占位性小脑梗死的手术决策：证据、困境与 个体化策略

Surgical Decision-Making for Space-Occupying Cerebellar Infarction: Evidence, Challenges, and Individualized Strategies

摘要: 占位性小脑梗死虽发病率低，但恶性脑水肿可致病情急剧恶化，病死率高达20%~30%。后颅窝减压术是挽救生命的关键，然而手术指征、时机及技术参数长期缺乏统一标准。近5年发表的Meta分析提供了手术优于保守治疗的证据，并提出了梗死体积 > 51 mL、GCS ≤ 13等预后阈值，但同期国际调查显示预后阈值差异巨大。本文系统梳理手术决策的关键证据，从证据局限性、疾病异质性、患者个体因素及指南盲区等方面剖析决策困境的成因。在此基础上，提出基于影像学动态演变、临床恶化趋势和个体因素的个体化决策框架，最后，呼吁开展多中心前瞻性登记研究，建立手术技术报告标准，以期弥合证据与临床实践之间的鸿沟。

Abstract: Although the incidence rate of space occupying cerebellar infarction is low, malignant brain edema can lead to rapid deterioration of the condition, with a mortality rate of 20%~30%. Posterior cranial fossa decompression is the key to saving lives, but there has been a lack of unified standards for surgical indications, timing, and technical parameters for a long time. Meta analyses published in the past 5 years have provided evidence that surgery is superior to conservative treatment, and have proposed prognostic thresholds such as infarct volume > 51 mL and GCS ≤ 13. However, international surveys conducted during the same period have shown significant differences in prognostic thresholds. This article systematically reviews the key evidence for surgical decision-making, analyzing the causes of decision-making dilemmas from the perspectives of limited evidence levels, disease heterogeneity, individual patient factors, and blind spots in guidelines. On this basis, an individualized decision-making framework based on the dynamic evolution of imaging, clinical deterioration trends, and individual factors is proposed. Finally, a multi center prospective registration study is called for to establish surgical technique reporting standards in order to bridge the gap between evidence and clinical practice.