微创置管吸引术救治高血压脑出血

【摘要】 目的 初步探讨应用微创置管吸引术救治高血压脑出血的临床效果及意义。方法 根据患者术前CT或CT片上提供的颅脑立体定位数据，采用微创定向颅内置管装置医疗器械，治疗高血压脑出血患者72例。所有病例术中经单或多靶点径路微创软管脑内血肿抽吸和术后残血尿激酶溶凝引流的方式及对血肿破入脑室积血患者配合腰穿置换治疗。 结果 血肿腔内置管准确率100%。术中血肿清除率和术后残血清除留管时间均值：单靶点径路32.2%和6.5 d，多靶点径路为56.5%和4.5 d，两方法比较有显著意义。结论 微创定向脑内血肿置软管吸引术治疗高血压脑出血是一种定位准确，方法简易，适宜抢救，创伤微小，疗效确切，易于推广的新技术。

【关键词】

微创置管；高血压脑出血；吸引术

Aspiration of hypertensive intracerebral hematoma by minimally invasive tube insertion

KONG Xiangcheng, Luzhong Mining Hospital of Laiwu,Shandong 271113,China

【Abstract】 Objective

To investigate the clinical results and significance of aspirating hypertensive intracerebral hematoma by a sofe tube inserted by minial invasive technigue. Methods According to the stereotactic data of CT or CTfilm in preoperative patients, 72 cases with hypertensive intracerebral hematoma were treated by the apparatus. All patients were treated by the aspiration of a minimaltrauma softtube by a single or more target approaches and the tube was left as drainage in place for further administration of unokinase and aspiration of the residual dissolved hematoma. Lumbar punctures for the replacement fluid with blood were also done with intraventricular hematomas. Results The accuracy of installing tubes into the cavity of hematomas was 100%. 32.2% of volume of the hematoma was evacuated during operations and the drainaging time was 6.5 days in a single target approach,56.5% hematoma was evacuated and 4.5 days drainage was in the more target approaches in average. The results of two approaches were compared significantly. Conclusion The aspiration of hypertensive intracerebral hematoma by minimaltrauma stereotactic installed soft tube in the hematoma is a new technique, which has been proved to be accurate, effective, simple, and with minimal trauma to the patient.

【Key words】

Minimaltrauma installed tube; Hypertensive intracerebral hematoma; Aspiration

高血压脑出血为临床常见病，随着社会老龄化加大，其发病率呈上升趋势，病死率和致残率极高。无论是保守治疗还是开颅手术，其病死率和致残率均维持在较高水平。自2008年以来，我们采用微创定向颅内置软管吸引术，治疗高血压脑出血患者72例，取得了良好疗效，现报告如下。

1 资料与方法

1.1 一般资料 72例，其中男48例，女24例。年龄37~82岁，平均58岁。患者均有高血压病史，发病后均出现意识障碍和程度不同的肢体瘫痪。意识状况(Glasgow计分)：3~5分26例(36.1%)；6~9分30例(41.6%)；10~12分16例(22%)。

1.2 症状与体征 72例均有不同程度的肢体瘫痪或一侧肢体偏瘫；脑膜刺激征；一侧瞳孔散大8例，双侧瞳孔缩小6例。

1.3 出血部位 壳核45例，出血量25~75 ml(38.6±15.2)ml；丘脑14例，出血量22~44 ml(30.5±5.5)ml；脑叶8例，出血量30~90 ml(42.5±18.5)ml；小脑2例，出血量20~30 ml(22±5)ml；脑干1例，出血量9 ml；脑室铸型2例。详见表1。

1.4 卒中至手术时间 最短5 h，最长7 d。5~7 h 6例(8.3%)，7~12 h 18例(25%),12~24 h 26例(36.1%)，1~3 d 18例(25%)，3~7 d 4例(5.5%)。

1.5 手术时间 最短35 min，最长2 h 50 min，平均58 min，其中62例在1 h内完成，占86.1%。

1.6 手术方法 手术均在基础+局麻下，配合持续静脉滴注或口服药物调控血压和生命指征监护。采用大连七颗星医疗器械公司生产的定向颅内置管装置(专利号:ZL962 38882.3)等医疗器械，首先准确测量患者颅脑CT或CT片上提供的脑内血肿靶点的三维数据，利用特制直角定位尺将上述三维数据以坐标的形式移画在患者的头部，确定血肿中心靶点和入颅路径。选择头部非功能血管区消毒局麻后，定向钻颅置管，向脑内导入园钝头、多侧孔软性吸引管达靶点中心，进行非阻力化缓慢抽吸清除脑内血肿，术毕留该管作术后脑血肿腔内引流管。单与多个靶点径路方法比较分析见表2。术后残留血肿于次日行尿激酶熔凝治疗，至残余血引出90%以上考虑拔除引流管。对血肿破入脑室或脑室内积血患者，除微创脑室内置管引流减压治疗外，均配合腰穿置换血性脑脊液。

2 结果

术后生活部分自理42例，生活不能自理18例，占存活者83%。死亡12例(16.6%)。5例死于中枢衰竭，3例死于肺炎和消化道出血，2例死于再出血，其他原因2例。术后随访3~24月，日常生活能力评判(Activity Daily Living,ADL): ADL1和ADL2 39例，ADL3 11例，ADL4和ADL5 10例。ADL3以上者50例，占存活者的83.3%。