探讨重型颅脑创伤去骨瓣减压术后脑积水的治疗方案

doi:10.3877/cma.j.issn.2095-9141.2015.04.005

目的

探讨治疗重型颅脑创伤去骨瓣减压术后合并创伤后脑积水(PTH)患者的不同手术方案。

方法

回顾性分析89例重型颅脑创伤患者行开颅去骨瓣减压后合并创伤后脑积水的临床资料。以手术方式不同分为：早期组即早期行脑室-腹腔分流术(VPS)+颅骨修补术17例；延期组即延期行脑室-腹腔分流术(VPS)+颅骨修补术22例；先行VPS再行颅骨修补术组31例(先VPS组)，先行颅骨修补术再行VPS组19例(后VPS组)。

结果

早期组、延期组、先VPS组和后VPS组治疗有效率分别为88.2%、86.4%、90.3%、89.5%，四组之间差异无统计学意义(P>0.05)；且各组并发症中分流堵管率并无差异(P>0.05)；早期组头皮感染发生率明显高于先行VPS组(17.6%VS 6.5%)，先VPS组及后行VPS组术后硬膜下积液或血肿发生率(分别为3.2%和5.2%)均明显低于早期组及晚期组(分别为11.76%和9.09；P<0.05)。

结论

针对重型颅脑创伤去骨瓣减压术后引起的创伤后脑积水患者，早期、晚期及先VPS组、后VPS组治疗方案选择无差异，手术方案的选择益于以患者病情而行。

关键词: 重型颅脑创伤, 创伤后脑积水, 颅骨修补术, 硬膜下积液, 手术方案

Objective

To investigating the different surgical plans for patients with hydrocephalus after decompressive craniectomy of severe traumatic brain injury.

Methods

The clinical data of 89 patients with severe traumatic brain injury underwent craniotomy to bone flap decompression combined with post-traumatic hydrocephalus after trauma were retrospectively analyzed.Four groups were difined according to the different operation mode:group of early ventriculo-peritoneal shunt(VPS)+cranioplasty seventeen cases;group delay extension of ventriculo peritoneal shunt(VPS)+skull neoplasty in twenty-two cases;first VPS for cranioplasty group thirty-one cases(VPS),first skull repair surgery again VPS group nineteen cases(after VPS group).

Results

Early group,group delay,first VPS group and after VPS group treatment efficiency was 88.2%,86.4%,90.3%and 89.5%,respectively.The differences between any two groups show no statistical significance(P>0.05);and the complications of the three groups in shunt tube plugging rate had no difference(P>0.05);early group scalp infection rate was significantly higher than that of the first VPSgroup(17.6%vs 6.5%),the first VPSgroup and underwent VPSgroup postoperative subdural hematoma or effusion incidence(respectively 3.2%and 5.2%)was significantly lower than that of the early group and late stage group(11.76%and 9.09%,respectively;P<0.05).

Conclusion

Directe at post-traumatic hydrocephalus patients caused by bone flap decompression after severe traumatic brain injury,early,late and VPSgroup,after VPS group treatment options no difference,operation scheme choicebenefits to patientswho underwent.

Key words: Severe traumatic brain injury, Post-traumatic hydrocephalus, Cranioplasty, Subdural collection of fluid, Surgical options

图1 早期组颅脑创伤患者手术治疗前后头颅CT图 A：患者去骨瓣减压术后5周余出现创伤后脑积水，骨窗凸出，张力较高；B：行脑室-腹腔分流术+颅骨修补术后1周复查CT，提示：手术满意，脑组织恢复尚可；C：术后4周复查头部CT，脑室系统明显缩小，脑组织恢复良好。

表1 各组患者手术后疗效［例(%)］

组别	例数	术后有效	术后无效
早期VPS+修补术	17	15 (88.2％)	2 (11.8％)
延期VPS+修补术	22	19 (86.4％)	3 (13.6％)
先行VPS术组	31	28 (90.3％)	3 (9.7％)
后行VPS术组	19	17 (89.5％)	2 (10.5％)

表1 各组患者手术后疗效［例(%)］

组别	例数	术后有效	术后无效
早期VPS+修补术	17	15 (88.2％)	2 (11.8％)
延期VPS+修补术	22	19 (86.4％)	3 (13.6％)
先行VPS术组	31	28 (90.3％)	3 (9.7％)
后行VPS术组	19	17 (89.5％)	2 (10.5％)

图2 先行VPS组及后行VPS组颅脑创伤患者手术治疗前后头颅CT图 A：先行VPS术组颅脑创伤患者去骨瓣减压术后出现脑积水，脑室扩大明显；B：行脑室-腹腔分流术后1周复查头颅CT示：脑室系统缩小，骨窗塌陷；C：及时调整腹分压力泵，颅骨修补术1周后复查头颅CT提示：脑室系统扩大明显改善，脑组织恢复良好；D：修补术后4周复查头颅CT。E：后行VPS术组颅脑损伤患者头颅CT提示脑室扩张明显，但脑组织张力尚可。F：行修补术后1周复查头颅CT提示：颅脑解剖结构恢复良好；G：约3周后行脑室-腹腔分流术，术后1周复查头颅CT提示：脑积水改善；H：腹分术后4周复查头颅CT。

表2 各组患者并发症比较(例)

组别	分流过度	术后发热	堵管	头皮感染	脑脊液漏	SDE/SDA
早期VPS+修补术	2	3	2	3	1	2
延期VPS+修补术	3	3	2	2	2	2
先行VPS术组	5	6	4	2	1	1
后行VPS术组	3	3	2	2	1	1

表2 各组患者并发症比较(例)

组别	分流过度	术后发热	堵管	头皮感染	脑脊液漏	SDE/SDA
早期VPS+修补术	2	3	2	3	1	2
延期VPS+修补术	3	3	2	2	2	2
先行VPS术组	5	6	4	2	1	1
后行VPS术组	3	3	2	2	1	1

［1］	Nelson Saade,JoséCarlos Esteves Veiga,Tcbc-Sp,et al.Evaluation of prognostic factors of decompressive craniectomy in the treatment of severe traumatic brain injury［J］.Rev.Col.Bras.Cir.2014;41(4):256-262
［2］	Jun Ding,Yan Guo,Hengli Tian.The influence of de compressive craniectomy on the development of hydrocephalus:a review［J］.Arq Neuropsiquiatr,2014,72(9):715-720.
［3］	Grossman H,Karttunen A,Jartti A,et al.Factors related to acute hydrocephalus after subararchnoid hemorrhage［J］.Acta Radiol,2004,45(3):333-339.
［4］	Poca MA,MataróM,Matarín M,et al.Good outcome in patients with normal pressure hydrocephalus and factors indicating poor prognosis［J］.J Neurosurg,2005,103(3):455-463.
［5］	Schaller B,Graf R,Sanada Y,et a1.Hemodynamic and metabolic effects of decompressive hemicraniectomy in normal brain.An experimental PET-study in cats［J］.Brain Res,2003,982(1):31-37.
［6］	Segal DH,Oppenheim JS,Murovic JA.Neurological recovery after cranioplasty［J］.Neurosurgery,1994,34(4):729-731.
［7］	Winkler PA,Stummer W,Linke R,et al.Influence of cranioplasty on postural blood flow regulation，cerebrovascular reserve capacity and cerebral glucose metabolism［J］.J Neurosurg,2000,93(1):53-61.
［8］	Dehdashti AR,Rilliet B,Rufenacht DA,et al.Shunt-dependent hydrocephalus after rupture of intracranial aneurysms:a prospective study of the influence of treatment modality［J］.J Neurosurg,2004,101(1):402-407.
［9］	Honeybul S.Complications of decompressive craniectomy for head injury［J］.Clin Neurosci,2010,17(4):430-435.
［10］	De Bonis P,Pompucci A,Mangiola A,et al.Post-traumatic hydrocephalus after decompressive craniectomy:an underestimated risk factor［J］.Neurotrauma,2010,27(11):1965-1970.
［11］	宋纯玉,潘强,王泉相等.不同手术方法治疗颅脑损伤去骨瓣减压术后脑积水疗效分析［J］.中国临床神经外科杂志,2014,19(3):170-172.
［12］	Mario Z,Nohra C,Robert M.,et al.Predictors of Infections following Cranioplasty:A Retrospective Review of a Large Single Center Study［J］.Hindawi Publishing Corporation the Scientific World,2014,22(10):356042.
［13］	Nelson S,JoséCarlos E,Tcbc S,et al.Evaluation of prognostic factors of decompressive craniectomy in the treatment of severe traumatic brain injury［J］.Rev Col Bras Cir,2014,41(4):256-262.

[1]	袁宝玉, 管义祥, 王东流, 陆正. 不同时机颅骨修补术治疗颅脑外伤的临床疗效[J]. 中华神经创伤外科电子杂志, 2024, 10(01): 35-41.
[2]	郭鹏, 李锦平. 去骨瓣减压术后与颅骨缺损相关的并发症及其防治[J]. 中华神经创伤外科电子杂志, 2023, 09(02): 119-122.
[3]	李长栋, 王志宏, 蔡霞. 成人颅骨修补术后并发症及其防治策略[J]. 中华神经创伤外科电子杂志, 2023, 09(02): 108-111.
[4]	周智, 王飚, 雷军, 黄弋洋, 汤秉洪, 毛磊. 去骨瓣减压术后硬膜下积液的治疗措施分析[J]. 中华神经创伤外科电子杂志, 2022, 08(01): 44-46.
[5]	赵卫良, 李娟, 郑永, 谢森, 缪国专. 颅骨修补术后钛网外露的临床特点及手术疗效[J]. 中华神经创伤外科电子杂志, 2021, 07(05): 297-300.
[6]	吴水华, 陈朝晖, 范双石, 李浩, 王海阳. 个性化聚醚醚酮植入物在儿童颅骨修补术中的临床应用及分析[J]. 中华神经创伤外科电子杂志, 2021, 07(04): 252-255.
[7]	王洪伟, 张剑宁, 皇甫罗凯, 康建刚. 硬膜下积液治疗经验总结（附27例临床分析）[J]. 中华神经创伤外科电子杂志, 2020, 06(05): 299-303.
[8]	高国一. 颅脑创伤难治性并发症[J]. 中华神经创伤外科电子杂志, 2020, 06(04): 193-195.
[9]	李亚斌, 李刚, 王希瑞, 尚金星, 赵志煌. 依达拉奉辅助亚低温对重型颅脑创伤的血清细胞因子及凝血功能的影响[J]. 中华神经创伤外科电子杂志, 2020, 06(03): 166-171.
[10]	何永昌, 杨建军, 崔阳, 王丹妹, 封立彬, 智天鹏, 尹连虎. 重型颅脑损伤开颅大骨瓣减压术后并发硬膜下积液的治疗和分析[J]. 中华神经创伤外科电子杂志, 2019, 05(06): 365-369.
[11]	程月飞, 王志明, 王洪生, 孙印臣, 王辉. 早期颅骨修补治疗颅脑损伤大骨瓣减压术后顽固性硬膜下积液[J]. 中华神经创伤外科电子杂志, 2019, 05(05): 307-309.
[12]	王绅, 王如海, 李春, 杨震, 孙菲琳. 中重型颅脑创伤患者住院时间延长的危险因素分析及预测模型构建[J]. 中华脑科疾病与康复杂志(电子版), 2024, 14(03): 146-153.
[13]	赵德枭, 郭永坤, 王新军, 刘婉清, 陈冠岐, 毛建超, 单峤. 聚醚醚酮与钛网修补颅骨缺损的临床应用对比分析[J]. 中华脑科疾病与康复杂志(电子版), 2021, 11(06): 362-365.
[14]	王如海, 孙菲琳, 杨震, 韩超, 于强, 胡海成. 硬膜下积液厚度对创伤性硬膜下积液转化为慢性硬膜下血肿的预测价值[J]. 中华脑科疾病与康复杂志(电子版), 2021, 11(04): 227-231.
[15]	周君, 石星原, 张庆玲, 刘向辉, 郭运林, 张之营, 张建. 颅骨修补术后癫痫发作的预后分析[J]. 中华临床医师杂志(电子版), 2021, 15(05): 356-359.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Discussion on the treatment programs of hydrocephalus after decompressive craniectomy of severe traumatic brain injury

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Discussion on the treatment programs of hydrocephalus after decompressive craniectomy of severe traumatic brain injury