重型颅脑损伤去骨瓣减压手术前后颅内压对预后的影响

The influences of intracranial pressures on the outcomes of severe craniocerebral injury pre-and post decompressive craniectomy

目的探讨重型颅脑损伤(TBI)去骨瓣减压手术前、后颅内压(ICP)对患者预后的影响。方法回顾性分析2009年11月至2019年7月四川大学华西医院神经外科行去骨瓣减压术的96例重型TBI患者的临床资料,所有患者手术前、后均行ICP监测。术后6个月行格拉斯哥预后评级(GOS)评估,据此将患者分为预后良好组和预后不良组。比较两组患者临床资料的差异,采用多因素logistic回归模型分析手术前、后ICP对预后的影响。结果96例患者术前ICP中位数值为40.0(31.5~46.0)mm Hg(1 mm Hg=0.133 kPa),术后立即测得ICP的中位数值为19.0(14.5~25.5)mm Hg,差异有统计学意义(P<0.001)。术后6个月,96例患者中,预后不良组57例,预后良好组39例。与预后良好组比较,预后不良组中术前瞳孔散大、环池消失、格拉斯哥昏迷评分(GCS)3~6分者所占比率高,术前、术后ICP均高,差异均有统计学意义(均P<0.05)。多因素logistic回归分析显示,在调整了年龄、性别、GCS、环池受压、瞳孔等因素后,初始ICP每增加1mm Hg,患者不良预后的风险升高5%(OR=1.05,95%CI:1.01~1.09,P=0.014);术后ICP每增加1 mm Hg,患者不良预后的风险升高11%(OR=1.11,95%CI:1.03~1.19,P=0.004)。结论重型TBI患者去骨瓣减压术前、后ICP对患者的预后均有影响。

Objective To investigate the effects of intracranial pressures(ICP)pre-and post decompressive craniectomy on the outcomes of patients with severe craniocerebral injury(TBI).Methods A retrospective analysis was conducted on the clinical data of 96 patients with severe TBI who underwent decompressive craniectomy in the Department of Neurosurgery,West China Hospital of Sichuan University from November 2009 to July 2019.All patients underwent ICP monitoring before and after the operation.Glasgow outcome scale(GOS)was used for assessment at 6 months post operation,and the patients were divided into a good outcome group and a poor outcome group.We then compared the differences in clinical data between the two groups of patients,and used a multivariate logistic regression model to analyze the effects of ICPs before and after surgery on the outcomes.Results The initial ICP of 96 patients[M(range)]was 40.0(31.5-46.0)mm Hg(1mm Hg=0.133 kPa),the ICP measured,immediately after the operation was,19.0(14.5-25.5)mm Hg,and the difference was statistically significant(P<0.001).Among 96 patients and at 6 months post operation,57 cases were in the poor outcome group and 39 were in the good outcome group.Compared with the good outcome group,the poor outcome group had higher proportions of patients with dilated pupils,disappearance of the ambient cistern,and GCS score of 3-6.The preoperative and postoperative ICPs in poor outcome group were both higher than in good outcome group,and the differences were statistically significant(both P<0.05).Multivariate logistic regression analysis showed that after adjusting for age,gender,GCS,compression of the ambient cistern,pupil conditions,etc.,for every 1 mm Hg increase in initial ICP,the risk of poor prognosis increased by 5%(OR=1.05,95%CI:1.01-1.09,P=0.014);for every 1 mm Hg increase in postoperative ICP,the risk of poor outcome increased by 11%(OR=1.11,95%CI:1.03-1.19,P=0.004).Conclusion Both preoperative and postoperative ICPs have certain influences on the prognosis of patients with severe TBI undergoing decompressive craniectomy.