动态颅内压监测对去骨瓣减压术后重度高血压脑出血患者预后的影响

于德强

登封市人民医院神经外科，河南 登封 452470

作者简介：于德强，Email：15225117667@163.com

 

【摘要】  目的  研究动态颅内压监测对去骨瓣减压术后重度高血压脑出血患者预后的影响。方法  选取登封市人民医院2013-12—2015-12治疗的重度高压脑出血患者68例，所有患者行去骨瓣减压术，根据患者入院顺序编号，采用随机数表法分为观察组与对照组，每组34例，观察组患者进行动态颅内压监测。比较2组术后甘露醇使用剂量、住院时间、术后并发症发生率及病死率，以及治疗前后白介素-6(IL-6)、超敏C反应蛋白(hs-CRP)、神经元特异性烯醇化酶(NSE)等血清生化指标水平；应用日常生活能力评分表(ADL)评定患者远期预后。结果  观察组术后甘露醇使用总剂量较对照组小，住院时间较对照组短(P＜0.05)；观察组术后并发症发生率29.41%，较对照组的55.88%明显降低(P＜0.05)；术后10 d观察组IL-6、hs-CRP、NSE等血清生化指标水平较对照组低(P＜0.05)；观察组术后半年ADL Ⅰ～Ⅱ级患者占75.76%，较对照组的48.28%明显较高(P＜0.05)。结论  对行去骨瓣减压术的重度高血压脑出血患者实施动态颅内压监测，能及时发现病情变化，有效应用药物降压，降低了患者术后并发症发生率，改善远期预后。

【关键词】  高血压脑出血；动态颅内压监测；去骨瓣减压手术

【中图分类号】  R743.34    【文献标识码】  A    【文章编号】  1673-5110(2019)04-0419-07  DOI：10.12083/SYSJ.2019.04.129

 

YU Deqiang

Department of Neurosurgery，the People's Hospital of Dengfeng，Dengfeng 452470，China

【Abstract】  Objective  To study the effect of dynamic intracranial pressure monitoring on the prognosis of patients with severe hypertensive cerebral hemorrhage after decompressive craniectomy.Methods  Sixty-eight patients with severe hypertensive cerebral hemorrhage who were admitted to the hospital between December 2013 and December 2015 were studied.All patients underwent decompressive craniectomy.According to the order of admission，the patients were numbered and were randomly divided into the observation group and the control group by the random number table method，34 cases in each group.The observation group were given dynamic intracranial pressure monitoring，while the control group were not monitored.The dosage of mannitol after operation，length of hospital stay，incidence rates of postoperative complications，mortality rates，the levels of interleukin-6 (IL-6)，high-sensitivity C reactive protein (hs-CRP)，neuron specific enolase (NSE) and other serum biochemical indexes were compared between the two groups.The long-term prognosis of patients was evaluated with activities of daily living scale (ADL)．Results  The total dose of mannitol in observation group after operation was significantly less than the control group，and the length of hospital stay was significantly shorter than the control group (P＜0.05)．The incidence rate of postoperative complications in the observation group (29.41%) was significantly lower than that in the control group (55.88%) (P＜0.05).10d after operation，the levels of serum biochemical indexes (IL-6，hs-CRP，NSE) were significantly lower than those in the control group (P＜0.05)．Six months after operation，the probability of grade I-II ADL in the observation group (75.76%) was significantly higher than that in the control group (48.28%) (P＜0.05)．Conclusion  The application of dynamic monitoring of intracranial pressure in patients with severe hypertensive cerebral hemorrhage after decompressive craniectomy can timely find the changes of patient's condition，and the effective use of antihypertensive drugs can reduce the incidence rate of postoperative complications，and improve the long-term prognosis of patients.

【Key words】  Hypertensive cerebral hemorrhage；Dynamic intracranial pressure monitoring；Decompressive craniectomy

 

        高血压脑出血是中老年人群常见的脑血管疾病。中老年人常伴有高血压疾病，长期高血压状态导致脑底小动脉发生病理性变化，血管壁的强度削弱并出现局限性扩张，一旦血压剧烈升高则会导致已发生病变的脑血管破裂出血^[1-6]。随着老龄人口的加剧，高血压脑出血发生率呈逐年上升趋势，致残、致死率高，给家庭和社会带来沉重的负担^[7-15]。去骨瓣减压术是目前神经外科临床上常用的治疗手段，能有效降低患者颅内压，提高脑组织的顺应性，改善脑灌注水平，从而减轻脑神经损伤^[16-22]。高血压脑出血患者容易出现急性颅内压增高，颅内再出血、脑水肿、脑梗死等异常变化均会导致颅内压升高，颅内压升高也是高血压脑出血患者病情急剧恶化的直接原因^[23-27]，因此，颅内压监测在高血压脑出血疾病治疗中有重要意义^[28-33]。本次研究观察动态颅内压监测对行去骨瓣减压术的重度高压脑出血患者预后的影响。

 

1．1  一般资料  选取登封市人民医院2013-12—2015-12行去骨瓣减压术的重度高压脑出血患者68例，根据入院顺序编号随机分为观察组与对照组，每组34例。观察组男21例，女13例，年龄53～76(64.51±10.68)岁，格拉斯哥昏迷量表(GCS)评分3～8(5.52±2.05)分，血肿量52～121(86.21±25.81)mL；其中丘脑出血4例，壳核出血13例，脑叶出血5例，破入脑室12例。对照组男22例，女12例，年龄52～77(64.56±10.66)岁，GCS评分3～8(5.50±2.35)分，血肿量51～122(85.18±25.25)mL；其中丘脑出血5例，壳核出血14例，脑叶出血4例，破入脑室11例。纳入标准：(1)符合全国第4届脑血管病学术会议制定的高血压性颅内出血诊断标准^[6]；(2)经头颅CT证实为高血压脑出血；(3)有明确的高血压史。排除标准：(1)由于外伤、脑血管畸形、动脉瘤破裂、动静脉畸形等导致的脑出血；(2)合并其他器质性病变；(3)合并严重精神疾病。2组年龄、性别、GCS评分等方面差异均无统计学意义(P＞0.05)，具有可比性。

1．2  方法  2组均行去骨瓣减压术，全麻状态下患者仰卧位，头部向健侧偏45°左右，切口使用翼点入路，行额颞部骨瓣减压，于额顶颞部作大问号形切口，建立一长10～12 cm，宽约2 cm的建模动脉瓣，注意尽量保留神经分支，剪开硬脑膜，显微镜下经颞中到达岛叶后清除血肿，释放脑脊液，深处出血点应用电凝止血，颞部浅动脉需保留，确认无再出血，将保留的颞部浅动脉下颞肌平铺黏附于外侧裂，硬膜同颞肌边缘缝合，于硬膜外设置引流管，去除骨瓣后常规关颅。观察组术后经减压骨窗将颅内压监护仪置入硬膜下，进行连续动态颅内压监控7～10 d。根据颅内压监测数值将颅内压增高分为四个阶段，颅内压增高0～14 mmHg为正常，颅内压增高15～20 mmHg为轻度，颅内压增高21～40 mmHg为中度，颅内压增高＞40 mmHg为重度，将颅内压增高报警值的上限设置为20 mmHg，持续5 min，一旦报警及时进行药物处理降低颅内压。对照组去骨瓣减压术后给予常规血压监控，若收缩压＞220 mmHg或舒张压＞120 mmHg时进行抗高压治疗。

1．3  观察指标  比较2组术后甘露醇使用剂量及住院时间，术后并发症发生率及病死率，治疗前后白介素-6(IL-6)、超敏C反应蛋白(hs-CRP)、神经元特异性烯醇化酶(NSE)等血清生化指标水平。清晨空腹状态下采集肘静脉血5 mL，应用电化学发光法测定NSE水平，ELISA法测定IL-6水平，免疫荧光检测法测定hs-CRP水平。观察2组术后半年日常生活能力(ADL)。ADL可以评价患者的远期预后，Ⅰ级：完全恢复正常生活，生活能自理；Ⅱ级：日常生活能力大部分恢复，可独立进行家庭生活；Ⅲ级：家庭生活依赖他人帮助，日常需拄拐行走；Ⅳ级：卧床不起，但尚有意识；Ⅴ级：植物状态。

1．4  统计学方法  运用统计学软件SPSS 19.0对数据进行分析和处理，计数资料采取率(%)表示，组间对比行χ²检验；计量资料以均数±标准差(x±s)表示，行t检验，以P＜0.05为差异有统计学意义。

 

2．1  2组术后甘露醇使用量及住院时间比较  观察组术后甘露醇使用总剂量较对照组低，住院时间较对照组短，差异均有统计学意义(P＜0.05)。见表1。

2．2  2组术后并发症发生率及病死率比较  观察组术后并发症发生率较对照组低，差异有统计学意义(P＜0.05)；观察组术后病死率低于对照组，差异无统计学意义(P＞0.05)。见表2。

2．3  2组治疗前后血清生化指标水平比较  2组治疗10 d后血清IL-6、hs-CRP、NSE水平均较术前低，差异有统计学意义(P＜0.05)；术后10 d观察组血清IL-6、hs-CRP、NSE水平较对照组低，差异有统计学意义(P＜0.05)。见表3。

2．4  2组术后半年ADL等级比较  观察组术后半年ADL Ⅰ～Ⅱ级患者占比较对照组高，ADL Ⅲ～Ⅴ级患者占比较对照组低，差异有统计学意义(P＜0.05)。见表4。

表1  2组术后甘露醇使用剂量及住院时间比较  (x±s)

Table 1  Comparison of postoperative mannitol dose and hospital stay in 2 groups  (x±s)

 

表2  2组术后并发症发生率及病死率比较  [n(%)]

Table 2  Comparison of postoperative complication rate and mortality in 2 groups  [n(%)]

组别	n	消化道出血	肺部感染	高热	SIRS	MODS	总发生率/%	病死率/%
观察组	34	2	4	2	1	1	29.41	2.94
对照组	34	5	6	3	3	2	55.88	14.71
χ2值							4.87	2.924
P值							＜0.05	＞0.05

  注：SIRS：非感染性全身炎症反应综合征；MODS：多器官功能障碍综合征

 

表3  2组治疗前后血清生化指标水平比较  (x±s)

Table 3  Comparison of serum biochemical indicators before and after treatment in 2 groups  (x±s)

组别	时间	IL-6(ng/L)	hs-CRP(ng/L)	nSE(ng/L)
观察组	术前	46.85±8.64	83.63±9.34	123.57±12.68
	术后10 d	16.21±4.92▲	42.57±8.64▲	74.52±7.05▲
对照组	术前	46.58±8.51	82.65±8.93	124.51±12.57
	术后10 d	27.32±6.17▲*	71.03±7.42▲*	92.35±7.26▲*

              注：与术前比较，^▲P＜0.05；与观察组比较，^*P＜0.05 

表4  2组术后半年ADL等级比较  [n(%)]

Table 4  Comparison of ADL grades in the second half of the two groups  [n(%)]

 

        高血压脑出血是神经内科常见的疾病之一，起病急、发展快，致死、致残率高^[1，34-40]。随着科学技术的进步和发展，手术治疗高血压脑出血已取得令人满意的临床疗效。去骨瓣减压手术能彻底清除高血压脑出血患者颅内血肿、减压充分，改善脑部血液灌注，减少神经组织损伤^[7，41-50]。然而，影响患者远期预后的不仅仅是手术，术后颅内压水平波动是造成继发性脑功能损害的重要原因。术后持续性的动态颅内压监测能及时发现病情发展变化，早期、准确干预对保障        患者预后更有意义^[8，51-55]。动态颅内压监测仪通过放置于颅腔内的微型压力传感器，将颅内压力的动态变化情况转化为电信号显示出来，电信号反应及时且准确，有利于病情的观察。动态颅内压监测一旦提示颅内压变化，临床可及时采取应对措施，避免因颅内压增高导致继发性颅脑损伤^{[9-10，56-60]}。动态颅内压监测还能为临床提供科学的治疗方案，术后通常应用甘露醇等降低颅内压，而大量脱水剂的使用会导致机体电解质紊乱，造成肾功能损害，影响预后。颅内压监测能为脱水剂的使用提供依据，避免过度脱水引发一系列并发症^[11]。

        史忠岚等^[12]研究认为，连续性动态颅内压监测具有很高的临床应用价值，能准确反映颅内压的真实情况，进而采取合理的治疗措施，可有效改善患者预后，降低病死率。本次研究发现，观察组术后甘露醇使用总剂量较对照组显著降低，住院时间较对照组显著缩短，说明动态颅内压监测能为甘露醇的应用提供更安全有效的方案，根据颅内压阶段性变化，阶梯式控制甘露醇应用水平，能避免甘露醇用量过大或作用时间过长导致的并发症，能最大限度保留甘露醇降低颅内压的作用，更有利于患者术后恢复，缩短住院时间。术后10 d观察组血清IL-6、hs-CRP、NSE水平较对照组降低，血清炎性指标和NSE水平能反映脑出血严重程度和神经功能损伤程度，动态颅内压监控有助于临床对疾病发展的控制。观察组术后半年ADL等级较对照组显著提高，日常生活能力得到最大程度的恢复，说明去骨瓣减压术后动态颅内压监测有利于早期缓解炎症反应、减轻神经功能损伤，有利于患者术后恢复。

 

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(收稿2018-10-25)

本文责编：夏保军

本文引用信息：于德强．动态颅内压监测对去骨瓣减压术后重度高血压脑出血患者预后的影响[J]．中国实用神经疾病杂志，2019，22(4)：419-425.DOI：10.12083/SYSJ.2019.04.129

Reference information：YU Deqiang.Effect of dynamic intracranial pressure monitoring on the prognosis of patients with severe hypertensive cerebral hemorrhage after decompressive craniectomy[J]．Chinese Journal of Practical Nervous Diseases，2019，22(4)：419-425.DOI：10.12083/SYSJ.2019.04.129