大面积脑梗死外科治疗的问题与策略

发布时间：2018-05-04 22:06

本文选题：大面积脑梗死 + 脑水肿　；参考：《重庆医科大学》2015年硕士论文

【摘要】：大面积脑梗死(massive cerebral infarction, MCI)通常是指颈内动脉主干、大脑中动脉(middle cerebral artery, MCA)主干的脑卒中,发生率约占所有缺血性脑卒中的10%。从细胞毒性脑水肿到血管源性脑水肿再到晚期占位性脑水肿的急剧出现是MCI的主要病理特点。由于颅腔的封闭性,脑组织体积增加,必然导致颅内压(intracranial pressure, ICP)逐渐增高,ICP增高又会导致脑灌注压(cerebral perfusion pressure, CPP)、脑血流量(cerebral blood flow, CBF)的降低,进一步加重脑水肿,形成了ICP增高的恶性循环,最后因脑疝形成而导致患者死亡。目前,许多降低ICP的内科治疗措施,均未获得肯定疗效。而且,即使采取最佳的内科治疗方法也无法完全打破此恶性循环,其死亡率仍高达80%,而存活患者多遗留严重的神经功能障碍。相较于内科治疗而言,去骨瓣减压术(decompressive hemicraniectomy, DHC)则是一种有效的外科治疗手段,它能降低患者死亡率及改善其功能预后。三大随机对照临床试验(DECIMAL, DESTINY, HAMLET)研究结果及相关的汇总分析证实,早期行外科减压术不仅能降低患者死亡率而且能改善神经功能障碍。目前,很多的MCI患者因DHC而获益,但不可否认的是,DHC术后患者遗留的不同程度的神经功能障碍也引发了相应的伦理问题。因此,是否每个MCI患者均需行DHC治疗,首先应对MCI患者进行认真筛选,同时需严格把握手术时机和采取适宜的手术方式,方能取得满意的治疗效果。这篇综述目的主要在于对MCI的外科治疗问题及策略进行一个概述。
[Abstract]:Large area cerebral infarction with massive cerebral infarction, MCI) usually refers to the main trunk of internal carotid artery, middle cerebral artery, MCA) trunk of middle cerebral artery, the incidence of which is about 10% of all ischemic stroke. The main pathological features of MCI are from cytotoxic brain edema to vasogenic brain edema to late occupying brain edema. As a result of the closure of the skull cavity and the increase of the volume of brain tissue, it is inevitable that the intracranial pressure will increase gradually and the ICP will increase, and the cerebral perfusion pressure will be increased, and the cerebral perfusion pressure, the cerebral blood flow and the cerebral blood flow, CBF) will be decreased, which will further aggravate the cerebral edema. This leads to a vicious circle of increased ICP and eventually death from brain hernia. At present, many medical treatment measures to reduce ICP have not obtained positive effect. Moreover, even if the best medical treatment can not completely break this vicious circle, the mortality rate is still as high as 80%, while the surviving patients have many serious neurological dysfunction. Compared with medical treatment, decompression of bone flap decompression (DHCs) is an effective surgical treatment, which can reduce mortality and improve functional prognosis. The results of three randomized controlled clinical trials DECIMALL DESTINY and HAMLET showed that early surgical decompression could not only reduce the mortality of patients but also improve neurological dysfunction. At present, many MCI patients benefit from DHC, but it is undeniable that the different degrees of neurological dysfunction caused by DHC patients also lead to the corresponding ethical problems. Therefore, if every MCI patient should be treated with DHC, the first step should be to carefully screen the MCI patients, and at the same time, we should strictly grasp the operation opportunity and adopt the appropriate operation method to obtain satisfactory therapeutic effect. The purpose of this review is to summarize the surgical treatment problems and strategies of MCI.
【学位授予单位】：重庆医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R651.12

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