高血压脑出血术后再出血的多因素分析及治疗策略
摘要
高血压脑出血是神经外科常见疾病。出血位于脑内或脑膜下,是由于高血压及动脉硬化引起的脑血管病变所致。高血压性脑出血已作为独立的疾病分类从非创伤性脑内出血多种类型中分离出来,它的病因、发病机理、临床经过及转归有一定规律性。保守治疗的病死率为70%-85%,外科治疗可使病死率降至28%-30%,但术后再出血是该病并发症之一,一旦诊治不及时,将会发生严重后果。本文收集了163例高血压性脑出血患者的临床资料并进行回顾性分析,发生术后再出血者16例。全文阐述了高血压性脑出血术后再出血的发生原因及危险因素、临床表现、早期诊断、治疗及预后,探讨高血压脑出血术后再出血的防治对策,从而加深对高血压性脑出血术后再出血的认识,进而有效提高脑出血病人的存活率及生活质量。综上所述,对高血压脑出血术后再出血进行多因素分析后得出如下结论:(1)术前及术后血压高水平状态是术后再出血主要原因[43,44],同时术后血压大幅度波动是重要诱因[43]。(2)高血压脑出血老年人多,其血管弹性和凝血机制可能较差,凝血尚未完善的血肿腔及手术创道很容易再出血。(3)原发性出血的血肿量越大,术后清除血肿后颅内压变化的梯度越大,再出血可能性大[37]。(4)术后应用甘露醇过早或量过大。(5)另外手术技术不够细致,术中过度牵扯血肿壁可造成小血管撕裂,吸除血肿时吸引力过大等因素都可造成新的出血。尤其是血肿位置深在,术中术野暴露不充分,彻底止血有一定的困难,导致止血欠佳,故再出血可能与手术因素有关。
Hypertensive intracerebral hemorrhage (HICH) locates in the brain or under the meninges, owing to the cerebrovascular pathological change which is caused by hypertension and arteriosclerosis. HICH has been as an independent classification of diseases from non-traumatic intracerebral hemorrhage, and there is a certain regularity in its pathogeny, the pathogenesis, the clinical process and the outcome. The death rate of conservative treatment is 70% to 85%, while surgical treatment may reduce the death rate to 28%-30%. But the recurrent hemorrhage after operation of HICH is one of its complications, once the treatment is not prompt, there will be serious consequences.
[Purpose and Methods]: This paper retrospectively analyzes the clinical data of 163 cases of hypertensive intracerebral hemorrhage patients. It comprehensively expatiates the causes, the risk factors, the clinical manifestations, the early diagnosis, the treatment and the prognosis of the recurrent hemorrhage after operation of HICH. It also discusses the prevention and the cure methods, in order to deepen the surgeons’understanding of the recurrent hemorrhage after operation of HICH, so that it effectively increases the survival rate and improves the quality of life of hypertensive cerebral hemorrhage patients.
[Results]: The recurrent hemorrhage after operation of HICH patients accounts for nearly 10% of HICH patients. It is mainly caused by the senility, the high blood pressure before and after operation, the big postoperative blood pressure fluctuation, the excessive preoperative cerebral hemorrhage, the premature or excessive application of mannitol, the intraoperative skills and so on.
[Conclusion]: (1) The preoperative and postoperative hypertension status is the main reason for the recurrent hemorrhage after operation, at same time the big postoperative blood pressure fluctuation is the important inducement. (2) Most HICH patients are the elderly. Their blood vessel elasticity and the cruor mechanism maybe poor, consequently the hematoma cavity in which the cruor has not been cure and the surgical cuts may easily lead to the recurrent cerebral hemorrhage. (3) Recurrent cerebral hemorrhage is likely to happen because the hematoma is large in primary hemorrhage and the change gradient of the encephalic pressure is big after purging the postoperative hematoma. (4) Recurrent cerebral hemorrhage owes to the premature or excessive application of mannitol. (5) Recurrent cerebral hemorrhage is due to the unreliable intraoperative hemostasis and the blood pressure is low when the surgeons subjectively consider themselves to stanch completely for the patients. (6) The typical clinical manifestations show the various awareness changes, going with other symptoms such as: the disparate pupils, headache, nausea, vomiting and meningeal irritation. (7) The preferred way of diagnosis is CT. (8) The way of treatment can choose surgical treatment or conservative treatment according to the illness of the patients. (9) The key of the recurrent hemorrhage after operation of HICH lies in prevention, at the same time whether the diagnosis is timely and the treatment of recurrent cerebral hemorrhage are also directly related to the patient’s prognosis.
Hypertensive intracerebral hemorrhage (HICH) locates in the brain or under the meninges, owing to the cerebrovascular pathological change which is caused by hypertension and arteriosclerosis. HICH has been as an independent classification of diseases from non-traumatic intracerebral hemorrhage, and there is a certain regularity in its pathogeny, the pathogenesis, the clinical process and the outcome. The death rate of conservative treatment is 70% to 85%, while surgical treatment may reduce the death rate to 28%-30%. But the recurrent hemorrhage after operation of HICH is one of its complications, once the treatment is not prompt, there will be serious consequences.
[Purpose and Methods]: This paper retrospectively analyzes the clinical data of 163 cases of hypertensive intracerebral hemorrhage patients. It comprehensively expatiates the causes, the risk factors, the clinical manifestations, the early diagnosis, the treatment and the prognosis of the recurrent hemorrhage after operation of HICH. It also discusses the prevention and the cure methods, in order to deepen the surgeons’understanding of the recurrent hemorrhage after operation of HICH, so that it effectively increases the survival rate and improves the quality of life of hypertensive cerebral hemorrhage patients.
[Results]: The recurrent hemorrhage after operation of HICH patients accounts for nearly 10% of HICH patients. It is mainly caused by the senility, the high blood pressure before and after operation, the big postoperative blood pressure fluctuation, the excessive preoperative cerebral hemorrhage, the premature or excessive application of mannitol, the intraoperative skills and so on.
[Conclusion]: (1) The preoperative and postoperative hypertension status is the main reason for the recurrent hemorrhage after operation, at same time the big postoperative blood pressure fluctuation is the important inducement. (2) Most HICH patients are the elderly. Their blood vessel elasticity and the cruor mechanism maybe poor, consequently the hematoma cavity in which the cruor has not been cure and the surgical cuts may easily lead to the recurrent cerebral hemorrhage. (3) Recurrent cerebral hemorrhage is likely to happen because the hematoma is large in primary hemorrhage and the change gradient of the encephalic pressure is big after purging the postoperative hematoma. (4) Recurrent cerebral hemorrhage owes to the premature or excessive application of mannitol. (5) Recurrent cerebral hemorrhage is due to the unreliable intraoperative hemostasis and the blood pressure is low when the surgeons subjectively consider themselves to stanch completely for the patients. (6) The typical clinical manifestations show the various awareness changes, going with other symptoms such as: the disparate pupils, headache, nausea, vomiting and meningeal irritation. (7) The preferred way of diagnosis is CT. (8) The way of treatment can choose surgical treatment or conservative treatment according to the illness of the patients. (9) The key of the recurrent hemorrhage after operation of HICH lies in prevention, at the same time whether the diagnosis is timely and the treatment of recurrent cerebral hemorrhage are also directly related to the patient’s prognosis.
引文
[1]张文科.高血压性脑出血外科治疗学概要, 1994,第1版:1.
[2] McKissock W, Richardson A, Taylor J. Primary intracerebral haemorrhage: a controlled trial of surgical and conservative treatment in 180 unselected cases. Lancet, 1961,2:221-226.
[3] Zuccarello M, Brott T, Derex L, et al. The treatment of spontaneous intracerebral hemorrhage: A prospective randomized trial of surgical and conservative treatment. J Neurosurg, 1999,30:1833-1839.
[4] Prasad K, Bowman G, Srivastava A, Menon G. Surgery in primary supratentorial intracerebral hematoma:a meta-analysis of randomized trials. Acta Neurol Scand, 1997,95:103-110.
[5] Hankey GJ, Hon C. Surgery for primary intracerebral hemorrhage: is it safe and effective? A systematic review of case series and randomized trials. Stroke, 1997,28:2126-2132.
[6] Fernandes HM, Gregson B, Siddique S, et al. Surgery in intracerebral hemorrhage. The uncertainty continues. Stroke, 2000, 31:2511-2516.
[7] Sato N, Nishimura K, Kanaya H, et al. Followup results one year after surgery in patients with hypertensive intracerebral hemorrhage. Neurol Med Chir (Tokyo), 1976,16:109-114.
[8] Morgenstern LB, Frankowski RF, Shedden P, et al. Surgical treatment for intracerebral hemorrhage (STICH): a single-center, randomized clinicaltrial. Neurology, 1998,51:1359-1363.
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[10] Lazorthes G. Surgery of cerebral hamorrhage:report on the result of 52 surgically treatment cases. J Neurosurg, 1959,16:335.
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[1]张文科.高血压性脑出血外科治疗学概要, 1994(11)第1版:1.
[2] McKissock W, Richardson A, Taylor J. Primary intracerebral haemorrhage: a controlled trial of surgical and conservative treatment in 180 unselected cases. Lancet. 1961,2:221-226.
[3] Zuccarello M, Brott T, Derex L, et al. The treatment of spontaneous intracerebral hemorrhage:A prospective randomized trial of surgical and conservative treatment. J Neurosurg. 1999,30:1833-1839.
[4] Prasad K, Bowman G, Srivastava A, Menon G.Surgery in primary supratentorial intracerebral hematoma:a meta-analysis of randomized trials. Acta Neurol Scand. 1997,95:103-110.
[5] Hankey GJ, Hon C. Surgery for primary intracerebral hemorrhage: is it safe and effective? A systematic review of case series and randomized trials. Stroke. 1997,28:2126-2132
[6] Fernandes HM, Gregson B, Siddique S, et al. Surgery in intracerebral hemorrhage. The uncertainty continues. Stroke 2000,31:2511-2516.
[7] Sato N, Nishimura K, Kanaya H, Yamaguchi K, Yukawa H. Followup results one year after surgery in patients with hypertensive intracerebral hemorrhage. Neurol Med Chir (Tokyo). 1976,16:109-114.
[8] Morgenstern LB, Frankowski RF, Shedden P, et al. Surgical treatment for intracerebral hemorrhage (STICH): a single-center, randomized clinicaltrial. Neurology. 1998,51:1359-1363.
[9] Saver JL, Hankey G, Hon C. Surgery for primary intracerebral hemorrhage: meta-analysis of CT-era. studies. Stroke. 1998,29:1477-1478.
[10] Lazorthes G. Surgery of cerebral hamorrhage: report on the result of 52 surgically treatment cases. J Neurosurg, 1959,16:335.
[11] Kanfman HH. Treatment of deep spontaneous in intracerebral hematomas. Stroke(Sup). 1993,24:101.
[12] Omae T, Ueda K, Ogate J, et al. Paren chymatous hemorrhage: etiology, pathology and clinical aspects. In: Toole JE. Edvol. 10 Handbook of clinical neurology. Revised series Amsterdam: Elsevier science Publication BV, 1989:287-331.
[13] Fernandes H, Mendelow A. Spontaneous intracerebral hemorrhage: a surgical dilemma. Br J Neurosurg. 1999.13:389-394.
[14] Yukawa H, Kanaya H. Indication for surgery in hypertensive intracerebral hemorrhage-a statistical study. Neurol Med Chir (Tokyo) 1978,18: 361-365
[15] Diringer MN. Intracerebral hemorrhage: Pathophysiology and management. Crit Care Med. 1993,21:1591-1603
[16] Kazui S, Naritomi H, Yamamoto H, et al. Enlargement of spontaneous intracerebral hemorrhage, incidence and time course. Stroke. 1996,27: 1783-1987.
[17] Xi GH, Wagner KR, Keep RF, et al. Role of blood clot formation on earlyedema development after experimental intracerebral hemorrhage. Stroke. 1998,29(12):2580-2586.
[18] HemphillⅢJC, Bonovich DC, Besmertis L, et al. A simple,reliable grading scale for intracerebral hemorrhage.Stroke,2001,32:891-897
[19] LeeKR, Kawai N, Kim S, et al. Mechanisms of edema formation after intracerebral hemorrhage: effects of thrombin on CBF, BBB, permeability and cell survival in a rat model. J. Neurosurg. 1997,86: 272-178.
[20] Cushing H. The blood-pressure reaction of acute cerebral compression, illustrated by cases of intracranial hemorrhage. Am J Med Sci 1903,125: 1017-1044.
[21] Fernandes H, Mendelow A. Spontaneous intracerebral hemorrhage: a surgical dilemma. Br J Neurosurg. 1999,13:389-394.
[22] Brott T, Broderick J, Kothari R, et al. Early hemorrhage in patients with intracerebral hemorrhage. Stroke. 1997,28:1-5.
[23] Kaneko M, Tanaka K, Shimada T, et al. Long-term evaluation of ultra-early operation for hypertensive intracerebral hemorrhage in 100 cases. J Neurosurg. 1983,58:838-842.
[24] Sato N, Nishimura K, Kanaya H, Yamaguchi K, Yukawa H. Followup results one year after surgery in patients with hypertensive intracerebral hemorrhage. Neurol Med Chir (Tokyo). 1976,16:109-114.
[25] Nakayama T, Date C, Yokoyama T, et al. A 15.5-year follow-up study of stroke in a Japanese provincial city-The Shibata Study. Stroke.1997,28:45-52
[26] Kadojic D, Barac B, Trkanjec Z., et al. The seclar trend in the incidence of hemorrhagic stroke in the region of Osijek, Eastern Croatia in the period 1988-2000-a hospital based study. Collegium Antropologicum. 2002,26:627-634
[27]万宏,张建平,范忠秀,等.高血压性脑出血微创治疗.中国临床神经科学, 1999,7:188.
[28]彭远强,陈善固,曾胜田.高血压脑出血的手术治疗.中华神经医学杂志, 2005,6:622-623.
[29]张延平,张攀,李业生.高血压脑出血继发重型脑室内出血的微创手术治疗(附169例报告).中国微侵袭神经外科杂志, 2006,11:84-85.
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[2] McKissock W, Richardson A, Taylor J. Primary intracerebral haemorrhage: a controlled trial of surgical and conservative treatment in 180 unselected cases. Lancet, 1961,2:221-226.
[3] Zuccarello M, Brott T, Derex L, et al. The treatment of spontaneous intracerebral hemorrhage: A prospective randomized trial of surgical and conservative treatment. J Neurosurg, 1999,30:1833-1839.
[4] Prasad K, Bowman G, Srivastava A, Menon G. Surgery in primary supratentorial intracerebral hematoma:a meta-analysis of randomized trials. Acta Neurol Scand, 1997,95:103-110.
[5] Hankey GJ, Hon C. Surgery for primary intracerebral hemorrhage: is it safe and effective? A systematic review of case series and randomized trials. Stroke, 1997,28:2126-2132.
[6] Fernandes HM, Gregson B, Siddique S, et al. Surgery in intracerebral hemorrhage. The uncertainty continues. Stroke, 2000, 31:2511-2516.
[7] Sato N, Nishimura K, Kanaya H, et al. Followup results one year after surgery in patients with hypertensive intracerebral hemorrhage. Neurol Med Chir (Tokyo), 1976,16:109-114.
[8] Morgenstern LB, Frankowski RF, Shedden P, et al. Surgical treatment for intracerebral hemorrhage (STICH): a single-center, randomized clinicaltrial. Neurology, 1998,51:1359-1363.
[9] Saver JL, Hankey G, Hon C. Surgery for primary intracerebral hemorrhage: meta-analysis of CT-era. studies. Stroke, 1998,29:1477-1478.
[10] Lazorthes G. Surgery of cerebral hamorrhage:report on the result of 52 surgically treatment cases. J Neurosurg, 1959,16:335.
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