Gaab M R, Rittierodt M, Lorenz M, Heissler H E
Neurosurgical Department, Hannover Medical School, Federal Republic of Germany.
Acta Neurochir Suppl (Wien). 1990;51:326-8. doi: 10.1007/978-3-7091-9115-6_110.
Since 1978, decompressive craniotomy was performed according to a standardized protocol. Exclusion criteria were age greater than or equal to 40 years, deleterious primary brain damage, operable space occupying lesions, larger infarctions in CT scan or irreversible brain stem incarceration/ischaemic damage as shown by bulbar syndrome, loss in BAEP or oscillating flow in TCD. Indication was given by progressive intracranial hypertension not controllable by conservative methods, if ICP decompensation was correlated with clinical (GCS, extension spasms, mydriasis) and electrophysiological (EEG, SEP, CCT) deteriorations. 18 patients were decompressed by unilateral. 19 by bilateral craniotomy with large fronto-parieto-temporal bone flap and a dura enlargement by use of temporal muscle/fascia. 37 patients at an age of 18 +/- 7 (4-34) years were operated 5 h-10 d after trauma. Recovery was surprisingly good: only 5 died, 2 due to an ARDS; 3 remained vegetative, all others achieved full social rehabilitation or remained moderately disabled. The best predictor of a favourable outcome was an initial posttraumatic GCS greater than or equal to 7. These in younger patients with delayed posttraumatic decompensation before irreversible ischaemic damage occurs.
自1978年以来，减压性开颅手术按照标准化方案进行。排除标准为年龄大于或等于40岁、原发性脑损伤严重、可手术切除的占位性病变、CT扫描显示较大梗死灶或出现延髓综合征、脑干听觉诱发电位消失或经颅多普勒显示血流振荡提示不可逆的脑干嵌顿/缺血性损伤。适应症为保守治疗无法控制的进行性颅内高压，且颅内压失代偿与临床（格拉斯哥昏迷评分、伸展性痉挛、瞳孔散大）和电生理（脑电图、体感诱发电位、皮层电图）恶化相关。18例患者接受单侧减压。19例接受双侧开颅手术，采用大型额颞顶骨瓣，并利用颞肌/筋膜扩大硬脑膜。37例年龄为18±7（4 - 34）岁的患者在受伤后5小时至10天接受手术。恢复情况出奇地好：仅5例死亡，其中2例死于急性呼吸窘迫综合征；3例仍处于植物人状态，其他所有患者均实现了完全的社会康复或仍有中度残疾。良好预后的最佳预测指标是伤后初始格拉斯哥昏迷评分大于或等于7分。这适用于在不可逆缺血性损伤发生前出现创伤后延迟减压的年轻患者。
