重症对冲性颅脑损伤的手术方式选择与效果对比

Selection and efficacy comparison on different kinds of operations for severe contrecoup craniocerebral injury

目的探讨重症对冲性颅脑损伤的手术策略及方法。方法选择2008年3月一2013年4月沈阳军区总医院神经外科收治的重症对冲式颅脑损伤患者105例，随机分为A、B、C三组，A组（41例）首次手术采用单侧额颞部开颅血肿清除联合去骨瓣减压术，B组（31例）采用双侧额颞部开颅血肿清除联合单侧或双侧去骨瓣减压术，C组（33例）行着力部位硬膜外血肿清除术；根据各组患者血肿及挫伤的具体情况，决定对侧血肿清除的时机（即刻或稍后），比较三组患者术后1、3、7d对侧血肿厚度、Glasgow评分、中线位移程度的变化。结果①术后1、3d三组患者Glasgow评分差异无统计学意义（P〉0．05），但A、C两组Glasgow评分高于B组，差异有统计学意义（P〈0．05）；术后7d三组Glasgow评分差异有统计学意义（P〈0．05），其中A、C两组患者Glasgow评分[（10．07±0．89）、（10．39±1．00）分]高于B组[（8．86±0．72）分】，差异有统计学意义（P〈0．05）。②术后B组患者中线位移程度[（1．85±0．37）cm]及血肿厚度[（3．67±0．68）cm]最大，A组次之[（1．63±0．25）、（3．25±0．52）cm]，A、B两组患者中线位移程度及血肿厚度均显著高于C组[（O．78±0．19）、（1．04±0．29）cm]，差异有统计学意义（P〈0．05）。结论对冲性颅脑损伤患者原发部位硬膜外血肿的变化显著，对脑组织造成二次压迫，及早处理明显呈进展趋势的硬膜外血肿。可明显改善患者预后。

Objective To investigate the operation strategies and methods for severe contrecoup craniocerebral injury. Methods 105 admitted patients with severe craniocerebral injury from March 2008 to April 2013 were selected and randomly divided into group A, group B, group C; group A （n = 41） was treated with unilateral frontotemporal craniotomy hematoma removal combined with decompressive cranieetomy, group B （n= 31） was treated with bilateral frontal temporal craniotomy hematoma removal combined with unilateral or bilateral decompressive craniectomy; group C （n = 33） was treated with epidural hematoma removal focued on stress areas, then immediately all 3 groups were performed with contralateral hematoma removal. Glasgow score, displacement degree of midline and thickness of contralateral hematoma were noted and compared among 3 groups 1, 3, 7 days after the operation. Results （1）The difference of Glasgow score l, 3 days after the operation among 3 groups was not statistically significant （P 〉 0.05）, Glasgow score of group A, group C were higher than those of group B, the differences were statistically significant （P 〈 0.05）; Glasgow scores among 3 groups at 7 days after the operation were statisti- cally significant （P 〈 0.05）, Glasgow score of group A [（10.07±0.89） scores], group C [（10.39_＋1.00） scores] were higher than those of group B [（8.86±0.72） scores], the differences were statistically significant （P 〈 0.05）. （2）Midline shift degree and hematoma thickness of group B after the operation [（1.85±0.37）, （3.67±0.68） cm] was the maximum, midline shift degree and hematoma thickness of group A after the operation [（1.63±0.25）, （3.25_＋0.52） cm] were taken the second place, midline shift degree and hematoma thickness of group A and group B were higher than those of group C [（0.78±0.19）, （1.04±0.29） cm], the differences were statistically significant （P 〈 0.05）. Conclusion Primary epidural hematoma in patients with contrecoup eranio- cerebral injury changes significantly, causes the secondary oppression of brain tissue. To patients with early stage brain hernia or without complicated cerebral hernia, early treatment of epidural hematoma with apparent progression can significantly im- prove prognosis.