骨瓣开颅血肿清除术与去骨瓣减压术治疗急性硬膜下血肿临床疗效的Meta分析

Meta analysis of clinical efficacy of craniotomy and decompressive craniectomy for acute subdural hematoma

目的系统评价骨瓣开颅血肿清除术和去骨瓣减压术在治疗急性硬膜下血肿的有效性及安全性。方法计算机检索PubMed、EMbase、Cochrane Library、Web of science、中国知网(CNKI)、万方数据知识服务平台和中国生物医学文献数据库(CBM),搜集骨瓣开颅血肿清除术对比去骨瓣减压术治疗急性硬膜下血肿临床疗效的文献,检索时限均从建库至2018年6月12日。对于二分类变量采用优势比(OR)及其95%可信区间(95% CI)表示。由2名研究者独立筛选文献、提取资料并评价纳入研究的偏倚风险后,采用Stata/SE 12.0软件进行Meta分析。结果共纳入8项研究,828例患者实施骨瓣开颅血肿清除术,663例患者实施去骨瓣减压术。Meta分析结果显示:接受去骨瓣减压术的患者在首次出现症状时格拉斯哥昏迷评分(GCS)明显较低。去骨瓣减压术组术后硬膜下血肿残余率明显低于骨瓣开颅血肿清除术组(P=0.015),但再次手术率差异无统计学意义(P>0.05)。随访结果显示骨瓣开颅血肿清除术组预后不良的发生率低于去骨瓣减压术组(50.1% vs 60.1%;P=0.003)。同样,骨瓣开颅血肿清除术组的死亡率低于去骨瓣减压术组(P=0.002)。结论去骨瓣减压术可能是急性硬膜下血肿的首选方案,但该研究受多种因素影响,不足以提供确切的证据。

Objective To systematically evaluate the efficacy and safety of craniotomy and decompressive craniectomy in the treatment of acute subdural hematoma. Methods A systematic search was performed in PubMed, EMbase, the Cochrane Library, Web of science, China National Knowledge Infrastructure (CNKI), WanFang Data, and CBM databases up to June 2018 for the studies that provided comparisons between craniotomy hematoma evacuation and decompressive craniectomy for acute subdural hematoma. For the two categorical variables, the Odds Ratio (OR) and its 95% Confidence Interval (95% CI) are used. Two researchers independently screened the literature, extracted the data, and evaluated the risk of bias of the included studies. The meta analysis was performed using Stata/SE 12.0 software. Results A total of 8 studies were included in the meta analysis, of which 828 patients underwent craniotomy, and 663 patients underwent decompressive craniectomy. Meta analysis results showed that patients receiving decompressive craniectomy had a significantly lower Glasgow Coma Scale (GCS) when they first had symptoms. The residual rate of acute subdural hematoma in the decompressive craniectomy group was significantly lower than that in the craniotomy group (P=0.015), but there was no significant difference in the rate of reoperation. The incidence of poor outcome at following was lower in the craniotomy group compared with decompressive craniectomy group (50.1% vs 60.1%;P=0.003). Similarly, the mortality of the craniotomy group was lower than that of the decompressive craniectomy group (P=0.002). Conclusions Decompressive craniectomy may be the first choice for acute subdural hematoma, but the study is influenced by many factors and is not sufficient to provide definitive evidence.