【作者】 周建；

【导师】 刘志雄；

【作者基本信息】 中南大学 ， 神经外科， 2010， 硕士

【摘要】 目的：颅脑外伤患者行去大骨瓣减压术,虽然降低了死亡率,但越来越多学者发现手术也带来较多的并发症,其中以脑膨出,颅内血肿,脑梗死多见。本研究旨在探讨颅脑外伤去大骨瓣减压术后患者中,脑膨出(The external cerebral herniation,膨胀脑组织突出于颅骨缺损处所形成的疝)、新发颅内血肿或／和脑挫裂伤病灶扩大及脑梗死三者与预后的关系。方法：对48例颅脑外伤去大骨瓣减压术后患者进行回顾性研究,测量患者术后不同时间段(术后3d、7d、14d、30d、60d)的脑膨出程度,测量患者术后新发颅内血肿或／和脑挫裂伤病灶扩大的量,以及脑梗死的发生率,并与患者术前的GCS评分,随访患者伤后六个月时GOS评分,运用SPSS13.0统计软件对结果进行分析。结果：(1)48例颅脑外伤去大骨瓣减压术后患者,死亡5例(死亡率10.4%)；长期昏迷、植物生存8例(16.7%)；重度残废19例(39.5%)；中度残废8例(16.7%)；恢复良好8例(16.7%)。(2)术后脑膨出发生率77%(37／48),术后不同时间的脑膨出程度：3d脑膨出程度0.935cm±0.144cm,7d脑膨出程度0.995cm±0.126cm,14d脑膨出程度1.501cm±0.125cm,30d脑膨出程度1.113cm±0.116cm,60d脑膨出程度1.244cm±0.163cm,通过上述时间段两两比较,14d时脑膨出程度与3d、7d、30d、60d脑膨出程度之间有显著差异性,其余各时间段无显著差异性。GCS评分低组更易出现脑膨出(P=0.047<0.05)。虽然GOS4-5级别组脑膨出的发生率(75%)比GOS 1-2级别组(92.3%)的低,但其差异统计学上无显著性意义(P=0.162>0.05),可能与本组病例数少有关。(3)术后新发颅内血肿或／和脑挫裂伤病灶扩大的发生率58.3%(28／48)例,其中硬膜外血肿有6例,脑内血肿或者脑挫伤扩大16例,硬膜外血肿加脑内血肿或者脑挫伤扩大6例。新发颅内血肿或／和脑挫裂伤病灶扩大的发生率在不同GOS组问的差异,统计学上无显著性意义(P=0.182>0.05)。(4)术后脑梗死发生率为12.5%(6／48),5例为大脑后动脉梗死,1例为大脑中动脉梗死,GCS3-5分组脑梗死的发生率为23.1%(3／13),GCS6-8分组脑梗死的发生率为8%(2／25),GCS>8分组脑梗死的发生率为10%(1／10),虽然GCS3-5分脑梗死的发生率比其他组高,但脑梗死发生率在不同GCS组间的比较统计学上无差异(P=0.398>0.05)。(5)脑梗死的发生率在不同GOS组间的差异,统计学上有显著性意义(P=0.048<0.05),脑梗死发生率高的预后较差。结论：颅脑外伤去大骨瓣减压术后患者脑膨出的总发生率为77%(37／48),14d时脑膨出程度与3d、7d、30d、60d脑膨出程度之间有显著差异,其余各时间段无显著差异。说明脑膨出程度14d达到高峰之后再减轻。GCS评分低的患者更容易出现脑膨出。术后患者新发颅内血肿或／和脑挫裂伤病灶扩大总发生率为58.3%(28／48),平均血肿量为48.8±42.1ml,其发生率与预后相关性不明显,而新发血肿体积与预后有关。颅脑外伤去骨瓣减压术后患者脑梗死发生率为12.5%(6／48),其发生患者脑梗死的平均体积为40.8±35ml,脑梗死的发生提示预后较差,脑梗死的发生率与GCS评分无明显相关性。更多还原

【Abstract】 Objective:This study is to explore the relationship between some factors and prognosis on patients with traumatic brain injury (TBI) who underwent decompressive craniectomy (DC).These factors analysed contain external cerebral herniation (Herniation formed by expansion of brain tissue protruding skull defect), expansion of intracranial hematoma or/and brain contusion and cerebral infarction.Method:48 patients with TBI who underwent DC were analyzed in the retrospective study. The thickness of external cerebral herniation were measured at different post-operative time (after third day, first week, second week, first month and second month).The expansion volumes of hemorrhagic contusion were also measured.The incidence rate of cerebral infarction, preoperative GCS score and 6-month GOS score were recorded. All the data were analyzed with SPSS 13.0.Result:(1)In all the 48 patients with TBI who underwent DC,5 cases died(10.4%); 8 cases of long-term coma or plant survival(16.7%), 19 cases of severe disability (39.5%);8 patients of moderate disability (16.7%);8cases of good recovery(16.7%).(2) The thickness of external cerebral herniation at different post-operative times:after third day, 0.935cm±0.144cm;after first week,0.995cm±0.126cm;after second week,1.501cm±0.125cm;after first month,1.113cm±0.116cm;after second month,1.244cm±0.163cm.There were significant difference in the thickness between these times (P=0.008<0.05),especially the second postoperative week, but no significant difference between the others.The external cerebral herniation was more likely to appear in the group with lower GCS score (P=0.047<0.05).Though the incidence rate of external cerebral herniation was lower in GOS 4-5(75%)than GOS 1-2 (92.3%),the difference was not statistically significant (P=0.162> 0.05),which maybe related to the less cases in this group.(3)Expansion of intracranial hematoma or brain contusion after DC appeared on 28 cases, consists of 6 caess with new epidural hematoma,16 caess with expansion of brain hematoma or/and contusion and 6 caess with new epidural hematoma plus expansion of brain hematoma or/and contusion. The differences were not statistically significant in incidence rate of expansion of intracranial hematoma or brain contusion between different GOS groups (P=0.182> 0.05).(4) The incidence rate of cerebral infarction on TBI patients after DC was 12.5%.5 cases occurred in posterior cerebral artery, and 1 case occurred in middle cerebral artery. Although the incidence rate of cerebral infarction was higher in GCS 3-5 (23.1%)than the others(GCS 6-8,8%; GCS>8,10%),but the differences were also not statistically significant (P=0.398> 0.05).(5) The differences were statistically significant in incidence rate of cerebral infarction between different GOS groups (P=0.048<0.05).The higher incidence, the poorer prognosis.Conclusion:The incidence rate of external cerebral herniation on TBI patients after DC was 77%.There were significant difference in the thickness of external cerebral herniation between the second week after decompressive craniectomy and the others (after third day, first week, first month and second month), but no significant difference between the others.It indicates that the thickness of external cerebral herniation has a process of initial increasing and then decreasing after the second week. In addition, The external cerebral herniation was more likely to appear in the group with lower GCS score.The incidence rate of cerebral infarction on TBI patients after DC was 12.5%,while the average volumes was 40.8±35ml.The incidence rate of cerebral infarction after decompressive craniectomy may indicates poor prognosis, but there were no significant correlation between the incidence rate of cerebral infarction and the GCS score.The incidence rate of Expansion of intracranial hematoma or/and brain contusion on TBI patients after DC was 58.3%,while the average volumes was 48.8±42.1ml.Prognosis did not correlate with the incidence rate of brain contusion expansion or new intracranial hematoma after decompressive craniectomy, but with the volumes of the hematoma.更多还原