去骨瓣減壓與內(nèi)科保守治療大面積腦梗死初步療效的比較研究

張子非，鄭雪丹，韓雅玲，陳會(huì)生

去骨瓣減壓與內(nèi)科保守治療大面積腦梗死初步療效的比較研究

張子非，鄭雪丹，韓雅玲，陳會(huì)生

目的探討外科去骨瓣減壓術(shù)和內(nèi)科保守治療對(duì)大面積腦梗死的療效。方法選擇沈陽(yáng)軍區(qū)總醫(yī)院2010 年8月－2013年10月收治的69例大面積腦梗死患者，按治療情況分為內(nèi)科保守治療組(n=53)與手術(shù)治療組(n=16)，對(duì)比兩組患者死亡發(fā)生率，對(duì)存活者采用美國(guó)神經(jīng)功能缺損評(píng)分(NIHSS)標(biāo)準(zhǔn)進(jìn)行療效評(píng)估。結(jié)果手術(shù)治療組死亡發(fā)生率(12.5%)明顯低于內(nèi)科保守治療組(39.6%，P<0.05)；兩組存活者治療后的NIHSS評(píng)分均較治療前明顯降低，且兩組間差異有統(tǒng)計(jì)學(xué)意義(19.38±1.86vs13.21±2.05，P<0.05)；手術(shù)治療組神經(jīng)功能恢復(fù)明顯優(yōu)于內(nèi)科保守治療組。結(jié)論手術(shù)治療能降低腦梗死患者的死亡發(fā)生率，提高患者生活質(zhì)量，對(duì)具備手術(shù)指征的患者應(yīng)爭(zhēng)取盡早行手術(shù)治療。

腦梗死；外科手術(shù)；藥物治療

大面積腦梗死是神經(jīng)內(nèi)科常見的危重癥之一，病死率和致殘率極高，占腦卒中的10%。大面積腦梗死通常由頸內(nèi)動(dòng)脈主干、大腦中動(dòng)脈主干或皮層支的完全性卒中引起[1-2]，且常合并嚴(yán)重腦水腫，導(dǎo)致顱內(nèi)壓增高，腦疝形成。目前臨床常用的治療方法有一般性內(nèi)科治療、溶栓治療、外科治療及康復(fù)治療等。近期有國(guó)外數(shù)據(jù)表明去骨瓣減壓手術(shù)能降低該病死亡發(fā)生率，改善神經(jīng)功能預(yù)后，為指南所推薦[3-5]。但有關(guān)手術(shù)適應(yīng)證如手術(shù)時(shí)機(jī)、患者適用年齡等指標(biāo)仍存在爭(zhēng)議[6-11]。國(guó)內(nèi)關(guān)于骨瓣減壓術(shù)的研究較少，缺乏高質(zhì)量的研究數(shù)據(jù)證實(shí)去骨瓣減壓術(shù)較一般內(nèi)科治療更能降低死亡發(fā)生率，中國(guó)人群療效是否與國(guó)外一致尚不清楚。本研究對(duì)近3年內(nèi)采取不同治療方法(一般性內(nèi)科治療和手術(shù)治療)的69例大面積腦梗死患者進(jìn)行回顧性分析，報(bào)告如下。

1 資料與方法

1.1 一般資料 選取2010年8月－2013年10月沈陽(yáng)軍區(qū)總醫(yī)院神經(jīng)內(nèi)科收治的大面積腦梗死患者69例，按治療情況分為內(nèi)科保守治療組(n=53)與手術(shù)治療組(n=16)。內(nèi)科治療組為神經(jīng)外科會(huì)診具備手術(shù)指征且無手術(shù)禁忌，但患者家屬拒絕手術(shù)的患者，其中男34例，女19例，年齡62.0±11.2(36～79)歲，手術(shù)治療組中男13例，女3例，年齡54.5±8.1(40～67)歲。

1.2 入選標(biāo)準(zhǔn) ①臨床癥狀與體征符合大腦中動(dòng)脈主干或頸內(nèi)動(dòng)脈梗死表現(xiàn)；②CT及(或)頭顱MRI(DWI)檢查提示大腦中動(dòng)脈或頸內(nèi)動(dòng)脈支配區(qū)缺血或梗死，影像學(xué)檢查符合大面積腦梗死診斷標(biāo)準(zhǔn)(Adama[12]將梗死灶直徑≥3cm及≥2個(gè)部位，或梗死灶面積≥20cm2定義為大面積腦梗死)；③所有患者均符合大面積腦梗死診斷標(biāo)準(zhǔn)，且均經(jīng)內(nèi)科保守治療病情進(jìn)行性加重，并經(jīng)外科醫(yī)師評(píng)定為必要手術(shù)者；④排除中途死于其他疾病者。

1.3 治療方法 內(nèi)科保守治療組：予20%甘露醇聯(lián)合甘油果糖及托拉塞米脫水降顱壓、腦保護(hù)、尤瑞克林改善側(cè)支循環(huán)、抗血小板聚集、阿托伐他汀鈣強(qiáng)化降脂等治療[13]。手術(shù)治療組：術(shù)前均行內(nèi)科積極保守治療，手術(shù)前均為昏迷狀態(tài)且伴腦疝征象，符合開顱手術(shù)指征，經(jīng)家屬知情同意后于神經(jīng)外科手術(shù)治療，術(shù)式為去骨瓣減壓術(shù)，術(shù)后給予呼吸機(jī)輔助呼吸、鎮(zhèn)靜、脫水治療。

1.4 觀察指標(biāo) 治療前后分別評(píng)估美國(guó)神經(jīng)功能缺損(NIHSS)評(píng)分，療效以NIHSS評(píng)分的降低率來判斷。計(jì)算方法為：NIHSS評(píng)分降低率=(治療前評(píng)分－治療后評(píng)分)/治療前評(píng)分×100%。療效評(píng)價(jià)：患者神經(jīng)功能缺損判讀：NIHSS評(píng)分減少91%～100%為基本痊愈； NIHSS評(píng)分減少46%～90%為顯效；NIHSS評(píng)分減少18%～45%為有效；NIHSS評(píng)分減少＜17%為無效[14]。

1.5 統(tǒng)計(jì)學(xué)處理 采用SPSS 17.0軟件進(jìn)行統(tǒng)計(jì)學(xué)分析。計(jì)量資料以表示，組間比較采用t檢驗(yàn)；計(jì)數(shù)資料以百分比(%)表示，組間比較采用χ2檢驗(yàn)。P<0.05為差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié) 果

2.1 人口學(xué)資料 兩組間性別、年齡、高血壓、糖尿病、心臟病、卒中、吸煙及飲酒史、左右大腦半球梗死等方面差異無統(tǒng)計(jì)學(xué)意義，兩組患者基礎(chǔ)狀態(tài)基本一致。發(fā)病距手術(shù)的時(shí)間間隔、手術(shù)前腦CT上的梗死體積差異亦無統(tǒng)計(jì)學(xué)意義，從發(fā)病到手術(shù)的時(shí)間看，手術(shù)治療組患者大部分在發(fā)病2d后進(jìn)行手術(shù)(表1)。

表1 入選患者的基線臨床特征Tab.1 Baseline clinical characteristics of enrolled patients

2.2 兩組患者總體死亡發(fā)生率及存活者NIHSS評(píng)分比較 內(nèi)科保守治療組死亡發(fā)生率39.6%，明顯高于手術(shù)治療組的12.5%(χ2=4.009，P<0.05，表2)。兩組存活患者NIHSS評(píng)分的比較：內(nèi)科保守治療組基礎(chǔ)NIHSS定義為癥狀加重后外科會(huì)診需要手術(shù)時(shí)的評(píng)分；手術(shù)治療組基礎(chǔ)NIHSS評(píng)分定義為轉(zhuǎn)至外科手術(shù)前的評(píng)分。兩組存活患者治療前基礎(chǔ)NIHSS評(píng)分差異無統(tǒng)計(jì)學(xué)意義(P>0.05)；治療2個(gè)月后兩組患者NIHSS評(píng)分均明顯下降，手術(shù)治療組NIHSS評(píng)分較內(nèi)科保守治療組更低，兩組比較差異有統(tǒng)計(jì)學(xué)意義(F=247.919，P<0.000，表3)。手術(shù)治療組與內(nèi)科保守治療組比較，無論是顯效、有效、無效患者例數(shù)均優(yōu)于內(nèi)科保守治療組(χ2=20.487，P<0.05，表4)。以上結(jié)果表明，手術(shù)治療患者在死亡發(fā)生率、總體預(yù)后情況、NIHSS評(píng)分等指標(biāo)的比較上，均明顯優(yōu)于內(nèi)科保守治療組。

表2 兩組死亡發(fā)生率比較[例(%)]Tab. 2 Comparison of the mortality between the two groups[n(%)]

表3 兩組存活患者治療前后NIHSS評(píng)分比較(±s)Tab.3 Comparison of NIHSS score before and after treatment between two groups of survivors (±s)

表3 兩組存活患者治療前后NIHSS評(píng)分比較(±s)Tab.3 Comparison of NIHSS score before and after treatment between two groups of survivors (±s)

(1)P<0.05 compared with the general medical treatment group

Group Before treatment After treatment General medical treatment group (n=32) 23.47±1.90 19.38±1.86 Surgical treatment group (n=14) 23.57±1.70 13.21±2.05(1)

表4 兩種不同治療方法的療效評(píng)定(例)Tab.4 Therapic efficacy of the two groups (n)

3 討 論

減輕腦水腫、降低顱內(nèi)壓是治療大面積腦梗死的關(guān)鍵[13]。目前對(duì)大面積腦梗死尚無有效的治療方法，大多選擇一些常規(guī)內(nèi)科治療，治療重點(diǎn)為脫水降顱內(nèi)壓，控制并發(fā)癥，維持生命體征。近年來有證據(jù)表明早期手術(shù)治療可能是合理的策略。本研究結(jié)果也支持積極外科手術(shù)在患者神經(jīng)功能預(yù)后與生存率方面優(yōu)于常規(guī)內(nèi)科治療的結(jié)論。

最近的3個(gè)隨機(jī)對(duì)照試驗(yàn)證實(shí)了保守治療的不足，而去骨瓣減壓術(shù)在降低病死率與改善遠(yuǎn)期預(yù)后等方面具有顯著優(yōu)勢(shì)[15-17]?；谏鲜鲅芯砍晒?，2008年歐洲卒中指南推薦年齡<60歲的惡性大腦中動(dòng)脈梗死患者在發(fā)病后48h內(nèi)開展去骨瓣減壓術(shù)治療[4]。但目前對(duì)大面積腦梗死減壓術(shù)的手術(shù)時(shí)機(jī)[6,8-9]、術(shù)前臨床癥狀體征及影像學(xué)指標(biāo)[7]等仍存在爭(zhēng)議。實(shí)際臨床工作中究竟是按發(fā)病時(shí)間還是根據(jù)患者的病情進(jìn)展來決定手術(shù)時(shí)機(jī)仍需在完善觀察例數(shù)基礎(chǔ)上探索更為可靠的結(jié)論。

基于國(guó)外的研究結(jié)果，我國(guó)2010年急性缺血性腦卒中診治指南也推薦對(duì)于60歲以下、發(fā)病48h內(nèi)的惡性大腦中動(dòng)脈梗死伴嚴(yán)重顱內(nèi)壓增高且內(nèi)科治療不滿意、無手術(shù)禁忌證者，可請(qǐng)腦外科會(huì)診考慮是否行減壓術(shù)[18]。但中國(guó)患者人群的手術(shù)和內(nèi)科保守治療結(jié)果對(duì)比是否與國(guó)外數(shù)據(jù)一致目前尚不清楚。本研究為針對(duì)中國(guó)人群的回顧性研究，結(jié)果表明：手術(shù)治療組死亡發(fā)生率明顯低于內(nèi)科保守治療組(39.6%vs12.5%)；治療后NIHSS評(píng)分也明顯優(yōu)于內(nèi)科保守治療組(19.38±1.86vs13.21±2.05)。

本研究樣本量有限，且為回顧性研究，可能存在多種偏倚，無法進(jìn)一步進(jìn)行分層分析，對(duì)研究結(jié)果可能產(chǎn)生影響。下一步還需進(jìn)行大樣本隨機(jī)對(duì)照研究，對(duì)早晚手術(shù)療效進(jìn)行比較，評(píng)定出現(xiàn)致命性腦水腫的量化指標(biāo)，從而及時(shí)采取手術(shù)干預(yù)以獲取最佳功能預(yù)后。本研究認(rèn)為應(yīng)規(guī)范大面積腦梗死的治療，在時(shí)間窗內(nèi)要積極溶栓治療，無溶栓指征則應(yīng)優(yōu)先考慮手術(shù)治療，內(nèi)科常規(guī)治療僅作為既無溶栓指征又有手術(shù)禁忌證時(shí)才考慮的姑息性治療。

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Pilot study of comparison of therapeutic effect of decompressive craniectomyvsconservative treatment in patients with large hemispheric infarction

ZHANG Zi-fei1,2, ZHENG Xue-dan2, HAN Ya-ling3*, CHEN Hui-sheng2*1Training Base of Postgraduate of Liaoning Medical University in General Hospital of Shenyang Military Command, Shenyang 110840, China
2Department of Neurology,3Department of Cardiology, General Hospital of Shenyang Command, Shenyang 110840, China
*< class="emphasis_italic">Corresponding authors. CHEN Hui-sheng, E-mail: chszh@aliyun.com; HAN Ya-ling, E-mail: hanyaling@263.net

s. CHEN Hui-sheng, E-mail: chszh@aliyun.com; HAN Ya-ling, E-mail: hanyaling@263.net
This work was supported by the Key Science and Technology Program of Liaoning Province(2013225089) and Ministry of Major New Drug Innovative Drug Research and Open Technology Platform (2012ZX0903016-002)

ObjectiveTo compare the results of decompressive craniectomy and conservative treatment in patients with massive hemispheric infarction.MethodsAccording to treatment methods, 69 patients with massive hemispheric infarction, admitted during Aug. 2010 to Oct. 2013, were divided into two groups:general medical conservative treatment (group 1) and surgery (group 2). The mortality rate of the both groups was analyzed, and neurological deficits was evaluated in survivors by NIHSS criteria.ResultsThe mortality rate was significantly lower in group 2 than in group 1 (12.5%vs39.6%,P<0.05). For survivors, the NIHSS score was reduced significantly after treatment in all the two groups, and there was a significant difference between the two groups (P<0.05). As improvement in neurological function was compared, the result in surgical treatment group was much better than that in medical conservative treatment group.ConclusionDecompressive surgery can reduce the mortality rate in patients with massive hemispheric infarction, and it improves their quality of life, therefore surgery should be done for the patients with surgical indications as soon as possible.

brain infarction; surgical procedures, operative; drug therapy

R743.33

A

0577-7402(2015)07-0526-04

10.11855/j.issn.0577-7402.2015.07.03

2015-01-27；

2015-04-30)

(責(zé)任編輯：沈?qū)?

遼寧省科技攻關(guān)計(jì)劃(2013225089)；科技部重大新藥創(chuàng)制創(chuàng)新藥物研究開放技術(shù)平臺(tái)建設(shè)項(xiàng)目(2012ZX0903016-002)

張子非，醫(yī)學(xué)碩士，住院醫(yī)師。主要從事腦血管病方面的臨床工作

110840 沈陽(yáng) 遼寧醫(yī)學(xué)院沈陽(yáng)軍區(qū)總醫(yī)院研究生培養(yǎng)基地(張子非)； 110840 沈陽(yáng) 沈陽(yáng)軍區(qū)總醫(yī)院神經(jīng)內(nèi)科(張子非、鄭雪丹、陳會(huì)生)，心內(nèi)科(韓雅玲)

陳會(huì)生，E-mail：chszh@aliyun.com；韓雅玲，E-mail:hanyaling@263.net