Rutigliano Daniel, Egnor Michael R, Priebe Cedric J, McCormack Jane E, Strong Nancy, Scriven Richard J, Lee Thomas K
Division of Pediatric Surgery, Department of Surgery, State University of New York, Stony Brook, NY 11794-8191, USA.
J Pediatr Surg. 2006 Jan;41(1):83-7; discussion 83-7. doi: 10.1016/j.jpedsurg.2005.10.010.
Care of pediatric traumatic brain injury (TBI) has placed emphasis on maximizing cerebral perfusion to prevent ischemia and reperfusion injury. A subset of patients with TBI will continue to have refractory intracranial pressure (ICP) elevation despite aggressive therapy including ventriculostomy, pentobarbital coma, hypertonic saline, and diuretics. Decompressive craniectomy (DC) is a controversial treatment of severe TBI. It is our hypothesis that DC can enhance survival and minimize secondary brain injury in this patient subset.
Patients younger than 20 years treated at a level I regional trauma center between November 2001 and November 2004, who met inclusion criteria for the Brain Trauma Foundation TBI-trac clinical database were included. All patients with a mechanism of injury consistent with TBI and Glasgow Coma Scale score of less than 9 for at least 6 hours after resuscitation and who did not die in the emergency department are entered into a clinical database. Patients who arrived at the study hospital more than 24 hours after injury are excluded.
There were 30 patients with TBI identified. The mean Glasgow Coma Scale score at presentation was 8 with a range of 3 to 13. Six patients underwent DC for intractable elevated ICP. Of 6 patient's postoperative ICP, 5 were less than 20 mm Hg. One patient required a return to the operating room where further débridement of brain was performed. All patients who received a DC survived and were discharged to a TBI rehabilitation facility.
Although this is a small sample, DC should be considered in patients with TBI with refractory elevated ICP. Long-term follow-up of this patient population should consist of neuropsychiatric evaluation in conjunction with measurement of social function.
小儿创伤性脑损伤（TBI）的治疗重点在于最大限度地增加脑灌注，以预防缺血和再灌注损伤。尽管采取了包括脑室造瘘术、戊巴比妥昏迷、高渗盐水和利尿剂在内的积极治疗措施，但仍有一部分TBI患者的颅内压（ICP）持续顽固性升高。减压性颅骨切除术（DC）是一种用于治疗重度TBI的存在争议的治疗方法。我们的假设是，DC可以提高这部分患者的生存率，并将继发性脑损伤降至最低。
纳入2001年11月至2004年11月期间在I级区域创伤中心接受治疗的20岁以下患者，这些患者符合脑创伤基金会TBI-trac临床数据库的纳入标准。所有损伤机制符合TBI且复苏后格拉斯哥昏迷量表评分至少6小时低于9分且未在急诊科死亡的患者均被录入临床数据库。受伤后超过24小时到达研究医院的患者被排除。
共确定30例TBI患者。入院时格拉斯哥昏迷量表评分的平均值为8分，范围为3至13分。6例患者因顽固性ICP升高接受了DC治疗。6例患者术后的ICP中，5例低于20 mmHg。1例患者需要返回手术室进行进一步的脑清创术。所有接受DC治疗的患者均存活并被转至TBI康复机构。
尽管这是一个小样本，但对于ICP顽固性升高的TBI患者应考虑DC治疗。对这一患者群体进行长期随访应包括神经精神评估以及社会功能测量。
