【作者】 张广宁；

【导师】 杨清江； 赵丛海；

【作者基本信息】 吉林大学 ， 急救医学， 2008， 硕士

【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。更多还原

【Abstract】 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.更多还原