去大骨瓣减压并颞肌贴附术抢救急性大面积脑梗塞临床对照研究

目的:研究去大骨瓣减压并颞肌帖附术抢救急性大面积脑梗塞的疗效。方法:选择65例急性大面积脑梗塞住院患者,按是否同意手术分为手术组31例,内科组34例,手术组行去大骨瓣减压并颞肌贴附于术,其余治疗两组相同。3月后统计各组死亡率、重症监护时间、存活病例日常生活能力(ADL)。结果:①手术组死亡率38.71％,内科组死亡率67.65％,P<0.01;术前有脑疝征象的病例手术组死亡率41.66％,内科组死亡率93.75％,P<0.05;早期手术组死亡率15.38％,晚期手术组死亡率55.56％,P<0.01;晚期手术组死亡率与内科组相比,P>0.05。②存活病例重症监护时间:手术组短于内科组,P<0.05;早期手术组短于晚期手术组P<0.05。③存活病例生存质量:手术组与内科组无差异;早期手术组高与内科组,P<0.05;晚期于术组与内科组无差异。④手术病人均未出现手术并发症。结论:去大骨瓣减压并颞肌贴附术能抢救急性大面积脑梗塞患者的生命,但晚期手术生活质量差;CT发现脑梗塞面积大,且中线结构移位明显,病情有加重趋势,应尽早手术。     

标准大骨瓣减压加颞肌贴敷开颅术治疗大面积脑梗死的临床研究

目的：探讨标准大骨瓣开颅加颞肌贴敷减压术与常规大骨瓣开颅减压术对治疗大面积脑梗死的效果。方法40例大面积脑梗死患者随机分成研究组（标准大骨瓣减压加颞肌贴敷开颅）和对照组（常规大骨瓣开颅）,在治疗前后对全部患者进行头颅CT检查并测量两组患者术前、术后1d、3d、7d、14d梗死灶体积的大小,经颅多普勒超声（Transcranial doppler,TCD）检测两组患者术前、术后1d、3d、7d、14d的大脑中动脉（Middle cerebral artery,MCA）平均血流速度（Mean flow velocity,Vm）指标和出院随访3个月时格拉斯哥预后评分（Glasgow outcome scale, GOS）。根据两组的治疗结果比较其疗效。结果术后7d,14d研究组较对照组脑梗死体积、脑血流改善程度比较有显著性差异,出院随访3个月预后情况优于对照组。结论标准大骨瓣减压加颞肌贴敷开颅术治疗大面积脑梗死,能降低死亡率,改善该类患者的预后,是手术治疗大面积脑梗死的有效方法。     

去骨瓣减压加颞肌脑表面贴附术治疗大面积脑梗塞分析

目的探讨去骨瓣减压加颞肌脑表面贴附术治疗大面积脑梗塞的临床疗效。方法回顾性分析本院14例去骨瓣减压加颞肌脑表面贴附术治疗大面积脑梗塞患者的临床资料。结果 14例患者,术后存活12例,大部分意识状态及肢体功能逐渐恢复,能独立生活（ADLⅡ级）5例,生活不能自理、长期卧床7例,死亡2例。结论去骨瓣减压加颞肌脑表面贴附术治疗大面积脑梗塞能够提高临床疗效,降低死亡率,改善生存质量。     

髓芯减压植骨术与带肌蒂骨瓣移植术治疗股骨头坏死的效果比较

目的探讨股骨头髓芯减压植骨术与开窗减压带蒂骨瓣移植术治疗股骨头坏死的临床疗效比较。方法本院自2004-02—2012-02诊治的非创伤性成人早期股骨头缺血坏死58例(64髋),其中28例(32髋)采用髓芯减压植骨术治疗(A组),30例(32髋)采用开窗减压加带蒂缝匠肌骨瓣移植术治疗(B组)。记录2种手术方法的患者术前、术后一般状况、X线平片、Harris评分。结果本组获随访1~36个月,平均20个月。开窗减压带肌蒂骨瓣移植术术后复发率及远期髋关节活动情况较单纯髓芯减压植骨术效果好。结论开窗减压带蒂骨瓣移植术的临床疗效在股骨头坏死的早中期优于单纯髓芯减压植骨术。     

标准大骨瓣术后带蒂颞肌筋膜瓣修补硬脑膜缺损

目的总结带蒂颞肌筋膜瓣修补硬脑膜缺损在标准大骨瓣开颅术治疗颅脑损伤病人中的应用经验。方法总对实施该项手术的63例患者进行回顾性总结。结果术后恢复良好46例,中残9例,重残1例,植物状态2例,死亡6例。没有出现脑嵌顿、皮下积液、脑脊液切口漏、感染和颞肌下坠等并发症。结论带蒂颞肌筋膜瓣是一种理想的硬脑膜修补材料,具有裁剪方便,手术操作简单等优点。     

骨膜为蒂的颞深筋膜瓣在标准外伤性大骨瓣开颅硬脑膜减张缝合中的应用研究

目的探讨骨膜为蒂的颞深筋膜瓣在标准外伤性大骨瓣开颅硬脑膜减张缝合中应用。方法分析研究重型颅脑损伤标准外伤性大骨瓣入路开颅的患者74例,分为人工脑膜组36例和骨膜为蒂的颞深筋膜组38例,2组均行开颅血肿清除术+去骨瓣减压术并减张缝合硬膜,观察术后的硬膜间积液等并发症和经济负担。结果骨膜为蒂的颞深筋膜组术后无并发症,经济负担轻,与对照组比较有统计学意义(P<0.01)。结论骨膜为蒂的颞深筋膜瓣在标准外伤性大骨瓣开颅硬脑膜减张缝合的手术操作方法可以安全应用,是对标准外伤性大骨瓣开颅术的重要补充。     

标准大骨瓣减压联合硬脑膜内翻、颞肌帖敷开颅术治疗大面积脑梗死的临床研究

目的探讨标准大骨瓣减压联合硬脑膜内翻、颞肌帖敷开颅术与常规大骨瓣开颅术对治疗大面积脑梗死的疗效观察。方法将40例大面积脑梗死患者随机分成研究组(标准大骨瓣减压联合硬脑膜内翻、颞肌帖敷开颅手术)和对照组(常规标准大骨瓣减压术),所有患者均在术后1个月、3个月进行头颅CTA检查,并评估侧枝循环代偿;CT灌注成像(CTP)在术后1个月、3个月进行,检查颅内灌注指数。评估出院3个月时JennettBondy预后分级。结果研究组术后1个月、3个月头颅CTA检查TIMI分级明显高于对照组;CTP颅内灌注显著高于对照组,JennettBondy预后分级在3个月时显著高于对照组。结论标准大骨瓣减压联合硬脑膜内翻、颞肌帖敷开颅术治疗大面积脑梗死,可有效改善脑血流代偿,该类患者的预后明显改善,是大面积脑梗死手术治疗的有效方法。     

前臂缺血性挛缩的手术治疗

目的：探讨前臂缺血性肌挛缩不同时机手术疗效和最佳手术时机。方法：早期手术组（病程3周以内）4例行坏死肌肉切除、筋膜切开减压，肌腱移位，其中2例行带蒂背阔肌皮瓣移位。晚期手术组（病程6周以上）6例行肌肉（腱）松解、屈肌止点下移、神经松解或移植、肌腱移位延长。其中4例行带蒂背阔肌皮瓣移位，1例行吻合血管神经的游离股薄肌移植重建屈指功能。结果：随访10例，时间2－6．5年。早期手术组优3例，良1例。晚期手术组良3例，差3例。结论：前臂缺血性肌挛缩早期手术能够有效解除组织缺血，防止挛缩纤维化，减轻神经压迫的损害，有利于手功能的恢复。     

手术治疗外伤后急性弥漫性脑肿胀75例

目的探讨急性弥漫性脑肿胀手术治疗的必要性、手术方法及治疗效果。方法75例急性弥漫性脑肿胀患者,52例行单侧开颅去骨瓣减压,21例行双侧开颅去骨瓣减压术,2例保守治疗。结果71例存活,死亡4例,存活71例中植物生存5例、偏瘫9例、57例完全恢复或中残。结论除脑疝晚期,已处濒死状态患者外,外伤后急性弥漫性脑肿胀患者早期快速行开颅去骨瓣减压手术,是治疗的关键,疗效确切。     

额颞顶部开颅手术颞肌的处理

<正>自1984年Yasargil[1]提出"标准翼点入路开颅手术"以后,该方法被广泛应用于临床。随后,人们发现使用Yasargi介绍的手术方法进行开颅,术后常出现颞肌萎缩、颞窝塌陷、颞区疼痛、咀嚼功能障碍、面神经额颞支麻痹等并发症。而在额颞顶部标准去大骨瓣减压手术中,则常因为术后颞肌充血、肿胀,颞肌出     

Early external decompressive craniectomy with duroplasty improves functional recovery in patients with massive hemispheric embolic infarction: timing and indication of decompressive surgery for malignant cerebral infarction

BACKGROUND: Extensive cerebral hemispheric infarction associated with massive brain swelling is known as malignant infarction because of the rapid clinical deterioration and mortality as high as 80% unless appropriate treatment is performed. Decompressive craniectomy is an effective treatment, but patient selection, timing, functional recovery, and complications remain unclear. METHODS: Seventy-one patients with massive embolic hemispheric infarctions (infarct volume >200 cm(3)) associated with brain swelling were retrospectively divided into 3 groups according to the therapeutic modalities: 21 patients were treated conservatively (conservative group); 50 patients were treated by external decompressive craniectomy with duroplasty in 2 groups; 29 patients treated after the appearance of clinical and radiologic findings of brain herniation (late surgery group); and 21 patients treated before the onset of brain herniation (early surgery group). RESULTS: The mortality at 1 and 6 months in the conservative group were 61.9% and 71.4%, respectively. The mortality at 1 and 6 months in the late surgery group were significantly improved to 17.2% and 27.6%, respectively, (p < 0.01) and in the early surgery group were further improved to 4.8% and 19.1%, respectively. The functional recovery of the patients was estimated by the Glasgow Outcome Scale (GOS) and Barthel Index (BI) at 6 months after the ictus. The GOS scores of the early surgery group were significantly better than that of the late surgery group (p < 0.05). The mean BI score of the survivors in the late surgery group (26.9 +/- 30.4) was not significantly different from that of the conservative group (28.3 +/- 42.2), but was significantly improved in the early surgery group (52.9 +/- 34.2) compared with the late surgery group (p < 0.05). CONCLUSIONS: Early decompressive craniectomy with duroplasty before the onset of brain herniation should be performed to achieve satisfactory functional recovery if the infarct volume of the hemispheric cerebral infarction is more than 200 cm(3) and computed tomography on the second day after the ictus shows mass effect.     

External decompressive craniectomy including resection of temporal muscle and fascia in malignant hemispheric infarction

Decompressive craniectomy procedures are used for malignant hemispheric infarctions. However, the temporal muscle and fascia are significant limiting factors for external herniation of an edematous brain. Therefore, the authors performed a decompressive craniectomy and expansive duraplasty combined with resection of the temporal muscle and fascia for 15 patients with a malignant hemispheric infarction. The volume of the maximum external herniation that was measured on the basis of a CT volumetry study ranged from 130 to 300 ml (mean +/- standard deviation, 200 +/- 64 ml) on postoperative Day 3.2 +/- 1.5 (range 2-5 days postoperatively). The mean value represented a 2-fold volume expansion in comparison with the conventional decompressive craniectomy, and the greater the external herniation obtained by external decompression, the smaller the midline brain shift after surgery. The mortality rate, favorable outcomes (modified Rankin Scale Scores 1-3), and unfavorable outcomes were 20, 60, and 20%, respectively, and the masticatory function was only minimally affected. Furthermore, a cranioplasty involving reconstruction of the temporal muscle defect performed using a MEDPOR implant resulted in good cosmetic outcomes with no temporal hollow. Resection of the temporal muscle in a decompressive craniectomy was shown to provide greater decompression and better clinical outcomes for malignant hemispheric infarctions at an acceptable cost of minimal masticatory dysfunction and cosmetic disfigurement.     

Decompressive craniectomy for massive infarction of middle cerebral artery territory

There is continuing controversy about the benefits of decompressive craniectomy for the treatment of massive infarction of middle cerebral artery (MCA) territory. Under conservative therapy, the mortality rate for this stroke is reported to be up to 80%. So the authors have actively carried out decompressive craniectomy since 1997, and have compared the outcome with patients who were admitted before 1997 and, consequently treated with conservative therapy. Fifteen consecutive victims of massive infarction of MCA territory were studied. Seven patients (male: 1, female: 6, mean age: 79.8 years) were treated with conservative therapy, and 8 patients (male: 3, female: 5, mean age: 71.8 years) were treated with decompressive craniectomy. There were no significant differences in age and consciousness level distribution between the two groups. Mortality rate in the conservative therapy group was 85.7% against 12.5% in the surgery group (p < 0.05). Functional performance, which was evaluated by activity in daily life (ADL), was also better in the surgery group e.g. 3 patients in ADL 3, and 3 in ADL 4 (1 patient died from a non-neurological cause). Even among the patients with speech-dominant hemispheric stroke, all except one were able to communicate in some way and understand language. Even though patients in this study were elderly, decompressive craniectomy reduced mortality and improved functional performance, so it seems that this surgery should be aggressively considered for massive infarction of MCA territory.     

Ultra-early decompressive craniectomy for malignant middle cerebral artery infarction

BACKGROUND: Early surgical decompressive craniectomy (less than 24 hours) for malignant middle cerebral artery infarction (MCA) provides life-saving benefits. Detection of the infarction territory with computed tomography (CT) scan is usually less sensitive and delayed than diffusion-weighted imaging (DWI) that is capable of defecting the infarction territory in as little as 5 minutes after onset. Based on the DWI and clinical neurologic evaluations, ultra-early (less than 6 hours) decompressive craniectomy for malignant MCA infarction may be very helpful in improving mortality and morbidity rates. METHODS: We treated 52 patients with malignant MCA infarction. Clinical neurologic presentation was evaluated using the National Institutes of Health Stroke Scale (NIHSS) and the Glasgow Coma Scale (GCS). The infarction territory was evaluated by either DWI or CT. Patients were divided into three groups (Group A: ultra-early, Group B: craniectomy beyond 6 hours, and Group C: no operation). Anterior temporal lobectomy was performed according to the ICP levels (ICP >30 mm Hg) after decompressive craniectomy. RESULTS: Group A had statistically lower mortality rates than Groups B and C (8.7% in Group A, 36.7% in Group B and 80% in Group C). Group A patients also had better prognosis of conscious recovery on the 7th day of onset (91.7% in Group A, 55% in Group B and 0% in Group C). Group A had statistically better Barthel Indexes than Group B, p < 0.05. Group A and Group B had better GOS levels than Group C, p < 0.001. Diagnosis by CT was accurate in only 33% of patients while the accuracy of DWI to detect malignant MCA infarction was 100% within 6 hours of onset. In surgical Group A and B, thirteen patients underwent anterior temporal lobectomy, and 67% survived. All patients with ICP levels of more than 30 mm Hg who did not undergo further anterior temporal lobectomy died. CONCLUSIONS: Patients who underwent decompressive surgery had better outcomes than patients who did not have the operation. Ultra-early intervention with decompressive craniectomy with ICP monitoring before neurologic conditions become worse may reduce the mortality rate, increase the conscious recovery rate, and improve neurologic sequels for malignant MCA infarction. DWI with clinical neurologic evaluation (NIHSS, hemiplegia, down-hill GCS) provides for early diagnosis and treatment of malignant MCA infarction. Anterior temporal lobectomy may further reduce intraoperative ICP and reduce mortality, especially when the infarction is at multiple arterial territories.     

Preservation of the temporal muscle during the frontotemporoparietal approach for decompressive craniectomy: Technical note

Background

In patients undergoing decompressive craniectomy, resection and detachment of the temporal muscle produces esthetic and functional damage, due to atrophy of the frontal portion of the temporal muscle in the temporal fossa. We have performed en-block temporal muscle detachment in decompressive craniectomy patients to avoid esthetic and functional damage to the temporal muscle.

Methods

Twenty-one patients underwent decompressive craniectomy using a frontotemporoparietal approach. Through a three-leaf clover flap skin incision, the temporal muscle was detached en-block and overturned antero-inferiorly conjoined with the frontal myocutaneous flap. A decompressive craniectomy and duraplasty were performed. A polyethylene sheet was added to prevent adherence of the temporal muscle to the dura mater.

Results

The decompressive craniectomy was effective in all patients. When subsequent cranioplasty was performed, the temporal muscle was easily repositioned. No complications resulted from the en-block temporal muscle detachment or the use of the polyethylene sheet. In 18 patients eligible for clinical and radiological follow-up, excellent (n?=?4) or good (n?=?14) esthetic results were detected. Chewing ability is considered normal by all patients.

Conclusion

Although it requires that the patient undergo two surgical procedures, en-block detachment of the temporal muscle during decompressive craniectomy allows good esthetic and functional results.     

双侧去骨瓣减压术中脑组织医源性损伤原因分析

目的：探讨基层医院双侧去骨瓣减压术中脑组织医源性损伤的发生机制。方法回顾性分析2006年6月至2012年1月,本院133例双侧去骨瓣减压术患者的临床资料,其中97例采用气钻、铣刀开颅的患者作为观察组,另36例采用手摇颅钻、线锯开颅的患者作为对照组。记录两组患者的后手术侧手术时间,对比研究两组患者的非预期再次手术率及病死率。结果观察组术后行非预期再次手术22例,其中先手术侧再次手术17例（后手术侧手术时间118±21分钟）,后手术侧再次手术5例。对照组非预期再次手术15例,先手术侧再次手术12例（后手术侧手术时间144±25分钟）,后手术侧再次手术3例。观察组死亡25例,对照组19例。观察组的非预期再次手术率及病死率显著低于对照组。两组的先手术侧非预期再次手术率均显著高于后手术侧。差异有统计学意义（P〈0.05）。结论在双侧去骨瓣减压术中,“重力-时间”因素及后手术侧开颅时产生的暴力对先手术侧脑组织的损伤是导致术中医源性损伤的主要原因。先进手术器械的合理使用及脑保护理念的始终贯彻,能显著减少术中脑组织医源性损伤,降低术后非预期再次手术率及病死率。     

大面积脑梗死38例临床分析

目的探讨大面积脑梗死的病因、临床特点、治疗及预后的关系。方法回顾性分析2007年1月～2009年12月笔者所在科室收治的38例大面积脑梗死患者的临床表现、头颅影像学检查结果及治疗和预后资料。结果 38例患者中,心源性栓塞12例,动脉源性栓塞7例,颅内动脉狭窄3例,来源不明的或非栓塞性16例。30例采用内科保守治疗,好转27例,死亡3例,均为严重脑疝患者。8例因颅内高压进行性加重转外科行开颅减压术,好转7例,死亡1例。结论大面积脑梗死发病突然,病情严重,并发症重,致残、致死率高,急性期治疗的关键是控制颅内压,降低脑水肿,防止脑疝形成,促进病变脑组织功能恢复。对内科治疗效果差者应尽早转外科行减压术,以改善预后。     

Comparison of the effect of decompressive craniectomy on different neurosurgical diseases

Background  Many previous studies have reported that decompressive craniectomy has improved clinical outcomes in patients with intractable increased intracranial pressure (ICP) caused by various neurosurgical diseases. However there is no report that compares the effectiveness of the procedure in the different conditions. The authors performed decompressive craniectomy following a constant surgical indication and compared the clinical outcomes in different neurosurgical diseases. Materials and methods  Seventy five patients who underwent decompressive craniectomy were analysed retrospectively. There were 28 with severe traumatic brain injury (TBI), 24 cases with massive intracerebral haemorrhage (ICH), and 23 cases with major infarction (MI). The surgical indications were GCS score less than 8 and/or a midline shift more than 6 mm on CT. The clinical outcomes were assessed on the basis of mortality and Glasgow Outcome Scale (GOS) scores. The changes of ventricular pressure related to the surgical intervention were also compared between the different disease groups. Findings  Clinical outcomes were evaluated 6 months after decompressive craniectomy. The mortality was 21.4% in patients with TBI, 25% in those with ICH and 60.9% in MI. A favourable outcome, i.e. GOS 4–5 (moderate disability or better) was observed in 16 (57.1%) patients with TBI, 12 (50%) with ICH and 7 (30.4%) with MI. The change of ventricular pressure after craniectomy and was 53.2 (reductions of 17.4%) and further reduced by 14.9% (with dural opening) and (24.8%) after returning to its recovery room, regardless of the diseases group. Conclusions  According to the mortality and GOS scores, decompressive craniectomy with dural expansion was found to be more effective in patients with ICH or TBI than in the MI group. However, the ventricular pressure change during the decompressive craniectomy was similar in the different disease groups. The authors thought that decompressive craniectomy should be performed earlier for the major infarction patients.     

Management of severe traumatic brain injury by decompressive craniectomy

OBJECTIVE: The beneficial effect of decompressive craniectomy in the treatment of head trauma patients is controversial. The aim of our study was to assess the value of unilateral decompressive craniectomy in patients with severe traumatic brain injury. METHODS: We retrospectively investigated 49 patients who underwent decompressive craniectomy. Intracranial pressure, cerebral perfusion pressure, therapy intensity level, and cranial computed tomographic scan features (midline shift, visibility of ventricles, gyral pattern, and mesencephalic cisterns) were evaluated before and after craniectomy. The gain of intracranial space was calculated from cranial computed tomographic scans. Patient outcome was graded using the Glasgow Outcome Scale. RESULTS: Thirty-one patients (63.3%) underwent rapid surgical decompression within 4.5 +/- 3.8 hours after trauma; in 18 patients (36.7%), delayed surgical decompression was performed 56.2 +/- 57.0 hours after injury. Patients younger than 50 years or patients who underwent rapid surgical decompression had a significantly better outcome than older patients or patients who underwent delayed surgical decompression. Craniectomy significantly decreased midline shift and improved visibility of the mesencephalic cisterns. The state of the mesencephalic cisterns correlated with the distance of the lower border of the craniectomy to the temporal cranial base. Alterations in intracranial pressure, cerebral perfusion pressure, and therapy intensity level were not significant. The overall mortality of the patients corresponded to the reports of the Traumatic Coma Data Bank (1991). CONCLUSION: Although there was a significant decrease in midline shift after craniectomy, this did not translate into decompressive craniectomy demonstrating a beneficial effect on patient outcome.     

Role of decompressive craniectomy in the management of severe head injury with refractory cerebral edema and intractable intracranial pressure. Our experience with 48 cases

BACKGROUND: The effects of decompressive craniectomy in the treatment of severe head injury remain unclear. Only very few randomized studies relating to this topic exist in the literature, including a very small number of patients with no class I evidence. METHODS: We rretrospectively reviewed a series of 221 patients operated on for a head injury during a 25-month period. Of these, 48 patients underwent a decompressive craniectomy. All data available on patients' Glasgow Coma Scale score, pupil size and reaction, and intracranial pressure were collected and analyzed. The patients' outcome was evaluated by the Glasgow Outcome Scale (GOS) and the results compared with the data available in the Traumatic Coma Data Bank. Furthermore, the results were analyzed in respect of the time of surgical intervention (early or late), age, and the preoperative Glasgow Coma Score. RESULTS: Decompressive craniectomy reduced the midline shift in all patients with monolateral diffuse brain edema and contusions having a median value of 7 mm; in the remaining, it ameliorated the basal cisterns effacement. At a mean follow-up of 14 months, 6 (12.5%) patients died, 7 (15%) were discharged home with a GOS of 5, 18 (40%) showed a favorable outcome after rehabilitation with a GOS of 4 and 5, 6 (12.5%) had a severe disability (GOS 3), 9 (20%) were in a vegetative state (GOS 2), and 2 were lost to follow-up. The younger age, earlier surgery, and higher preoperative Glasgow Coma Scale score were related to better outcome (P < .001, P < .05, and P < .034, respectively). CONCLUSION: Our results seem to support the idea that decompressive craniectomy coupled with neurointensive care may be an effective way to reduce intractable raised intracranial pressure, and probably to improve patients outcome. However, it should be obvious that our results and those available in the literature can not be considered conclusive.