颅内压监测下阶梯减压技术在重型颅脑创伤治疗中的作用

Application of stepwise decompression technique under intracranial pressure monitoring in severe traumatic brain injury

目的探讨颅内压监测下阶梯减压技术在重型颅脑创伤(sTBI)治疗中的作用。方法回顾性分析2018年1月至2019年7月于内蒙古自治区人民医院神经外科接受手术治疗的47例sTBI患者的临床资料,格拉斯哥昏迷评分(GCS)为3~8分。其中21例采用颅内压监测下阶梯减压技术,26例采用常规大骨瓣减压技术。术后评估患者的GCS、手术时长、入住神经重症监护室(NICU)时长、颞肌厚度、甘露醇使用情况及术后3个月的格拉斯哥预后评级(GOS)。结果颅内压监测下阶梯减压组与常规大骨瓣减压组术后24 h GCS分别为(6.7±1.8)分、(5.6±1.5)分;术后24 h CT显示蝶鞍层面颞肌厚度分别为(1.19±0.33)cm、(1.43±0.41)cm,其与术前的差值分别为(0.12±0.07)cm、(0.38±0.14)cm;甘露醇应用时间分别为(4.7±1.4)d、(9.4±2.0)d,应用剂量分别为(500±137)ml/d、(1250±283)ml/d;入住NICU时间分别为(10.7±2.3)d、(17.9±2.0)d。两组上述指标比较差异均有统计学意义(均P<0.05)。手术时间分别为(120.0±12.3)min和(115.0±13.5)min,差异无统计学意义(P>0.05)。术后3个月GOSⅠ~Ⅲ级(预后不良)者分别占34.4%(7/21)、65.4%(17/26),Ⅳ~Ⅴ级(预后良好)者分别占65.6%(14/21)、34.6%(9/26),差异有统计学意义(P<0.05)。结论颅内压监测下阶梯减压技术在sTBI患者手术救治中,可更好地控制术中脑膨出、急性脑肿胀的发生,缓解颅内高压,缩短NICU入住时间,减少脱水剂用量和手术并发症,改善患者的预后。

Objective To investigate the effect of stepwise decompression technique under intracranial pressure monitoring in severe traumatic brain injury(sTBI).Methods The clinical data of 47 patients[GCS(Glasgow coma scale)score:3-8 points]with sTBI who underwent surgery at Department of Neurosurgery,Inner Mongolia People′s Hospital from January 2018 to July 2019 were retrospectively analyzed.Among those,the stepwise decompression technique was applied in 21 patients under intracranial pressure monitoring,and 26 patients underwent conventional large bone flap decompression.We evaluated the postoperative GCS score,operation duration,length of stay at neurological intensive care unit(NICU),temporal muscle thickness,usage of mannitol and GOS score at 3 months post surgery.Results The 24 h postoperative GCS scores were 6.7±1.8 points and 5.6±1.5 points in the group of stepwise decompression under intracranial pressure monitoring and the group of conventional large bone flap decompression,respectively.The 24 h postoperative CT showed that the temporal muscle thickness at the sella level was 1.19±0.33 cm and 1.43±0.41 cm in stepwise decompression group and conventional group respectively,and their differences from preoperative conditions were 0.12±0.07 cm and 0.38±0.14 cm,respectively.In stepwise decompression group and conventional group,the usage duration of mannitol was 4.7±1.4 d and 9.4±2.0 d,and the dosage was 500±137 ml/d and 1250±283 ml/d,respectively;the length of stay at NICU was 10.7±2.3 d and 17.9±2.0 d,respectively.Those inter-group differences as above were all significant(all P<0.05).The operation duration was 120.0±12.3 min and 115.0±13.5 min in stepwise decompression and conventional groups respectively,and there was no significant difference(P>0.05).At 3-month postoperative follow-up in stepwise decompression and conventional groups,the GOS(Glasgow outcome scale)gradeⅠ-Ⅲ(poor outcomes)accounted for 34.4%(7/21)and 65.4%(17/26)respectively,gradeⅣ-Ⅴ(good outcomes)accounted for 65.6%(14/21)and 34.6%(9/26)respectively,and both differences between the two groups were statistically significant(P<0.05).Conclusion In the surgical treatment of sTBI patients,stepwise decompression under intracranial pressure monitoring could help better control the occurrence of encephalocele and acute brain swelling during operation,relieve high intracranial pressure,shorten the length of stay at NICU,reduce the amount of dehydrate agent and complications,and improve the outcomes of patients.