Requirements on the designation of craniotomy flap according to the volume of acute epidural hematoma

摘要

Objective To investigate the most reasonable size of craniotomy flap in hematoma removal craniotomy for acute supratentorial epidural hematoma (EDH) with no need of decompressive craniectomy. Methods Surgical and clinical data of 191 patients with acute supratentorial EDH were retrospectively reviewed and their operation time, intraoperative blood loss, range of hematoma evacuation, residual hematoma, postoperative midline shift and ambient cistern were compared among 3 groups (3 cm craniotomy group, N = 67; 5 cm craniotomy group, N = 61; ordinary craniotomy group, N = 63). Results For EDHs with maximal diameter ≤ 8 cm (N = 47), compared with ordinary craniotomy, 3 cm craniotomy achieved smaller range of hematoma evacuation ( t =-3.370, P = 0.002), shorter operation time ( t =-14.469, P = 0.000) and less intraoperative blood loss ( t =-9.310, P = 0.000). However, 5 cm craniotomy could obtain larger range of hematoma evacuation compared with 3 cm craniotomy (t =-2.331, P = 0.026). For EDHs with maximal diameter > 8-10 cm (N = 106), compared with ordinary craniotomy, 5 cm craniotomy achieved smaller range of hematoma evacuation ( t =-4.248, P = 0.002), smaller residual hematoma ( t =-2.083, P = 0.041), shorter operation time ( t =-10.715, P = 0.000) and smaller intraoperative blood loss ( t =-10.828, P = 0.000). For EDHs with maximal diameter > 10 cm (N = 38), compared with ordinary craniotomy group, although 5 cm craniotomy could reduce range of hematoma evacuation ( t =-3.125, P = 0.003) and operation time ( t =-2.948, P = 0.006), it could notably increase the residual hematoma ( t = 3.478, P = 0.001). Spearman rank correlation analysis suggested that the operable angle on the edge of craniotomy defect was positively correlated with size of craniotomy defect ( r s = 0.330, P = 0.000) and maximal hematoma diameter ( r s = 0.177, P = 0.003), and negatively correlated with hematoma thickness ( r s =-0.678, P = 0.000). Conclusions With prerequisite of effective EDH evacuation and satisfactory radiological and clinical recovery, the EDH is recommended to be microsurgically treated with craniotomy in rational size. For maximal diameter ≤ 8 cm EDHs and hemotome volume ≤ 50 ml, 3 cm craniotomy is the best choice, whereas the 5 cm craniotomy is more suitable when the hematoma volume > 50 ml. For maximal diameter > 8-10 cm EDHs, 5 cm craniotomy is a more rational surgical approach. And for maximal diameter > 10 cm EDHs, ordinary craniotomy (≥ 6 cm) is recommended. DOI: 10.3969/j.issn.1672-6731.2017.02.011