Manawadu Dulka, Quateen Ahmed, Findlay J Max
Division of Neurology, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada.
Can J Neurol Sci. 2008 Nov;35(5):544-50. doi: 10.1017/s031716710000932x.
Hemicraniectomy and opening underlying dura mater permits the expansion of infarcted, swollen brain outwards, reversing dangerous intracranial pressure elevations and the risk of fatal transtentorial temporal lobe or diencephalic herniation. Recently published randomized controlled trials have proven this procedure a powerful life-saving measure in the setting of malignant middle cerebral artery infarction and allayed concerns that a reduction in mortality is accompanied by an unacceptable increase in patients suffering severe neurological impairments. Appropriate patients are relatively young, in the first five decades of life, suffering infarction of a majority of the middle cerebral artery (MCA) territory in either hemisphere, and decompression should be performed prior to progression to coma or two dilated, fixed pupils. Lethargy combined with midline shift and uncal herniation on neuroimaging is an appropriate trigger to consider and discuss surgical intervention. Families and, when possible, patients themselves, should be informed of the certainty of at least moderate to mild permanent deficits, and the possibility of worse. To be successful decompression must be extensive, targeting a bone flap measuring 14 cm from front to back, and extending 1 to 2 cm lateral to the midline sagittal suture to the floor of the middle cranial fossa at the level of the coronal suture. An augmentation duraplasty is mandatory.
颅骨切除术并打开硬脑膜可使梗死、肿胀的脑组织向外扩张，扭转危险的颅内压升高以及致命的经天幕颞叶或间脑疝形成的风险。最近发表的随机对照试验已证明，在恶性大脑中动脉梗死的情况下，该手术是一项强有力的挽救生命的措施，并消除了人们对死亡率降低会伴随严重神经功能障碍患者不可接受的增加的担忧。合适的患者相对年轻，年龄在生命的前五十岁，一侧大脑半球的大脑中动脉（MCA）大部分区域发生梗死，减压应在进展为昏迷或双侧瞳孔散大、固定之前进行。嗜睡伴神经影像学上的中线移位和钩回疝是考虑和讨论手术干预的合适触发因素。应告知家属，如有可能，还应告知患者本人，至少会有中度至轻度永久性缺陷是确定的，且有更糟情况的可能性。要成功进行减压，范围必须广泛，目标骨瓣前后径为14厘米，从矢状中线向外侧延伸1至2厘米，至冠状缝水平的中颅窝底部。必须进行硬脑膜修补术。
