小脑幕裂孔切开联合大骨瓣减压治疗小脑幕切迹疝

Curative effect of opening the hiatus of tentorium cerebelli combined with decompressive craniectomy on the patients with transtentorial herniation induced by traumatic brain injury or hypertensive cerebral hemorrhage

目的研究小脑幕裂孔切开联合常规大骨瓣减压手术在小脑幕切迹疝病人中的临床疗效与实际应用价值。方法120例术前已发生小脑幕切迹疝的重型颅脑损伤及脑出血病人,按照患者入院顺序依次分为3组:标准大骨瓣减压组、内减压组和小脑幕裂孔切开组,每组40例,分别按照不同的手术原则进行手术。术后48h复查头颅CT,比较各组间的死亡率及脑干周围池改善率,对比各组间术后2周、4周GCS评分及术后24周GOS评分。结果术后小脑幕裂孔切开组死亡率显著低于标准大骨瓣减压组(P<0.05),但与内减压组比较无统计学显著性差异(P>0.05)。脑干周围池改善率,小脑幕裂孔切开组显著高于大骨瓣减压组及内减压组(P<0.01)。术后2周、4周GCS评分及术后24周GOS评分小脑幕裂孔切开组显著优于大骨瓣减压组及内减压组(P<0.01)。结论小脑幕裂孔切开联合常规大骨瓣减压术治疗小脑幕切迹疝疗效肯定,可以显著降低病人的死亡率和伤残率,改善其预后,值得临床推广。

Objective To investigate the curative effect of opening the hiatus of the tentorium cerebelli combined with decompressive craniectomy on the patients with transtentorial herniation due to traumatic brain injury （TBI） or hypertensive cerebral hemorrhage and its applied value.Methods One hundred and twenty patients with transtentorial herniation induced by TBI or hypertensive cerebral hemorrhage were half-randomly divided into 3 groups of 40 patients each,i.e.decompressive craniectomy group,decompressive craniectomy ＋ partial cerebral lobectomy group and decompressive craniectomy ＋ opening the hiatus of the tentorium cerebelli group.The improvement of narrow perimesencehalic cisterns was observed by CT 48 hours after the operation.GCS 2 and 4 weeks after the surgery and GOS 24 weeks after the surgery were compared among three groups.Results The mortality （12.5%,5/40） decompressive craniectomy ＋ opening the hiatus of the tentorim cerebelli group was significantly lower than that （32.5%,13/40） in decompressive craniectomy group （P〈0.05）.The improvement rate of the narrow perimesenceplalic cisterns was significantly higher in the decompressive craniectomy ＋ opening the hiatus of the tentorium cerebelli group than those in the other two groups （P〈0.01）.GCS 2 and 4 weeks after the operation and GOS 24 weeks after the operation in the decompressive craniectomy ＋ opening the hiatus of the tentorium cerebelli group were significantly higher than those in the other two groups （P〈0.01）.Conclusion The mortalily may be reduced and the prognosis may be improved by the decompressive craniectomy combined with opening the hiatus of the tentorium cerebelli in the patients with transtentorial herniation induced by TBI or hypertensive cerebral hemorrhage.