traumatic brain edema decompression

Increased intracranial pressure caused by traumatic acute diffuse brain swelling is one of the important reasons for high mortality and high disability. A common method used in surgical treatment is to open the cranium and cut the dura mater to relieve brain swelling and elevated intracranial pressure, and to reduce or avoid secondary damage to the brain stem. As early as the early 20th century, the reduction of the diaphragm under the pressure of Horsley and Cushing is still in use today. Gurdjian and Thomas (1964) suggest that simple diaphragmatic decompression is often difficult to achieve. Kiellberg and Prieto (1971) used double-frontal large bone decompression for post-traumatic brain edema, a total of 73 cases, with a survival rate of only 18%. Ransohoff et al (1971) reported 35 cases of hemi-cervical resection and decompression, with a mortality rate of 60% and a good 28%, and the results were not satisfactory. In recent years, Münch et al (2000) reported 49 cases of unilateral large bone flap decompression, that early surgery after injury is better than the late stage, and emphasized that the lower edge of the decompression bone window is closer to the skull base than the bone flap. Size is more important. Of particular note: in 1999, Guerra et al reported a prospective clinical study of 57 cases of large bone flap decompression of traumatic brain swelling. In the early stage of surgery, bilateral coronal incision of the frontal humerus and large bone flap was performed. All cases were followed. The large bone flap and the dura mater were used to enlarge and decompress the anterior, iliac crest, and the top, and 31 cases were unilateral and 26 cases were bilateral. The excellent results were obtained after surgery. The mortality rate was only 19%, and the vegetative state was 9%. 11%, 21% of the disability, 37% good. He suggested that all cases with indications should be operated early. Curing disease: Indication 1. CT showed that the brain parenchyma was high density or equal density, the ventricle and brain pool were reduced, and the unilateral brain swelling showed midline shift. The intracranial pressure continues to rise after conservative treatment. 2, patient consciousness in the GCS score of 4 or more, no cerebral palsy symptoms. The intracranial pressure is close to 3.9 kPa (40 cm H2O). Contraindications 1. There is an irreversible primary brain stem or secondary cerebral palsy. If the GCS continues to be 3 points, the deep coma, the bilateral pupils have been enlarged, fixed, and no photoreaction. 2. Electrophysiological examination has an irreversible response to brain damage. Preoperative preparation 1. Prepare for emergency surgery. 2, intravenous infusion of 20% mannitol 200 ~ 400ml. Surgical procedure 1, scalp incision and musculocutaneous flap Make a large incision of the forehead, ankle, and a top, starting at 2 to 3 cm beside the midline of the hairline, parallel to the superior sagittal sinus and tangentially to the top nodule, and then turning downward to the front to the ankle. Straight down in front of the ear, 1cm straight in front of the tragus. The scalp incision can reach the skull directly, forming a musculocutaneous flap, turning it forward and downward, exposing the frontal area of the skull. 2, free bone flap formation 5 or 6 holes are drilled in the exposed skull and the bone holes are sawn off to form a large free bone flap including the frontal bone, the sacral scale and the parietal bone. If the lower edge of the bone window is higher than the bottom of the cranial fossa, the bone of the proximal cranial fossa is bitten with a rongeur. The free bone flap is wrapped in sterile gauze. 3, cut the dura mater The dura mater is cut transversely at the bottom of the crotch region near the bottom of the cranial fossa, and then cut forward and backward in a dovetail shape until the sagittal sinus. 4, dural expansion repair After examining the exposed cerebral hemisphere without focal lesions, the dura mater-enlarged incision is diva enlargement with the fascia or meningeal substitute, causing the swollen brain to bulge under the enlarged dural sac. Can prevent cerebral cortical laceration. 5, bilateral diffuse brain swelling treatment If the bilateral diffuse brain swelling, after one side of the operation, turn the head to the same side, so that the opposite side is on, and then apply the same large bone flap decompression. Thereby retaining the skull above the superior sagittal sinus, making it a bone beam to protect the superior sagittal sinus. The bone flaps were placed in a sterile container and stored frozen at -80 °C. 6, bone flap planting back After 6 weeks to 3 months postoperative brain swelling and edema disappeared, the bone flap was implanted again. complication 1. Postoperative recurrent hematoma and delayed hematoma. It should be discovered and disposed of in time. 2, secondary brain swelling and cerebral edema should be properly controlled. 3, long-term coma patients prone to lung infection, water and electrolyte balance disorders, hypothalamic dysfunction and malnutrition, etc., should be treated accordingly.