中文摘要：

目的 探讨大骨瓣开颅减压术（DC）治疗重型颅脑创伤（sTBI）后顽固性高颅压的作用及实施DC的时机对预后的影响.方法 回顾性分析132例临床资料,根据伤后6个月时的GOS评分将其分为良好组（GOS 4～5分,n=55）,不良组（GOS 2～3分,n=46）和死亡组（GOS 1分,n=31）.研究DC对于sTBI患者伤后颅内压（ICP）和脑灌注压（CPP）治疗作用及不同时间实施DC对预后的影响.结果 本研究病例的死亡率为23.5%（31/132）,恢复良好率41.7%（55/132）.DC前后的ICP平均值为（35.0±12.8）mmHg和（18.3±12.0）mmHg（P＜0.05）、CPP平均值为（50.2±12.4）mmHg和（60.6±12.0）mmHg（P＜0.05）,在恢复良好组,DC前后这两个指标变化则更为显著.在伤后不同时间段实施DC与死亡率和恢复良好率无显著相关性.结论 DC对于sTBI后弥漫性脑肿胀、脑水肿所致顽固性高颅压患者在存活组比死亡组更能有效地降低ICP和升高CPP,而伤后实施DC的时间对于预后影响不明显.DC后持续存在ICP≥25 mmHg是预测死亡的敏感指标.

英文摘要：

Objective To investigate the role of decompressive craniectomy （DC） to decrease the intractable intracranial hypertension（ICH） due to the diffuse brain swelling and/or cerebral edema after severe traumatic brain injury and the time window of DC to affect on the prognosis.Methods The clinical record of 132 patients who underwent DC for post- traumatic intractable ICH in our hospital from July 2003 to December 2009 with sTBI（Glasgow coma scale≤8） were analyzed retrospectively.The outcome was as measured by Glasgow Outcome Scale （GOS） at the 6th month post-trauma and these patients were divided into favorable group（GOS 4～5,n = 55 ）,unfavorable group （GOS 2 ～ 3,n = 46） and Death （GOS 1,n = 31 ）.The influence of DC on intracranial pressure （ICP）,cerebral perfusion pressure （CPP） and timing of DC on prognosis were analyzed.Methods Of 132 patients,mortality was 23.5% （31/132 ）,favorable outcome was observed in 41.7% （55/132 ）.Through undergoing DC,ICP decreased from （35.0±12.8） mmHgto （18.3±12.0） mmHg（P＜0.05）and CPP increased from （50.2±12.4）mmHg to （60.6±12.0）mmHg（P＜0.05）.These changes were more significant in survivors than in non- survivors （P=0.001 and P=0.003）.No tendency towards either increased or decreased in favorable outcome and mortality was found relative to the timing of DC post-trauma.Persistent ICP≥25 mmHg of post- DC was a predicted parameter of mortality（sensitivity 81.6% ,specificity 92.4%,positive predictive value 68.4%,negative predictive value 94.7%）.Conclusion DC deceased ICP and increased CPP more obviously in survivors compared to non-survivors in sTBI with ICH.The timing of DC showed no clear trend,for either good neurological outcome or death.The postoperative ICP ≥ 25 mmHg was a threshold to predicted mortality.