神经内镜通道内技术治疗重度脑室内出血的研究

Neuroendoscopic channel interior technique treats severe intraventricular hemorrhage

目的探讨神经内镜通道内技术在治疗重度脑室内出血（IVH）疾病中的应用价值、技术要点及手术体会。方法回顾性分析2013—07～2016—01符合纳入标准的32例神经内镜通道内技术治疗重度IVH病例的临床资料：其中全脑室系统积血铸型病例11例，双侧侧脑室、三脑室积血病例9例，单侧侧脑室、三脑室及四脑室积血病例7例，单侧侧脑室、三脑室积血病例5例；术前均行脑CT／CTA确定诊断，术前血肿体积（75．6＋_12．5）mL，Graeb评分6—12分，GCS评分5～12分。所有患者均采用神经内镜通道内技术清除脑室内血肿，伴有四脑室内积血病例行腰大池外引流术；记录并比较手术前后患者的IVH体积、Graeb评分、GCS评分，术中指标、引流管拔除时间、堵管例数、ICU住院天数、并发症以及随访3个月时的GOS评分等。结果神经内镜通道内技术术后即时CT显示侧脑室及三脑室内积血几乎完全清除，存在四脑室内积血患者经腰大池引流后平均血肿清除时间2—4d。术后伤口脑脊液漏4例，颅内感染2例，颅内积气8例，无二次出血及堵管病例，EVD管拔除时间2—3d，腰大池外引流管拔除时间3～4d，ICU住院天数4—6d。头皮切口均采用3cm基底小弧形皮瓣，骨孔直径0．8～1．0cm，术中平均失血量30mL（20—50mL），平均手术时间65min（45—110min）。术后随访3个月GOS评分：恢复良好21例，轻度残疾6例，重度残疾5例，无死亡病例。结论神经内镜通道内技术清除脑室内血肿仅需在颅骨上钻孔即可完成手术，具有操作方便、损伤小、血肿清除率高、恢复快、并发症少等优点。技术要点：常规侧脑室额角穿刺，充分发挥透明导管鞘和血肿碎吸器的作用；侧脑室和三脑室内血肿清除吸引器采用不同压力，侧脑室内血肿以吸除／碎吸为主，三脑室内血肿要以低负压拖拉出室间孔后再调高负压吸引清除，三脑室内操作要避免损伤和刺激下丘脑，在安全准确的情况下尽量多清除血肿。

Objective To explore the application value, technical key points and operation experience of neuroendoscopic channel interior technique in the treatment of severe intraventricular hemorrhage. Methods Thirty-two cases with severe intraventricular hemorrhage （IVH） treated by neuroendoscopic channel interior technique were analyzed and the patients were from Emergency Department of Shenzhen People＇s Hospital and Neurosurgery Department of Nanfang Hospital from July 2013 to January 2016. The research cases included 11 cases with total IVH, 9 cases with bilateral ventricular and third ventricle hematoma, 7 cases with unilateral lateral ventricle, the third ventricle and the fourth ventricle hematoma, 5 cases with unilateral lateral ventricle and the third ventricle hematoma. CT/CTA scans were done before operations. The average hematoma volume was （75.6_＋ 12.5） mL; Graeb score was 6 ~ 12, Glasgow coma score （GCS） was 5 ~ 12. All patients were received neuroendoscopic channel interior technique treatment and some patients with fourth ventricle hematoma received external drainage of lumbar cistern additionally. Record and compare the diameters before and after operation, such as IVH volume, Graeb score, GCS score, etc. Results CT scans showed that the lateral ventricle and the third ventricle were almost completely removed after neuroendoscopic channel interior tech- nique operation immediately and the average hematoma clearance time of the fourth ventricle was 2 - 4 days after the lumbar cistern drainage. There were 4 cases occurred cerebrospinal fluid leakage, 2 cases got intracranial infection and 8 cases had pneumocrania. Fortunately, no rebleeding and drainage tube blocking cases found in this study. We recorded that the time of removing ventricular drainage tubes was 2 - 3 days, the tube removing time of lumbar cistern drainage was 3 ~ 4 days and the ICU staying time was 4 ~ 6 days. A 3 cm base small arc skin flap and a 0.8 to 1.1 cm bone window were needed during the operation. The intraoperative blood loss was 20 to 50 mL with a mean of 30 mL and the operation time was 45 to 110 minutes with a mean of 65 minutes. The Glasgow outcome scale （ GOS ） score 3 months after the operation revealed： 21 patients recovered well, 6 cases had mild disability, 5 cases had severe disability and no died cases. Conclusion Neuroendoscopic channel interior technique treats severe ven- tricular hemorrhage just need one skull hole can complete the operation and practicing processing proved excellent performance of convenient operation, small trauma, quick recovery and little complications. Technical points： the puncture position is located in the lateral ventricle frontal horn and make full use of the transparent sheath and hematoma smashing suction apparatus. The negative suction pressure is different between the lateral ventricles and the third ventricle. Using suction/broken suction to clear lateral ventricle＇s hematoma, and to the hematoma in the third ventricle, firstly, using low negative pressure to drag the hematoma out of interventricular foramen and then using relatively higher negative pressure to remove. The operation in the third ventricle should avoid damage/stimulate the hypothalamus and the hematoma should be removed as much as possible under safety.