高血压性脑出血分型及外科治疗方法选择的探讨

Discuss on classification and choice of surgical method of hypertensive intracerebral hemorrhage

目的对高血压性脑出血(HICH)根据临床需要进行较全面的分型,针对每一类型依据其病情及出血量找出合适的外科治疗方法。方法收集赤峰学院附属医院神经外科和巴林左旗人民医院神经内科自2013年12月至2018年12月收治的380例HICH患者的临床资料,外科治疗的方法为开颅显微手术和微创治疗(血肿腔置管引流术)。将所有病例按出血部位进行分型,然后将血肿位于脑叶及基底节区的HICH患者按照意识障碍程度分为2组。未昏迷组患者120例,GCS 10~14分;昏迷组患者120例,GCS 4~9分。比较2组患者的治疗效果。结果HICH患者分型统计:脑叶出血51例,基底节区出血208例,丘脑出血59例,混合型出血23例,小脑出血18例,脑干出血9例,原发脑室出血6例(继发性脑室出血例数被包含在其他型出血的例数里面),多发脑出血6例。多见的脑叶及基底节区出血的分组比较:未昏迷组中开颅治疗患者的死亡率为3.8%,微创治疗患者的死亡率为4.5%,差异无统计学意义(P>0.05)。昏迷组中开颅治疗患者的死亡率为10.6%,微创治疗患者的死亡率为25.6%,差异有统计学意义(P<0.05)。结论治疗HICH应根据分型及意识障碍程度、出血量等因素选择手术方式,摒弃只用一种手术方法的思维模式,既减少了开颅手术带来的大创伤和高花费,又降低了微创治疗的死亡率。

Objective To comprehensively classify hypertensive intracerebral hemorrhage(HICH)according to clinical needs,and to find appropriate surgical methods for each type based on patient’s condition and hematoma volume.Methods The clinical data of 380 eligible HICH patients in our two hospitals from December 2013 to December 2018 were collected.The surgical methods were craniotomy and minimally invasive treatment(catheter drainage of hematoma).All cases were classified according to the location of hematoma.Then 240 patients with hematoma located in the cerebral lobe and basal ganglia,who underwent craniotomy or minimally invasive surgery,were divided into two groups according to the degree of consciousness disturbance:Non coma group and coma group.Each group was divided into craniotomy group and minimally invasive treatment group according to the surgical methods.The outcomeof two groups(non coma group and coma group)were compared.There were 120 patients in the non coma group with GCS of 10-14 points.There were 120 patients in the coma group with GCS of 4-9 points.Results Classification statistics of HICH patients:51 cases of lobar hemorrhage,208 cases of basal ganglia hemorrhage,59 cases of thalamus hemorrhage,23 cases of mixed hemorrhage,18 cases of cerebellar hemorrhage,9 cases of brainstem hemorrhage,6 cases of primary ventricular hemorrhage and 6 cases of multiple cerebral hemorrhage.In the non coma group,the mortality rate of patients with craniotomy and minimally invasive treatment was 3.8%and 4.5%respectively,with no significant difference(P>0.05).The most common hemorrhage in lobar and basal ganglia was compared.In coma group,the mortality rate of patients with craniotomy was 10.6%,and that of minimally invasive treatment was 25.6%,the difference was statistically significant(P<0.05).Conclusion In the treatment of HICH,the operation mode should be selected according to the classification,the degree of consciousness disturbance,the amount of bleeding and other factors,and the thinking mode of only one operation method should be abandoned,which not only reduces the large trauma and high cost of craniotomy,but also reduces the mortality of minimally invasive treatment.