一、背景与临床需求

1.1 颅内高压的病理生理机制与临床危害

颅内高压（Intracranial Hypertension, ICH）是创伤性脑损伤（TBI）、大面积脑梗死、脑出血等急重症的终末共同病理生理环节。当颅内压（ICP）持续超过20-25 mmHg，脑灌注压（CPP）显著下降，引发脑缺血、脑疝及不可逆神经损伤^[1]。

关键机制：Monro-Kellie学说：颅腔容积固定，脑组织、血液与脑脊液体积失衡导致ICP升高^[2]。

继发性损伤：TBI后炎症因子风暴、钙超载等加剧血管源性/细胞毒性水肿^[3]。

1.2 DC的历史演变与核心作用

DC通过扩大颅腔容积降低ICP，是药物难治性颅高压的终极外科手段：

早期探索（1905年）：Cushing首次描述减压手术，但感染率高^[4]。

标准化时代（1980s）：CT与ICP监测推动标准外伤大骨瓣（如Kempe术式）应用^[5]。

精准化阶段（2010s至今）：多模态监测（脑氧、微透析）指导个体化骨窗设计^[6]。

1.3 未被满足的临床需求

尽管DC显著降低死亡率（RESCUEicp试验：TBI死亡率从49%降至26%）^[7]，仍面临挑战：

功能预后争议：DECRA试验显示DC组植物状态比例增加^[8]。

适应症分歧：TBI中ICP阈值（>20 vs. >25 mmHg）、脑卒中DC与血管内治疗（EVT）的竞争^[9,10]。

特殊人群证据缺乏：老年（>65岁）与儿童手术获益缺乏RCT支持^[11]。

二、手术指征与禁忌症

2.1 创伤性脑损伤（TBI）

核心指征：

难治性颅高压：ICP>25 mmHg持续>15分钟（一线治疗无效）^[12]。

影像标准：Marshall CT分级Ⅲ-Ⅳ级或中线移位>5 mm伴脑疝^[13]。

临床状态：GCS 3-8分且无不可逆脑干损伤^[14]。

支持证据：

RESCUEicp试验：DC降低死亡率（26% vs. 49%），但严重残疾率升高（45%）^[7]。

中国共识：推荐骨窗≥12×15 cm^[15]。

2.2 大面积脑梗死（MCI）

核心指征：

MCA供血区梗死>50%或DWI体积>145 mL^[16]。

NIHSS≥15分，GCS≤12分伴中线移位>5 mm^[17]。

发病48小时内，尤其EVT后仍恶化者^[18]。

支持证据：

DECIMAL/DESTINY试验：DC降低死亡率（29% vs. 78%），但50%存活者mRS 4-5分^[17]。

AHA/ASA指南：年龄≤60岁患者IIa类推荐^[19]。

2.3 其他适应症（争议性）

脑出血（ICH）：血肿量>30 mL伴中线移位（证据等级C）^[20]。

颅内感染/静脉窦血栓：挽救性治疗联合抗感染/抗凝^[21]。

2.4 禁忌症

绝对禁忌：

不可逆脑干损伤（双侧瞳孔散大>4小时）^[22]。

终末期疾病（凝血障碍INR>1.5，脑死亡）^[23,24]。

相对禁忌：

高龄（>70岁，RESCUEicp亚组死亡率仍高）。

家属拒绝或资源限制（低收入国家康复支持不足）^[25]。

2.5 争议与未解问题

ICP阈值分歧：DECRA（>20 mmHg）与RESCUEicp（>25 mmHg）结论矛盾^[7,26]。

儿童与老年：PediBIRNS队列提示儿童手术安全，但缺乏RCT^[27]。

三、预后评估与伦理学

3.1 预后评估工具

功能预后：GOS-E（RESCUEicp主要终点）^[15]、mRS（DECIMAL标准）^[17]。

生存质量（QoL）：SF-36/EQ-5D量表（SUNRISE研究30%家属不满意）。

经济负担：美国DC人均费用>$100,000^[28]。

3.2 伦理学挑战

知情同意：需明确告知植物状态风险（NCCN伦理指南）^[29]。

资源分配：低收入国家“生存但残疾”负担（WHO报告）^[30]。

多学科决策：德国DC-MDT模式联合神经外科、伦理专家^[31]。

四、未来研究方向

4.1 精准医学：CT灌注（CBF<20 mL/100g/min）筛选手术人群（CENTER-TBI子研究）^[32]。

4.2 技术改良：阶梯式减压降低并发症（Preliminary研究）、早期颅骨成形术（CRANIAL-2试验）。

4.3 特殊人群：儿科DC注册研究（PediBIRNS）^[30]、老年预后预测模型。

4.4 伦理优化：开发DC特异性QoL量表（NeuroQoL倡议）。

文献资料

[1]Marmarou A. Pathophysiology of traumatic brain edema: current concepts. Acta Neurochir Suppl. 2003;86:7-10. doi: 10.1007/978-3-7091-0651-8_2. PMID: 14753394.

[2]Mokri B. The Monro-Kellie hypothesis: applications in CSF volume depletion. Neurology. 2001 Jun 26;56(12):1746-8. doi: 10.1212/wnl.56.12.1746. PMID: 11425944.

[3]Jha RM, Kochanek PM, Simard JM. Pathophysiology and treatment of cerebral edema in traumatic brain injury. Neuropharmacology. 2019 Feb;145(Pt B):230-246. doi: 10.1016/j.neuropharm.2018.08.004. Epub 2018 Aug 4. PMID: 30086289; PMCID: PMC6309515.

[4]Cushing, H. (1905) The Establishment of Cerebral Hernia as a Decompressive Measure for Inaccessible Brain Tumors; with the Description of Intermuscular Methods of Making the Bone Defect in Temporal and Occipital Regions. Surgery, Gynecology & Obstetrics, 1, 297-314.

[5]Kolias AG, Viaroli E, Rubiano AM, Adams H, Khan T, Gupta D, Adeleye A, Iaccarino C, Servadei F, Devi BI, Hutchinson PJ. The current status of decompressive craniectomy in traumatic brain injury. Curr Trauma Rep. 2018 Sep 1;4(4):326-332. doi: 10.1007/s40719-018-0147-x. PMID: 30473990; PMCID: PMC6244550.

[6]Hawryluk GWJ, Rubiano AM, Totten AM, O'Reilly C, Ullman JS, Bratton SL, Chesnut R, Harris OA, Kissoon N, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, Lumba-Brown A, Ghajar J. Guidelines for the Management of Severe Traumatic Brain Injury: 2020 Update of the Decompressive Craniectomy Recommendations. Neurosurgery. 2020 Sep 1;87(3):427-434. doi: 10.1093/neuros/nyaa278. PMID: 32761068; PMCID: PMC7426189.

[7]Hutchinson PJ, Kolias AG, Timofeev IS, Corteen EA, Czosnyka M, Timothy J, Anderson I, Bulters DO, Belli A, Eynon CA, Wadley J, Mendelow AD, Mitchell PM, Wilson MH, Critchley G, Sahuquillo J, Unterberg A, Servadei F, Teasdale GM, Pickard JD, Menon DK, Murray GD, Kirkpatrick PJ; RESCUEicp Trial Collaborators. Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension. N Engl J Med. 2016 Sep 22;375(12):1119-30. doi: 10.1056/NEJMoa1605215. Epub 2016 Sep 7. PMID: 27602507.

[8]Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D'Urso P, Kossmann T, Ponsford J, Seppelt I, Reilly P, Wolfe R; DECRA Trial Investigators; Australian and New Zealand Intensive Care Society Clinical Trials Group. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med. 2011 Apr 21;364(16):1493-502. doi: 10.1056/NEJMoa1102077. Epub 2011 Mar 25. Erratum in: N Engl J Med. 2011 Nov 24;365(21):2040. PMID: 21434843.

[9]Carney N, Totten AM, O'Reilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N, Rubiano AM, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, Ghajar J. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017 Jan 1;80(1):6-15. doi: 10.1227/NEU.0000000000001432. PMID: 27654000.

[10]Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, McTaggart RA, Torbey MT, Kim-Tenser M, Leslie-Mazwi T, Sarraj A, Kasner SE, Ansari SA, Yeatts SD, Hamilton S, Mlynash M, Heit JJ, Zaharchuk G, Kim S, Carrozzella J, Palesch YY, Demchuk AM, Bammer R, Lavori PW, Broderick JP, Lansberg MG; DEFUSE 3 Investigators. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. N Engl J Med. 2018 Feb 22;378(8):708-718. doi: 10.1056/NEJMoa1713973. Epub 2018 Jan 24. PMID: 29364767; PMCID: PMC6590673.

[11]Jiang JY, Gao GY, Feng JF, Mao Q, Chen LG, Yang XF, Liu JF, Wang YH, Qiu BH, Huang XJ. Traumatic brain injury in China. Lancet Neurol. 2019 Mar;18(3):286-295. doi: 10.1016/S1474-4422(18)30469-1. Epub 2019 Feb 12. PMID: 30784557.

[12]Stocchetti N, Carbonara M, Citerio G, Ercole A, Skrifvars MB, Smielewski P, Zoerle T, Menon DK. Severe traumatic brain injury: targeted management in the intensive care unit. Lancet Neurol. 2017 Jun;16(6):452-464. doi: 10.1016/S1474-4422(17)30118-7. PMID: 28504109.

[13]Marshall, L.F., Marshall, S.B., Klauber, M.R., Clark, M., Eisenberg, H.M., Jane, J.A., Luerssen, T.G., Marmarou, A., & Foulkes, M.A. (1991). A new classification of head injury based on computerized tomography. Journal of Neurosurgery, 75.

[14]Chesnut RM, Temkin N, Carney N, Dikmen S, Rondina C, Videtta W, Petroni G, Lujan S, Pridgeon J, Barber J, Machamer J, Chaddock K, Celix JM, Cherner M, Hendrix T; Global Neurotrauma Research Group. A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med. 2012 Dec 27;367(26):2471-81. doi: 10.1056/NEJMoa1207363. Epub 2012 Dec 12. Erratum in: N Engl J Med. 2013 Dec 19;369(25):2465. PMID: 23234472; PMCID: PMC3565432.

[15]中华神经外科学会神经创伤专业组. 颅脑创伤去骨瓣减压术中国专家共识 [J] . 中华神经外科杂志,2013,29( 09 ): 967-969. DOI: 10.3760/cma.j.issn.1001-2346.2013.09.033

[16]Thomalla G, Simonsen CZ, Boutitie F, Andersen G, Berthezene Y, Cheng B, Cheripelli B, Cho TH, Fazekas F, Fiehler J, Ford I, Galinovic I, Gellissen S, Golsari A, Gregori J, Günther M, Guibernau J, Häusler KG, Hennerici M, Kemmling A, Marstrand J, Modrau B, Neeb L, Perez de la Ossa N, Puig J, Ringleb P, Roy P, Scheel E, Schonewille W, Serena J, Sunaert S, Villringer K, Wouters A, Thijs V, Ebinger M, Endres M, Fiebach JB, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Gerloff C; WAKE-UP Investigators. MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset. N Engl J Med. 2018 Aug 16;379(7):611-622. doi: 10.1056/NEJMoa1804355. Epub 2018 May 16. PMID: 29766770.

[17]Vahedi K, Vicaut E, Mateo J, Kurtz A, Orabi M, Guichard JP, Boutron C, Couvreur G, Rouanet F, Touzé E, Guillon B, Carpentier A, Yelnik A, George B, Payen D, Bousser MG; DECIMAL Investigators. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke. 2007 Sep;38(9):2506-17. doi: 10.1161/STROKEAHA.107.485235. Epub 2007 Aug 9. PMID: 17690311.

[18]Jüttler E, Unterberg A, Woitzik J, Bösel J, Amiri H, Sakowitz OW, Gondan M, Schiller P, Limprecht R, Luntz S, Schneider H, Pinzer T, Hobohm C, Meixensberger J, Hacke W; DESTINY II Investigators. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med. 2014 Mar 20;370(12):1091-100. doi: 10.1056/NEJMoa1311367. PMID: 24645942.Vahedi K et al. DECIMAL Trial. Stroke. 2007;38(9):2506-17.

[19]Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL; American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018 Mar;49(3):e46-e110. doi: 10.1161/STR.0000000000000158. Epub 2018 Jan 24. Erratum in: Stroke. 2018 Mar;49(3):e138. doi: 10.1161/STR.0000000000000163. Erratum in: Stroke. 2018 Jun;49(6):e233-e234. doi: 10.1161/STR.0000000000000172. PMID: 29367334.

[20]Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, Karimi A, Shaw MD, Barer DH; STICH investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet. 2005 Jan 29-Feb 4;365(9457):387-97. doi: 10.1016/S0140-6736(05)17826-X. PMID: 15680453.

[21]Ferro JM, Bousser MG, Canhão P, Coutinho JM, Crassard I, Dentali F, di Minno M, Maino A, Martinelli I, Masuhr F, Aguiar de Sousa D, Stam J; European Stroke Organization. European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis - endorsed by the European Academy of Neurology. Eur J Neurol. 2017 Oct;24(10):1203-1213. doi: 10.1111/ene.13381. Epub 2017 Aug 20. PMID: 28833980.

[22]Jüttler E, Unterberg A, Woitzik J, Bösel J, Amiri H, Sakowitz OW, Gondan M, Schiller P, Limprecht R, Luntz S, Schneider H, Pinzer T, Hobohm C, Meixensberger J, Hacke W; DESTINY II Investigators. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med. 2014 Mar 20;370(12):1091-100. doi: 10.1056/NEJMoa1311367. PMID: 24645942.

[23]Frontera JA, Lewin JJ 3rd, Rabinstein AA, Aisiku IP, Alexandrov AW, Cook AM, del Zoppo GJ, Kumar MA, Peerschke EI, Stiefel MF, Teitelbaum JS, Wartenberg KE, Zerfoss CL. Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage: A Statement for Healthcare Professionals from the Neurocritical Care Society and Society of Critical Care Medicine. Neurocrit Care. 2016 Feb;24(1):6-46. doi: 10.1007/s12028-015-0222-x. PMID: 26714677.

[24]Wijdicks EF, Varelas PN, Gronseth GS, Greer DM; American Academy of Neurology. Evidence-based guideline update: determining brain death in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2010 Jun 8;74(23):1911-8. doi: 10.1212/WNL.0b013e3181e242a8. PMID: 20530327.

[25]World Health Organization. (2018). World health statistics 2018: Monitoring health for the SDGs, sustainable development goals. World Health Organization.

[26]Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D'Urso P, Kossmann T, Ponsford J, Seppelt I, Reilly P, Wolfe R; DECRA Trial Investigators; Australian and New Zealand Intensive Care Society Clinical Trials Group. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med. 2011 Apr 21;364(16):1493-502. doi: 10.1056/NEJMoa1102077. Epub 2011 Mar 25. Erratum in: N Engl J Med. 2011 Nov 24;365(21):2040. PMID: 21434843.

[27]Hawryluk GWJ, Selph S, Lumba-Brown A, Totten AM, Ghajar J, Aarabi B, Ecklund J, Shackelford S, Adams B, Adelson D, Armonda RA, Benjamin J, Boone D, Brody D, Dengler B, Figaji A, Grant G, Harris O, Hoffer A, Kitigawa R, Latham K, Neal C, Okonkwo DO, Pannell D, Rosenfeld JV, Rosenthal G, Rubiano A, Stein DM, Stippler M, Talbot M, Valadka A, Wright DW, Davis S, Bell R. Rationale and Methods for Updated Guidelines for the Management of Penetrating Traumatic Brain Injury. Neurotrauma Rep. 2022 Jun 21;3(1):240-247. doi: 10.1089/neur.2022.0008. PMID: 35919507; PMCID: PMC9279118.

[28]Diringer MN, Bleck TP, Claude Hemphill J 3rd, Menon D, Shutter L, Vespa P, Bruder N, Connolly ES Jr, Citerio G, Gress D, Hänggi D, Hoh BL, Lanzino G, Le Roux P, Rabinstein A, Schmutzhard E, Stocchetti N, Suarez JI, Treggiari M, Tseng MY, Vergouwen MD, Wolf S, Zipfel G; Neurocritical Care Society. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society's Multidisciplinary Consensus Conference. Neurocrit Care. 2011 Sep;15(2):211-40. doi: 10.1007/s12028-011-9605-9. PMID: 21773873.

[29]National Comprehensive Cancer Network. (2023). NCCN Clinical Practice Guidelines in Oncology: Breast Cancer (Version 1.2023).

[30]Institute for Health Metrics and Evaluation. (2019). Global burden of disease study 2019. The Lancet, 394(Suppl 2), S1-S32.

[31]Unterberg AW, Stover J, Kress B, Kiening KL. Edema and brain trauma. Neuroscience. 2004;129(4):1021-9. doi: 10.1016/j.neuroscience.2004.06.046. PMID: 15561417.

[32]Zeiler FA, Ercole A, Cabeleira M, Carbonara M, Stocchetti N, Menon DK, Smielewski P, Czosnyka M; CENTER-TBI High Resolution (HR ICU) Sub-Study Participants and Investigators. Comparison of Performance of Different Optimal Cerebral Perfusion Pressure Parameters for Outcome Prediction in Adult Traumatic Brain Injury: A Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study. J Neurotrauma. 2019 May 15;36(10):1505-1517. doi: 10.1089/neu.2018.6182. Epub 2018 Dec 17. PMID: 30384809.