创伤性脑肿胀重度颅内压增高的临床救治及预后分析
摘要
目的探讨并发颅内压(ICP)重度增高(ICP≥40mmHg)的急性创伤性弥漫性脑肿胀(PADBS)患者初始ICP、去骨瓣减压术前ICP负荷及去骨瓣减压术后ICP与预后的关系及临床救治方法。方法回顾性分析2012年3月至2016年6月在有创ICP监测下救治伤后2h内急诊入院的急性创伤性弥漫性脑肿胀19例患者的临床资料。分析初始ICP、去骨瓣减压术前ICP负荷及去骨瓣减压术后ICP与预后的关系。结果按伤后6个月格拉斯哥预后评分(GOS),良好1例,中残1例,重残7例,死亡10例。将预后良好和中残归为预后较好组,将重残、植物生存和死亡归为预后不好组。初始ICP≥60mmHg组7例,均预后不好,死亡率71.4%(5/7);初始ICP<60mmHg组12例,预后较好2例,预后不好10例,死亡率41.7%(5/12)。去骨瓣减压术前ICP负荷≥90mmHg·h组11例,均预后不好,死亡率90.9%(10/11);去骨瓣减压术前ICP负荷<90mmHg·h组8例,预后较好2例,预后不好6例,无死亡病例。去骨瓣减压术后ICP≥20mmHg组8例均死亡,死亡率100%;去骨瓣减压术后ICP<20mmHg组11例,预后较好2例,预后不好9例,死亡率18.2%(2/11)。结论并发颅内压重度增高(ICP≥40mmHg)的PADBS患者死残率高,预后差。初始ICP≥60mmHg、去骨瓣减压术前ICP负荷≥90mmHg·h及处理后ICP≥20mmHg的PADBS患者死亡率极高。优化救治流程、尽快脑室外引流、有效去骨瓣减压,降低ICP负荷是降低此类患者死残率的可能办法。
引文
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2 Cordobes F,Lobato RD,Rivas JJ,et al Post-traumatic diffuse brain swelling:isolated or associated with cerebral axonal injury.Clinical course and intracranial pressure in 18 children[J].Childs Nerv Syst,1987,3(4):235-238.
3 Parikh S,Koch M,Narayan RK.Traumatic brain injury[J].Int Anesthesiol Clin,2007,45(3):119-135.
4 Farahvar A,Gerber LM,Chiu YL,et al.Response to intracranial hypertension treatment as a predictor of death in patients with severe traumatic brain injury[J].J Neurosurg.2011,114(5):1471-1478.
5 Carney N,Totten AM,O’Reilly C,et al Guidelines for the management of severe traumatic brain injury,fourth edition[J]Neurosurgery,2017,80(1):6-15.
6 Bao YH,Liang YM,Gao GY,et al.Bilateral decompressive craniectomy for patients with malignant diffuse brain swelling after severe traumatic brain injury:a 37-case study[J].JNeurotrauma,2010,27(2):341-347.
7 Wilson MH.Monro-Kellie 2.0:the dynamic vascular andvenous pathophysiological components of intracranial pressure[J].J Cereb Blood Flow Metab,2016,36(8):1338-1350.
8 Hutchinson PJ,Kolias AG,Timofeev IS,et al.RESCUEICP Trial Collaborators.Trial of decompressive craniectomy for traumatic intracranial hypertension[J].N Engl J Med,2016,375(12):1119-1130.
9 Honeybul S,Ho KM,Gillett GR.Reconsidering the role of decompressive craniectomy for neurological emergencies[J].J Crit Care2017,39():185-189.