重型颅脑损伤术后大面积脑梗死临床分析

Clinical analysis of extensive cerebral infarction following surgery for severe bead injury

目的分析重型颅脑损伤开颅术后大面积脑梗死发生的相关因素及治疗效果。方法 选择东莞市石碣医院神经外科自2002年1月至2008年4月收治的重型颅脑损伤开颅术治疗的332例患者，其中术后出现大面积脑梗死20例，回顾性分析术衙出现或未出现大面积脑梗死这两类患者术前GCS评分，出血量，颅底骨折，瞳孔变化，是否有脑疝存在及持续时间情况，彩标准大骨瓣减压术治疗及常规综合治疗，并对其疗效进行评价。结果术前GCS评分〈5分，颅内出血量60mL以上及鼎底骨折合并脑疝持续时间长者大面积脑梗死发生率明显增加。本组20例患者随访12月，应用GOS评估预后，其中良好8例，中残3例，重残2例，植物生存3例，死亡4例。结论开颅术后出现大面积脑梗死是多种因素所致，术前GCS评分越低，颅内出血量大，颅底骨折合并脑疝持续时间长是其发生的重要原因。及时发现并行标准大骨瓣减压，脱水降颅内压，改善脑循环，预防脑血管痉挛，亚低温等治疗可有效降低其致残率和病死率，改善预后。

Objective To analyze the factors related to the occurrence of extensive cercbral infarction following surgeries for severe head injury and anlyze the clinical outcomes of the patients. Methods Twenty patients with extensive cerebral infarction following surgeries for severe head injury were retrospectively analyzed for preoperative Glasgow Coma Scale（GCS）scores, hemorrhage volume, skull base fracture, pupil size, presence and duration of cerebral hernia. All the patients were treated with standard large bone fap decompression and/or routine comprehensive treatments. Results Patients with preoperative GCS score less than5, intracranial hemorrhage over60 mL, and skull base factures complicated by prolonged cenebral hernia had significantly increased incidence of cerebral infarction. The 20 patients were followed up for 12 months and their clinical outcomes were evaluated with Glasgow Outcome Scale（GOS）,which showed good recovery in 8 cases moderate disability in 3cases, severe disability in 2 cases, and vegetative survival in 3 cases, Death occurred in 4cases. Conclusion Multiple factors may contribute to extensive cerebral infarction following surgery for severe head injury, among which low preoperative GCS score, massive intracranial hemorrhage, and prolonged skull base fracture with cerebral hernia are highly risk factors. Early detection of the infarction and timely management with decompression, dehydration, intracranial pressure control, promoting brain circulation, prevention of cerebral vasospasm. and mild hypothermia treatment may help lower the disability and mortality rtes of the patients.