特大骨瓣减压治疗特重型颅脑损伤

目的评估实施特大骨瓣减压术治疗特重型颅脑损伤的手术适应证及疗效。方法对50例特重型颅脑损伤患者均实施了特大骨瓣减压术。结果按格拉斯哥预后评分(GOS)：恢复0例，良好2例，中残8例，重残21例，植物生存6例，死亡13例。37例存活者出院后随访1-4年，再次GOS评定：恢复2例，良好5例，中残10例，重残10例，植物生存3例，死亡7例。共死亡20例，总死亡率40％。结论对特重型颅脑损伤实施特大骨瓣减压术是挽救该类垂危病人的首选办法。在严格掌握手术适应证的同时，确定、实施适当手术方案，并减张缝合修复硬膜．是值得提倡的手术措施，辅以术后常规治疗，可明显提高疗效。

Surgical decompression with extensive bone flap resection for most severe traumatic brain injury

Objective To evaluate the efficacy of extensive bone flap decompressive craniotomy and indications for its performance. Methods 50 patients with most severe brain trauma, scored 3~5 by Glasgow Coma Scale (GCS), underwent decompressive craniotomy with extensive bone flap of diameter 12~20 cm. In the case that unilateral decompression couldn't achieve a desirable result, bilateral decompression would be considered. Of the 50 patients, 24 were decomopressed by either a large bi-fronto-temporal skin incision or a curvilinear incision (16 bilateral and 8 unilateral), 20 across the fronto-temporo-parietal region (8 bilateral, 12 unilateral) and 6 across the fronto-temporo-parieto-occipital rigion. The dura remained open after decompression, followed by watertight closure of the skin incision. Routine treatment came immediately after surgical decompression. Results The outcomes were surprisingly good: 37 patients survived. Glasgow Outcome Scale (GOS) showed that 2 patients achieved good recovery, 8 came out with moderate disability, 21 with severe disability and 6 in vegetative state. Among the 37 patients at a follow-up ranging from 1 to 4 years, 2 got recovered well, 5 recuperated suboptimally, 10 were in moderate disability, 10 in severe disability, 3 in a persistent vegetative state and 7 died. The overall mortality rate was 40%(20/50). Conclusion Surgical decompression with extensive bone flap resection should be performed as a preferred therapy before irreversible brain damage occurs. The dura can be enlarged with the temporal fascia, followed by watertight closure of the dura and a fascial graft and then by closure of the skin incision. In our opinion, extensive bone flap decompression craniotomy is simple, safe and effective; it is better if with postoperative routine treatment.