I. Purpose
To standardize the surgical indications, timing and surgical methods for craniocerebral trauma patients in China, and to improve the success rate of craniocerebral trauma patients in China.
Clinical evidence-based medical evidence and expert consensus
At present, there are controversies at home and abroad regarding the indications, timing and methods of surgical treatment for craniocerebral trauma patients, especially acute craniocerebral trauma patients. In 2006, American neurosurgeons compiled the “Guidelines for the management of craniocerebral trauma surgery” based on more than 800 papers (secondary or tertiary evidence) on craniocerebral trauma surgery published in international medical journals. (Guidelines for the management of traumatic brain injury), published in full in the journal Neurosurgery. It has served as a good guide for neurosurgeons in the United States and around the world in the surgical treatment of patients with traumatic brain injury. On the basis of the American Guidelines for the Surgical Treatment of Craniocerebral Trauma and the experience of Chinese neurosurgeons, the monograph “Surgical Guidelines for Acute Craniocerebral Trauma” was prepared and published in 2007.
In view of the rich clinical experience accumulated by Chinese neurosurgeons in the surgical treatment of craniocerebral trauma, and combined with the injury characteristics and medical conditions of craniocerebral trauma patients in China, the Chinese Association of Neurosurgeons and the Chinese Neurological Injury Expert Committee convened more than 60 neurosurgeons in November 2008, carefully analyzed the successful experiences and failed lessons of surgical operations for craniocerebral trauma patients in China, and compiled The expert consensus of craniocerebral trauma surgery suitable for China’s national conditions was prepared to guide the clinical medical practice of physicians engaged in craniocerebral trauma diagnosis and treatment in China and to improve the treatment level of craniocerebral trauma patients in China.
(I) Acute epidural hematoma
1.Surgical indications: ① acute epidural hematoma >30ml, temporal >20ml, requiring immediate craniotomy to remove the hematoma; ② acute epidural hematoma <30ml, temporal <20ml, maximum thickness <15mm, midline shift <5mm, GCS score >8, patients without symptoms and signs of focal brain damage can be treated conservatively. However, patients must be hospitalized for close observation of changes in their condition, and dynamic observation of hematoma changes by performing head CT. Once clinical consciousness changes, cranial hypertension symptoms, or even pupil changes or CT hematoma enlargement occur, craniotomy should be performed immediately.
2.Surgical method: According to the site of hematoma, take the corresponding area bone flap craniotomy to remove the hematoma and stop the hemorrhage completely, suspend the dura at the edge of the bone window, and reset and fix the bone flap in situ. However, for patients with huge epidural hematoma, obvious midline dependence and dilated pupils, debridement decompression and dural decompression suture techniques can be used to avoid secondary cranial hypertension and brain herniation caused by large cerebral infarction after surgery, and debridement decompression surgery can be performed again.
(B) Acute subdural hematoma
1. Surgical indications: ① Patients with acute subdural hematoma >30ml, temporal >20ml, hematoma thickness >10mm, or midline shift >5mm need immediate surgical removal of hematoma; ② Patients with acute subdural hematoma <30ml, temporal <20ml, maximum hematoma thickness <10mm, midline shift <5mm, and acute subdural hematoma with GCS score <9 can first Non-surgical treatment. If there is progressive post-injury impairment of consciousness and GCS score decreases >2 points, surgical treatment should be adopted immediately; ③ For hospitals with ICP monitoring technology, patients with GCS score < 8 points who have heavy craniocerebral trauma combined with intracranial hemorrhage should all undergo intracranial pressure monitoring.
2.Surgical method: For the most common acute subdural hematoma of frontotemporal parietal, especially for patients with combined cerebral contusion cranial hypertension, it is advocated to use standard large bone flap craniotomy for hematoma removal and decide to preserve or decompress the bone flap according to the intracranial pressure intraoperatively, and to close the dura in situ or reduce the tension suture. Bilateral frontotemporal parietal acute subdural hematomas should be performed with bilateral standard trauma large bone flap surgery, and anterior coronal craniotomy with decompression of the large bone flap can also be used.
(C) Acute intracerebral hematoma and cerebral contusion
1, surgical indications: ① for patients with acute brain parenchymal injury (intracerebral hematoma, cerebral contusion), if there is progressive impairment of consciousness and neurological function, if drugs cannot control high cranial pressure, and if CT shows obvious occupying effect, surgical treatment should be performed immediately; ② frontotemporoparietal contusion volume > 20 ml, midline displacement > 5 mm, with basal pool compression, surgical treatment should be performed immediately; ③ acute brain parenchymal injury (intracerebral hematoma, cerebral contusion) patients, ICP ≥ 25 mmHg, CPP ≤ 65 mmHg after treatment by dehydration and other drugs, should undergo surgical treatment; ④ acute brain parenchymal injury (intracerebral hematoma, cerebral contusion) patients without altered consciousness and neurological damage, drugs can effectively control high cranial pressure, CT does not show obvious occupancy, can be under close observation of consciousness and pupils, etc. Under the change of disease condition, we can continue the conservative treatment with drugs.
2.Surgical methods: ①For patients with extensive frontotemporal parietal cerebral contusion combined with intracerebral hematoma and obvious occupancy effect on CT, we should advocate the use of standard trauma large bone flap craniotomy to remove intracerebral hematoma and inactivated cerebral contusion tissue, complete hemostasis, routine decompression of debridement flap and dural decompression suture technique. ②For patients without intracerebral hematoma, frontotemporal parietal extensive cerebral contusion swelling combined with difficult to control high cranial pressure and signs of cerebellar herniation, standard traumatic large bone flap craniotomy, dural decompression and dural decompression suture technique should be routinely performed; ③For patients with simple intracerebral hematoma, no obvious cerebral contusion and obvious occupying effect on CT, according to the site of hematoma, a larger bone flap craniotomy should be used in the corresponding area to remove the hematoma and completely stop the hemorrhage. (3) For patients with simple intracerebral hematoma, without contusion, and with obvious occupying effect on CT, according to the site of the hematoma, a larger bone flap was used to remove the hematoma and stop the hemorrhage completely. ④ For multiple intracerebral hematomas caused by posterior occipital landing deceleration injury and hedgehog injury resulting in bilateral cerebral hemisphere brain parenchymal injury (intracerebral hematoma, cerebral contusion), craniotomy should be performed first on the severely injured side of the lesion, and if necessary, bilateral craniotomy with large bone flap decompression should be performed.
(D) Acute posterior cranial recess hematoma
1.Surgical indications: ① Posterior cranial recess hematoma >10ml, CT scan with occupying effect (deformation, displacement or occlusion of four ventricles; basal pool compression or disappearance; obstructive hydrocephalus), surgical treatment should be performed immediately. ②Patients with posterior cranial sulcus hematoma <10ml, no neurological abnormalities, and CT scan showing no occupying sign or slight occupying sign, can be treated with close observation and occasional CT review.
2. Surgical method: craniotomy with suboccipital approach, complete removal of the hematoma, and dural in situ or reduction suture.
(E) Chronic subdural hematoma
1, surgical indications: ① clinical symptoms and signs of cranial hypertension, with or without altered consciousness and hemispheric pressure signs; ② CT or MR scan shows unilateral or bilateral subdural hematoma thickness >10mm, unilateral hematoma resulting in midline shift >10mm; ③ no clinical symptoms and signs, CT or MR scan shows unilateral or bilateral subdural hematoma thickness <10mm, midline shift <10mm. 10mm patients can be taken for dynamic clinical observation.
2, surgical methods: ① low-density subdural hematoma usually adopts single-hole borehole drainage; ② mixed density can adopt double-hole borehole drainage and flushing method; ③ for patients with recurrent chronic subdural hematoma, thick envelope and mechanized hematoma, open flap surgery is required to peel off the hematoma membrane and remove the mechanized hematoma.
(VI) Depressed skull fracture
1.Operation indications: ①closed depressed fracture >1.0cm; ②closed depressed fracture is located in the functional brain area and the compression causes neurological dysfunction; ③open depressed fracture; ④closed depressed skull fracture compresses the venous sinus and causes blood return and cranial hypertension; ⑤depressed skull fracture located in the venous sinus does not affect blood return and patients without cranial hypertension should not be operated.
2.Surgical methods: ① the uncontaminated fracture fragment should be removed and shaped and fixed in situ; ② the severely contaminated fracture fragment should be removed for second-stage repair; ③ combined intracranial hemorrhage and brain contusion should be handled according to the corresponding surgical standard.
(G) skull repair
1, surgical indications: ① cranial defect > 2cm; ② affect cosmetic; ③ usually in the post-injury > 3 months for cranial repair, for patients with larger cranial defects resulting in clinical symptoms and signs, the clinical condition allows conditions, can be appropriately advanced; ④ due to the characteristics of children’s cranial development, the principle of cranial repair surgery > 12 years old. For patients with large cranial defects, affecting children’s normal life and learning, and good scalp development, the age limit can be waived; ⑤ For patients with intracranial and extracranial infections after cranial injury, cranial repair must be performed more than 1 year after the infection is cured.
2.Surgical methods: ① Select the corresponding plastic titanium mesh or other materials according to the size and morphology of the cranial defect; ② Separate carefully under the temporalis muscle fascia and outside the dura, try not to break the dura, and fix the repair material at the edge of the skull; ③Autologous cranial bone preservation and repair can also be used.
III. Description
The indications of surgery for patients with craniocerebral trauma are applicable to most patients with craniocerebral trauma. However, the clinician must also take into account the patient’s age, general compound injury, vital signs, the presence of important organ diseases before the injury, the time of post-injury CT scan and other comprehensive factors to make a reasonable judgment.
The volume of intracranial hematoma requiring craniotomy as indicated in the Guidelines refers to adults, and the volume of intracranial hematoma requiring surgery in children and the elderly should be appropriately adjusted due to the large differences in cranial cavity compensatory volume between children and adults.
As clinical evidence-based medical evidence continues to increase and experience accumulates, the Chinese Surgical Guidelines for Craniocerebral Trauma will be continuously improved and revised.