幕上高血压脑出血患者不同手术方式的临床疗效比较

doi:10.13481/j.1671-587x.20190333

摘要/Abstract

摘要： 目的：探讨颞叶皮层入路、沟裂显微手术和钻孔引流术治疗幕上高血压脑出血（SHICH）患者的安全性及疗效，为选择SHICH手术方式提供参考。方法：收集118例SHICH患者临床资料，按手术方式不同分为颞叶皮层组（皮层组，39例），沟裂显微手术组（沟裂组，31例）和钻孔引流组（钻孔组，48例）。记录3组患者年龄、血肿量、哥拉斯哥昏迷评分（GCS）、发病至手术开始的时间、血肿清除率、术后24h病情好转率、术后再出血率、颅内感染率、生存率和预后良好率。结果：沟裂组患者血肿清除率、术后24 h病情好转率、生存率和预后良好率明显高于皮层组（P<0.05）。3组患者发病至手术开始时间、术后再出血率和颅内感染率比较差异无统计学意义（P>0.05）。沟裂组和钻孔组中血肿量30~49 mL和50~69 mL亚组患者预后指标（血肿量、GCS评分、生存率和预后良好率）比较差异无统计学意义（P>0.05），但钻孔组血肿量50~69 mL亚组患者年龄明显高于沟裂组（P<0.05）。结论：经沟裂显微手术和钻孔引流术治疗SHICH患者的手术效果和预后好于颞叶皮层入路，对高龄、中等量以上脑出血患者更宜适时行钻孔引流术；大量血肿患者可采用沟裂显微手术。

关键词: 幕上高血压脑出血, 颞叶皮层入路, 沟裂显微手术, 侧裂, 顶间沟, 钻孔引流

Abstract: Objective:To explore the safeties and efficacies of temporal cortex approach, transsulcus or fissure microsurgery and drilling drainage in the treatment of the patients with supratentorial hypertensive intracerebral hemorrhage (SHICH),and to provide the references for choosing the operation methods for the SHICH patients. Methods:The clinical materials of 118 patients with SHICH were collected and were divided into temporal cortex approach group (cortex group,n=39), transsulcus or fissure microsurgery group (fissure group,n=31) and drilling drainage group (drilling group,n=48) according to their different operation methods. The age, hematoma volumes, Glasgow Coma Scale Score(GCS), time from onset to operation, hematoma clearance rates,improvement rates 24 h after operation, rebleeding rates after operation, intracranial infection rates, survival rates,and good prognosis rates of the patients in three groups were recorded. Results:The hematoma clearance rate, improvement rate, survival rate and good prognosis rate of the patients in fissure group were significantly higher than those in cortex group (P<0.05). There were no statistical differences in the time from onset to operation, rebleeding rates after operation and intracranial infection rates among the patients in three groups (P>0.05). There were no statistically significant differences in the prognosis indexes(hematoma,GCS,survival rate,and good prognosis rate) of the patients between 30-49 mL and 50-69 mL subgroups in fissure group and drilling group. The age of patients in 50-69 mL subgroup in drilling group was significantly higher than that in fissure group(P<0.05). Conclusion:The efficacies and prognosis of SHICH patients treated by transsulcus or fissure microsurgery and drilling drainage are better than those by temporal cortex approach.Drilling drainage is more suitable to the old patients with above moderate hematoma; and transsulcus or fissure microsurgery is more suitable to the patients with massive hematoma.

Key words: supratentorial hypertensive intracerebral hemorrhage, temporal coxtexapproach, transsulcus of fissure microsurgery, sylvian fissure, interparietal fissure, drilling drainage

中图分类号:

R651.1

王芃, 李挪, 黄山, 李铁男, 郎晓峰, 刘伟. 幕上高血压脑出血患者不同手术方式的临床疗效比较[J]. 吉林大学学报(医学版), 2019, 45(03): 667-672.

WANG Peng, LI Nuo, HUANG Shan, LI Tienan, LANG Xiaofeng, LIU Wei. Comparison of clinical effects of different surgical methods in patients with supratentorial hypertensive intracerebral hemorrhage[J]. Journal of Jilin University(Medicine Edition), 2019, 45(03): 667-672.

参考文献

[1] KAYA R A, TÜRKMENOGLU O, ZIYAL I M, et al. The effects on prognosis of surgical treatment of hypertensive putaminal hematomas through transsylvian transinsular approach[J].Surg Neurol,2003,59(3):176-183.
[2] 夏永利.大骨瓣减压及小骨窗开颅骨瓣复位治疗高血压性幕上脑出血的疗效比较[J].基层医学论坛,2018,22(19):2625-2627.
[3] 文戴华,易丹.幕上高血压性脑出血个体化手术治疗[J].中国临床神经外科杂志,2017,22(10):709-710.
[4] 黄赛,姜洪,邓忠勇.微创清除术与传统开颅手术治疗高血压脑出血患者的对比研究[J].中国实用神经疾病杂志,2016,19(8):67-68.
[5] WANG Z F, LIU F, LIAO D G,et al. Endoscopic surgery for hypertensive cerebral hemorrhage[J]. J Central South Univers Med Sci,2005,30(4):424-426.
[6] 伍学斌,康强,李敏,等.3D-Slicer联合sina软件辅助神经内镜微创手术治疗高血压脑出血的疗效观察[J].中国脑血管病杂志,2018,15(3):134-139.
[7] 郝铮,刘楠,王路,等.立体定向与简易定位颅内置管治疗中等量高血压脑出血患者临床效果比较[J].吉林大学学报:医学版,2017,43(1):130-134.
[8] 中华医学会第四届全国脑血管病学术会议组.各项脑血管病诊断要点[J].中华神经内科杂志,1996,29(6):379.
[9] 刘江峰,刘振锋,白凯,等.不同术式对高血压脑出血患者术后脑水肿的影响[J].中国实用神经疾病杂志,2014,17(14):22-23.
[10] 党帅.比较三种不同手术方式对基底节脑出血患者长期神经功能及颅内感染的影响[J].国际神经病学神经外科学杂志,2016,43(6):526-530.
[11] 邵鸿飞,杨维明,曹英肖,等.不同手术方式治疗高血压脑出血的临床对比[J].中国老年学杂志,2015,35(1):41-43.
[12] 曾冉,王飞红,袁邦清,等.高血压脑出血不同手术方式及手术时机的比较[J].广东医学,2016,37(3):393-396.
[13] 赵继宗,周定标,周良辅,等. 2464例高血压脑出血外科治疗多中心单盲研究[J]. 中华医学杂志,2005,85(32):2238-2242.
[14] 司雨,王振宇.高血压脑出血超早期患者手术方式和术后再出血的关系[J].中华老年心脑血管病杂志,2012,14(7):740-742.
[15] 陈东辉,程宏伟.高血压脑出血术后再出血的多因素分析[J].安徽医科大学学报,2015,50(6):873-875.
[16] 孙昭胜,赵旺森,葛春燕,等.开颅血肿清除术和钻孔引流术治疗中等量基底核区高血压脑出血的临床疗效比较研究[J].中国全科医学,2018,21(6):702-706.
[17] 陈清坤.传统开颅手术与钻孔引流术治疗高血压脑出血后颅内压变化的对比观察[J].临床合理用药,2017,10(11A):125-126.
[18] 穆林森,宋述清,单强,等.基底节-丘脑区高血压脑出血的显微手术治疗[J].中华神经外科杂志,2009,25(11):1002-1004.
[19] 黄永凯, 包正军,韩德清,等.优势侧基底节区脑出血手术入路的选择[J].中国现代医学杂志,2017,27(5):59-62.
[20] 唐勇, 樊友武,王汉东,等.侧脑室三角区脑膜瘤的显微外科治疗分析[J].医学研究生学报,2018,31(1):52-55.
[21] 孙建平,王峰,谷晓玉,等.开颅患者术后颅内感染的病原学特点及影响因素分析[J].中华医院感染学杂志,2018,28(2):218-221.
[22] 朱宏伟,刘希尧,谭国伟,等.1033例神经外科择期手术感染分析[J].中华医院感染学杂志,2016,26(22):5153-5155.