Honeybul S, Ho K M, Gillett G R
Department of Neurosurgery, Sir Charles Gairdner Hospital and Royal Perth Hospital, Western Australia, Australia.
Department of Intensive Care Medicine and School of Population Health, University of Western Australia, Australia.
J Crit Care. 2017 Jun;39:185-189. doi: 10.1016/j.jcrc.2017.03.006. Epub 2017 Mar 8.
There is little doubt that decompressive craniectomy can reduce mortality. However, there is concern that any reduction in mortality comes at an increase in the number of survivors with severe neurological disability.
Over the past decade there have been several randomised controlled trials comparing surgical decompression with standard medical therapy in the context of ischaemic stroke and severe traumatic brain injury. The results of each trial are evaluated.
There is now unequivocal evidence that a decompressive craniectomy reduces mortality in the context of "malignant" middle infarction and following severe traumatic brain injury. However, it has only been possible to demonstrate an improvement in outcome by categorizing a mRS of 4 and upper severe disability as favourable outcome. This is contentious and an alternative interpretation is that surgical decompression reduces mortality but exposes a patient to a greater risk of survival with severe disability.
It would appear unlikely that further randomised controlled trials will be possible given the significant reduction in mortality achieved by surgical decompression. It may be that observational cohort studies and outcome prediction models may provide data to determine those patients most likely to benefit from surgical decompression.
毫无疑问，减压性颅骨切除术可降低死亡率。然而，有人担心死亡率的任何降低都伴随着严重神经功能残疾幸存者数量的增加。
在过去十年中，有几项随机对照试验比较了在缺血性卒中和严重创伤性脑损伤情况下手术减压与标准药物治疗的效果。对每项试验的结果进行了评估。
现在有明确的证据表明，减压性颅骨切除术可降低“恶性”大脑中动脉梗死和严重创伤性脑损伤后的死亡率。然而，只有将改良Rankin量表（mRS）评分为4及以上的严重残疾归类为良好结局，才有可能证明结局有所改善。这是有争议的，另一种解释是手术减压降低了死亡率，但使患者面临更高的严重残疾存活风险。
鉴于手术减压已显著降低死亡率，似乎不太可能进行进一步的随机对照试验。观察性队列研究和结局预测模型可能会提供数据，以确定最有可能从手术减压中获益的患者。
