微创抽吸辅助无延迟开颅减压治疗原发性脑出血伴脑疝的随机对照研究

A randomized controlled trial of minimally invasive suction combined with craniotomy and decompression without delay in treatment of primary intracerebral hemorrhage with cerebral hernia

目的 研究微创抽吸辅助无延迟开颅减压治疗原发性脑出血伴脑疝的临床疗效。方法前瞻性纳入2018年1月至2020年12月100例幕上原发性脑出血伴脑疝患者,随机数表法分为观察组50例(放弃治疗2例,余48例)和对照组50例(放弃治疗3例+失访1例,余46例)。观察组床边微创穿刺抽吸同时术前准备,无延迟行开颅血肿清除并去骨瓣减压术;对照组常规行开颅血肿清除并去骨瓣减压术。根据入院时单侧或双侧瞳孔散大区分脑疝严重程度。比较两组患者围手术期及术后6个月预后情况。结果 观察组良好/中残率和死亡率显著优于对照组(39.4%vs. 19.6%;8.3%vs. 26.1%),两组术后6个月预后差异有统计学意义(P <0.05)。两组中单侧瞳孔散大患者,观察组良好/中残率显著高于对照组(59.4%vs. 31.0%),两组术后6个月预后差异有统计学意义(P <0.05)。两组中双侧瞳孔散大患者术后6个月预后差异无统计学意义(P> 0.05)。观察组单侧瞳孔散大患者中,微创抽吸后瞳孔明显回缩者良好/中残率显著高于无明显回缩者(78.3%vs. 11.1%,P <0.01)。观察组双侧瞳孔散大患者中,微创抽吸后瞳孔明显回缩者植物生存/死亡率显著低于无明显回缩者(36.4%vs. 100.0%,P <0.05)。结论 微创抽吸辅助无延迟开颅减压治疗原发性脑出血伴脑疝患者预后优于常规开颅减压,并可提高单侧瞳孔散大患者的良好/中残率,降低双侧瞳孔散大患者的死亡率。

Objective To investigate the clinical efficacy of minimally invasive suction combined with craniotomy and decompression without delay in the treatment of primary cerebral hemorrhage with cerebral hernia.Methods 100 patients of supratentorial primary cerebral hemorrhage with cerebral hernia from January 2018 to December 2020 were prospectively enrolled and randomly divided into observation group(n = 50)and control group(n = 50). In the observation group,bedside minimally invasive suction and preoperative preparation were performed without delay for craniotomy hematoma removal and bone flap decompression. The control group received conventional craniotomy hematoma removal and bone flap decompression. The severity of cerebral hernia was distinguished by unilateral or bilateral dilated pupils at admission. The perioperative conditions and outcomes 6 months after operation of the two groups were compared. Results The good recovery/moderate disability rate and death rate in the observation group were significantly better than those in the control group(good recovery/moderate disability:39.4% vs. 19.6%;death rate:8.3% vs. 26.1%),and the difference in prognosis between the two groups at 6 months after surgery was statistically significant(P < 0.05). In patients with unilateral dilated pupil,the good recovery/moderate disability rate in the observation group was significantly higher than that in the control group(59.4% vs.31.0%),and the difference in prognosis between the two groups at 6 months after surgery was statistically significant(P < 0.05). In patients with bilateral dilated pupils,there were no statistically differences in prognosis between the two groups at 6 months after surgery(P > 0.05). In the observation group with unilateral dilated pupil,the good recovery/moderate disability rate of patients with significant contracted pupil after minimally invasive suction was significantly higher than that without significant contracted pupil(78.3% vs. 11.1%,P < 0.01). In the observation group with bilateral dilated pupils,the persistent vegetative state/death rate of patients with significant contracted pupil after minimally invasive suction was lower than that without significant contracted pupil(36.4% vs. 100.0%,P < 0.05). Conclusion The outcomes of patients with primary intracerebral hemorrhage accompanied by cerebral hernia treated with minimally invasive suction combined with craniotomy and decompression without delay are better than conventional craniotomy and decompression,and this approach can improve the good recovery/moderate disability rate of patients with unilateral dilated pupil and reduce the death rate of patients with bilateral dilated pupils.