1Division of Neurosurgery, SBH Health System, Bronx, New York.
2Department of Neurosurgery, Ascension Providence Hospital, College of Human Medicine, Michigan State University, Southfield, Michigan.
J Neurosurg. 2023 Jul 28;140(2):544-551. doi: 10.3171/2023.5.JNS23163. Print 2024 Feb 1.
The predictors of survival and functional recovery following emergency decompressive surgery in patients with transtentorial brain herniation, particularly those with pupillary abnormalities, have not been established. In this study, the authors aimed to assess the outcome of patients with intracranial mass lesions, transtentorial brain herniation, and nonreactive mydriasis, following emergency surgical decompression.
A retrospective chart review was performed of all patients with transtentorial herniation and pupillary abnormalities who underwent craniotomy or craniectomy at two trauma and stroke centers between 2016 and 2022. The functional outcome was determined using the modified Rankin Scale (mRS).
Forty-three patients, 34 men and 9 women with a mean age of 47 years (range 16-92 years), were included. The underlying etiology was traumatic brain injury in 33 patients, hemorrhagic stroke in 8 patients, and tumor in 2 patients. The median preoperative Glasgow Coma Scale score was 3 (range 3-8), and the median midline shift was 9 mm (range 1-29 mm). Thirty-two patients (74.4%) had bilaterally fixed and dilated pupils. The median time to surgery (from pupillary changes) was 133 minutes (mean 169 minutes, range 30-900 minutes). Eighteen patients (41.9%) died postoperatively. After a median follow-up of 12 months (range 3-12 months), 11 patients (26.8%) had a favorable functional outcome, while 10 remained severely disabled (mRS score 5). On univariate analysis, younger age (p < 0.001), less midline shift (p = 0.049), and improved pupillary response after osmotic therapy (p < 0.01) or decompressive surgery (p < 0.001) were associated with favorable outcomes at 3 months.
With aggressive medical and surgical management, patients with transtentorial brain herniation, including those with bilaterally fixed and dilated pupils, may have considerable rates of survival and functional recovery. Young age, less midline shift, and improved pupillary response following osmotic therapy or decompressive surgery are favorable prognosticators.
对于因颅腔内容积过大导致脑疝、尤其是瞳孔异常的患者，目前尚未明确其接受紧急减压手术后的生存和功能恢复的预测因素。本研究旨在评估在 2016 年至 2022 年间，于 2 家创伤和卒中中心接受开颅或去骨瓣减压手术的颅内肿块病变、颅腔内容积过大导致脑疝和瞳孔固定散大患者的手术结局。采用改良 Rankin 量表（mRS）评估功能结局。
回顾性分析了 2016 年至 2022 年间，于 2 家创伤和卒中中心接受开颅或去骨瓣减压手术的因颅腔内容积过大导致脑疝且瞳孔异常的所有患者的病历。采用改良 Rankin 量表（mRS）评估功能结局。
共纳入 43 例患者，男 34 例，女 9 例，平均年龄为 47 岁（范围 16-92 岁）。病因包括创伤性脑损伤 33 例、出血性卒中 8 例和肿瘤 2 例。术前格拉斯哥昏迷量表评分中位数为 3 分（范围 3-8 分），中线移位中位数为 9mm（范围 1-29mm）。32 例（74.4%）患者双侧瞳孔固定散大。从瞳孔变化到手术的中位时间为 133 分钟（平均 169 分钟，范围 30-900 分钟）。术后 18 例（41.9%）患者死亡。中位随访 12 个月（范围 3-12 个月）后，11 例（26.8%）患者功能结局良好，10 例仍严重残疾（mRS 评分 5 分）。单因素分析显示，年龄较小（p<0.001）、中线移位较少（p=0.049）、渗透性治疗后（p<0.01）或减压手术后（p<0.001）瞳孔反应改善与 3 个月时的良好结局相关。
对于接受积极的内科和外科治疗的颅腔内容积过大导致脑疝患者，包括双侧瞳孔固定散大的患者，其生存和功能恢复的可能性较大。年龄较小、中线移位较少、渗透性治疗或减压手术后瞳孔反应改善是有利的预后预测因素。
