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目的:重型颅脑损伤脑疝去骨瓣减压的手术指征及预后因素研究。方法:收集2013-12-2015-11在我院住院治疗的重型颅脑外伤合并脑疝的患者65例,分析患者行去骨瓣减压术的手术指征,利用单因素和多因素Logistic回归分析影响患者预后的危险因素。结果:65例患者中47例(72.31%)行去瓣膜减压术,18例(27.69%)患者保留骨瓣;其中双侧瞳孔散大的患者19例(29.23%)、GCS评分≤6分的患者40例(61.54%)、硬膜下血肿的患者36例(55.38%)行去瓣膜减压术的比例较高,且差异均有统计学意义(P<0.05);根据GOS分级,患者术后预后不良(GOSⅠ~Ⅱ级)者29例(44.62%),预后良好(GOSⅢ~Ⅵ级)者36例(55.38%);多因素Logistic回归分析结果显示:合并伤(OR=4.768,95%CI=2.769~8.127)、双侧瞳孔散大(OR=2.632,95%CI=1.625~6.545)、GCS评分≤6分(OR=3.545,95%CI=2.230~10.714)、术前CT基底池形态异常(OR=2.771,95%CI=1.698~12.532)是影响患者发生不良预后的主要危险因素(P<0.05)。结论:重型颅脑损伤瞳孔散大的脑疝患者,CT显示脑挫裂伤、出血、脑水肿等占位效应明显(中线移位、基底池受压),ICP进行性升高、>30mmHg持续30min的重型颅脑损伤患者,以及进行性意识障碍的急性颅脑创伤患者,CT显示脑挫裂伤、出血、脑水肿等占位效应明显(中线移位、基底池受压)、经渗透脱水利尿药物等一线治疗方案颅高压无法控制的患者是去骨瓣减压的手术指征。其中双侧瞳孔散大、GCS评分≤6分、硬膜下血肿的重型颅脑损伤脑疝患者行去瓣膜减压术的比例较高,合并伤、双侧瞳孔散大、GCS评分≤6分、术前CT基底池形态异常是影响患者发生不良预后的主要危险因素。
Objective: Severe craniocerebral injury herniation decompressive craniectomy indications and prognostic factors. Methods: A total of 65 patients with severe craniocerebral traumatic brain herniation hospitalized in our hospital from December 2013 to December 2015 were enrolled. The surgical indications of patients undergoing decompressive craniectomy were analyzed. One-factor and multivariate Logistic regression Analysis of risk factors affecting the prognosis of patients. Results: Of the 65 patients, 47 cases (72.31%) underwent valvular decompression and 18 cases (27.69%) retained the bone flap. There were 19 patients (29.23%) with bilateral mydriasis and GCS score ≤6 (61.54%), and 36 (55.38%) patients with subdural hematoma had a higher rate of valvular decompression. The difference was statistically significant (P <0.05). According to the GOS classification, patients There were 29 cases (44.62%) with good prognosis (GOSⅠ ~ Ⅱ grade) and 36 cases (55.38%) with good prognosis (GOS Ⅲ ~ Ⅵ). The multivariate Logistic regression analysis showed that the combined injury (OR = 4.768,95 (OR = 2.632, 95% CI = 1.625 ~ 6.545), GCS score≤6 points (OR = 3.545, 95% CI = 2.230 ~ 10.714) Pool abnormalities (OR = 2.771, 95% CI = 1.698 ~ 12.532) were the main risk factors affecting the patients with poor prognosis (P <0.05). CONCLUSIONS: In patients with moranges and hernias with severe craniocerebral injury, CT showed significant space-occupying effects of cerebral contusion and laceration, hemorrhage and cerebral edema (median shift, basal cistern compression) with ICP progressively increasing> 30mmHg 30min patients with severe craniocerebral injury, as well as patients with progressive traumatic brain injury who had impaired consciousness, CT showed significant space-occupying effects of cerebral contusion, hemorrhage and cerebral edema (midline shift, basal cistern compression) Diuretic drugs and other first-line treatment programs Uncontrolled patients with intracranial hypertension is the surgical indication for decompressive craniectomy. The bilateral mydriasis, GCS score ≤ 6 points, subdural hematoma in patients with severe traumatic brain herniation underwent aortic valve decompression of a higher proportion of combined injury, bilateral mydriasis, GCS score ≤ 6 points Preoperative CT basal cistern abnormalities affect the prognosis of patients with the main risk factors.