三种术式治疗基底节区高血压性脑出血的效果对比研究

A Comparative Study of Effects of Three Surgical Methods in Treatment of Patients with Hypertensive Basal Ganglia Hemorrhage

目的比较经颞叶大骨瓣开颅血肿清除术、微创血肿碎吸术及显微镜辅助小骨窗经侧裂开颅术治疗基底节区高血压性脑出血的效果及近远期预后。方法选取2017年6月—2019年12月本院收治的166例基底节区高血压性脑出血患者,根据术式不同分为大骨瓣组(行经颞叶大骨瓣开颅血肿清除术治疗)70例、微创组(行微创血肿碎吸术治疗)46例及小骨窗组(行显微镜辅助小骨窗经侧裂开颅术治疗)50例,对比3组术后72 h血肿清除率、再出血率和并发症发生情况,以及术后1、6个月预后情况。结果大骨瓣组与小骨窗组术后72 h血肿清除率均显著高于微创组(P<0.05),但大骨瓣组与小骨窗组比较差异无统计学意义(P>0.05);3组术后72 h再出血率比较差异无统计学意义(P>0.05)。3组术后肺部感染、应激性溃疡、消化道出血及颅内感染发生率比较差异均无统计学意义(P>0.05)。随访1个月,3组术后病死率比较差异无统计学意义(P>0.05),3组格拉斯哥预后评分(GOS)比较差异有统计学意义(P<0.01);微创组与小骨窗组GOS评分比较差异无统计学意义(P>0.05),但均显著高于大骨瓣组(P<0.05)。随访6个月,大骨瓣组术后病死率和改良Rankin量表(mRS)评分显著高于微创组和小骨窗组(P<0.05或P<0.01),微创组与小骨窗组术后病死率和mRS评分比较差异无统计学意义(P>0.05)。结论经颞叶大骨瓣开颅血肿清除术可直视下清除血肿,实现减压目的,但近远期预后不佳,适用于基底节区高血压性脑出血严重者;微创血肿碎吸术治疗后患者恢复快,但其不能有效减压,适用于年纪大、手术耐受较差、出血情况较轻者;显微镜辅助小骨窗经侧裂开颅术血肿清除及减压效果较好,且患者术后恢复快,但对医生操作技术要求高,且术后易出现颅内感染。

Objective To compare effects and short-term and long-term prognoses of three surgical methods(large bone flap craniotomy via temporal lobe approach for hematoma clearance,minimally invasive aspiration and microscope-assisted small bone window craniotomy)in treatment of patients with hypertensive basal ganglia hemorrhage(HBGH).Methods A total of 166 HBGH patients admitted during June 2017 and December 2019 were selected and divided into large bone flap group(n=70,receiving large bone flap craniotomy via temporal lobe approach for hematoma clearance),minimally invasive surgery group(n=46,minimally invasive aspiration and drainage of the hematoma)and small bone window group(n=50,microscope-assisted small bone window craniotomy)according to different operation methods.Hematoma clearance rates,rebleeding rates and incidence rates of complications after operation for 72 h,and prognosis conditions after operation for 1-and 6-months were compared among three groups.Results Hematoma clearance rates after operation for 72 h in large bone flap and small bone window groups were significantly higher than that in minimally invasive surgery group(P<0.05),but there was no significant difference in the rate between the large bone flap and small bone window groups(P>0.05).There were no significant differences in rebleeding rates among three groups after operation for 72 h(P>0.05).There were no significant differences in the incidence rates of postoperative pulmonary infection,stress ulcer,gastrointestinal bleeding and intracranial infection among three groups(P>0.05).At postoperative follow-up for 1-month,there were no significant differences in postoperative mortality rates among three groups(P>0.05),while there were significant differences in Glasgow Outcome Scale(GOS)scores among three groups(P<0.01);there was no significant difference in GOS score between minimally invasive surgery and small bone window groups(P>0.05),but the scores in the above two groups were all significantly higher than that in large bone flap group(P<0.05).At postoperative follow-up for 6-months,values of mortality rate and modified Rankin Scale(mRS)score in large bone flap group were significantly higher than those in minimally invasive surgery and small bone window groups(P<0.05 or P<0.01),while there were no significant differences in postoperative mortality rate and mRS score between minimally invasive surgery and small bone window groups(P>0.05).Conclusion Large bone flap craniotomy via temporal lobe approach may remove hematoma and achieve decompression under direct vision,but its short-term and long-term prognoses are poor,which is applicable to patients with severe HBGH.Minimally invasive aspiration and drainage of the hematoma may ensure quick recovery,but it can not effectively reduce pressure,which is appropriate for elderly patients with poor surgical tolerance and mild hemorrhage.Microscope-assisted small bone window craniotomy is effective in hematoma clearance and decompression,and patients will recover quickly after operation.However,highly-skilled doctors are needed,and postoperative intracranial infection is more likely to occur.