择期颅脑外科手术全身麻醉期间进行性脑膨出的临床分析

Clinical Anaiysis of Progressive Cephalocele in Cerebral Surgery during General Anesthesia

目的:回顾性分折择期颅脑外科手术全身麻醉下发生进行性脑膨出的临床特点、原因及诊断,探讨其防治对策。方法:对2002～2008年期间择期颅脑外科手术全身麻醉下手术过程中8例并发进行性脑膨出的特征、诊断及诱因和所采取的处理措施进行回顾性分析。结果:3例头钉造成硬膜外或下血肿、2例同侧硬膜下纵深部血肿、1例对侧硬膜下血肿、1例巨大颅咽管瘤术中因损伤下视丘、1例体位不当+气道痰栓阻塞致CO_2蓄积;均表现为手术初期颅内压无异常,手术进程中异常进行性局灶性脑组织膨出,降低颅内压措施无效;生命体征相对稳定;6例术中、1例术毕经紧急CT确诊;8例病例中6例先紧急行血肿清除术,再行病灶切除,1例病灶清除后术毕再行血肿清除,同时适度低温、脑脱水等措施,6例术后苏醒(75.0%),2例术后严重脑损伤死亡(25.0%);术后疗效采用GOS标准,于治疗6个月评定结果,重残1例(12.5%)、中残1例(12.5%)、良好4例(50.0%)。结论:择期颅脑外科手术全身麻醉下发生进行性局灶性脑膨出应警惕安置头钉和硬膜下探查造成的硬膜下血肿;术中CT可明确诊断并有利于及时行血肿清除;积极预防、快速诊断和及时治疗有助于改善患者的预后,提高生存质量。

Objective：To retrospectively analyze acute progressive external brain herniation during elective craniotomy under general anesthesia, its clinical characteristics,etiology and diagnosis,management and prevention.Methods：To analyze case files of elective craniotomy performed under general anesthesia from 2002 to 2008,which resulted in intraoperative complication of the brain bulging out transcalvarially,though the craniotomy site.Data on the characteristics of the herniation,etiological causative factors,methods of management and prognosis were collected.Results：Out of the 8 230 patients undergoing elective craniotomy under general anesthesia between 2002 and 2008,8 of them developed external brain herniation intraoperatively.3 patients were found to have developed epidural hematomas due to the trauma induced by the pins of head holders （Sugita head holder）,2 others developed deeply located hematomas,ipsilaterally to the craniotomy sites, l patients had a hematoma,ipsilateral to the craniotomy site,1 patient during resection of a giant craniopharyngioma,sustained injury to hypothalamus and 1 patient developed external brain herniation due to inappropriate head position,ETT obstructed with secretion leading to hypercapnia. Among these 8 patients,preoperatively ICP was not unusually high.When the dura was open,there was no bulging of the brain and the latter was adequately relaxed.6 patients required emergent CT scan and 1 on the completion of the surgery.Out of these 8 patients,6 of them required emergent decompression craniotomy followed by the originally planned procedures.For 1 of the patients,hematoma drained was performed on completion of the management of the primary pathology, at the same time.Mild hypothermia was initiated and diuretics.6 patients were able to emerge for anesthesia after surgery and 2 passed away due to global brain injury （25%）.Using GOS standard, the surviving patients were evaluated 6 months after surgery, 1 patient was suffering for severe disability （12.5%）, 1 had moderate disability and the other 4 had good recoveries （50%）.Conclusion：We should be care of subdural hematoma caused by manipulate in cerebral surgery during general anesthesia.The check of CT during operation will help the diagnosis and will be benefit for the removing of hematoma promptly. Energetic prevention,rapid diagnosis and prompt treatment will make for Prognosis and improve the life quality.