大骨瓣减压术抢恶性大脑中动脉梗塞疗效分析

目的总结大骨瓣减压术抢救恶性大脑中动脉梗塞(mMCAI)的临床经验.方法总结我院经头颅CT证实并进行大骨瓣减压术的16例mMCAI患者的临床资料、辅助检查、治疗等,以分析手术时机及其他因素与预后的相关性.结果死亡6例(6/16).死亡和存活患者的中线结构移位的中位数分别为10.5 mm和7 mm,手术距脑疝的时间中位数分别为15.5 h和4 h.手术前加强脱水后瞳孔一度回缩的患者有7例,其中6例存活.手术前12h内TCD检查示MCA主干闭塞的3例患者均死亡,部分再通的5例患者全部存活.3个月时存活患者BI评分,仅有1例严重残疾.结论大骨瓣减压术治疗mMCAI是重要的救命措施,但要把握手术时机,术前强力脱水后瞳孔能短时回缩及TCD监测MCA有部分再通的患者预后较好.     

去骨瓣减压术治疗大面积脑梗死18例临床分析

目的探讨去骨瓣减压术治疗大面积脑梗死的临床效果。方法回顾性分析2003-01~2008-01收治的18例经去骨瓣减压术治疗的大面积脑梗死患者的临床资料。结果18例患者存活17例,死亡1例。随访3~6个月,根据GOS评分,恢复良好9例,中残5例,重残3例。结论对保守治疗无效的大面积脑梗死患者,去骨瓣减压术能显著改善患者的预后。合理选择手术适应证,及时把握手术时机以及充分手术减压是取得良好预后的关键。     

治疗大面积脑梗死的术式选择与疗效

目的探讨大面积脑梗死的手术治疗方法及疗效。方法对12例大面积脑梗死的手术时机、术式、疗效进行分析。其中5例外减压;7例行内、外减压。结果12例病人全部存活,功能均有不同程度恢复。结论减压术是治疗大面积脑梗塞的重要救命措施,但要把握手术时机和术式,术前强力脱水后瞳孔回缩的病人预后良好。     

大骨瓣减压术治疗脑梗死所致脑疝

目的 探讨开颅大骨瓣减压术对大面积脑梗死所致脑疝的手术时机及手术方法.方法 对大面积脑梗死所致天幕疝12例采用大骨瓣减压术,同时剪开硬脑膜.结果 10例早期手术者均存活,1例死亡,1例病危出院.结论 大骨瓣减压术治疗大面积脑梗死所致脑疝是有效的方法.     

大骨瓣减压术治疗恶性大脑中动脉供血区脑梗死

大骨瓣减压术能缓解颅内高压,防止脑疝和由其引起的死亡,提高恶性大脑中动脉供血区脑梗死(MMCI)患者的存活率,改善患者的功能预后。但MMCI存活患者中有相当一部分遗留严重的功能障碍,就MMCI患者手术时机的选择、手术指征的掌握等方面也存在不同观点,由此也影响了大骨瓣减压术在MMCI临床治疗中的应用。目前多数情况下临床上仍将大骨瓣减压术作为保守治疗无效情况下的一种救命性治疗手段,而随着手术的开展,大骨瓣减压术在改善MMCI患者的功能预后方面的积极作用正日益受到重视。     

标准大骨瓣减压-颞肌贴敷术治疗急性大面积脑梗死13例疗效分析

目的探讨标准大骨瓣减压并颞肌贴敷术治疗急性大面积脑梗死患者的有效性。方法回顾性分析经标准大骨瓣减压并颞肌贴敷术治疗的13例急性大面积脑梗死患者临床资料。结果本组存活10例，死亡3例。随访3-6年，恢复良好6例，中残3例，重残1例。结论标准大骨瓣减压并颞肌贴敷术可有效治疗急性大面积脑梗死。手术时机、适应证、减压范围、术后侧支循环建立情况有进一步总结。     

去骨瓣减压术治疗大面积脑梗死(附30例报道)

目的 探讨去骨瓣减压治疗大面积脑梗死的意义、手术适应证及手术技巧。方法 回顾分析2010年7月～2015年7月江门市中心医院神经外科收治的30例大面积脑梗死行去骨瓣减压术患者的临床资料,总结分析其手术的意义、手术时机及手术操作的体会。结果 25例患者术后存活,5例死亡。去骨瓣减压术后格拉斯哥昏迷评分(GCS)较术前明显改善(t=-5.08,P<0.05)。术前瞳孔散大24例,术后有16例瞳孔缩小(80%)。术后绝大多数病例CT中线移位较术前回复(28/30)。术后3个月时GOS评分4分7例,3分17例,2分1例,1分5例。结论 去骨瓣减压术是大面积脑梗死的有效治疗手段,早期外科干预、术中充分减压可提高大面积脑梗死患者的生存率。     

TCD对重度颅脑损伤去骨瓣减压术围手术期血流动力学监测的意义

目的探讨应用经颅多普勒(TCD)监测重度颅脑损伤患者开颅去骨瓣减压手术前、后的血流动力学变化,及其与患者预后的关系。方法对2015年4月至2017年4月收治的86例重度颅脑损伤(格拉斯哥昏迷量表评分8分)患者,行开颅去骨瓣减压术治疗;并在术前和术后应用TCD检测患者双侧大脑中动脉(MCA)及颈内动脉颅外段(ICAex)的血流动力学参数。结果与术前相比,术后患者双侧MCA及ICAex平均流速(Vm)明显增快(均P0.05),且手术侧血管Vm增快更为显著。与术前相比,搏动指数(PI)术后明显降低,其中手术侧降低更显著(均P0.05)。频谱形态术后转为高血流低阻力型。结论 TCD能很好地显示重度颅脑损伤患者开颅去骨瓣减压术围手术期血流动力学的改变,并对预后判断亦有重要意义。     

大骨瓣开颅减压术治疗重型颅脑损伤临床观察

目的探讨大骨瓣开颅减压术治疗重型颅脑损伤的效果。方法收集我院68例重型颅脑损伤患者,分为治疗组34例,对照组34例,治疗组使用大骨瓣开颅减压术进行治疗,对照组使用常规手术治疗,比较2组治疗效果。结果治疗组34例患者手术成功存活31例,经预后处理后,恢复19例,中度残疾6例,重度残疾2例,植物性昏迷4例,死亡3例;对照组手术成功20例,其中预后处理后恢复7例,中度残疾4例,重度残疾7例,植物性昏迷2例,死亡13例。结论使用大骨瓣开颅减压术治疗重型颅脑损伤比常规手术治疗的效果更佳,可有效降低病死率,值得推广使用。     

大骨瓣减压加血管通道的建立治疗大面积脑梗死

目的探讨采用大骨瓣减压加血管通道建立的方法治疗大面积脑梗死的效果及手术时机。方法对24例经CT、MRI证实为大面积脑梗死患者采用12cm×15cm大骨瓣减压加明胶海绵支架建立血管通道的方法进行治疗。结果24例患者20例存活,4例死亡。7例早期手术者均存活。结论大骨瓣减压加血管通道的建立是治疗大面积脑梗死的有效方法,早期手术效果更好。     

Decompressive hemicraniectomy in severe cerebral venous thrombosis: a prospective case series

Small retrospective case series suggest that decompressive hemicraniectomy can be life saving in patients with cerebral venous thrombosis (CVT) and impending brain herniation. Prospective studies of consecutive cases are lacking. Thus, a single centre, prospective study was performed. In 2006 we adapted our protocol for CVT treatment to perform acute decompressive hemicraniectomy in patients with impending herniation, in whom the prognosis with conservative treatment was considered infaust. We included all consecutive patients with CVT between 2006 and 2010 who underwent hemicraniectomy. Outcome was assessed at 12 months with the modified Rankin Scale (mRS). Ten patients (8 women) with a median age of 41 years (range 26-52 years) were included. Before surgery 5 patients had GCS < 9, 9 patients had normal pupils, 1 patient had a unilaterally fixed and dilated pupil. All patients except one had space-occupying intracranial hemorrhagic infarcts. The median preoperative midline shift was 9 mm (range 3-14 mm). Unilateral hemicraniectomy was performed in 9 patients and bilateral hemicraniectomy in one. Two patients died from progressive cerebral edema and expansion of the hemorrhagic infarcts. Five patients recovered without disability at 12 months (mRS 0-1). Two patients had some residual handicap (one minor, mRS 2; one moderate, mRS 3). One patient was severely handicapped (mRS 5). Our prospective data show that decompressive hemicraniectomy in the most severe cases of cerebral venous thrombosis was probably life saving in 8/10 patients, with a good clinical outcome in six. In 2 patients death was caused by enlarging hemorrhagic infarcts.     

Outcome of and prognostic factors for decompressive hemicraniectomy in malignant middle cerebral artery infarction.

Decompressive hemicraniectomy as an appropriate treatment for malignant middle cerebral artery (MCA) infarction is still a controversial issue. This study aimed to determine the survival rate and functional outcome, and factors associated with these, in patients with malignant MCA infarction. From January 2000 to December 2003, 60 patients with malignant MCA infarction were treated in our hospital. All patients in the study underwent a large ipsilateral craniectomy and duroplasty for decompression. The infarction territory was evaluated by either diffusion weighted magnetic resonance imaging or computed tomography. Clinical neurological presentation was evaluated using the Glasgow Coma Scale. Functional outcome was evaluated using the Barthel index (BI) and the Glasgow Outcome Scale (GOS) at follow-up 12 months later. Thirty-day mortality was 20% (12 patients) and 12-month mortality was 26.6%. The factors associated with higher mortality were age>or=60 years, involvement of more than one vascular territory, presence of signs indicating clinical herniation before surgery, and treatment more than 24 hours after ictus. The mean GOS score was 3.3+/-1.7. The mean Barthel index was 65.1+/-40.1. Twenty-nine (65.9%) patients had a favourable outcome (BI>or=60). The factors associated with favourable outcome were age<60 years and treatment within 24 hours of ictus, before clinical signs of herniation were noted. Decompressive hemicraniectomy should be performed in patients younger than 60 years within 24 hours of ictus before clinical signs of herniation develop. Age, timing of surgery and clinical signs of herniation are prognostic factors for mortality and functional outcome.     

The Swedish Malignant Middle cerebral artery Infarction Study: long-term results from a prospective study of hemicraniectomy combined with standardized neurointensive care

OBJECTIVES: Hemicraniectomy in patients with malignant middle cerebral artery (mMCA) infarct may be life-saving. The long-term prognosis is unknown. METHODS: Patients with mMCA infarct treated with hemicraniectomy between 1998 and 2002 at three hospitals were included. The criterion for surgical intervention was if the patients deteriorated from awake to being responding to painful stimuli only. All patients were followed for at least 1 year. Outcome was defined as alive/dead, walkers/non-walkers or modified Rankin Scale (mRS) score 相似文献   

Treatment of right hemispheric cerebral infarction by hemicraniectomy

An anecdotal series of nine patients (three men and six women with an average age of 57 years) presented with progressive neurologic deterioration while on medical therapy for large right hemispheric cerebral infarction. Clinical signs of uncal herniation (anisocoria or fixed and dilated pupils, and/or left hemiplegia with right decerebrate posturing) were present in seven of these nine patients. Computerized tomography of the head confirmed mass effect from cerebral edema. It was the clinical judgment of the treating neurologists and neurosurgeons that each of these nine patients would perish unless surgical decompression of the infarcted brain was performed. Accordingly, each was treated with right hemicraniectomy and dural augmentation. Six patients demonstrated neurologic improvement on the first postoperative day. One patient, with a postoperative diagnosis of lung cancer, died 1 month after surgery. The remaining eight patients are currently living with their families with a follow-up period ranging from 5 to 25 months. Patient outcome as evaluated by the Barthel Index indicates that three individuals are functioning with minimal assistance and that the remaining six patients are functionally dependent. After rehabilitative therapy, four patients returned for elective cranioplasty. These results suggest that hemicraniectomy can be an effective lifesaving procedure for malignant cerebral edema after large hemispheric infarction.     

Poor Prognosis of Acute Stroke Patients Denied Thrombolysis Due to Early CT Findings

OBJECTIVES: Whether acute stroke patients with major early infarct signs on computed tomography (CT) should be treated with intravenous (i.v.) thrombolysis remains controversial. The authors sought to define the outcomes in 5 consecutive patients who were not treated with i.v. thrombolysis, according to established guidelines. METHODS: The authors retrospectively analyzed the outcomes of a consecutive series of 5 patients evaluated by an acute stroke team at a university medical center and who were denied i.v. tissue plasminogen activator due to early CT changes. RESULTS: Five patients with a median National Institutes of Health Stroke Scale score of 22 (range 20-28) were evaluated. Despite aggressive care (e.g., hemicraniectomy), 2 patients died owing to herniation, 1 patient died of cardiac causes, and neither of the 2 surviving patients achieved a 3-month Rankin score below 4 (moderately severe disability). CONCLUSIONS: Given the poor prognosis of patients with hemispheric stroke and early CT changes, alternative treatment modalities such as intra-arterial thrombolysis, early hemicraniectomy, and neuroprotective therapy should be vigorously pursued.     

Ultrasound-Enhanced Thrombolysis for Acute Ischemic Stroke: Phase I. Findings of the CLOTBUST Trial

BACKGROUND: Tissue plasminogen activator (TPA) activity may be enhanced with ultrasound, potentially 2 MHz transcranial Doppler (TCD). The authors present Phase I data of the CLOTBUST (Combined Lysis of Thrombus in Brain ischemia using transcranial Ultrasound and Systemic TPA). SUBJECTS AND METHODS: Nonrandomized stroke patients with proximal arterial occlusion on a prebolus TCD receiving intravenous 0.9 mg/kg TPA within 3 hours after stroke onset were monitored with portable diagnostic TCD equipment and a standard headframe. Complete recanalization was defined as thrombolysis in brain ischemia (TIBI) flow grades 4-5. RESULTS: 55 patients (mean age 69 +/- 15 years, median baseline NIH Stroke Scale [NIHSS] 18, range 4-29, 90% with 3 9 points) were treated at 125 +/- 36 minutes from symptom onset. TCD monitoring began at 117 +/- 39 minutes. Complete recanalization on TCD within 2 hours after bolus was found in 20 patients (36%). Dramatic recovery (NIHSS score < or = 3) occurred in 20% at 2 hours and in 24% at 24 hours. Overall improvement by > or = 4 NIHSS points was found in 49% at 24 hours. Improvement was associated with recanalization during or shortly after TPA infusion (phi r2 = .5, P = .03); however, in 6/20 patients with complete recanalization (30%), no immediate clinical change was noticed within 2 hours. Overall symptomatic hemorrhage rate was 5.5%. CONCLUSIONS: Continuous TCD insonation for up to 2 hours at maximum intensities allowed by current bio-safety guidelines is safe. Dramatic recovery and complete recanalization shortly after TPA bolus are feasible goals for thrombolysis given with TCD monitoring.     

Postoperative midline shift as secondary screening for the long-term outcomes of surgical decompression of malignant middle cerebral artery infarcts

Decompressive hemicraniectomy (DC) can save the lives of patients with malignant middle cerebral artery (MCA) infarction. We proposed that postoperative midline shift is important for the long-term outcome of patients with MCA infarction. We conducted a retrospective study of DC in 38 patients with malignant MCA infarction. The long-term outcome was assessed one year after surgery using the modified Rankin Scale (mRS) score. Patients who had midline shift less than the optimal diagnostic cut-off point on the fourth postoperative day were classified as having a successful decompression and the remaining patients were classified in the failed decompression group. The successful decompression group mRS score was 4.20±0.89 one year after surgery and the failed decompression group mRS score was 5.11±0.76 (p<0.0001). Successful decompression, resulting in postoperative midline shift of less than 5mm, was a key factor for beneficial, long-term functional outcomes in patients with malignant MCA infarction.     

外伤后急性半球脑肿胀的手术治疗

目的 探讨外伤后急性大脑半球肿胀（ACHS）的治疗效果以及影响疗效的主要因素.方法 对38例外伤后急性半球脑肿胀病人的资料进行回顾性分析.所有患者均接受了去骨瓣减压手术.结果 大骨瓣减压术后,CT影像显示脑中线结构无明显移位、环池结构清晰.术后6个月按GOS评分标准评估：良好14例（占36.8%）、中残9例（占23.7%）、重残5例（占13.2%）、植物生存4例（占10.5%）、死亡6例（占15.8%）.结论 早期去骨瓣减压手术可改善患者预后,而脑肿胀合并急性硬膜下血肿、手术后出血性脑挫伤处血肿量明显增加以及出现创伤后大面积脑梗死的患者预后较差.     

经颅多普勒超声脑缺血溶栓分级与阿替普酶静脉溶栓治疗急性前循环不同大动脉闭塞性脑梗死预后相关性研究

目的探讨分析经颅多普勒超声脑缺血溶栓分级与静脉溶栓治疗急性前循环不同大动脉闭塞性脑梗死患者血管再通评价与预后的相关性研究。方法选择急性前循环大动脉闭塞性脑梗死患者,对符合静脉溶栓者给予阿替普酶静脉溶栓治疗,分别于溶栓前及溶栓后24 h行床旁经颅多普勒超声(transcranial Doppler,TCD)检查并记录脑缺血溶栓分级(thrombolysis in brain ischemia,TIBI)。采用美国国立卫生研究院卒中量表(National Institutes of Health Stroke Scale,NIHSS)评分记录患者临床神经功能缺损,3个月随访时采用改良Rankin量表(modified Rankin Scale,m RS)评分评估患者预后,分析前循环不同大血管闭塞性脑梗死患者静脉溶栓前后血管再通情况及患者3个月预后。结果共入选46例患者,其中颈内动脉(internal carotid artery,ICA)闭塞患者19例,大脑中动脉(middle cerebral artery,MCA)闭塞患者27例。溶栓前与溶栓后24 h TCD监测TIBI分级提示血管再通者,ICA闭塞组5.26%,MCA闭塞组55.56%。ICA闭塞组与MCA闭塞组比较,MCA闭塞组90 d随访生活自理及良好预后的比例均高于ICA闭塞组,死亡率低于ICA闭塞组,而两组间溶栓后的症状性颅内出血发生率差异无显著性。结论急性前循环大动脉闭塞性脑梗死经静脉溶栓治疗后可获得血管再通,尤其是MCA闭塞患者;溶栓前后TIBI血流分级变化可反映大动脉血管再通情况,且有助于判断患者临床预后。     

Computed tomographic parameters predicting fatal outcome in large middle cerebral artery infarction

BACKGROUND: Large middle cerebral artery (MCA) ischaemic stroke when associated with extensive mass effect can result in brain herniation and neurological death. As yet there are few guidelines to aid the selection of patients for aggressive interventional therapies, such as decompression hemicraniectomy and/or hypothermia. METHODS: We studied a cohort of patients from seven centres with large MCA infarction requiring neurocritical care. The purpose of this analysis was to assess the use of early radiological signs on follow-up computed tomographic (CT) signs performed within 48 h of stroke onset for predicting mortality at 30 days. The CT parameters assessed included horizontal displacement of the septum pellucidum, pineal shift, complete or partial infarction of the temporal lobe, involvement of additional vascular territories, and the presence of hydrocephalus. The primary outcome measure was in-hospital death within 30 days. RESULTS: One hundred and thirty-five patients who had follow-up CT scans within 48 h were identified from a total of 201 patients with large MCA infarction that received conventional medical therapy alone. The median age was 68 (range 29-99), 56% were female, and the median NIHSS category was 26-30 at 48 h. Among CT variables in univariable analysis, anteroseptal shift >/=5 mm, pineal shift >/=2 mm, complete temporal lobe infarction, involvement beyond the MCA territory, and moderate or severe hydrocephalus were equally predictive of death. Multivariable analysis adjusting for time to CT scan revealed the following predictors of fatal outcome: anteroseptal shift >/=5 mm (OR 10.9; 95% CI 3.2-37.6), NIHSS within 48 h >20 (OR 6.6; 95% CI 2.3-19.3), and infarction beyond the MCA territory (OR 4.9; 95% CI 1.6-15.0). CONCLUSIONS: We identified the role of early CT signs in predicting death following massive MCA infarction. The CT parameters anteroseptal shift (>5 versus /=2 mm, hydrocephalus, temporal lobe infarction, and other vascular territory infarction if present were predictive of fatal outcome. These CT parameters require prospective validation before they should be considered reliable markers for decision-making.