Efficacy Of Standard Large Bone Flap Decompression For Severe Traumatic Brain Injury And Analysis Of Influencing Factors Of Postoperative Brain Swelling

BackgroundSevere traumatic brain injury（sTBI）is a common disease in neurosurgery,and the disability rate and mortality rate are very high,the surgery is still the main treatment method for rescuing of sTBI patients.As soon as possible to remove the place and effectively reduce intracranial pressure is the key step for treatment of sTBI in clinic.Standard large bone flap decompression can rapidly reduce intracranial pressure in patients with sTBI,and has the advantages of wide exposure range,adequate decompression,convenient hemostasis,favorable cerebral palsy,postoperative smooth cerebral edema peak,etc,it has become a recognized standard procedure for rescuing sTBI patients.This article compares the efficacy of standard large bone flap decompression and conventional craniotomy on sTBI,and aims to provide a reference for surgeon to treatment for sTBI patients.ObjectiveThis study was designed to investigate the efficacy of standard large bone flap decompression in the treatment of sTBI and to analyze the influencing factors of postoperative brain swelling.Methods354 cases of sTBI patients who were treated in our department from April 2015 to February 2018 were selected and divided into experiment group（n=202）and control group（n=152）according to the different surgical methods.The experiment group underwent standard large bone flap decompression,and the control group underwent conventional craniotomy.The intracranial pressure,neurological function-related factors,inflammatory factors and cerebral hemodynamics were compared before and after treatment in the 2 groups,the neurological deficits,cognitive dysfunction and activities of daily living were compared before and after treatment in the 2 groups,the prognosis,physical health and organ function were recorded,postoperative complications and mortality situation were recorded in the 2 groups.All the patients were divided into brain swelling group（n=54）and non-brain swelling group（n=300）according to whether there was brain swelling after operation,the risk factors related to postoperative brain swelling were screened by statistical analysis.Results（1）Compared with before treatment,the intracranial pressure of the 2 groups significantly decreased after treatment（P<0.01）,and the experiment group was significantly lower than that of the control group（P<0.01）.（2）Compared with before treatment,the serum levels of NSE,GFAP,MBP and S-100B in the 2 groups significantly decreased after treatment（P<0.05 or P<0.01）,and the experiment group were significantly lower than those of the control group（P<0.01）.（3）Compared with before treatment,the serum levels of TNF-α,IL-6 and CRP in the 2 groups significantly decreased after treatment（P<0.01）,and the experiment group were significantly lower than those of the control group（P<0.01）.（4）Compared with before treatment,the Vs,Vd,Vmean,PI and R of cerebral artery and basilar artery in the 2 groups significantly decreased after treatment（P<0.01）,and the experiment group were significantly lower than those of the control group（P<0.05 or P<0.01）;the Q_mean of cerebral artery and basilar artery in the 2 groups significantly decreased after treatment（P<0.01）,and the experiment group were significantly higher than that of the control group（P<0.05）.（5）Compared with before treatment,the scores of NIHSS in the 2 groups significantly decreased 1 month after treatment（P<0.01）,and the experiment group was significantly lower than that of the control group（P<0.01）.（6）Compared with before treatment,the scores of MMSE in the 2groups significantly increased 1 month after treatment（P<0.01）,and the experiment group was significantly higher than that of the control group（P<0.01）.（7）Compared with before treatment,the scores of Barthel index in the 2 groups significantly increased 3 month after treatment（P<0.01）,and the experiment group was significantly higher than that of the control group（P<0.05）.（8）The incidence of total complications in the experiment group was significantly lower than that in the control group（P<0.01）.（9）The score of GOS in the experiment group was significantly higher than that of the control group（P<0.01）.（10）Compared with before treatment,the scores of APACHEⅡin the 2 groups significantly decreased 1 month after treatment（P<0.01）,and the experiment group was significantly lower than that of the control group（P<0.01）.（11）Compared with before treatment,the scores of SOFA in the 2 groups significantly decreased 1 month after treatment（P<0.01）,and the experiment group was significantly lower than that of the control group（P<0.01）.（12）The mortality of the experiment group was significantly lower than that of the control group（P<0.05）.（13）Logistic regression analysis showed that the lower preoperative GCS,preoperative midline shift≥1 cm,no artificial dura mater suture relaxation suture during operation,postoperative delayed traumatic intracranial hematoma were positively correlated with the occurrence of postoperative brain swelling（P<0.05）,which were the risk factors for postoperative brain swelling（OR>1）.Conclusion（1）Standard large bone flap decompression can significantly reduce intracranial pressure in patients with sTBI,reduce inflammation situation of sTBI patients,dilate cerebral vessels,reduce vascular resistance,increase cerebral blood flow,improve cerebral hemodynamics,improve the neurological deficits and degree of cognitive dysfunction of patients,improve their ability to daily activities,improve physical health and prognosis of sTBI patients,protect the organ function of patients,reduce mortality,the clinical efficacy is superior to conventional craniotomy.（2）The lower preoperative GCS,preoperative midline shift≥1 cm,no artificial dura mater suture relaxation suture during operation,postoperative delayed traumatic intracranial hematoma were the risk factors for postoperative brain swelling,underwent artificial dura mater suture relaxation suture during operation can prevent postoperative brain swelling.