重型及特重型颅脑损伤手术治疗的若干问题

Surgical treatment strategies of the 410 cases of heavy/severe craniocerebral injury

目的分析格拉斯哥昏迷评分(GCS)为3～8分的重型及特重型颅脑损伤病人手术治疗经验和疗效,探讨提高其手术救治成功率的有效方法。方法对2002年1月～2009年12月收治的410例重型及特重型颅脑损伤患者临床及影像学资料、手术治疗经验进行回顾分析,比较常规去骨瓣减压手术与标准大骨瓣减压手术患者抢救成功率,手术中加用人工硬膜宽松无张力缝合与未加用人工硬膜手术术后脑膨出发生率。结果 410例中,恢复良好75例(18.3%),中度残疾93例(22.7%),重度残疾101例(24.6%),植物生存27例(6.6%);死亡114例(27.8%);抢救成功率为72.2%。采用标准大骨瓣减压手术组抢救成功率明显高于常规去骨瓣减压手术组(P﹤0.01),术中使用人工硬膜患者术后脑膨出发生率明显低于未加用人工硬膜手术组(P﹤0.01)。结论重型及特重型颅脑损伤的早期诊断及救治至关重要。根据具体病情及时制定手术策略,快速开颅手术,充分减压,改善脑缺血、低氧,减轻脑干损伤,可提高伤者抢救成功率;对于标准骨瓣减压在术中加用人工硬膜宽松无张力修补硬膜,可降低术后脑膨出发生率。

Objective To analyze the surgical treatment experience and curative effect of heavy/severe craniocerebral injury patients with GCS 3-8 and discuss the effective way of improving surgical treatment result.Methods Clinical data and CT images of the 410 cases of heavy/severe craniocerebral injury patients from Jan.2002 to Dec.2009 were retrospectively analyzed.The rescue achievement ratio was compared between the standard large-trauma decompression craniectomy group and conventional group.The cephalocele rate was also compared between the surgery group with artificial dura mater application and the conventional group without artificial dura mater application.Results In the 410 cases,the rescue achievement ratio was 72.2%,indicating good recovery in 75 cases（18.3%）,moderate disability in 93 cases（22.7%）,severe disability in 101 cases（24.6%）,vegetative status in 27 cases（6.6%）,death in 114 cases（27.8%）.The survival rate of the standard large-trauma decompression craniectomy group was significantly higher than conventional group（P〈0.01）.The cephalocele rates of surgery group with artificial dura mater application were significantly lower than the conventional group without artificial dura mater application（P〈0.01）.Conclusion The early diagnosis/remedy is very important for the management of heavy/severe craniocerebral injury.Surgical strategies should be quickly made according to the patients＇ condition.Performing prompt craniotomy and thorough decompression,improving cerebral ischemia/hypoxia and relieving brain stem injury can improve the survival rate and the prognosis.The application of artificial dura mater can reduce the rate of the postoperative cephalocele rate.