Decompressive craniectomy.
Decompressive craniectomy.
复制标题
去骨瓣减压术。
DOI：
10.1097/01.ccm.0000089636.73484.bf
复制
发表时间：
2003
影响因子：
8.8
通讯作者：
E. Farace
中科院分区：
文献类型：
--
作者：
M. Shaffrey;E. Farace
Albanèse 博士及其同事 (1) 发表在本期《重症监护医学》上的文章提出了一些有趣的问题，涉及可能有益的手术治疗，以控制严重创伤性脑损伤 (TBI) 后的脑水肿和/或高颅内压 (ICP)。在他们的中心，对 816 名严重 TBI 患者（入院时格拉斯哥昏迷量表评分≤ 8）进行的回顾性队列研究显示，40 名患者（5%）接受了去骨瓣减压术（DC）；因此，这不是该机构的常见程序。这些患者基本上根据 24 小时窗口被进一步分为“早期”和“晚期”DC；早期患者 (n = 27) 在肿块病变清除后接受 DC 治疗。对于其余 13 名患者，进行 DC 治疗难治性 ICP。所有患者均存在瞳孔异常。主要结局是 1 年生存率。虽然严重 TBI 导致的发病率和死亡率与 ICP 升高有关 (2)，但 DC 在早期或晚期的作用一直存在争议，正如作者在本文中详细介绍的那样。尽管 TBI 后经常进行 ICP 管理，但目前缺乏通过前瞻性、多中心、随机、对照研究证明任何治疗效果的严格证据 (3-5)。关于难治性 ICP 的治疗还有很多需要了解的最明确的迹象可能来自严重 TBI 的治疗和预后指南 (6)。尽管有“指南”水平建议在 20-25 毫米汞柱下开始 ICP 治疗，但无法对治疗模式做出明确的说明。
The article by Dr. Albanèse and colleagues (1) appearing in this issue of Critical Care Medicine has raised some interesting questions about a potentially beneficial surgical therapy to manage cerebral edema and/or high intracranial pressure (ICP) following severe traumatic brain injury (TBI). At their center, a retrospective cohort study of 816 patients with severe TBI (Glasgow Coma Scale score on admission≤ 8) revealed that 40 patients (5%) had decompressive craniectomy (DC); therefore, this is not a common procedure at this institution. These patients were further divided into “early” and “late” DC, essentially based on a 24-hr window; early patients (n= 27) were treated with DC following the evacuation of mass lesions. For the remaining 13 patients, DC was performed to treat ICP refractory to medical treatment. Pupillary abnormalities were present in all patients. Primary outcome was survival at 1 yr.Although morbidity and mortality resulting from severe TBI have been linked to raised ICP (2), the role of DC at either an early or late period has been debated, as the authors detail in this article. Despite frequent management of ICP following TBI, currently there is lack of rigorous proof of any treatment efficacy through a prospective, multiple-center, randomized, controlled study (3–5). Perhaps the clearest indication that much remains to be learned about the management of refractory ICP comes from the guidelines for management and prognosis of severe TBI (6). Although there is a “guideline” level recommendation to initiate ICP treatment at 20–25 mm Hg, definitive statements could not be made for mode of treatment.