高血压脑出血的外科治疗方式与二次脑创伤因素研究
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摘要
背景和目的：脑卒中是人类死亡的第三位主要原因，属神经内、外科的常见病、多发病。高血压脑出血(Hypertensive intracerebralhemorrhage，HICH)是指由高血压病引起的脑实质内出血，约占全部脑卒中的10％。在非损伤性脑出血中，约90％左右是HICH。该病多起病急骤，进展迅速，病情凶险，具有很高的死亡率(40～60％)和病残率，部分病人长期丧失劳动力。HICH为高血压病最严重的并发症之一，也是高血压病人的主要死亡原因。在脑血管病中，其死亡率居首位，据统计，死于急性脑血管病的病人中每4名就有1名是HICH。
近年来，随着CT、MRI和MRA等影像技术的广泛应用，对HICH病理过程的深入研究和临床治疗经验的积累，特别是立体定向等技术用于HICH的治疗，使其疗效和生存病例的生活质量有较大提高。虽然以外科手段治疗HICH成为神经外科学者探索的热门课题，但国内外治疗HICH的方法较多，标准不一，死亡率也有较大差异。
二次脑损伤理论系Miller在1978年首次提出，即在原发脑损伤后二次脑损伤因素如血压、体温、颅内压(ICP)、脑血流(CBF)及脑灌注压(CPP)等的异常改变，可造成第二次脑损害，从而加重原发脑损伤和创伤性脑水肿。临床研究表明，二次脑损伤的发生率为44.5％；与单纯脑损伤相比较，合并血压或体温明显变化者死亡率与致残率显著提高。
有关HICH患者二次脑损伤的发生率研究，国内外尚无相关报道。
方法：本课题选择HICH患者112(男73，女39)例，按哥拉斯格昏迷评分(GCS)，5-8分21例(19％)，9-12分53例(47％)，13-15分38例(34％)。全部病例随机分为两组，开颅血肿清除术组(开颅组)60例(男
第四军医大学硕士学位论文
41，女19)，年龄38~57岁，平均42土8.1岁;钻孔血肿引流术组(引流
组)52例(男34，女18)，年龄39一55岁，平均43士7.9岁。对GCS、手术
方式、手术时机、血肿量、血肿部位及二次脑损伤因素进行多因素回归分
析。采用哥拉斯格预后评分(GOS)和日常生活能力分级法(ADL)对手术患者
进行预后评估。
病例入选标准:1.经CT扫描证实为自发颅内出血;2.患者的 GCS
评分)5分;3.初次CT扫描显示幕上血肿>20ml;幕下血肿>10ml;
4.患者年龄)30岁。排除标准:1.有明确证据显示出血是由于脑动脉
瘤、动静脉畸形破裂、脑外伤或肿瘤卒中所致;2.有脑干出血;3.年龄
超过70岁的深昏迷病人;4.脑病晚期，双侧瞳孔散大，去脑强直、有病
理性呼吸者;5.伴有严重的原发疾病或智力障碍。
结果:
1.GCS评分对预后的影响:GCS13一巧分的患者预后良好16例，中残
20例，无死亡病例;5一8分患者预后良好1例，中残4例，重残9例，植
物生存和死亡7例，GCS分高者预后好，两者对比有显著差异(P<0.05)。
2.不同手术方式对预后的影响:开颅组和引流组的近期预后指标GOS
比较无显著差异(P>0.05);两组的远期预后指标ADL评分无显著差异
(P)0 .05)。
3.手术时机对预后的影响:超早期手术患者(出血后7小时以内)
36例，预后均为良好或中残，无重残、植物生存和死亡病例:在7一24小
时手术的42例患者，3例重残，1例植物生存;在24一48小时手术的20
例患者，预后良好2例，重残5例，植物生存1例，死亡1例;在48小
时以后手术的患者预后差，14例患者中重残7例，植物生存3例，死亡1
例。统计处理显示超早期手术者预后明显优于晚期手术者(P<0.01)。
4.出血量对预后的影响:死亡病例出血量均>6 0ml，与出血量<60ml
的患者比较，其预后明显差(P<0.05)。
5.出血部位对预后的影响:不同部位的H工CH预后无明显差异(P>
0.05)。血肿破入脑室和丘脑出血患者预后较差。
6.二次脑损伤因素:67例(60%)患者合并有二次脑损伤(SBI)，按
GOS评价，良好14例(21%)、中残19例(28%)、重残24例(36%)、植
物生存4例(6%)、死亡6例(9%);无SBI者45例(40%)，恢复良好16
第3页共73页
第四军医大学硕士学位论文
例(36%)、中残20例(44%)、重残5例(12%)、植物生存2例(4%)、死
亡2例(4%)。合并有SBI的患者预后差(P<0.01)。
结论:
1.HICH的外科治疗应首先综合评价病人情况，然后决定不同的处理
方法，对不同的病例选择不同的术式。幕上血肿量在ZOml以上，尤其是
外侧型底节区血肿，皮层下血肿，小脑血肿IOml以上意识障碍较轻(包
括轻、中度昏迷)，有不同程度肢体瘫痪，无明显内脏功能不全者宜积极
手术治疗。凡血肿量较大，意识障碍较重，病情进展较快或已出现早期脑
庙者应及时开颅清除血肿，以期达到迅速、充分的内外减压，挽救生命。
钻孔穿刺引流一般难以达到上述目的。其他有手术适应证的病人，一般均
适合行CT定位血肿穿刺引流术。丘脑出血破入脑室有铸型，保守治疗和
一般脑室外引流效果差。
2.早期或超早期手术较延期手术疗效好，是降低病死率的重要条件。
在条件具备时应采取早期手术，即在脑实质遭受严重损害之前清除血肿，
解除组织受压，减轻脑组织不可逆的病理变化，从而降低死亡率和病残率。
3.H工CH病人证实有二次脑损伤因素
Background and purpose Cerebral stroke is the third reason of human death and cause hospitalization and incapability for a long time. Hypertensive Intracerebral Hemorrhage (HICH) means intracephalic bleeding by the reason of vascular hypertension and about 10 percent of the cerebral apoplexy, 90 percent of the nbn-trumatogenic encepalorrhagia. HICH is the common disease in the bad way that occurs frequently at clinical Neurology, which access unexpectedly, make progress rapidly and has high mortality (40~60 percent)and mutilate rate. It is the serious complication and main death reason of hypertension patients which death rate heads the list of cerebrovascular disease.
Along with the extensive use of CT, MRI and MRA, in depth study of pathology, accumulation of clinical medicine and use of stereotactic operating, curative effect and viability of HICH has been upgraded greatly. Therefore, surgical operating of HICH became heat subject in neurosurgeons. There are more surgical methods without a uniform standard in treating HICH in our country, and it has a different mortality.
The theory of secondary insults had been suggested by Miller in 1978. It means that the changes of the secondary insults just like blood pressure, body temperature, intracranial pressure, cerebral blood flow and cerebral perfusion pressure will be cause secondary brain injury. These insults will be
exacerbating the primary head injury and traumatic cerebral edema. Indication of clinical data, the incidence rate of secondary insults is 44.5%. Compare with pure brain injury, the patients who incorporating distinct changes of temperature and blood pressure have the heighten death and disability rate.
There is no a correlation research about the incidence rate of secondary insults in HICH. Our data displayed that it has a highly incidence rate which the secondary insults occur in HICH patients. And the secondary insults influence the prognosis of HICH patients immediately. The reason is there is many changes of secondary insults just like vascular hypertension, highly temperature, highly intracranial pressure and it has the relationship with the prognosis of patients. It has the significance to raise the cure effect that treat and prevent the secondary injuries as soon as possible.
Method We sum up the clinical data of 112 HICH patients with 73 male and 39 female. The admitted patients were divided to group of craniotomy and group of drainage randomly. Evaluate the prognosis by Compare with the GCS, operating methods, treatment time, hematoma volume and secondary insults.
Admission rules: 1. spontaneity intracerebral hemorrhage confirmed by CT scan. 2. GCS points not under to 5. 3. the hemotoma volume more than 20ml in hemisphere and 10ml in cerebellar. 4. age of the patients not less than 30 years old. Elimination rules: 1. the hemorrhage by aneurysm or AVMs. 2. hematoma by brain injury or tumor apoplexy. 3. brain stem hemotoma. 4. the patients elder than 70 years old with batho-coma; e. hernia of brain in advanced stage, amb-mydrasis, decerebrate rigidity and have pathological breath; f. severe original disease or dysgnosia.
Results
1.Effect of GCS: 16 patients have good recovery, 20 have moderate disability and no death who with GCS 13-15. Only one patient has good recovery, 4 patients have moderate disability, 9 patients have severe disability and 7 have persistent vegetative or death who with GCS5-8. That displayed significant deviation betrwen the two groups (P<0.05 ) .
2. Effect to prognosis by different modus operandi: the GOS which signature the prognostic indicator in the near future has no significant deviation bettwen craniotomy group and puncturation group (P>0.05) .Also has no significant deviation bettwen the two groups in long-term prognostic indicator ADL (P>0.05) .
3. Effect to prognosis by operation opportunity: 36 patients with operation at hyper-morning (within 7 hours after to hemorrhage) have good revovery and no patient have severe disability, persistent vegetative or deat
近年来，随着CT、MRI和MRA等影像技术的广泛应用，对HICH病理过程的深入研究和临床治疗经验的积累，特别是立体定向等技术用于HICH的治疗，使其疗效和生存病例的生活质量有较大提高。虽然以外科手段治疗HICH成为神经外科学者探索的热门课题，但国内外治疗HICH的方法较多，标准不一，死亡率也有较大差异。
二次脑损伤理论系Miller在1978年首次提出，即在原发脑损伤后二次脑损伤因素如血压、体温、颅内压(ICP)、脑血流(CBF)及脑灌注压(CPP)等的异常改变，可造成第二次脑损害，从而加重原发脑损伤和创伤性脑水肿。临床研究表明，二次脑损伤的发生率为44.5％；与单纯脑损伤相比较，合并血压或体温明显变化者死亡率与致残率显著提高。
有关HICH患者二次脑损伤的发生率研究，国内外尚无相关报道。
方法：本课题选择HICH患者112(男73，女39)例，按哥拉斯格昏迷评分(GCS)，5-8分21例(19％)，9-12分53例(47％)，13-15分38例(34％)。全部病例随机分为两组，开颅血肿清除术组(开颅组)60例(男
第四军医大学硕士学位论文
41，女19)，年龄38~57岁，平均42土8.1岁;钻孔血肿引流术组(引流
组)52例(男34，女18)，年龄39一55岁，平均43士7.9岁。对GCS、手术
方式、手术时机、血肿量、血肿部位及二次脑损伤因素进行多因素回归分
析。采用哥拉斯格预后评分(GOS)和日常生活能力分级法(ADL)对手术患者
进行预后评估。
病例入选标准:1.经CT扫描证实为自发颅内出血;2.患者的 GCS
评分)5分;3.初次CT扫描显示幕上血肿>20ml;幕下血肿>10ml;
4.患者年龄)30岁。排除标准:1.有明确证据显示出血是由于脑动脉
瘤、动静脉畸形破裂、脑外伤或肿瘤卒中所致;2.有脑干出血;3.年龄
超过70岁的深昏迷病人;4.脑病晚期，双侧瞳孔散大，去脑强直、有病
理性呼吸者;5.伴有严重的原发疾病或智力障碍。
结果:
1.GCS评分对预后的影响:GCS13一巧分的患者预后良好16例，中残
20例，无死亡病例;5一8分患者预后良好1例，中残4例，重残9例，植
物生存和死亡7例，GCS分高者预后好，两者对比有显著差异(P<0.05)。
2.不同手术方式对预后的影响:开颅组和引流组的近期预后指标GOS
比较无显著差异(P>0.05);两组的远期预后指标ADL评分无显著差异
(P)0 .05)。
3.手术时机对预后的影响:超早期手术患者(出血后7小时以内)
36例，预后均为良好或中残，无重残、植物生存和死亡病例:在7一24小
时手术的42例患者，3例重残，1例植物生存;在24一48小时手术的20
例患者，预后良好2例，重残5例，植物生存1例，死亡1例;在48小
时以后手术的患者预后差，14例患者中重残7例，植物生存3例，死亡1
例。统计处理显示超早期手术者预后明显优于晚期手术者(P<0.01)。
4.出血量对预后的影响:死亡病例出血量均>6 0ml，与出血量<60ml
的患者比较，其预后明显差(P<0.05)。
5.出血部位对预后的影响:不同部位的H工CH预后无明显差异(P>
0.05)。血肿破入脑室和丘脑出血患者预后较差。
6.二次脑损伤因素:67例(60%)患者合并有二次脑损伤(SBI)，按
GOS评价，良好14例(21%)、中残19例(28%)、重残24例(36%)、植
物生存4例(6%)、死亡6例(9%);无SBI者45例(40%)，恢复良好16
第3页共73页
第四军医大学硕士学位论文
例(36%)、中残20例(44%)、重残5例(12%)、植物生存2例(4%)、死
亡2例(4%)。合并有SBI的患者预后差(P<0.01)。
结论:
1.HICH的外科治疗应首先综合评价病人情况，然后决定不同的处理
方法，对不同的病例选择不同的术式。幕上血肿量在ZOml以上，尤其是
外侧型底节区血肿，皮层下血肿，小脑血肿IOml以上意识障碍较轻(包
括轻、中度昏迷)，有不同程度肢体瘫痪，无明显内脏功能不全者宜积极
手术治疗。凡血肿量较大，意识障碍较重，病情进展较快或已出现早期脑
庙者应及时开颅清除血肿，以期达到迅速、充分的内外减压，挽救生命。
钻孔穿刺引流一般难以达到上述目的。其他有手术适应证的病人，一般均
适合行CT定位血肿穿刺引流术。丘脑出血破入脑室有铸型，保守治疗和
一般脑室外引流效果差。
2.早期或超早期手术较延期手术疗效好，是降低病死率的重要条件。
在条件具备时应采取早期手术，即在脑实质遭受严重损害之前清除血肿，
解除组织受压，减轻脑组织不可逆的病理变化，从而降低死亡率和病残率。
3.H工CH病人证实有二次脑损伤因素
Background and purpose Cerebral stroke is the third reason of human death and cause hospitalization and incapability for a long time. Hypertensive Intracerebral Hemorrhage (HICH) means intracephalic bleeding by the reason of vascular hypertension and about 10 percent of the cerebral apoplexy, 90 percent of the nbn-trumatogenic encepalorrhagia. HICH is the common disease in the bad way that occurs frequently at clinical Neurology, which access unexpectedly, make progress rapidly and has high mortality (40~60 percent)and mutilate rate. It is the serious complication and main death reason of hypertension patients which death rate heads the list of cerebrovascular disease.
Along with the extensive use of CT, MRI and MRA, in depth study of pathology, accumulation of clinical medicine and use of stereotactic operating, curative effect and viability of HICH has been upgraded greatly. Therefore, surgical operating of HICH became heat subject in neurosurgeons. There are more surgical methods without a uniform standard in treating HICH in our country, and it has a different mortality.
The theory of secondary insults had been suggested by Miller in 1978. It means that the changes of the secondary insults just like blood pressure, body temperature, intracranial pressure, cerebral blood flow and cerebral perfusion pressure will be cause secondary brain injury. These insults will be
exacerbating the primary head injury and traumatic cerebral edema. Indication of clinical data, the incidence rate of secondary insults is 44.5%. Compare with pure brain injury, the patients who incorporating distinct changes of temperature and blood pressure have the heighten death and disability rate.
There is no a correlation research about the incidence rate of secondary insults in HICH. Our data displayed that it has a highly incidence rate which the secondary insults occur in HICH patients. And the secondary insults influence the prognosis of HICH patients immediately. The reason is there is many changes of secondary insults just like vascular hypertension, highly temperature, highly intracranial pressure and it has the relationship with the prognosis of patients. It has the significance to raise the cure effect that treat and prevent the secondary injuries as soon as possible.
Method We sum up the clinical data of 112 HICH patients with 73 male and 39 female. The admitted patients were divided to group of craniotomy and group of drainage randomly. Evaluate the prognosis by Compare with the GCS, operating methods, treatment time, hematoma volume and secondary insults.
Admission rules: 1. spontaneity intracerebral hemorrhage confirmed by CT scan. 2. GCS points not under to 5. 3. the hemotoma volume more than 20ml in hemisphere and 10ml in cerebellar. 4. age of the patients not less than 30 years old. Elimination rules: 1. the hemorrhage by aneurysm or AVMs. 2. hematoma by brain injury or tumor apoplexy. 3. brain stem hemotoma. 4. the patients elder than 70 years old with batho-coma; e. hernia of brain in advanced stage, amb-mydrasis, decerebrate rigidity and have pathological breath; f. severe original disease or dysgnosia.
Results
1.Effect of GCS: 16 patients have good recovery, 20 have moderate disability and no death who with GCS 13-15. Only one patient has good recovery, 4 patients have moderate disability, 9 patients have severe disability and 7 have persistent vegetative or death who with GCS5-8. That displayed significant deviation betrwen the two groups (P<0.05 ) .
2. Effect to prognosis by different modus operandi: the GOS which signature the prognostic indicator in the near future has no significant deviation bettwen craniotomy group and puncturation group (P>0.05) .Also has no significant deviation bettwen the two groups in long-term prognostic indicator ADL (P>0.05) .
3. Effect to prognosis by operation opportunity: 36 patients with operation at hyper-morning (within 7 hours after to hemorrhage) have good revovery and no patient have severe disability, persistent vegetative or deat
引文
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