高血压脑出血急诊微创手术治疗的临床研究
摘要
高血压脑出血(Hypertensive Intracerebral Hemorrhage ,HICH)是急诊科、神经外科常见的急危重症之一,是病死率和致残率都较高的疾病,HICH占所有卒中患者的10%～20% ,但早期病死率可高达49.4%,仅不足半数预后良好。该病起病急,病情进展迅速,及时的诊断,及早的治疗是降低残、死率的关键。目前国际上手术治疗高血压脑出血的方法较多,至今也没有研究表明,哪种手术方式是最好的,也没有研究表明超早期手术疗效的优劣。开颅血肿清除术在减低病死率方面取得较大进步,但不能减低致残率和提高患者的生存质量。微创手术日益受到神经外科医师的青睐,微创手术在降低致残率方面取得了显著的进步。本文对吉林大学中日联谊医院神经外科2006年1月～2008年1月收治的高血压脑出血急性期患者71例进行回顾性对比研究分析,分成微创组41例和开颅血肿清除组30例,观察两组的各项临床指标,探讨早期微创手术治疗高血压脑出血的安全性和疗效,手术时机对预后的影响。
吉林大学中日联谊医院神经外科2006年1月～2008年1月收治的高血压脑出血急性期患者71例,分成微创组41例和开颅血肿清除组30例,全部患者均经(Computer Tomography, CT)扫描确定血肿部位和血肿量,全部患者血压均符合高血压诊断标准(国际标准值:血压≧140/90mmHg)。采用回顾性对照研究,研究的内容有各组的年龄,性别,血肿部位及血肿量,入院时意识状态,血压,手术时机对预后的影响,综合分析两组的疗效。
经统计学分析两组在年龄,性别,血肿部位及血肿量,入院时意识状态,血压上没有明显差异。外科手术前的等待时间和手术时间以分钟(m)计,微创钻孔引流组外科手术前的等待时间为68.68±43.56m,开颅血肿清除组时间为95.20±58.5m,两组相比有明显差异(t=2.1752,p=0.0330<0.05),微创钻孔引流组手术时间为102.48±25.24,开颅血肿清除组手术时间为228.46±49.23m,两组相比有明显差异(t=14.0748,p=0.0000<0.05.)。本研究中在发病6h内手术微创组14例,开颅血肿清除组8例,共22例,预后良好10例(优良率为45.4%),发病后6h～24h内行手术治疗微创组25例,开颅血肿清除组20例,共45例,预后良好20例(优良率44.4%),24h后手术预后最差,4例患者中只有1例预后良好(优良率25.0%)。急诊手术预后较好,24h内手术优良率高于24h后手术优良率。两组出院时GOS评分经统计学分析没有明显差异,说明两种手术方式近期预后没有明显差异,两组方法近期死亡率没有明显差异。术后3个月barthel评分,两组经秩和检验后,p<0.05,两组相比疗效有统计学意义。微创钻孔引流组的远期预后要优于开颅血肿清除组。
微创钻孔置管血肿抽吸引流术的外科手术等待时间短,手术时间短,可以作为一种紧急降低颅内压的手术方式,适合应用于急诊手术。在高血压脑出血治疗中能提高有效率、降低死亡率,而且是一种安全有效适合超早期手术治疗高血压脑出血的一种治疗手段。高血压脑出血手术应该尽早进行,最好是在发病后6h内进行,超早期止血的问题的解决,为超早期手术术后再出血率的降低成为可能。
根据我们的经验,总结出微创钻孔引流术的手术适应症为:
(1)出血在皮质下,基底节区,出血量在30～50ml的患者适用;脑深部出血,如丘脑出血>10ml者也适用;而小脑出血一般行开颅血肿清除术。
(2)对于病情平稳,意识障碍轻,血肿量>20ml的1～2级患者可行微创钻孔引流术,有利于恢复,并可降低致残率。
(3)对于高龄和(或)合并多器官功能不全的重型脑出血患者,血肿危机生命,且不能耐受全身麻醉下行开颅手术,为了挽救患者的生命,应首选微创钻孔引流术。
对于昏迷程度较深,出血量大,血肿体积>50ml或扩散至丘脑,中线结构偏移较重,有明显脑疝症状的患者应行大骨瓣开颅并去骨瓣减压,从而降低了患者的病死率。
Objective: 71 cases with hypertensive intracerebral hemorrhage who were treated in neurosurgery of China-Japan Hospital from January 2006 to January 2008 were analyzed retrospectively.71 cases were divided two groups, 41 in groups A received micro-traumatic hematoma cleaning operation base on medical treatment, 30 in groups B received craniotomy based on medical. Observed the clinical indicators, and evaluated the effectiveness and safety of minimally invasive (MIS) emergency operation for treatment for hypertensive intracerebral hemorrhage, and the timing of surgery on the prognosis.
Methods: 71 cases with hypertensive intracerebral hemorrhage who were treated in neurosurgery of China-Japan Hospital from January 2006 to January 2008 were analyzed retrospectively. In the trail 71 cases were divided two groups, 41 in groups A received micro-traumatic hematoma cleaning operation base on medical treatment, 30 in groups B received craniotomy based on medical. The hematoma sit and volume of all patients was identified by CT scan. All the patients’blood pressure was consistent with the diagnostic criteria for hypertension (international standard numerus, BP>140/90mmHg). The age; sex; consciousness of onset; hemorrhage volume and site; blood pressure of the two groups were observed, the operative time on therapeutic was also observed, the effectiveness of the two groups was compared to the effective and safety of minimally invasive emergency operation for treatment for hypertensive intracerebral hemorrhage.
Result: There were no significant differences in the age; sex; consciousness of onset; hemorrhage volume and site; blood pressure of the two groups. There was significant delay in waiting timing of craniotomy (95.20±58.54m p<0.05), and also craniotomy had the longest operation time (228.46±49.23m p<0.05). In this trail,22 were received emergency operation within 6h, the effective was 45.4%,45 were received operation within 24h of onset, the effective was 44.4%,4 were received operation after 24h of onset, the effective was 25%,the group received operation within 24h of onset had higher effective rate than the group received operation after 24h of onset, There was no significant difference in GOS score after hospitalization between both groups, and mortality rates between the 2 groups did not show statistically significant differences. The Barthel index score after 3 months of postoperative showed statistically significant differences. There were significant differences in the long-term outcome between the two methods; MIS resulted in better long-term outcome than craniotomy. Conclusions: The waiting time for surgery and the operation time were short, implying that shorter waiting time and shorter operation time is suitable for emergent decompression. The minimally invasive (MIS) evacuation of hematoma can improve the effective rate, decrease the mortality, also it was an effective and safe therapeutic tool for hypertensive intracerebral hemorrhage. The operation for hypertensive intracerebral hemorrhage should be carried out as soon as possible, preferably within the 6 h of onset. If the problem of ultra-early homeostasis was solved, the rate of bleeding after super-early surgery could be reduced.
According our experience, our study did conclude that: 1.MIS is suggested for the patients with subcortex and basal ganglia hemorrhage when the hemorrhage volume is 30～50ml, and also suggested for the patients with deep intracerebral hemorrhage such as thalamic hemorrhage when the hemorrhage volume is more than 10 ml. Cerebella hemorrhage often underwent craniotomy.
(2)Patients with neurological gradeⅠ～Ⅱ(GCS score,12～15)when the hemorrhage volume is more than 20ml could underwent MIS, because the minimally invasive (MIS) evacuation of hematoma can improve the effective rate.
(3) For the aged and (or) with multiple organ dysfunction (MODS) and those can not stand for craniotomy, MIS is most suitable. For those patients MIS is recommended for life saving.
Decompressive craniotomy is suggested for the comatose patients with large hematoma when the hemorrhage volume more than 50ml, decompressive craniotomy is recommended when hematoma spread to the thalamus when and patients with cerebral hernia for life saving.
吉林大学中日联谊医院神经外科2006年1月～2008年1月收治的高血压脑出血急性期患者71例,分成微创组41例和开颅血肿清除组30例,全部患者均经(Computer Tomography, CT)扫描确定血肿部位和血肿量,全部患者血压均符合高血压诊断标准(国际标准值:血压≧140/90mmHg)。采用回顾性对照研究,研究的内容有各组的年龄,性别,血肿部位及血肿量,入院时意识状态,血压,手术时机对预后的影响,综合分析两组的疗效。
经统计学分析两组在年龄,性别,血肿部位及血肿量,入院时意识状态,血压上没有明显差异。外科手术前的等待时间和手术时间以分钟(m)计,微创钻孔引流组外科手术前的等待时间为68.68±43.56m,开颅血肿清除组时间为95.20±58.5m,两组相比有明显差异(t=2.1752,p=0.0330<0.05),微创钻孔引流组手术时间为102.48±25.24,开颅血肿清除组手术时间为228.46±49.23m,两组相比有明显差异(t=14.0748,p=0.0000<0.05.)。本研究中在发病6h内手术微创组14例,开颅血肿清除组8例,共22例,预后良好10例(优良率为45.4%),发病后6h～24h内行手术治疗微创组25例,开颅血肿清除组20例,共45例,预后良好20例(优良率44.4%),24h后手术预后最差,4例患者中只有1例预后良好(优良率25.0%)。急诊手术预后较好,24h内手术优良率高于24h后手术优良率。两组出院时GOS评分经统计学分析没有明显差异,说明两种手术方式近期预后没有明显差异,两组方法近期死亡率没有明显差异。术后3个月barthel评分,两组经秩和检验后,p<0.05,两组相比疗效有统计学意义。微创钻孔引流组的远期预后要优于开颅血肿清除组。
微创钻孔置管血肿抽吸引流术的外科手术等待时间短,手术时间短,可以作为一种紧急降低颅内压的手术方式,适合应用于急诊手术。在高血压脑出血治疗中能提高有效率、降低死亡率,而且是一种安全有效适合超早期手术治疗高血压脑出血的一种治疗手段。高血压脑出血手术应该尽早进行,最好是在发病后6h内进行,超早期止血的问题的解决,为超早期手术术后再出血率的降低成为可能。
根据我们的经验,总结出微创钻孔引流术的手术适应症为:
(1)出血在皮质下,基底节区,出血量在30～50ml的患者适用;脑深部出血,如丘脑出血>10ml者也适用;而小脑出血一般行开颅血肿清除术。
(2)对于病情平稳,意识障碍轻,血肿量>20ml的1～2级患者可行微创钻孔引流术,有利于恢复,并可降低致残率。
(3)对于高龄和(或)合并多器官功能不全的重型脑出血患者,血肿危机生命,且不能耐受全身麻醉下行开颅手术,为了挽救患者的生命,应首选微创钻孔引流术。
对于昏迷程度较深,出血量大,血肿体积>50ml或扩散至丘脑,中线结构偏移较重,有明显脑疝症状的患者应行大骨瓣开颅并去骨瓣减压,从而降低了患者的病死率。
Objective: 71 cases with hypertensive intracerebral hemorrhage who were treated in neurosurgery of China-Japan Hospital from January 2006 to January 2008 were analyzed retrospectively.71 cases were divided two groups, 41 in groups A received micro-traumatic hematoma cleaning operation base on medical treatment, 30 in groups B received craniotomy based on medical. Observed the clinical indicators, and evaluated the effectiveness and safety of minimally invasive (MIS) emergency operation for treatment for hypertensive intracerebral hemorrhage, and the timing of surgery on the prognosis.
Methods: 71 cases with hypertensive intracerebral hemorrhage who were treated in neurosurgery of China-Japan Hospital from January 2006 to January 2008 were analyzed retrospectively. In the trail 71 cases were divided two groups, 41 in groups A received micro-traumatic hematoma cleaning operation base on medical treatment, 30 in groups B received craniotomy based on medical. The hematoma sit and volume of all patients was identified by CT scan. All the patients’blood pressure was consistent with the diagnostic criteria for hypertension (international standard numerus, BP>140/90mmHg). The age; sex; consciousness of onset; hemorrhage volume and site; blood pressure of the two groups were observed, the operative time on therapeutic was also observed, the effectiveness of the two groups was compared to the effective and safety of minimally invasive emergency operation for treatment for hypertensive intracerebral hemorrhage.
Result: There were no significant differences in the age; sex; consciousness of onset; hemorrhage volume and site; blood pressure of the two groups. There was significant delay in waiting timing of craniotomy (95.20±58.54m p<0.05), and also craniotomy had the longest operation time (228.46±49.23m p<0.05). In this trail,22 were received emergency operation within 6h, the effective was 45.4%,45 were received operation within 24h of onset, the effective was 44.4%,4 were received operation after 24h of onset, the effective was 25%,the group received operation within 24h of onset had higher effective rate than the group received operation after 24h of onset, There was no significant difference in GOS score after hospitalization between both groups, and mortality rates between the 2 groups did not show statistically significant differences. The Barthel index score after 3 months of postoperative showed statistically significant differences. There were significant differences in the long-term outcome between the two methods; MIS resulted in better long-term outcome than craniotomy. Conclusions: The waiting time for surgery and the operation time were short, implying that shorter waiting time and shorter operation time is suitable for emergent decompression. The minimally invasive (MIS) evacuation of hematoma can improve the effective rate, decrease the mortality, also it was an effective and safe therapeutic tool for hypertensive intracerebral hemorrhage. The operation for hypertensive intracerebral hemorrhage should be carried out as soon as possible, preferably within the 6 h of onset. If the problem of ultra-early homeostasis was solved, the rate of bleeding after super-early surgery could be reduced.
According our experience, our study did conclude that: 1.MIS is suggested for the patients with subcortex and basal ganglia hemorrhage when the hemorrhage volume is 30～50ml, and also suggested for the patients with deep intracerebral hemorrhage such as thalamic hemorrhage when the hemorrhage volume is more than 10 ml. Cerebella hemorrhage often underwent craniotomy.
(2)Patients with neurological gradeⅠ～Ⅱ(GCS score,12～15)when the hemorrhage volume is more than 20ml could underwent MIS, because the minimally invasive (MIS) evacuation of hematoma can improve the effective rate.
(3) For the aged and (or) with multiple organ dysfunction (MODS) and those can not stand for craniotomy, MIS is most suitable. For those patients MIS is recommended for life saving.
Decompressive craniotomy is suggested for the comatose patients with large hematoma when the hemorrhage volume more than 50ml, decompressive craniotomy is recommended when hematoma spread to the thalamus when and patients with cerebral hernia for life saving.
引文
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17 冯丽洁,黎檀实,沈洪.高血压脑出血早期治疗的新观点[J].中国危重病急救医学,2002,14(1):64.
18 Broderick JP, Adams HP and Barsan W, et al., Guidelines for the management of spontaneous intracerebral hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association, Stroke 1999,30 (4): 905-915.
19 吴智平 蒲传强 脑出血后血肿扩大 国际脑血管病杂志[J]2004 12(9)672-674.
20 Ohwaki K.Yano E.Nagashima H.et al. Blood pressure management in acute intracerebral hemorrhage: relationship between elevated blood pressure and hematoma enlargement stroke, 2004, 35: 1364-1367.
21 Mayer SA. Ultra-early hemostatic therapy for intracerebral hemorrhage .Srtoke, 2003, 34:22 4-229.
22 王忠诚.神经外科学[M].湖北:科学技术出版社,1998.686-689.
23 Kaneko M, Tanaka K,Shimada T, et al., Long-term evaluation of ultraearly operation for hypertensive intracerebral hemorrhage in 100 ases.J Neurosurg,1983,58:838-842.
24 Lee JI, Namdo H, Kim JS,et al., Stereotactic aspiration of intracerebral haematoma significance of surgical timing andhaematoma volume online reduction. J Clin Neurosci, 2003, 10:439-443.
25 Patrick Mitchell , Barbara A. Gregson, Raghu R. Vindlacheruvu, A. David Mendelo et al., Surgical options in ICH including decompressive craniotomy. Neurological Sciences 2007, 261:89-98.
26 Mendelow AD, Gregson BA,. Fernandes HM, Murray GD,. Teasdale GM and. Hope DT et al., STICH investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral hematomas in the International Surgical Trial in Intracerebral Hemorrhage (STICH): a randomised trial, Lancet 2005,365 (9457):387-397.
27 Backlund ED, Holst VH. Controled subtotal evacuation of intracerebral hematomas by stereotactic technique. SurgNeurol, 1978,9:99-101.
28 Teernstra OP, Evers SM,Udder J, et al., Stereotactic treatment of intracerebral hematoma by means of a plasminogen activator: a multicenter randomized controlled trial(SICHPA ).Stroke, 2003,13:371-383.34:968-974.
29 NINDS ICH Workshop Participants, Priorities for clinical research in intracerebral hemorrhage. report from a National Institute of Neurological Disorders and Stroke Workshop. Stroke, 2005,36:23-41.
30 Naff NJ, Carhuapoma JR, Williams MA, et al., Treatment of intraventricular hemorrhage with urokinase; effects on 30-daysurvival. Stroke, 2000,31:841-847.
31 葛峻岭,潘速跃等 脑出血的手术和超早期止血治疗 国际脑血管病杂志 2005,13(1)23-25.
32 庞力,周良辅.微创手术治疗高血压脑出血的术式比较[J].中国微侵袭神经外科杂志,2001,6(3):147-150.
33 Teernstra OP, Evers SM, Lodder J et al., Leffers P and Franke CL and Blaauw G, Stereotactic treatment of intracerebral hematoma by means of plasminogen activator: a multicenter randomized controlled trial (SICHPA), Stroke 2003, 34: 968-974.
34 Vespa P, Miller C, McArthur D, O'Phelan C, Kidwell C and Saver J et al., Frameless stereotactic aspiration and thrombolysis of deep intracerebral hemorrhage is associated with reduction of hemorrhage volume and neurological improvement, Neurocritical Care 2004, 1: 268.
35 Prasad and Shrivastava A, Surgery for primary supratentorial intracerebral hemorrhage, Cochrane Database Syst Rev 2000 (2) : CD000200 [Review].
36 Schaller C, Rohde V, Meyer B and Hassler W, Stereotactic puncture and lysis of spontaneous intracerebral hemorrhage using recombinant tissue-plasminogen activator, Neurosurgery 1995,36 :
328-333 [discussion 333–325].
37. Barrett RJ, Hussain R, Coplin WM, Berry S, Keyl MK and Hanley DF et al., Frameless stereotactic aspiration and thrombolysis of spontaneous intracerebral hemorrhage, Neurocritical Care 2005,3 (3) :237-245
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1 Broderick JP,Adams HP Jr,Barsanw,et a1.,Guidelines for the management of spontaneous intracerebral hemorrhage:A statement for healthcare professionals from a special writing group of the stroke council,American Heart Association Stroke,1999,30(4):905-915.
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3 McCarron Mo,Weir CJ,Muir KW,et a1.,Effect of apolipoprotein Egenotype on in-hospital mortality following intracerebral haemorrhage.Acta Neurol Scand,2003.107:106-l09.
4 Brott T, Thalinger K and Hertzberg V, Hypertension as a risk factor for spontaneous intracerebral hemorrhage, Stroke 1986,17 (6) :1078–1083.
5 Kase CMJ. General features of intracerebral hemorrhage. In:H.Barnett, Stein B and Mohr JP, Editors, Stroke: pathophysiology, diagnosis and management 1986 :497–523.
6 Chen ST, Chen SD, Hsu CY and. Hogan EL, Progression of hypertensive intracerebral hemorrhage, Neurology 1989,39 (11) :1509-1514.
7 Fujitsu K, Muramoto M, Ikeda Y, Inada Y, Kim I and Kuwabara T, Indications for surgical treatment of putaminal hemorrhage.Comparative study based on serial CT and time–course analysis, J Neurosurg 1990, 73 (4):518–525.
8 Kazui S, Naritomi H, Yamamoto H, Sawada T and Yamaguchi T, Enlargement of spontaneous intracerebral hemorrhage. Incidence and time course, Stroke 1996, 27 (10): 1783-1787.
9 Gebel JM,Jr, Jauch EC and Brott TG et al., Relative edema volume is a predictor of outcome in patients with hyperacute spontaneous intracerebral hemorrhage, Stroke 2002, 33 (11): 2636-2641.
10 Juvela S, Risk factors for impaired outcome after spontaneous intracerebral hemorrhage, Arch Neurol 1995, 52 (12): 1193-1200.
11 Tuhrim S, Dambrosia JM and. Price TR et al., Intracerebral hemorrhage: external validation and extension of a model for prediction of 30-day survival, Ann Neurol 1991, 29 (6):658-663.
12 Daverat P, Castel JP, Dartigues JF and. Orgogozo JM, Death and functional outcome after spontaneous intracerebral hemorrhage. A prospective study of 166 cases using multivariate analysis, Stroke 1991, 22 (1): 1-6.
13 Portenoy RK, Lipton RB, Berger AR, Lesser ML and Lantos G, Intracerebral hemorrhage: a model for the prediction of outcome, J Neurol Neurosurgery Psychiatry 1987, 50 (8): 976-979.
14 Qureshi AI, Safdar K and Weil J et al., Predictors of early deterioration and mortality in black Americans with spontaneous intracerebral hemorrhage, Stroke 1995, 26 (10): 1764-1767.
15 Hallevy C, Ifergane G, Kordysh E and Herishanu Y, Spontaneoussupratentorial intracerebral hemorrhage. Criteria for short-term functional outcome prediction, J Neurol 2002,249 (12):1704-1709.
16 陈灏珠.实用内科学[M].第11版.北京:人民卫生出版社,2001:2433.
17 冯丽洁,黎檀实,沈洪.高血压脑出血早期治疗的新观点[J].中国危重病急救医学,2002,14(1):64.
18 Broderick JP, Adams HP and Barsan W, et al., Guidelines for the management of spontaneous intracerebral hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association, Stroke 1999,30 (4): 905-915.
19 吴智平 蒲传强 脑出血后血肿扩大 国际脑血管病杂志[J]2004 12(9)672-674.
20 Ohwaki K.Yano E.Nagashima H.et al. Blood pressure management in acute intracerebral hemorrhage: relationship between elevated blood pressure and hematoma enlargement stroke, 2004, 35: 1364-1367.
21 Mayer SA. Ultra-early hemostatic therapy for intracerebral hemorrhage .Srtoke, 2003, 34:22 4-229.
22 王忠诚.神经外科学[M].湖北:科学技术出版社,1998.686-689.
23 Kaneko M, Tanaka K,Shimada T, et al., Long-term evaluation of ultraearly operation for hypertensive intracerebral hemorrhage in 100 ases.J Neurosurg,1983,58:838-842.
24 Lee JI, Namdo H, Kim JS,et al., Stereotactic aspiration of intracerebral haematoma significance of surgical timing andhaematoma volume online reduction. J Clin Neurosci, 2003, 10:439-443.
25 Patrick Mitchell , Barbara A. Gregson, Raghu R. Vindlacheruvu, A. David Mendelo et al., Surgical options in ICH including decompressive craniotomy. Neurological Sciences 2007, 261:89-98.
26 Mendelow AD, Gregson BA,. Fernandes HM, Murray GD,. Teasdale GM and. Hope DT et al., STICH investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral hematomas in the International Surgical Trial in Intracerebral Hemorrhage (STICH): a randomised trial, Lancet 2005,365 (9457):387-397.
27 Backlund ED, Holst VH. Controled subtotal evacuation of intracerebral hematomas by stereotactic technique. SurgNeurol, 1978,9:99-101.
28 Teernstra OP, Evers SM,Udder J, et al., Stereotactic treatment of intracerebral hematoma by means of a plasminogen activator: a multicenter randomized controlled trial(SICHPA ).Stroke, 2003,13:371-383.34:968-974.
29 NINDS ICH Workshop Participants, Priorities for clinical research in intracerebral hemorrhage. report from a National Institute of Neurological Disorders and Stroke Workshop. Stroke, 2005,36:23-41.
30 Naff NJ, Carhuapoma JR, Williams MA, et al., Treatment of intraventricular hemorrhage with urokinase; effects on 30-daysurvival. Stroke, 2000,31:841-847.
31 葛峻岭,潘速跃等 脑出血的手术和超早期止血治疗 国际脑血管病杂志 2005,13(1)23-25.
32 庞力,周良辅.微创手术治疗高血压脑出血的术式比较[J].中国微侵袭神经外科杂志,2001,6(3):147-150.
33 Teernstra OP, Evers SM, Lodder J et al., Leffers P and Franke CL and Blaauw G, Stereotactic treatment of intracerebral hematoma by means of plasminogen activator: a multicenter randomized controlled trial (SICHPA), Stroke 2003, 34: 968-974.
34 Vespa P, Miller C, McArthur D, O'Phelan C, Kidwell C and Saver J et al., Frameless stereotactic aspiration and thrombolysis of deep intracerebral hemorrhage is associated with reduction of hemorrhage volume and neurological improvement, Neurocritical Care 2004, 1: 268.
35 Prasad and Shrivastava A, Surgery for primary supratentorial intracerebral hemorrhage, Cochrane Database Syst Rev 2000 (2) : CD000200 [Review].
36 Schaller C, Rohde V, Meyer B and Hassler W, Stereotactic puncture and lysis of spontaneous intracerebral hemorrhage using recombinant tissue-plasminogen activator, Neurosurgery 1995,36 :
328-333 [discussion 333–325].
37. Barrett RJ, Hussain R, Coplin WM, Berry S, Keyl MK and Hanley DF et al., Frameless stereotactic aspiration and thrombolysis of spontaneous intracerebral hemorrhage, Neurocritical Care 2005,3 (3) :237-245