经纵裂胼胝体入路治疗重型内侧型丘脑出血

Surgical treatment of severe medial thalamic hemorrhage via the interhemispheric transcallosal approach

目的探讨经纵裂胼胝体入路治疗重型内侧型丘脑出血的疗效。方法回顾性分析11例重型内侧型丘脑出血病人的临床资料,均选择经纵裂胼胝体入路清除血肿。入院时格拉斯哥昏迷评分（GCS）4～8分,平均（6.5±1.5）分。丘脑内侧局限血肿2例,血肿量分别为16 ml、20 ml。血肿破入脑室9例,丘脑内血肿量8～35 ml,平均（18.2±9）ml。合并非交通性脑积水6例。结果术后24 h内复查头部CT,血肿均大部分清除。术后3 d平均GCS（8.9±2.9）分。术后3个月格拉斯哥预后评分（GOS）平均（3.6±0.5）分。10例病人随访12个月,平均GOS（4.1±0.9）分。术后出现颅内感染1例,经治疗后得到控制;1例病人遗留缄默症状,4个月后恢复;1例病人出现迟发性脑积水并行腰大池腹腔分流术,无癫疒间发作病例。结论对于重型内侧型丘脑出血,经纵裂胼胝体入路清除血肿是一种可行方法,该入路可在直视下清除丘脑及破入脑室内的血肿,早期缓解占位效应,改善脑脊液循环,减少脑积水发生率,同时明显降低感染率,可望改善病人预后。

Objective To investigate the efficacy of the interhemispheric transcallosal approach for severe medial thalamic hemorrhage（SMTH）. Methods The clinical data of 11 SMTH patients were analyzed retrospectively. The hematoma was evacuated by via the interhemispheric transcallosal approach. The Glasgow Coma Scores（GCS） at admission was 4-8 points, average 6.5±1.5. The hematoma was limited within the thalamus in 2 patients, hematoma volume was 16 and 20 ml respectively. The hematoma ruptured and entered into the ventricle in 9 patients, hematoma volumes within the thalamus were 8-35 ml, with a mean of 18.2±9 ml. Concomitant noncommunicating hydrocephalus was seen in 6 patients. Results Postoperative CT scan revealed that hematoma was subtotally evacuated in all patients within 24 h after operation. The mean GCS was 8.9±2.9 points at 3 days after surgery. The mean Glasgow Outcome Scale（GOS） was 3.6±0.5points at 3 months after surgery. Ten patients were followed up for 12 months, the mean GOS was 4.1±0.9 points. Infection occurred only in 1patient, and was controlled by anti-infection treatment. Mutism occurred in 1 patient and recovered after 4 months. There was one delayed hydrocephalus, which was treated by lumboperitoneal shunt. Postoperative epilepsy was not present. Conclusions The microsurgical hematoma evacuation via the interhemispheric transcallosal approach is a feasible method for SMTH. Through this approach, hematoma located in the thalamus and ventricle can be evacuated simultaneously under direct vision, cerebrospinal fluid circulation can be improved and space-occupying effect can be eliminated at the early stage. The method may reduce the incidence of delayed hydrocephalus and infection, and improve the prognosis.