颅内血肿微创抽吸引流术联合rt-PA治疗自发性脑出血的初步观察

Preliminary Study of Minimally Invasive Intracranial Hematoma Evacuation Surgery Combined with rt-PA in Patients with Spontaneous Intracerebral Hemorrhage

目的:评估颅内血肿微创抽吸引流术(微创术)联合重组组织型纤溶酶原激活剂(rt-PA)治疗自发性脑出血的可行性和可能的rt-PA用药方案。方法:回顾性分析接受微创术联合rt-PA治疗的脑出血患者。容量分析方法计算血肿体积和灶周水肿体积,改良的Rankin量表(m RS)评估预后(m RS 0~3 v.s.4~5),并比较30 d的实际死亡率与预估死亡率。结果:共纳入患者45例。rt-PA中位用药次数和量为2(1)次和1.5(1)mg,最大量4.0 mg。术后血肿和水肿体积明显小于术前(P=0.000;P=0.000)。穿刺准确度与残余血肿体积明显负相关(ρ=-0.61;P<0.01)。拔针时GCS评分明显高于入院时(P=0.000)。30 d时实际死亡率为0,远低于预估死亡率(46.7%)。微创期间无颅内感染发生,再出血2例。中位数随访2.5年,5例死亡、3例失访,21例预后好(m RS 0~3)(46.7%)。结论:微创术联合小剂量rt-PA治疗脑出血有助于加速血肿清除、降低30 d死亡率和可能改善长期预后。0.5~1.0 mg/12~24 h、≤4.0 mg的rt-PA应用方案可能适合我国脑出血微创人群。

Objective:To evaluate the feasibility and safety of minimally invasive intracranial hematoma suction drainage surgery(MIS)plus intraclot use of recombinant tissue-type plasminogen activator(rt-PA)in patients with spontaneous intracerebral hemorrhage(ICH)and to explore the potential treatment regimen of intraclot rt-PA.Methods:Patients with ICH treated with MIS and intraclot rt-PA were retrospectively identified.A volumetric analysis to assess hematoma and perihematomal edema(PHE)volumes was conducted.Glasgow Coma Score(GCS)was used to assess consciousness.The modified Rankin Scale(mRS)was used for scoring clinical outcomes(mRS 0~3 v.s.4~5).The observed 30-day cohort mortality was compared with its predicted mortality.Results:Forty-five patients were included.The median number of doses and dose of rt-PA was 2(1)doses and 1.5(1)mg,with a maximum cumulative dose of 4.0 mg.The ICH volume and PHE volume post-MIS was significantly lower compared with that of pre-MIS,respectively(P=0.000;P=0.000).There was a significantly negative correlation between puncture accuracy and residual hematoma volume(ρ=-0.61;P<0.01).GCS at post-MIS was significantly higher than that at pre-MIS(P=0.000).The 30-day patient morality was 0,significantly lower than the predicted mortality(46.7%).No patients developed intracranial infection,and only 2 patients experienced rebleeding.The patients were followed up for a median of 2.5 years;5 patients died,3 patients lost contact,and 21 patients had good outcomes(mRS 0~3).Conclusion:MIS combined with low dose rt-PA in the treatment of ICH enhances clot evacuation,lowers 30-day mortality,and improves long-term clinical outcome.The rt-PA dosage regimen of 0.5~1.0 mg/12~24 h,≤4.0 mg cumulative may be favorable for treatment in ICH patients receiving minimally invasive surgery.