脑功能区慢性扩展性脑内血肿的立体定向手术及文献复习

Chronic expanding intracerebral hematoma in the eloquent region: stereotactic surgery and review of literature

目的探讨脑功能区或位置较深的慢性扩展性脑内血肿立体定向手术治疗的可行性。方法回顾2例慢性扩展性脑内血肿患者的临床资料,分析其流行病学特点、发病机制、影像学特点、诊断与鉴别诊断特点、治疗原则及预后。结果2例患者发病年龄分别为76岁和69岁,病程1个月和6个月;例1病变位于右侧额顶叶运动功能区,例2病变位于右侧丘脑及右侧大脑脚。临床症状以颅内高压及局灶性神经功能损害为主。CT平扫显示脑实质内囊性占位性病变,伴病灶周围水肿,呈低密度或稍低密度影,较脑脊液密度高;慢性基础上急性出血者可呈分层状液平,包膜呈等或稍高密度环,周围可有水肿存在;增强扫描包膜呈均匀一致性环状强化,其内液体无强化。MRI检查T1WI显示囊内呈高信号的亚急性或慢性积血,如有分层现象则可明确诊断。2例均行立体定向手术引流,1例痊愈,1例于3个月后复发,再次行立体定向手术后痊愈。结论慢性扩展性脑内血肿起病隐匿,症状呈进行性加重,临床表现为颅内高压及局灶性神经功能损害,头部CT和MRI表现为主要诊断依据。手术切除血肿疗效良好,脑非功能区者首选开颅手术;脑功能区或位置较深的慢性病变者则以立体定向手术为宜。

Objective To discuss the feasibility of stereotactic surgery for chronic expanding intracerebral hematoma （CEICH） in the eloquent region. Methods Clinical data of 2 CEICH cases treated with stereotactic surgery were reviewed. The epidemiological features, pathogenesis, imaging characteristics, diagnosis and differential diagnosis, treatment and prognosis were analysed. Results Two CEICH patients （76 and 69 years old） were reported. The course of CEICH was one month and 6 months respectively. In case 1 the lesion located at the motor area of right frontoparietal lobe. In case 2 the lesion located at right thalamus and right cerebral peduncle. Intracranial hypertension and focal nervous function damage were the major symptoms. Computed tomography （CT） showed parenchymatous cystic space occupying lesion with edema around the focus. Low or slightly low density was seen, but it was higher than that of cerebrospinal fluid. On the base of chronic stage, acute hemorrhage could present a stratified image. The capsule presented isodensity or slightly high density ring and edema could be seen around it. On contrast-enhanced CT scanning, the capsule presented homogeneous ring-shaped enhancement. Liquid in the capsule showed no enhancement. MRI exhibited high signal of subacute or chronic hematocele on T1-weighted images. It could be definitely diagnosed by stratified image. Two patients were all operated with stereotactic surgical drainage. One patient recovered. Another one, recurred 3 months later and received the second stereotactic surgery, and also recovered. Conclusion The onset of CEICH is latent but the symptoms aggravate progressively. The clinical presentations are intracranial hypertension and focal nervous function damage. Findings on brain CT and MRI are the main diagnostic evidences. Craniotomy surgery is the first choice for treating CEICH in the non-eloquent region. The efficancy of hematoma resection is good. CEICH in the eloquent region should be treated by stereotactic surgery.