摘要：

目的 初步探讨无需行去骨瓣减压术的急性幕上硬膜外血肿行开颅血肿清除术应选择的骨瓣大小。方法 共191 例急性幕上硬膜外血肿患者分别采取3 cm 小骨窗（67 例）、5 cm 小骨窗（61 例）和常规骨瓣（63 例）开颅血肿清除术，记录手术时间、术中出血量、血肿清除范围、残留血肿量和术后中线移位、环池结构。结果 191 例患者中血肿最大径≤ 8 cm 47 例、> 8 ~ 10 cm 106 例和> 10 cm 38 例。血肿最大径≤ 8 cm 时，与常规骨瓣组相比，3 cm 小骨窗组血肿清除范围小（t =-3.370，P = 0.002）、手术时间短（t =-14.469，P = 0.000）、术中出血量少（t =-9.310，P = 0.000）；与3 cm 小骨窗组相比，5 cm 小骨窗组血肿清除范围大（t =-2.331，P = 0.026）。血肿最大径> 8 ~ 10 cm 时，与常规骨瓣组相比，5 cm 小骨窗组血肿清除范围小（t =-4.248，P = 0.002）、残留血肿量少（t =-2.083，P = 0.041）、手术时间短（t =-10.715，P =0.000）、术中出血量少（t =-10.828，P = 0.000）。血肿最大径> 10 cm 时，与常规骨瓣组相比，5 cm 小骨窗组血肿清除范围小（t =-3.125，P = 0.003）、手术时间短（t =-2.948，P = 0.006），但残留血肿量增加（t =3.478，P = 0.001）。Spearman 秩相关分析显示，骨窗缘可操作视角与骨窗大小（r_s = 0.330，P = 0.000）和血肿最大径（r_s = 0.177，P = 0.003）呈正相关，与血肿厚度呈负相关（r_s =-0.678，P = 0.000）。结论 在有效清除血肿并取得满意影像学和临床康复前提下，为达微创手术效果，急性幕上硬膜外血肿最大径≤ 8 cm时，血肿量≤ 50 ml者可选择3 cm 小骨窗、> 50 ml者可选择5 cm 小骨窗；血肿最大径> 8 ~ 10 cm 时，可选择5 cm 小骨窗；血肿最大径> 10 cm 时，可选择常规骨瓣（骨瓣长径≥ 6 cm）。

关键词: 血肿, 硬膜外, 颅内, 颅骨切开术

Abstract:

Objective To investigate the most reasonable size of craniotomy flap in hematoma removal craniotomy for acute supratentorial epidural hematoma (EDH) with no need of decompressive craniectomy. Methods Surgical and clinical data of 191 patients with acute supratentorial EDH were retrospectively reviewed and their operation time, intraoperative blood loss, range of hematoma evacuation, residual hematoma, postoperative midline shift and ambient cistern were compared among 3 groups (3 cm craniotomy group, N = 67; 5 cm craniotomy group, N = 61; ordinary craniotomy group, N = 63). Results For EDHs with maximal diameter ≤ 8 cm (N = 47), compared with ordinary craniotomy, 3 cm craniotomy achieved smaller range of hematoma evacuation (t =-3.370, P = 0.002), shorter operation time (t =-14.469, P = 0.000) and less intraoperative blood loss (t =-9.310, P = 0.000). However, 5 cm craniotomy could obtain larger range of hematoma evacuation compared with 3 cm craniotomy (t =-2.331, P = 0.026). For EDHs with maximal diameter > 8-10 cm (N = 106), compared with ordinary craniotomy, 5 cm craniotomy achieved smaller range of hematoma evacuation (t =-4.248, P = 0.002), smaller residual hematoma (t =-2.083, P = 0.041), shorter operation time (t =-10.715, P = 0.000) and smaller intraoperative blood loss (t =-10.828, P = 0.000). For EDHs with maximal diameter > 10 cm (N = 38), compared with ordinary craniotomy group, although 5 cm craniotomy could reduce range of hematoma evacuation (t =-3.125, P = 0.003) and operation time (t =-2.948, P = 0.006), it could notably increase the residual hematoma (t = 3.478, P = 0.001). Spearman rank correlation analysis suggested that the operable angle on the edge of craniotomy defect was positively correlated with size of craniotomy defect (r_s = 0.330, P = 0.000) and maximal hematoma diameter (r_s = 0.177, P = 0.003), and negatively correlated with hematoma thickness (r_s =-0.678, P = 0.000). Conclusions With prerequisite of effective EDH evacuation and satisfactory radiological and clinical recovery, the EDH is recommended to be microsurgically treated with craniotomy in rational size. For maximal diameter ≤ 8 cm EDHs and hemotome volume ≤ 50 ml, 3 cm craniotomy is the best choice, whereas the 5 cm craniotomy is more suitable when the hematoma volume > 50 ml. For maximal diameter > 8-10 cm EDHs, 5 cm craniotomy is a more rational surgical approach. And for maximal diameter > 10 cm EDHs, ordinary craniotomy (≥ 6 cm) is recommended.

Key words: Hematoma, epidural, cranial, Craniotomy