexMaleFemale Age (years)MeanRange SDLocation of hematoma Unilateral Bilateral Location of burr-hole AnteriorPosteriorIntracapsular air after surgery No/smallModeratelargeNo/small+ moderateLargeThickness of residual hematoma≤10mm>10mmLocation of drainage catheterFrontal OccipitalDuration of drainageMean (hours)Range SD8(7.8%)0 (0%)69.2547-8314.46 (8.1%)2 (8.7%)2 (4.7%) 6 (7.7%)3 (5%) 2 (5%)3 (14.3)5 (5%)3 (14.3%)3 (4.1%)5 (10.6%)7 (6.67%)1 (6.25%)6747-10919.2941967.0614-9316.868 21 41725738189518714298159230-19432.59P=0.354﹡P=0.722﹡﹡P=1.000﹡P=0.71﹡P=0.297﹡P=0.141﹡P=0.259﹡P=1.000﹡P=0.034﹡﹡ ﹡ Chi-square test or Fisher’s Exact Test﹡﹡ Analysis of VarianceRecurrence developed in 8 hemispheres (6.6%) of 8 patients (8.2%). Reoperation was performed in 5 patients. The other three patients were treated with repeated subdural aspirations. The 8 patients of recurrence were all males, but the difference in the CSH recurrence rate between men (7.8%) and women (0%) did not reach a significant level (P>0.05). In addition, statistical analysis indicates that the CSH recurrence is not affected by patient age,alcohol abuse, bleeding tendency, unilateral or bilateral hematomas, anterior or posterior burr-hole location, thickness of residual hematoma, and location of drainage catheter (Table 1). It appears that CSH recurrence is marginally affected by the amount of residual postsurgery intracapsular air. Specifically, 3 of the 60 patients (5%) with no or small intracapsular air, 2 of the 40 patients (5%) with moderate intracapsular air, and 3 of 21 patients (14.3%) with large intracapsular air were identified with recurrent CSH. However, statistical analysis indicates that this correlation did not reach a statistically significant level, even when the large air group was compared with the no or small air group and moderate group combined (P=0.141).Table 2:Relationship between duration of drainage and recurrence rate of CSHDuration of drainageNo. RecurrenceNo. Noncurrence<3 days3-4 days≥5 days7 (16.3%) 1 (2%)036 (83.7%)49 (98%)28(100%)X2=8.33 p=0.007 (Fisher’s exact test)Importantly, we found that the duration of drainage postsurgery was significantly shorter in CSH recurrent patients (mean 67 h, SD 19.2 h) than in the nonrecurrent patients (mean 92 h, SD 32.59h) ( P<0.05, Table 1)Further analysis indicates that in the group with less than three days of drainage, seven patients (16.3%) recurred (Table 2) and 5 of them were performed reoperations, two patients were cured with repeated subdural aspirations. In the group with 3 to 4 days of drainage, only one patient (2%) developed recurrence and got recovery after a single subdural aspiration. No patient of recurrence was found in the group with more than 5 days of drainage (0%). The recurrence rate was 1.3% when all patients with 3 days or longer drainage were analyzed. The difference in recurrence rate was statistically significant between patients had less than 3 days of drainage and those had at least 3 full days of drainage (P<0.01). Furthermore, there were two patients with bilateral hematomas who had less than 3 days drainage in one side, and more than 3 days drainage in the other side. Hematomas recurred only in the side of shorter duration of drainage in both patients.. Table 3: Relationship between duration of drainage and ageAge hematomasDuration of drainage(hours)Mean Range SD<60 years≥60 yearsTotal 328912174.4796.0890.3630-15047-19430-19435.0429.632.44 F=11.346 P=0.001 (Analysis of Variance)Table 4:Relationship between duration of drainage, age, and recurrence rateAge Duration of drainageNo. RecurrenceNo. Nonrecurrence<60 years<3 days≥3 days201911P=0.423≥60 years<3 days≥3 days511766P=0.003Fisher’s exact test To further examine whether drainage duration differentially affect patients in different age groups, we divided all patients in an under 60-and an over-60 group. Interestingly, the duration of drainage was shorter in patients under 60 years of age (mean 74.5h) than in patients of 60 years and over (mean 96h) (Table 3). Consistent with our earlier observation, a statistically significant difference was found in the recurrence rate between the two different periods of drainage groups (Table 4, P<0.01) for patients of 60 years and over. However, the recurrence rate of CSH was not significantly related with the duration of drainage for patients under 60 years of age (P>0.05). No major infectious complications was found in this series, except for one patients who, after 6 days of drainage, had a minor infection in the incision, and got cured with another three days antibiotic treatment.DiscussionDebate has ensued over the mechanisms underlying the recurrence of CSH. It is most author’s opinion that poor brain re-expansion and recurrent bleeding from the outer membrane are the major causes.4,,21,22 Fukuhara et al 23 found that a brain with high surface elastance tended to reexpand poorly And brain elastance increases with age. So, if the brain re-expansion were the major cause for recurrence of CSH, the age of patient should in theory affect the recurrence rate of CSH. But this prediction turned out to be not true in many investigations yet.7,9,14,15 Intracapsular air intrusion after surgery was suggested to contribute to the recurrence of CSH.13,17 Nakaguchi17 studied a series of patients treated with burr-hole irrigation and closed-system drainage of CSH, and found out that the patients with no subdural air observed on CT scans postsurgery had a recurrence rate of 8%, whereas those with 5% or more subdural air had a recurrence rate of 26%. They concluded that intracapsular air prevents brain re-expansion and leads to pressure imbalance across the inner membrane. Intracapsular air may also induce prolonged widening of the subdural space and disturbs adhesion between the inner and outer membrane, which is considered to be necessary for cure of CSH. Our investigation failed to confirm a statistically significant correlation between residual intracapsular air and recurrence rate of CSH. Furthermore, Takeda et al 24 developed a new therapeutic method for CSH by replacing the hematoma with oxygen, which might act as intrcapsular air and would have a high recurrence rate according to Nakaguchi’s study. However, the recurrence rate of patients treated with this method was 10%, which is almost the same as that of no subdural air group reported by Nakaguchi17. From our study, it was noted that the duration of drainage affected the recurrence rate of CSH. The longer duration of drainage, the lower recurrence rate of CSH, especially for old patients. Our observation is consistent with those made in several previous studies.25-28 For example, Kiymaz 25 compared two groups of patients with CSH. One group was treated with burr-hole and continuous drainage (CD), another group was treated with burr-hole and one-time drainage (OTD). The recurrence rate in the CD group was 6.8%, and 28.5% in OTD group. As a matter of fact, it turned out that, from many investigations, the incidences of recurrence were not significantly difference when different methods of surgery but same drainage duration were compared, 3,6,7,13 By contrast, the recurrence rate for patients with drainage was always significantly lower than that of patients without drainage.9,25,27 Furthermore, the recurrence rate of CSH, in almost all investigations in which the duration of drainage were limited to less than 48 hours, was as high as 10% or over.7,15,17 To our knowledge, no investigations were carried out to examine the effect of longer duration of drainage on CSH recurrence. We found in this study that the duration of drainage play an important role in the treatment of CSH and three full days of drainage seems to be necessary, especially for patients of 60 years and over. The recurrence rate of CSH was 16.3% in patients with less than three days of drainage, but only 1.3% of recurrence rate was found in patients with drainage duration of three days or more. Among the seven patients of recurrence in group under three days of drainage, five of them underwent reoperation. In contrast, the only patient of recurrence with more than three days of drainage accomplished a complete recovery after a single subdural aspiration. More convincingly, two patients with bilateral hematomas in this study who had duration of drainage less than 3 days in one side, and more than 3 days in another. Hematomas recurred all in the side of shorter duration of drainage, and no recurrence occurred in the side with three and over days of drainage. These results strongly suggest that drainage duration affects CSH recurrence.Why and how does the duration of drainage affect the recurrence rate? And why is the three days drainage a necessary time for preventing recurrence of CSH? It was believed that the defective capillaries of outer membrane and local hyperfibrinolysis lead to the vicious cycle of repetitive hemorrhage, defective clot formation and impairment of hemostasis, which result in the enlargement of CSH. Unless this cycle is interrupted, it is unlikely that the CSH is going to satisfactorily resolve. Many substances contained in the liquid of CSH, such as plasminogen activator, fibrin degradation products (FDPs), eosinophil granules, linoleic acid, and some inflammatory mediators: kallikrein,bradykinin, platelet-activating factor (PAF) may play an important role in the vicious cycle.28-32 Washing out or draining the liquid contents is a more effective way for treating a CSH than removing the membranes themselves.11,33 These maneuvers may reduce the amount of above substance and their contact with the outer membrane, thus allowing for continued clot organization, and preventing further bleeding. It would take a period of time, probably at least 3 days, for outer membrane to get the restoration of a normal balance between coagulation and fibrinolysis after reducing the amount of the fibrinolytic factors and inflammatory mediators postoperatively, and interrupt the vicious cycle. If the drainage catheter was removed before the restoration of a normal balance between coagulation and fibrinolysis, the fibrinolytic factors or/and inflammatory mediators might be accumulated in the hematoma cavity again, leading to the recurrence of the vicious cycle and CSH. A longer time drainage as in our practice may help to keep the aforementioned substances at very low levels and provide with a sufficient time for hemostasis, fibrosis of outer membrane, which would put an end to the vicious cycle and finally get the resolution of hematoma. This hypothesis is supported by Saito’s 34 research showing that when the concentration of fibrinolytic factors remained high in the postoperative drainage fluid, the risk of recurrence was increased. The data in this study suggest that the recurrence rate of CSH was not significantly correlated to the duration of drainage for patients under 60 years of age (P>0.05 Table 4). This is probably due to the small sample size of the under 60 group. Alternatively, compared with the old patients, the younger patients may have better capacity for rehabilitating blood vessels on membrane of CSH and regain the balance of coagulation and fibrinolysis in a shorter period of time. As this study is wholly based on medical records reviewed retrospectively, further clinical studies are warranted in order to confirm this hypothesis. conclusionsWe concluded from this investigation that 3 days were the necessary duration of drainage in preventing recurrence of CSH at least for old patients. We presumed that it probably take at least 3 days for the outer membrane of CSH to restore a normal balance between coagulation and fibrinolysis at a low level of detrimental substances after surgery, such a balance is necessary to terminate the vicious cycle,and resolve hematoma.References1 Santarius T, Lawton R. Kirkpatrick P J. Hutchinson P J: The management of primary chronic subdural haematoma: a questionnaire survey of practice in the United Kingdom and the Republic of Ireland. Br J Neurosurg 2008;22 (4): 529-5342 Taussky P, Fandino J, Landolt H: Number of burr holes as independent predictor of postoperative recurrence in chronic subdural haematoma Br J Neurosurg 2008;22 (2): 279 – 2823 Ernestus RI, Beldzinski P, Lanfermann H, Klug N: Chronic subdural hematoma: surgical treatment and outcome in 104 patients. Surg Neurol 1997;48 (3): 220-2254 Markwalder TM, Reulen HI: Influence of neomembranous organization, cortical expansion and subdural pressure on the post-operative course of chronic subdural hematoma- an analysis of 201 cases. Acta Neurochir 1986;79 (2-4): 100-1065 Markwalder TM, Steinsiepe KF, Rohner M, Reichenbach W, Markwalder H: The course of chronic subdural hematomas after burr-hole craniostomy and closed-system drainage. J Neurosurg 1981;55 (3): 390-396 6 Muzii VF, Bistazzoni S, Zalaffi A, Carangelo B Mariottini A, Palma L: Chronic subdural hematoma: comparison of two surgical techniques: preliminary results of a prospective randomized study. J Neurosurg Sci 2005; 49 (2): 41-46 7 Nakaguchi H, Tanishima T, Yoshimasu N: Factors in the natural history of chronic subdural haematomas that influence their postoperative recurrence. J Neurosurg 2001; 95 (2): 256-262 8 Sambasivan M: An overview of chronic subdural hematoma: experience with 2300 cases. Surg Neurol 1997; 47 (5): 418-4229 Tsutsumi K, Maeda K, Iijima A, Usui M, Okada Y and Kirino T: The relationship of preoperative magnitic resonance imaging findings and closed system drainage in the recurrence of chronic subdural hematoma. J Neurosurg 1997; 87 (6): 870-87510 Wier B, Gordon P: Factors affecting coagulation: Fibrinolysis in chronic subdural fluid collections. J Neurosurg 1983; 58 (2): 242-24511 Frati A, Salvati M, Mainiero F, et al: Inflammation markers and risk factors for recurrence in 35 patients with a posttraumatic chronic subdural hematoma: a prospective study. J Neurosurg 2004; 100 (1): 24-3212 Hamilton MG, Frizzell JB, Tranmer BI: Chronic subdural haematoma: the role for craniotomy reevaluated. Neurosurgery 1993; 33 (1): 67-72 13 Kuroki T, Katsume M, Harada N, Yamazaki T, Aoki K, and Takasu N: Strict closed-system drainage for treating chronic subdural haematoma. Acta Neurochir 2001; 143 (10): 1041-1044, 14 Kwon TH, Park YK, Lim DJ, et al: Chronic subdural haematoma: evaluation of the clinical significance of postoperative drainage volume. J Neurosurg 2000 ;93 (5): 796-799, 15 Matsumoto K, Akagi K, Abekura M, et al: Recurrence factors for chronic subdural haematomas after burr-hole craniostomy and closed system drainage. Neurol Res 1999; 21 (3): 277-280, 16 Murakami H, Hirose Y, Sagch M, et al: Why do chronic subdural haematomas continue to grow slowly and not coagulate ? Role of thrombomodulin in the mechanism. J Neurosurg 2002; 96 (5): 877-884, 17 Nakaguchi H, Tanishima T, Yoshimasu N: Relationship between drainage catheter location and postoperative recurrence of chronic subdural haematoma after burr-hole irrigation and closed-system drainage. J Neurosurg 2000; 93 (5): 791-795, 18 Oishi M, Toyama M, Tamatani S, et al: Clinical Factors of Recurrent Chronic Subdural Hematoma. Neurol Med Chir 2001; 41 (8): 382-386, 19 Okada Y, Akai T, Okamoto K, Lida T, Takata H, Lizuka H: A comparative study of the treatment of chronic subdural haematoma burr-hole drainage versus burr hole irrigation. Surg Neurol 2002; 57 (6): 405-409, 20 Tanikawa M, Mase M, Yamada K, et al: Surgical treatment of chronic subdural haematoma based on intrahematomal membrane structure on MRI. Acta Neurochir (Wein) 2001; 143 (6): 613-619, 21 Camel MGR: Treatment of chronic subdural hematoma by twist-drill craniostomy with continuous catheter drainage. J Neurosurg 1986; 65 (2): 183-187,22 Rosenorn JGF: Long-term follow-up review of patients with acute and subacute subdural hematomas. J Neurosurg 1978;48(3): 345-349, 23 Fukuhara T, Gotoh M, Asari S, Ohmoto T, Akioka T: The relationship between brain surface elastance and brain reexpansion after evacuation of chronic subdural hematoma. Srug Neurol 1996; 45 (6): 570-574, 24 Takeda N., Sasaki K., Oikawa A., Aoki N., and Hori T.: A new simple therapeutic method for chronic subdural hematoma without irrigation and drainage. Acta Neurochir (Wein) 2006;148 (5): 541-546, 25 Kiymaz N, Yilmaz N, Mumcu C: Controversies in chronic subdural hematoma:continuous drainage versus one-time drainage. Med Sci Monit, 2007;13 (5): cr240-24326 Kotwica Z, Brzezirfski J: Chornic subdural haematoma treated by burr holes and closed system drainage: personal experience in 131 patients. Br J Neurosurg 1991;5 (5): 461-465 27 . Markwakler TM, Seiler RW: Chronic subdural hematomas: to drain or not to drain ? Neurosurgery 1985; 16 (2): 185-188, 28 . Wakai S, Hiashimoto K, Watanabe N, Inoh S, Ochiai C, Nagai M: Efficacy of closed-system drainage in treating chronic subdural hematoma: A prospective comparative study. Neurosurgery 1990; 26 (5): 771-773, 29 Killeffer James A., Killeffer Fred A., Schochet Sydney S: The outer neomembrane of chronic subdural hematoma: Neurosurg Clin N Am 2000;11 (3): 407-412, 30 . Stoodley M, Weir B: Contents of chronic subdural hematome. Neurosurg Clin N Am 2000;11 (3): 425-434, 31 Suzuki K, Takano S, Nose T, et al: Increased concentration of vascular endothelial growth factor(VRGF) in chronic subdural hematoma. J Trauma1999; 46 (3): 532-533, 32 Wilberger Jack E: Pathophysiology of evolution and recurrence of chronic subdural hematoma. Neurosurg Clin N Am 2000; 11(3): 435-438, 33 Weigel R, Schmiedek P, Krauss JK: Outcome of contemporary surgery for chronic subdural haematoma: evidence based review. J Neurol Neurosurg Psychiatry 2003; 74 (7): 937-943, 34 Saito K, Ito H, Hasegawa T, Yamatomo S: Plasmin-alpha 2-plasmin inhibitor complex and alpha 2-plasmin inhibitor in chronic subdural hematoma. J Neurosurg 1989; 70 (1): 68-72,
癫痫病人应首先应用抗癫痫药物治疗。如果药物治疗失败或疗效不满意,即所谓“难治性癫痫”,才考虑手术方案。 “药物治疗失败”和“疗效不满意”的标准是什么? 一般认为:规范服用两种或以上适当的抗癫痫药物并持续两年以上,每月仍至少一次癫痫发作的病人,可认为属于难治性癫痫。 但临床资料显示:有些癫痫类型,如颞叶癫痫,脑外伤、脑炎等原因导致的继发性癫痫等,通常是难以用药物控制的。也就是说,这些癫痫类型在确定诊断时,就可以定性为难治性癫痫,不必再等待两年。
人类疾病中有些现象值得回味:糖尿病人如果只看“血糖增高”的字面意义会有一种甜滋滋的感觉,但高血糖对人体脏器的损害却令人不寒而栗。而癫痫却是另一个极端的例子:当你面对正在癫痫大发作的病人时,常会感到十分恐惧。而实际上,癫痫病对人体器官几乎没有直接的伤害,反而抗癫痫药的副作用却是损害人体器官的主凶。癫痫对病人的间接伤害主要包括两方面:一是发作时的突然性可能导致病人发生外伤性意外伤害;二是癫痫的发作,特别是在公众场合的发作会给病人带来心理方面的压力,并可造成病人的心理障碍以及对认知功能的损害,后者主要表现为记忆力减退,思维缓慢,注意力减低。在各种癫痫发作形式中,痉挛性发作(或肢体抽搐性发作),特别是继发性全面发作和复杂部分性发作对病人的伤害较为显著。
起初癫痫灶位于一侧大脑半球的部分性发作癫痫,在经历数年的发作后,约1/3的病人会在对侧大脑出现新癫痫灶,医学上称之为“继发灶”。继发灶的出现可能与原发灶癫痫发作频率有关。动物实验表明:继发灶由产生到成熟需要经历3个阶段:第一阶段:所有异常放电均依赖对侧的原发灶。此时切除原发灶后,继发灶的放电立即停止。第二阶段:继发灶能够独立放电,但是可逆的。也就是说:此时切除原发灶,继发灶会继续一段时间的放电,但最终会慢慢消失。第三阶段:继发灶完全独立。切除原发灶后,继发灶仍会持续异常放电。一般来说,在出现继发灶时,病人的脑电图和临床发作表现会出现很大差异。也就是说:如果病人脑电图出现新部位的异常放电灶,或病人的发作表现与此前有明显的不同,就应想到继发灶的可能,就应尽快采取更为积极地治疗措施,包括手术治疗。只要继发灶没有达到第三阶段,就不会对病人造成太大危害。