立体定向血肿抽吸术治疗幕上高血压脑出血：与保守治疗的比较

Stereotacfic hematoma aspiration for supratentorial hypertensive intracerebral hemorrhage： comparison with conservative treatment

目的 比较立体定向血肿抽吸术与保守治疗对血肿体积25～40 ml的幕上高血压脑出血（hypertensive intracerebral hemorrhage,HICH）的有效性.方法 回顾性纳入2014年1月至2017年1月郑州大学第五附属医院神经外科收治的幕上HICH患者.比较立体定向血肿抽吸组和保守治疗组再出血发生率、转归良好（定义为发病后3个月时改良Rankin量表评分0～2分）率和病死率.结果 共纳入204例患者,平均年龄（61.3±9.2）岁,男性114例（55.9％）,血肿体积中位数32 ml（四分位数间距25～39 ml）,基线格拉斯哥昏迷量表评分中位数11分（四分位数间距9～14分）,无脑疝形成病例.120例（58.8％）行立体定向血肿抽吸术,84例（41.2％）行保守治疗.与保守治疗组相比,立体定向血肿抽吸组再出血发生率显著较低（2.5％ 对22.6％;χ2=20.788,P〈0.001）,发病后3个月时转归良好率显著更高（85.0％ 对70.2％;χ2=8.305,P=0.004）,但病死率无显著差异（5.0％ 对11.9％;χ2=3.259,P=0.071）.多变量logistic回归分析显示,高龄[优势比（odds ratio,OR）1.77,95％ 可信区间（confidence interval,CI）1.25～2.46;P=0.006]、既往卒中史（OR 1.36,95％CI 1.12～1.64;P=0.032）和保守治疗（OR 1.42,95％CI 1.25～1.78;P=0.021）为转归不良的独立危险因素.结论 对于血肿体积25～40 ml的幕上HICH患者,立体定向血肿抽吸能显著降低再出血发生率和转归不良风险,因此应考虑早期积极手术治疗.

Objective To compare the effectiveness of stereotactic hematoma aspiration and conservative treatment for supratentorial hypertensive intracerebral hemorrhage （HICH） with hematoma volume 25-40 ml. Methods Patients with supratentorial HICH admitted to the Department of Neurosurgery, the Fifth Affiliated Hospital of Zhengzhou University from January 2014 to January 2017 were retrospectively enrolled. The incidence of rebleeding, good outcome （defined as the modified Rankin Scale score 0-2 at 3 months after onset） rate, and mortality were compared between the stereotactic hematoma aspiration group and the conservative treatment group. Results A total of 204 patients were enrolled. Their mean age was 61. 3 ±9. 2 years, 114 were males, and their median hematoma volume was 32 ml （interquartile range 25- 39 ml）, median baseline Glasgow Coma Scale score was 11 （interquartile range 9-14）, and there was no patient with brain herniation. One hundred and twenty patients （58. 8%） underwent stereotactic hematoma aspiration and 84 （41. 2%） received conservative treatment. Compared with the conservative treatment group, the incidence of rebleeding in the stereotactic hematoma aspiration group was significantly lower （2. 5% vs. 22. 6%, χ2 =20. 788, P 〈 0. 001）, and the rate of good outcome was significantly higher at 3 months after onset （85. 0% vs. 70. 2%; χ2 = 8. 305, P = 0. 004 ）, but there was no significant difference in mortality （5. 0% vs. 11. 9%, χ2 =3. 259, P =0. 071）. Multivariable logistic regression analysis showed that advanced age （odds ratio [OR] 1. 77, 95% confidence interval [CI] 1. 25-2. 46; P = 0. 006）, previous stroke history （OR 1. 36, 95% CI 1. 12-1. 64; P =0. 032）, and conservative treatment （OR 1. 42, 95% CI 1. 25-1. 78; P = 0. 021） were the independent risk factors for poor outcomes. Conclusions Stereotactic hematoma aspiration can significantly reduce the incidences of rebleeding and risk of the poor outcome in the supratentorial HICH patients with hematoma volume 25-40 ml. Therefore, early active surgical treatment should be considered.