Flint Alexander C, Manley Geoffrey T, Gean Alisa D, Hemphill J Claude, Rosenthal Guy
Department of Neurology, Neurovascular and Neurocritical Care Service, University of California San Francisco, San Francisco General Hospital, San Francisco, California 94110, USA.
J Neurotrauma. 2008 May;25(5):503-12. doi: 10.1089/neu.2007.0442.
Decompressive hemicraniectomy is commonly performed in patients with traumatic brain injury (TBI) with diffuse brain swelling or refractory raised intracranial pressure. Expansion of hemorrhagic contusions in TBI patients is common, but its frequency following decompressive hemicraniectomy has not been well established. The aim of this retrospective study was to determine the rate of hemorrhagic contusion expansion following unilateral hemicraniectomy in severe TBI, to identify factors associated with contusion expansion, and to examine whether contusion expansion is associated with worsened clinical outcomes. Computed tomography (CT) scans of 40 consecutive patients with non-penetrating TBI who underwent decompressive hemicraniectomy were analyzed. Hemorrhagic contusion volumes were measured on initial, last pre-operative, and first post-operative CT scans. Mortality and 6-month Glasgow Outcome Scale (GOS) score were recorded. Hemorrhagic contusions of any size were present on the initial head CT scan in 48% of patients, but hemorrhagic contusions with a total volume of >5 cc were present in only 10%. New or expanded hemorrhagic contusions of >or=5 cc were observed after hemicraniectomy in 58% of patients. The mean volume of increased hemorrhage among these patients was 37.1+/-36.3 cc. The Rotterdam CT score on the initial head CT was strongly associated with the occurrence and the total volume of expanded hemorrhagic contusions following decompressive hemicraniectomy. Expanded hemorrhagic contusion volume greater than 20 cc after hemicraniectomy was strongly associated with mortality and poor 6-month GOS even after controlling for age and initial Glasgow Coma Scale (GCS) score. Expansion of hemorrhagic contusions is common after decompressive hemicraniectomy following severe TBI. The volume of hemorrhagic contusion expansion following hemicraniectomy is strongly associated with mortality and poor outcome. Severity of initial CT findings may predict the risk of contusion expansion following hemicraniectomy, thereby identifying a subgroup of patients who might benefit from therapies aimed at augmenting the coagulation system.
减压性颅骨切除术常用于治疗伴有弥漫性脑肿胀或难治性颅内压升高的创伤性脑损伤（TBI）患者。TBI患者出血性挫伤扩大很常见，但减压性颅骨切除术后其发生率尚未明确。本回顾性研究的目的是确定严重TBI患者单侧颅骨切除术后出血性挫伤扩大的发生率，识别与挫伤扩大相关的因素，并研究挫伤扩大是否与临床预后恶化相关。分析了40例接受减压性颅骨切除术的非穿透性TBI连续患者的计算机断层扫描（CT）图像。在首次、术前最后一次和术后首次CT扫描上测量出血性挫伤体积。记录死亡率和6个月格拉斯哥预后评分（GOS）。48%的患者首次头部CT扫描显示有任何大小的出血性挫伤，但仅10%的患者出血性挫伤总体积>5 cc。58%的患者在颅骨切除术后观察到新的或扩大的≥5 cc出血性挫伤。这些患者中出血增加的平均体积为37.1±36.3 cc。首次头部CT上的鹿特丹CT评分与减压性颅骨切除术后出血性挫伤扩大的发生和总体积密切相关。即使在控制年龄和初始格拉斯哥昏迷量表（GCS）评分后，颅骨切除术后出血性挫伤体积大于20 cc与死亡率和6个月GOS评分差密切相关。严重TBI后减压性颅骨切除术后出血性挫伤扩大很常见。颅骨切除术后出血性挫伤扩大的体积与死亡率和不良预后密切相关。初始CT检查结果的严重程度可能预测颅骨切除术后挫伤扩大的风险，从而识别出可能从旨在增强凝血系统的治疗中获益的患者亚组。
