脑池造瘘术治疗重型颅脑损伤的机制及应用进展

Advances in Mechanism and Application of Cisternostomy in Treatment of Severe Traumatic Brain Injury

重型颅脑损伤(severe traumatic brain injury,sTBI)是神经外科患者残疾和死亡的重要原因。去骨瓣减压术(decompressive craniectomy,DC)是公认的用于治疗sTBI的经典术式,但其远期疗效不令人满意。尼泊尔神经外科医师Iype Cherian结合颅底外科和显微神经外科技术创立了脑池造瘘术。本文主要阐述sTBI后继发性颅脑损伤(包括脑水肿)的发生机制及脑池造瘘术治疗sTBI的相关基础和临床研究,认为大脑类淋巴系统在脑脊液(cerebrospinal fluid,CSF)循环中起着重要作用。脑池造瘘术的核心机制为逆转脑脊液移位性脑水肿,引流脑组织受损时产生的多种神经毒性物质,从而很好地减轻脑水肿、控制ICP、改善临床预后。脑池造瘘术有望部分取代DC,但目前多为基础及小样本的临床研究,论证强度不足,未来还需要更多大样本、多中心的研究加以支持和论证。

Severe traumatic brain injury(sTBI)is an important cause of disability and death in neurosurgery patients.Decompressive craniectomy(DC)is recognized as a classic procedure for sTBI,but its long-term efficacy is not satisfactory.Iype cherian,a Nepalese neurosurgeon,has created cisternostomy by combining skull base surgery and microneurosurgery.This paper mainly describes the mechanism of post-sTBI craniocerebral injury(including cerebral edema),as well as the relevant basic and clinical studies of cisternostomy for sTBI.It is believed that glymphatic system plays an important role in cerebrospinal fluid(CSF)circulation.The core mechanism of cisternostomy is to reverse the brain edema caused by CSF displacement and to drain a variety of neurotoxic substances,so as to reduce brain edema,control ICP and improve clinical prognosis.Cisternostomy is expected to partially replace DC.However,at present most of clinical studies are based on small samples and the demonstration is insufficient.In the future,more large sample and multi-center studies are needed to support and demonstrate the application of cisternostomy in the treatment of sTBI.