【作者】 王鹏；

【导师】 孙金龙；

【作者基本信息】 山东大学 ， 外科学， 2010， 硕士

【摘要】 目的研究快速细孔(微创)钻颅在重症高血压性脑出血中的临床应用,评价其临床价值。方法回顾性分析2002～2009年山东省千佛山医院神经外科收治且行外科治疗的236例重症高血压性脑出血(脑出血后意识状况分级Ⅳ-Ⅴ级,格拉斯哥昏迷评分GCS≤9分)患者的临床资料,并按照手术方式不同分为钻孔组和开颅组,钻孔组局麻下行快速细孔(微创)钻颅引流术,开颅组全麻下行开颅血肿清除术,其中钻孔组163例、开颅组73例；术前对组间可能影响疗效的相关因素如性别、年龄、高血压病史、血肿部位及血肿量、发病至手术的时间等进行统计学分析；术中对手术时间进行比较；术后1天、7天、14天、30天复查颅脑CT评价颅内情况,术后1个月评价格拉斯哥预后评分GOS以比较其近期疗效,并分析病死率及再出血、糖和电解质代谢紊乱、肺部感染、颅内感染等主要并发症的情况。结果1.手术时间比较：钻孔组(8.7±3.9)分钟明显少于开颅组(136.5±19.6)分钟。2.术后并发症比较：①钻孔组术后肺部感染患者55例(33.7%)；开颅组35例(47.9%)；钻孔组低于开颅组。②钻孔组术后高血糖与水电解质代谢平衡紊乱49例(30.1%)；开颅组31例(42.5%)；钻孔组低于开颅组。③钻孔组术后颅内感染患者15例(9.2%)；开颅组6例(8.2%)；两组不具有显著性差异。④钻孔组术后再出血患者17例(10.4%)；开颅组8例(11%)；两组不具有显著性差异。3.近期疗效比较：术后1月近期疗效两组样本血肿量较小的患者(基底节区≤60ml、脑叶≤60ml、小脑≤15ml),钻孔组优于开颅组。两组样本间中大血肿量的患者(基底节区60～90ml、基底节区≥90ml、脑叶60～90ml、脑叶≥90ml、小脑>15ml)钻孔组与开颅组不具有显著性差异。脑干出血的患者1例行血肿腔钻孔引流术,4例行侧脑室钻孔引流术,GOS3分的患者2例(40%)；2分的患者1例(20%)；1分的患者2例(40%)。4.术后1月死亡患者(GOS=1分)比较：钻孔组死亡患者57例(35.0%)死因分析：术后再出血死亡14例,术后病情继续进展死亡21例,多脏器功能衰竭死亡22例；开颅组患者28例(38.4%),死因分析：术后再出血死亡6例,术后病情继续进展死亡11例,多脏器功能衰竭死亡11例。两组总体死亡率,不具有统计学差异；基底节区出血、脑叶出血、小脑出血不同出血量间比较都不具有统计学差异；脑干出血死亡2例(40%)。结论快速细孔(微创)钻颅所需器械简单、不需全麻、创伤小、操作快捷：①钻孔组手术时间明显少于开颅组；②钻孔组术后肺部感染及高血糖与水电解质代谢平衡紊乱的发生率低于开颅组；术后颅内感染及再出血的患者与开颅组无差异；③钻孔组基底节区、脑叶及小脑血肿量较小的患者的近期疗效优于开颅组,中大血肿量的患者与开颅组无差异；脑干出血的患者术后1月重残2例(40%)；植物生存1例(20%)；死亡2例(40%)；④钻孔组与开颅组总体死亡率及基底节区出血、脑叶出血、小脑出血不同出血量间比较均无差异。更多还原

【Abstract】 ObjeetiveResearch swift pore (minimally invasive) drilling cranial nerve surgery in Severe Hypertensive Intracerebral Hemorrhage and evaluate its clinical value.MethodsWe analyzed retrospectively clinical data of 236 patients of Severe Hypertensive Intracerebral Hemorrhage (Awareness of the situation after cerebral hemorrhage grade IV-V class, GCS≤9 points) from 2002 to 2009 in Qianfoshan Hospital in Shandong Province. And follow the surgical procedure were divided into groups and craniotomy group drilling, drilling under local anesthesia group rapid pore (minimally invasive) drilling drainage surgery, craniotomy group anesthesia and hematoma evacuation, which groups 163 drilling cases, craniotomy group of 73 patients; before surgery the relevant factors that may affect the efficacy such as gender, age, history of hypertension, hematoma locationand hematoma volume and time from onset to surgery were statistically analyzed; operation time were compared; after 1 day,7 days,14 days,30 days, review head CT evaluation of intracranial cases, evaluation after 1 month Glasgow Outcome Scale GOS, and statistically compare mortality and rebleeding, sugar and electrolyte metabolism disorders, pulmonary infection, intracranial infection and other major complications.Results1. Operation time:drilling group (8.7±3.9) minutes, significantly less than the craniotomy group (136.5±19.6) minutes.2. Comparison of postoperative complications:①drilling group were 55 cases of pulmonary infection (33.7%); craniotomy group of 35 patients (47.9%); drilling group than craniotomy group.②drilling group were high blood sugar metabolism of water and electrolyte balance disorders and 49 cases (30.1%); craniotomy in 31 cases (42.5%); drilling group than craniotomy group.③drilling group were 15 cases of intracranial infection (9.2%),; Craniotomy 6 patients (8.2%),; two groups was not significant difference.④drilling group were 17 patients with rebleeding (10.4%); craniotomy 8 patients (11%); the two groups was not significant difference.3. Comparison of curative effect: 1 month after surgery, the recent efficacy between patients with relatively small hematoma(basal ganglia≤60ml, cerebral lobes≤60ml, cerebellum≤15ml), drilling was better than craniotomy groups. Large hematoma volume(basal ganglia 60-90ml, basal ganglia≥90ml, cerebral lobes 60-90ml, cerebral lobes≥90ml, cerebellum>15ml) in patients with cranial drilling group showed no significant group differences. Brainstem hemorrhage hematoma in patients with a routine cavity drainage hole,4 hole routine lateral drainage, GOS3 points in 2 cases (40%); 2 points 1 case patients (20%); 1 point 2 cases (40%).4. the death of patients after 1 month (GOS= 1):Drilling group 57 patients died (35.0%), the cause of death analysis:14 cases died of postoperative bleeding, disease continues to progress after the death of 21 cases, multiple organ failure in 22 cases of death; craniotomy group of 28 patients (38.4%), the cause of death analysis:6 died of postoperative bleeding, disease continues to progress after the death of 11 cases, multiple organ failure and 11 died. Two overall mortality was not statistically different; basal ganglia hemorrhage, lobar hemorrhage, cerebellar hemorrhage compared with different amount of bleeding is not statistically different between; brain stem hemorrhage and 2 cases died (40%).ConclusionSwift pore (minimally invasive) drilling skull craniotomy drainage method and compared to the required simple equipment, without anesthesia, trauma, operating fast:①drilling operation time was less than craniotomy group;②drilling postoperative pulmonary infection and high blood sugar and water electrolyte metabolism disorder in the incidence of lower cranial group; postoperative intracranial infection and re-bleeding was no difference between patients and craniotomy;③drilling group basal ganglia, cerebral lobes and cerebellar hematoma volume in patients with smaller Recent effective than craniotomy group, large hematoma volume was no difference between patients and craniotomy; brain stem hemorrhage in patients with severe disability after January 2 (40%); plants in 1 (20%); death 2 cases (40%);④drilling group and the craniotomy group overall mortality and basal ganglia hemorrhage, lobar hemorrhage, cerebellar hemorrhage was no different to compare differences in blood loss.更多还原