陳永漢 賈林偉張剛
開(kāi)放側(cè)裂池、基底池治療外側(cè)裂區(qū)對(duì)沖性腦挫傷的療效觀(guān)察
陳永漢 賈林偉△張剛
目的探討外側(cè)裂區(qū)腦挫傷術(shù)中開(kāi)放側(cè)裂池、基底池治療腦挫裂傷術(shù)后腦血管痙攣的效果。方法將106例外側(cè)裂區(qū)域?qū)_性腦挫傷患者分為對(duì)照組與治療組,對(duì)照組給予常規(guī)開(kāi)顱清除腦挫裂傷灶及血腫,治療組在此基礎(chǔ)上充分開(kāi)放側(cè)裂池、頸動(dòng)脈池、終板池、基底池。檢測(cè)術(shù)后第3、7、14天血漿和腦脊液中內(nèi)皮素-1(ET-1)水平,并觀(guān)察出院時(shí)格拉斯哥昏迷(GCS)評(píng)分、重癥監(jiān)護(hù)室(ICU)監(jiān)護(hù)時(shí)間和總住院時(shí)間;術(shù)后隨訪(fǎng)3個(gè)月,統(tǒng)計(jì)預(yù)后良好率。結(jié)果術(shù)后患者血漿和腦脊液中ET-1水平在不同時(shí)點(diǎn)(血漿F時(shí)間=603.436,腦脊液F時(shí)間=684.276)、不同組間(血漿F組間=272.531,腦脊液F組間=317.641)差異均有統(tǒng)計(jì)學(xué)意義,從各時(shí)點(diǎn)看,除術(shù)后3 d 2組差異無(wú)統(tǒng)計(jì)學(xué)意義外,術(shù)后7 d、14 d治療組均明顯低于對(duì)照組(均P<0.01)。治療組出院GCS評(píng)分高于對(duì)照組,ICU監(jiān)護(hù)時(shí)間和總住院時(shí)間均低于對(duì)照組(均P<0.01)。治療組預(yù)后良好率明顯高于對(duì)照組[78.85%(41/52)vs51.85%(28/54),χ2=8.496,P<0.01]。結(jié)論顱腦外傷術(shù)中開(kāi)放側(cè)裂池、基底池可改善腦挫傷患者的腦血管痙攣,改善預(yù)后。
腦損傷;內(nèi)皮縮血管肽1;腦脊髓液;血管痙攣,顱內(nèi);蛛網(wǎng)膜下腔出血;開(kāi)放側(cè)裂池;側(cè)裂區(qū)對(duì)沖傷;內(nèi)皮素-1
外側(cè)裂區(qū)的腦挫傷也稱(chēng)為額顳部對(duì)沖性腦挫裂傷,在臨床十分常見(jiàn),盡管有時(shí)傷后影像表現(xiàn)不嚴(yán)重,但可繼發(fā)血管源性腦水腫,需急癥手術(shù)。術(shù)后因腦池內(nèi)血性腦脊液或血凝塊可導(dǎo)致遲發(fā)型血管痙攣,進(jìn)一步加重腦缺血并導(dǎo)致患者預(yù)后較差。內(nèi)皮素-1(ET-1)是一種內(nèi)源性長(zhǎng)效血管收縮調(diào)節(jié)因子,其對(duì)血管的收縮作用呈劑量依賴(lài)性,血漿及腦脊液中ET-1的水平可作為腦血管痙攣程度的檢測(cè)指標(biāo)[1]。目前研究認(rèn)為加快蛛網(wǎng)膜下腔出血的排出,可預(yù)防遲發(fā)性腦血管痙攣的發(fā)生[2]。本研究通過(guò)檢測(cè)術(shù)后血漿和腦脊液中ET-1水平,探討開(kāi)放側(cè)裂池治療外側(cè)裂區(qū)、基底池對(duì)沖性腦挫傷術(shù)后遲發(fā)型血管痙攣的療效。
1.1 一般資料選擇2010年1月—2012年6月我院經(jīng)CT確診為外側(cè)裂區(qū)域?qū)_性腦挫傷患者106例,年齡18~61歲,平均(32.4±14.5)歲;其中男64例,女42例。納入標(biāo)準(zhǔn):(1)急性閉合性外側(cè)裂區(qū)腦挫傷。(2)傷后12 h內(nèi)入院治療。(3)入院時(shí)格拉斯哥昏迷(Glasgow coma score,GCS)評(píng)分3~10分。排除標(biāo)準(zhǔn):(1)合并其他系統(tǒng)的嚴(yán)重外傷。(2)血液系統(tǒng)疾病史。(3)嚴(yán)重的肝腎功能不全、凝血障礙史。(4)入院時(shí)合并休克。按術(shù)中是否開(kāi)放側(cè)裂池、基底池將患者分為對(duì)照組和治療組。對(duì)照組54例,其中GCS評(píng)分3分8例,4~7分33例,7~10分13例。治療組52例,其中GCS評(píng)分3分7例,4~7分32例,9~12分13例。2組患者年齡、性別、入院GCS評(píng)分差異均無(wú)統(tǒng)計(jì)學(xué)意義,見(jiàn)表1。
Tab.1 Comparison of basic clinical data between two groups表1 2組一般資料比較
1.2 治療方法對(duì)照組采取額顳部骨瓣開(kāi)顱,咬平蝶骨嵴,顯露蝶骨平臺(tái),懸吊硬膜。顱內(nèi)壓較高者宜從額底部逐步打開(kāi)硬腦膜,邊清除血腫邊剪開(kāi)硬腦膜,避免正常腦組織快速自骨窗處膨出,徹底清除血腫及挫傷失活的腦組織,必要時(shí)切除額極、顳葉失活腦組織,完善止血后去除骨瓣、關(guān)顱[3]。治療組在去骨瓣減壓基礎(chǔ)上,顯微鏡下貼近額葉撕開(kāi)側(cè)裂表面蛛網(wǎng)膜,向遠(yuǎn)、近端游離大腦中淺靜脈,如有出血,以止血紗布止血,由淺入深分離側(cè)裂,剪斷側(cè)裂近端、額眶回與顳回之間增厚的蛛網(wǎng)膜索帶,充分顯露頸內(nèi)動(dòng)脈分叉部,開(kāi)放頸動(dòng)脈池、視交叉池、終板池,輕抬額葉和顳葉底面,棉片保護(hù)好重要血管,清除剩余失活腦組織,反復(fù)沖洗清除腦池內(nèi)的積血。術(shù)后均采用抗感染、三高療法、鈣離子拮抗劑、預(yù)防并發(fā)癥等綜合治療措施。
1.3 監(jiān)測(cè)指標(biāo)(1)術(shù)后第3、7、14天血漿和腦脊液中ET-1水平。(2)出院時(shí)GCS評(píng)分、重癥監(jiān)護(hù)室(ICU)監(jiān)護(hù)時(shí)間、總住院時(shí)間。(3)術(shù)后隨訪(fǎng)3個(gè)月,根據(jù)格拉斯哥預(yù)后評(píng)分劃分為預(yù)后良好(恢復(fù)良好、輕殘)和預(yù)后不良(重殘、植物生存以及死亡)[4]。
1.4 統(tǒng)計(jì)學(xué)方法采用SPSS 12.0軟件進(jìn)行統(tǒng)計(jì)學(xué)處理,計(jì)量資料數(shù)據(jù)以均數(shù)±標(biāo)準(zhǔn)差(±s)表示,組間比較采用獨(dú)立樣本t檢驗(yàn),不同時(shí)點(diǎn)組間比較采用重復(fù)測(cè)量設(shè)計(jì)的方差分析。計(jì)數(shù)資料組間比較行χ2檢驗(yàn)。P<0.05為差異有統(tǒng)計(jì)學(xué)意義。
2.1 2組術(shù)后不同時(shí)點(diǎn)ET-1水平比較2組內(nèi)術(shù)后不同時(shí)點(diǎn)血漿和腦脊液中的ET-1水平差異均有統(tǒng)計(jì)學(xué)意義(均P<0.01),在對(duì)照組、治療組血漿、腦脊液ET-1水平逐漸降低(均P<0.01)。2組間血漿和腦脊液中的ET-1水平差異有統(tǒng)計(jì)學(xué)意義(均P<0.01),從各時(shí)點(diǎn)看,除術(shù)后3 d 2組間比較差異無(wú)統(tǒng)計(jì)學(xué)意義外,術(shù)后7 d、14 d治療組均明顯低于對(duì)照組(均P<0.01)。組間和處理時(shí)間之間存在交互效應(yīng)(均P<0.01),見(jiàn)表2、3。
Tab.2 Comparison of plasma levels of ET-1 in different time points after operation between two groups表2 2組術(shù)后不同時(shí)點(diǎn)血漿ET-1水平比較(μg/L,±s)
Tab.2 Comparison of plasma levels of ET-1 in different time points after operation between two groups表2 2組術(shù)后不同時(shí)點(diǎn)血漿ET-1水平比較(μg/L,±s)
組別對(duì)照組治療組t n F 54 52 3 d 103.4±21.7 98.5±17.3 1.282 7 d 127.9±24.7 92.3±11.8 9.409**14 d 97.4±12.9 65.9±10.1 13.963**103.257**98.463**F組間=272.531,F(xiàn)時(shí)間=603.436,F(xiàn)交互=85.610,均P<0.01;**P<0.01
Tab.3 Comparison of ET-1 levels of cerebrospinal fluid in different time points after operation between two groups表3 2組術(shù)后不同時(shí)點(diǎn)腦脊液ET-1水平比較(μg/L,±s)
Tab.3 Comparison of ET-1 levels of cerebrospinal fluid in different time points after operation between two groups表3 2組術(shù)后不同時(shí)點(diǎn)腦脊液ET-1水平比較(μg/L,±s)
F組間=317.641,F(xiàn)時(shí)間=684.276,F(xiàn)交互=95.410,均P<0.01;**P<0.01
?
2.2 2組出院GCS評(píng)分、ICU監(jiān)護(hù)時(shí)間和總住院時(shí)間的比較治療組出院GCS評(píng)分高于對(duì)照組,ICU監(jiān)護(hù)時(shí)間和總住院時(shí)間均低于對(duì)照組(均P<0.01),見(jiàn)表4。
Tab.4 Comparison of GCS score,ICU guardianship time and total length of hospital stay between two groups表4 2組出院GCS評(píng)分、ICU監(jiān)護(hù)時(shí)間和總住院時(shí)間的比較(±s)
Tab.4 Comparison of GCS score,ICU guardianship time and total length of hospital stay between two groups表4 2組出院GCS評(píng)分、ICU監(jiān)護(hù)時(shí)間和總住院時(shí)間的比較(±s)
**P<0.01
組別對(duì)照組治療組t出院GCS評(píng)分8.5±2.1 11.3±3.2 5.345**ICU監(jiān)護(hù)時(shí)間(d)25.4±18.3 15.6±8.7 3.499**總住院時(shí)間(d)34.2±22.6 18.6±9.4 4.608**
2.3 治療組與對(duì)照組預(yù)后情況比較治療組預(yù)后良好率明顯高于對(duì)照組[78.85%(41/52)vs51.85% (28/54)],差異有統(tǒng)計(jì)學(xué)意義(χ2=8.496,P<0.01)。
腦血管痙攣是顱腦創(chuàng)傷后比較常見(jiàn)的一種現(xiàn)象,據(jù)報(bào)道其在中重型腦損傷中的發(fā)生率為27%~50%[1]。流入蛛網(wǎng)膜下腔的血液及其降解產(chǎn)物是導(dǎo)致腦血管痙攣的最主要原因,血管痙攣引起相應(yīng)血管區(qū)產(chǎn)生缺血或梗死,最終致殘或死亡[2]。研究顯示蛛網(wǎng)膜下腔的積血以及由積血裂解而來(lái)的各類(lèi)產(chǎn)物是導(dǎo)致腦血管痙攣的啟動(dòng)因子,初始刺激越大,痙攣程度就越高,提示痙攣的嚴(yán)重程度與蛛網(wǎng)膜下腔出血的量有關(guān)[1]。目前外傷性蛛網(wǎng)膜下腔出血引起腦血管痙攣的防治多應(yīng)用鈣離子拮抗劑尼莫地平[5]。但藥物治療無(wú)法從源頭上去除或抑制引起血管痙攣的啟動(dòng)因子,而且藥物對(duì)已形成的血管痙攣的治療作用有限。目前腦脊液引流方式主要有腦室外引流、間斷性腰穿和持續(xù)腰大池引流[6-7],但是這些方式對(duì)血性腦脊液的清除速度不盡如人意,且術(shù)后早期顱內(nèi)壓力偏高,腰大池引流受到明顯限制。而打開(kāi)外側(cè)裂池行腦脊液引流則較為簡(jiǎn)單易行,其可在行標(biāo)準(zhǔn)外傷大骨瓣開(kāi)顱血腫清除后就直接打開(kāi)側(cè)裂池、基底池,無(wú)需術(shù)后再另行腰大池置管,減少了另行腰大池置管操作引起的痛苦、局部創(chuàng)傷、出血、感染等并發(fā)癥發(fā)生的概率。但筆者認(rèn)為僅開(kāi)放側(cè)裂池不能充分通暢引流血性腦脊液。開(kāi)放視交叉池、終板池、基底池,其作用在于打開(kāi)腦池后,便于清除積血及引流血性腦脊液,減輕血管痙攣及降低顱內(nèi)壓,還可使大腦中淺靜脈部分游離,減少其壓迫扭曲,有利于靜脈回流。另外剪斷側(cè)裂近端、額眶回之間的纖維,能夠增大額、顳葉移動(dòng)范圍,便于抬起腦葉解除腦疝。本研究結(jié)果顯示,除術(shù)后3 d治療組與對(duì)照組血漿、腦脊液ET-1無(wú)明顯差異外,術(shù)后7 d、14 d治療組均明顯低于對(duì)照組。提示對(duì)外側(cè)裂區(qū)腦挫傷患者術(shù)中開(kāi)放側(cè)裂池、基底池可在血管痙攣的早期及高峰期有效地減輕腦血管痙攣程度。另外,本研究中治療組出院GCS評(píng)分高于對(duì)照組,ICU監(jiān)護(hù)時(shí)間和總住院時(shí)間均低于對(duì)照組,且預(yù)后良好率明顯高于對(duì)照組。有研究表明腦脊液通暢引流可明顯降低致死率、致殘率[8],與本研究結(jié)果基本一致。
綜上所述,顱腦外傷術(shù)中開(kāi)放側(cè)裂池、基底池可改善腦挫傷患者的腦血管痙攣,改善預(yù)后。
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(2013-09-01收稿2014-02-08修回)
(本文編輯陳麗潔)
Observations on the Effects of Opening Side Crack Pool and Basal Cistern for the Treatment of Lateral Fissure Hedge Brain Contusion
CHEN Yonghan,JIA Linwei,ZHANG Gang
Department of Neurosurgery,the Cangzhou Central Hospital,Heibei 061001,China JIA Linwei,E-mail:czsjwk@163.com
ObjectiveTo investigate the therapeutic effect of the lateral fissure opened intraoperative cerebral contusion sylvian cistern,basal cistern for improving the cerebral vasospasm.MethodsA total of 106 patients with cerebral contusion in lateral fissure area were randomly divided into 2 groups.The control group was given conventional craniotomy to clear focal cerebral contusion of hematoma.And the experimental group was further to fully open sylvian cistern,jugular vein pool,endplate pool and basal cistern on the basis of the conventional craniotomy to remove the brain contusion and hematoma.The levels of endothelin 1(ET-1)in plasma and cerebrospinal fluid(CSF)were detected postoperative 3,7 and 14 days. The Glasgow coma scale(GCS)score,ICU guardianship time and total length of hospital stay were observed on discharge and followed up for 3 months in two groups.The rate of good prognosis was compared between two groups.ResultsThere were significant differences in ET-1 levels of plasma and CSF at different time points(plasma Ftime=603.436 and CSF Ftime= 684.276)between two groups of patients(plasma Fgroup=272.531 and CSF Fgroup=317.641).The ET-1 levels were significantly lower after 7 d and 14 d treatment in experimental group,but no significant difference 3d after operation between two groups(P<0.01).The GCS score was significantly higher on discharge in experimental group than that of control group.The values of ICU guardianship time and the total hospitalization time were both significantly lower in experimental group than those of control group(P<0.01).The rate of good prognosis was significantly higher in experimental group than that of control one[78.85%(41/52)vs 51.85%(28/54),χ2=8.496,P<0.01].ConclusionOpenning side crack pool and basal cistern in the surgical treatment of traumatic brain injury can improve the cerebral vasospasm and prognosis.
brain injuries;endothelin-1;cerebrospinal fluid;vasospasm,intracranial;subarachnoid hemorrhage; open side crack pool;lateral fissure area hedge;ET-1
R651.1
A
10.3969/j.issn.0253-9896.2014.07.023
河北省科技廳科技攻關(guān)項(xiàng)目(12276104D-14)
河北省滄州市中心醫(yī)院神經(jīng)外二科(郵編061001)
△通訊作者E-mail:czsjwk@163.com