Clinical analysis of modified stepwise decompression technique combined with decompressive craniectomy under intracranial pressure monitoring to treat high intracranial pressure

doi:10.3877/cma.j.issn.2095-9141.2022.01.006

Abstract

Abstract:

Objective

To explore the clinical effect of modified stepwise decompression technique combined with decompressive craniectomy under intracranial pressure monitoring in the treatment of high intracranial pressure.

Methods

A retrospective case-control study was used to analyze the clinical data of 312 patients with intracranial hypertension caused by various causes who needed decompressive craniotomy admitted to Neurosurgery Department of the Second People's Hospital of Guiyang from January 2017 to June 2020. The patients were divided into modified stepwise decompression combined with decompressive craniectomy group (improved group) and conventional decompressive craniotomy group (conventional group). All patients received real-time intracranial pressure monitoring during the operation. The changes of intraoperative intracranial pressure, postoperative complications and prognosis of the two groups were compared and analyzed.

Results

In the conventional group, intracranial pressure decreased sharply, rebounded and became stable after cutting the dura mater. In the modified group, intracranial pressure decreased gradually and stabilized. There were significant differences in intraoperative brain swelling, encephalocele, delayed contralateral hematoma, postoperative GCS score, pupil changes, complications and GOS score 6 months after operation between the two groups (P<0.05).

Conclusion

Modified stepwise decompression technique combined with decompressive craniectomy can effectively control intracranial pressure, reduce intraoperative encephalocele, and reduce the formation of delayed hematoma. It is a safe, effective and feasible method for decompressive craniectomy.

Key words: Intracranial pressure monitoring, Stepwise decompression technique, Decompressive craniectomy, High intracranial pressure, Traumatic brain injury

Yigong Wei, Kun Zhou, Guangtang Chen, Cheng Wang, Chuangxi Liu. Clinical analysis of modified stepwise decompression technique combined with decompressive craniectomy under intracranial pressure monitoring to treat high intracranial pressure[J]. Chinese Journal of Neurotraumatic Surgery(Electronic Edition), 2022, 08(01): 28-33.

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References 27

[1]	Sun H, Wang H, Diao Y, et al. Large retrospective study of artificial dura substitute in patients with traumatic brain injury undergo decompressive craniectomy[J]. Brain Behav, 2018, 8(5): e00907.
[2]	薛泽彬，陈俊琛，谭殿辉,等.控制性减压在重型颅脑损伤手术中的应用[J].中国临床神经外科杂志, 2018, 23(3): 170-172.
[3]	王正锐，李平，高永清,等.逐步控制性减压手术治疗重型、特重型颅脑损伤[J].中华神经外科杂志, 2011, 27(11): 1154-1156.
[4]	陈亚军，蒋宇钢，刘少波.控制性阶梯式减压术治疗重型、特重型颅脑损伤疗效分析[J].中国临床神经外科杂志, 2015, 20(3): 175-177.
[5]	段继新，王承，钟治军,等.阶梯减压结合去骨瓣减压术治疗重型创伤性脑损伤的疗效[J].中华创伤杂志, 2019, 35(5): 394-399.
[6]	Champeaux C, Weller J. Long-term survival after decompressive craniectomy for malignant brain infarction: a 10-year nationwide study[J]. Neurocrit Care, 2020, 32(2): 522-531.
[7]	Hutchinson PJ, Kolias AG, Timofeev IS, et al. Trial of decompressive craniectomy for traumatic intracranial hypertension[J]. N Engl J Med, 2016, 375(12): 1119-1130.
[8]	Kapapa T, Brand C, Wirtz CR, et al. Outcome after decompressive craniectomy in different pathologies[J]. World Neurosurg, 2016, 93: 389-397.
[9]	Shah A, Almenawer S, Hawryluk G, et al. Timing of decompressive craniectomy for ischemic stroke and traumatic brain injury:a review[J]. Front Neurol, 2019, 10: 11.
[10]	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.
[11]	Hiruta R, Jinguji S, Sato T, et al. Acute paradoxical brain herniation after decompressive craniectomy for severe traumatic brain injury: a case report[J]. Surg Neurol Int, 2019, 10: 79.
[12]	陈晨，赵龙详，陈旭仁,等.颅脑损伤手术中急性脑膨出的形成原因初步探讨[J].国际神经病学神经外科学杂志, 2017, 44(1): 20-23.
[13]	孙瑾，张俊卿，黄延林,等.外伤后急性弥漫性脑肿胀术中急性脑膨出相关危险因素分析[J].中华神经创伤外科电子杂志, 2016, 2(4): 215-219.
[14]	齐文涛，彭爱军，曹德茂,等.重型颅脑损伤术中急性脑膨出治疗体会[J].中华神经创伤外科电子杂志, 2017, 3(4): 221-225.
[15]	Su TM, Lan CM, Lee TH, et al. Risk factors for the development of contralateral epidural hematoma following decompressive craniectomy in patients with calvarial skull fracture contralateral to the craniectomy site[J]. World Neurosurg, 2016, 89: 223-229.
[16]	Nasi D, di Somma L, Gladi M, et al. New or blossoming hemorrhagic contusions after decompressive craniectomy in traumatic brain injury: analysis of risk factors[J]. Front Neurol, 2019, 9: 1186.
[17]	Kinoshita T, Yoshiya K, Fujimoto Y, et al. Decompressive craniectomy in conjunction with evacuation of intracranial hemorrhagic lesions is associated with worse outcomes in elderly patients with traumatic brain injury: a propensity score analysis[J]. World Neurosurg, 2016, 89: 187-192.
[18]	中华医学会神经外科学分会.神经外科围手术期出血防治专家共识(2018)[J].中华医学杂志, 2018, 98(7): 483-495.
[19]	中国医师协会脑胶质瘤专业委员会.中国神经外科术后加速康复外科(ERAS)专家共识[J].中华神经外科杂志, 2020, 36(10): 973-983.
[20]	Hawryluk GWJ, Rubiano AM, Totten AM, et al. Guidelines for the management of severe traumatic brain injury: 2020 update of the decompressive craniectomy recommendations[J]. Neurosurgery, 2020, 87(3): 427-434.
[21]	刘福增，殷尚炯，韩树生,等.改良T形切口开颅减压术治疗重型颅脑损伤的临床效果[J].中国微侵袭神经外科杂志, 2015, 20(10): 453-455.
[22]	Yang HS, Hyun DK, Oh CH, et al. A faster and wider skin incision technique for decompressive craniectomy:n-Shaped incision for decompressive craniectomy[J]. Korean J Neurotrauma, 2016, 12(2): 72-76.
[23]	Schur S, Martel P, Marcoux J. Optimal bone flap size for decompressive craniectomy for refractory increased intracranial pressure in traumatic brain injury: taking the patient’s head size into account[J]. World Neurosurg, 2020, 137: e430-e436.
[24]	Lyon KA, Patel NP, Zhang Y, et al. Novel hemicraniectomy technique for malignant middle cerebral artery infarction:technical note[J]. Oper Neurosurg(Hagerstown), 2019, 17(3): 273-276.
[25]	Lilja-Cyron A, Andresen M, Kelsen J, et al. Long-term effect of decompressive craniectomy on intracranial pressure and possible implications for intracranial fluid movements[J]. Neurosurgery, 2020, 86(2): 231-240.
[26]	Stoner KE, Abode-Iyamah KO, Grosland NM, et al. Volume of brain herniation in patients with ischemic stroke after decompressive craniectomy[J]. World Neurosurg, 2016, 96: 101-106.
[27]	王利军，周杰，黄立勇,等.去骨瓣减压术后硬脑膜减张修补的临床意义[J].中国急救医学, 2002, 22(2): 52-53.

分组	例数	（男性/别女）	（年龄，岁±s）	发病原因（颅脑损伤/自发出血）	发病部位（左侧/右侧）	基础疾病[例（%）]
常规组	154	110/44	54.1±2.67	72/82	69/85	46（59.9）
改良组	158	117/41	55.6±2.89	71/87	73/85	51（32.3）
t/χ²值		0.271	1.377	0.104	0.061	0.111
P值		0.603	0.169	0.747	0.804	0.739

分组	例数	（男性/别女）	（年龄，岁±s）	发病原因（颅脑损伤/自发出血）	发病部位（左侧/右侧）	基础疾病[例（%）]
常规组	154	110/44	54.1±2.67	72/82	69/85	46（59.9）
改良组	158	117/41	55.6±2.89	71/87	73/85	51（32.3）
t/χ²值		0.271	1.377	0.104	0.061	0.111
P值		0.603	0.169	0.747	0.804	0.739

指标		常规组（n=154）	改良组（n=158）	χ²/Z值	P值
脑肿胀		13（8.4）	3（1.9）	6.862	0.009
脑膨出		16（10.4）	5（3.2）	6.485	0.011
迟发对侧血肿		13（8.4）	4（2.5）	5.287	0.022
术后1周内GCS评分				2.749	0.006
	7~8分	67（43.5）	83（52.5）
	5~6分	38（24.7）	54（34.2）
	3~4分	49（31.8）	21（13.3）
瞳孔变化				17.098	<0.001
	健侧	28（68.3）	44（56.4）
	病侧	13（31.7）	34（43.6）
并发症				22.873	<0.001
	伤口愈合不良	16（10.4）	7（4.4）
	愈合不良并感染	19（12.3）	5（3.2）
	术区脑梗死	28（18.8）	14（8.9）
术后6个月GOS评分				2.484	0.013
	良好	41（26.6）	62（39.2）
	中残	35（22.7）	34（21.5）
	重残	31（20.1）	27（17.1）
	植物生存	32（20.8）	26（16.5）
	死亡	15（9.7）	9（5.7）

指标		常规组（n=154）	改良组（n=158）	χ²/Z值	P值
脑肿胀		13（8.4）	3（1.9）	6.862	0.009
脑膨出		16（10.4）	5（3.2）	6.485	0.011
迟发对侧血肿		13（8.4）	4（2.5）	5.287	0.022
术后1周内GCS评分				2.749	0.006
	7~8分	67（43.5）	83（52.5）
	5~6分	38（24.7）	54（34.2）
	3~4分	49（31.8）	21（13.3）
瞳孔变化				17.098	<0.001
	健侧	28（68.3）	44（56.4）
	病侧	13（31.7）	34（43.6）
并发症				22.873	<0.001
	伤口愈合不良	16（10.4）	7（4.4）
	愈合不良并感染	19（12.3）	5（3.2）
	术区脑梗死	28（18.8）	14（8.9）
术后6个月GOS评分				2.484	0.013
	良好	41（26.6）	62（39.2）
	中残	35（22.7）	34（21.5）
	重残	31（20.1）	27（17.1）
	植物生存	32（20.8）	26（16.5）
	死亡	15（9.7）	9（5.7）

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