早期去骨瓣减压并颅内压监测治疗大面积脑梗死

Early Decompressive Craniectomy and Intracranial Pressure Monitoring and Treatment of Malignant Massive Cerebral Infarction

目的:本研究旨在评估早期去骨瓣减压术对大面积脑梗死早期及短期预后的影响。方法:选取2010年9月-2015年12月本院大面积脑梗死患者42例,根据是否同意手术分为三组,9例<12 h手术为A组,24例>12 h手术为B组,9例保守治疗为C组。采用美国国立卫生院脑卒中量表(NIHSS)及昏迷评分(GCS)评估神经功能,弥散加权磁共振(DWI)或CT用于界定脑梗死范围,在NICU统一治疗并行颅内压(ICP)监测,ICP持续超过30 mm Hg给予降颅压无效行梗死侧颞极切除。采用巴氏指数(BI)和预后评分(GOS)评估所有患者病后3个月神经功能。结果:脑梗死后12 h内颅脑CT诊断的准确率为44.4%,DWI的准确率为100%。入院后GCS均呈现下降趋势,A、B组术前GCS比较差异有统计学意义(P<0.05)。手术组早期及短期治疗效果均优于保守组,A组早期及短期评价指标亦大多优于B组,比较差异有统计学意义(P<0.05)。结论:去骨瓣减压术手术本身风险相对较低,容易实施并可确切降低大面积脑梗死的死亡率,尤其12 h内实施更能改善预后,术后连续ICP监测可及早发现恶性高颅压并及时实施颞极切除。

Objective： To assess the influence of short term prognosis of early decompressive craniectomy in patients with massive cerebral infarction.Method： From September 2010 to December 2015, 42 cases of massive cerebral infarction in our hospital were selected, they were divided into three groups, 9 cases of 〈12 h operation as group A, 24 cases of 〉12 h operation as B group, 9 cases with conservative treatment as group C.The national institutes of health stroke scale （ NIHSS ） and glasgow coma scale （ GCS ） were used to evaluate clinical neurologic function.Diffusion weighted imaging （ DWI ） and CT were used to evaluate the cerebral infarction territory. All patients were treated in NICU with intracranial pressure （ ICP ） monitoring.Anterior temporal lobectomy was performed when the ICP continued to exceed 30 mm Hg.The outcome was assessed using the Barthel Index （ BI ） and the GOS in aU patients after 3 months.Result： The accuracy rate of diagnosis by CT was 44.4% and the accuracy rate of DWI was 100% within 12 h after onset.Compared groupA and B of GCS scores before operation, the difference was statistically significant （ P〈0.05 ） .The early and short term outcome of the operation group were better than that of the conservative group.The early and short-term evaluation indexes of the group A were also better than those of group B, the difference was statistically significant （ P〈0.05 ） .Conclusion： In this trial, the risk of decompressive craniectomy is relatively low, it is easy to implement and can significantly reduce the mortality rate, especially within 12 h. Postoperative continuous ICP monitoring can detect malignant high ICP and timely implementation of temporal lobectomy.