目的：观察去骨瓣减压术（ DHC）治疗恶性大脑中动脉脑梗死（ m－MCAI）患者的临床指标，探讨DHC的手术时机，以提高手术疗效。方法收集80例行DHC的m－MCAI患者，根据预后分为预后良好组（GOS 4～5分）26例，预后不良组（GOS 1～3分）54例。记录各组患者脑梗死体积，是否予重组人组织型纤溶酶原激活剂（ rt－PA ）溶栓治疗，脑萎缩程度，中线移位情况， NIHSS 评分及急性生理和慢性健康评分Ⅱ（ APACHEⅡ），术前GCS评分、是否出现瞳孔不等大，病情恶化至手术时间，起病至病情恶化时间。结果两组患者中线移位、瞳孔不等大、术前GCS、术前APACHEⅡ的差异有统计学意义（P＜0．05～0．01）。术前GCS （OR＝0．549，95％CI：0．328～0．919，P＝0．023）、术前APACHEⅡ（OR＝1．098，95％CI：1．007～1．197，P＝0．034）是影响DHC治疗的m－MCAI患者预后的独立危险因素。合并肾功能不全的m－MCAI患者行DHC后预后不良（P＝0．032）。结论患者出现严重昏迷，瞳孔散大，中线结构严重移位前行DHC，是提高疗效的关键，术前GCS及APACHEⅡ可用于评估预后，肾功能不全的患者，DHC手术风险更高。%Objective To investigate the clinical index of Malignant middle cerebral artery infarction ( m-MCAI) patients treated by decompressive hemicraniectomy ( DHC) , and to investigate proper surgical timing for DHC, for improving surgical results.Methods Eighty m-MCAI patients treated with DHC were divided into good prognosis group ( GOS 4 -5, 26 cases) and bad prognosis groups ( GOS 1 -3, 54 cases) basing on patients' prognosis.The charges of infarct volume, whether to thrombolysis treatment with recombinant tissue-plasminogen activator ( rt-PA), the degree of brain atrophy, the midline shift, NIHSS, acute physiology and chronic health evaluationⅡ ( APACHEⅡ) , GCS, whether there're the pupil size of both eyes was not equal, the condition deteriorated to the surgery time to start, from after the onset to the deterioration of time.Results There were significant differences of the midline shift, anisocoria, GCS and APACHEⅡ(P<0.05-0.01).GCS(OR=0.549, 95%CI:0.328-0.919, P=0.023), preoperative APACHⅡ(OR=1.098, 95%CI:1.007-1.197, P=0.034) were independent risk factors affect m-MCAI patients for DHC treatment.Merger of renal insufficiency of m-MCAI patients poor prognosis after DHC treatment ( P=0.032 ) .Conclusions Finding that disease changes in these patients, such as severe coma, mydriasis and severe midline shift, should do DHC.GCS and APACHEⅡcould be used to evaluate the prognosis of patients.To merge renal insufficiency in these patients, the DHC risk is higher.
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