Yue John K, Rick Jonathan W, Deng Hansen, Feldman Michael J, Winkler Ethan A
Department of Neurological Surgery, University of California, San Francisco, CA, USA.
Department of Neurological Surgery, Vanderbilt University, Nashville, TN, USA.
J Neurosurg Sci. 2019 Aug;63(4):425-440. doi: 10.23736/S0390-5616.17.04133-9. Epub 2017 Nov 7.
Traumatic brain injury (TBI) is a common cause of permanent disability for which clinical management remains suboptimal. Elevated intracranial pressure (ICP) is a common sequela following TBI leading to death and permanent disability if not properly managed. While clinicians often employ stepwise acute care algorithms to reduce ICP, a number of patients will fail medical management and may be considered for surgical decompression. Decompressive craniectomy (DC) involves removing a component of the bony skull to allow cerebral tissue expansion in order to reduce ICP. However, the impact of DC, which is performed in the setting of neurological instability, ongoing secondary injury, and patient resuscitation, has been challenging to study and outcomes are not well understood. This review summarizes historical and recent studies to elucidate indications for DC and the nuances, risks and complications in its application. The pathophysiology driving ICP elevation, and the corresponding medical interventions for their temporization and treatment, are thoroughly described. The current state of DC - including appropriate injury classification, surgical techniques, concurrent medical therapies, mortality and functional outcomes - is presented. We also report on the recent updates from large randomized controlled trials in severe TBI (Decompressive Craniectomy [DECRA] and Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of ICP [RESCUEicp]), and recommendations for early DC to treat refractory ICP elevations in malignant middle cerebral artery syndrome. Limitations for DC, such as the equipoise between immediate reduction in ICP and clinically meaningful functional outcomes, are discussed in support of future investigations.
创伤性脑损伤（TBI）是导致永久性残疾的常见原因，其临床管理仍不尽人意。颅内压（ICP）升高是TBI后的常见后遗症，如果管理不当会导致死亡和永久性残疾。虽然临床医生通常采用逐步的急性护理算法来降低ICP，但仍有许多患者药物治疗无效，可能需要考虑手术减压。减压性颅骨切除术（DC）包括去除部分颅骨，以使脑组织扩张从而降低ICP。然而，在神经功能不稳定、持续继发性损伤和患者复苏的情况下进行的DC的影响一直难以研究，其结果也尚未得到充分了解。本综述总结了以往和近期的研究，以阐明DC的适应症及其应用中的细微差别、风险和并发症。详细描述了导致ICP升高的病理生理学以及相应的临时处理和治疗的医学干预措施。介绍了DC的现状，包括适当的损伤分类、手术技术、同期药物治疗、死亡率和功能结局，并报告了重度TBI大型随机对照试验（减压性颅骨切除术[DECRA]和颅内压无法控制升高的颅骨切除术随机评估[RESCUEicp]）的最新进展，以及早期DC治疗恶性大脑中动脉综合征难治性ICP升高的建议。讨论了DC的局限性，如ICP立即降低与具有临床意义的功能结局之间的平衡，以支持未来的研究。
