逐步硬膜减张法治疗重型创伤性脑损伤的疗效  

Efficacy of gradual dural decompression in treatment of severe traumatic brain injury

作　　者：张涛[1] 熊平[1] 李峥[1] 彭华[1] 赵龙[1] 印晓鸿[1] 段劼[1] 罗仁国[1] 唐晓平[1] Zhang Tao;Xiong Ping;Li Zheng;Peng Hua;Zhao Long;Yin Xiaohong;Duan Jie;Luo Renguo;Tang Xiaoping(Department of Neurosurgery,Affiliated Hospital of North Sichuan Medical College,Nanchong 637000,China)

机构地区：[1]川北医学院附属医院神经外科,南充637000

出　　处：《中华创伤杂志》2020年第6期526-530,共5页Chinese Journal of Trauma

摘　　要：目的探讨逐步硬膜减张法(GDD)治疗重型创伤性脑损伤(TBI)的临床效果。方法采用回顾性病例对照研究分析2015年1月—2018年10月川北医学院附属医院收治的78例重型TBI患者临床资料,其中男55例,女23例;年龄15~68岁,平均38.2岁。38例采用GDD治疗(GDD组):先在血肿较多区域开窗清除血肿,再逐步清除未开窗区域血肿,最后在覆盖硬脑膜补片后剪开硬膜"连接带"并快速关颅。40例采用快速敞开硬膜法(FOD)治疗(FOD组)。比较两组术中脑膨出率,术毕当时、24 h、72 h及7 d的颅内压,术后迟发性颅内血肿发生率及术后3个月格拉斯哥预后评分(GOS)。结果患者(除死亡26例外)均获随访3~14个月,平均8个月。GDD组术中均未出现脑膨出,FOD组术中出现脑膨出8例(P<0.05)。术毕当时、24 h、72 h及7 d,GDD组颅内压[(18.4±3.6)mmHg、(20.4±4.0)mmHg、(27.7±4.6)mmHg、(28.3±4.5)mmHg]与FOD组[(19.1±3.4)mmHg、(20.9±3.9)mmHg、(27.0±3.5)mmHg、(27.6±3.4)mmHg]比较差异均无统计学意义(P>0.05)。两组术后迟发性颅内血肿发生率比较[GDD组16%(6/38),FOD组(除术中脑膨出8例)16%(5/32)]差异无统计学意义(P>0.05)。两组术后3个月GOS评分比较,GDD组良好率[61%(23/28)]较FOD组[28%(11/40)]高,GDD组病死率[21%(8/38)]较FOD组[45%(18/40)]低(P<0.05);中重残及植物生存率两组差异无统计学意义(P>0.05)。结论对于重型TBI患者,相对于FOD,GDD治疗可更有效降低术中脑膨出发生率,对改善患者预后和降低病死率更有优势。Objective To explore the effect of gradual dural decompression(GDD)in preventing intraoperative encephalocele in severe traumatic brain injury(TBI).Methods A retrospective case-control study was conducted to analyze the clinical data of 78 patients with severe TBI admitted to Affiliated Hospital of North Sichuan Medical College from January 2015 to October 2018,including 55 males and 23 females,aged 15-68 years with an average age of 38.2 years.Thirty-eight patients were treated by GDD(GDD group).During the operation,the hematoma was cleared by opening a window in the area with more hematoma,then gradually cleared in the area without opening a window.Finally,the dural"junction"was cut and the skull was closed quickly after covering the dural patch.The other 40 patients were operated by fast open dural(FOD)operation(FOD group).The incidence of intraoperative encephalocele,intracranial pressure data at the time,24 hours,72 hours and 7 days after operation,incidence of delayed intracranial hematoma and glasgow outcome score(GOS)at 3 months after operation were compared between the two groups.Results All patients(except for 26 deaths)were followed up for 3-14 months,with an average of 8 months.None had intraoperative encephalocele in GDD group,compared to 8 patients in FOD group(P<0.05).Intracranial pressure in GDD group was respective(18.4±3.6)mmHg,(20.4±4.0)mmHg,(27.7±4.6)mmHg and(28.3±4.5)mmHg at the time,24 hours,72 hours and 7 days after operation,showing no significant differences compared to FOD group[(19.1±3.4)mmHg,(20.9±3.9)mmHg,(27.0±3.5)mmHg,(27.6±3.4)mmHg,respectively](P>0.05).There was no significant difference in the incidence of delayed intracranial hematoma between the two groups[16%(6/38)in GDD group and 16%(5/32)in FOD group(except 8 cases of intraoperative encephalocele)](P>0.05).Three months after operation,the good rate of GOS score of GDD group was 61%(23/28)higher than that of FOD group[28%(11/40)],and the mortality rate of GDD group was 21%(8/38)lower than that of FOD group[45%(18/40)]

关 键 词：颅脑损伤 脑膜膨出 硬膜 减张治疗 

分 类 号：R651.15[医药卫生—外科学]