两种微创手术方法治疗高血压基底节区脑出血的临床分析
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摘要
目的:回顾分析小骨窗开颅经侧裂入路显微手术与钻孔经颞叶微创穿刺引流术两种手术方法治疗高血压基底节区出血的疗效,探讨其临床应用价值。
方法:收集广西医科大学第九附属医院神经外科2007年10月至2009年7月手术治疗的60例高血压基底节区出血患者的临床资料,按照手术方式不同分为二组:小骨窗开颅经外侧裂人路显微镜下清除血肿30例(经侧裂组)和钻孔经颞叶微创穿刺抽吸30例(微创穿刺组)。比较两组病人在病死率,术后再出血率等并发症及近远期生活质量改善率方面的差异。
结果:经侧裂组30例中死亡4例,无术后再出血;微创穿刺组30例死亡5例,术后再出血1例,术后血肿清除率经侧裂组优于微创穿刺组,两组在病死率、再出血率及术后并发症等临床疗效优良率方面无统计学差异,改善幸存者近远期生活质量方面经侧裂组优于微创穿刺引流组。
结论:对于基底节区30-60mL内中等量出血患者小骨窗开颅经外侧裂显微血肿清除术能够有效提高患者的近远期预后。
Objective To evaluate and compare the effectiveness of different types of surgical therapy for patients with hypertensive intracerebral hemorrhage, and summarize the clinical experience.
Methods A total of 60 cases with hypertensive intracerebrel hemorrhage hospitalized in Beihai 1st hospital from Oct 2007 to July 2009 were subjected in this study .They were divided into 2 groups according to operation method: Group I (n=30),receiving craniotomy with small bone flap via lateral fissure and Group II (n=30)receiving CT guided minimal invasive hematoma aspiration .All data were analyzed retrospectively.
Result The case fatality, rehaemorrhage rate and the incidence of postoperative complication in group I were 13%,0%,30%respectively. The case fatality ,rehaemorrhage rate and the incidence of postoperative complication in group II were 25%,3.3%,39%. There was no significant statistical difference between the two groups. As for Their GOS fitneness and score of activities of daily living(ADL)were investigated during the 6 months’close follow up, GOS and ADL in group I is much higher than the other one.
Conclusion To hypertensive cerebral hemorrhage in basal ganglion with operative indication,especially whose volume of hematoma is between 30-60ml,the microsurgery treatment by small skull fenestral is a safe and efective way.
方法:收集广西医科大学第九附属医院神经外科2007年10月至2009年7月手术治疗的60例高血压基底节区出血患者的临床资料,按照手术方式不同分为二组:小骨窗开颅经外侧裂人路显微镜下清除血肿30例(经侧裂组)和钻孔经颞叶微创穿刺抽吸30例(微创穿刺组)。比较两组病人在病死率,术后再出血率等并发症及近远期生活质量改善率方面的差异。
结果:经侧裂组30例中死亡4例,无术后再出血;微创穿刺组30例死亡5例,术后再出血1例,术后血肿清除率经侧裂组优于微创穿刺组,两组在病死率、再出血率及术后并发症等临床疗效优良率方面无统计学差异,改善幸存者近远期生活质量方面经侧裂组优于微创穿刺引流组。
结论:对于基底节区30-60mL内中等量出血患者小骨窗开颅经外侧裂显微血肿清除术能够有效提高患者的近远期预后。
Objective To evaluate and compare the effectiveness of different types of surgical therapy for patients with hypertensive intracerebral hemorrhage, and summarize the clinical experience.
Methods A total of 60 cases with hypertensive intracerebrel hemorrhage hospitalized in Beihai 1st hospital from Oct 2007 to July 2009 were subjected in this study .They were divided into 2 groups according to operation method: Group I (n=30),receiving craniotomy with small bone flap via lateral fissure and Group II (n=30)receiving CT guided minimal invasive hematoma aspiration .All data were analyzed retrospectively.
Result The case fatality, rehaemorrhage rate and the incidence of postoperative complication in group I were 13%,0%,30%respectively. The case fatality ,rehaemorrhage rate and the incidence of postoperative complication in group II were 25%,3.3%,39%. There was no significant statistical difference between the two groups. As for Their GOS fitneness and score of activities of daily living(ADL)were investigated during the 6 months’close follow up, GOS and ADL in group I is much higher than the other one.
Conclusion To hypertensive cerebral hemorrhage in basal ganglion with operative indication,especially whose volume of hematoma is between 30-60ml,the microsurgery treatment by small skull fenestral is a safe and efective way.
引文
[1] Qureshi AI,Tuhrim S,Bmderick JP,et a1.Spontaneous intracerebral hemorrhage.[J] N Engl J Med, 2001, 344:1450.1460.
[2] Zhang LF,Yang J,Hong Z,et a1.Collaborative Group of China Muhicenter Study of Cardiovascular Epidemiology.Proportion of diferent subtypes of stroke in China.[J] Stroke 2003,34:2091.2096
[3] Fewel ME , Thompson BG Jr , Hof JT . Spontaneous intracerebral hemorhage: a review.[J] Neurosurg Focus, 2003,15:1.
[4]周良辅,庞力.高血压脑出血的微侵袭手术治疗一前瞻随机多中心研究[J].中国临床神经科学,2001,9(2):151—154
[5] Xi G,Wagner KR,keep FR,et a1.Role of blood clot formation on early edema developm ent after experimental intracerebral hemorrhage[J]. Stroke,1998,29:2580—2586
[6] Zazulia AR,Diringer MN,Videen TO,et a1.Hypoperfusion without ischemia surrounding acute intracerebral hamOrrhage.[J] J Cereb Blood Flow Metab,2001,21:804.8l0.
[7] Warach S. Editorial comment- is there a perihematomal ischemic penumbra More questions and an overlooked clue.[J] Stroke,2003,34:1680.
[8] Prasad K,Rrowan G,Sirvastava A ,et a1.Surgery in primary supratentorial intracerebral hematoma:A meta-analysis of randomized trails.[J] Acta Neurol Scand,1997,95:103-110.
[9]陈汉民,黄国河,刘剑云.立体定向单纯置管加尿激酶溶解治疗高血压脑出血.[J]。中国微侵袭神经外科杂志,2003,8(11):507
[10]田增民.神经导航与无框架脑立体定向手术在神经外科中的应用[J].中华医学杂志,2001,81(17):1028—1029
[11]本藤秀树1高血压性脑出血的手术方法及手术适应症[J ]Jpn J Neurosurg, 1999; 8: 692761
[12] Wagner KR,Xi G,Hau Y,et a1.Early metabolic alterations in edematous perihematomal brain regions following experimental intracerebral hemorrhage[J].J Neurosurg,1998,88;1058-1065
[13] Huang FP,Xi GH,Keep RF,et a1.Brain edema after expermental intracerebral hemorrhage:role of hemoglobin degradation products[J].J Neurosurg,2002,96(2):287-293
[14] Badjatia N, Rosand J. Intracerebral hemorrhage. [J]Neurologist. 2005 Nov;11(6):311-24.
[15] J Claude Hemphill,David C Bonovich,Lavrentios Besmertis,et a1.The ICH score a simple, reliable grading scale for intracerebral hemorhage.[J]Stroke,2001,32:891-897
[16] Tuhrim Stanley,Horowi Deborab R,Sacher Michael et a1.Validation and comparison of models predicting survival following intracerebra hemorhage.[J]CritCareMed ,1995,23:950-954
[17] Kaneko M, Koba T, Yokoyama T. Early surgical treatment for hypertensive intracerebral hemorrhage. [J] J Neurosurg. 1977 May;46(5):579-83.
[18] Morgenstern LB, Demchuk AM, Kim DH, et.al. Rebleeding leads to poor outcome in ultra-early craniotomy for intracerebral hemorrhage.[J] Neurology. 2001 May 22;56(10):1294-9.
[19] Mayer SA.Ultra-early hemostatic therapy for intracerebral hemorrhage.[J] Stroke,2003,34(1):224-229
[20]张建军,董伟峰,顾水均,等.高血压脑出血外科治疗近期预后因素临床分析.[J]中国危重急救医学,2005,17:311—312.
[21]王德江,王硕,赵元立,等.高血压脑出血外科治疗近期预后多因素分析.[J]中华医学杂志,2005,85:3l18-3122
[1] Zhang LF,Yang J,Hong Z,et a1.Collaborative Group of China Multicenter Study of Cardiovascular Epidemiology .Proportion of different subtypes of stroke in China.[J] Stroke, 2003,34:2091.2096.
[2] Qureshi AI, Tuhrim S, Broderick JP, et al . Spontaneous intracerebral hemorrhage. [J] N Engl J Med. 2001 May 10;344(19):1450-60.
[3] Brott T, Broderick J, Kothari R, et al. Early hemorrhage growth in patients with intracerebral hemorrhage.[J] Stroke. 1997;28:1–5.
[4] Deveras RA, Kessler CM. Reversal of warfarin-induced excessive anticoagulation with recombinant human factor VIIa concentrate. [J] Ann Intern Med. 2002;137:884–888.
[5] Qureshi AI, Bliwise DL, Bliwise NG, et alMR.Rate of 24-hour blood pressure decline and mortality after spontaneous intracerebral hemorrhage: a retrospective analysis with a random effects regression model.[J] Crit Care Med. 1999;27:480–485.
[6] Chambers IR, Banister K, Mendelow AD. Intracranial pressure within a developing intracerebral haemorrhage. [J] Br J Neurosurg. 2001; 15:140–141.
[7] Powers WJ, Zazulia AR, Videen TO, et al. Autoregulation of cerebral blood flow surrounding acute (6 to 22 hours) intracerebral hemorrhage.[J] Neurology. 2001;57:18–24.
[8] Kazui S, Minematsu K, Yamamoto H, et al. Predisposing factors to enlargement of spontaneous intracerebral hematoma. [J] Stroke. 1997;28:2370–2375.
[9] Tsivgoulis G, Spengos K, Zakopoulos N et.al. Twenty four hour pulse pressure predicts long term recurrence in acute stroke patients.[J] J Neurol Neurosurg Psychiatry. 2005 Oct;76(10):1360-5.
[10]Vemmos KN, Tsivgoulis G, Spengos K et.al. Pulse pressure in acute strokeis an independent predictor of long-term mortality. [J] Cerebrovasc Dis. 2004;18(1):30-6. Epub 2004 May 19.
[11] Rosner MJ, Daughton S. Cerebral perfusion pressure management in head injury.[J] J Trauma. 1990;30:933–940.
[12] Nirula R, Gentilello LM. Detrimental effects of hypothermia. In:Tisherman SA, Sterz F, eds.[J] Therapeutic Hypothermia. New York, NY: Springer; 2005:235–251.
[13] Steiner T, Friede T, Aschoff A, et al. Effect and feasibility of controlled rewarming after moderate hypothermia in stroke patients with malignant infarction of the middle cerebral artery. [J] Stroke. 2001;32:2833–2835.
[14] Fogelholm R, Murros K, Rissanen A, et al. Admission blood glucose and short term survival in primary intracerebral haemorrhage: a population based study. [J] J Neurol Neurosurg Psychiatry. 2005;76:349–353.
[15] Passero S, Rocchi R, Rossi S, et al. Seizures after pontaneous supratentorial intracerebral hemorrhage. [J] Epilepsia. 2002;43: 1175–1180.
[16] Schwab S, Georgiadis D, Berrouschot J, et al. Feasibility and safety of moderate hypothermia after massive hispheric infarction. [J] Stroke. 2001;32:2033–2035.
[17] Gupta R, Jovin TG, Krieger DW. Therapeutic hypothermia for stroke:do new outfits change an old friend?[J]pert Rev Neurother. 2005;5:235–246.
[18] Rossi S, Zanier ER, Mauri I, et al, Stocchetti N. Brain emperature, body core temperature, and intracranial pressure in acutecrebral damage. [J] J Neurol Neurosurg Psychiatry. 2001;71:448–454.
[19] Kawai N, Nakamura T, Okauchi M, et al. Effects of hypothermia on intracranial pressure and brain edema formation: studies in a rat acute subdural hematoma model.[J]J neurotramua. 2000;17:193–202.
[20]王德江,王硕,赵元立,等.高血压脑出血外科治疗近期预后多因素分析.[J]中华医学杂志,2005,85:3l18-3122
[21] Prasad K,Rrowan G,Sirvastava A ,et a1.Surgery in primary supratentorial intracerebral hematoma:A meta-analysis of randomized trails.[J] Acta Neurol Scand, 1997, 95:103-110
[22]李云辉,林中平,黄建龙,等.超早期锁孔血肿清除术治疗高血压基底节出血24例.[J]中国危重病急救医学,2005,5.66
[23] Schaller C, Rohde V, Meyer B, et al. Stereotactic puncture and lysis of spontaneous intracerebral hemorrhage using recombinant tissueplasminogen activator. [J] Neurosurgery. 1995;36:328–333.
[24] Lippitz BE, Mayfrank L, Spetzger U, et al . Lysis of basal ganglia haematoma with recombinant tissue plasminogen activator (rtPA) after stereotactic aspiration: initial results. [J] Acta Neurochir (Wien). 1994;127:157–160
[25] Deinsberger w,vogel j , fuchs c,et al.fibrinolysis and aspiration of experimental intracerebral hematoma reduces the volume of ischemic brain in rats.[J] Neurol Res. 1999 Jul;21(5):517-23.
[26]李云驰,阚志生,崔永鹏,等.微侵袭神经内窥镜手术治疗高血压脑出血的疗效观察.[J]中华实用中西医杂志,2004,13:10-1
[27] Unsgaard G,Gronningsaeter A,Ommedal S,et a1.Brain operations guided by real-time two-dimensional ultrasound:new possibilities as a result of improved image quality.[J]Neurosurgery ,2002,51:402-41
[28]赵继宗,周定标,周良辅,等.2464例高血压脑出血外科治疗多中心单盲研究.[J]中华医学杂志,2005,85:2238-2242
[2] Zhang LF,Yang J,Hong Z,et a1.Collaborative Group of China Muhicenter Study of Cardiovascular Epidemiology.Proportion of diferent subtypes of stroke in China.[J] Stroke 2003,34:2091.2096
[3] Fewel ME , Thompson BG Jr , Hof JT . Spontaneous intracerebral hemorhage: a review.[J] Neurosurg Focus, 2003,15:1.
[4]周良辅,庞力.高血压脑出血的微侵袭手术治疗一前瞻随机多中心研究[J].中国临床神经科学,2001,9(2):151—154
[5] Xi G,Wagner KR,keep FR,et a1.Role of blood clot formation on early edema developm ent after experimental intracerebral hemorrhage[J]. Stroke,1998,29:2580—2586
[6] Zazulia AR,Diringer MN,Videen TO,et a1.Hypoperfusion without ischemia surrounding acute intracerebral hamOrrhage.[J] J Cereb Blood Flow Metab,2001,21:804.8l0.
[7] Warach S. Editorial comment- is there a perihematomal ischemic penumbra More questions and an overlooked clue.[J] Stroke,2003,34:1680.
[8] Prasad K,Rrowan G,Sirvastava A ,et a1.Surgery in primary supratentorial intracerebral hematoma:A meta-analysis of randomized trails.[J] Acta Neurol Scand,1997,95:103-110.
[9]陈汉民,黄国河,刘剑云.立体定向单纯置管加尿激酶溶解治疗高血压脑出血.[J]。中国微侵袭神经外科杂志,2003,8(11):507
[10]田增民.神经导航与无框架脑立体定向手术在神经外科中的应用[J].中华医学杂志,2001,81(17):1028—1029
[11]本藤秀树1高血压性脑出血的手术方法及手术适应症[J ]Jpn J Neurosurg, 1999; 8: 692761
[12] Wagner KR,Xi G,Hau Y,et a1.Early metabolic alterations in edematous perihematomal brain regions following experimental intracerebral hemorrhage[J].J Neurosurg,1998,88;1058-1065
[13] Huang FP,Xi GH,Keep RF,et a1.Brain edema after expermental intracerebral hemorrhage:role of hemoglobin degradation products[J].J Neurosurg,2002,96(2):287-293
[14] Badjatia N, Rosand J. Intracerebral hemorrhage. [J]Neurologist. 2005 Nov;11(6):311-24.
[15] J Claude Hemphill,David C Bonovich,Lavrentios Besmertis,et a1.The ICH score a simple, reliable grading scale for intracerebral hemorhage.[J]Stroke,2001,32:891-897
[16] Tuhrim Stanley,Horowi Deborab R,Sacher Michael et a1.Validation and comparison of models predicting survival following intracerebra hemorhage.[J]CritCareMed ,1995,23:950-954
[17] Kaneko M, Koba T, Yokoyama T. Early surgical treatment for hypertensive intracerebral hemorrhage. [J] J Neurosurg. 1977 May;46(5):579-83.
[18] Morgenstern LB, Demchuk AM, Kim DH, et.al. Rebleeding leads to poor outcome in ultra-early craniotomy for intracerebral hemorrhage.[J] Neurology. 2001 May 22;56(10):1294-9.
[19] Mayer SA.Ultra-early hemostatic therapy for intracerebral hemorrhage.[J] Stroke,2003,34(1):224-229
[20]张建军,董伟峰,顾水均,等.高血压脑出血外科治疗近期预后因素临床分析.[J]中国危重急救医学,2005,17:311—312.
[21]王德江,王硕,赵元立,等.高血压脑出血外科治疗近期预后多因素分析.[J]中华医学杂志,2005,85:3l18-3122
[1] Zhang LF,Yang J,Hong Z,et a1.Collaborative Group of China Multicenter Study of Cardiovascular Epidemiology .Proportion of different subtypes of stroke in China.[J] Stroke, 2003,34:2091.2096.
[2] Qureshi AI, Tuhrim S, Broderick JP, et al . Spontaneous intracerebral hemorrhage. [J] N Engl J Med. 2001 May 10;344(19):1450-60.
[3] Brott T, Broderick J, Kothari R, et al. Early hemorrhage growth in patients with intracerebral hemorrhage.[J] Stroke. 1997;28:1–5.
[4] Deveras RA, Kessler CM. Reversal of warfarin-induced excessive anticoagulation with recombinant human factor VIIa concentrate. [J] Ann Intern Med. 2002;137:884–888.
[5] Qureshi AI, Bliwise DL, Bliwise NG, et alMR.Rate of 24-hour blood pressure decline and mortality after spontaneous intracerebral hemorrhage: a retrospective analysis with a random effects regression model.[J] Crit Care Med. 1999;27:480–485.
[6] Chambers IR, Banister K, Mendelow AD. Intracranial pressure within a developing intracerebral haemorrhage. [J] Br J Neurosurg. 2001; 15:140–141.
[7] Powers WJ, Zazulia AR, Videen TO, et al. Autoregulation of cerebral blood flow surrounding acute (6 to 22 hours) intracerebral hemorrhage.[J] Neurology. 2001;57:18–24.
[8] Kazui S, Minematsu K, Yamamoto H, et al. Predisposing factors to enlargement of spontaneous intracerebral hematoma. [J] Stroke. 1997;28:2370–2375.
[9] Tsivgoulis G, Spengos K, Zakopoulos N et.al. Twenty four hour pulse pressure predicts long term recurrence in acute stroke patients.[J] J Neurol Neurosurg Psychiatry. 2005 Oct;76(10):1360-5.
[10]Vemmos KN, Tsivgoulis G, Spengos K et.al. Pulse pressure in acute strokeis an independent predictor of long-term mortality. [J] Cerebrovasc Dis. 2004;18(1):30-6. Epub 2004 May 19.
[11] Rosner MJ, Daughton S. Cerebral perfusion pressure management in head injury.[J] J Trauma. 1990;30:933–940.
[12] Nirula R, Gentilello LM. Detrimental effects of hypothermia. In:Tisherman SA, Sterz F, eds.[J] Therapeutic Hypothermia. New York, NY: Springer; 2005:235–251.
[13] Steiner T, Friede T, Aschoff A, et al. Effect and feasibility of controlled rewarming after moderate hypothermia in stroke patients with malignant infarction of the middle cerebral artery. [J] Stroke. 2001;32:2833–2835.
[14] Fogelholm R, Murros K, Rissanen A, et al. Admission blood glucose and short term survival in primary intracerebral haemorrhage: a population based study. [J] J Neurol Neurosurg Psychiatry. 2005;76:349–353.
[15] Passero S, Rocchi R, Rossi S, et al. Seizures after pontaneous supratentorial intracerebral hemorrhage. [J] Epilepsia. 2002;43: 1175–1180.
[16] Schwab S, Georgiadis D, Berrouschot J, et al. Feasibility and safety of moderate hypothermia after massive hispheric infarction. [J] Stroke. 2001;32:2033–2035.
[17] Gupta R, Jovin TG, Krieger DW. Therapeutic hypothermia for stroke:do new outfits change an old friend?[J]pert Rev Neurother. 2005;5:235–246.
[18] Rossi S, Zanier ER, Mauri I, et al, Stocchetti N. Brain emperature, body core temperature, and intracranial pressure in acutecrebral damage. [J] J Neurol Neurosurg Psychiatry. 2001;71:448–454.
[19] Kawai N, Nakamura T, Okauchi M, et al. Effects of hypothermia on intracranial pressure and brain edema formation: studies in a rat acute subdural hematoma model.[J]J neurotramua. 2000;17:193–202.
[20]王德江,王硕,赵元立,等.高血压脑出血外科治疗近期预后多因素分析.[J]中华医学杂志,2005,85:3l18-3122
[21] Prasad K,Rrowan G,Sirvastava A ,et a1.Surgery in primary supratentorial intracerebral hematoma:A meta-analysis of randomized trails.[J] Acta Neurol Scand, 1997, 95:103-110
[22]李云辉,林中平,黄建龙,等.超早期锁孔血肿清除术治疗高血压基底节出血24例.[J]中国危重病急救医学,2005,5.66
[23] Schaller C, Rohde V, Meyer B, et al. Stereotactic puncture and lysis of spontaneous intracerebral hemorrhage using recombinant tissueplasminogen activator. [J] Neurosurgery. 1995;36:328–333.
[24] Lippitz BE, Mayfrank L, Spetzger U, et al . Lysis of basal ganglia haematoma with recombinant tissue plasminogen activator (rtPA) after stereotactic aspiration: initial results. [J] Acta Neurochir (Wien). 1994;127:157–160
[25] Deinsberger w,vogel j , fuchs c,et al.fibrinolysis and aspiration of experimental intracerebral hematoma reduces the volume of ischemic brain in rats.[J] Neurol Res. 1999 Jul;21(5):517-23.
[26]李云驰,阚志生,崔永鹏,等.微侵袭神经内窥镜手术治疗高血压脑出血的疗效观察.[J]中华实用中西医杂志,2004,13:10-1
[27] Unsgaard G,Gronningsaeter A,Ommedal S,et a1.Brain operations guided by real-time two-dimensional ultrasound:new possibilities as a result of improved image quality.[J]Neurosurgery ,2002,51:402-41
[28]赵继宗,周定标,周良辅,等.2464例高血压脑出血外科治疗多中心单盲研究.[J]中华医学杂志,2005,85:2238-2242