The brain stem is a part of the brain, located below the brain, and the medulla oblongata of the brain stem is connected with the spinal cord. Irregular column. The brain stem consists of medulla oblongata, pons and midbrain.
It is connected with the third ~12 pair of cranial nerves. The white matter in the brain stem consists of ascending and descending conduction bundles and nerve fibers from various parts of the brain stem. It is an important way to communicate with the brain, cerebellum and spinal cord. The gray matter in the brain stem is scattered into gray matter blocks of different sizes, which are called "nerve nuclei". The nerve nucleus is related to receiving peripheral afferent impulses and efferent impulses to dominate organ activities and the conduction of ascending and descending conduction bundles. In addition, there are reflex centers in the medulla oblongata and pons that regulate cardiovascular movement, breathing, swallowing, vomiting and other important physiological activities. If these centers are damaged, it will cause serious obstacles to heartbeat and blood pressure, and even endanger life.
Objective To improve the success rate of treatment of brainstem hemorrhage. Methods Tracheotomy and mild hypothermia were actively carried out to reduce the metabolism of brain cells, crystal combined with colloid dehydrating agent combined with renal protection, antioxidant brain protective agent was applied early, drugs for promoting blood circulation and removing blood stasis were applied early, and multidisciplinary cooperation was carried out to improve nursing and rehabilitation training. Results 18 patients, 12 patients got better and were discharged. 2 cases were locked; Two cases were in stable condition after active treatment, and they gave up treatment and were discharged due to financial difficulties; Two cases died, and the success rate of treatment was 77.8% (including those who gave up treatment). Conclusion The comprehensive treatment of brainstem hemorrhage has high success rate and remarkable effect, which is worth recommending to peers.
Keywords: brain stem; Cerebral hemorrhage; Tracheotomy; Low temperature; comprehensive control
China Library Classification Number: R743.34
Brainstem hemorrhage is an acute severe nervous system disease with poor prognosis and high mortality. We have successfully treated 18 cases of brain stem hemorrhage recently. The following introduction is for the benefit of colleagues.
Materials and methods
Clinical data: From January 2002 to July 2004, our department treated 48 cases of cerebral hemorrhage, including 8 cases of brain stem hemorrhage, accounting for 12.62% of cerebral hemorrhage. Male 10, female 8, aged 40-65 years, with an average of 52.4 years. Form of onset: All cases are dynamic. There were hypertension 16 cases, myocardial infarction 1 case and diabetes in the past, and there was no previous history of cerebral hemorrhage or cerebral infarction. In 18 patients, the shortest time from admission to onset is 1 hour, and the longest time is 4 hours. There were 8 cases of confusion or agitation at admission, 2 cases of shallow coma, 2 cases of moderate coma, 6 cases of severe coma, and blood pressure190 ~ 220/10 ~129 mmhg. The average blood pressure was197 21118 7 mmhg. All cases were diagnosed by CT examination, and the amount of bleeding was between 1ml ~ 10ml. Among them, there were 6 cases of pontine hemorrhage, 8 cases of midbrain involvement and 4 cases of medullary hemorrhage. 6 cases ruptured to cisternal ring or the fourth ventricle.
Treatment methods: oxygen inhalation and ECG monitoring immediately after admission to CCU, taking 15, taking off the pillow and lying flat, protecting the head at low temperature, indwelling catheter and opening venous channel (indwelling needle); That is, dehydration and lowering blood pressure, as well as the application of brain protective agents; All patients with snoring and dyspnea underwent tracheotomy; If there is no hypercoagulability tendency, apply 1 hemostatic agent (6- aminocaproic acid or hemostatic aromatic acid) for 3-4 days after admission; After 48 hours, put a nasal feeding tube to ensure the heat supply and medication; Patients with dryness or high fever were treated with sub-hibernation therapy; Timely application of traditional Chinese medicine for promoting blood circulation and removing blood stasis; Prevent infection and strengthen nursing and rehabilitation training.
Results tracheotomy 14 cases, ventilator-assisted 12 cases. The longest hospitalization days were 50 days and the shortest was less than 1 day, with an average of 20.4 days. 12 cases were discharged (sequela in different degrees: diplopia, peripheral facial paralysis, paraplegia, etc. ), and locked 2 cases; Two patients were in stable condition after active treatment, and gave up treatment for less than 1 week due to economic difficulties. Two patients died within 12 hours after admission (both refused tracheotomy), the bleeding volume was more than 5ml, and the success rate of treatment was 77.8% (including those who gave up treatment after successful treatment).
Typical case: Zhang, male, 55 years old. Before the onset, overwork and drunkenness. I got up at 5: 30 in the morning and suddenly felt dizzy and my right limb was weak. Called 120 for treatment. Vomiting and incontinence occurred on the way. Immediately, the brain CT showed: "There are flaky high-density shadows on the two levels of the brain stem, accompanied by local edema to the compression of the fourth ventricle and cisterna annularis." CCU will be delivered at 6: 30. He has a history of hypertension for 4 years, but denies having a history of diabetes, myocardial infarction and angina pectoris. Physical examination on admission: T 37.2℃, P 120 times/minute, blood pressure 192/ 120 mmHg, awake, restless, snoring like sleeping. The two pupils are needlepoint-shaped, the fissure in the left eye is smaller than that in the side, the nasolabial groove on the left side is slightly shallow, the limb movement on the right side is less, and the right foot is slightly abduction, and the double pathological signs are positive. Laboratory examination: blood routine WBC 9.4× 109/L, neutral 77%, lymph 23%; Electrolyte and renal function are normal; CCG: "Old inferior myocardial infarction". Diagnosis: Brain stem hemorrhage. That is, sedation, lowering intracranial pressure (mannitol plus glycerol fructose) and lowering blood pressure. Two hours later, the patient developed respiratory depression, and the blood oxygen saturation (SpO2) decreased from 98% to 82%, that is, after tracheotomy, the above symptoms improved, and the pulse and blood pressure returned to normal. After 10h, the patient's body temperature rose to 38.5℃, and then sub-hibernation therapy was performed. Mechanical respiration was performed until spontaneous respiration recovered, and SpO2 was maintained above 98%. After 72 hours, the ventilator was used, and the gas cutting cannula was still retained. Nasal feeding, daily electrolyte and renal function monitoring, maintaining water-electrolyte balance. Application of brain protective agents such as high dose vitamin C and cerebroside carnosine. On the sixth day of hospitalization, 2 Xiangdan pills were put into the hospital, and 5%GS250ml intravenous qd was added. Hibernation stopped on the eighth day and the patient regained consciousness. On day 15, the tracheal intubation was removed and he could speak. CT reexamination for many times. On the 20th day, CT showed that the brain stem hematoma was completely absorbed. On the 25th day, the patient had diplopia, left peripheral facial paralysis and 5- 0 muscle strength in the right limb, and was discharged. The placement of functional posture and passive movement in the early stage and the training of limb and language function in the later stage run through.
The experience of discussing the high success rate of treatment in this group mainly lies in: ① eliminating concerns and actively implementing tracheotomy; (2) Hibernation therapy and head hypothermia protection should be actively used to reduce brain cell metabolism, but early use of awakening agent should try to reduce the brain function load of patients; ③ Active and orderly treatment for lowering intracranial pressure: crystal dehydrating agent combined with colloidal dehydrating agent (human albumin); ④ Early application of brain protective agents such as antioxidants; ⑤ Chinese patent medicine preparations for promoting blood circulation and removing blood stasis are put into use in time; ⑥ Supplementing nutrition and maintaining water, electrolyte and acid-base balance; ⑦ Key nursing; ⑧ Establishment and operation of comprehensive treatment system for cerebrovascular diseases (implementation of stroke unit and multidisciplinary cooperation concept).
Brain stem hemorrhage with bulbar palsy, snoring makes the head shake and vibrate, which is not conducive to brain protection and is bound to aggravate the condition. In the past, I was cautious about the implementation of tracheotomy because I was worried about the intensity of nursing work and the risk of surgery. It is a bold evaluation to take brain stem hemorrhage with loud snoring as the indication of pneumonectomy. Mild hypothermia therapy can reduce tissue oxygen consumption and metabolism, improve tolerance to hypoxia, alleviate brain edema and protect blood-brain barrier [1]. Early application of mild hypothermia therapy can also prevent or reduce reactive high fever after brain injury and prolong the action time of dehydrating agent. It can also stop bleeding for patients with persistent bleeding [2]; It is the best protection for brain cells to avoid premature use of brain cell excitation activating drugs in the critical acute phase; In the treatment of reducing intracranial pressure, especially in elderly patients, the dosage of mannitol should be cautious, and glycerol and fructose should be supplemented. The application of human albumin is not only an excellent drug to enhance immunity and nutritional support, but also a good medicine to improve colloid osmotic pressure and reduce intracranial pressure. The application of brain cell protective agents, including calcium antagonists, free radical scavengers and NMDA receptor antagonists of excitatory amino acids, is beneficial to the treatment of brain stem hemorrhage. In recent years, the method of promoting blood circulation and removing blood stasis has been paid attention to in the treatment of acute cerebral hemorrhage [3]. According to the theories of traditional Chinese medicine, such as "blood stasis is caused by collateral obstruction", "blood stasis does not go away, and new blood does not produce", "treating wind first, activating blood circulation to extinguish itself", combined with the basis of clinical objective "blood stasis syndrome" and the self-stop of cerebral hemorrhage. Early use of drugs for promoting blood circulation and removing blood stasis has a good therapeutic effect on hypertensive cerebral hemorrhage, which is safe and effective [4]. Early application of antibiotics and anti-ulcer drugs is necessary to prevent infection and peptic ulcer. Supplementing nutrition and maintaining the balance of water and electrolyte are important links that cannot be ignored; Introducing the concept of "stroke unit", multidisciplinary cooperation, comprehensive and standardized holistic nursing and rehabilitation training are the guarantee for the successful treatment of brainstem hemorrhage.
refer to
1. Edited by Huang Ruxun, Liang and Liu. Clinical neurology [M]. First edition: People's Health Publishing House. 1996. 172- 173.
2. Qin Deying, Li Xiangfeng. Adjuvant treatment of cerebral hemorrhage with mild hypothermia [J]. Zhongyuan Medical Journal.2003,30 (7): 24-25
3. Wang Wei Overview of research on the treatment of acute cerebral hemorrhage by activating blood circulation and removing blood stasis in recent years [J]. modern journal of integrated traditional chinese and western medicine.2002, 1 1 (7): 672-674.
4. Huang Ying. Clinical observation on early treatment of hypertensive cerebral hemorrhage with drugs for promoting blood circulation and removing blood stasis [J]. China Journal of Integrated Traditional Chinese and Western Medicine.2000,7 (5): 279-281
Note: This article was published in chinese journal of neuromedicine, Volume 4,No./kloc-0,No. 83-84, June 2005.
Authors: Chen Jian, director of the Department of Neurology, Sanming Hospital of Integrated Traditional Chinese and Western Medicine, Fujian.
The tail end of the medulla oblongata is connected with the spinal cord at the foramen magnum, and the head end of the midbrain is connected with the diencephalon. The medulla oblongata and pons are located on the slope of the skull base.
The function of brain stem is mainly to maintain individual life, including heartbeat, respiration, digestion, body temperature, sleep and other important physiological functions, all related to the function of brain stem.
Nerve impulses introduced into the brain through the spinal cord enter in a cross way: impulses from the right side of the spinal cord first pass to the left side of the brain stem and then to the brain; From the left side of the spinal cord, to the right side of the brain stem, and then to the brain.