中国临床神经外科杂志2008年4月第13卷第4期一217一.论著.特重型颅脑损伤患者术中急性脑膨出的预防方法探讨杜浩徐国政秦尚振郭再玉秦海林【摘要】目的探讨特重型颅脑损伤患者手术中发生急性脑膨出的防治措施。方法采用扩大额颞顶开颅去骨瓣减压术治疗19例特重型颅脑损伤,术中均采取顺序硬脑膜切开法分次切开硬脑膜。对此19例病例临床资料进行了回顾性分析。结果所有病例术中均未出现难以控制的脑膨出。术后复查头颅CT显示,血肿基本清除12例,血肿仍大片存在4例,其它部位继发血肿3例;环池、基底池、第三脑室复现12例,无明显变化7例。出院时行GOS预后评定:良好l例,中残1例,重残2例。植物生存4例,死亡11例(死亡率57.9%)。结论特重型颅脑损伤患者颅内压高,术中减压过快容易出现急性脑膨出,采用“尽早减压、逐步减压”和顺序硬脑膜切开法能明显降低术中急性脑膨出发生率,降低残死率。【关键词】颅脑损伤;特重型;脑膨出;脑肿胀;减压术.【文章编号】1009—153X(2008)04--0217-03【文献标识码】A【中图分类号】R651.1+5PreventionofAcuteEncephaloceleduringSurgeryinPafientswithEspeciallySevereBrainInjuryDUHao,XUGuo-zheng,QINShang-zhen,et01.DepartmentofNeurosurgery,WuhanGeneralHospital,GuangzhouCommand,PLA,WuhanHubei430070,China【Abstract】0bjectiveToexplorethemeasurestopreventacuteeneephaloceleduringthedecompessiveeraniotomyinthepatientswithespeciaDyseverebraininjury.MethodsTheclinicaldataof19patientswithespeciallyseverebraininjury,whoweretreatedbyextendedfronto—temporo-prietaleraniotomyinourdepartmentfromJanuary,2005toDecember,2006,wereanalyzedretrospectively.Thesequentialduralincision(SDI)wagperformedduringtheoperationinallthepatients.Results’nlecatastrophicencephaloceledidnotoccurinallthecasesevenifveryhighintracranialpressurewascausedbyfulminantbrainsweHinginSomecases.Thetotalremovalofhematomaswasachievedin12causes,buttherestillwasextensivehemorrhageintheoperativefieldin4casesandsecondaryintracranialhematomasintheotherregionsin3casesobservedOHpostoperativeCTscan.ThedisappearedbasalcisternandthethiMventriclecouldbeobservedagainin12casesandwereunchangedin7.AccordingtoGOS,1patientobtainedgoodrecovery,1Wasmoderatelydisabled,2wereseverelydisabled,4vegetativelysurvived,and11died.ConclusionTheencephalocele,whichiseasilyproducedbyrapiddecompression,ispreventedbycontrollabledecompressionasearlyaspossibleandSDIinthepatientswithespeciallyseverebraininjury.【KeyWords】Especiallyseverebraininjury;Eneephaloeele;Brainswelling;Decompressiveeraniotomy特重型颅脑损伤病人残死率很高,预后差。目前去骨瓣减压术是治疗特重型颅脑损伤主要的手术方式,多采用“标准外伤大骨瓣开颅术”【1’2I,但术中减压过快易出现急性脑膨出。自2005年1月至2006年12月中.我科共收治特重型颅脑损伤67例.63例行去骨瓣减压术,其中19例采用“尽早减压、逐步减压”,及新的硬膜切开方式。明显降低了术中急性脑膨出的发生率。1临床资料1.1一般资料本组男14例,女5例;年龄29—78岁。平均50岁;全部为闭合性颅脑损伤(包括颅底骨折)。受伤情况:车祸伤14例,高处坠落伤3例,摔伤l例,打击伤1例。受伤至入院时间1-6h,其中小于2h2例。2~4h11例,4h以上6例,平均3.7h。1.2临床表现人院时深昏迷11例,中度昏迷8例。GCS评分:5分3例,4分5例。3分11例。双侧瞳孔散大13例。一侧瞳孑L散大6例,瞳孔散大距受伤时间小于1h3例,1~2h6例,2~4h8例,大于4h2例。瞳孔散大至手术时间小于1h3例,1~2h4例,作者单位:广州军区武汉总医院神经外科(湖北武汉,430070)万方数据一218一ChinJClinNeurosurg,Apr2008,Vol13,No42~4h9例。大于4h3例。耳鼻出血或脑脊液漏等明显颅底骨折征象5例,呕吐15例,呼吸障碍(呼吸节律变化或停止)16例,血压不稳定4...