Rosner M J, Rosner S D, Johnson A H
Department of Surgery, University of Alabama at Birmingham, USA.
J Neurosurg. 1995 Dec;83(6):949-62. doi: 10.3171/jns.1995.83.6.0949.
Early results using cerebral perfusion pressure (CPP) management techniques in persons with traumatic brain injury indicate that treatment directed at CPP is superior to traditional techniques focused on intracranial pressure (ICP) management. The authors have continued to refine management techniques directed at CPP maintenance. One hundred fifty-eight patients with Glasgow Coma Scale (GCS) scores of 7 or lower were managed using vascular volume expansion, cerebrospinal fluid drainage via ventriculostomy, systemic vasopressors (phenylephrine or norepinephrine), and mannitol to maintain a minimum CPP of at least 70 mm Hg. Detailed outcomes and follow-up data bases were maintained. Barbiturates, hyperventilation, and hypothermia were not used. Cerebral perfusion pressure averaged 83 +/- 14 mm Hg; ICP averaged 27 +/- 12 mm Hg; and mean systemic arterial blood pressure averaged 109 +/- 14 mm Hg. Cerebrospinal fluid drainage averaged 100 +/- 98 cc per day. Intake (6040 +/- 4150 cc per day) was carefully titrated to output (5460 +/- 4000 cc per day); mannitol averaged 188 +/- 247 g per day. Approximately 40% of these patients required vasopressor support. Patients requiring vasopressor support had lower GCS scores than those not requiring vasopressors (4.7 +/- 1.3 vs. 5.4 +/- 1.2, respectively). Patients with vasopressor support required larger amounts of mannitol, and their admission ICP was 28.7 +/- 20.7 versus 17.5 +/- 8.6 mm Hg for the nonvasopressor group. Although the death rate in the former group was higher, the outcome quality of the survivors was the same (Glasgow Outcome Scale scores 4.3 +/- 0.9 vs. 4.5 +/- 0.7). Surgical mass lesion patients had outcomes equal to those of the closed head-injury group. Mortality ranged from 52% of patients with a GCS score of 3 to 12% of those with a GCS score of 7; overall mortality was 29% across GCS categories. Favorable outcomes ranged from 35% of patients with a GCS score of 3 to 75% of those with a GCS score of 7. Only 2% of the patients in the series remained vegatative and if patients survived, the likelihood of their having a favorable recovery was approximately 80%. These results are significantly better than other reported series across GCS categories in comparisons of death rates, survival versus dead or vegetative, or favorable versus nonfavorable outcome classifications (Mantel-Haenszel chi 2, p < 0.001). Better management could have improved outcome in as many as 35% to 50% of the deaths.
在创伤性脑损伤患者中使用脑灌注压（CPP）管理技术的早期结果表明，针对CPP的治疗优于专注于颅内压（ICP）管理的传统技术。作者继续完善针对维持CPP的管理技术。对158例格拉斯哥昏迷量表（GCS）评分为7分及以下的患者，采用血管内容量扩充、通过脑室造瘘进行脑脊液引流、使用全身性血管升压药（去氧肾上腺素或去甲肾上腺素）以及甘露醇，以维持至少70 mmHg的最低CPP。维护了详细的结果和随访数据库。未使用巴比妥类药物、过度通气和低温治疗。脑灌注压平均为83±14 mmHg；颅内压平均为27±12 mmHg；平均全身动脉血压平均为109±14 mmHg。脑脊液引流平均每天100±98 cc。仔细调整入量（每天6040±4150 cc）以使其与出量（每天5460±4000 cc）相匹配；甘露醇平均每天188±247 g。这些患者中约40%需要血管升压药支持。需要血管升压药支持的患者GCS评分低于不需要血管升压药的患者（分别为4.7±1.3和5.4±1.2）。需要血管升压药支持的患者需要更多的甘露醇，并且他们入院时的颅内压为28.7±20.7 mmHg，而非血管升压药组为17.5±8.6 mmHg。尽管前一组的死亡率较高，但幸存者的预后质量相同（格拉斯哥预后量表评分为4.3±0.9对4.5±0.7）。手术治疗有占位性病变的患者的预后与闭合性颅脑损伤组相同。死亡率在GCS评分为3分的患者中为52%，在GCS评分为7分的患者中为12%；总体死亡率在各GCS类别中为29%。良好预后在GCS评分为3分的患者中为35%，在GCS评分为7分的患者中为75%。该系列中只有2%的患者仍处于植物状态，并且如果患者存活，其获得良好恢复的可能性约为80%。在死亡率、存活与死亡或植物状态、良好与不良预后分类的比较中，这些结果显著优于其他报告的各GCS类别系列（Mantel-Haenszel卡方检验，p<0.001）。更好的管理可能使多达35%至50%的死亡患者改善预后。
