Department of Neurosurgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania.
Neurosciences Institute, Lithuanian University of Health Sciences, Kaunas, Lithuania.
World Neurosurg. 2021 Jul;151:e753-e759. doi: 10.1016/j.wneu.2021.04.109. Epub 2021 May 1.
Epidural hematoma causing brain herniation is a major cause of mortality and morbidity after severe traumatic brain injury, even if surgical treatment is performed quickly. Decompression may be effective in decreasing intracranial pressure, but its effect on outcomes remains unclear.
A retrospective analysis of deeply comatose patients (Glasgow Coma Scale score 3-5) who underwent surgical treatment during a 12-year period, either via osteoplastic craniotomy (OC) or decompressive craniectomy, was carried out. Patient groups were compared on the basis of demographics, admission clinical state, head computed tomography imaging characteristics, and discharge outcome.
A total of 60 patients were examined. The first group of 31 patients (52%) needed decompression during primary surgery. The second group of 29 patients (48%) underwent OC with evacuation of epidural hematoma without decompression. Both patient groups were similar according to age (40.9 ± 13 vs. 40.6 ± 12.5 years), Glasgow Coma Scale score before surgery (4 [3-5] vs. 4 [3-5]), hematoma thickness (based on computed tomography) (3.44 ± 1 vs. 3.36 ± 1.62 cm), and midline shift (1.42 ± 0.83 vs. 1.36 ± 0.9 cm). Mortality was more evident in the decompression group (45.2% vs. 13.8%; P = 0.008), and the Glasgow Outcome Score was also lower, 2.26 ± 1.5 versus 3.45 ± 1.5 (P = 0.003).
Decompressive craniectomy following the evacuation of an acute epidural hematoma in deeply comatose patients demonstrated inferior outcomes in comparison with OC. Brain injury in the decompressive craniectomy patient group was more severe (concomitant subdural hematoma, early brain ischemia, and early brain herniation), which may have influenced the outcome. Further prospective studies are needed.
硬膜外血肿导致脑疝是严重颅脑损伤后死亡和致残的主要原因，即使迅速进行手术治疗也是如此。减压可能有效降低颅内压，但对结果的影响尚不清楚。
对 12 年间行手术治疗的深度昏迷患者（格拉斯哥昏迷量表评分为 3-5 分）进行回顾性分析，手术方式为骨瓣成形开颅术（OC）或去骨瓣减压术。根据患者的人口统计学、入院临床状态、头颅 CT 影像学特征和出院结局对患者进行分组比较。
共检查了 60 例患者。第一组 31 例（52%）患者在初次手术时需要减压。第二组 29 例（48%）患者行 OC 术清除硬膜外血肿但未减压。两组患者的年龄（40.9 ± 13 岁比 40.6 ± 12.5 岁）、手术前格拉斯哥昏迷量表评分（4 [3-5] 分比 4 [3-5] 分）、血肿厚度（基于 CT）（3.44 ± 1 厘米比 3.36 ± 1.62 厘米）和中线移位（1.42 ± 0.83 厘米比 1.36 ± 0.9 厘米）均相似。减压组死亡率更高（45.2%比 13.8%；P = 0.008），格拉斯哥预后评分也更低，分别为 2.26 ± 1.5 分和 3.45 ± 1.5 分（P = 0.003）。
在深度昏迷患者中，急性硬膜外血肿清除术后行去骨瓣减压术的预后较 OC 差。去骨瓣减压术患者组的脑损伤更严重（伴发硬膜下血肿、早期脑缺血和早期脑疝），这可能影响了结局。需要进一步的前瞻性研究。
