1、Neurosurgery,THE FIRST AFFILIATED HOSPITAL OF DALIAN MEDICAL UNIVERSITY Dr. XU YINGHUI,Unearthed in Dawenkou culture,道与术,科学与艺术,管理,President Reagans Remarks at Fudan University in Shanghai, China, 1984 We have much to learn from you in neurosurgery and in your use of herbs in medicine,Academician Wan
2、g,The United States Military Academy at West Point,Motto： Duty Honor Country Punctual, Disciplined, Serious, Straight, Tough,Put the needs of the patient first,Archimedes Give me a lever long enough and a fulcrum on which to place it, and I shall move the world.,Reverence for life,美国撒拉纳克湖畔铭言 （ELTrud
3、ean),To cure sometimes , To relieve often , To comfort always . 偶 尔 治 愈 ， 常 常 缓 解 ， 总是 安 慰！,徐英辉 大连医科大学附属第一医院 神经外科 116011 0411-83635963-3001 e-mail: xuyh_dl,Brief review of anatomy,3-D Views of Brain,CHAPTER 1 Increased Intracranial Pressure,一、General Consideration,Pathophysiology of intracranial pre
4、ssure(ICP),a. Adults skull is a closed cavity,The cranium and the vertebral canal, along with the relatively inelastic dura, form a rigid container,(1)80% brain tissue and water (2)10% cerebrospinal fluid (CSF) (3) 10% blood: Cerebral blood flow (CBF),b. There are three components within the skull,c
5、. ICP: Intracranial pressure or ICP is the pressure or force exerted on the skull by the brain and fluid inside the skull cavity. d. Normal range of ICP: adult:70-200mm H2O(0.7-2.0kPa) child:50-100mm H2O(0.5-1.okPa),e. Compensatory Mechanism The skull is rigid and does not allow much expansion of th
6、e brain, so increases in ICP is a critical medical condition that can lead to brain damage. An increase in one should cause a decrease in one or both of the remaining two.,Monro-Kellie doctrine,Scottish Edinburgh,The pressure-volume relationship between ICP, volume of CSF, blood, and brain tissue, a
7、nd cerebral perfusion pressure (CPP) is known as the Monro-Kellie doctrine or the Monro-Kellie hypothesis .,The Monro-Kellie hypothesis states that the cranial compartment is incompressible, and the volume inside the cranium is a fixed volume. The cranium and its constituents (blood, CSF, and brain
8、tissue) create a state of volume equilibrium, The increase in any of its contents; brain, blood, or CSF, will tend to increase the ICP , such that any increase in volume of one of the cranial constituents must be compensated by a decrease in volume of another . .,Lanfitt curve 1965,To compensate for
9、 increased ICP, the brain will reduce the volume of fluid inside the skull cavity by: Limiting blood flow to the head Moving the cerebrospinal fluid into the spinal canal Increasing the absorption of CSF Decreasing the production of CSF With large ICP, however, these compensatory measures can be ove
10、rwhelmed and small changes in fluid volumes can lead to large changes in pressure inside the skull. However, once the ICP has reached around 25 mmHg, small increases in brain volume can lead to marked elevations in ICP; this is due to failure of intracranial compliance.,2. The concept of intracrania
11、l hypertension(IH): adult: ICP200 mm H2O child: ICP100 mm H2O 3. Common causes of ICH a. Brain tissue:brain edema b. CBF: cerebral venous obstruction c. CSF: obstruction of CBF pathway d. Intracranial space-occupied lesions e. Decrease of intracranial volume: cranio- synostosis, large depressed skul
12、l fracture.,brain edema,Hydrocephalus,4. Factors influencing the clinical progress of IH a. Age: Infant: Separation of skull sutures, compensatory volume increase Senile: Atropy of brain tissue compensatory volume increase b. Expansion of lesions: Pressure-volume exponential curve( langfitt curve) I
13、f critical volume is reached, dditional volume increase produces prominent increase of ICP.,c. Locations of the lesions midline Hydrocephalus ICH sinus Obstruction of venous regurgitation ICH d. Brain edema ICH e. General condition: high fever, hypoxia,An increase in intracranial pressure is a serio
14、us medical problem. The pressure itself can damage the by pressing on important brain structures and by restricting blood flow through blood vessels that supply the brain.,5. The outcome of ICP elevation: a. ICP CBF b. Brain herniation c. Brain edema e. G-I tract disturbances f. Cushings response g.
15、 Pulmonary edema,6. Clinical features of IH: a. Headache b. Vomiting Triad c. Papilloedema e. Cushings response: Cushings triad involves an increased systolic blood pressure, a widened pulse pressure, bradycardia, and an abnormal respiratory pattern d. abducent nerve paresis, Epilepsia f. coma, Inco
16、ntinence g.Child:circumstance of head increase,7. Diagnosis: a. clinical features b. X-ray c. CT/MRI etc.,二、Brain herniation,1.Anatomy and pathology,The falx cerebri, also known as the cerebral falx, so named from its sickle-like form, is a strong, arched fold of dura mater which descends vertically
17、 in the longitudinal fissure between the cerebral hemispheres.,The tentorium cerebelli or cerebellar tentorium (Latin: “tent of the cerebellum“) is an extension of the dura mater that separates the cerebellum from the inferior portion of the occipital lobes.,Brief review of anatomy,2.Classification
18、a. Transtentorial herniation: b. Tonsillar herniation: 3.Clinical manifestations: a. Trans-tentorial H: (1)Triad (2)Loss of consciousness (3)Ipsilateral mydriasis (4)Contralateral hemiparesis (5)Vital signs change b. Tonsillar H: (1)nuchal rigidity, neck pain, cough reflex (2)respiratory failure ear
19、ly stage (3)loss of consciousness late stage,4.Treatment: Management of specific causes Dehydration CSF puncture and drainage,THANK YOU!,ENGLAND ROSE,颅脑损伤,颅脑损伤分为头皮损伤、颅骨损伤、脑损伤。三者可单独发生，也可合并存在，中心问题是脑损伤，因此学习时，既要根据头皮、颅骨、脑三者的各自解剖特点、受伤机理分别分析，也要系统全面的整体理解。 颅脑损伤常与身体其他部分的损伤复合存在。称为多发伤。,发生机理,加速性损伤,加速性损伤(injury o
20、f acceleration)：运动的物体撞击于静止的头部（打击伤）。,减速性损伤,减速性损伤(injury of deceleration)运动的头部撞击于静止的物体（坠落伤）。,挤压性损伤,挤压性损伤(crush injury)头部两侧同时挤压所致脑损伤。如婴儿的产伤，头颅变形引起颅内出血。,挥鞭样损伤,挥鞭样损伤(Whiplash injury)头部运动落后于躯干所致的脑损伤。,传递性损伤,如坠落时双足或臀部着地，暴力沿脊柱传导作用于头部，引起颅颈交界处损伤(Craniocervical junction injury)，重者当场毙命。,胸部挤压伤,胸部挤压伤：又称创伤性窒息，胸内压静脉
21、压脑损伤。,CHAPTER 2 Craniocerebral Trauma,Cranio-cerebral trauma can involve scalp, skull, and brain or in any combination. 一.Scalp: a. hematoma:(1)subcutaneous H:lower in center (2)subgaleal H:diffuse (3)subperiosteal H:bony suture b. laceration: bleeding shock suture debridement within 24hrs with anti
22、biotics. complications:1)Fracture 2)Open injury c. avulsion: detached from the skull , skin graft,头皮解剖图示,表皮层 皮下结缔组织层 帽状腱膜层 帽状腱膜下层 骨膜层,It is usually described as having five layers, which can be remembered with the mnemonic “SCALP“: S: The skin on the head from which head hair grows. C: Connective ti
23、ssue. A thin layer of fat and fibrous tissue lies beneath the skin. A: The aponeurosis called epicranial aponeurosis (or galea aponeurotica) is the next layer. It is a tough layer of dense fibrous tissue L: The loose areolar connective tissue layer provides an easy plane of separation between the up
24、per three layers and the pericranium. P: The pericranium is the periosteum of the skull bones and provides nutrition to the bone and the capacity for repair. It may be lifted from the bone to allow removal of bone windows (craniotomy).,Harvey Cushing Gravestone Epitaph,The clinically important layer
25、 is the aponeurosis. Scalp lacerations through this layer mean that the “anchoring“ of the superficial layers is lost and gaping of the wound occurs; this requires suturing.,皮下血肿示意图,二.Skull fracture a. Vault skull fracture: (1)linear, non displaced: no specific T. (2)depressed indications for operat
26、ion: 1)large depressed fracture ICH 2)deficit of Neurological system :paraplegia, epilepsy 3)depth1.0cm 4)open injury 5)near sagital sinus:comtraindication,SKULL FRACTURE,凹陷性骨折图示,b. Basal skull fractures: Cranial fossa symptom & signs Anterior Middle Posterior - Bleeding CSF leakage rhinorrhagia oto
27、rrhagia no rhinorrhea Otorrhea rhinorrhea leakage through Eustachium tube - ecchymosis subconjunctival temporal region perimastoidal periorbita eyelid swelling suboccipital Racoons sign Battles sign pharyngeal- submucosal - Cranial nerve olfactory n facial n vagus n optic n auditory n accessory n gl
28、ossopharygeal n -,c. Diagnosis:clinical manifestations d. Treatment: Prevention of infection Plastic surgery is needed if ineffective after 4 weeks,I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses,三.Brain Injury:,Primary, Secondary Close, Open. a. Mec
29、hanism: acceleration injury: coup injury deceleration injury: contrecoup injury b. Primary brain injury: (1)Concussion: 1) loss of consciousness 2) recovery within 30mins 3) no positive neurological findings,(2)Cerebral contussion and laceration Organic damage to the brain tissue (grey and white mat
30、ter) accompanying laceration of blood vessels which results in intracerebral hemorrhage. Clinical manifestations 1). disturbance of consciousness:30min 2). local symptoms and signs 3). ICH herniation (3)Diffuse axon injury(DAI) pathological diagnosis: rupture of the axon axonal retraction ball sever
31、e brain injury with high mortality. Primary brain stem injury is nothing but a special type of brain injury .,c. Secondary Brain injury: intracranial hematoma and brain edema. (1) classification: 1)Time acute type: within 3 days subacute type: 3 days to 3 weeks chronic type: over 3 weeks 2)Location
32、epidural hematoma subdural hematoma intracerebral hematoma,(2) Clinical manifestatiions : ICH herniation death 1)Epidural 2) Subdural Mechanism: acceleration deceleration Location: coup injury contrecoup injury bleeding: middle meningeal A. coriical A, bridging V. Lucid interval: obvious atypical CT
33、: convex mirror semilunar Combination: less more Prognosis: good bad 3)Interacerebral H: mainly secondary to brain laceration, may occur in any part of the brain. 4)Delayed traumatic intracranial hematoma,CT scans of hematomas,Fig.1. Epidural Hematoma Fig.2. Subdural Hematoma,CT scans of hematomas,(
34、3)Treatment: Indication of operation: 1)Supratentorial H: *GCS1.0cm *amount of blood40ml 2)infratentorial H: amount of blood10ml non-operative treatment 1)dehydration:20% Mannitol. CSF draiage. 2)corticosteroid 3)drugs to improve CNS metabolism and recover of tissue function : co-enzyme, ATP, CDPC,
35、etc,Glasgow 昏迷计分法,CHAPTER 3 Intracranial Tumors (ICTs) 一、General features of ICTs 1.Classifications: Primary Secondary,a.Primary: come from intracranial tissues. (1)Tumors of neuroepithelial tissues Glioblastomas Astrocytomas Oligodendrogliomas Ependymomas (2)Tumors of cranial and spinal nerves Acou
36、stic neurinomas(schwannomas) Neurofibromas (3)Tumors of the meninges Meningiomas, Meningeal sarcomas, Malignant meningiomas (4)Tumors of anterior pituitary Pituitary adenomas/carcinomas,(5)Tumors of blood vessels Hemangioblastomas, (6)Congenital tumors craniopharyngiomas, Germinomas Chordomas, Epide
37、rmoid cysts, Dermoid cysts, Teratomas (7)Tumors of bone tissues Osteomas (8)Granulomas b.Secondary: Metastatic tumors,2.Morbidity In adult : accounting for only 2% of total tumors in the body In child: 7% second in occurance only to leukemias male female any range of ages 3.Etiology: activation of c
38、arcinogenic gene with or without inhibition of anti-cancer gene a.Genetic factors b.Physical factors c.Chemical factors d.Carcinogenic viruses 4.Mode of growth: a.Expansion :compression of brain tissues b.Infiltration: destruction of tissues c.Metastasis,5.Distribution: cerebral hemisphere , the sel
39、lar region, CPA, cerebellum, ventricles and brain stem 6.Onset: a.Chronic:gradual compression of the brain tissues due to slow enlargement of the tumors b.Acute: herniation or stroke due to bleeding , necrosis and cystic degeneration c.Epilepsy 7.Evidence of a patient with a possible intracranial ne
40、oplasm a.ICP increase b.Local compression c.Increasingly aggravate,8.Clinical manifestations (features): a.Headache, projectile vomiting, papilloedema loss of consciousness, b.Epilepsy, focal seizures c.Progressive disability of motor function: lateralizing paresis d.Discrete sensory loss e.Dysfunct
41、ion of cranial nerves f.Symptoms and signs of the cerebellum:ataxia g.Advanced neurological activities: speaking, reading, calculating and emotion etc h.Disturbance of endocrine system,9.Diagnosis: a.Clinical manifestations b.Location of tumors : x-ray CT .MRI etc c.Histological diagnosis 10.Treatme
42、nt: a.Surgical operation b.Radiation +r-knife + x-knife c.Chemotherapy d.Biological treatment,二、Characteristics of different kinds of tumors 1.GLIOMAS: the most common ICTs. making up about 40-50% of the total nummbers. GB MB AC OD EM Celluler Malignancy 4+ 3+ 2+ + + Location cerebrum children cereb
43、rum cerebrum ventricles cerebellum Sensitivity To RT&CT (-) (+) (+/-) (+/-) (+/-) 5-year surviving Rate 6-10 m 30-80% 14-31% 52% 30%,CT scans of Gliomas,Fig.3. Medulloblastoma Fig.4. Astrocytoma,2. Menigiomas: second to gliomas in morbidity, constituting about 20%of ITs: largest group of benign intr
44、acranial tumors, a rare lesion is malignant , They are thought to originate from the arachnoid villi Total execision whenever possible. 10-year surviving rate is 43-78% Fig.5. Menigiomas,3.Pituitary adenomas: tumors of the pituitary usually originate in the adenohypophysis . a.Clinical features: (1)
45、 Deterioration of visual fields is almost the first neruological deficit caused by gradually expanding tumors resulting from involving of the optic chiasm . Tumors can enlarge so much that they cause total blindness. (2)Disturbance of the endocrine system PRL:amenorrhea , galactorrhea , anovulation GH: gigantism , acromegaly ACTH:Cushings disease b.Treatment: (1)Surgical resection :1.transfr
