重型颅脑损伤患者阶梯式减压策略下行去骨瓣减压术的应用效果及术中急性脑膨出的影响因素分析

摘要 目的：观察阶梯式减压策略下行去骨瓣减压术在重型颅脑损伤中的临床应用效果,并分析患者术中急性脑膨出的影响因素。方法：回顾性分析2020年1月~2021年8月期间我院收治的103例重型颅脑损伤患者的临床资料。根据手术方式的不同分为A组（常规去骨瓣减压术,n=50）和B组（阶梯式减压策略下行去骨瓣减压术,n=53）,比较两组手术相关指标、并发症发生率以及患者预后情况。此外,根据开颅术中是否出现急性脑膨出将患者分为膨出组（n=41）和未膨出组（n=62）,采用多因素Logistic回归分析重型颅脑损伤患者术中急性脑膨出的影响因素。结果：B组的迟发性颅内血肿、急性脑膨出发生率低于A组,术中出血量少于A组,手术时间短于A组（P<0.05）。B组的预后良好率高于A组（P<0.05）。单因素分析结果显示：重型颅脑损伤患者术中急性脑膨出与年龄、受伤至手术时间、合并迟发性外伤性颅内血肿（DTIH）、合并对侧颅骨骨折、入院后首次格拉斯哥昏迷指数（GCS）评分、合并外伤性弥漫性脑肿胀（PADBS）、高血压病史、术前体温、术前颅内压、血小板计数（PLT）、凝血酶原时间（PT）有关（P<0.05）。多因素Logistic回归分析结果显示：合并对侧颅骨骨折、合并DTIH、合并PADBS、受伤至手术时间＜3 h、入院后首次GCS评分＜6分、术前颅内压偏高、术前体温偏高是重型脑损伤患者术中急性脑膨出的危险因素（P＜0.05）,而阶梯式减压策略下行去骨瓣减压术则是其保护因素（P＜0.05）。结论：采用阶梯式减压策略下行去骨瓣减压术治疗重型颅脑损伤,可减少术中出血量,缩短手术时间,降低并发症发生率,改善患者的预后。重型颅脑损伤患者术中是否发生急性脑膨出受到合并对侧颅骨骨折、合并DTIH、合并PADBS、受伤至手术时间、入院后首次GCS评分、术前体温、术前颅内压等因素影响。     

CT灌注成像技术用于重型颅脑损伤患者脑室型颅内压探头植入的临床价值评估

目的:探讨CT灌注成像技术用于重型颅脑损伤患者脑室型颅内压(Intracranial Pressure, ICP)探头植入的临床价值。方法:选取60例重型颅脑损伤患者,均行患侧开颅去骨瓣减压和颅内压监测探头置入术。其中,行普通型颅内压监测探头置入术28例,脑室型颅内压监测探头置入术32例。比较两组术后甘露醇应用剂量和应用时间,术后局部脑血流参数区域脑血流量(regional Cerebral Blood Flow, r CBF)、相对脑血容量(relative Cerebral Blood Volume, r CBV)、平均通过时间(Mean Transit Time, MTT)、对比剂达峰时间(time to peak, TTP)恢复情况。结果:脑室型颅内压监测组患者术后应用甘露醇的剂量和天数较普通颅内压监测组明显缩短(P0.05),术后3个月随访提示脑室型ICP监测组预后良好比例较普通型ICP组显著增加(P0.05)。并且螺旋CT灌注成像结果提示脑室型颅内压监测组患者术后局部脑血流参数r CBF、r CBV、MTT、TTP恢复情况明显优于普通型颅内压监测组(P0.05)。结论:重型颅脑损伤患者应用脑室型颅内监测探头改变了脱水剂在临床应用中的治疗模式,通过螺旋CT灌注成像检测患者损伤部位的r CBF、r CBV、MTT和TTP可评估脑损伤的程度以及预后,对重型颅脑损伤的临床治疗和改善患者预后具有重要意义。     

标准外伤大骨瓣开颅术与常规骨瓣开颅术治疗重型颅脑损伤的疗效对比

目的:探讨标准外伤大骨瓣开颅术与常规骨瓣开颅术治疗重型颅脑损伤的临床疗效。方法:收集我院2011年1月到2015年1月收治的重型颅脑损伤患者80例,按照随机数字表法分为观察组和对照组,每组40例,患者术前均给予常规护理,观察组给予标准外伤大骨瓣开颅术,对照组给予常规骨瓣开颅术,采用格拉斯哥预后评分(GOS)法评价两组术后12个月疗效,比较两组术前和术后7 d患者颅内压变化,记录两组患者并发症发生情况。结果:观察组疗效、良好率、存活率均显著高于对照组(P0.05)。治疗后7 d两组颅内压差异具有统计学意义(P0.05),并且两组术后7d与治疗前相比差异均具有统计学意义(P0.05)。观察组脑切口疝发生率为2.5%,明显低于对照组的20.0%,差异具有统计学意义(P0.05)。结论:标准外伤大骨瓣开颅术治疗效果优于常规骨瓣开颅术,具有一定安全性,值得临床推荐。     

标准去大骨瓣减压手术治疗老年重型颅脑损伤的疗效和安全性探究

目的探究标准去大骨瓣减压手术治疗老年重型颅脑损伤的疗效及安全性。方法选取2013年4月~2016年4月我院收治的老年重型颅脑损伤患者33例,按就诊的时间顺序分为观察组17例和对照组16例。观察组给予标准去大骨瓣减压手术治疗,对照组给予常规颞顶骨瓣开颅手术治疗,观察比较两组患者的治疗优良率,手术前、后颅内压以及并发症发生情况。结果观察组的治疗总有效率为70.59%,对照组为37.5%,组间差异具有统计学意义(P0.05)。手术前,两组患者的颅内压比较,差异无统计学意义(P0.05);手术后,两组患者的颅内压均较手术前有所改善,且观察组的改善幅度明显优于对照组(P0.05)。两组患者术后并发症发生率比较,观察组为11.76%,对照组为43.75%,组间比较差异有统计学意义(P0.05)。结论老年重型颅脑损伤治疗中,应用标准去大骨瓣减压手术治疗的临床疗效确切,并可降低颅内压和术后并发症发生率,值得临床应用和推广。     

颅脑外伤术中脑膨出的分型研究与综合治疗方法分析

目的:分析颅脑外伤术中发生急性脑膨出的分型及综合治疗方法。方法:选取我院2008年01月-2013年06月间收治的108例脑外伤术中发生急性脑膨出的患者作为研究对象,分析其症状类型和不同类型的临床特点,并采取相应的治疗措施,总结综合治疗方法。结果:对侧硬膜外血肿型GOS4~5分患者例数高于本文研究中其他类型患者,GOS4~5分的患者例数中对侧硬膜外血肿型与其他脑膨出患者对比,数据差异有统计学意义(P0.05)。从GOS1分患者,即死亡患者发生率以弥漫性脑肿胀型居高,弥漫性脑肿胀型死亡相较于其他型脑膨出患者对比差异显著,(P0.05),差异有统计学意义。结论:颅脑外伤术中发生急性脑膨出可以分为多种类型,若降低患者死亡率应建议保守治疗为宜。     

超早期三维钛网颅骨修补术的临床研究

目的:探讨重型颅脑损伤去骨瓣减压手术后颅骨缺损在超早期(4~6周内)行三维钛网颅骨修补的可行性和对患者长期预后的影响,探讨超早期颅骨修补术手术中是否较常规手术存在优势。方法:回顾性分析自2012年1月-2015年1月行颅脑损伤后颅骨缺损手术修补患者99例。将所有患者根据去骨瓣减压术后行颅骨修补的间隔时间分为两组,4-6周以内为超早期组,共52例,3-6个月为常规组,共47例。采用不同国际评分标准比较两组患者在颅骨修补术后1个月、3个月、12个月的生存质量;对比分析两组患者的术中头皮剥离时间及术中出血量;比较两组患者术后1个月、3个月、12个月相应并发症的差异。结果:超早期组患者术后1个月的格拉斯哥评分(Glasgow outcome scale,GOS)、美国国立卫生院神经功能缺损评分(NIHSS)和远期卡氏功能状态(Karnofsky performance status,KPS)评分较常规组比较无统计学意义(P0.05);超早期组患者术后3个月和12个月的GOS、NIHSS和KPS评分较常规组均有显著提高(P0.05)。超早期组患者头皮剥离时间较常规修补组明显缩短(P0.05),出血量明显减少(P0.05);两组颅骨修补术后硬膜下积液发生率明显降低,差异有统计学意义(P0.05),然而总体并发症发生率并无明显差异(P0.05)。结论:重度颅脑损伤去骨瓣减压术后患者在超早期(4~6周内)行颅骨修补在临床上是安全有效的,能够改善患者的预后和减少术后并发症的发生概率,并且能够减少术中出血,手术中头皮剥离时间也有缩短。     

早期高压氧联合去骨瓣减压治疗重型颅脑损伤的疗效及对患者神经功能、炎性因子的影响

摘要 目的：分析早期高压氧联合去骨瓣减压治疗重型颅脑损伤的疗效及对患者神经功能、炎性因子的影响。方法：选择我院自2018年1月至2021年10月接诊的106例重型颅脑损伤患者,随机分为对照组和观察组,各53例。两组均予以常规对症支持治疗,在此基础上,对照组采取去骨瓣减压治疗,观察组采取早期高压氧联合去骨瓣减压治疗。随访3个月,比较两组治疗前后的脑代谢指标、Fugl-Meyer运动功能评分、神经功能指标、炎性因子、严重并发症发生率及近期疗效。结果：观察组治疗后脑氧摄取率（CEO₂）、混合静脉血氧饱和度（SVO₂）均高于对照组（P＜0.05）;观察组治疗后上肢、下肢及总体Fugl-Meyer运动功能评分均高于对照组（P＜0.05）;观察组治疗后血清脑源性神经营养因子（BDNF）、神经元特异性烯醇化酶（NSE）、S100β蛋白、胶质纤维酸性蛋白（GFAP）水平均低于对照组,神经生长因子（NGF）水平高于对照组（P＜0.05）;观察组治疗后血清C反应蛋白（CRP）、白介素-1β（IL-1β）、肿瘤坏死因子-α（TNF-α）均低于对照组（P＜0.05）;观察组严重并发症发生率低于对照组,预后良好率高于对照组（P＜0.05）。结论：早期高压氧联合去骨瓣减压治疗重型颅脑损伤的疗效显著,能够有效优化患者神经功能,抑制炎症反应,促进肢体运动功能恢复,进而改善预后,值得临床予以重视。     

PICCO在重型颅脑损伤患者容量管理中的临床应用价值研究

目的:探讨脉搏指数连续心输出量(PICCO)技术在重型颅脑损伤患者液体管理中的临床应用价值。方法:回顾性分析重型颅脑损伤患者46例(男性27例,女性19例),以应用PICCO技术监测血流动力学指标指导液体管理的患者为治疗组(n=26),未应用PICCO技术指导液体管理的患者为对照组(n=20)。比较两组患者的日平均液体量、格拉斯哥昏迷评分(GCS)、急性生理与慢性健康评分(APACHE II)、肺水肿发生率、住院时间、住院总费用以及治疗6个月后的格拉斯哥预后评分(GOS)、生存率、颅脑损伤恢复良好率。结果:治疗期间,治疗组的GCS评分以及APACHEII评分均优于对照组,而治疗组的住院总费用高于对照组,但差异并无统计学意义(P0.05)。治疗组的日平均液体量、肺水肿发生率及住院时间均明显少于对照组,差异有统计学意义(P0.05)。治疗6个月后,治疗组患者的GOS评分、生存率和颅脑损伤恢复良好率均高于对照组,但差异亦无统计学意义(P0.05)。结论:应用PICCO技术监测血流动力学指标指导重型颅脑损伤患者的容量管理可在一定程度上缩短危重患者的住院时间并降低肺水肿的发生率,但并不能明显改善患者的预后。     

糖尿病患者重型颅脑外伤术后脑梗死发生的预防性治疗研究

目的:观察分析糖尿病患者重型颅脑外伤术后脑梗死发生情况.方法:重型颅脑外伤共112例,糖尿病患者31例,非糖尿病患者81例,糖尿病患者按术后血糖控制水平分为血糖控制良好组(＜16.0)和血糖控制不良组(＞16.0),分别为13例、18例;所有病人均采用常规去骨瓣开颅术清除血肿减压,术后早期行脱水治疗,糖尿病组患者给予胰岛素治疗,术后1天、3天、7天复查CT.结果:糖尿病组患者15例(48.4%)出现脑梗死,血糖控制良好组和血糖控制不良组分别为3例(23.1%)、12例(66.7%),非糖尿病组患者9例(13.2%)出现脑梗死.结论:通过术后早期控制血糖水平于合适状态(＜16.0),可有效降低糖尿病患者重型颅脑外伤术后脑梗死发生,明显改善患者预后.     

重型颅脑损伤后颅内高压的治疗研究进展

重型颅脑损伤后颅内压增高预示着不良的神经功能预后和极高的死亡率,一直是临床治疗中的研究热点,可采取高渗性脱水,亚低温疗法,巴比妥昏迷治疗及外科手术干预等治疗措施控制颅内压。由于亚低温治疗会增加患者发生肺炎的风险,巴比妥类药物副作用较大,现均已少用。近来研究发现,监测颅内压、脑灌注压、脑组织氧分压并指导临床治疗,可降低死亡率与改善预后。也有研究发现去骨瓣减压术治疗顽固性颅内高压与神经功能预后较差有关。目前关于颅内高压治疗的最佳方案仍存在争议,未来还需根据患者病情,为其制定规范化与个体化的治疗方案,预防继发性颅脑损伤,降低颅内压。本文就近年来重型颅脑损伤后颅内高压的治疗进展进行阐述。     

Therapeutic mechanism of intracranial infection in patients with hydrocephalus after craniocerebral injury based on decompressive craniectomy

The objective of this study is to analyze the treatment mechanism of decompressive craniectomy for intracranial infection in patients with hydrocephalus after craniocerebral injury, and to provide a treatment plan for intracranial infection in patients with hydrocephalus after craniocerebral injury. In this study, literature screening and data acquisition were carried out firstly based on the research content, and then heterogeneity analysis, Meta-analysis, sensitivity analysis, and publication bias analysis were performed using statistical methods for the unilateral and bilateral decompressive craniectomy. Heterogeneity analysis, Meta-analysis and sensitivity analysis of indiscriminate unilateral decompressive craniectomy was performed; heterogeneity analysis, Meta-analysis, cumulative Meta-analysis, and sensitivity analysis for bilateral decompressive craniectomy were performed. In this study, the order of influence on patients with hydrocephalus after brain injury was as follows: bilateral decompressive craniectomy > unilateral and bilateral decompressive decompression > indiscriminate unilateral decompressive. Intracranial infection in patients with hydrocephalus after the craniocerebral injury should be comprehensively evaluated before the surgery and given clinical treatment in time.     

Effect of Decompressive Craniectomy on Perihematomal Edema in Patients with Intracerebral Hemorrhage

Background

Perihematomal edema contributes to secondary brain injury in the course of intracerebral hemorrhage. The effect of decompressive surgery on perihematomal edema after intracerebral hemorrhage is unknown. This study analyzed the course of PHE in patients who were or were not treated with decompressive craniectomy.

Methods

More than 100 computed tomography images from our published cohort of 25 patients were evaluated retrospectively at two university hospitals in Switzerland. Computed tomography scans covered the time from admission until day 100. Eleven patients were treated by decompressive craniectomy and 14 were treated conservatively. Absolute edema and hematoma volumes were assessed using 3-dimensional volumetric measurements. Relative edema volumes were calculated based on maximal hematoma volume.

Results

Absolute perihematomal edema increased from 42.9 ml to 125.6 ml (192.8%) after 21 days in the decompressive craniectomy group, versus 50.4 ml to 67.2 ml (33.3%) in the control group (Δ at day 21 = 58.4 ml, p = 0.031). Peak edema developed on days 25 and 35 in patients with decompressive craniectomy and controls respectively, and it took about 60 days for the edema to decline to baseline in both groups. Eight patients (73%) in the decompressive craniectomy group and 6 patients (43%) in the control group had a good outcome (modified Rankin Scale score 0 to 4) at 6 months (P = 0.23).

Conclusions

Decompressive craniectomy is associated with a significant increase in perihematomal edema compared to patients who have been treated conservatively. Perihematomal edema itself lasts about 60 days if it is not treated, but decompressive craniectomy ameliorates the mass effect exerted by the intracerebral hemorrhage plus the perihematomal edema, as reflected by the reduced midline shift.     

A New Improved Method for Assessing Brain Deformation after Decompressive Craniectomy

Background

Decompressive craniectomy (DC) is a surgical intervention used following traumatic brain injury to prevent or alleviate raised intracranial pressure. However the clinical effectiveness of the intervention remains in doubt. The location of the craniectomy (unilateral or bifrontal) might be expected to change the brain deformation associated with the operation and hence the clinical outcome. As existing methods for assessing brain deformation have several limitations, we sought to develop and validate a new improved method.

Methods

Computed tomography (CT) scans were taken from 27 patients who underwent DC (17 bifrontal patients and 10 unilateral patients). Pre-operative and post-operative images were processed and registered to determine the change in brain position associated with the operation. The maximum deformation in the herniated brain, the change in volume and estimates of the craniectomy area were determined from the images. Statistical comparison was made using the Pearson’s correlation coefficient r and a Welch’s two-tailed T-test, with statistical significance reported at the 5% level.

Results

There was a reasonable correlation between the volume increase and the maximum brain displacement (r = 0.64), a low correlation between the volume increase and the craniectomy area (r = 0.30) and no correlation between the maximum displacement and the craniectomy area (r = −0.01). The maximum deformation was significantly lower (P  = 0.023) in the bifrontal patients (mean = 22.5 mm) compared with the unilateral patients (mean = 29.8 mm). Herniation volume was significantly lower (P = 0.023) in bifrontal (mean = 50.0 ml) than unilateral patients (mean = 107.3 ml). Craniectomy area was not significantly different for the two craniectomy locations (P = 0.29).

Conclusions

A method has been developed to quantify changes in brain deformation due to decompressive craniectomy from CT images and allow comparison between different craniectomy locations. Measured displacement is a reasonable way to characterise volume changes.     

Efficancy of decompressive craniectomy in treatment of severe brain injury at the Rijeka University Hospital Centre

Decompressive Craniectomy (DC) is a treatment option for severe brain injury (SBI). This method is applied when the growth of intracranial pressure (ICP) can no longer be controlled with conservative methods. DC belongs to class III "Guidelines"--"option" which has not clear clinical certainty. They do not correspond to "Standards" (class I) in treatment protocol for SBI, which is common in most neurotraumatological centers. We have analyzed retrospectively 95 patients with SBI who were admitted to the Clinical Hospital Centre Rijeka. All patients were managed based on a protocol of current Brain Trauma Foundations (BTF) Guidelines. 39 patients underwent DC while 34 patients underwent standard craniotomy. 22 patients did not undergo any surgical procedures. In each patient we analyzed ICP changes within the first 11 days and in that way we correlated them statistically with the initial Glasgow Coma Scale (GCS) and then with Glasgow Outcome Scale (GOS), after the end of the treatment. We particularly analyzed the outcome with reference to the time of the operation and the size of DC. The standard measurement of ICP shows statistical significance in recovery in the group without DC after 5 days of intensive treatment, when the pressure is stabilized between 20-25 mm Hg. The stabilization of ICP in the DC group is observed already after 3 days of intensive treatment. Furthermore, better functional recovery according to GOS, which is statistically significant, was observed in patients who underwent DC where the area of craniectomy was larger than 25 cm2, within the first 24 hours from the time of injury. The use of DC considerably reduces the need for CT check-ups. Increase in the number of encephalocele was noted, which is to be expected considering that dural decompression is used in DC procedure. The results of our study indicate that the utilization of DC is characterized with lower mortality and better functional recovery if it is applied at an early stage of treatment and if the size of DC is satisfactory.     

单侧与双侧穿刺入路PKP术对骨质疏松性胸腰椎压缩骨折患者手术效果、生活质量以及血清应激因子的影响

目的:探讨单侧与双侧穿刺入路经皮椎体后凸成形术(PKP)对骨质疏松性胸腰椎压缩骨折(OVCF)患者手术效果、生活质量以及血清应激因子的影响。方法:回顾性选取2016年7月～2019年7月期间我院接收的行PKP的OVCF患者83例。根据入路方式的不同分为A组(n=41,单侧穿刺入路)和B组(n=42,双侧穿刺入路),对比两组患者围术期指标、影像学指标、视觉模拟评分法(VAS)评分、Oswestry腰椎功能障碍指数(ODI)评分、健康调查生活质量量表(SF-36)评分、血清应激因子以及并发症发生情况。结果:A组手术时间短于B组,骨水泥用量、术中透视次数少于B组(P0.05)。两组术后6个月VAS评分、ODI评分降低,SF-36评分升高(P0.05)。两组术后3d去甲肾上腺素(NE)、肾上腺素(E)、皮质醇(Cor)均升高,但A组低于B组(P0.05)。两组术后6个月椎体前缘高度、后凸Cobb角均升高(P0.05)。两组并发症发生率比较差异无统计学意义(P0.05)。结论:单侧穿刺入路PKP可获得与双侧穿刺入路PKP相当的治疗效果和安全性,同时可缩短手术时间,减少骨水泥用量及术中透视次数,减轻机体应激反应。     

亚低温治疗对重型颅脑损伤患者颅内压、脑血流及氧代谢的影响

目的:探讨亚低温治疗对重症颅脑损伤(sTBI)患者颅内压(ICP)、脑血流及氧代谢的影响。方法:收集50例sTBI患者随机分为实验组和对照组,每组25例,均给予常规治疗,观察组在常规治疗基础上给予亚低温辅助治疗,检测患者治疗前、治疗第3、5、7天ICP动态变化以及治疗前和治疗7天后脑血流和氧代谢等指标变化。结果:治疗第3、5、7天ICP组间差异均具有统计学意义(P0.05),随着治疗时间增加两组ICP均逐渐降低,差异具有统计学意义(P0.05);治疗前Qmean、Vmean、Wv、DR等组间差异无统计学意义(P0.05),治疗7天后Qmean、Vmean均升高,Wv、DR均降低,差异具有统计学意义(P0.05);治疗前SjvO_2、CjvO_2、CaO_2、CERO_2组间差异无统计学意义(P0.05),治疗7天后SjvO_2、CjvO_2、CERO_2均升高,CaO_2降低,差异具有统计学意义(P0.05)。结论:亚低温治疗可以显著降低患者颅内压,改善脑血流和氧代谢水平。     

不同手术时机治疗颅内前循环动脉瘤破裂疗效及预后分析

目的:比较不同手术时机治疗颅内前循环动脉瘤破裂患者的疗效及对患者远期预后的影响。方法:回顾性分析我院2010年3月~2015年10月收治的120例颅内前循环动脉瘤破裂患者的临床资料,所有患者均接受显微手术夹闭治疗,按手术时机分为超早期组(24 h,n=43)、早期组(24-72 h,n=36)、延期组(≥10 d,n=41),比较各组术后颅内动脉栓塞改善程度,统计各组术中及术后并发症发生情况,采用格拉斯哥量表(GOC)评定患者术后恢复情况,采用改良Rankin(m RS)表评定患者远期预后。结果:超早期组完全栓塞率略高于早期组、延期组,但对比差异无统计学意义(P0.05);超早期组术中、术后各并发症发生率略低于早期组、延期组,但对比差异无统计学意义(P0.05);术后6、12、24个月,超早期组、延期组GOS评分高于早期组、m RS评分低于早期组,超早期组GOS评分高于延期组,m RS评分低于延期组(P0.05)。结论:不同手术时机治疗颅内前循环动脉瘤破裂手术效果无明显差异,但超早期、延期手术患者术后恢复及预后评分稍优于早期手术。