Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Hills Road, Cambridge, CB2 0QQ, UK.
Acta Neurochir (Wien). 2012 Sep;154(9):1555-61. doi: 10.1007/s00701-012-1428-8. Epub 2012 Jun 30.
Acute subdural haematomas (ASDH) occur commonly following traumatic brain injury and may be evacuated by either craniotomy (CR) or decompressive craniectomy (DC). We reviewed a series of consecutive patients undergoing evacuation of a traumatic ASDH at a regional centre, comparing observed clinical outcomes (assessed by Glasgow Outcome Scale at six months) with those predicted by the CRASH-CT prognostic model.
Retrospective review of prospectively collected data.
Ninety-one patients were identified (51 DC and 40 CR ). Eighty-five had available admission data sets from which predicted outcome could be calculated. The DC group were younger than the CR group (p = 0.015). The DC group also had a greater proportion of patients whose pre-intubation GCS was ≤8 (p = 0.001), with significant extracranial injuries (p = 0.001) and obliterated basal cisterns (p = 0.001) on their pre-operative CT scan. Bone flaps in the DC group (n = 45) were longer (mean 11.6 cm; 95 % CI: 11.1-12.1) in comparison to bone flaps in the CR (n = 34) group [(mean 10.2 cm; 95 % CI: 9.35 - 10.9); p = 0.0024] The mean CRASH-CT predicted risk of 14-day mortality and of unfavourable outcome at six months was significantly higher in the DC group compared with the CR group. Eighty-eight patients had available 6-month Glasgow Outcome Scale scores. Favourable outcomes were observed in 42 % of DC versus 45 % of CR (p = 0.83). The overall mortality rate was 38 % in DC versus 32 % in CR (p = 0.65). The standardised morbidity ratio (observed/expected unfavourable outcomes) was 0.75 (95 % CI: 0.51-1.07) for DC and 0.90 (95 % CI: 0.57-1.35) for CR.
CR and DC for traumatic ASDH are both commonly used for primary evacuation of ASDH. Primary DC may be more effective than CR for selected patients with ASDH. Class I evidence is required in order to refine the indications for DC following evacuation of ASDH.
急性硬膜下血肿（ASDH）在颅脑外伤后很常见，可通过开颅术（CR）或减压性颅骨切除术（DC）清除。我们回顾了在一个区域中心对创伤性 ASDH 进行清除的一系列连续患者，比较了观察到的临床结果（通过 6 个月时的格拉斯哥预后量表评估）与 CRASH-CT 预后模型预测的结果。
回顾性分析前瞻性收集的数据。
确定了 91 例患者（51 例 DC 和 40 例 CR）。85 例有可用于计算预测结果的入院数据集。DC 组比 CR 组年轻（p=0.015）。DC 组中，在插管前 GCS 评分≤8 的患者比例更高（p=0.001），术前 CT 扫描显示有更多的颅外损伤（p=0.001）和基底池闭塞（p=0.001）。DC 组（n=45）的骨瓣比 CR 组（n=34）长（平均 11.6cm；95%CI：11.1-12.1）[（平均 10.2cm；95%CI：9.35-10.9）；p=0.0024]。在 DC 组中，CRASH-CT 预测的 14 天死亡率和 6 个月时不良结局的平均风险显著高于 CR 组。有 88 例患者有可用的 6 个月格拉斯哥结局量表评分。在 DC 组中，有 42%的患者结局良好，而 CR 组中为 45%（p=0.83）。DC 组的总死亡率为 38%，CR 组为 32%（p=0.65）。标准化发病率比（观察到的/预期的不良结局）为 DC 组 0.75（95%CI：0.51-1.07），CR 组 0.90（95%CI：0.57-1.35）。
CR 和 DC 均可用于创伤性 ASDH 的初次清除。对于特定的 ASDH 患者，原发性 DC 可能比 CR 更有效。需要 I 级证据来细化 ASDH 清除后的 DC 适应证。
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