Liebenberg W Adriaan, Demetriades Andreas K, Hankins Matthew, Hardwidge Carl, Hartzenberg Bennie H
Department of Neurosurgery, Hurstwood Park Neurological Centre, West Sussex, England.
Neurosurgery. 2005 Aug;57(2):293-9; discussion 293-9. doi: 10.1227/01.neu.0000166662.77797.ec.
Several factors have led to our unique approach of delayed definitive débridement. We wanted to evaluate the effectiveness of our management and compare it with the existing data in the literature.
We retrospectively reviewed the records of 194 patients presenting between January 1996 and October 2003 with penetrating craniocerebral gunshot wounds. After exclusion criteria, 125 patients qualified.
Of the patients, 88.8% were male. The mean age was 24.9 +/- 10.9 years. In 70.4% of patients, the presenting Glasgow Coma Scale (GCS) score was 3 to 8. Only 38 (30.4%) of the 125 patients survived, with poor outcome in 2 and good outcome in 36. Bilaterally fixed and dilated pupils and bihemispheric tract on computed tomographic scan were significantly related to poor outcome. There were 49 surgical procedures performed on 27 of the patients, with a mortality rate of 7.4%. Of the 38 survivors, 13 underwent no surgery. Average time to surgery was 11.04 days. Total rate of infection was 8%, and it did not influence outcome. No patient presenting with a GCS score of 3 or 4 survived. Seventeen patients attended follow-up, for a total of 3609 days (average, 212 d) and very few late complications.
Our supportive care of patients is not optimal. We should have saved more of our patients who presented with GCS scores of 14 and 15 who subsequently died. We have been able to report unconventionally late surgical management of two-thirds of survivors, with no surgery in one-third of survivors. Despite a high rate of infectious complications, infection did not lead to death or disability. Our protocol rarely leads to patients surviving in a permanently vegetative state. In the future, we would perform early surgery for patients who present awake and continue our current management for poor-grade patients. In this way, we will improve the number of good outcomes without increasing the population of severely damaged and dependent survivors.
多种因素促使我们采用独特的延迟确定性清创方法。我们希望评估我们这种治疗方法的有效性，并将其与文献中的现有数据进行比较。
我们回顾性分析了1996年1月至2003年10月期间194例穿透性颅脑枪伤患者的病历。经过排除标准筛选后，有125例患者符合条件。
患者中88.8%为男性。平均年龄为24.9±10.9岁。70.4%的患者入院时格拉斯哥昏迷量表（GCS）评分为3至8分。125例患者中仅有38例（30.4%）存活，其中2例预后差，36例预后良好。双侧瞳孔固定散大以及计算机断层扫描显示双侧大脑半球受累与预后差显著相关。27例患者接受了49次外科手术，死亡率为7.4%。38例幸存者中，13例未接受手术。平均手术时间为11.04天。总感染率为8%，且感染并未影响预后。GCS评分为3或4分的患者无一存活。17例患者接受了随访，随访总时长为3609天（平均212天），晚期并发症极少。
我们对患者的支持治疗并不理想。我们本应挽救更多入院时GCS评分为14分和15分但随后死亡的患者。我们能够报告三分之二幸存者采用了非常规的延迟手术治疗，三分之一幸存者未接受手术。尽管感染并发症发生率较高，但感染并未导致死亡或残疾。我们的治疗方案很少导致患者处于永久性植物人状态存活。未来，对于清醒的患者我们将尽早进行手术，对于病情较差的患者继续采用我们目前的治疗方法。通过这种方式，我们将在不增加严重受损和依赖他人生存患者数量的情况下提高良好预后的数量。
