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Clinical efficacy of minimally invasive surgery for hypertensive cerebral hemorrhage in basal ganglia
Wu Shiqiang, Luo Anlin, Fang Ting, Guan Huidong, Li Wentian
JOURNAL OF NEW MEDICINE ›› 2020, Vol. 51 ›› Issue (11) : 861-865.
PDF(1165 KB)
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Clinical efficacy of minimally invasive surgery for hypertensive cerebral hemorrhage in basal ganglia
Objective To evaluate the application value of minimally invasive surgery in the treatment of hypertensive cerebral hemorrhage in the basal ganglia. Methods Clinical data of 90 patients with hypertensive cerebral hemorrhage in the basal ganglia undergoing surgery were retrospectively analyzed. According to different surgical methods, all patients were divided into the control group （traditional bone flap craniotomy, n = 15）, group A （stereotactic hematoma drainage, n = 45） and group B （small bone window craniotomy, n = 30）. Surgical efficacy, improvement of nerve function, postoperative complications and rebleeding rate were statistically compared among three groups. Results The clinical efficacy of three surgeries did not significantly differ （P > 0.05）. Preoperative NIHSS scores did not significantly differ among three groups （P > 0.05）. At postoperative 7, 14 and 28 d, the NIHSS scores in the group A and group B were significantly lower than those in the control group （all P < 0.05）. The total incidence of postoperative complications and rebleeding rate significantly differed among three groups （both P < 0.05）. The incidence of postoperative complications in group A was significantly lower than that in group B, and the rebleeding rate was remarkably lower compared with that in the control group （both P < 0.017）. Conclusions Compared with traditional surgery, minimally invasive surgery can achieve equivalent clinical efficacy, improve the nerve function and lower the risk of postoperative complications and rebleeding rate in patients with hypertensive cerebral hemorrhage in the basal ganglia. Compared with small bone window craniotomy, stereotactic hematoma drainage can yield higher safety.
Hypertension / Basal ganglia hemorrhage / Minimally invasive / Stereotactic hematoma drainage / Small bone window craniotomy / Rebleeding {{custom_keyword}} /
表1 3组高血压基底节区脑出血患者的一般资料比较 |
| 组 别 | 例数 | 性别构成[例（%）] | 年龄（岁） | 发病至救治时间（h） | 血肿量（ml） | |
|---|---|---|---|---|---|---|
| 男 | 女 | |||||
| 观察A组 | 45 | 24（53） | 21（47） | 57.02±6.34 | 3.20±0.41 | 48.33±5.24 |
| 观察B组 | 30 | 15（50） | 15（50） | 56.89±6.52 | 3.12±0.38 | 48.17±5.32 |
| 对照组 | 15 | 7（47） | 8（53） | 56.94±6.47 | 3.18±0.45 | 48.76±5.65 |
| χ2/F值 | 0.222 | 0.004 | 0.353 | 0.062 | ||
| P值 | 0.895 | 0.996 | 0.704 | 0.940 | ||
表2 3组高血压基底节区脑出血患者手术的临床治疗效果比较[例（%）] |
| 组 别 | 例数 | 痊愈 | 显效 | 有效 | 无效 |
|---|---|---|---|---|---|
| 观察A组 | 45 | 13（29） | 17（38） | 12（27） | 3（7） |
| 观察B组 | 30 | 8（27） | 16（53） | 3（10） | 3（10） |
| 对照组 | 15 | 3（20） | 5（33） | 3（20） | 4（27） |
表3 3组高血压基底节区脑出血患者术后NIHSS评分比较（ |
| 时 间 | 观察A组 （45例） | 观察B组 （30例） | 对照组 （15例） |
|---|---|---|---|
| 术前 | 15.13±2.25ab | 15.10±2.32b | 15.07±2.23 |
| 术后7 d | 10.19±1.87ab | 10.20±1.65b | 13.31±1.85 |
| 术后14 d | 7.74±1.35ab | 7.92±1.37b | 10.33±1.64 |
| 术后28 d | 4.90±0.86ab | 4.98±0.75b | 7.15±0.92 |
| 注：与观察B组比较,aP < 0.05;与对照组比较,bP < 0.05 |
表4 3组高血压基底节区脑出血患者术后并发症及再出血情况比较[例（%）] |
| 组 别 | 例数 | 电解质紊乱 | 脑血管痉挛 | 脑积水 | 颅内感染 | 总发生 | 再出血 |
|---|---|---|---|---|---|---|---|
| 观察A组 | 45 | 1（2） | 2（4） | 0（0） | 0（0） | 3（7）a | 2（4）b |
| 观察B组 | 30 | 3（10） | 2（7） | 2（7） | 1（3） | 8（27） | 6（20） |
| 对照组 | 15 | 1（7） | 1（7） | 0（0） | 2（13） | 4（27） | 4（27） |
| χ2值 | 6.480 | 6.538 | |||||
| P值 | 0.039 | 0.038 |
| 注：与观察B组比较,aP < 0.017;与对照组比较,bP < 0.017 |
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周达全, 彭鹏, 胡克琦, 王志勇, 王旭, 陈锋. 经颞部和额部入路微创钻孔引流治疗中等量基底节区高血压性脑出血临床对比. 中国临床研究, 2017,30(6):798-800.
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Hematoma expansion (HE) is an independent predictor of poor outcome and secondary neurological deterioration in intracerebral hemorrhage (ICH) and is associated with high morbidity and mortality. Noncontrast computed tomography (NCCT) may identify the sites of active extravasation. Therefore, we have attempted to (1) devise a reliable and easy-to-use prediction score to predict the risk of HE in ICH and (2) validate the accuracy of this grading system and perform an independent analysis of HE predictors. We included patients in whom an intracerebral hemorrhage (ICH) occurred in the basal ganglia between Jan. 2015 and Jan. 2018. These patients had undergone a baseline CT scan at Qinghai Provincial People's Hospital within 24 hours after the onset of ICH symptoms. Two observers independently assessed the presence of the island sign, blend sign, or swirl sign on an NCCT scan during patient selection. Patients underwent a baseline NCCT scan and 24-hour NCCT follow-up for analysis of HE. The accuracy of this grading system was assessed. Independent predictors of HE were identified using multivariable regression. Of 266 patients with ICH, 61 (22.93%) presented with the island sign, 63 (23.68%) presented with the blend sign, and 50 (18.80%) presented with the swirl sign. The overall incidence of HE was 37.22% (99/266). Of 125 patients (46.99%) who underwent a baseline CT scan within 6 hours of onset, 141 (53.01%) underwent a scan in 6-24 hours. Multivariable logistic regression analysis identified the hematoma volume (OR, 0.974; P = 0.042), intraventricular hemorrhage (IVH) extension (OR, 3.225; P = 0.003), time from onset to the baseline CT scan (OR, 0.986; P < 0.001="" and="" anticoagulant="" use="" or="" an="" international="" normalized="" ratio="" inr=""> 1.5 (OR, 3.362; P = 0.006) as closely associated with HE. In conclusion, the grading system demonstrated reliable accuracy at predicting HE. The grading system demonstrated acceptable accuracy in an independent single-institution study. The role of the grading system in predicting HE and poor outcome in patients with ICH is significant. NCCT imaging markers may serve as key markers for HE prediction.
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刘万荣, 魏忠, 方有利, 王辉, 郭中国, 焦健, 彭燕, 吕东. 传统骨瓣开颅血肿清除术与小骨窗入路血肿清除术治疗基底节区高血压脑出血的临床疗效对比观察. 安徽医药, 2017,21(10):1844-1846.
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谭支强. CT引导立体定向血肿抽吸术与保守治疗对基底节区高血压性脑出血患者的临床疗效分析. 实用临床医药杂志, 2017,21(5):113-114.
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李晖, 戴孝森, 侯德文, 王进昆. 早期微孔手术治疗中小量基底节脑出血后脑水肿的疗效及对血清炎性因子的影响. 实用临床医药杂志, 2017,21(1):65-67.
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刘文祥. 微创穿刺术与大骨瓣开颅术对老年高血压基底节区脑出血患者的临床疗效对比探究. 中国地方病防治杂志, 2017,32(11):1311-1311.
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王为文, 张伟, 闫忠军. 小骨窗微创手术治疗急性基底节区高血压脑出血疗效分析. 临床军医杂志, 2017,45(12):1226-1229,1232.
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张军, 吕建光, 廖启伟, 冯达云, 李玉骞, 李少鹏. 神经内窥镜与穿刺引流术治疗基底节区自发性高血压脑出血的临床疗效对比. 山西医科大学学报, 2017,48(3):283-286.
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崔永华, 夏咏本, 虞正权. 高血压性基底节区脑出血的CT分型及手术策略. 中国现代医学杂志, 2017,27(3):139-141.
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This study investigated the clinical value of performing microsurgical treatment on hypertensive basal ganglia hemorrhage assisted by intraoperative ultrasound localization (IUL). A total of 107 patients with hypertensive basal ganglia hemorrhage were randomly separated into two groups for this controlled clinical trial. In the IUL group, 51 patients with hypertensive basal ganglia hemorrhage were operated on with the support of ultrasonic imaging; 56 patients underwent conventional microsurgery to evacuate the hemorrhage. The results of the two methods were evaluated according to the rate of hematoma evacuation, re-hemorrhage, mortality, complications, and activities of daily living (ADL). A greater quantity of the hemorrhage was removed from patients in the IUL group, with over 90% of masses being eliminated from the brain in 78.43% of these patients (40 out of 51 patients) compared with 60.71% of patients in the control group (34 out of 56 patients). The IUL group experienced a lower rate of re-hemorrhage after the operation (7.84%, 4 out of 51 patients) compared with the control group (17.86%, 10 out of 56 patients). A significant difference in the ADL score was recorded between the two groups, with ADL scores of the IUL group exceeding 60 (indicating good recovery) at 6 months after the operative procedure (P < 0.05.="" in="" conclusion="" the="" microsurgical="" treatment="" of="" hypertensive="" basal="" ganglia="" hemorrhage="" assisted="" by="" iul="" improved="" the="" precision="" of="" the="" operation.="" this="" procedure="" removed="" the="" hemorrhage="" and="" reduced="" the="" changes="" of="" re-occurrence="" as="" well="" as="" elevated="" the="" quality="" of="" life="" of="" patients="" after="" the="" operation.="">
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OBJECTIVE: Decompressive hemicraniectomy (DC) and duroplasty after malignant brain infarction or traumatic brain injury is a common surgical procedure. Usually, preserved bone flaps are being reimplanted after resolution of brain swelling. Alloplast cranioplasties are seldom directly implanted due to the risk of wound healing disorders. While numerous studies deal with DC, little is known about the encountered problems of bone flap reimplantation. Thus, aim of the study was to identify surgery-associated complications after bone flap reimplantation. METHODS: We performed a retrospective chart analysis of patients that underwent DC and subsequent bone flap reimplantation between 2001 and 2011 at our institution. We registered demographic data, initial clinical diagnosis and surgery-associated complications. RESULTS: We identified 136 patients that underwent DC and subsequent reimplantation. Forty-one patients (30.1%) had early or late surgery-associated complications after bone flap reimplantation. Most often, bone flap resorption and postoperative wound infections were the underlying causes (73%, n=30/41). Multivariate analysis identified age (p=0.045; OR=16.30), GOS prior to cranioplasty (p=0.03; OR=2.38) and nicotine abuse as a prognostic factor for surgery-associated complications (p=0.043; OR=4.02). Furthermore, patients with early cranioplasty had a better functional outcome than patients with late cranioplasty (p<0.05). conclusions:="" almost="" of="" the="" patients="" that="" are="" operated="" for="" bone="" flap="" reimplantation="" after="" dc="" suffer="" from="" surgery-associated="" complications.="" most="" often="" wound="" healing="" disorders="" as="" well="" as="" bone="" flap="" resorption="" lead="" to="" a="" second="" or="" even="" third="" operation="" with="" the="" need="" for="" artificial="" bone="" implantation.="" these="" results="" might="" raise="" the="" question="" if="" subsequent="" operations="" can="" be="" avoided="" if="" an="" artificial="" bone="" is="" initially="" chosen="" for="" cranioplasty.="">
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Background: Cerebral hyperperfusion after carotid endarterectomy (CEA), even when asymptomatic, often impairs cognitive function. However, conventional magnetic resonance (MR) imaging rarely demonstrates structural brain damage associated with postoperative cognitive impairment. MR diffusion tensor imaging (DTI) is potentially more sensitive for detection of white matter damage. Among the common parameters derived by DTI, fractional anisotropy (FA) is a marker of tract integrity, and mechanical disruption of axonal cylinders and loss of continuity of myelin sheaths may be responsible for reduced FA in white matter. The purpose of the present study was to determine whether postoperative cerebral white matter damage that can be detected by FA derived by DTI is associated with cerebral hyperperfusion after CEA and correlates with postoperative cognitive impairment. Methods: In 70 patients undergoing CEA for ipsilateral internal carotid artery stenosis (>= 70%), cerebral blood flow (CBF) was measured using single-photon emission computed tomography (SPECT) before and immediately after CEA and on postoperative day 3. FA values in cerebral white matter were assessed using DTI before and 1 month after surgery. These values were normalized and analyzed using statistical parametric mapping 5. In each corresponding voxel in the pre- and postoperative normalized FA maps of each patient, a postoperative FA value minus a preoperative FA value was calculated, and a voxel with postoperatively reduced FA was defined based on data obtained from healthy volunteers. The number of voxels with postoperatively reduced FA was calculated and defined as the volume with postoperatively reduced FA. Neuropsychological testing, consisting of the Wechsler Adult Intelligence Scale Revised, the Wechsler Memory Scale and the Rey-Osterreith Complex Figure test, was also performed preoperatively and after the first postoperative month. Postoperative cognitive impairment on neuropsychological testing in each patient was defined based on data obtained from patients with asymptomatic unruptured cerebral aneurysms. Results: Post-CEA hyperperfusion on brain perfusion SPECT (CBF increase >= 100% compared with preoperative values) and postoperative cognitive impairment on neuropsychological testing were observed in 11 (16%) and 9 patients (13%), respectively. The volume with postoperatively reduced FA in cerebral white matter ipsilateral to surgery was significantly greater in patients with post-CEA hyperperfusion than in those without (p < 0.0001.="" this="" volume="" in="" cerebral="" white="" matter="" ipsilateral="" to="" surgery="" was="" also="" significantly="" associated="" with="" postoperative="" cognitive="" impairment="" 95="" confidence="" interval="" 1.559-8.853="" p="0.0085)." conclusions:="" cerebral="" hyperperfusion="" after="" cea="" results="" in="" postoperative="" cerebral="" white="" matter="" damage="" that="" correlates="" with="" postoperative="" cognitive="" impairment.="" copyright="" c="" 2012="" s.="" karger="" ag="" basel="">
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PURPOSE: Blood-brain barrier (BBB) damage aggravates perihematomal edema, and edema volume predicts prognosis independently. But the BBB permeability at the late stage of acute intracerebral hemorrhage (ICH) patients is uncertain. We aimed to assess the BBB permeability of spontaneous basal ganglia ICH using computed tomographic perfusion (CTP) and investigates its relationship with hematoma and perihematomal edema volume. METHODS: We performed CTP on 54 consecutive ICH patients within 24 to 72 h after symptom onset. Permeability-surface area product (PS) derived from CTP imaging was measured in hematoma,
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孙红星, 闫忠军, 韩繁龙, 曹宁, 张国来. 传统开颅手术、显微镜下微创手术治疗基底节区高血压脑出血的临床疗效分析. 现代生物医学进展, 2017,17(28):5497-5500.
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PDF(1165 KB)
表1 3组高血压基底节区脑出血患者的一般资料比较表2 3组高血压基底节区脑出血患者手术的临床治疗效果比较[例（%）]表3 3组高血压基底节区脑出血患者术后NIHSS评分比较（表4 3组高血压基底节区脑出血患者术后并发症及再出血情况比较[例（%）]/
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