小骨窗开颅血肿清除术与血肿腔穿刺外引流术在高血压脑出血中的应用
|
摘要
目的:探讨小骨窗开颅血肿清除术和血肿腔穿刺外引流术两种手术方法在治疗幕上高血压脑出血(HICH)中近期疗效的差别。
方法:小骨窗开颅血肿清除术组:广西医科大学第九附属医院神经外科2006年01月至2007年10月小骨窗开颅血肿清除的31例HICH;血肿腔穿刺外引流术组:第九附属医院同期神经外科行血肿穿刺外引流治疗的HICH 37例,比较两组病人在病死率、改善幸存者近期生活质量以及再出血率方面的差异。
结果:小骨窗组的病死率,GOS(Glasgow outcome scale)近期预后优良率,再出血率分别是16%,48%,13%,而穿刺组的病死率,GOS近期预后优良率,再出血率分别是38%,35%,11%,小骨窗组的病死率低于血肿腔穿刺组,小骨窗组与血肿穿刺组在再出血率、改善幸存者近期生存质量方面没有明显统计学差别。
结论:对于幕上脑叶内血肿,特别是出血量≤60ml的中等出血量以下的患者,小骨窗开颅血肿清除术能够降低病死率,而对基底节内脑出血,两种手术方法在降低病死率方面没有明显统计学差别;而且两种手术方法对于改善幸存者的近期生活质量以及降低再出血率方面没有明显统计学差别。
Objectives: To compare the curative effect of removing hematoma through small skull window and that of CT guided aspiration in the treatment of hypertensive intracerebral hemorrhage (HICH)happen up the tentorium of cerebellum.
Methods: Group 1 (Removing Hematoma through Small Skull Window): 31 patients with HICH who were admitted to the Nith Hospital of Guang xi Medical University from January 2006 to October 2007 were removed hematoma through small skull window. Group 2 (CT Guided Aspiration): 37 patients with HICH who were admitted to the Ninth Hospital of Guang xi Medical University at the same time were drained the haematoma by CT guided aspiration. The clinical data of the patients were collected and analyzed.
Results: The case fatality, GOS fineness rate and rehaemorrhage rate in small skull windows group were 16%, 48%, and 13% respectively. The case fatality, recent GOS fineness ratio and rehaemorrhage ratio of CT guided aspiration group were 38%, 35%, 11%. The case fatality of the small skull window group was lower than that of the CT guided aspiration group. As for the rehaemorrhage rate and the recent quality of life, there was no significant statistical difference between the two groups.
Conclusions: The method of removing hematoma through small skull window can decrease the case fatality of the HICH patients whose hematoma happen in the Lobe of brain, especially whose volume of hematoma is no more than 60ml, while the case fatality of the two groups whose hematoma happen in the basal nuclei has no significant statistical difference. The two methods have no significant statistical difference in rehaemorrhage ratio, in improving the survivors' recent quality of life.
方法:小骨窗开颅血肿清除术组:广西医科大学第九附属医院神经外科2006年01月至2007年10月小骨窗开颅血肿清除的31例HICH;血肿腔穿刺外引流术组:第九附属医院同期神经外科行血肿穿刺外引流治疗的HICH 37例,比较两组病人在病死率、改善幸存者近期生活质量以及再出血率方面的差异。
结果:小骨窗组的病死率,GOS(Glasgow outcome scale)近期预后优良率,再出血率分别是16%,48%,13%,而穿刺组的病死率,GOS近期预后优良率,再出血率分别是38%,35%,11%,小骨窗组的病死率低于血肿腔穿刺组,小骨窗组与血肿穿刺组在再出血率、改善幸存者近期生存质量方面没有明显统计学差别。
结论:对于幕上脑叶内血肿,特别是出血量≤60ml的中等出血量以下的患者,小骨窗开颅血肿清除术能够降低病死率,而对基底节内脑出血,两种手术方法在降低病死率方面没有明显统计学差别;而且两种手术方法对于改善幸存者的近期生活质量以及降低再出血率方面没有明显统计学差别。
Objectives: To compare the curative effect of removing hematoma through small skull window and that of CT guided aspiration in the treatment of hypertensive intracerebral hemorrhage (HICH)happen up the tentorium of cerebellum.
Methods: Group 1 (Removing Hematoma through Small Skull Window): 31 patients with HICH who were admitted to the Nith Hospital of Guang xi Medical University from January 2006 to October 2007 were removed hematoma through small skull window. Group 2 (CT Guided Aspiration): 37 patients with HICH who were admitted to the Ninth Hospital of Guang xi Medical University at the same time were drained the haematoma by CT guided aspiration. The clinical data of the patients were collected and analyzed.
Results: The case fatality, GOS fineness rate and rehaemorrhage rate in small skull windows group were 16%, 48%, and 13% respectively. The case fatality, recent GOS fineness ratio and rehaemorrhage ratio of CT guided aspiration group were 38%, 35%, 11%. The case fatality of the small skull window group was lower than that of the CT guided aspiration group. As for the rehaemorrhage rate and the recent quality of life, there was no significant statistical difference between the two groups.
Conclusions: The method of removing hematoma through small skull window can decrease the case fatality of the HICH patients whose hematoma happen in the Lobe of brain, especially whose volume of hematoma is no more than 60ml, while the case fatality of the two groups whose hematoma happen in the basal nuclei has no significant statistical difference. The two methods have no significant statistical difference in rehaemorrhage ratio, in improving the survivors' recent quality of life.
引文
1.周良辅.现代神经外科学[M].上海:复旦大学出版社,2001:798-799.
2.张玉琪.再论微创神经外科学(述评)[J].中华神经外科杂志,2005,21(4):193-194.
3.贾保祥,李志超,吕涌涛,等,主编.全国颅内血肿微创清除术临床应用培训教材[M].北京:全国颅内血肿微创技术协作组,2001:34.
4.李毓生,赵艳,杨成宝.高血压脑出血手术时机与适应证的探讨[J].内蒙古民族大学学报.自然科学版,2004,19(2):225-227.
5.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.
6.胡大一.高血压急症.新认识与临床实践[J].中国危重病急救医学,2003,15(9):517.
7.Nilsson OG,Lindgren AR,Brandt L,et al.Prediction of death in patients with primary intracerebral hemorrhage:a prospective study of a defined population[J].J Neurosurg,2002,97(3):531-536.
8.Mayer S A.Ultra-early hemo-static therapy for intracerebral hemorrhage[J].Stroke,2003,34(1):224-229.
9.毛群,勾俊龙,刘宗惠.外科治疗脑出血:回顾与展望[J].国外医学神经病学神经外科学分册,2003,30(5):420-423.
10.韦武腾.微创穿刺抽吸治疗高血压脑出血200例体会[J].中国临床神经外科杂志,2004,(9):372-373.
11.Kaneko M,koba T.Early surgical treatment for hypertensive intracerebral hemorrhage[J].J Neurosurg,1997,46:597.
12.刘振川,徐立明,赵仕欣,等.微创介入颅内出血(血肿)清除术在神经内科的应用研究[J].中国临床神经科学,2000,8(2):137-138.
13.Zuccarello M,Andaluz N,Wagner KR.Minimally invasive therapy for intracerebral hematomas[J].Neurosurg Clin N Am,2002,13(3):349-354.
14.Huang CF,Tsai ZP,Li CS,et al.Surgical improvement of brain edema related to hypertensive,intracerebral hemorrhage[J].Zhonghua Yi Xue Za Zhi (Taipei),2002,65(6):241-246.
15.Zazulia AR,Diringer MN,Derdeyn CP,et al.Progression of mass effect after intracerebral hemorrhage.Stroke,1999,30:1167-1173.
16.单爱军,赵永阳.CT引导钻颅抽吸外引流术治疗高血压性脑出血[J].广东医学,2001,22(12):1142-1143.
17.包华,阿荣高娃,陈碧林,等.微创颅内血肿清除术治疗脑出血23例[J].中国急救医学,2002,14(1):48.
18.Bhasin RR,Xi G,Hua Y,et al.Experimental intracerebral hemorrhage:effect of lysed erythrocytes on brain edema and blood-brain barrier permeability [J].Acta Neurochir Suppl,2002,81:249-251.
19.Ryter SW,Tyrrell RM.The heme synthesis and degradation path-ways:role in oxidant sensitivity.Heme oxygenase has both pro-and antioxidant properties[J].Free Radic Biol Med,2000,28:289-309.
20.Gong C,Hoff JT,Keep RF.Acute inflammatory reaction following.experimental intracerebral hemorrhage in rats[J].Brain Res,2000,871(1):57-65.
21.Guan JX,Sun SG,Cao XB,et al.Effect of thrombin on blood brain barrier permeability and its mechanism[J].Chin Med J(Engl),2004,117(11):1677-1678.
22.Gong C,Boulis N,Qian J,et al.Intracelebral hemorrhage-induced neuronal deeath[J].Neurosurgery,2001,48(4):875-883.
23.Song EC,Chu K,Jeong SW,et al.Hyperglycemia exacerbates brain edema and peribe matomal cell death after intracerebral hemorrhage[J].Stroke,2003,34(9):2215-2220.
24.Holmin S,Mathiesen T.Intracerebra administration of in-terleukin-1 beta and induction of inflammation.Apoptosis and vasogenic edema[J].J Neurosurg,2000,92:108-120.
25.Xi Guohua,Keep RF,Yonger JG,et al.Systemic complement depletion diminishes perihematomal brain edema in rats[J].Stroke,2001,32(1):162-167.
1. Fujii Y,Takeuchi S,Sasaki O,et al.Multivariate analysis of predictors of hematoma enlargement in spontaneous intracerebral hemorrhage [J]. Stroke, 1998,29:1160-1166.
2. Qureshi AI, Tuhrim S, Broderick JP, et al. spontaneous intracerebral hemorrhage[J]. N Engl J Med, 2001,344(19):1450-1460.
3. Mayer Stephan A. Ultra-Early Hemostatic Therapy for Intracerebral Hemorrhage [J]. Stroke, 2003,34 (1): 224-229.
4. Yonezawa T, Hashimoto H, Sakaki T.Serial change of cerebral blood flow after Collagenase induced intracerebral hemorrhage in rats [J] .No Shinkei Geka, 1999,27(5):419-425.
5. Hua Y, Xi G, Keep RF, et al.Complement activation in the brain after experimental intracerebral hemorrhage[J]J Neurosurg, 2000,92:1016.
6. Teernstra OP, Evers SM, Lodder J, et al. Stereotactic treatment of intracerebral hematoma by means of a plasminogen activator: a multicenter randomized controlled trial [J] .Stroke, 2003, 34: 968-974.
7. Siddique MS, Fernandes HM, Wooldridge TD, et al. Reversible ischemia around intracerebral hemorrhage:a singlephoton emission computerized tomography study [J] J Neurosurg, 2002 ,96(4):736-741.
8. Chu WJ, Mason GF, Pan JW, et al Mountz JM. Regional cerebral blood flow and magnetic resonance spectroscopic imaging findings in diaschisis from stroke [J] . Stroke, 2002, 33:1243 -1248.
9. Qureshi AI, Suri MF, Ostrow PT, et al. Apoptosis as a form of cell death in intracerebral hemorrhage [J] .Neurosurgery ,2003,52 (5):1041-1047.
10. Diringer MN, Adams RE, Dunford-Shore JE, et al. Cerebral blood flow is symmetrically reduced in patients with ICH.Neurology,1998,50:338-345.
11.rasad K,Shrivastava A.Surgery for primary supratentorial imracerebral haemorrhage[J].Cochrane Database Syst Rev,2000,CD000200.
12.Zazula AR,Diringer MN,Videen TO,et al.Acute intracerebral hemorrhage does not produce peri-clot cerebral ischemia.Neurology,2000,54(supp13):A261.Abstract.
13.Hirano T,Read SJ,Abbott DF,et al.Prediction of the final infarction volume within 6 h of stroke using single photon emission computed tomography with technetium-99m hexamethypropylene amine oxime[J].Cerebrovasc Dis,2001,11:119-127.
14.Rohde V,Rohde I,Reinges MH,et al.Frameless stereotactically guided catheter placement and fibrinolytic therapy for spontaneous intracerebral hematomas:technical aspects and initial clinical results[J].Minim Invasive Neurosurg(Germany),2000,43(1):9-17.
15.Wanger KR,Xi G,Hua Y,et al.Clot retraction contributes to early perihemotomal edema volumes following intracerebral hemorrhage[J].Soc Neurosci,1997,23(11):1921.
16.Yoshida Y,Yoshimoto T,Shirane R,et al.Clinical course,surgical management,and long-term outcome of moyamoya patients with rebleeding after an episode of intracerebral hemorrhage:an extensive follow-up study.Stroke,1999,30(11):2272-2276.
17.Guan JX,Sun SG,Cao XB,et al.Effect of thrombin on blood brain barrier permeability and its mechanism[J].Chin Med J(Engl),2004,117(11):1677-1678.
18.娄季宇,杨霄鹏,李建章,等.水蛭素对抗脑出血后脑水肿作用机制的研究[J].河南实用神经疾病杂志,2004,7:1-2.
19.. Gong C, Boulis N, Qian J, et al. Intracelebral hemorrhage-induced neuronal deeath[J].Neurosurgery, 2001,48(4):875-883.
20. Xi GH, Hua Y, Bhasin RR, Ennis SR, et al. Mechanisms of edema formation.after intracerebral hemorrhage: effects of extravasated red blood cells on blood flow and blood-brain barrier integrity [J]. Stroke, 2001, 32:2932-2938.
21. Ryter SW, Tyrrell RM. The heme synthesis and degradation path-ways: role in oxidant sensitivity. Heme oxygenase has both pro-and antioxidant properties[J]. Free Radic B iolMed, 2000,28: 289 - 309.
22. Suttner DM, Dennery PA. Reversal of HO-1 related cytoprotection with increased expression is due to reactive iron[J]. FASEB J, 1999 ,13: 1800-1809.
23. Holmin S, Mathiesen T. Intracerebra administration of in-terleukin-1 beta and induction of inflammation. Apoptosis and vasogenic edema[J]. J Neuro-surg, 2000, 92:108-120.
24. Del Bigio MR, Yan HJ, Buist R, et al. Experimental intracerebral hemorrhage in rats Magnetic resonance imaging and histopathological correlates [J]. Stroke, 1996,27:2312-2320.
25. Hua Y, Xi G, Keep RF, et al. Complement activation in the brain after experimental intracerebral hemorrhage [J]. J Neurosurg, 2000, 92 (6): 1016-1022.
26. Hua Y, Xi G, Keep RF, et al. N-acetylheparin, a nonanticoagulant, diminishes brain edema after experimental interacerebral hemorrhage [J]. Stroke, 2000,31: 339.
27. Xi Guohua, Keep RF, Yonger JG,et al.Systemic complement depletion diminishes perihematomal brain edema in rats [J]. Stroke, 2001, 32(1): 162-167.
2.张玉琪.再论微创神经外科学(述评)[J].中华神经外科杂志,2005,21(4):193-194.
3.贾保祥,李志超,吕涌涛,等,主编.全国颅内血肿微创清除术临床应用培训教材[M].北京:全国颅内血肿微创技术协作组,2001:34.
4.李毓生,赵艳,杨成宝.高血压脑出血手术时机与适应证的探讨[J].内蒙古民族大学学报.自然科学版,2004,19(2):225-227.
5.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.
6.胡大一.高血压急症.新认识与临床实践[J].中国危重病急救医学,2003,15(9):517.
7.Nilsson OG,Lindgren AR,Brandt L,et al.Prediction of death in patients with primary intracerebral hemorrhage:a prospective study of a defined population[J].J Neurosurg,2002,97(3):531-536.
8.Mayer S A.Ultra-early hemo-static therapy for intracerebral hemorrhage[J].Stroke,2003,34(1):224-229.
9.毛群,勾俊龙,刘宗惠.外科治疗脑出血:回顾与展望[J].国外医学神经病学神经外科学分册,2003,30(5):420-423.
10.韦武腾.微创穿刺抽吸治疗高血压脑出血200例体会[J].中国临床神经外科杂志,2004,(9):372-373.
11.Kaneko M,koba T.Early surgical treatment for hypertensive intracerebral hemorrhage[J].J Neurosurg,1997,46:597.
12.刘振川,徐立明,赵仕欣,等.微创介入颅内出血(血肿)清除术在神经内科的应用研究[J].中国临床神经科学,2000,8(2):137-138.
13.Zuccarello M,Andaluz N,Wagner KR.Minimally invasive therapy for intracerebral hematomas[J].Neurosurg Clin N Am,2002,13(3):349-354.
14.Huang CF,Tsai ZP,Li CS,et al.Surgical improvement of brain edema related to hypertensive,intracerebral hemorrhage[J].Zhonghua Yi Xue Za Zhi (Taipei),2002,65(6):241-246.
15.Zazulia AR,Diringer MN,Derdeyn CP,et al.Progression of mass effect after intracerebral hemorrhage.Stroke,1999,30:1167-1173.
16.单爱军,赵永阳.CT引导钻颅抽吸外引流术治疗高血压性脑出血[J].广东医学,2001,22(12):1142-1143.
17.包华,阿荣高娃,陈碧林,等.微创颅内血肿清除术治疗脑出血23例[J].中国急救医学,2002,14(1):48.
18.Bhasin RR,Xi G,Hua Y,et al.Experimental intracerebral hemorrhage:effect of lysed erythrocytes on brain edema and blood-brain barrier permeability [J].Acta Neurochir Suppl,2002,81:249-251.
19.Ryter SW,Tyrrell RM.The heme synthesis and degradation path-ways:role in oxidant sensitivity.Heme oxygenase has both pro-and antioxidant properties[J].Free Radic Biol Med,2000,28:289-309.
20.Gong C,Hoff JT,Keep RF.Acute inflammatory reaction following.experimental intracerebral hemorrhage in rats[J].Brain Res,2000,871(1):57-65.
21.Guan JX,Sun SG,Cao XB,et al.Effect of thrombin on blood brain barrier permeability and its mechanism[J].Chin Med J(Engl),2004,117(11):1677-1678.
22.Gong C,Boulis N,Qian J,et al.Intracelebral hemorrhage-induced neuronal deeath[J].Neurosurgery,2001,48(4):875-883.
23.Song EC,Chu K,Jeong SW,et al.Hyperglycemia exacerbates brain edema and peribe matomal cell death after intracerebral hemorrhage[J].Stroke,2003,34(9):2215-2220.
24.Holmin S,Mathiesen T.Intracerebra administration of in-terleukin-1 beta and induction of inflammation.Apoptosis and vasogenic edema[J].J Neurosurg,2000,92:108-120.
25.Xi Guohua,Keep RF,Yonger JG,et al.Systemic complement depletion diminishes perihematomal brain edema in rats[J].Stroke,2001,32(1):162-167.
1. Fujii Y,Takeuchi S,Sasaki O,et al.Multivariate analysis of predictors of hematoma enlargement in spontaneous intracerebral hemorrhage [J]. Stroke, 1998,29:1160-1166.
2. Qureshi AI, Tuhrim S, Broderick JP, et al. spontaneous intracerebral hemorrhage[J]. N Engl J Med, 2001,344(19):1450-1460.
3. Mayer Stephan A. Ultra-Early Hemostatic Therapy for Intracerebral Hemorrhage [J]. Stroke, 2003,34 (1): 224-229.
4. Yonezawa T, Hashimoto H, Sakaki T.Serial change of cerebral blood flow after Collagenase induced intracerebral hemorrhage in rats [J] .No Shinkei Geka, 1999,27(5):419-425.
5. Hua Y, Xi G, Keep RF, et al.Complement activation in the brain after experimental intracerebral hemorrhage[J]J Neurosurg, 2000,92:1016.
6. Teernstra OP, Evers SM, Lodder J, et al. Stereotactic treatment of intracerebral hematoma by means of a plasminogen activator: a multicenter randomized controlled trial [J] .Stroke, 2003, 34: 968-974.
7. Siddique MS, Fernandes HM, Wooldridge TD, et al. Reversible ischemia around intracerebral hemorrhage:a singlephoton emission computerized tomography study [J] J Neurosurg, 2002 ,96(4):736-741.
8. Chu WJ, Mason GF, Pan JW, et al Mountz JM. Regional cerebral blood flow and magnetic resonance spectroscopic imaging findings in diaschisis from stroke [J] . Stroke, 2002, 33:1243 -1248.
9. Qureshi AI, Suri MF, Ostrow PT, et al. Apoptosis as a form of cell death in intracerebral hemorrhage [J] .Neurosurgery ,2003,52 (5):1041-1047.
10. Diringer MN, Adams RE, Dunford-Shore JE, et al. Cerebral blood flow is symmetrically reduced in patients with ICH.Neurology,1998,50:338-345.
11.rasad K,Shrivastava A.Surgery for primary supratentorial imracerebral haemorrhage[J].Cochrane Database Syst Rev,2000,CD000200.
12.Zazula AR,Diringer MN,Videen TO,et al.Acute intracerebral hemorrhage does not produce peri-clot cerebral ischemia.Neurology,2000,54(supp13):A261.Abstract.
13.Hirano T,Read SJ,Abbott DF,et al.Prediction of the final infarction volume within 6 h of stroke using single photon emission computed tomography with technetium-99m hexamethypropylene amine oxime[J].Cerebrovasc Dis,2001,11:119-127.
14.Rohde V,Rohde I,Reinges MH,et al.Frameless stereotactically guided catheter placement and fibrinolytic therapy for spontaneous intracerebral hematomas:technical aspects and initial clinical results[J].Minim Invasive Neurosurg(Germany),2000,43(1):9-17.
15.Wanger KR,Xi G,Hua Y,et al.Clot retraction contributes to early perihemotomal edema volumes following intracerebral hemorrhage[J].Soc Neurosci,1997,23(11):1921.
16.Yoshida Y,Yoshimoto T,Shirane R,et al.Clinical course,surgical management,and long-term outcome of moyamoya patients with rebleeding after an episode of intracerebral hemorrhage:an extensive follow-up study.Stroke,1999,30(11):2272-2276.
17.Guan JX,Sun SG,Cao XB,et al.Effect of thrombin on blood brain barrier permeability and its mechanism[J].Chin Med J(Engl),2004,117(11):1677-1678.
18.娄季宇,杨霄鹏,李建章,等.水蛭素对抗脑出血后脑水肿作用机制的研究[J].河南实用神经疾病杂志,2004,7:1-2.
19.. Gong C, Boulis N, Qian J, et al. Intracelebral hemorrhage-induced neuronal deeath[J].Neurosurgery, 2001,48(4):875-883.
20. Xi GH, Hua Y, Bhasin RR, Ennis SR, et al. Mechanisms of edema formation.after intracerebral hemorrhage: effects of extravasated red blood cells on blood flow and blood-brain barrier integrity [J]. Stroke, 2001, 32:2932-2938.
21. Ryter SW, Tyrrell RM. The heme synthesis and degradation path-ways: role in oxidant sensitivity. Heme oxygenase has both pro-and antioxidant properties[J]. Free Radic B iolMed, 2000,28: 289 - 309.
22. Suttner DM, Dennery PA. Reversal of HO-1 related cytoprotection with increased expression is due to reactive iron[J]. FASEB J, 1999 ,13: 1800-1809.
23. Holmin S, Mathiesen T. Intracerebra administration of in-terleukin-1 beta and induction of inflammation. Apoptosis and vasogenic edema[J]. J Neuro-surg, 2000, 92:108-120.
24. Del Bigio MR, Yan HJ, Buist R, et al. Experimental intracerebral hemorrhage in rats Magnetic resonance imaging and histopathological correlates [J]. Stroke, 1996,27:2312-2320.
25. Hua Y, Xi G, Keep RF, et al. Complement activation in the brain after experimental intracerebral hemorrhage [J]. J Neurosurg, 2000, 92 (6): 1016-1022.
26. Hua Y, Xi G, Keep RF, et al. N-acetylheparin, a nonanticoagulant, diminishes brain edema after experimental interacerebral hemorrhage [J]. Stroke, 2000,31: 339.
27. Xi Guohua, Keep RF, Yonger JG,et al.Systemic complement depletion diminishes perihematomal brain edema in rats [J]. Stroke, 2001, 32(1): 162-167.