Whittle I R, Viswanathan R
Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK.
J Neurol Neurosurg Psychiatry. 1996 Dec;61(6):584-90. doi: 10.1136/jnnp.61.6.584.
To describe operative procedures, pathophysiological events, management strategies, and clinical outcomes after acute intraoperative brain herniation during elective neurosurgery.
Review of clinical diagnoses, operative events, postoperative CT findings, intracranial pressure, and arterial blood pressure changes and outcomes in a series of patients in whom elective neurosurgery had to be abandoned because of severe brain herniation.
Acute intraoperative brain herniation occurred in seven patients. In each patient subarachnoid or intraventricular haemorrhage preceded the brain herniation. The haemorrhage occurred after intraoperative aneurysm rupture either before arachnoidal dissection (three) or during clip placement (one); after resection of 70% of a recurrent hemispheric astroblastoma; after resection of a pineal tumour; and after a stereotactic biopsy of an AIDS lesion. In all patients the procedure was abandoned because of loss of access to the intracranial operating site, medical measures to control intracranial pressure undertaken (intravenous thiopentone), an intraventricular catheter or Camino intracranial pressure monitor inserted, and CT performed immediately after scalp closure. The patients were transferred to an intensive care unit for elective ventilation and multimodality physiological monitoring. Using this strategy all patients recovered from the acute ictus and no patient had intracranial pressure > 35 mm Hg. Although one patient with an aneurysm rebled and died three days later the other six patients did well considering the dramatic and apparently catastrophic nature of the open brain herniation.
There are fundamental differences in the pathophysiological mechanisms, neuroradiological findings, and outcomes between open brain herniation occurring in post-traumatic and elective neurosurgical patients. The surprisingly good outcomes in this series may have occurred because the intraoperative brain herniation was secondary to extra-axial subarachnoid or intraventricular haemorrhage rather than intraparenchymal haemorrhage or acute brain oedema. Expeditious abandonment of the procedure and closure of the cranium may also have contributed to the often very satisfactory clinical outcome.
描述择期神经外科手术中急性术中脑疝形成后的手术操作、病理生理事件、管理策略及临床结局。
回顾一系列因严重脑疝而不得不放弃择期神经外科手术的患者的临床诊断、手术事件、术后CT表现、颅内压、动脉血压变化及结局。
7例患者发生急性术中脑疝。每例患者在脑疝形成前均有蛛网膜下腔或脑室内出血。出血发生在术中动脉瘤破裂后，分别为蛛网膜下腔分离前（3例）或夹闭时（1例）；在切除复发性半球星形母细胞瘤的70%后；在切除松果体肿瘤后；以及在对艾滋病病变进行立体定向活检后。所有患者均因无法进入颅内手术部位而放弃手术，采取了控制颅内压的医疗措施（静脉注射硫喷妥钠），插入了脑室内导管或Camino颅内压监测仪，并在头皮缝合后立即进行了CT检查。患者被转入重症监护病房进行选择性通气和多模式生理监测。采用该策略，所有患者均从急性发作中恢复，且无一例患者颅内压>35 mmHg。尽管1例动脉瘤患者术后3天再次出血并死亡，但考虑到开放性脑疝的严重性和明显灾难性，其他6例患者情况良好。
创伤后和择期神经外科手术患者发生的开放性脑疝在病理生理机制、神经放射学表现和结局方面存在根本差异。本系列患者取得令人惊讶的良好结局可能是因为术中脑疝继发于轴外蛛网膜下腔或脑室内出血，而非脑实质内出血或急性脑水肿。迅速放弃手术和关闭颅骨也可能对通常非常满意的临床结局起到了作用。
