早期经侧裂小骨瓣显微手术治疗高血压基底节出血
摘要
目的:研究早期经侧裂小骨瓣显微手术方式对基底节脑出血的疗效、预后,为高血压基底节出血的规范化治疗提供依据。
方法:回顾性分析在本院2006年10月至2008年7月入院的高血压基底节出血36例,病例入选标准为GCS评分6-9分,发病距手术时间10小时,年龄35-75岁。分为两组,A组为经侧裂小骨瓣显微手术组,共17例;B组为经颞叶大骨瓣手术组,共19例。手术方法:经侧裂小骨瓣手术采用以外侧裂为中心的翼点开颅,切开颞肌及骨膜,行颅骨钻孔后用咬骨钳扩大骨窗,直径约3cm,牵开侧裂,经岛叶至血肿腔,清除血肿;经颞叶大骨瓣手术,取颞部马蹄形切口,骨窗约7cm×8cm,经颞中回切开皮质,至血肿腔,清除血肿。术后随访6月,统计学分析两组的死亡率,ADL评分,GOS评分。
结果:经侧裂小骨瓣显微手术组17例,死亡3例,术后6月ADL分级:II级3例,III级8例,IV级3例,V级3例;术后6月GOS评分:1分3例,3分11例,4分3例。经颞叶大骨瓣手术组19例,死亡7例,术后6月ADL分级:III级12例,V级7例;术后6月GOS评分:1分7例,3分12例。
结论:经侧裂小骨瓣显微手术组的死亡率为17.65%,经颞叶大骨瓣手术组死亡率为36.84%,但两者比较无显著性差异(P>0.05)。经侧裂小骨瓣显微手术组的术后6月平均GOS评分为2.82分,经颞叶大骨瓣手术组的术后6月平均GOS评分为2.26分,但两者比较无显著性差异(P>0.05)。经侧裂小骨瓣显微手术组的术后6月平均ADL分级为3.35分,经颞叶大骨瓣手术组的术后6月平均ADL评分为3.74分,但两者比较无显著性差异(P>0.05)。通过经侧裂小骨瓣显微手术组和经颞叶大骨瓣手术组分析,结果显示两组比较无显著性差异。所以高血压基底节出血的外科治疗技术,至今孰优孰劣,综合各方面的研究成果和本组的研究材料,我们认为对脑血肿较小,无脑疝的患者以经侧裂小骨瓣显微手术创伤较小。
Objective: To analyse the outcome and prognosis of hypertensive basal ganglia hemorrhage patients who underwent early microsurgical transsylvian approach .
Methods: 36 patients who were admitted in our hospital from October 2006 to July 2008 because of hypertensive basal ganglia hemorrhage were retrospectively analysed. The inclusion criterias are GCS 6-9 operated within 10 hours of ictus ,age between 35-75 year. Patients were divided into 2 groups. 17 patients who underwent transsylvian mircosurgical approach were grouped as A. 19 patients who underwent transcortical approach were grouped as B. Operation method:For the Group A patients, pterion craniotomy was performed and bone window extended for 3 cm in diameter, the sylvian fissure was drawn off gently and access made to the hematoma cavity through insula. For the transcortical approach horse shoe incision was given over temporal region ,craniotomy extended for 7cm×8cm, then middle temporal gyrus was resected and hematoma cavity entered. 6 month postoperatively,statistical analysis was performed regarding the mortality rate ,GOS score and ADL score.
Result-In the microsurgical transsylvian approach group, out of 17 patients, 3 patient died ,6 month postoperatively ADL scores are as follows: gradeⅡ,Ⅲ,Ⅳ, andⅤhave respectively 3, 8, 3,and 3 patients:6 month postoperative GOS scoring are as follows:three patients have score 1,eleven patients have score 3, and three patients have score 4. In the transcortical craniotomy group out of 19 patients,7 patients died,6 month postoperative ADL scores are as follows: gradeⅢandⅤhave respectively 12 and 7 patients:6 month postoperative GOS scoring are as follows:seven patients have score 1, twelve patients have score 3.
Conclusion-Mortality rate of transsylvian microsurgical approach group is 17.65% and mortality rate of transcortical approach group is 36.84% but the differences are not statistically significant between the two groups(P>0.05). Average GOS score of transsylvian microsurgical approach group and transcortical approach group 6 month postoperatively are 2.82 and 2.26 respectively but the differences are not statistically significant between the two groups(P>0.05). Average ADL score of transsylvian microsurgical approach group and transcortical approach group 6 month postoperatively are 3.35 and 3.74 respectively but the differences are not statistically significant between the two groups(P>0.05). Between the two groups , the result shows there is no statitically significance. For patients with small volume of hematoma and without brain herniation ,the use of transsylvian approach provides less trauma to the brain.
方法:回顾性分析在本院2006年10月至2008年7月入院的高血压基底节出血36例,病例入选标准为GCS评分6-9分,发病距手术时间10小时,年龄35-75岁。分为两组,A组为经侧裂小骨瓣显微手术组,共17例;B组为经颞叶大骨瓣手术组,共19例。手术方法:经侧裂小骨瓣手术采用以外侧裂为中心的翼点开颅,切开颞肌及骨膜,行颅骨钻孔后用咬骨钳扩大骨窗,直径约3cm,牵开侧裂,经岛叶至血肿腔,清除血肿;经颞叶大骨瓣手术,取颞部马蹄形切口,骨窗约7cm×8cm,经颞中回切开皮质,至血肿腔,清除血肿。术后随访6月,统计学分析两组的死亡率,ADL评分,GOS评分。
结果:经侧裂小骨瓣显微手术组17例,死亡3例,术后6月ADL分级:II级3例,III级8例,IV级3例,V级3例;术后6月GOS评分:1分3例,3分11例,4分3例。经颞叶大骨瓣手术组19例,死亡7例,术后6月ADL分级:III级12例,V级7例;术后6月GOS评分:1分7例,3分12例。
结论:经侧裂小骨瓣显微手术组的死亡率为17.65%,经颞叶大骨瓣手术组死亡率为36.84%,但两者比较无显著性差异(P>0.05)。经侧裂小骨瓣显微手术组的术后6月平均GOS评分为2.82分,经颞叶大骨瓣手术组的术后6月平均GOS评分为2.26分,但两者比较无显著性差异(P>0.05)。经侧裂小骨瓣显微手术组的术后6月平均ADL分级为3.35分,经颞叶大骨瓣手术组的术后6月平均ADL评分为3.74分,但两者比较无显著性差异(P>0.05)。通过经侧裂小骨瓣显微手术组和经颞叶大骨瓣手术组分析,结果显示两组比较无显著性差异。所以高血压基底节出血的外科治疗技术,至今孰优孰劣,综合各方面的研究成果和本组的研究材料,我们认为对脑血肿较小,无脑疝的患者以经侧裂小骨瓣显微手术创伤较小。
Objective: To analyse the outcome and prognosis of hypertensive basal ganglia hemorrhage patients who underwent early microsurgical transsylvian approach .
Methods: 36 patients who were admitted in our hospital from October 2006 to July 2008 because of hypertensive basal ganglia hemorrhage were retrospectively analysed. The inclusion criterias are GCS 6-9 operated within 10 hours of ictus ,age between 35-75 year. Patients were divided into 2 groups. 17 patients who underwent transsylvian mircosurgical approach were grouped as A. 19 patients who underwent transcortical approach were grouped as B. Operation method:For the Group A patients, pterion craniotomy was performed and bone window extended for 3 cm in diameter, the sylvian fissure was drawn off gently and access made to the hematoma cavity through insula. For the transcortical approach horse shoe incision was given over temporal region ,craniotomy extended for 7cm×8cm, then middle temporal gyrus was resected and hematoma cavity entered. 6 month postoperatively,statistical analysis was performed regarding the mortality rate ,GOS score and ADL score.
Result-In the microsurgical transsylvian approach group, out of 17 patients, 3 patient died ,6 month postoperatively ADL scores are as follows: gradeⅡ,Ⅲ,Ⅳ, andⅤhave respectively 3, 8, 3,and 3 patients:6 month postoperative GOS scoring are as follows:three patients have score 1,eleven patients have score 3, and three patients have score 4. In the transcortical craniotomy group out of 19 patients,7 patients died,6 month postoperative ADL scores are as follows: gradeⅢandⅤhave respectively 12 and 7 patients:6 month postoperative GOS scoring are as follows:seven patients have score 1, twelve patients have score 3.
Conclusion-Mortality rate of transsylvian microsurgical approach group is 17.65% and mortality rate of transcortical approach group is 36.84% but the differences are not statistically significant between the two groups(P>0.05). Average GOS score of transsylvian microsurgical approach group and transcortical approach group 6 month postoperatively are 2.82 and 2.26 respectively but the differences are not statistically significant between the two groups(P>0.05). Average ADL score of transsylvian microsurgical approach group and transcortical approach group 6 month postoperatively are 3.35 and 3.74 respectively but the differences are not statistically significant between the two groups(P>0.05). Between the two groups , the result shows there is no statitically significance. For patients with small volume of hematoma and without brain herniation ,the use of transsylvian approach provides less trauma to the brain.
引文
1.刘伟国,杨小锋.神经损伤的基础与临床.杭州.浙江大学出版社.2007:29-32.
2.凌峰,李铁林.介入神经放射学.北京.人民卫生出版社,1998:65-67.
3.倪红斌,梁维邦,陈明基,等.影响高血压性脑出血手术疗效的因素分析.江苏医药杂志,2000,26(11):873-875.
4.章翔.脑卒中诊断治疗学.北京.人民军医出版社,2001:118-134.
5.刘伟国,杨小锋.神经外科危急重症诊治.杭州.浙江大学出版社,2005:375-386.
6.徐学华,肖孝刚,林承怀,等.高血压脑出血的外科治疗.医学信息手术学分册,2007,20(5):446-447.
7.H Richard Winn.Youmens Neurosurgery.New York.2003:1733-1764.
8.赵雅度.高血压脑出血手术时机的规范化研究.中国微侵袭神经外科杂志.2003,8(1):4-5.
9.李德康,李晓滨,张孙富,等.高血压脑出血手术时机的临床研究.中国现代医学杂志,2008,46(28):117-119.
10.陈俊典,张小峰,黄保民,等.高血压脑出血手术与疗效分析.中国医师杂志,2002,6(8):32-33.
11.刘炜,马尚斌,宋会双,等.基底节区高血压脑出血不同微创手术方式的比较.中华神经外科杂志,2008,5(7):495-497.
12.王卫余,朱君明,卢刚,等.高血压脑出血不同手术方式的治疗.中华急诊医学杂志,2005,6(14):520-521.
13.彭友波,周建学,潘云峰,等.标准大骨瓣开颅治疗高血压脑出血的临床分析.浙江创伤外科,2008,6(13):254.
14.王忠诚.神经外科学.武汉.湖北科学技术出版社,2005:864-871.
15.丁昊,游湖,邓琳,等.手术治疗高血压基底节核脑出血的预后因素分析.中 国微侵袭神经外科杂志,2007,12(12):531-533.
16.车万民,周杰,董涛等.外侧裂入路显微手术治疗高血压性基底节区血肿.医学信息手术学分册 2007,6(20)497-498
17.王洪军,杨立庄.高血压脑出血的不同治疗方式疗效的探讨.医学综述,2004:5-12.
18.Joseph P B,Harold P A,Willian B,et al.guidelines for management of sponteneous intracerebral hemorrhage.Journel of American heart association.2007,38:2001-2023.
19.龚岳明,张飞翔.高血压脑出血三种手术方式的临床分析.临床医学研究,2002,19(4):300-301.
20.张元.早期手术治疗高血压脑出血的临床疗效总结.proceeding of clinical medicine,2007,16(9):850-851.
21.李培栋,王新军,马林,等.高血压出血 60 列手术治疗分析.中国使用神经病杂志,2007,10(6):21-23.
22.李玉山,刘平,样子键,等.早期手术治疗 74 列高血压基底节出血术式比较.中国老年学杂志,2006,11(26):1471-1473.
23.Mario Z,Thomas B,Laurent D,et al.early surgical treatment for supratentorial hemorrhage:A randomised feasibility study.Journel of American heart assosiation,1999130:1833-1839.
24.尹文军,姜国建,姜浩.高血压脑出血手术治疗体会.工企医刊,2006,(19):1-2.
25.张军,扬桐,苏平.基底节区高血压出血的手术治疗分析.黑龙江医学,2005,29(3):202-203.
26.殷续新.高血压脑出血手术的治疗进展.国际神经病学神经外科学杂志,2008,35(4):364-366.
27.徐晓.高血压脑出血手术患者的死亡因素分析.浙江使用医学,2007,3(4):263-265.
28.A David M,Barbara AG,Helen MF,et al.Early surgery versus initial conservative treatment in patient with sponteneous supratentorial intracerebral hematoma in the international Surgical Trial in intracerebral hemorrhage(STICH).Lancet:2005:365,387-395.
29.Wagner KR,Xi G;Hua Y,et al.Ultra early clot aspiration after lysis with tissue plasminogen activator in a porcine model of intracerebral hemorrhage:edema reduction and blood brain barrier protection.J Neurosurg,1999,90(3):491-498.
30.陈宝师.常规手术及显微手术治疗高血压脑出血 80 列疗效对照分析(硕士学位论文).山东大学,2006:26-28
31.Dong-S S,Seok M Y,Sung H K,et al.open surgical evacuation of spontaneous putaminal hematomas:prognostic factors and comparision of outcomes between transylvian and trancortical approach.J Korean Neurosurg,2008,44:1-7.
1.刘伟国,杨小锋.神经损伤的基础与临床.杭州.浙江大学出版社.2007:29-32.
2.凌峰,李铁林.介入神经放射学.北京.人民卫生出版社,1998:65-67.
3.章翔.脑卒中诊断治疗学.北京.人民军医出版社,2001:118-134.
4.刘伟国,杨小锋.神经外科危急重症诊治.杭州.浙江大学出版社,2005:375-386.
5.H Richard Winn.Youmens Neurosurgery.New York.2003:1733-1764.
6.赵雅度.高血压脑出血手术时机的规范化研究.中国微侵袭神经外科杂志.2003,8(1):4-5.
7.陈宝师.常规手术及显微手术治疗高血压脑出血 80 列疗效对照分析(硕士学位论文).山东大学,2006:26-28
8.陈俊典,张小峰,黄保民,等.高血压脑出血手术与疗效分析.中国医师杂志,2002,6(8):32-33.
9.刘炜,马尚斌,宋会双,等.基底节区高血压脑出血不同微创手术方式的比较.中华神经外科杂志,2008,5(7):495-497.
10.王卫余,朱君明,卢刚,等.高血压脑出血不同手术方式的治疗.中华急诊医学杂志,2005,6(14):520-521.
11.彭友波,周建学,潘云峰,等.标准大骨瓣开颅治疗高血压脑出血的临床分析.浙江创伤外科,2008,6(13):254.
12.王忠诚.神经外科学.武汉.湖北科学技术出版社,2005:864-871.
13.丁昊,游湖,邓琳,等.手术治疗高血压基底节核脑出血的预后因素分析.中国微侵袭神经外科杂志,2007,12(12):531-533.
14.王洪军,杨立庄.高血压脑出血的不同治疗方式疗效的探讨.医学综述,2004:5-12.
15.Joseph P B,Harold P A,Willian B,et al.guidelines for management of sponteneous intracerebral hemorrhage.Journel of American heart asscciation.2007,38:2001-2023.
16.李玉山,刘平,样子键,等.早期手术治疗 74 列高血压基底节出血术式比较.中国老年学杂志,2006,11(26):1471-1473.
17.Mario Z,Thomas B,Laurent D,et al.early surgical treatment for supratentorial hemorrhage:A randomised feasibility study.Joumel of American heart assosiation,1999,30:1833-1839.
18.殷续新.高血压脑出血手术的治疗进展.国际神经病学神经外科学杂志,2008,35(4):364-366.
19.徐晓.高血压脑出血手术患者的死亡因素分析.浙江使用医学,2007,3(4):263-265.
20.A David M,Barbara AG,Helen MF,et al.Early surgery versus initial conservative treatment in patient with sponteneous supratentorial intracerebral hematoma in the international Surgical Trial in intracerebral hemorrhage(STICH).Lancet:2005:365,387-395.
2.凌峰,李铁林.介入神经放射学.北京.人民卫生出版社,1998:65-67.
3.倪红斌,梁维邦,陈明基,等.影响高血压性脑出血手术疗效的因素分析.江苏医药杂志,2000,26(11):873-875.
4.章翔.脑卒中诊断治疗学.北京.人民军医出版社,2001:118-134.
5.刘伟国,杨小锋.神经外科危急重症诊治.杭州.浙江大学出版社,2005:375-386.
6.徐学华,肖孝刚,林承怀,等.高血压脑出血的外科治疗.医学信息手术学分册,2007,20(5):446-447.
7.H Richard Winn.Youmens Neurosurgery.New York.2003:1733-1764.
8.赵雅度.高血压脑出血手术时机的规范化研究.中国微侵袭神经外科杂志.2003,8(1):4-5.
9.李德康,李晓滨,张孙富,等.高血压脑出血手术时机的临床研究.中国现代医学杂志,2008,46(28):117-119.
10.陈俊典,张小峰,黄保民,等.高血压脑出血手术与疗效分析.中国医师杂志,2002,6(8):32-33.
11.刘炜,马尚斌,宋会双,等.基底节区高血压脑出血不同微创手术方式的比较.中华神经外科杂志,2008,5(7):495-497.
12.王卫余,朱君明,卢刚,等.高血压脑出血不同手术方式的治疗.中华急诊医学杂志,2005,6(14):520-521.
13.彭友波,周建学,潘云峰,等.标准大骨瓣开颅治疗高血压脑出血的临床分析.浙江创伤外科,2008,6(13):254.
14.王忠诚.神经外科学.武汉.湖北科学技术出版社,2005:864-871.
15.丁昊,游湖,邓琳,等.手术治疗高血压基底节核脑出血的预后因素分析.中 国微侵袭神经外科杂志,2007,12(12):531-533.
16.车万民,周杰,董涛等.外侧裂入路显微手术治疗高血压性基底节区血肿.医学信息手术学分册 2007,6(20)497-498
17.王洪军,杨立庄.高血压脑出血的不同治疗方式疗效的探讨.医学综述,2004:5-12.
18.Joseph P B,Harold P A,Willian B,et al.guidelines for management of sponteneous intracerebral hemorrhage.Journel of American heart association.2007,38:2001-2023.
19.龚岳明,张飞翔.高血压脑出血三种手术方式的临床分析.临床医学研究,2002,19(4):300-301.
20.张元.早期手术治疗高血压脑出血的临床疗效总结.proceeding of clinical medicine,2007,16(9):850-851.
21.李培栋,王新军,马林,等.高血压出血 60 列手术治疗分析.中国使用神经病杂志,2007,10(6):21-23.
22.李玉山,刘平,样子键,等.早期手术治疗 74 列高血压基底节出血术式比较.中国老年学杂志,2006,11(26):1471-1473.
23.Mario Z,Thomas B,Laurent D,et al.early surgical treatment for supratentorial hemorrhage:A randomised feasibility study.Journel of American heart assosiation,1999130:1833-1839.
24.尹文军,姜国建,姜浩.高血压脑出血手术治疗体会.工企医刊,2006,(19):1-2.
25.张军,扬桐,苏平.基底节区高血压出血的手术治疗分析.黑龙江医学,2005,29(3):202-203.
26.殷续新.高血压脑出血手术的治疗进展.国际神经病学神经外科学杂志,2008,35(4):364-366.
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