摘要：

目的 探讨预见性早期双侧去骨瓣减压术治疗重型颅脑创伤的有效性和安全性。方法 共计92 例重型颅脑创伤患者行预见性早期双侧去骨瓣减压术（观察组，42 例）以及常规一线治疗后患侧去骨瓣减压术或双侧去骨瓣减压术（对照组，50 例），监测手术前后颅内压，Glasgow 预后分级评价预后，记录术后并发症。结果观察组患者创伤至手术时间少于对照组［（4.63 ± 1.61）h 对（36.61 ± 1.92）h；t = 32.464，P = 0.001］。与术前相比，两组患者术后1 d 颅内压即降低（P = 0.001），至术后7d 颅内压持续降低（P = 0.001）；与对照组相比，观察组患者颅内压降低（P = 0.001）。92 例患者中预后良好37 例（40.22%），预后不良55 例（59.78%），观察组预后良好率高于对照组［54.76%（23/42）对28%（14/50）；χ² = 5.697，P = 0.017］，且两组< 41 岁患者预后良好率高于≥ 41 岁患者（χ² = 5.526，P = 0.025）。92 例患者中31 例（33.70%）出现术后并发症，包括硬膜下积液11 例（11.96%）、颅内出血4 例（4.35%）、脑积水3 例（3.26%）、感染4 例（4.35%）、癫痫2 例（2.17%）和器官功能障碍7 例（7.61%），观察组术后并发症发生率低于对照组［21.43%（9/42）对44%（22/50）；χ² = 5.205，P = 0.022］。结论 预见性早期双侧去骨瓣减压术可以有效降低重型颅脑创伤患者颅内压，预防单侧去骨瓣减压术后的迟发性颅内血肿，明显改善预后，降低术后并发症发生率，提高患者生活质量。

关键词: 颅脑损伤, 减压术, 外科, 神经外科（学）

Abstract:

Objective  To investigate the efficacy and safety of predictive early bilateral decompressive craniectomy in the treatment of severe traumatic brain injury (sTBI). Methods  A total of 92 patients with sTBI underwent predictive early bilateral decompressive craniectomy (observation group, N = 42) and conservative first?line treatment followed by unilateral or bilateral decompressive craniectomy (control group, N = 50). Intracranial pressure (ICP) before and after treatment was monitored, Glasgow Outcome Scale (GOS) was used to evaluate prognosis, and postoperative complications were recorded. Results The observation group patients had less time interval than control group patients [(4.63 ± 1.61) h vs. (36.61 ± 1.92) h; t = 32.464, P = 0.001]. Compared with before operation, ICP decreased 1 d after operation (P = 0.001), and continued to decrease 7 d after operation (P = 0.001) in both groups. Compared with control group, the ICP in observation group patients decreased more (P = 0.001). Of 92 patients, 37 had a good prognosis (40.22% ) and 55 had a poor prognosis (59.78% ). The rate of good prognosis in observation group was significantly higher than that in control group [54.76% (23/42) vs. 28% (14/50); χ² = 5.697, P = 0.017]. The good prognosis rate of patients less than 41 years old was significantly higher than that of patients older than 41 years old ( χ² = 5.526, P = 0.025). Of 92 patients, 31 (33.70% ) had postoperative complications, including 11 cases (11.96% ) of subdural effusion, 4 cases (4.35% ) of intracranial hemorrhage, 3 cases (3.26%) of hydrocephalus, 4 cases (4.35%) of infection, 2 cases (2.17%) of epilepsy and 7 cases (7.61% ) of organ dysfunction. The postoperative complication rate in observation group was lower than that in control group [21.43% (9/42) vs. 44% (22/50); χ² = 5.205, P = 0.022].  Conclusions  Predictive early bilateral decompressive craniectomy for sTBI could reduce ICP, prevent delayed intracranial hematoma caused by unilateral decompressive craniectomy, significantly improve the prognosis, decrease the incidence of postoperative complications, and improve the patients' quality of life.

Key words: Craniocerebral trauma, Decompression, surgical, Neurosurgery