Surgical decompression for traumatic brain swelling: indications and results
Surgical decompression for traumatic brain swelling: indications and results
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DOI：
10.3171/jns.1999.90.2.0187
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发表时间：
1999-02-01
影响因子：
4.1
通讯作者：
Fritsch, MJ
中科院分区：
文献类型：
--
作者：
Guerra, WKW;Gaab, MR;Fritsch, MJ
Object.自1977年以来，对创伤性脑损伤患者进行了去骨瓣减压术。作者评估了这种治疗的有效性及其使用的适应症。在标准方案中前瞻性记录了57例患者的临床状态、计算机断层扫描（CT）和颅内压（ICP）水平。在研究开始时，排除了所有30岁以上的患者。从1989年起，40岁以上的患者被排除，直到1991年;从那时起，50岁以上的患者被排除。原发性脑或脑干损伤伴完全发育的球脑综合征、听觉诱发电位（AEP）丧失和/或经颅多普勒超声检查中的振荡血流是去骨瓣减压术的禁忌症。在进行性难治性颅内高压病例中，根据临床（格拉斯哥昏迷量表[GCS]评分、去脑姿势、瞳孔扩张）和电生理（脑电图、体感诱发电位和AEP）参数以及CT扫描结果，给出了减压的阳性指征。单侧去骨瓣减压31例，双侧去骨瓣减压26例。在所有病例中，在额颞顶骨大骨瓣切除术后，硬膜扩大并覆盖颞肌筋膜，治疗效果令人惊讶的好。只有11名患者（19%）死亡，其中3人死于急性呼吸道疾病综合征。5名患者（9%）存活，但仍处于持续性植物人状态; 6名患者（11%）存活，但存在严重的永久性神经功能缺损，33名患者（58%）获得社会康复。2例患者（3.5%）未接受随访检查。伤后第1天GCS评分和平均颅内压是预后良好的最佳预测指标。结果表明去骨瓣减压术在治疗外伤性脑肿胀中的重要性。在不可逆缺血性脑损伤发生之前，应常规进行手术减压。
Object. Decompressive craniectomy has been performed since 1977 in patients with traumatic brain injury. The authors assess the efficacy of this treatment and the indications for its use.Methods. The clinical status of the 57 patients, their computerized tomography (CT) scans, and intracranial pressure (ICP) levels were documented prospectively in a standard protocol. At the beginning of the study, all patients older than 30 years were excluded. As of 1989 patients older than 40 years were excluded until 1991; since that time patients older than 50 years have been excluded. Primary brain or brainstem injury with fully developed bulbar brain syndrome, loss of auditory evoked potentials (AEPs), and/or oscillation flow in a transcranial Doppler ultrasound examination were contraindications to decompressive craniectomy. A positive indication for decompression was given in the case of progressive therapy-resistant intracranial hypertension in correlation with clinical (Glasgow Coma Scale [GCS] score, decerebrate posturing, dilating of pupils) and electrophysiological (electroencephalography, somatosensory evoked potentials, and AEPs) parameters and with findings on CT scans. Unilateral decompressive craniectomy was performed in 31 patients and bilateral craniectomy in 26 patients. In all cases, a wide frontotemporoparietal craniectomy was followed by a dura enlargement covered with temporal muscle fascia.The outcomes of the treatment were surprisingly good. Only 11 patients (19%) died, three of whom died of acute respiratory disease syndrome. Five patients (9%) survived, but remained in a persistent vegetative state; six patients (11%) survived with a severe permanent neurological deficit, and 33 patients (58%) attained social rehabilitation. Two patients (3.5%) did not have a follow-up examination. The GCS score on the 1st day posttrauma and the mean ICP turned out to be the best predictors for a good prognosis. The results demonstrate the importance of decompressive craniectomy in the treatment of traumatic brain swelling.Conclusions. Surgical decompression should be routinely performed when indicated before irreversible ischemic brain damage occurs.