改進手術方法治療額顳部重型顱腦損傷

1、改進手術方法治療額顳部重型顱腦損傷    【摘要】 目的 探討高原額顳部重型顱腦損傷的改進手術方法及效果。方法 采用改良式Kelly問號形切口，沿前額發(fā)際內(nèi)正中旁3cm，向后呈弧形在頂骨結(jié)節(jié)前轉(zhuǎn)向顳部到達乳突上緣，從耳后發(fā)際邊緣拐向前緣止于顴弓上。從顳骨鱗部開窗，顱骨鉆孔取下擴大骨瓣，切開硬腦膜，清除血腫及挫碎腦組織。同時去骨瓣減壓，將骨瓣浸泡在55%酒精瓶內(nèi)密封低溫冷藏。結(jié)果 本組46例患者經(jīng)手術治療后存活36例，良好28例，中度殘廢6例，重度殘廢2例；死亡10例。結(jié)論 46例患者采用改進手術方法擴大入路硬腦膜成形術治療額顳部重型顱腦損傷，存活36例，

2、取得了較好的效果。            【關鍵詞】 重型顱腦損傷；額顳部；改進手術方法            Using the improving surgery method to treat heavy craniocerebral trauma of frontal and temporal part    

3、        【Abstract】 Objective To study the improving surgery method and effect about plateau heavy craniocerebral trauma of frontal and temporal part.Methods Use of the improving type Kelly question mark shape incision,along the forehead hair center side 3cm,ad

4、opt the arc shape back to arrive the mastoid upper part in the parietal bone tubercle anteversion to temporal part,along the border edge after the ear to turn to the front edge to the arcus zygomaticus.Open a window from the scale part of os temporale,take down the expanded bone petal using the skul

5、l drill,incise the dura mater,eliminate the haematoma and the broken brain tissue.At the same time get rid of the bone patal to reduce the pressure,soak the bone petal in 55% ethyl alcohol bottle and seal by the low temperature refrigeration.Results This group of 46 patients treated by the surgery s

6、urvive 36 patients,the good 28 patients,the moderate disabled 6 patients,the heavy disabled 2 patients,died 10 patients.Conclusion 46 patients of heavy craniocerebral trauma of frontal and temporal part used the improving surgery method to expand into the road dura mater forming technique treatment,

7、survived 36 patients,has obtained the good effect.            【Key words】 heavy craniocerbral trauma;frontal and temporal part;the improving surgery method            額顳部重型顱腦損傷在顱腦外

8、科中占比例較高，因損傷重、死亡率高、手術治療難度比較大。過去手術治療強調(diào)顳肌下充分減壓，術后出現(xiàn)較多問題，筆者近年來采用改良式手術方法治療額顳部重型顱腦損傷46例，取得較好的效果，現(xiàn)報告如下。            1 資料與方法            1.1 一般資料 本組46例，男38例，女8例，平均年齡38歲(1848歲)。根據(jù)GCS評分38分，閉合性

9、顱腦損傷39例，開放性顱腦損傷7例；打擊傷6例，車禍致傷30例，墜落傷8例，其他原因致傷2例。傷后雙側(cè)瞳孔散大者6例，一側(cè)瞳孔散大者15例。頭顱CT掃描檢查：一側(cè)額顳葉腦挫裂傷，硬膜下血腫伴腦內(nèi)出血者36例，硬膜外伴硬膜下血腫者10例，硬膜下血腫8例，腦內(nèi)出血伴硬膜外血腫6例。血腫呈36160ml,腦內(nèi)線結(jié)構均有移位。伴有下肢骨折4例，腹腔臟器損傷3例。            1.2 手術方法 采用改良Kelly問號形切口1，從前額發(fā)際內(nèi)沿正中線旁3cm，向后呈弧形在頂結(jié)節(jié)前

10、轉(zhuǎn)向顳部直達乳突肌上緣，從耳后發(fā)際邊緣拐向前緣至于顴弓上耳屏前2cm。翻轉(zhuǎn)皮瓣剝離骨膜，從顳骨鱗部鉆孔開窗，直徑約3cm，環(huán)形切開硬腦膜放出硬膜下血腫以達到暫時減壓。經(jīng)此處理后腦波動常迅速改善。在所取顱骨處行顱骨鉆56孔，用線鋸導板引導下鋸開相鄰骨孔間骨板。取下骨瓣后用咬骨鉗向下擴大骨窗。前至顳窩及額骨隆突，保留額骨隆突及顴弓，后至乳突前方2。前下咬出蝶骨嵴外1/3處，向下主要是咬除顳骨鱗部直達中顱窩底，骨窗一般可達8cm×5cm大小3，最大者的達15cm×8cm。對廣泛挫裂傷無生機的腦組織和血腫應徹底充分清除，經(jīng)清除后大多數(shù)患者均能達到充分內(nèi)減壓。經(jīng)沖洗后徹底止血，取顳肌

11、筋膜，剔除顳深、淺筋膜之間的脂肪組織，將其分離，翻轉(zhuǎn)后分別與硬腦膜邊緣間斷縫合成形以擴大硬腦膜表面張力。如果顱內(nèi)壓不高無明顯腦組織膨出者，可使骨瓣成浮動放回，將骨膜覆蓋之上，對于顱內(nèi)壓高有明顯腦膨出者，采用去骨瓣減壓。將骨瓣放入55%酒精內(nèi)密封浸泡冷藏，3個月行顱骨缺損修補術。            2 結(jié)果            經(jīng)改良手術治療46例，本組存活36例，