去骨瓣减压术后硬膜下积液的临床研究

目的总结去骨瓣减压术后硬膜下积液的治疗体会。方法回顾性的分析37例患者采用文章中不同治疗方法。结果全部病例中30例痊愈，7例出院时大部分消失。结论去骨瓣减压术后硬膜下积液选择恰当的方法能取得良好的治疗效果。     

Use of decompressive craniectomy after severe head trauma

Ten percent of head injuries quality as "severe," requiring prompt diagnosis and treatment. This level I trauma center uses an aggressive approach to treatment of severe head injuries and, when indicated, intervenes with decompressive craniectomy. This article explains decompressive craniectomy, including indications, procedures, and protocols. The case studies presented highlight two patients with profound head injuries. Additionally, cranioplasty replacement of autograft flap is explained and discussed.     

Somatosensory evoked potentials after decompressive craniectomy for traumatic brain injury

Somatosensory evoked potentials (SSEPs) are used for neuroprognosis after severe traumatic brain injury (TBI). However decompressive craniectomy (DC), involving removal of a portion of the skull to alleviate elevated intracranial pressure, is associated with an increase in SSEP amplitude. Accordingly, SSEPs are not available for neuroprognosis over the hemisphere with DC. We aim to determine the degree to which SSEP amplitudes are increased in the absence of cranial bone. This will serve as a precursor for translation to clinically prognostic ranges. Intra-operative SSEPs were performed before and after bone flap replacement in 22 patients with severe TBI. SSEP measurements were also performed in a comparison non-traumatic group undergoing craniotomy for tumor resection. N20/P25 amplitudes and central conduction time were measured with the bone flap in (BI) and out (BO). Linear regressions, adjusting for skull thickness and study arm, were performed to evaluate the contribution of bone presence to SSEP amplitudes. Latencies were not different between BO or BI trials in either group. Mean N20/P25 amplitudes recorded with BO were statistically different (p?=?0.0001) from BI in both cohorts, showing an approximate doubling in BO amplitudes. For contralateral–ipsilateral montages r² was 0.28 and for frontal pole montages r² was 0.62. Cortical SSEP amplitudes are influenced by the presence of cortical bone as is particularly evident in frontal pole montages. Larger, longitudinal trials to assess feasibility of neuroprognosis over the hemisphere with DC in severe TBI patients are warranted.     

去骨瓣减压术后缺损区头皮表面积变化率及凹凸度的研究

目的 建立研究去骨瓣减压术后缺损区域凹凸度与头皮表面积变化率关系的数学模型.方法 12例颅脑损伤患者,采集去大骨瓣减压术后CT图像数据,应用Mimics软件将CT图像导入,并生成颅骨和颅脑的三维几何模型.采用基于去骨瓣减压术后头皮表面积测量方法估算出缺损区头皮表面积及对比侧头皮表面积,计算缺损区头皮表面积变化率;通过距离变化量测量值估算病变侧凹凸度;在Matlab软件中基于最小二乘逼近理论建立用于研究去骨瓣减压术后缺损区域凹凸度与头皮表面积变化率关系的数学模型.结果 成功建立去骨瓣减压术后缺损区域凹凸度与头皮表面积变化率关系的数学模型,获得12例患者病变侧头皮表面积变化率随凹凸度变化的4阶多项式曲线.结论 基于最小二乘逼近理论建立颅脑损伤患者病变侧头皮表面积变化率与凹凸度关系的数学模型,可为研究去骨瓣减压术后缺损区域凹凸度与头皮表面积变化率关系提供新的分析方法,估算的去大骨瓣术后缺损区头皮表面积可为临床提供参考.     

Mass brain tissue lost after decompressive craniectomy: A case report

BACKGROUNDThe brain is the most important organ to maintain life. However, the amount of brain tissue required for maintaining life in humans has not been previously reported.CASE SUMMARYA 33-year-old woman fell from the third floor three months before admission to our department. She received a decompressive craniectomy soon after injury. After the operation, operative incision disunion occurred due to the high pressure. Brain tissue flowed from the incision, and intracranial infection occurred. She fell into deep coma and was sent to our hospital. Her right temporal surgical incision was not healed and had a cranial defect of 10 cm × 10 cm. Her intracranial cavity was observed from the skull defect, and the brain tissue was largely lost. In addition, no brain tissue was observed by visual inspection. Cranial computed tomography showed that only a small amount of brain tissue density shadow was compressed in the cerebellum and brainstem. Four days after hospitalization in our hospital, her parents transferred her to a hospital near her hometown. The patient died six days after discharge from our hospital.CONCLUSIONThis rare case provides some proof of the importance of the brainstem in the maintenance of cardiac rhythm and vascular tension. Neurosurgeons should carefully protect brainstem neurons during operations. Clinicians can maintain the cardiac rhythm of patients who lose their major brain tissue with modern technology, but the family of the patients should be aware of death and end-life care.     

Paradoxical herniation after decompressive craniectomy provoked by mannitol: A case report

BACKGROUNDParadoxical transtentorial herniation is a rare but life-threatening complication of cerebrospinal fluid drainage in patients with large decompressive craniectomy. However, paradoxical transtentorial herniation after rapid intravenous infusion of mannitol has not been reported yet. CASE SUMMARYA 48-year-old male suffered from a right temporal vascular malformation with hemorrhage. In a coma, the patient was given emergency vascular malformation resection, hematoma removal, and the right decompressive craniectomy. The patient woke up on the 1st d after the operation and was given 50 g of 20% mannitol intravenously every 8 h without cerebrospinal fluid drainage. On the morning of the 7th postoperative day, after 50 g of 20% mannitol infusion in the Fowler’s position, the neurological function of the patient continued to deteriorate, and the right pupils dilated to 4 mm and the left to 2 mm. Additionally, computed tomography revealed an increasing midline shift and transtentorial herniation. The patient was placed in a supine position and given 0.9% saline intravenously. A few hours later, the patient was fully awake with purposeful movements on his right side and normal communication.CONCLUSIONParadoxical herniation may occur, although rarely, after infusing high-dose mannitol intravenously in the Fowler’s position in the case of a large craniectomy defect. An attempt should be made to place the patient in the supine position because this simple maneuver may be life-saving. Do not use high-dose mannitol when the flap is severely sunken.     

Severe traumatic brain injury managed with decompressive craniectomy

Patients with severe traumatic brain injury may develop intractable raised ICP resulting in high mortality and morbidity. This may be anticipated from the patient's clinical status and imaging findings even where intracranial monitoring is unavailable. Outcome may be improved by early and aggressive control of ICP and surgical decompressive craniectomy is increasingly advocated as necessary.     

去骨瓣减压术在重型颅脑损伤中的应用进展

【摘要】 创伤性脑损伤（TBI）是世界范围内的公众健康和社会经济问题。重型颅脑损伤后常出现颅内压（ICP）升高,进而导致脑灌注压（CPP）、脑血流量和氧合降低。这些效应会进一步加重脑水肿,形成恶性循环,严重致脑疝和死亡。去骨瓣减压术（DC）是一种去除部分颅骨并打开下方硬脑膜的手术,为不断肿胀的脑组织提供额外的空间,从而降低TBI患者ICP升高和脑疝风险。尽管DC提高了生存率,但更高比例的DC幸存者经历了中重度残疾。DC相关残疾引发了激烈的伦理争议,并且DC及随后的颅骨成形术与许多并发症有关。本文就DC重型颅脑损伤的应用进展做一综述,为重型颅脑损伤的诊疗与DC的选择提供帮助。     

重型颅脑损伤急行双侧去大骨瓣减压术后立即应用尼莫地平的临床疗效观察

目的通过实验对比观察分析重型颅脑损伤急行双侧去大骨瓣减压术后立即应用尼莫地平的临床作用效果。方法 128重型颅脑损伤急性双侧去大骨瓣减压术后患者随机分成两组,照组患者进行术后常规治疗,实验组患者术后进行常规治疗的同时立即应用尼莫地平。观察比较两组的临床疗效。结果两组患者的治疗方法均有明显效果(P<0.05),但是两组差异无显著性(P>0.05)。实验组治疗后1个月及治疗后6个月的简易精神状态检查(MMSE)评分均高于对照组(P<0.05)。结论重型颅脑损伤急行双侧去大骨瓣减压术后立即应用尼莫地平能够明显提高患者的术后疗效,有助于患者的精神状态恢复。建议去大骨瓣减压术后立即应用尼莫地平。     

Early decompressive craniectomy and duraplasty for refractory intracranial hypertension in children: results of a pilot study

Introduction  

Severe traumatic brain injury (TBI) in childhood is associated with a high mortality and morbidity. Decompressive craniectomy has regained therapeutic interest during past years; however, treatment guidelines consider it a last resort treatment strategy for use only after failure of conservative therapy.     

高血压脑出血术后早期二次开颅手术扩大去骨瓣减压术28例临床分析

目的分析高血压脑出血术后早期二次开颅手术的原因,探讨扩大去骨瓣减压术在二次开颅手术中的应用,提高手术抢救的成功率。方法回顾性分析成都市第七人民医院神经外科近10年高血压脑出血术后早期二次开颅患者的手术原因、手术方式及成功率。结果二次开颅手术中28例采用扩大去骨瓣减压术,术后恢复良好3例,中度残疾者5例,严重残疾者10例,植物状态3例,死亡7例。结论术后再出血是高血压脑出血早期二次开颅手术的主要原因,另外还有术后严重脑水肿和大范围的脑梗死。二次手术中采用扩大去骨瓣减压术能够提高抢救成功率。     

去骨瓣减压术治疗颅内高压的临床效果观察

目的 探讨去骨瓣减压术治疗颅内高压的手术指征、方法及时机。方法 回顾性分析87例重型脑伤和高血压脑出血等颅内高压患者的临床资料。结果 本组87例，治愈22例，轻残16例，重残32例，植物生存3例，死亡14例。12例出现脑穿通畸形，9例出现硬膜下积液，1例癫痫发作。结论 严格掌握手术指征和手术时机，应用正确的手术技巧可取得良好疗效。     

去骨瓣减压术治疗重型脑伤86例临床分析

目的 探讨重型脑伤去骨瓣减压术的治疗时机、手术方法 及治疗效果.方法 回顾性分析86例重型脑伤(GCS 3～5分30例、6～12分56例)行去骨瓣减压术患者的临床资料,并复习相关文献.结果 行单侧去骨瓣减压69例,双侧去骨瓣减压17例;死亡34例,存活52例;出院时COS预后标准评分良好33例,中残8例,重残7例,植物生存4例.结论 去骨瓣减压术可快速有效降低重型脑伤患者的颅内压,并发症少,成活率高,致残率低,是简单、安全的治疗方法 ,而及时准确地掌握手术时机和技术要点至关重要.     

去骨瓣减压对心跳骤停大鼠脑复苏的影响

目的探讨去骨瓣减压对心跳骤停大鼠脑复苏的影响。方法选取成年雄性Wistar大鼠48只,随机分为假手术组(n=16)、对照组(n=16)、去骨瓣干预组(n=16)。每组又分为A(6 h)、B(12 h)、C(24 h)、D(48 h)4个亚组。对照组与去骨瓣干预组采用窒息致大鼠心脏骤停(CA)和心肺复苏(CPR)模型。去骨瓣干预组在大鼠心肺复苏成功1 h后行去骨瓣减压。假手术组仅行气管插管、股动静脉置管术。分别于各时间点取血和组织标本,以免疫组化染色法测定的内源性白蛋白渗出的面积百分比来表示BBB的破坏程度,ELISA法检测血清S100b蛋白质量浓度,TUNEL法检测细胞凋亡变化,HE染色观察海马及大脑皮质细胞大体形态。结果与假手术组比较,对照组及去骨瓣干预组BBB的破坏程度于6 h后开始加重,并持续上升至12 h并达到峰值,之后略有下降,差异具有统计学意义(P0.05)。与对照组比较,去骨瓣干预组自主循环恢复(ROSC)后12 h显著降低(P0.01),6 h、24 h、48 h亦降低(P0.05)。与假手术组比较,对照组血清S100b蛋白在ROSC后6 h明显升高,并持续上升至12 h达峰值,24 h、48 h有所回落,差异具有统计学意义(P0.01)。与对照组比较,去骨瓣干预组ROSC后6、12、24、48 h显著降低(P0.01)。假手术组仅可见≤3个散在的凋亡细胞出现在皮质。对照组和去骨瓣干预组可见皮质有大量神经元、胶质细胞及部分血管内皮细胞发生凋亡。去骨瓣干预组细胞凋亡数量较对照组明显减少(P0.05)。结论去骨瓣减压能减轻血脑屏障的破坏程度,降低大鼠心肺复苏后血清中S100 b蛋白的表达,减少细胞凋亡,从而减轻脑损伤。     

大骨瓣减压治疗重型颅脑损伤疗效分析

目的探讨大骨瓣减压比较常规骨瓣减压治疗重型、特重型颅脑损伤的疗效和优势。方法回顾性分析本科近年收治的263例重型颅脑损伤（GCS≤8分）患者，治疗组135例[含特重治疗组（GCS≤5分）54例]采用标准大骨瓣开颅术减压，对照组128例（含特重对照组49例）采用常规骨瓣减压。术后6个月，比较GOS评定和并发症。结果治疗组有效96例（71.1％），对照组为75例（58.6％），P〈0.05；特重治疗组有效34例（63％），特重对照组为18例（36.7％），P〈0.01。治疗组在术后因继发颅内高压而再次手术的发生率低于对照组（P〈0.05），但术后迟发血肿和对侧硬膜下积液发生率多于对照组（P〈0，05）。结论大骨瓣减压治疗重型，尤其是特重型颅脑损伤，能提高治疗效率；减少因继发颅内高压而再次手术的发生；但术后迟发血肿和对侧硬膜下积液增多。