Guerra W K, Gaab M R, Dietz H, Mueller J U, Piek J, Fritsch M J
Department of Neurosurgery, Ernst Moritz Arndt University, Greifswald, Germany.
J Neurosurg. 1999 Feb;90(2):187-96. doi: 10.3171/jns.1999.90.2.0187.
Decompressive craniectomy has been performed since 1977 in patients with traumatic brain injury. The authors assess the efficacy of this treatment and the indications for its use.
The clinical status of the 57 patients, their computerized tomography (CT) scans, and intracranial pressure (ICP) levels were documented prospectively in a standard protocol. At the beginning of the study, all patients older than 30 years were excluded. As of 1989 patients older than 40 years were excluded until 1991; since that time patients older than 50 years have been excluded. Primary brain or brainstem injury with fully developed bulbar brain syndrome, loss of auditory evoked potentials (AEPs), and/or oscillation flow in a transcranial Doppler ultrasound examination were contraindications to decompressive craniectomy. A positive indication for decompression was given in the case of progressive therapy-resistant intracranial hypertension in correlation with clinical (Glasgow Coma Scale [GCS] score, decerebrate posturing, dilating of pupils) and electrophysiological (electroencephalography, somatosensory evoked potentials, and AEPs) parameters and with findings on CT scans. Unilateral decompressive craniectomy was performed in 31 patients and bilateral craniectomy in 26 patients. In all cases, a wide frontotemporoparietal craniectomy was followed by a dura enlargement covered with temporal muscle fascia. The outcomes of the treatment were surprisingly good. Only 11 patients (19%) died, three of whom died of acute respiratory disease syndrome. Five patients (9%) survived, but remained in a persistent vegetative state; six patients (11%) survived with a severe permanent neurological deficit, and 33 patients (58%) attained social rehabilitation. Two patients (3.5%) did not have a follow-up examination. The GCS score on the 1st day posttrauma and the mean ICP turned out to be the best predictors for a good prognosis. The results demonstrate the importance of decompressive craniectomy in the treatment of traumatic brain swelling.
Surgical decompression should be routinely performed when indicated before irreversible ischemic brain damage occurs.
自1977年以来，减压性颅骨切除术已应用于创伤性脑损伤患者。作者评估了这种治疗方法的疗效及其使用指征。
按照标准方案前瞻性记录57例患者的临床状况、计算机断层扫描（CT）结果及颅内压（ICP）水平。研究开始时，排除所有年龄大于30岁的患者。截至1989年，排除年龄大于40岁的患者，直至1991年；从那时起，排除年龄大于50岁的患者。原发性脑或脑干损伤伴完全发展的延髓脑综合征、听觉诱发电位（AEP）消失和/或经颅多普勒超声检查出现振荡血流是减压性颅骨切除术的禁忌证。当与临床（格拉斯哥昏迷量表[GCS]评分、去大脑强直姿势、瞳孔散大）和电生理（脑电图、体感诱发电位和AEP）参数以及CT扫描结果相关的进行性治疗抵抗性颅内高压时，给予减压的阳性指征。31例患者行单侧减压性颅骨切除术，26例患者行双侧颅骨切除术。在所有病例中，均行广泛的额颞顶颅骨切除术，随后用颞肌筋膜扩大硬脑膜。治疗结果出奇地好。仅11例患者（19%）死亡，其中3例死于急性呼吸窘迫综合征。5例患者（9%）存活，但仍处于持续性植物状态；6例患者（11%）存活但有严重的永久性神经功能缺损，33例患者（58%）实现社会康复。2例患者（3.5%）未进行随访检查。创伤后第1天的GCS评分和平均ICP结果是良好预后的最佳预测指标。结果表明减压性颅骨切除术在创伤性脑肿胀治疗中的重要性。
当有指征时，应在不可逆性缺血性脑损伤发生前常规进行手术减压。
