重型原发性脑干出血的显微外科治疗

Microsurgical treatment of severe primary brainstem hemorrhage

目的探讨显微外科在重型原发性脑干出血患者中的运用价值。方法回顾性分析2020年10月至2022年5月期间福建省立医院收治的18例重型原发性脑干出血(primary brainstem hemorrhage,PBSH)患者的临床资料,根据是否行显微手术治疗,分为手术组7例(颞下入路4例、乙状窦后入路2例、枕下正中入路1例)和非手术组11例(仅接受保守治疗),两组患者均接受了严格重症监护、呼吸循环支持、控制血压、营养支持、脑保护等治疗措施。随访6~12月,根据末次随访的改良Rankin量表(modified Rankin scale,mRS)评估远期预后,将mRS评分小于5分定义为预后良好,将mRS评分≥5分定义为预后不良。分析手术组和非手术组患者的年龄、性别、入院病程、血肿量、入院格拉斯哥昏迷评分(Glasgow Coma Score,GCS)、死亡率及预后的差异,总结不同显微外科入路在重型PBSH中的运用要点。结果两组患者的基线资料差异均无统计学意义(P>0.05),具有可比性。手术组患者术后6个月内死亡率[14.3%(1/7)]较非手术组低[90.9%(10/11)],差异有统计学意义(P<0.05);手术组患者末次随访(>6个月)的mRS评分:0分1例,4分4例,5分1例,6分1例,合计预后良好5例(71.4%),非手术组患者末次随访(>6月)的mRS评分:5分1例,6分10例,合计预后良好0例(0%),手术组预后较非手术组好,差异具有统计学意义(P<0.05)。手术组患者手术过程均顺利,5例血肿清除90%以上,2例血肿清除80%~90%,平均手术时长(3.7±0.8)h,术中出血(192.9±159.2)ml,均无手术部位相关并发症。结论显微外科手术能降低重型原发性脑干出血患者的死亡率并改善远期预后,可以在显微外科技术成熟的医院应用。

Objective To assess the value of microsurgical treatment in patients with severe primary brainstem hemorrhage(PBSH).Method Clinical data from 18 patients with severe PBSH admitted to our hospital from October 2020 to May 2022 were retrospectively analyzed and divided into surgery and non-surgery groups.Both groups received intensive care,respiratory and circulatory support,blood pressure control,nutritional support,brain protection and other measures.The modified Rankin scale(mRS)at the last follow-up was used to evaluate long-term outcomes.Good outcome was defined as mRS Score<5 and poor outcome as mRS Score≥5.Differences in age,gender,course of admission,hematoma volume,Glasgow coma score(GCS)at admission,mortality and prognosis between the two groups were analyzed.Result There were no significant differences in age,gender,course of admission,hematoma volume or GCS score at admission between the two groups(P>0.05).Mortality within 6 months was lower in the surgery group[14.3%(1/7)]than in the nonsurgery group[90.9%(10/11)](P<0.05).At the last follow-up(>6 months),mRS Scores in the surgery group were 0 in 1 case,4 in 4 cases,5 in 1 case,and 6 in 1 case;five cases had a good prognosis(71.4%).The prognosis of the surgery group was better than that of the nonsurgery group(P<0.05).The operation process for patients in the surgery group was smooth;more than 90%of hematomas were removed in five cases and 80-90%in two cases.The average operation time was(3.7±0.8)h and intraoperative bleeding was(192.9±159.2)ml.Conclusion Microsurgery can reduce mortality and improve long-term prognosis for patients with PBSH and can be used in hospitals with mature microsurgery technology.