目的 探讨硬通道微创穿刺对创伤性急性硬膜下血肿并脑疝开颅前减压的治疗效果. 方法 采用回顾性病例对照研究分析2004年1月-2016年10月收治的303例创伤性急性硬脑膜下血肿并脑疝患者临床资料,其中男206例,女97例;年龄12 ~77岁[(43.6±20.1)岁];格拉斯哥昏迷评分(GCS)3 ~5分187例,6~8分116例.按手术方式分为研究组(199例)和对照组(104例).研究组采用一次性颅内血肿清除套装针穿刺抽吸+引流血肿后,再行大骨瓣开颅、硬脑膜下血肿清除的方法.对照组采用传统大骨瓣开颅、硬脑膜下血肿清除.比较两组获减压时间、术后清醒时间、住院时间及术后颅内感染等.采用格拉斯哥预后评分(GOS)评估预后. 结果 获减压时间:研究组10~15 min[(12.5±1.7)min],对照组50~75 min[(133.0±7.9)min](P<0.05).术后清醒时间:术后≤3 d清醒研究组62例,对照组18例;术后4~7d清醒研究组76例,对照组22例;术后8~ 15 d清醒研究组26例,对照组29例;术后>15 d清醒研究组10例,对照组12例;术后不能清醒(含死亡)研究组25例,对照组23例(P<0.05).住院时间:研究组为(19.5±1.1)d,对照组为(22.8 ±2.8)d (P <0.05).研究组无一例颅内感染,对照组发生1例(P>0.05).根据GOS结果,研究组恢复良好133例,中残、重残41例,植物生存7例,死亡18例;对照组恢复良好34例,中残、重残47例,植物生存9例,死亡14例(P<0.05). 结论 硬通道微创穿刺血肿清除术在创伤性急性硬膜下血肿并脑疝开颅前可快速减轻血肿对脑的压迫,降低致残率,具有较高的临床应用价值.
Objective To explore the value of minimally invasive puncturation via the hard tunnel in decompression before craniotomy for acute subdural hematoma combined with cerebral hernia.Methods A retrospective method was adopted to analyze the clinical data of 303 patients with traumatic acute subdural hematoma combined with cerebral hernia treated from January 2004 to October 2016.There were 206 males and 97 females,with age range of 12-77 years [(43.6 ± 20.1) years].The Glasgow coma scale (GCS) was 3-5 points in 187 patients and 6-8 points in 116.The patients were divided into study group (n =199) and control group (n =104) according to the different surgical procedures.For study group,the patients were treated with disposable ventricular needle to suck out and drain the intracranial hematoma,and the skull was opened through the large craniotomy to remove the subdural hematoma.For control group,the skull was opened through the large craniotomy which was used to directly remove the subdural hematoma according to the traditional instruction.The differences between two groups were compared with regard to time from confirming the cerebral hernia to the first decompression,time of regaining consciousness after surgery,hospitalization duration and cranial cavity infection after surgery.Glasgow outcome scale (GOS) was used to evaluate the prognosis.Results The time to first decompression was 10-15 minutes [(12.5 ± 1.7)minutes] in study group and 50-75 minutes [(133.0 ± 7.9) minutes] in control group (P < 0.05).Regaining consciousness within 3 days after surgery was found in 62 patients of study group and 18 of control group.Regaining consciousness at days 4-7 after surgery was found in 76 patients of study group and 22 of control group.Regaining consciousness at days 8-15 days after surgery was found in 26 patients of study group and 29 of control group.Regaining consciousness over 15 days after surgery was found in 10 patients of study group and 12 of control group.Postoperative unconsciousness including death was found in 25 patients of study group and 23 of control group (P < 0.05).The hospitalization duration was (19.5 ± 1.1) days in study group and (22.8 ± 2.8) days in control group (P < 0.05).No cranial cavity infection was found in study group,while cranial cavity infection occurred in one patient in control group.According to the GOS,the outcome in study group was good in 133 patients,moderate to severe disability in 41,vegetative state in 7 and death in 18,while the outcome in control group was good in 34 patients,moderate to severe disability in 47,vegetative state in 9 and death in 14 (P < 0.05).Conclusion The minimally invasive puncturation via the hard tunnel to remove the hematoma is capable of reducing the intracranial pressure before craniotomy for acute subdural hematoma combined with cerebral hernia,can decrease the disability rate and hence is prioritized to clinical application.