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时间就是大脑!245例蛛网膜下腔出血减压性颅骨切除术病例分析。

Time Is Brain! Analysis of 245 Cases with Decompressive Craniectomy due to Subarachnoid Hemorrhage.

作者信息

Jabbarli Ramazan, Oppong Marvin Darkwah, Dammann Philipp, Wrede Karsten H, El Hindy Nicolai, Özkan Neriman, Müller Oliver, Forsting Michael, Sure Ulrich

机构信息

Department of Neurosurgery, University Hospital of Essen, Essen, Germany.

Department of Neurosurgery, University Hospital of Essen, Essen, Germany.

出版信息

World Neurosurg. 2017 Feb;98:689-694.e2. doi: 10.1016/j.wneu.2016.12.012. Epub 2016 Dec 18.

Abstract

OBJECTIVE

Decompressive craniectomy (DC) may become a life-saving measure for patients with subarachnoid hemorrhage (SAH). However, the benefit of early DC has not been shown yet. We aimed at identifying the clinical value of DC timing.

METHODS

We retrospectively analyzed 245 patients with SAH who underwent DC between January 2003 and December 2015. The cohort was stratified into primary (at admission, n = 171) and secondary DC (n = 74). In addition, primary DC was subdivided into early (≤24 hours after ictus, n = 120) and delayed (n = 51).

RESULTS

There was no difference between primary and secondary DC (65.5% and 74.3%, P = 0.1828) with regard to unfavorable outcome at 6 months after SAH (defined as modified Rankin scale >3). However, individuals with early primary DC presented with significantly better functional outcome than the remaining cohort (P = 0.014, odds ratio [OR] = 2.02) and even compared with the subgroup with delayed primary DC (P = 0.023, OR = 2.42). Among individuals with World Federation of Neurosurgical Societies Grade <5 at admission, the benefits of early DC were more impressive: lower rates of unfavorable outcome (P = 0.003, OR = 0.28), in-hospital mortality (P = 0.031, OR = 0.37), and cerebral infarctions (P = 0.028, OR = 0.38) on the follow-up computed tomography scans.

CONCLUSIONS

Not the timing of DC indication (primary/secondary), but rather the actual time left between the ictus and DC is crucial for the functional improvement of patients with SAH requiring DC. Especially, individuals without the signs of severe early brain injury strongly benefit from early DC.

摘要

目的

去骨瓣减压术(DC)可能成为蛛网膜下腔出血(SAH)患者的一种挽救生命的措施。然而,早期DC的益处尚未得到证实。我们旨在确定DC时机的临床价值。

方法

我们回顾性分析了2003年1月至2015年12月期间接受DC治疗的245例SAH患者。该队列被分为原发性(入院时,n = 171)和继发性DC(n = 74)。此外,原发性DC又细分为早期(发病后≤24小时,n = 120)和延迟性(n = 51)。

结果

SAH后6个月时,原发性和继发性DC的不良结局(定义为改良Rankin量表评分>3)无差异(分别为65.5%和74.3%,P = 0.1828)。然而,早期原发性DC患者的功能结局明显优于其余队列(P = 0.014,优势比[OR]=2.02),甚至与延迟原发性DC亚组相比也是如此(P = 0.023,OR = 2.42)。在入院时世界神经外科协会联合会分级<5级的患者中,早期DC的益处更为显著:随访计算机断层扫描显示不良结局发生率较低(P = 0.003,OR = 0.28)、院内死亡率较低(P = 0.031,OR = 0.37)以及脑梗死发生率较低(P = 0.028,OR = 0.38)。

结论

对于需要DC的SAH患者的功能改善而言,关键不是DC指征的时机(原发性/继发性),而是发病与DC之间的实际时间。特别是,没有严重早期脑损伤迹象的患者从早期DC中获益显著。

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