颅脑外伤去大骨瓣减压术后并发脑膨出、颅内血肿及脑梗死的临床分析

Clinical analysis of external cerebral herniation、expansion of hemorrhagic contusions and cerebral infarction after decompressive craniectomy in traumatic brain injury

目的探讨颅脑外伤去大骨瓣减压术后主要并发症:脑膨出、新发颅内血肿或/和脑挫裂伤病灶扩大及脑梗死三者的发生率及其预后情况。方法对48例颅脑外伤去大骨瓣减压术后患者进行回顾性探讨。提出了自己测量脑膨出的方法;统计术后脑膨出的发生率,不同时间段测量脑膨出程度,术后新发颅内血肿或/和脑挫裂伤病灶扩大以及脑梗死等的发生率、部位;并与患者术前GCS评分、伤后六个月GOS评分进行分析。结果颅脑外伤去大骨瓣减压术后,(1)脑膨出发生率为77%,手术后14d脑膨出程度最显著。(2)新发颅内血肿或/和脑挫裂伤病灶扩大发生率为58.3%;其部位可以在手术野内、手术同侧非手术区甚至在手术对侧。(3)脑梗死发生率12.5%,均在手术侧。(4)本组伤后六个月GOS评分:死亡率10.4%;预后不良率56.2%(含植物生存率16.7%;重度残废率39.5%);预后较好率33.4%(含中度残废16.7%;恢复良好16.7%)。结论颅脑外伤去大骨瓣减压术后,脑膨出、新发颅内血肿或/和脑挫裂伤病灶扩大、脑梗死等的发生率高,虽然去大骨瓣减压术可以降低死亡率但植物生存率、重度残废率高,手术要慎重。

Objective To explore the major complications and prognosis of patients with severe traumatic brain injury（sTBI） who underwent decompressive craniectomy（DC）.Methods 48 patients with sTBI after DC were analyzed retrospectively.We present a modified method of measuring external cerebral herniation.The incidence rate and thickness of external cerebral herniation at different post-operative time were measured.We also recorded the incidence rate and position of expansion of intracranial hematoma or/and brain contusion and cerebral infarction.In addition,preoperative GCS score and 6-month GOS score were involved in the analysis.Results External cerebral herniation secondary to decompressive craniectomy occurred in 37 of the 48（77%） patients with sTBI,,and the most significant degree appeared in the 14th day post-operation.58.3% patients suffered expansions of intracranial hematoma or/and brain contusion,which occurred in the operative area,the ipsilateral nonoperative area and even the contralateral area.The incidence rate of cerebral infarction was 12.5%,which were all found in operative side.According to the 6-month GOS scores,the mortality rate was 10.4%,and 56.2% patients had unfavorable outcomes（long-term coma or vegetative state 16.7%;severe disability 39.5%）,while the rate of favorable outcomes was 33.4%（moderate disability 16.7%;good recovery 16.7%）.Conclusions The patients with sTBI may get decreased mortality by decompressive craniectomy,but still have high incidence of vegetative state and severe disability.This suggests that this surgery should be carried out under careful consideration.