突发反常性脑疝治疗体会(附2例报告)

Insights into the treatment of acute paradoxical brain herniation: An analysis of two patients

摘要:

目的 报告去骨瓣减压术后出现反常性脑疝2例，结合文献复习，提高对于反常性脑疝的认识。方法 收集2015年6月-2020年3月山东第一医科大学第一附属医院神经外科发生2例去骨瓣减压术后后期突发反常性脑疝患者的资料。2例均为高血压脑出血患者，1例为腰大池引流后，另1例为脑室腹腔分流术后，均出现减压皮瓣凹陷侧瞳孔散大，意识障碍加重。结果 1例经过腰穿紧急注入生理盐水40 mL，体位调整为头低脚高、头偏向颅骨缺损侧卧位，及输液扩容约4 h解除脑疝，意识状态好转；另1例分流后患者同样经体位调整，输液扩容治疗，瞳孔于处理后约10 h恢复，于恢复后第2天行颅骨修补治疗。结论 颅脑手术去骨瓣减压应早期修补，合并脑积水者修补分流一期手术为佳；过度引流及腰大池引流有反常性脑疝发生可能。出现反常性脑疝要及时正确诊断及治疗，以期取得良好的效果。

Abstract:

Objective To report two patients developing paradoxical brain herniation after decompressive craniectomy, and to improve our understanding of paradoxical brain herniation by reviewing the relevant literature.Methods Clinical data were collected from two patients developing acute paradoxical brain herniation after decompressive craniectomy in Department of Neurosurgery, The First Affiliated Hospital of Shandong First Medical University from June 2015 to March 2020. Both patients had hypertensive intracerebral hemorrhage. One patient was treated with lumbar cerebrospinal fluid drainage, while the other received ventriculoperitoneal shunt surgery. Both of them had mydriasis on the side of decompression flap and aggravated disturbance of consciousness after surgery. Patients with hypertensive intracerebral hemorrhage should take decompressive craniectomy with caution.Results One patient was urgently injected with 40 mL of saline through lumbar puncture in the Trendelenburg position with the head turned to the side with skull defect. Brain herniation was relieved by infusion dilatation for about 4 hours and patient's state of consciousness was improved. The other patient was also treated with posture adjustment and infusion dilatation after shunting. The pupils recovered at about 10 hours after treatment and cranioplasty was performed on the second day after recovery.Conclusions Cranioplasty should be performed early after decompressive craniectomy. Patients complicated by hydrocephalus need one-stage surgery with cranioplasty and shunting. Excessive drainage or lumbar cerebrospinal fluid drainage may cause paradoxical brain herniation. In order to achieve satisfactory outcomes, timely and accurate diagnosis and treatment are necessary for patients developing paradoxical brain herniation.