Otani Naoki, Takasato Yoshio, Masaoka Hiroyuki, Hayakawa Takanori, Yoshino Yoshikazu, Yatsushige Hiroshi, Miyawaki Hiroki, Sumiyoshi Kyoko, Chikashi Aoyagi, Takeuchi Satoru, Suzuki Goh
Department of Neurosurgery, National Hospital Organization Disaster Medical Center, Tokyo, Japan.
Cerebrovasc Dis. 2008;26(6):612-7. doi: 10.1159/000165115. Epub 2008 Oct 23.
Patients with poor-grade aneurysmal subarachnoid hemorrhage (SAH) presenting with large intracerebral (ICH) or sylvian hematomas (SylH) have poor outcomes due to the mass effect of significant brain stem compression following mass effect. On the other hand, decompressive craniectomy (DC) can reduce morbidity and mortality in critically ill patients with massive ischemic infarction and severe head injury. However, the role of DC in SAH patients is not fully understood. We investigated the outcome of DC in poor-grade SAH presenting with large ICH or SylH.
110 consecutive patients with poor-grade SAH (Hunt & Kosnik (H&K) grades IV and V, and Fisher group 4) were admitted to our hospital between April 1, 1993, and July 30, 2004. We treated 57 of those who presented with large ICH or SylH using DC. We retrospectively reviewed medical charts, radiological findings, operative notes, and video records.
Among the 57 patients (mean age 57.8, male 29, female 28), 25 were classified as H&K grade IV and 32 as grade V. Ruptured aneurysms were located on the internal carotid artery in 11 and the middle cerebral artery in 46 patients. 50 of the aneurysms were small, 5 were medium, and 2 were large. Rerupture was preoperatively confirmed in 13 (22.8%). Hypothermia was applied to 17 (29.8%). The Glasgow Outcome Scale on discharge showed good recovery, moderate recovery, severe disability, vegetative state, and death in 8 (14.0%), 13 (22.8%), 16 (28.1%), 8 (14.0%), and 12 (21.1%), respectively. The outcomes of grade IV patients were favorable and poor in 14 (56.0%) and 10 (40.0%), respectively, and 1 (4.0%) died.
Several experimental studies have also indicated that DC significantly improves outcome due to reduced intracranial pressure or increased perfusion pressure. Urgent DC for poor-grade SAH with space-occupying hematoma can lead to survival with good recovery in some patients.
伴有大脑内血肿（ICH）或大脑外侧裂血肿（SylH）的低级别动脉瘤性蛛网膜下腔出血（SAH）患者，由于占位效应导致脑干显著受压，预后较差。另一方面，减压性颅骨切除术（DC）可降低大量缺血性梗死和重度颅脑损伤的危重症患者的发病率和死亡率。然而，DC在SAH患者中的作用尚未完全明确。我们研究了DC在伴有大型ICH或SylH的低级别SAH患者中的疗效。
1993年4月1日至2004年7月30日期间，110例连续的低级别SAH患者（Hunt & Kosnik（H&K）分级为IV级和V级，Fisher分级为4级）入住我院。我们对其中57例伴有大型ICH或SylH的患者采用DC进行治疗。我们回顾性分析了病历、影像学检查结果、手术记录和视频资料。
在这57例患者（平均年龄57.8岁，男性29例，女性28例）中，25例为H&K IV级，32例为V级。破裂动脉瘤位于颈内动脉的有11例，位于大脑中动脉的有46例。动脉瘤小的有50例，中等大小的有5例，大的有2例。术前证实再破裂的有13例（22.8%）。17例（29.8%）采用了低温治疗。出院时格拉斯哥预后量表显示恢复良好、中度恢复、重度残疾、植物状态和死亡的患者分别有8例（14.0%）、13例（22.8%）、16例（28.1%）、8例（14.0%）和12例（21.1%）。IV级患者的预后分别为良好和较差，各有14例（56.0%）和10例（40.0%），1例（4.0%）死亡。
多项实验研究也表明，DC可通过降低颅内压或增加灌注压显著改善预后。对于伴有占位性血肿的低级别SAH患者紧急施行DC，部分患者可实现良好恢复并存活。
