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去骨瓣減壓造成繼發(fā)性腦損傷54例臨床分析
【關(guān)鍵詞】 ,顱內(nèi)血腫Clinical analysis of secondary brain damage of 54 cases after decompressive craniectomy
【Abstract】 AIM: To study the causes of secondary brain injury and how to treat the injury after decompressive craniectomy. METHODS: Two hundred and sixtyseven intracranial hematoma patients with frontaltemporal decompressive craniectomy, were divided into 3 groups according to the size of the bone window group Ⅰ, 5 cm×7 cm×~6 cm×11 cm (n=72); group Ⅱ, 7 cm×12 cm~11 cm×14 cm (n=103); group Ⅲ 12 cm×15 cm or larger. Language function and upper limb motor function opposite to the side of hematoma before and after operation were recorded and compared. RESULTS: Secondary brain damage happened in 54 of all the patients. 35.9% (37/103) patients with mediumsized bone window had secondary brain damage, while the incidence of secondary brain damage for patients with smaller or larger size of bone window was 10.3%(7/12) and 10.9%(10/92), respectively. No such damage was observed in those patients whose dura had been repaired. CONCLUSION: Attention should be paid to the brain damage after decompressive craniectomy. The patients with mediumsized bone window have a high incidence rate of secondary brain damage. Protecting the vein and bone flap above functional domain and repairing the dura are good solutions to prevent the secondary brain injury.
【Keywords】 intracranial hematoma;bone flap decompression; secondary brain injury
【摘要】 目的: 探討去骨瓣減壓術(shù)引起繼發(fā)性腦損害的原因和解決方法. 方法: 1994/2004收治的顱內(nèi)血腫行額顳部去骨瓣減壓患者267例,根據(jù)骨窗大小將所有患者分為3組,Ⅰ組5 cm×7 cm~6 cm×11 cm (n=72),Ⅱ組7 cm×12 cm~11 cm×14 cm (n=103),Ⅲ組12 cm×15 cm 以上(n=92),記錄術(shù)前、術(shù)后早期血腫對(duì)側(cè)上肢運(yùn)動(dòng)或語(yǔ)言功能與術(shù)后的比較. 結(jié)果: 發(fā)生繼發(fā)性腦損害54例. 中等大小骨窗的病例繼發(fā)性損害的發(fā)生率為35.9%(37/103),較小或較大的骨窗繼發(fā)性損害的發(fā)生率較低,分別為10.3%(7/72)和10.9%(10/92),修補(bǔ)硬膜者無(wú)繼發(fā)性損害. 結(jié)論: 繼發(fā)于去骨瓣減壓的腦損害應(yīng)引起注意,中等大小骨窗的病例較易發(fā)生. 保護(hù)靜脈,保護(hù)功能區(qū)上方的骨瓣和減張修補(bǔ)硬膜是預(yù)防繼發(fā)性腦損害發(fā)生的好方法.
【關(guān)鍵詞】 顱內(nèi)血腫;去骨瓣減壓術(shù);繼發(fā)性腦損害
0引言
去骨瓣減壓是神經(jīng)外科治療嚴(yán)重的顱腦損傷,增加顱腔容積,緩解顱內(nèi)壓增高的常用有效手段. 但由于血腫清除急性減壓后,腦組織缺血再灌注所致的腦腫脹,可造成腦組織由減壓窗呈蕈樣膨出,引起腦組織的嵌頓,導(dǎo)致局部腦組織的水腫加重[1],腦組織發(fā)生缺血壞死,由此而引起了由于去骨瓣減壓而造成的新的神經(jīng)功能損害. 這種功能損害的發(fā)生很容易籠統(tǒng)地歸結(jié)為顱腦外傷所致. 我科54例發(fā)生繼發(fā)于去骨瓣減壓造成的腦組織由骨窗部疝出而引發(fā)的神經(jīng)功能障礙如下.
1對(duì)象和方法
1.1對(duì)象
199409/200409顱腦損傷后行額顳部去骨瓣減壓267(男182,女85)例,年齡4~72(平均37.6)歲. 單純硬膜外血腫94例;硬膜下血腫及腦挫裂傷141例;硬膜外合并硬膜下血腫32例. 右側(cè)血腫176例,左側(cè)血腫91例. 手術(shù)采用“馬蹄形”或“倒問(wèn)號(hào)”切口,行額顳部的骨瓣或骨窗. 其中37例取自體顳肌筋膜行硬腦膜減張修補(bǔ)術(shù),其余病例均行放射狀剪開(kāi)硬膜,未予修補(bǔ).
1.2方法
本組病例均選擇的是行單側(cè)額顳部去骨瓣減壓并存活出院的病例. 入選病例來(lái)院時(shí)或術(shù)后早期血腫對(duì)側(cè)上肢有活動(dòng)或躁動(dòng)或刺激后有活動(dòng)的記錄. 術(shù)后4 d,患者骨窗對(duì)側(cè)上肢肌力下降,甚至為0級(jí),同時(shí)CT掃描提示有骨窗部腦膨出. CT排除皮層下有新的腦損傷. 若為優(yōu)勢(shì)半球側(cè)血腫,入院時(shí)及術(shù)后早期和后期同時(shí)觀察運(yùn)動(dòng)性語(yǔ)言的改變. 根據(jù)手術(shù)記錄中的骨窗大小,將所有病例分為3組;第1組骨窗大小范圍5 cm×7 cm~6 cm×11 cm,共72例(27%),右側(cè)42例,左側(cè)30例;第2組骨窗大小范圍7 cm×12 cm~11 cm×14 cm,共103例(38.6%),右側(cè)69例,左側(cè)34例;第3組病例骨窗大小范圍在12 cm×15 cm以上,共92例(34.5%),右側(cè)65例,左側(cè)27例. 修補(bǔ)硬膜37例,第1組4例,第2組19例,第3組14例.
統(tǒng)計(jì)學(xué)方法: 對(duì)1,2,3組應(yīng)用卡方檢驗(yàn)進(jìn)行顯著性區(qū)別,以α=0.05為檢驗(yàn)水準(zhǔn).
2結(jié)果
第1組病例中10.3%(7/72)出現(xiàn)術(shù)后逐漸加重的血腫對(duì)側(cè)上肢癱瘓,失語(yǔ)1例;第2組病例中35.9%(37/103)
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