左侧延髓血管减压术治疗原发性高血压病的疗效研究

Therapeutic effect of left medullary microvascular decompression on primary hypertension

目的探索左侧延髓微血管减压术（MVD）对颅神经疾病、脑出血病人的原发性高血压病的手术疗效。方法26例左侧幕上脑内血肿、2例小脑血肿病人在血肿清除后，再行同侧枕下乙状窦后开颅．并对延髓进行MVD，其中15例病人是急诊手术；4例三叉神经痛、2例听神经瘤、1例三叉神经鞘瘤、1例舌咽神经痛的高血压病人，在完成肿瘤切除、颅神经MVD手术后再行MVD。观察病人的血压以及降血压药物用量和种类的变化。结果术中发现压迫延髓和迷走神经根入脑区（REZ）的责任血管为小脑后下动脉20例，椎动脉主干11例，小脑前下动脉5例；其中接触型14例、压迫型10例、粘连型9例、贯穿型3例。24例高血压病得到治愈、好转10例、2例无效。结论左侧延髓MVD可以有效治疗原发性高血压病。术中仔细探查远离REZ区的血管袢，并解除它们对迷走神经及延髓腹外侧的“琴弦式”牵拉刺激可以提高延髓MVD治疗原发性高血压病的疗效。

Objective To explore the clinical effect of left medullary microvascular decompression （MVD） on primary hypertension complicated by cerebral hematoma and cranial nerve disease. Methods After left cerebral hematomas in 26 patients and cerebellar hematomas in 2 patients were evacuated, left medullary MVD was performed via suboccipital retromastoidal approach. Fifteen of them were operated emergently. Eight hypertensive patients complicated by cranial nerve diseases （4 trigeminal neuralgia, 1 glossopharyngeal neuralgia, 2 acoustic neuroma, 1 trigeminal neuroma） underwent left medullary MVD after the planned cranial nerve MVD and tumor resection. Blood pressure was monitored and the variety and dosage changes of anti-hypertension were recorded. Results Vessel loops that compressed, contacted or transfixed the medulla oblongata and vagus nerve root entry zone （REZ） were found in all patients. The offending vessel loops included posterior inferior cerebellar artery （PICA, n=20）, vertebral artery （VA, n=l 1）, and anterior inferior cerebellar artery （AICA, n=5）. The relationship between the offending vessel loops and medulla oblongata, vagus nerve REZ were divided into four types： Contacting type （n=14）, compressing type （n=10）, adhesion type （n=9） and transfixing type （n=3）. In the 36 patients, 24 hypertension cases （66.7%） were cured, 10 （27.8%） were improved, and 2 （5.5%） did not get better. Conclusions Left medulla oblongata MVD is effective in treating primary hypertension. To explore and settle carefully of the drag stimulation like a string from the vessel loops deviated from the medulla, vagus nerve REZ will improve the effects of medullary MVD for primary hypertension.