Pickard J D, Czosnyka M
Academic Neurosurgical Unit, Addenbrooke's Hospital, Cambridge, UK.
J Neurol Neurosurg Psychiatry. 1993 Aug;56(8):845-58. doi: 10.1136/jnnp.56.8.845.
This review has been written at an unfortunate time. Novel questions are being asked of the old therapies and there is an abundance of new strategies both to lower ICP and protect the brain against cerebral ischaemia. In the United Kingdom, the problem is to ensure that appropriate patients continue to be referred to centres where clinical trials of high quality can be undertaken. One of the success stories of the past decade has been the decline in the number of road accidents as a result of seat belt legislation, improvements in car design and the drink/driving laws. Hence, fortunately there are fewer patients with head injuries to treat and it is even more important that patients are appropriately referred if studies to assess efficacy of the new strategies are not to be thwarted. The nihilistic concept that intensive investigation with ICP monitoring for patients with diffuse head injury or brain swelling following evacuation of a haematoma or a contusion has no proven beneficial effect on outcome, requires revision. A cocktail of therapies may be required that can be created only when patients are monitored in sufficient detail to reveal the mechanisms underlying their individual ICP problem. Ethical problems may arise over how aggressively therapy for intracranial hypertension should be pursued and for how long. There has always been the concern that cranial decompression or prolonged barbiturate coma may preserve patients but with unacceptably severe disability. Some patients may be salvaged from herniating with massive cerebral infarction with the use of osmotherapy but is the outcome acceptable? Similar considerations apply to some children with metabolic encephalopathies. Where such considerations have been scrutinised in patients with severe head injury, the whole spectrum of outcomes appears to be shifted so that the number of severe disabilities and persistent vegetative states are not increased. However, it is important to be sensitive to such issues based on experience of the particular cause of raised intracranial pressure in a given age group.
这篇综述撰写于一个不幸的时期。人们对传统疗法提出了新问题，并且有大量降低颅内压和保护大脑免受脑缺血损伤的新策略。在英国，问题在于要确保合适的患者继续被转介至能够开展高质量临床试验的中心。过去十年的成功案例之一是，由于安全带立法、汽车设计改进以及酒驾法律的实施，道路交通事故数量有所下降。因此，幸运的是，需要治疗的头部受伤患者减少了，如果要评估新策略的疗效，那么患者得到恰当转介就显得更为重要。那种认为对弥漫性头部损伤或血肿或挫伤清除术后出现脑肿胀的患者进行颅内压监测的深入研究对预后没有已证实的有益效果的虚无观念，需要修正。可能需要一种综合疗法，而这只有在对患者进行足够详细的监测以揭示其个体颅内压问题背后的机制时才能制定出来。在如何积极地以及持续多长时间进行颅内高压治疗方面可能会出现伦理问题。一直存在这样的担忧，即颅骨减压或长时间巴比妥类药物昏迷可能挽救了患者，但却导致了严重到无法接受的残疾。使用渗透性疗法可能会使一些患者从大面积脑梗死导致的脑疝中获救，但这样的结果能被接受吗？类似的考虑也适用于一些患有代谢性脑病的儿童。在对重度颅脑损伤患者进行此类考量时，整个预后范围似乎发生了变化，以至于严重残疾和持续植物状态的数量并未增加。然而，根据特定年龄组颅内压升高的具体病因的经验，对这些问题保持敏感很重要。
