重型颅脑损伤合并脑疝患者去骨瓣减压结果和短期预后分析

Outcomes and short-term prognostic factors following decompressive craniectomy in patients with severe traumatic brain injury complicated by brain herniation

摘要:

目的 分析重型创伤性脑损伤（sTBI）合并脑疝患者选择去骨瓣减压术（DC）的适应证和治疗结局，并评估潜在的预后因素。方法 回顾性调查2022年5月—2024年12月在新疆医科大学第五附属医院接受开颅手术的152例sTBI患者信息，如果术中发现脑实质隆起至颅骨内板以上，提示脑肿胀、颅内压（ICP）升高，由医生决定是否进行控制性DC。使用格拉斯哥延伸评定量表评估6个月后的预后状态。结果 共有90例（59.21%）患者接受了控制性DC（DC组），其他62例（40.79%）接受了开颅手术（非DC组）。受伤至入院时间（OR=4.688，P=0.021）、血肿类型（P<0.05）、中线移位（MLS）（OR=1.177，P=0.002）是与DC相关的术前因素。DC组患者术后6个月内病死率高于非DC组（37.78% vs. 22.58%，P=0.048）。多因素Logistic回归分析显示，入院格拉斯昏迷量表（GCS）评分较低、双侧瞳孔散大、受伤至入院时间≥1 h、术前ICP>40 mmHg和≥60岁是预后不良的危险因素（P<0.05）。结论 术前分析sTBI合并脑疝患者的受伤至入院时间、血肿类型、MLS可对后续是否进行DC有指导价值。此外，入院GCS评分较低、双侧瞳孔散大、受伤至入院时间≥1 h、术前ICP>40 mmHg和≥60岁与患者预后不良相关。

Abstract:

Objective To analyze the indications for and outcomes of decompressive craniectomy （DC） in patients with severe traumatic brain injury （sTBI） complicated by brain herniation， and to evaluate potential prognostic factors.Methods A retrospective investigation was conducted on 152 patients with sTBI who underwent craniotomy in The Fifth Affiliated Hospital of Xinjiang Medical University from May 2022 to December 2024. If the brain parenchyma was found to bulge above the inner table of the skull during the operation， which indicated brain swelling and elevated intracranial pressure （ICP）， the doctor decided to perform controlled DC. The Glasgow Outcome Scale extended was used to evaluate the prognosis at 6 months.Results A total of 90 patients （59.21%） underwent controlled DC （DC group）， while the other 62 patients （40.79%） underwent craniotomy only （non-DC group）. The time from injury to admission （odds ratio=4.688， P=0.021）， hematoma type （P<0.05）， and midline shift （odds ratio=1.177， P=0.002） were preoperative factors associated with DC. The DC group had a significantly higher mortality rate within 6 months after surgery than the non-DC group （37.78% vs. 22.58%， P=0.048）. The multivariable logistic regression analysis showed that a low admission Glasgow Coma Scale score， bilateral pupillary dilation， time from injury to admission ≥1 hour， preoperative ICP >40 mmHg， and aged 60 or above were risk factors for poor prognosis （P<0.05）.Conclusion Preoperative analysis of the time from injury to admission， hematoma type， and midline shift in patients with sTBI accompanied by brain herniation has guiding value for whether DC is performed subsequently. In addition， a low admission Glasgow Coma Scale score， bilateral pupillary dilation， time from injury to admission ≥1 hour， preoperative ICP >40 mmHg， and aged 60 or above are associated with a poor prognosis.