Timofeev Ivan, Czosnyka Marek, Nortje Jurgens, Smielewski Peter, Kirkpatrick Peter, Gupta Arun, Hutchinson Peter
Academic Neurosurgery Unit, University of Cambridge/Addenbrooke's Hospital, Cambridge, United Kingdom.
J Neurosurg. 2008 Jan;108(1):66-73. doi: 10.3171/JNS/2008/108/01/0066.
Decompressive craniectomy is an advanced treatment option for intracranial pressure (ICP) control in patients with traumatic brain injury. The purpose of this study was to evaluate the effect of decompressive craniectomy on ICP and cerebrospinal compensation both within and beyond the first 24 hours of craniectomy.
This study was a retrospective analysis of the physiological parameters from 27 moderately to severely head-injured patients who underwent decompressive craniectomy for progressive brain edema. Of these, 17 patients had undergone prospective digital recording of ICP with estimation of ICP waveform-derived indices. The pressure-volume compensatory reserve (RAP) index and the cerebrovascular pressure reactivity index (PRx) were used to assess those parameters. The values of parameters prior to and during the 72 hours after decompressive craniectomy were included in the analysis.
Decompressive craniectomy led to a sustained reduction in median (interquartile range) ICP values (21.2 mm Hg [18.7; 24.2 mm Hg] preoperatively compared with 15.7 mm Hg [12.3; 19.2 mm Hg] postoperatively; p = 0.01). A similar improvement was observed in RAP. A significantly lower mean arterial pressure (MAP) was needed after decompressive craniectomy to maintain optimum cerebral perfusion pressure (CPP) levels, compared with the preoperative period (99.5 mm Hg [96.2; 102.9 mm Hg] compared with 94.2 mm Hg [87.9; 98.9 mm Hg], respectively; p = 0.017). Following decompressive craniectomy, the PRx had positive values in all patients, suggesting acquired derangement in pressure reactivity.
In this study, decompressive craniectomy led to a sustained reduction in ICP and improvement in cerebral compliance. Lower MAP levels after decompressive craniectomy are likely to indicate a reduced intensity of treatment. Derangement in cerebrovascular pressure reactivity requires further studies to evaluate its significance and influence on outcome.
去骨瓣减压术是控制创伤性脑损伤患者颅内压（ICP）的一种先进治疗选择。本研究的目的是评估去骨瓣减压术在开颅术后24小时内及之后对ICP和脑脊液代偿的影响。
本研究是对27例因进行性脑水肿而接受去骨瓣减压术的中度至重度颅脑损伤患者的生理参数进行的回顾性分析。其中，17例患者进行了ICP的前瞻性数字记录，并估计了ICP波形衍生指数。压力-容量代偿储备（RAP）指数和脑血管压力反应性指数（PRx）用于评估这些参数。分析包括去骨瓣减压术前及术后72小时内的参数值。
去骨瓣减压术导致ICP中位数（四分位间距）持续降低（术前为21.2 mmHg [18.7；24.2 mmHg]，术后为15.7 mmHg [12.3；19.2 mmHg]；p = 0.01）。RAP也有类似改善。与术前相比，去骨瓣减压术后维持最佳脑灌注压（CPP）水平所需的平均动脉压（MAP）显著降低（分别为99.5 mmHg [96.2；102.9 mmHg]和94.2 mmHg [87.9；98.9 mmHg]；p = 0.017）。去骨瓣减压术后，所有患者的PRx均为正值，提示压力反应性出现后天性紊乱。
在本研究中，去骨瓣减压术导致ICP持续降低，脑顺应性改善。去骨瓣减压术后较低的MAP水平可能表明治疗强度降低。脑血管压力反应性紊乱需要进一步研究以评估其意义及其对预后的影响。
