Acute Brain Injury Research Laboratory, Department of Neurosurgery, Rambam Medical Center, Faculty of Medicine, The Technion-Israel Institute of Technology, Haifa, Israel.
Neurosurgery. 2010 Jul;67(1):65-72; discussion 72. doi: 10.1227/01.NEU.0000370604.30037.F5.
Decompressive craniectomy (DC) is a common practice for control of intracranial pressure (ICP) following traumatic brain injury (TBI), although the impact of this procedure on the fate of operated patients is still controversial.
Cerebral blood flow (CBF) and metabolic rates were monitored prospectively and daily as a surrogate of neuronal viability in 36 TBI patients treated by DC and compared with those of 86 nonoperated patients. DC was performed either on admission (n=29) or within 48 hours of admission (n=7).
DC successfully controlled ICP levels and maintained CBF within a normal range although the cerebral metabolic rate of oxygen (CMRO2) was significantly lower in this group. In 7 patients, pre- and postoperative recordings showed a significant ICP decrease that correlated with CBF augmentation but not with concurrent improvement of CMRO2 that remained particularly low. Logistic regression analysis of all investigated variables showed that DC was not associated with higher mortality despite more severe injuries in this group. However, operated patients were 7-fold more likely to have poor functional outcomes than nonoperated patients. Good functional outcome was strongly associated with higher CMRO2 but not with higher CBF values. CMRO2 levels were significantly lower in the DC group, even after adjustment for injury severity, and showed a progressive and sustained trend of deterioration significantly different from that of the non-DC group.
These results suggest that DC may enhance survival in the presence of severe brain swelling, although it is unlikely to represent an adequate answer to mitochondrial damage responsible for cellular energy crisis and edema.
去骨瓣减压术（DC）是颅脑创伤（TBI）后控制颅内压（ICP）的常用方法，但该手术对手术患者预后的影响仍存在争议。
前瞻性监测并每日监测 36 例 TBI 患者接受 DC 治疗的脑血流（CBF）和代谢率，将其与 86 例未手术患者进行比较。DC 在入院时（n=29）或入院后 48 小时内进行（n=7）。
DC 成功控制了 ICP 水平，并维持了 CBF 在正常范围内，尽管该组的脑氧代谢率（CMRO2）明显降低。在 7 例患者中，术前和术后记录显示 ICP 显著下降，与 CBF 增加相关，但与同时未改善的 CMRO2相关，CMRO2仍明显较低。对所有研究变量进行逻辑回归分析显示，尽管该组损伤更严重，但 DC 与死亡率升高无关。然而，与非手术患者相比，手术患者的功能结局较差的可能性高 7 倍。良好的功能结局与较高的 CMRO2显著相关，但与较高的 CBF 值无关。即使在调整损伤严重程度后，DC 组的 CMRO2 水平仍明显较低，且呈进行性和持续性恶化趋势，与非 DC 组明显不同。
这些结果表明，尽管 DC 可能会增强严重脑水肿患者的生存率，但它不太可能成为导致细胞能量危机和水肿的线粒体损伤的有效治疗方法。
