标准大骨瓣减压术治疗重型颅脑损伤的体会

目的探讨标准大骨瓣减压术治疗重型颅脑损伤的临床效果。方法回顾性分析2007年2月至2011年2月用标准大骨瓣减压术治疗68例重型颅脑损伤患者的临床资料。结果 68例重型颅脑损伤患者中,出院后随访6~12个月,按GOS分级,Ⅰ级15例,Ⅱ级4例,Ⅲ级5例,Ⅳ级11例,Ⅴ级33例。结论标准大骨瓣减压术是治疗重型颅脑损伤的重要方法。     

标准大骨瓣与常规骨瓣减压术对重型颅脑损伤的疗效对比

目的：探讨重型颅脑损伤患者应用标准大骨瓣开颅减压术与常规骨瓣开颅减压术的疗效。方法选取我院2010-01-2012-12收治的124例重型颅脑损伤患者,随机分为2组,对照组60例患者采取常规骨瓣开颅减压术清除颅内血肿,观察组64例患者采取标准大骨瓣开颅减压术处理颅内血肿,观察分析2组治疗效果及术后并发症发生情况。结果术后随访6个月,按GOS评分分级,对照组Ⅰ级20例,Ⅱ级10例,Ⅲ级12例,Ⅳ级10例,Ⅴ级8例;观察组分别为11例、8例、12例、21例、12例。术后观察组颅内压、脑水肿体积和中线移位等明显低于对照组,差异有统计学意义（ P＜0·05）。2组脑切口疝、外伤性脑梗死等并发症发生率相比,差异有统计学意义（P＜0·05）;2组脑积水、外伤性癫痫等发生情况差异无统计学意义（均 P＞0·05）。结论标准大骨瓣开颅减压术治疗重型颅脑损伤可使患者脑组织得到充分减压,病死率降低,患者预后较好,并发症较少,生活质量明显提高。     

标准外伤大骨瓣开颅术治疗重型颅脑损伤61例临床分析

目的探讨标准外伤大骨瓣开颅术治疗重型颅脑损伤的手术方法、疗效及并发症。方法以61例重型颅脑损伤患者行标准外伤大骨瓣开颅术治疗,术后随访12个月,按GOS评价疗效。结果良好13例,中残11例,重残14例,植物生存8例,死亡15例。结论标准外伤大骨瓣开颅术,显露清晰,减压充分,可显著降低重型颅脑损伤的病死率,是治疗重型颅脑损伤的有效方法。     

早期应用双侧额颞顶部超大骨瓣减压术治疗重型颅脑损伤的效果分析

目的探讨早期应用双侧超大骨瓣减压术治疗重型颅脑损伤的效果。方法对51例早期行双侧超大骨瓣减压术治疗的重型颅脑损伤患者临床资料进行回顾性分析。结果术后1年随访,采用GOS预后评分评估51例患者,其中GOS1分8例,GOS2分6例,GOS3分9例,GOS4分11例,GOS5分17例。结论早期应用双侧额颞顶部超大骨瓣减压术治疗重型颅脑损伤尤为重要,能有效降低死亡率和改善预后,值得临床推广应用。     

控制性阶梯式减压术治疗重型、特重型颅脑损伤疗效分析

目的探讨控制性阶梯式减压手术治疗重型、特重型颅脑损伤的疗效。方法将186例重型、特重型颅脑损伤患者按入院顺序分为观察组(96例)和对照组(90例)。对照组采用标准大骨瓣减压手术,观察组在标准大骨瓣减压的基础上术中采用控制性阶梯式降颅压手术。结果观察组术中急性脑膨出发生率、术后迟发性颅内血肿发生率显著降低(P<0.05)。随访6个月,根据GOS评分评估患者预后,观察组预后良好率(GOS评分4~5分)显著增高(P<0.05)。结论在标准大骨瓣减压术基础上,术中采用控制性阶梯式减压手术,能有效降低重型、特重型颅脑损伤患者并发症发生率,改善患者预后。     

重型颅脑损伤65例标准大骨瓣开颅治疗体会

目的探讨标准大骨瓣开颅减压术治疗重型颅脑损伤的临床治疗效果。方法对65例重型颅脑损伤患者,采用标准外伤大骨瓣开颅加去骨瓣减压术,观察其治疗效果及术后并发症。结果术后随访1年根据GOS评分,本组65例中,恢复良好26例,轻、中残24例,植物生存4例,死亡11例。结论标准大骨瓣开颅术暴露充分,能彻底清除颅内血肿和坏死脑组织且减压充分,提高治疗存活率,个性化采用,能取得满意的临床治疗效果。     

逐步减压技术在重型、特重型颅脑损伤救治中的应用

目的探讨控制性逐步减压手术在重型、特重型颅脑损伤救治中的效果。方法回顾性分析2013年9月~2014年12月采用控制性逐步减压方法进行标准大骨瓣减压术治疗的67例重型、特重型颅脑损伤的临床资料。结果 67例术后共发生并发症11例(16.42%)。术后6个月,按GOS评分评估预后,恢复良好46例(68.66%)。结论控制性逐步减压方法进行标准大骨瓣减压术治疗重型、特重型颅脑损伤可以有效减少术后并发症,改善病人预后。     

标准大骨瓣开颅减压术在治疗重型颅脑损伤并发脑疝中的应用

目的讨标准大骨瓣开颅减压术治疗重型颅脑损伤并发脑疝的疗效。方法将33例符合手术治疗的重型颅脑损伤并发脑疝的患者行标准大骨瓣开颅减压术,术后随访6~10个月。采用GOS评判预后。结果 33例重型颅脑损伤并发脑疝病人,行标准大骨瓣开颅减压术后,经随访恢复良好15例(45.5%),中残6例(18.2%),重残3例(9.1%),植物生存2例(6.1%),死亡7例(21.2%)。结论标准外伤大骨瓣开颅减压术,具有暴露广泛,颅骨减压窗大,压力容易分散,最大限度地增加有效容积,减压充分,脑疝易复位,能明显降低脑疝病人的死亡率和病残率。     

标准大骨瓣减压术治疗重型颅脑损伤的体会

目的探讨标准大骨瓣减压术治疗重型颅脑损伤的疗效。方法 69例重型颅脑损伤患者均采用标准大骨辨减压术治疗,术后随访6～36个月,根据GOS预后评分法评定疗效。结果良好13例(18.84%),中残10例(14.49%),重残14例(20.29%),植物生存9例(13.04%),死亡23例(33.33%)。结论标准大骨瓣减压术骨窗减压范围大,显露好,可充分降低颅内压,是治疗重型颅脑损伤的有效手术方式。     

改良大骨瓣减压术治疗重型颅脑损伤52例临床观察

目的 观察改良大骨瓣减压术治疗重型颅脑损伤的疗效.方法 对52例重型颅脑损伤的患者均采用改良标准大骨瓣减压术,但去骨瓣时尽可能咬除蝶骨嵴及颞骨,使前中颅窝相通,以扩大颅底减压空间.结果 按GOS评分,生存43例,其中恢复良好29例,中残9例,重残5例,死亡9例.结论 改良大骨瓣减压治疗重型颅脑损伤,处理损伤灶方便,减压充分有效,是一种较为理想的手术方法.     

Factors predictive of fatality in massive middle cerebral artery territory infarction and clinical experience of decompressive hemicraniectomy

To determine the factors predictive of fatality in massive middle cerebral artery (MCA) territory infarction and outcome of decompressive hemicraniectomy, 62 patients who were retrospectively verified with first event massive MCA infarctions were enrolled in this study. Amongst them, 21 received decompressive hemicraniectomy during hospitalization. Clinical data between early and late hemicraniectomy groups were also compared. Significant deterioration occurred in 40 cases, 21 of whom received decompressive hemicraniectomy. The other 19 received conservative treatment. The mortality rate of these 40 cases between decompressive hemicraniectomy and conservative treatment was 29% (six of 21) and 42% (eight of 19), respectively. Factors that predicted fatalities in our massive MCA infarction patients with or without decompressive hemicraniectomy were total scores of baseline GCS at the time of admission, associated with coronary artery diseases, and significant deterioration during hospitalization. This study confirms the lifesaving procedure of hemicraniectomy that prevents death in patients deteriorating because of cerebral edema after infarction, although it may produce severe disability with an unacceptably poor quality of life in survival. Despite high mortality and morbidity, decompressive hemicraniectomy to prevent cerebral herniation when significant deterioration is demonstrated are essential for maximizing the potential for survival.     

Decompressive hemicraniectomy in children with severe ischemic stroke and life-threatening cerebral edema

Decompressive hemicraniectomy has been discussed as a treatment option that increases survival in adults with malignant stroke. This approach has not been studied extensively in children. From a prospective cohort, we identified 4 children who underwent decompressive hemicraniectomy for malignant infarctions with life-threatening cerebral edema within 72 hours of their stroke. All 4 children had different causes for their stroke and experienced severe cerebral edema with increasing intracranial pressure and an impending fatal outcome. Despite massive cerebral infarction, all patients were ambulant and able to speak at the time of follow-up. Although a limited experience, decompressive hemicraniectomy is a life-saving approach for malignant stroke in children.     

Decompressive hemicraniectomy in a 2-year-old girl with a left middle cerebral artery infarct

Introduction We report on the case of a 2-year 5-month-old girl with congenital heart disease who developed left middle cerebral artery occlusion and cerebral hemorrhagic infarction a day after ventricular septal defect patch closure.Results Cranial computed tomography scan revealed an acute hemorrhagic infarct over the left middle cerebral artery territory with midline shift to the right. Since medical treatment failed, decompressive hemicraniectomy with duraplasty was performed, successfully reversing herniation. Decompressive surgery allows extracranial expansion of the swollen brain and relieves CSF space compression. We believe this to be the youngest reported patient to undergo decompressive hemicraniectomy for middle cerebral artery territory infarction. Although the patient survived, her functional outcome was poor.Conclusion Decompressive hemicraniectomy can be lifesaving and should be considered as an alternative therapy for patients with brain swelling refractory to medical management.     

Hemicraniectomy for massive cerebral infarction: Evoked potentials as presurgical prognostic factors.

In patients with massive hemispheric infarctions, mortality exceeds 80% with medical therapy alone. In certain conditions hemicraniectomy may result in meaningful survival. We studied presurgical clinical and electrophysiological parameters that may serve as prognostic factors to assess efficacy of decompressive surgery. We evaluated 26 consecutive patients with severe focal neurological deficit, deterioration of consciousness, and massive hemispheric infarction by cranial computerized tomography who underwent hemicraniectomy. Clinical examination included pupillary size and reaction, and determination of level of consciousness on an hourly basis. Median nerve somatosensory evoked potentials and brainstem auditory evoked potentials were obtained before and after hemicraniectomy. Outcome was assessed by using the Barthel Index. Clinical and evoked potential data were correlated with the outcome. Fisher's Exact Test was applied to establish statistical significance. With surgery 18 of 26 patients survived on an average intensive care treatment of 29.6 (+/-27.5) days. Barthel Index at discharge was 61.7 (+/-24.4) in survivors. Presurgical pupillary reaction, level of consciousness, and somatosensory evoked potentials were not found to correlate with outcome. In contrast, presurgical brainstem auditory evoked potentials showed a significant correlation with survival (P<.05). All patients with good outcomes (Barthel Index >/=60: n=12, 46.1%) had normal brainstem auditory evoked potentials before surgery. Clinical parameters did not reliably forecast prognosis in patients with massive cerebral infarction treated with hemicraniectomy.     

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.     

Decompressive hemicraniectomy in ischaemic stroke

Background and purposeHemispheric ischaemic stroke complicated by oedema is associated with high mortality. The results of randomized studies showed that decompressive hemicraniectomy performed in this group of patients could be beneficial. First experiences with implementation of hemicraniectomy in patients with brain infarct in our stroke centre are presented.Material and methodsBetween August 2007 and July 2008, four patients with hemispheric brain infarcts complicated by malignant oedema underwent decompressive hemicraniectomy within 72 hours from symptoms onset. Stroke severity was assessed with the National Institutes of Health Stroke Scale (NIHSS). Clinical outcome was assessed 3, 6 and 12 months after the event using the modified Rankin scale (mRS).ResultsIn the first patient, the neurosurgical procedure included only decompressive hemicraniectomy, whereas in the other three duraplasty was performed additionally. The first patient died 23 days after the stroke onset due to acute respiratory failure. Another died at four months after the event, due to infectious complications. The remaining two patients presented severe functional disability 12 months after the procedure (mRS score 4).ConclusionsDecompressive surgery with duraplasty can be a life-saving procedure for patients with brain oedema. To our knowledge, the presented cases are among the first reported cases of hemispheric ischaemic stroke treated with decompressive hemicraniectomy in Poland. Extended follow-up with a larger group of patients is necessary to assess long-term outcome.     

大面积脑梗死手术治疗效果的临床研究

目的 对比去骨瓣减压术（decompressive hemicraniectomy，DCH）联合内科治疗与单纯内科治疗大面积脑梗死的效果。方法 采用前瞻性研究方法，连续收集符合入组条件的大面积脑梗死患者，分别进行DCH联合内科治疗（手术组）和单纯内科治疗（对照组），6个月后复查并对比两组患者的修正Rankin量表（modifiedrankin scale，MRS）评分情况。结果 手术组23例患者，对照组48例，6个月时手术组结局良好率高于对照组（39.1% vs 16.7%，P =0.042）。结论 DCH联合内科治疗大面积脑梗死患者，可改善患者预后。     

Decompressive hemicraniectomy improves outcome in patients with failed arterial recanalization after acute carotid artery occlusion

Abstract

Background and objectives: Decompressive hemicraniectomy reduces morbidity and mortality in patients with large hemispheric stroke. However, its role in patients that underwent failed endovascular reperfusion remains unknown.

Methods: Patients with acute stroke secondary to internal carotid artery occlusion who underwent endovascular multimodal reperfusion therapy were evaluated. Patients with failed revascularization who were referred for decompressive hemicraniectomy were compared with patients with failed reperfusion who did not undergo decompressive hemicraniectomy. Functional outcome was assessed with the modified Rankin Score (mRS) and neurological disability with the NIH Stroke Scale Score (NIHSS) at 90 days from stroke onset.

Results: Six decompressive hemicraniectomy-treated patients were included (four females, mean age: 36.7 years, mean NIHSS: 24.5). None of the decompressive hemicraniectomy-treated patients died compared to six of seven patients with failed multi-modal reperfusion therapy that did not undergo decompressive hemicraniectomy. All decompressive hemicraniectomy-treated patients were discharged to a rehabilitation facility whereas the only surviving non-decompressive hemicraniectomy-treated patient was discharged to a nursing facility. Five of the six decompressive hemicraniectomy-treated (84%) and none of the non-decompressive hemicraniectomy-treated patients had an mRS ≤3 at 90 days post-stroke.

Discussion: Decompressive hemicraniectomy can significantly improve functional outcome in patients with large carotid artery strokes that failed to recanalize following multi-modal reperfusion therapy. These results imply that decompressive hemicraniectomy should be planned in patients who undergo multi-modal reperfusion therapy for large carotid artery stroke.     

Resolution of extra-axial collections after decompressive craniectomy for ischemic stroke

Extra-axial fluid collections are known consequences of decompressive hemicraniectomy. Studies have examined these collections and their management. We retrospectively reviewed 12 consecutive patients who underwent decompressive hemicraniectomy for the treatment of malignant cerebral edema after infarction and evaluated the evolution, resolution and treatment of post-operative extra-axial fluid collections. All patients underwent standard-sized frontotemporoparietal hemicraniectomy with duraplasty as treatment for medically intractable malignant cerebral edema at an average of 3 days after the stroke (median 2 days). Their 30-day mortality was 25%. Three patients developed some extra-axial fluid collections after craniectomy: two patients developed the collections early in their post-operative course, 3 days and 5 days after the craniectomy. Both experienced spontaneous resolution of the collections without corrective cranioplasty or shunt placement at 34 days and 58 days after surgery. The third patient developed a collection 55 days after the operation related to a subgaleal bacterial infection. In the final analysis, 18% of patients developed extra-axial collections and all resolved spontaneously. The incidence of extra-axial collections after decompressive hemicraniectomy following ischemic stroke was lower in our retrospective series than has been reported by others. The collections resolved spontaneously, suggesting that early anticipatory, corrective treatment with cerebrospinal fluid diversion or cranioplasty may not be warranted.