摘目 探讨标准骨瓣减压术联合血重建术治疗重型颅脑损伤疗效脑灌注影响 方法 选择2014年1月2017年1月院接诊90例重型颅脑损伤患者进行研究通机数表法分观察组(n45)组(n45)组标准骨瓣减压术治疗观察组联合脑硬脑膜肌肉血重建术治疗较两组血液流变学凝血功颅压(ICP)脑灌注量(CCP)术发症预结果 手术7d两组全血高切粘度全血低切粘度血浆粘度红细胞压积较手术前均显著降低(P<005)观察组两组全血高切粘度全血低切粘度血浆粘度红细胞压积均明显组低(P<005)手术7d两组凝血酶原时间(PT)部分凝血活酶时间(APTT)凝血酶原时间(TT)较手术前均显著升高(P<005)观察组PTAPPTTT明显高组(P<005)手术7d两组ICP较手术前均显著降低CCP显著升高(P<005)观察组ICP明显低组CCP明显组高[(1631±170)mmHg vs(2140±194)mmHg(6498±730)mmHg vs(5754±619)mmHg](P<005)两组颅感染癫痫脑积水切口疝发生率较均显著差异(P>005)术6月时观察组预良率6667(3045)明显高组4000(1845)(P<005)结 重型颅脑损伤患者中标准骨瓣减压术联合血重建术效果显著效改善血液流变学凝血功促进脑灌注术发症少预高值应推广
关键词重型颅脑损伤标准骨瓣减压术血重建术脑灌注
Curative efficacy of standard large bone flap decompression combined with revascularization in treatment of severe craniocerebral injury and its effects on cerebral perfusion
[Abstract] Objective To study the curative efficacy of standard large bone flap decompression combined with revascularization in treatment of severe craniocerebral injury and its effects on cerebral perfusion Methods 90 patients of severe craniocerebral injury who received therapy fromJanuary 2014 to January 2017 in our hospital were selected as research objects According to random number tablethose patients were divided into the observation group (n45) and the control group (n45) the control group was treated with standard large bone flap decompression while the observation group was combined with brainduramatermuscle revascularization The blood rheology coagulation function intracranial pressure (ICP) cerebral perfusion volume (CCP) postoperative complications and prognosis were compared between the two groups Results After surgery 7d the whole blood viscosity whole blood viscosity plasma viscosity and hematocrit of two groups were significantly lower than those before surgery(P<005) the whole blood viscosity whole blood viscosity plasma viscosity and hematocrit in the observation group were significantly lower than those in the control group(P<005) after surgery 7d the prothrombin time (PT) activated partial thromboplastin time (APTT) prothrombin time (TT) of two groups were significantly higher than those before operation(P<005) the PT APPT and TT in the observation group were significantly higher than those in the control group(P<005) after surgery 7d the ICP of two groups was significantly lower than those before operation and the CCP was significantly increased(P<005) the ICP in the observation group was significantly lower than those in the control group and the CCP was significantly higher than those in the control group[(1631±170) mmHg vs(2140±194)mmHg (6498±730)mmHg vs(5754±619)mmHg] (P<005) there was no significant difference in the incidence of intracranial infection epilepsy hydrocephalus and incisional hernia between the two groups(P>005) after surgery 6 months the good prognosis rate in the observation group was 6667 (3045) which was significantly higher than those in the control group 4000(1845)(P<005) Conclusion Standard large bone flap decompression combined with revascularization is well for severe craniocerebral injury which can effectively improve blood rheology and coagulation function promote cerebral perfusion and has less postoperative complications and higher prognosis it’s worthy of popularization and application
[Key words] Severe craniocerebral injury Standard large bone flap decompression Revascularization Cerebral perfusion
颅脑损伤床常见外伤见交通事伤坠落伤工矿事等相关数显示颅脑损伤全身部位伤中占例17~22重型颅脑损伤致死率居全身部位伤首位高达35[1]尤伤致额颞叶脑挫裂伤重型颅脑损伤患者中通常脑水肿颅血肿脑梗死等疾病合疾病进展快预差[2]早降低颅压改善脑部血流恢复脑灌注该病治疗关键类患者目前床行急诊标准骨瓣减压术重型颅脑患者中脑组织血损伤血液循环血脑屏障破坏等现象重新建立新血耗费时间长部分患者甚难重新建立血[34]血重建术脑缺血疾病中种常见方式改善脑组织血运中效果显著重型颅脑损伤中应报道较少[56]研究旨探讨重型颅脑损伤中标准骨瓣减压术联合血重建术治疗优势观察脑灌注影响现报道
1资料方法
11 般资料
选择2014年1月2017年1月院接诊90例重型颅脑损伤患者进行研究纳入标准:①存明确外伤额颞叶脑挫裂伤重型颅脑损伤CT检查中显示幕病变侧额颞叶脑挫伤硬膜血肿②偏瘫昏迷失语等床症状生命体征改变③单侧双侧瞳孔散④符合手术适应证⑤患者家属研究知情意排标准:①原发性脑干损伤②合失血性休克系统衰竭凝血功障碍者③存长期头痛高血压等疑性脑血病④脑肿瘤史血栓史等⑤外伤短期(6h)死亡受伤入院时间超24h宜采取手术治疗者⑥未完成访通机数表法分2组45例观察组男24例女21例年龄23~69岁均(4485±862)岁致伤原:交通伤24例坠落伤13例混合伤6例余2例受伤手术时间1~6h(385±120)h组男26例女19例年龄21~70岁均(4613±795)岁致伤原:交通伤23例坠落伤15例混合伤5例余2例受伤手术时间05~7h均(376±128)h两组般资料较显著差异(P>005)具性
12 方法
组予标准骨瓣减压术颧骨耳屏前作弧形切口前延额标处放延顶骨中线处头皮切口直颅骨制作肌皮瓣充分显露颅骨额颞顶区裸露颅骨处作5~6钻孔骨孔钻断咬骨钳颅骨咬延伸中颅窝底12cm×14cm形成型游离骨瓣骨瓣包括额骨顶骨颞骨鳞部硬膜外脑挫伤处坏死组织脑水肿彻底清干净悬吊硬脑膜留置引流次缝合腱膜层关颅
观察组联合脑硬脑膜肌肉血重建术治疗术中标准骨瓣减压术组基致切开头皮程中需避开颞浅动脉干骨膜剥离子通颞肌剥离保证颞深动脉网络完整骨瓣游离时保证脑膜中动脉硬脑膜失活血肿组织仔细清脑膜中动脉干两侧分支硬脑膜切开宽度约08cm放射状余部分硬脑膜切开止血脑皮层表面反折贴敷硬脑膜颞浅动脉损颞肌减张缝合骨瓣硬膜外放置引流次缝合帽状腱膜层头皮
13 观察指标
术前术7dMVIS全动血液流变分析仪检测全血高切粘度全血低切粘度血浆粘度红细胞压积变化罗氏INR凝血检测仪检测凝血酶原时间(PT)部分凝血活酶时间(APTT)凝血酶原时间(TT)变化飞利浦Light Speed 256排螺旋CT检测颅压(ICP)脑灌注量(CCP)记录术发症
术6月格拉斯哥量表(GOS)[7]评价患者预恢复良:GOS评分5分稍残疾正常工作生活造成影响轻度残疾:GOS评分4分独立生活保护性完成工作重度残疾:GOS评分3分重度残疾意识清晰日常生活需顾植物状态:GOS评分2分仅睁眼睡眠周期等反应死亡:GOS评分1分恢复良+轻度残疾预良率
14 统计学分析
spss180软件包处理计量资料均数±标准差(±s)表示组间较独立样t检验计数资料率表示χ2检验等级资料秩检验P<005表示差异具统计学意义
2 结果
21 两组血液流变学较
手术前两组全血高切粘度全血低切粘度血浆粘度红细胞压积较均显著差异(P>005)手术两组血液流变学指标较手术前均显著降低(P<005)观察组两组全血高切粘度全血低切粘度血浆粘度红细胞压积均明显组低(P<005)见表1
表1两组血液流变学较(±s)
组
例数
全血高切粘度(mPa·s)
全血低切粘度(mPa·s)
血浆粘度(mPa·s)
红细胞压积()
手术前
手术
手术前
手术
手术前
手术
手术前
手术
观察组
45
489±125
387±093*
985±151
729±124*
157±024
117±014*
5684±931
4393±572*
组
45
502±112
433±107*
968±170
839±140*
164±020
138±018*
5834±869
4924±651*
t值
0520
2177
0502
3946
1503
6178
0790
4110
P值
0605
0032
0617
0000
0136
0000
0432
0000
手术前较*P<005
22 两组凝血功较
手术前两组PTAPPTTT较均显著差异(P>005)手术两组PTAPPTTT较手术前均显著升高(P<005)观察组PTAPPTTT明显高组(P<005)见表2
表2两组凝血功较(±ss)
组
例数
PT
APPT
TT
手术前
手术
手术前
手术
手术前
手术
观察组
45
1083±117
1453±135*
2284±374
3483±425*
1594±116
1893±177*
组
45
1046±104
1204±±122*
2337±340
2816±388*
1620±104
1734±152*
t值
1586
9180
0703
7775
1120
4572
P值
0116
0000
0484
0000
0266
0000
手术前较*P<005
23 两组脑灌注情况较
手术前两组ICPCCP较显著差异(P>005)手术两组ICP较手术前均显著降低CCP显著升高(P<005)观察组ICP明显低组CCP明显组高(P<005)见表3
表3两组脑灌注情况较(±smmHg)
组
例数
ICP
CCP
手术前
手术
手术前
手术
观察组
45
2745±242
1631±170*
4895±569
6498±730*
组
45
2817±220
2140±194*
5013±517
5754±619*
t值
1476
13237
1030
5215
P值
0143
0000
0306
0000
手术前较*P<005
24 两组术发症较
两组颅感染癫痫脑积水切口疝发生率较均显著差异(P>005)见表4
表4两组术发症较(例)
组
例数
颅感染
癫痫
脑积水
切口疝
观察组
45
3(667)
1(222)
1(222)
3(667)
组
45
2(444)
2(444)
2(444)
2(444)
χ2值
0212
0345
0345
0212
P值
0645
0557
0557
0645
25 两组预情况较
术6月时观察组预良率6667明显高组4000(P<005)见表5
表5两组预情况较(例)
组
例数
恢复良
轻度残疾
重度残疾
植物状态
死亡
预良率
观察组
45
13(2889)
17(3778)
11(2444)
3(667)
1(222)
30(6667)
组
45
6(1333)
12(2667)
20(4444)
5(1111)
2(444)
18(4000)
uχ2值
u2496
χ26429
P值
P0013
P0011
3 讨
颅脑损伤外界暴力作头部引发着年交通事断频发改变发病率日趋升高重型颅脑损伤患者中出现恶心呕吐意识障碍昏迷等症状合广泛硬膜血肿广泛脑挫裂伤增加颅压严重甚发生脑疝脑移位等导致患者残疾死亡重素[89]
标准骨瓣减压术20世纪80年代末提出广泛应较研究指出效降低颅压术发症少安全性高[1011]研究显示该方式重建脑组织血供中效果欠佳[12]血重建术烟雾病治疗中迅速改善脑灌注足促进血流恢复效果优异年逐渐应颅动脉瘤等疾病中[1314]
血液流变学十分观反映血血液间联系血液血中流动特点评价血液微循环状态中作关键易萍[15]研究显示重型颅脑患者受伤机体项血液流变学指标发生明显改变表现全血高切粘度全血低切粘度血浆粘度红细胞压积升高等类现象直接导致脑组织微循环恶化影响脑组织修复脑外伤脑组织缺氧缺血等状态激活凝血系统致凝血功出现障碍引发微循环障碍Liu J等[16]报道指出积极纠正颅脑损伤患者血液流变学凝血功促进脑灌注神恢复中具积极意义
研究显示两组患者术7d时血液流变学凝血指标较术前均明显改善联合血重建术患者全血高切粘度全血低切粘度血浆粘度红细胞压积降低程度PTAPPTTT升高程度均优单独标准骨瓣患者分析研究联合脑硬脑膜肌肉血重建术硬脑膜血带血颞肌损伤脑表面直接贴敷血间相互融合利增生毛细血直接损伤部位脑组织血液循环进行改善[17]患者血液流变学凝血指标改善程度更加明显联合血重建术患者ICPCCP改善程度均优单独标准骨瓣减压术患者提示联合术式效改善微循环障碍进步降低颅压促进脑组织灌注恢复黄良珍等[18]研究具相似性两组患者术颅感染癫痫脑积水切口疝发生率均显著差异提示联合血重建术未增加术发症风险安全性高
外术6月时联合血重建术患者预良率6667明显高单独标准骨瓣减压术患者4000进步显示联合术式提高预中效果显著分析联合术式仅效降低颅压明显促进脑灌注改善脑组织缺血缺氧状态令脑组织恢复降低脑梗死发生率继提高生存质量
综述重型颅脑损伤患者中标准骨瓣减压术联合血重建术效果显著效改善血液流变学凝血功促进脑灌注术发症少预高值应推广
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