应用联合减压术治疗中晚期脑疝疗效观察

目的　观察联合减压术治疗特重型颅脑损伤合并嵌顿性脑疝的效果。方法　将 97例格拉斯哥昏迷评分 (GCS) 3～ 5分的特重型颅脑损伤合并嵌顿性脑疝患者随机分为两组 ,分别采用联合减压术 (46例 )与常规骨瓣开颅术 (5 1例 )治疗 ,术后两组均经常规治疗。随访 1～ 32个月 ,平均 7个月。比较两组患者临床疗效、颅内压变化及并发症发生率。结果　联合减压治疗组有效率为 80 .4 % (37/ 4 6例 ) ,其中恢复良好、中残2 7例 (占 5 8.7% ) ,重残 10例 (占 2 1.7% ) ,死亡 9例 (占 19.6 % ) ;常规骨瓣开颅术对照组有效率为 33.4 %(17/ 5 1例 ) ,其中恢复良好、中残 6例 (占 11.8% ) ,重残 11例 (占 2 1.6 % ) ,死亡 34例 (占 6 6 .6 % ) ,两组有效率和病死率比较差异均有显著性 (P均 <0 .0 1)。联合减压治疗组患者颅内压下降速度和程度优于常规骨瓣开颅术对照组 (P<0 .0 5 )。联合减压治疗组患者的急性脑膨出、切口疝、切口脑脊液漏、外伤性癫疒间及术后枕叶脑梗死发生率均明显低于常规骨瓣开颅术对照组 (P<0 .0 5或 P<0 .0 1) ,但两组术后颅内感染发生率差异无显著性 (P>0 .0 5 )。结论　联合减压术治疗特重脑损伤合并嵌顿性脑疝患者的疗效优于常规骨瓣开颅术。

Effect of combined decompression operation on middle and late stage cerebral herniation

OBJECTIVE: To observe the effect of combined decompression operation on patients with severe traumatic brain injury complicated by tentorial cerebral herniation. METHODS: Ninety-seven patients with an admission Glasgow Coma Scale score 3-5 were randomly divided into two groups: combined decompression group (n=46), in whom tentorium cerebelli was incised (2-4 cm) combined with bone flap craniectomy decompression [(10-15)cm x (15-17)cm], and conventional temporoparietal craniectomy group (n=51). CT scanning was performed in the patients before and after the operation. The patients of both groups received routine treatment and followed up for 1-32 months (mean 7 months) after the operation. The clinical symptoms, change in intracranial pressure and incidence of complications were compared between the two groups. RESULTS: The efficacious rate was 80.4% (37/46) in the combined decompression group, and among them 27 patients were cured (58.7%) and 10 patients remained to have moderate disability(21.7%). Nine patients (19.6%) died after combined decompression. However, in patients with conventional temporoparietal craniectomy decompression, favorable outcome was only found in 6 cases(11.8%), moderate disability accounted for 21.6% of patients, and 34 patients died(66.6%). In patients with combined decompression, the intracranial pressure was more efficiently lowered compared with conventional craniectomy decompressin(P<0.01). Furthermore the incidence of acute brain edema, incisional herniation, traumatic epilepsy, occipital cerebral infarct and cerebro-spinal fluid(CSF) leakage were lower in combined decompression group compared with conventional craniectomy group (P<0.05 or P<0.01). The incidence of intracranial infection was not significantly different between two groups (P>0.05). CONCLUSION: Combined decompression is preferable to routine temporoparietal craniectomy for patients with severe head injury complicated by tentorial herniation.