重症高血压性脑桥出血的显微外科手术治疗分析

Microsurgery Treatment of Severe Hypertensive Pontine Hemorrhage

目的探讨显微外科手术治疗重症高血压性脑桥出血[出血量>5 mL、格拉斯哥昏迷评分(Glasgow Coma Scale,GCS)3~4分]的效果。方法回顾性分析2016年1月—2021年5月临沂市中医医院脑血管病中心内科保守治疗的重症高血压性脑桥出血患者[出血量(8.35±1.64)mL,GCS评分3~4分]共19例为内科治疗组;同期行CT定位血肿腔穿刺的18例重症高血压性脑桥出血患者[出血量(9.09±1.43)mL,GCS评分3~4分]为穿刺治疗组;同期显微外科手术治疗的21例重症高血压性脑桥出血患者[出血量(8.79±1.35)mL、GCS评分3~4分]为手术治疗组。按格拉斯哥预后评分(Glasgow Outcome Scale,GOS)评估预后,比较3组患者1、3个月存活患者例数。结果内科治疗组患者1个月时按GOS评分重残和植物状态生存10例,死亡9例;3个月时按GOS评分重残和植物状态生存8例,死亡2例。穿刺治疗组患者术后1月时按GOS评分重残和植物状态生存12例,死亡6例;术后3月时按GOS评分重残和植物状态生存11例,死亡1例。手术治疗组患者术中无死亡病例,术后患者自主呼吸均逐渐恢复,术后2周未出现多器官功能衰竭及电解质紊乱,2周时无死亡病例,术后1个月时按GOS评分:重残和植物状态生存20例,死亡1例;术后3个月时按GOS评分:重残和植物状态生存18例,死亡2例。1、3个月时比较内科治疗组、穿刺治疗组和手术治疗组存活患者,差异有统计学意义(χ^(2)=9.496、8.294,P<0.05)。结论对重症脑桥出血患者早期行显微外科手术治疗是简便、安全、有效的治疗方法,配合规范化神经外科重症管理,与穿刺治疗和内科治疗相比可以明显降低患者病死率。

Objective To investigate the effect of microsurgery in the treatment of severe hypertensive pontine hemor⁃rhage[bleeding volume>5 mL,Glasgow coma score(GCS)3 to 4 points].Methods A retrospective study was carried out in patients with severe hypertensive pontine hemorrhage treated conservatively in the department of internal medi⁃cine,cerebrovascular disease center,Linyi Hospital of Traditional Chinese medicine from January 2016 to May 2021 The 19 patients with severe hypertensive pontine hemorrhage[blood volume was(8.35±1.64)mL,GCS score 3 to 4 points]treated with internal medicine were medical treatment group A total of 18 patients with severe hypertensive pontine hemorrhage[blood volume(9.09±1.43)mL,GCS score 3 to 4 points]who underwent CT localization of hema⁃toma cavity puncture were included in the puncture treatment group.In the same period,21 patients with severe hy⁃pertensive pontine hemorrhage treated by microsurgery[bleeding volume(8.79±1.35)mL,GCS score 3 to 4 points]were included in the surgical treatment group.The prognosis was assessed by Glasgow prognostic score(GOS),and the number of 1-month and 3-month survival patients in the three groups was compared.Results In the medical treatment group,10 patients survived and 9 died according to GOS score of severe disability and vegetative state at 1 month.At 3 months,according to GOS score of severe disability and vegetative state,8 patients survived and 2 died.In the punc⁃ture treatment group,12 patients survived and 6 died 1 month after surgery according to GOS score of severe disability and vegetative state.At 3 months after operation,11 cases were alive and 1 case was dead according to GOS score of severe disability and vegetative state.There were no death cases in the surgical treatment group,and spontaneous res⁃piration gradually recovered after surgery.No multiple organ failure and electrolyte disturbance occurred 2 weeks after surgery,and no death cases occurred 2 weeks after surgery.According to GOS score 1 month after operation,20 pa⁃tients survived in severe disability and vegetative state,and 1 died.According to GOS score at 3 months after opera⁃tion,18 patients survived in severe disability and vegetative state and 2 died.At 1 month and 3 months,the survival of patients in the medical treatment group,puncture treatment group and surgical treatment group was compared(χ^(2)=9.496,8.294,P<0.05),and the differences were statistically significant.Conclusion Early microsurgery treatment for patients with severe pontine hemorrhage is simple,safe and effective,and combined with standardized neurosurgical critical management,it can significantly reduce the mortality of patients compared with puncture therapy and medical treatment.