【作者】 马晓伟；

【导师】 王立群；

【作者基本信息】 河北医科大学 ， 外科学， 2012， 硕士

【摘要】 目的：比较颅骨钻孔引流术与开颅手术治疗高血压脑出血(hypertensive intracerebral hemorrhage，HICH)的优缺点及疗效，为临床选用合适手术方式提供依据。方法：回顾性分析2010年至2012年于我院手术治疗的85例高血压脑出血病人的资料，其中采用骨瓣开颅血肿清除术组40例，颅骨钻孔引流术组45例。术前对两组病例的一般特征(性别、年龄)、神经功能缺损程度、血肿量、出血位置、手术时机等进行均衡性比较。按照1995年第四届脑血管病学术会议研究通过的神经功能缺损评分标准，对患者的神经功能缺损情况及病情的轻重进行评估。评分总共45分，缺损越重，患者评分越高，轻型为0至15分，中型为16至30分，重型为31至45分。比较两种手术方法治疗后一个月患者神经功能缺损程度、并发症发生率、病死率、术后再出血发生率、手术时间等指标的差别。结果：1对开颅组及钻孔组患者在年龄、性别、出血部位、出血量、治疗前临床神经功能缺损程度评分、手术时机等一般情况进行均衡性检验没有统计学差异，具有可比性。2手术前后两组组内比较，术后一个月临床神经功能缺损程度评分均较术前有明显降低，有统计学的差异。术后两组间临床神经功能缺损程度，轻型组间比较及中型组间比较，有统计学差异（p<0.05）；重型组间比较，无统计学差异（p>0.05）。钻孔引流术对于改善轻型及中型患者神经功能缺损程度优于开颅手术，但对于重型患者二者没有统计学的差异。3不同出血量手术前后两组组内比较，术后临床神经功能缺损程度评分均较术前有明显降低，有统计学的差异（p<0.05）。术后两组间临床神经功能缺损程度，血肿量≤40ml组间比较及40ml <血肿量≤60ml组间比较，有统计学的差异（p<0.05）；血肿量>60ml组间比较，无统计学的差异（p>0.05）。钻孔引流术对血肿量≤60ml患者，改善神经功能缺损程度优于开颅手术。但对血肿量>60ml患者二者没有统计学的差异。4并发症发生情况比较，开颅组肺部感染发生率35％，消化道出血发生率18％；钻孔组肺部感染发生率18％，消化道出血发生率9％，两组病人并发症发生率有统计学的差异（p<0.05）。5不同手术方法病死率的比较：开颅组病死率20％，钻孔组病死率20％，两组病人病死率无统计学的差异（p>0.05）。6开颅组与钻孔组术后再出血率比较：开颅组术后再出血率5％，钻孔组术后再出血率18％，两组病人再出血发生率有统计学的差异（p<0.05）。7两组平均手术时间、血肿消失时间比较。开颅组平均手术时间为149.7±10.9min，首次血肿清除量约76.1±8.2(％)；钻孔组平均手术时间为36.2±11.3min，首次血肿清除量约39.9±7.6(％)，有统计学的差异（p<0.05）。结论：1开颅手术和钻孔引流术对治疗高血压脑出血有效，术后神经功能缺损程度较术前减轻。2病情分级与疗效紧密相关，术前神经功能缺损程度越重，预后越差。术前神经功能缺损程度为中型组患者预后好于术前重型组，而术前轻型组预后又好于术前中型组。对于术前轻型组和中型组患者，钻孔引流术对于改善神经功能缺损程度优于开颅手术，但对于重型患者二者没有统计学差异。3出血量越大临床神经功能缺损程度越重，手术后患者预后也越差。对于幕上血肿量≤60ml患者，钻孔引流术改善神经功能缺损程度优于开颅手术。但对于幕上血肿量>60ml患者二者没有统计学差异。4开颅手术首次血肿清除量明显多于钻孔引流术，开颅术手术时间长，平均手术时间明显高于钻孔术。开颅手术并发症发生率高于钻孔术。钻孔术再出血发生率高于开颅术。开颅术与钻孔术的患者病死率没有统计学差异。更多还原

【Abstract】 Purpose: To compare the advantages and disadvantages and curative effectof drilling drainage operation and craniotomy in the treatment of HICH,provide the basis evidence for the clinical choice of appropriate surgicalapproach.Methods: Retrospective analysis85cases of HICH patient informationfrom2010to2012in our hospital, bone flap craniotomy group are40cases,skull drilling drainage group45cases. Preoperation, we compared the generalcharacteristics(sex, age), the degree of neurological deficits, the amount ofbleeding, the bleeding site, and the opportunity of surgery about the twogroups. According the evaluation standard in the fourth academic conferenceon cerebral vascular disease, evaluate patients’ situation of neurologicalimpairment and the severity of the disease. There is a total of45scores. Theheavier impairment is, the higher scores are. Light degree is0-15scores.Middle degree is16-30scores.Serious degree is31-45scores. The factors ofneurological impairment, complication incidence, fatality rate, rebleedingrate，operation time between the two groups after treatment for one monthwere compared.Results：1There were no statistical differences between the two groups in thefollowing factors，including age,general characteristics，the bleeding site, theamount of bleeding, degree of neurological deficits before treatment and thetiming of surgery.2One month after operation, the scores of neurological impairment degree inboth groups are lower than preoperation. p<0.05, There was statisticaldifference. Comparision the neurological impairment between craniotomy anddrilling drainage after operation, p<0.05in light degree group and middle degree group,.There was statistical difference. And the neurologicalimpairment between craniotomy and drilling drainage after operation, p>0.05.There was no statistical difference. Drilling drainage operation is moreeffective for improving the degree of neurological deficits for light degreepatients and middle degree patients. But there was no statistical difference inthe treatment of severe degree patients.3The scores of neurological impairment degree after surgery in both groupsare lower than preoperation in different amount of bleeding. p<0.05, Therewas statistical difference. After operation, the degree of neurologicalimpairment between craniotomy and drilling drainage has statistical difference,both in hematoma volume less than40ml group and between40to60ml group.p<0.05. But in hematoma volume more than60ml group, p>0.05, There wasno statistical difference. Drilling drainage operation is more effective forimproving the degree of neurological deficits for the patients whose hematomavolume was less than60ml. There was no statistical difference in treatmentfor the patients whose hematoma volume was more than60ml.4There was statistical difference between the two groups in the incidence ofpulmonary infection and gastrointestinal bleeding during hospital.For thepulmonary infection, drilling drainage operation group is18%，craniotomygroup is35%. And for the gastrointestinal,drilling drainage operation group is9%，craniotomy group is18%.5There was no statistical difference between the two groups in the fatality rateduring hospital，Drilling drainage operation group is20%，craniotomy groupis20%.6There was statistical difference between the two groups in the rebleedingrate during hospital. Drilling drainage operation group is18%，craniotomygroup is5%.7The average operation time of drilling drainage operation group is36.2±11.3min，and for craniotomy group,it’s149.7±10.9min. There was statisticaldifference between two groups. The first volume of hematoma in drillingdrainage operation group is39.9±7.6(％)，which in craniotomy group is 76.1±8.2(％).There was statistical difference between two groups.Conclutions:1Craniotomy and drilling drainage are effective in treating HICH. The degreeof neurologic impairment after surgery is lower than preoperation.2Disease classification is closely related to efficacy. Clinical neurologicaldeficit is more severe, the prognosis is worse. The patients who are in middledegree group preoperative have a better prognosis than serious degree group.And light degree group are better than middle group. For the patients who isbelong to light degree group or middle group, drilling drainage is moreeffective for improving the degree of neurological deficits. But there was nostatistical difference in treatment of severe patients.3The amount of bleeding is more great, the clinical neurological deficit ismore severe. The prognosis of patients after surgery is worse. The patientswhose hematoma volume was less than60ml, drilling drainage is moreeffective for improving the degree of neurological deficits. There was nostatistical difference in treatment for the patients whose hematoma volumewas more than60ml.4Craniotomy can remove more hematoma than drilling drainage operation forthe first time. The average time of craniotomy was longer than drillingdrainage operation. The complication rate of Craniotomy is higher than thedrilling drainage operation. The rebleeding rate of Craniotomy was higherthan drilling technique. There was no statistical difference in fatality rate.更多还原