Polin R S, Shaffrey M E, Bogaev C A, Tisdale N, Germanson T, Bocchicchio B, Jane J A
Department of Neurosurgery, University of Virginia Health Sciences Center, Charlottesville, USA.
Neurosurgery. 1997 Jul;41(1):84-92; discussion 92-4. doi: 10.1097/00006123-199707000-00018.
The management of malignant posttraumatic cerebral edema remains a frustrating endeavor for the neurosurgeon and the intensivist. Mortality and morbidity rates remain high despite refinements in medical and pharmacological means of controlling elevated intracranial pressure; therefore, a comparison of medical management versus decompressive craniectomy in the management of malignant posttraumatic cerebral edema was undertaken.
At the University of Virginia Health Sciences Center, 35 bifrontal decompressive craniectomies were performed on patients suffering from malignant posttraumatic cerebral edema. A control population was formed of patients whose data was accrued in the Traumatic Coma Data Bank. Patients who had undergone surgery were matched with one to four control patients based on sex, age, preoperative Glasgow Coma Scale scores, and maximum preoperative intracranial pressure (ICP).
The overall rate of good recovery and moderate disability for the patients who underwent craniectomies was 37% (13 of 35 patients), whereas the mortality rate was 23% (8 of 35 patients). Pediatric patients had a higher rate of favorable outcome (44%, 8 of 18 patients) than did adult patients. Postoperative ICP was lower than preoperative ICP in patients who underwent decompression (P = 0.0003). Postoperative ICP was lower in patients who underwent surgery than late measurements of ICP in the matched control population. A statistically significant increased rate of favorable outcomes was seen in the patients who underwent surgery compared to the matched control patients (15.4%) (P = 0.014). All patients who exhibited sustained ICP values above 40 torr and those who underwent surgery more than 48 hours after the time of injury did poorly. Evaluation of the 20 patients who did not fit into either of those categories revealed a 60% rate of favorable outcome and a statistical advantage over control patients (P = 0.0001).
Decompressive bifrontal craniectomy provides a statistical advantage over medical treatment of intractable posttraumatic cerebral hypertension and should be considered in the management of malignant posttraumatic cerebral swelling. If the operation can be accomplished before the ICP value exceeds 40 torr for a sustained period and within 48 hours of the time of injury, the potential to influence outcome is greatest.
对于神经外科医生和重症监护医生而言，创伤后恶性脑水肿的治疗仍然是一项令人沮丧的工作。尽管在控制颅内压升高的医学和药理学方法上有所改进，但死亡率和发病率仍然很高；因此，对创伤后恶性脑水肿治疗中药物治疗与减压性颅骨切除术进行了比较。
在弗吉尼亚大学健康科学中心，对患有创伤后恶性脑水肿的患者进行了35例双额减压性颅骨切除术。对照组由创伤昏迷数据库中积累数据的患者组成。接受手术的患者根据性别、年龄、术前格拉斯哥昏迷量表评分和术前最高颅内压（ICP）与1至4名对照患者进行匹配。
接受颅骨切除术的患者良好恢复和中度残疾的总体发生率为37%（35例患者中的13例），而死亡率为23%（35例患者中的8例）。儿科患者的良好结局发生率（44%，18例患者中的8例）高于成年患者。接受减压手术的患者术后ICP低于术前ICP（P = 0.0003）。接受手术的患者术后ICP低于匹配对照组中ICP的后期测量值。与匹配的对照患者相比，接受手术的患者中良好结局的发生率有统计学意义的增加（15.4%）（P = 0.014）。所有持续ICP值高于40托的患者以及受伤后48小时以上接受手术的患者预后较差。对不符合上述任何一类的20例患者进行评估，发现良好结局发生率为60%，且与对照患者相比有统计学优势（P = 0.0001）。
双额减压性颅骨切除术在治疗顽固性创伤后脑高压方面比药物治疗具有统计学优势，在创伤后恶性脑肿胀的治疗中应予以考虑。如果手术能在ICP值持续超过40托之前且在受伤后48小时内完成，对结局产生影响的可能性最大。
