Vilcinis Rimantas, Bunevicius Adomas, Tamasauskas Arimantas
Department of Neurosurgery, Hospital of Lithuanian University of Health Sciences, Kaunas, Lithuania.
Department of Neurosurgery, Hospital of Lithuanian University of Health Sciences, Kaunas, Lithuania; Neuroscience Institute, Lithuanian University of Health Sciences, Kaunas, Lithuania.
World Neurosurg. 2017 May;101:335-342. doi: 10.1016/j.wneu.2017.02.010. Epub 2017 Feb 13.
We investigated the association of decompressive craniectomy (DC) and osteoplastic craniotomy (OC) with outcomes in consecutive patients undergoing surgical evacuation of acute subdural hematoma (ASDH) and analyzed prognostic indicators to determine optimal surgical management strategy for patients with ASDH.
We performed a prospective review of all adult patients with ASDH operated on by craniotomy from January 2009 to January 2016. Mortality and discharge outcomes (Glasgow Outcome Scale) were analyzed as a function of surgical method adjusting for age, admission Glasgow Coma Scale score, ASDH thickness and midline shift.
OC was performed in 394 (61%) patients, and DC was performed in 249 (39%) patients. Patients undergoing DC were younger, with lower Glasgow Coma Scale score, greater ASDH thickness, and greater midline shift (P < 0.001). Mortality rate (54% vs. 20%; P < 0.001) and proportion of patients with poor discharge outcomes (85% and 45%; P < 0.001) were greater in DC patients versus OC patients. Glasgow Outcome Scale score was lower and mortality rate was greater (P ≤ 0.048) in DC patients versus OC patients across all patient subgroups. Outcomes were similar between the 2 groups in patients with Glasgow Coma Scale score of 3 and midline shift of ≥2 cm. Adjusting for disease severity, DC remained associated with greater risk for in-hospital mortality (odds ratio = 3.442 [95% confidence interval 2.196-5.396], P < 0.001) and unfavorable discharge outcome (odds ratio = 5.277 [95% confidence interval 3.030-9.191], P < 0.001).
DC was performed more often in younger and more severely injured patients. DC is associated with greater mortality and handicap rates independent of disease severity. Clinical trials investigating optimal surgical management strategy of patients with ASDH are needed.
我们研究了去骨瓣减压术（DC）和骨成形性开颅术（OC）与接受急性硬膜下血肿（ASDH）手术清除的连续患者预后的相关性，并分析了预后指标以确定ASDH患者的最佳手术管理策略。
我们对2009年1月至2016年1月期间接受开颅手术的所有成年ASDH患者进行了前瞻性回顾。根据手术方法分析死亡率和出院结局（格拉斯哥预后量表），并对年龄、入院格拉斯哥昏迷量表评分、ASDH厚度和中线移位进行校正。
394例（61%）患者接受了OC，249例（39%）患者接受了DC。接受DC的患者更年轻，格拉斯哥昏迷量表评分更低，ASDH厚度更大，中线移位更明显（P<0.001）。DC患者的死亡率（54%对20%；P<0.001）和出院结局不良的患者比例（85%和45%；P<0.001）高于OC患者。在所有患者亚组中，DC患者的格拉斯哥预后量表评分更低，死亡率更高（P≤0.048）。格拉斯哥昏迷量表评分为3分且中线移位≥2 cm的患者中，两组结局相似。校正疾病严重程度后，DC仍然与更高的院内死亡率风险（优势比=3.442[95%置信区间2.196 - 5.396]，P<0.001）和不良出院结局（优势比=5.277[95%置信区间3.030 - 9.191]，P<0.001）相关。
DC在更年轻、损伤更严重的患者中实施更为频繁。DC与更高的死亡率和残疾率相关，与疾病严重程度无关。需要进行临床试验来研究ASDH患者的最佳手术管理策略。
