(Polenov Research Neurosurgical Institute, Saint Petersburg)
It is known, that severe craniocerebral trauma (CCT) is one of the urgent problems of modern medicine. It accounts for 39-40% of all trauma; severe contusion of the brain is watched in about 25% of cases.
Despite considerable achievements in the field of resuscitation and improved methods of surgical treatment and intensive care, mortality in patients with severe CCT, especially in its combination with intracerebral hematomas and crush foci, is still very high. According to different and numerous authors, it is 60-80%; the rate of invalidism and reduced working capacity reaches 40-60%.
First of all, it concerns such clinical forms of severe CCT, which need emergency neurosurgical care. Here one can mention casualties with intracranial hematomas, hydromas, crush foci within the brain, depressed fractures, rhino- and otoliquorrhea. This category of patients is the main source of fatal outcomes and invalidism in severe CCT. It demands timely surgical treatment and intensive care in resuscitation units.
A leading link of multimodality treatment of severe CCT with presence of intracranial hematomas and focal crushing of cerebral hemispheres is timely and adequate surgical intervention.
The main tasks of a neurosurgeon and anesthesiologist are estimating a state severity and necessity of resuscitative measures, choosing a minimum complex of neurodiagnostic methods and tactics of treatment (surgical or conservative). It should be done on admission of a patient in an admitting office. Examination is followed by making a decision on necessity of surgical treatment. Then a patient is transferred from an antishock unit either to an operating room or a neuroresuscitation department.
It has been proved, that as a rule intracranial hematomas are formed during the first hours after trauma. Augmentation of a syndrome of brain compression is conditioned not by a gradual increase of hematoma volume, but by a response of the brain to it. There should not be any subacute and chronic intracranial hematomas in the presence of modern neurodiagnostic tools (CT, MRI).Usually subacute and chronic hematomas are hematomas, which have not been diagnosed or removed in an acute period of trauma due to some causes. Existing data have become the basis for revising tactics of surgical treatment of such hematomas. The main tactical problem of surgery of intracranial hematomas is their early diagnosis and urgent intervention, aimed at elimination of brain compression. Large intracranial hematomas with marked dislocation syndrome should be removed as quickly as possible. Removal of their fluid part can be achieved via burr holes, made in typical areas, as it considerably reduces manifestations of dislocation before completing main stages of operation. Chronic subdural hematomas can be also removed via burr holes with the help of washing and subsequent applying tidal drainage for 3-5 days. The only exception is small (20-40 cm3) supratentorial hematomas (plate-like, meningeal or intracerebral) with absent clinical manifestations of brain compression or irritation. In our opinion, indications for surgical intervention should be dependent not only on a volume of an intracranial compressing factor, but also on a clinical course and severity of accompanying contusion of the brain. However, remote results of conservative treatment of the so-called “small-volume hematomas” need further study. Poor results of removing only intracranial hematomas in patients with areas of brain destruction have served the basis for improving surgical treatment of crush foci in cerebral hemispheres.
It is necessary to give more precise terminological definition, concerning surgical forms of focal brain destruction. A contusion focus is an area of hemorrhagic softening of brain substance without its crushing; pia mater is intact; configuration of sulci and convolutions is preserved; there is no detritus. Usually it demands conservative treatment and is not subject to surgery.
A crush focus is a macroscopic area of traumatic lesion of brain tissue with its complete destruction, multiple hemorrhages, ruptures of pia mater and formation of detritus. Taking into account a clinical-surgical approach to this pathology and peculiarities of preoperative diagnosis, it is important to determine the most characteristic forms, demanding surgical treatment. We have elaborated a clinical-morphologic classification of crush foci of cerebral hemispheres, based on studying types of a clinical course, operative findings, section and CT data. It allows to determine indications and to time surgical intervention in these pathologic states. A volume of operation is dependent on a degree of dislocation syndrome severity and a character of brain injury.
Выбор адекватного хирургического доступа, метода и объема его осуществления, должны направляться не только на сохранение жизни пациента, но и улучшение ее качества. Достаточно эффективными являются традиционные хирургические доступы, соответствующие локализации объемного поражения мозга и обеспечивающие его адекватное удаление. Предпочтение следует отдавать формированию трепанационного окна методом выпиливания костного лоскута. По возможности использование в практике резекционной трепанации черепа методом выкусывания должно быть исключено, так как она по нашим данным значительно увеличивает инвалидизацию пострадавших на 30-40%.
It should be emphasized, that a positive result of surgical treatment of traumatic intracranial formations is fully dependent on performing intervention before development of marked dislocation syndrome. Thus, wait-and-see tactics is not justified in such cases. As for multiple or bilateral lesions of the brain, it is preferable to perform extended decompressive trephination of the skull with removal of compressing factors on the side, characterized by a larger volume and causing brain dislocation. Our dynamic studies have shown, that it creates conditions for resolution of unremoved foci of other localization. It should be noted, that each case demands an individual approach to estimation of a clinical picture of the disease with taking into account age peculiarities and accompanying somatic pathology. A choice of an adequate surgical access, a method and volume of it performing should to be aimed not only at a patient’s survival, but also at improvement of his life quality. Conventional surgical approaches, corresponding to localization of a mass and providing its adequate removal, are rather effective. It is preferable to saw a bone flap in making a trephination window. If possible, one should exclude use of cutting forceps in resecting trephination, as according to our experience it increases invalidism by 30-40%. Extended osteoplasic trephination is expedient in removal of intracranial hematomas and crush foci, accompanied by marked brain edema. Depending on edema severity, operation is completed either by returning a bone flap to its place or its preserving in weak formalin solution. Resecting trephination (with use of cutting forceps) is acceptable only when there is a comminuted fracture in a zone of surgical intervention and it is impossible to saw a bone flap. Large bone fragments demand reposition and fixation with a glue or removal with subsequent preserving in formalin solution. It depends on a character of damage and severity of brain edema. Removal of intracranial factors of compression should be radical. Peculiar attention should be paid to a degree of radical removal of cerebral destruction foci. This problem needs a differentiated approach. According to the results of our study, the most effective way of surgical intervention in hemispheric destruction foci and presence of hypertension-dislocation syndrome of the 1st-2nd degrees is their removal within the limits of a destruction zone with subsequent therapy, aimed at prevention of secondary disorders of cerebral circulation. It should be sparing and dependent on functional eloquence of a damaged area, as it reduces invalidism. More radical removal of crush foci, including both a destruction zone and almost unchanged tissue (vast parenchymal hemorrhages), should be performed in hypertension-dislocation syndrome of the 3rd degree and marked brain edema. Radical removal in such cases is an additional factor, which allows to reduce intracranial pressure and to improve venous drainage.
As a rule, complete removal of intracranial mass reduces edema and the brain begins to pulsate. It is the result of restoration of venous drainage from the scull cavity. Dura is returned to its place. Depending on severity of brain edema, its plasty is performed with different materials (dura, fascia). In marked edema, it is necessary to remove a bone flap and to make additional subtemporal decompression by resecting a squamous portion of the temporal bone in the base direction.
However, successful treatment of severe CCT can be achieved only in case of combining surgical methods with pathogenetically substantiated intensive care, aimed at elimination of hypoxia, microcirculation disorders, impaired rheologic properties of blood, developed secondary inflammatory complications. It prevents further spread of a necrotic zone within an area of destruction foci, edema development and brain dislocation.