颅底手术中的三叉-心反射  

Trigemino-cardiac reflex in skull base surgery

作　　者：段鸿洲[1] 张扬[1] 李良[1] 张家湧[1] 伊志强[1] 鲍圣德[1] 

机构地区：[1]北京大学第一医院神经外科,北京100034

出　　处：《北京大学学报（医学版）》2017年第1期164-168,共5页Journal of Peking University:Health Sciences

基　　金：国家自然科学基金(81541119);高等学校博士学科点专项科研基金(20110001120050)资助~~

摘　　要：目的:探讨颅底手术中出现三叉-心反射(trigemino-cardiac reflex,TCR)的形成机制、临床特征及相关预后。方法:回顾性分析2009年1月至2015年10月北京大学第一医院神经外科291例颅底手术患者,通过复习相关的手术资料及麻醉记录,找出术中出现TCR的病例(在刺激或操作三叉神经相关区域时,出现与麻醉因素无关的平均动脉压突然下降和心率突然减慢并超过基线值的20%),分析其手术方式、临床特征、影响因素及相应预后。结果:291例颅底手术患者中,9例患者术中共出现TCR 19次,包括神经鞘瘤4例(听神经瘤3例,三叉神经鞘瘤1例)、脑膜瘤1例、表皮样囊肿1例、海绵窦海绵状血管瘤1例、垂体瘤1例、三叉神经痛1例。TCR诱发方式均与三叉神经主干或其分支受操作、牵拉有关,操作前基线心率为62~119/min,平均(79.4±14.6)/min,TCR发生时,心率为22~60/min,平均(44.2±9.6)/min,心率下降比例为29.0%~66.4%,平均下降比例为44.3%。基线平均动脉压为75~103 mm Hg,平均(87.5±7.8)mm Hg,TCR发生时,平均动脉压为45~67 mm Hg,平均为(54.9±6.3)mm Hg,血压下降比例为23.4%~47.2%,平均下降比例为37.3%。TCR出现后,停止刺激或操作心率血压自行恢复者8例次,应用阿托品8例次,剂量0.5~1.0 mg,平均0.69 mg,应用盐酸麻黄碱1例次,应用肾上腺素1例次,应用多巴胺1例次,患者血压及心率均很快恢复至基线水平,重复刺激可再次诱发。术后24 h无TCR相关心血管并发症及神经功能障碍。结论:TCR是在颅底手术中由于对三叉神经或其分支操作刺激时出现的一种以心率变慢、血压降低为表现的神经反射,虽然其预后良好,但仍需正确判断、密切观察,必要时需给予处理。Objective： To explore the mechanism,clinical features,and prognosis of trigemino-cardiac reflex（ TCR） during skull base operations. Methods： A retrospective analysis was performed on 291 patients with skull base disease from Jan. 2009 to Oct. 2015 in Peking University First Hospital. By reviewing the patients＇ operative data and anaesthetic electrical record,and we picked out all the patients who suffered from TCR during the operation and analyzed their surgical procedures,clinical features,influence factors,and prognosis. TCR was defined as a drop in mean arterial blood pressure（ MABP） and the heart rate（ HR） of more than 20% to the baseline values before the stimulus and coinciding with the manipulation of the trigeminal nerve. Results： In all the 291 patients receiving skull base surgery,9 patients suffering TCR for 19 times during the operation were found. These 9 cases included three acoustice schwannomas,one trigeminal schwannoma,one petroclival meningioma,one epidermoid cyst in cerebellopontine angle,one cavernous sinus cavernous hemangioma,one pituitary adenoma,and one trigeminal neuralgia. The trigger of TCR was related to manipulation,retraction,and stimulation of the trunk or branches of trigeminal nerve. The baseline heart rate was 62-119/min [mean（ 79. 4 ± 14. 6）/min]and dropped about 29. 0%-66. 4%（ mean 44. 3%） to 22-60/min [mean（ 44. 2 ± 9. 6）/min]after TCR. The baseline mean arterial blood pressure was 75-103 mm Hg [mean（ 87. 5 ± 7. 8） mm Hg]and dropped about 23. 4%-47. 2%（ mean 37. 3%） to 45-67 mm Hg [mean（ 54. 9 ± 6. 3） mm Hg] after TCR. During the 19 times of TCR,heart rate and blood pressure could return to baseline in a short time while stopping manipulation（ 8 times）,using atropine（ 8 times,dose 0. 5-1. 0 mg,mean 0. 69 mg）,using ephedrine hydrochloride（ one time,15 mg）,using epinephrine（ one time,1 mg）,and using dopamine（ one time,2 mg）. TCR also could be triggered again by a second stimulation. There was no relative cardiol

关 键 词：颅底 神经外科手术 预后 三叉-心反射 

分 类 号：R743.3[医药卫生—神经病学与精神病学]