单纯硬膜外血肿合并脑疝继发大面积脑梗死的术前预警研究

Pre-operative risk evaluation on massive cerebral infarction secondary to acute hematoma and concurrent cerebral herniation

目的建立单纯急性硬膜外血肿合并脑疝继发大面积脑梗死（MCI）患者术前预警评估系统，为患者是否需要去骨瓣减压提供依据。方法选择自2006年1月至2012年1月厦门大学东南医院神经外科收治的单纯创伤性硬膜外血肿合并脑疝的手术患者纳入回顾性手术组，根据此部分患者资料，建立术前预警评分量表（EDH-MCI量表）；随后选择自2012年2月至2014年12月收治的同类患者（前瞻性手术组1前瞻性应用该量表进行术前预警研究，验证量表的临床应用价值。结果多因素回归分析提示颞部血肿（P=0．005）、术前休克（P=0．003）、血肿体积〉100mL（P=0．003）、瞳孔双侧散大（P=0．015）、术前脑疝时间〉90min（P=-0．001）及入院GCS评分≤5分（P=0．070）是单纯急性硬膜外血肿并脑疝患者术后继发MCI的独立危险因素。将这6项临床要素的偏回归系数标准化后作为量化分值制订出EDH—MCI量表（分值0～18分），将EDH-MCI评分分为低度危险区间（0～9分）、临界危险区间（10～12分）和高度危险区间（13～18分），对低度和高度危险病例分别采取还纳骨瓣和去除骨瓣的手术方案；对临界危险病例，如存在重度继发性脑干损伤或术前锥颅后散大瞳孔仍无回缩，采取一期去除骨瓣的手术方案。与回顾性手术组比较，前瞻性手术组的低度（100．00％vs．91．92％，P=0．046）、临界（77．78％vs．46．67％，P=-0．034）和高度危险病例（100．00％vs．68．18％，P=-0．023）一期手术决策的准确率均显著提升，差异有统计学意义（P〈0．005）。总体手术准确度从79．47％上升至95．88％，差异有统计学意义（P〈0．05）。结论本研究创建的术前预警评分系统可为单纯急性硬膜外血肿合并脑疝患者是否行去骨瓣减压提供可靠依据。

Objective To develop and validate a novel preoperative risk evaluating system for surgical decision on decompressive cranieetomy for patients with massive cerebral infarction （MCI） secondary to acute epidural hematoma （EDH） and concurrent cerebral herniation. Methods Clinical data of a retrospective patient cohort （from January 2006 to January 2012, n=151） were analyzed by multivariate Logistic regression analysis for the risk factors correlated with postoperative MCI so as to establish a preoperative risk scoring system, whose clinical accuracy of surgical decision-making were validated in another prospective patient cohort （from February 2012 to December 2014, n=97）. Results Incidences of secondary cerebral infarction were 19.2% （29/151） and 18.6% （18/97） in the retrospective and prospective patient cohorts, respectively. Regression analyses indicated that 6 clinical factors were identified to be independently correlated with postoperative MCI, including temporal hematoma （P=0.005）, preoperative hemorrhagic shock （P=-0.003）, hematoma volume greater than 100 mL （P=0.003）, bilateral mydriasis （P=0.015）, duration of cerebral herniation longer than 90 min （P=0.001）, and Glasgow Coma Scale （GCS） scores≤5 （P=0.070）. A novel preoperative risk scoring system was established by totting-up the standardized partial regression coefficients of each identified risk factor （EDH-MCI scale, with total scores of 0-18）. Results suggested that the incidence and mean volume of cerebral infarction increased along with risk scores in a stair-stepping manner. Therefore, three intervals were divided into low （0-9）, borderline （10-12）, and high risk intervals （13-18） according to the EDH-MCI scores. Clinical reliability of surgical decision-making guided by novel EDH-MCI scale was validated by a prospective clinical study. As compared with traditional empirical surgical strategy, EDH-MCI scale-guided prospective surgical strategy exhibited remarkable superiority that it significantly increased the accuracy of surgical decision （low risk interval, 100.00% vs. 91.92%, P=-0.046; borderline risk interval, 77.78% vs. 46.67%, P=0.034; high risk interval, 100.00% vs. 68.18%, P=0.023; overall accuracy, 95.88% vs. 79.47%, P=0.000）. Conclusion The established preoperative risk scoring system can make a precise judgment on the clinical risks of postoperative massive cerebral infarction secondary to cerebral herniation from isolated acute epidural hematoma and thereby provide a reliable reference on the surgical decision of decompressive craniectomy.