Millar Kate, Eljamel Sam
Centre for Neurosciences, the University of Dundee, Dundee, Scotland, United Kingdom.
Centre for Neurosciences, the University of Dundee, Dundee, Scotland, United Kingdom; HTNMS, Edinburgh, Scotland, United Kingdom.
World Neurosurg. 2016 Nov;95:441-446. doi: 10.1016/j.wneu.2016.08.061. Epub 2016 Aug 25.
Therapeutic decompressive craniectomy (TDC) controls increased intracranial pressure (ICP). Its role was controversial until its successful introduction to treat malignant middle cerebral artery ischemia. However, standardization of size and site of TDC remains controversial. This study was designed to evaluate whether size and site matter in TDC.
A replica skull of a patient with refractory increased ICP and successful TDC was used. ICP was increased using an intracranial balloon modified to monitor ICP and permit progressive incremental increases in ICP. When a desired increased ICP was reached, segments of TDC were removed sequentially to increase its size until the ICP normalized. We also measured the volume of air required to raise the ICP back to the increased ICP value.
The most effective TDC size to lower increased ICP was 8.3 cm in diameter (P < 0.001). However, a 7.5-cm TDC was sufficient to control increased ICP of 25-30 mm Hg (P < 0.01). There was strong correlation between TDC size and potential volume created to accommodate brain swelling postoperatively (Pearson correlation coefficient = 0.95928). The location of TDC did not matter when size was ≤3.5 cm or ≥7.5 cm; location mattered when size was 4.5 cm or 5.5 cm, where anteriorly located flaps were more effective in lowering increased ICP and increasing cranial volume (P < 0.05).
The size of a TDC is very important in reducing increased ICP. The size should be tailored to the level of increased ICP and the likelihood of further brain swelling postoperatively. A smaller TDC should be located more anteriorly to control increased ICP. Although location is not as important when increased ICP is >30 mm Hg and TDC size ≥8.3 cm is required.
治疗性减压颅骨切除术（TDC）可控制颅内压（ICP）升高。在其成功用于治疗恶性大脑中动脉缺血之前，其作用一直存在争议。然而，TDC的大小和部位标准化仍存在争议。本研究旨在评估TDC中大小和部位是否重要。
使用一名难治性ICP升高且TDC成功的患者的颅骨复制品。通过改良的颅内球囊增加ICP，该球囊可监测ICP并允许ICP逐步递增。当达到所需的ICP升高值时，依次移除TDC的部分以增加其大小，直至ICP恢复正常。我们还测量了将ICP回升至升高值所需的空气体积。
降低升高的ICP最有效的TDC大小为直径8.3 cm（P < 0.001）。然而，7.5 cm的TDC足以控制25 - 30 mmHg的ICP升高（P < 0.01）。TDC大小与术后为容纳脑肿胀而产生的潜在体积之间存在强相关性（Pearson相关系数 = 0.95928）。当TDC大小≤3.5 cm或≥7.5 cm时，其位置无关紧要；当大小为4.5 cm或5.5 cm时，位置很重要，此时位于前方的皮瓣在降低升高的ICP和增加颅内容积方面更有效（P < 0.05）。
TDC的大小在降低升高的ICP方面非常重要。大小应根据ICP升高的程度和术后进一步脑肿胀的可能性进行调整。较小的TDC应更靠前放置以控制ICP升高。尽管当ICP升高>30 mmHg且需要TDC大小≥8.3 cm时，位置不那么重要。
