重型颅脑损伤病人去骨瓣减压术后早期行颅骨修补的疗效及脑血流动力学变化

Efficacy of early cranioplasty after decompressive craniectomy for patients with traumatic brain injury and cerebral hemodynamics changes

目的探讨重型颅脑损伤(STBI)病人去骨瓣减压术(DC)后早期行颅骨修补的疗效及对脑血流动力学的影响。方法DC术后STBI病人124例,随机分为两组。观察组59例,DC术后早期(1~3个月)行颅骨修补术,对照组65例,DC术后晚期(3~6个月)行颅骨修补术。比较两组术后并发症发生情况、美国国立卫生研究院卒中量表(NIHSS)评分、Barthel指数(BI)与格拉斯哥预后量表(GOS)评分,分别于术前及术后14天,测量大脑中动脉(MCA)平均血流速度(Vm)及大脑皮质、基底节区、丘脑区的局部脑血流量(CBF)、脑血容量(CBV)、到达峰值时间(TTP)、通过时间(MTT)。结果术后14天,观察组患侧与健侧MCA的Vm分别为(70.13±9.25)cm/s、(69.45±9.96)cm/s,对照组分别为(66.17±7.82)cm/s、(67.86±9.63)cm/s,两组均较术前显著升高,且观察组术后患侧MCA的Vm显著高于对照组(P<0.05)。术后14天,观察组大脑皮层、基底节区及丘脑的CBF改变值分别为(29.88±6.32)、(8.87±2.61)、(7.61±1.64)[ml/(100 g·min)],均高于对照组的(19.84±5.13)、(4.15±1.15)、(5.37±1.52)[ml/(100 g·min)](P<0.05);观察组大脑皮层、基底节区及丘脑的CBV改变值分别为(3.81±0.64)ml/100 g、(1.11±0.33)ml/100 g,均高于对照组的(1.62±0.52)ml/100 g、(0.47±0.15)ml/100 g(P<0.05);观察组大脑皮层及基底节区TTP值改变值分别为-(5.22±1.06)s、-(3.50±0.56)s,均高于对照组的-(2.78±0.85)s、(1.99±0.51)s(P<0.05),但两组间MTT改变值比较差异无统计学意义(P>0.05)。术后3个月,观察组的NIHSS评分为(3.73±0.56)分,显著低于对照组的(4.02±0.71)分,BI及GOS评分分别为(85.83±6.79)分、(4.05±0.45)分,显著高于对照组的(80.12±6.14)分、(3.72±0.41)分(P<0.05)。观察组的预后优良率为88.14%,显著高于对照组的75.38%(P<0.05)。观察组术后并发症发生率为8.47%,与对照组的10.77%比较差异无统计学意义(P>0.05)。结论STBI病人DC术后早期施行颅骨缺损修补术有利于改善脑血流动力学状态,促进神经功能的恢复并改善临床预后。

Objective To investigate the effect of early cranioplasty after decompressive craniectomy(DC)for patients with traumatic brain injury(STBI)and influence on cerebral hemodynamics.Methods 124 STBI patients after DC operation were collected and randomly divided into two groups:observation group(n=59)underwent early cranioplasty(1 to 3 months after DC operation),and control group(n=65)underwent late cranioplasty(3 to 6 months after DC operation).The postoperative complications,the National Institutes of Health Stroke Scale(NIHSS)score,Barthel Index(BI)and Glasgow Outcome Scale(GOS)score were compared between the two groups.The average blood flow velocity(Vm)of the middle cerebral artery(MCA),the regional cerebral blood flow(CBF),cerebral blood volume(CBV),time to peak(TTP),and mean transit time(MTT)in the cerebral cortex,basal ganglia and thalamus were measured before and 14 days after surgery.Results 14 days after the surgery,the Vm of MCA at injured side and uninjured side of the observation group was(70.13±9.25)cm/s and(69.45±9.96)cm/s,the control groups was(66.17±7.82)cm/s and(67.86±9.63)cm/s,both groups were significantly higher than before surgery,and the Vm at injured side of the observation group was significantly higher than that of the control group(P<0.05).At 14 days after surgery,the changes of CBF in the cerebral cortex,basal ganglia and thalamus in the observation group was(29.88±6.32),(8.87±2.61)and(7.61±1.64)[ml/(100 g·min)],both higher than(19.84±5.13),(4.15±1.15)and(5.37±1.52)[ml/(100 g·min)]in the control group(P<0.05);the changes of CBV in the cerebral cortex,basal ganglia and thalamus in the observation group were(3.81±0.64)ml/100 g and(1.11±0.33)ml/100 g,which were higher than(1.62±0.52)ml/100 g and(0.47±0.15)ml/100 g in the control group(P<0.05);the changes of TTP values in the cerebral cortex and basal ganglia of the observation group were-(5.22±1.06)s and-(3.50±0.56)s,which were higher than the control group[-(2.78±0.85)s and-(1.99±0.51)s](P<0.05),but the difference in MTT changes between the two groups was not significant(P>0.05).At 3 months after surgery,the NIHSS score of the observation group was(3.73±0.56)points,which was significantly lower than(4.02±0.71)points of the control group(P<0.05).The BI and GOS scores were(85.83±6.79)points and(4.05±0.45)points,respectively,which were significantly higher than(80.12±6.14)points and(3.72±0.41)points of the control group(P<0.05).The excellent rate of prognosis of the observation group was 88.14%,which was significantly higher than 75.38%of the control group(P<0.05).The postoperative complication rate of the observation group was 8.47%,there was no statistically significant difference compared with 10.77%of the control group(P>0.05).Conclusion Early cranioplasty after DC for STBI patients is beneficial to improve cerebral hemodynamics,promote the recovery of nerve function and improve clinical prognosis.