重型颅脑损伤脑疝139例治疗分析

The treatment of severe traumatic brain injury with herniation： a report of 139 cases

目的探讨重型颅脑损伤脑疝去骨瓣减压的手术指证及预后因素。方法收集2009年5月至2011年12月四川大学华西医院神经外科139例重型颅脑损伤脑疝患者的资料，对患者的伤情、手术治疗情况、术后颅内压（ICP）值和预后等进行回顾性分析。结果去骨瓣减压102例，保留骨瓣37例。其中GCS≤6分的106例中，有85例去骨瓣，占80．1％；双瞳孔散大有88％（35／40）去骨瓣，单瞳孔散大有68％（67／99）去骨瓣。伤后3个月GOS评定，死亡42例，植物生存31例，重残16例，中残8例，恢复良好42例，病死率为30．2％（42／139）。其中GCS3分病死率为63％（19／30）。双瞳孑L散大病死率为60％（24／40），单瞳孔散大病死率为18％（18／99）。术后ICP30～40mmHg病死率为74％（14／19），术后ICP〉40mmHg病死率为100％（8／8）。结论GCS≤6分、双瞳孔散大和术中脑膨出可作为去骨瓣减压的手术指证。GCS评分低、双瞳孔散大、ICP≥30mmHg等提示病死率高、预后不良。

Objective To present our experiences on the treatment of severe traumatic brain injury on patients with herniation and discuss the indication for decompressive craniectomy （DC） and prognostic factors. Methods From May 2009 to Dec. 2011, 139 patients aged between 3 and 83 years with severe traumatic cerebral herniation were included. The patients＇ Glasgow Coma Scale score （GCS）, pupil reaction, diagnosis, surgical treatment methods, and prognosis were analyzed retrospectively. Results 102 patients underwent DC and 37 patients underwent non -decompressive craniectomy. Amongst 106 patients with GCS〈~6, there were 85 patients undergoing DC （80. 1% ）. Thirty -five patients with bilateral pupil dilation underwent DC （88%, 35/40 ）, and 67 （68%, 67/99 ） patients with unilateral pupil dilation underwent DC（ P 〈0.05）. Based on the Glasgow Outcome Scale,42 patients were dead, 31 in vegetative state, 16 with severe disabilities, 8 with moderate disabilities, and 42 had good recovery at the 3 - month follow - up. Overall mortality was 30. 2%. As for patients with GCS = 3, the mortality was 63% （19/30）. Lower GCS was associated with worse outcomes. The mortality was 60% in 40 patients with bilateral pupil dilation and 18% in 99 patients with unilateral pupil dilation （ P 〈0. 05）. The mortality was 5% （2/37） in patients with epidural hematoma and 43% （26/61） with subdural hematoma （ P 〈 0. 05 ）. The mortality was 74% （14/19） when ICP 30 -40 mm Hg, and the mortality was 100% （8/8） when ICP 〉40 mm Hg. Conclusions Low GCS, bilateral pupil dilations, and ICP 〉I 30 mm Hg suggest higher mortality and unfavorable outcomes. GCS~〈6, bilateral pupil dilations, and intraoperative brain swelling can be viewed as indications for DC in severe traumatic brain injury patients with herniation. Smart surgical technique is helpful for the treatment of herniation.