Jauss M, Krieger D, Hornig C, Schramm J, Busse O
Department of Neurology, University of Lübeck, Germany.
J Neurol. 1999 Apr;246(4):257-64. doi: 10.1007/s004150050344.
Surgical intervention (ventricular drainage or decompressive craniotomy) may be necessary in patients with cerebellar infarction if mass effect develops. However, patient selection and timing of surgery remain controversial, and there are few data on clinical signs in the early course that are predictive for outcome. The clinical course and neuroradiological features of 84 patients (aged 22-78, mean 58.5 years) with massive cerebellar infarction confirmed by computed tomography were prospectively observed for 21 days after admission and at 3-month follow-up using a standardized protocol. Data were gathered from 1992 to 1996 in 17 centers. The patients were assigned to three treatment groups depending on the decision of the primary caretaker: 34 underwent craniotomy and evacuation, 14 received ventriculostomy, and 36 were treated medically. Treatment groups differed regarding the level of consciousness, signs of mass effect in computed tomography and signs of brainstem involvement. The overall risk for poor outcome depended on the level of consciousness after clinical deterioration (odds ratio = 2.8). Subgroup analysis of awake/drowsy or somnolent/stupor patients revealed no relationship to treatment. The vascular territory involved did not affect outcome. Surgical treatment for massive cerebellar infarctions was not found to be superior to medical treatment in awake/drowsy or somnolent/stupor patients. Half of all patients deteriorating to coma treated with ventricular drainage or decompressive craniotomy had a meaningful recovery. We were unable to compare surgical versus medical therapy in this subgroup due to lack of control group. This study supports the notion that the level of consciousness is the most powerful predictor of outcome, superior to any other clinical sign and treatment assignment. Deterioration of consciousness typically occurred between days 2 and 4, with a maximum on day 3.
对于小脑梗死患者，如果出现占位效应，可能需要进行手术干预（脑室引流或减压开颅术）。然而，患者的选择和手术时机仍存在争议，而且关于早期病程中可预测预后的临床体征的数据很少。对84例经计算机断层扫描确诊为大面积小脑梗死的患者（年龄22 - 78岁，平均58.5岁），采用标准化方案在入院后21天及3个月随访时进行前瞻性观察。数据于1992年至1996年在17个中心收集。根据主要护理人员的决定，将患者分为三个治疗组：34例行开颅清除术，14例行脑室造瘘术，36例接受药物治疗。治疗组在意识水平、计算机断层扫描显示的占位效应体征和脑干受累体征方面存在差异。预后不良的总体风险取决于临床病情恶化后的意识水平（优势比 = 2.8）。对清醒/嗜睡或昏睡/昏迷患者的亚组分析显示与治疗无关。受累的血管区域不影响预后。在清醒/嗜睡或昏睡/昏迷患者中，未发现大面积小脑梗死的手术治疗优于药物治疗。接受脑室引流或减压开颅术治疗的所有昏迷恶化患者中，有一半获得了有意义的恢复。由于缺乏对照组，我们无法在该亚组中比较手术治疗与药物治疗。本研究支持意识水平是预后最有力的预测指标这一观点，其优于任何其他临床体征和治疗分配。意识恶化通常发生在第2天至第4天之间，第3天达到高峰。
