目的 观察应用神经内镜清除血肿及三脑室底造瘘在脑室出血中的治疗效果。方法 选取 2016-06-2017-06在郑州大学附属郑州中心医院诊治的脑室出血患者 63例为研究对象,根据治疗方法不同分为内镜组和钻孔组,观察对比2组术后8 h CT的Graeb评分、注射尿激酶次数、拔管时间、术后颅内感染发生率、术后脑积水率、术后6个月患者的神经功能恢复的状况(mRS),分析应用神经内镜清除血肿及三脑室底造瘘在脑室出血中的治疗效果。结果 内镜组术后8 h Graeb评分(4.060 6±1.390 6)分,钻孔组(9.5±1.634 8)分,差异有统计学意义(P<0.05);内镜组注药次数(1.39±1.029)次,钻孔组(6.43±1.851)次,差异有统计学意义(P<0.05);内镜组拔管时间(2.52±0.795)d,钻孔组(5.5±1.167)d,差异有统计学意义(P<0.05);术后内镜组发生颅内感染1例(3.03%),钻孔组5例(16.67%),差异无统计学意义(P>0.05)。内镜组出现脑积水1例(3.03%),钻孔组 6例(20%),差异有统计学意义(P<0.05)。内镜组mRS评分优于钻孔组,差异有统计学意义(P<0.05)。结论 应用神经内镜清除脑室血肿+三脑室底造瘘术治疗脑室出血能够快速清除脑室血肿,减少尿激酶脑室内注射次数、缩短拔管时间、减少术后颅内感染及脑积水的发生,能够改善患者的预后,提高患者生活质量。
神经内镜清除血肿及三脑室底造瘘治疗脑室出血的疗效分析
赵重庆
郑州大学附属郑州中心医院,河南 郑州 450007
作者简介:赵重庆,Email:jyzhaochq@126.com
【摘要】 目的 观察应用神经内镜清除血肿及三脑室底造瘘在脑室出血中的治疗效果。方法 选取 2016-06-2017-06在郑州大学附属郑州中心医院诊治的脑室出血患者 63例为研究对象,根据治疗方法不同分为内镜组和钻孔组,观察对比2组术后8 h CT的Graeb评分、注射尿激酶次数、拔管时间、术后颅内感染发生率、术后脑积水率、术后6个月患者的神经功能恢复的状况(mRS),分析应用神经内镜清除血肿及三脑室底造瘘在脑室出血中的治疗效果。结果 内镜组术后8 h Graeb评分(4.060 6±1.390 6)分,钻孔组(9.5±1.634 8)分,差异有统计学意义(P<0.05);内镜组注药次数(1.39±1.029)次,钻孔组(6.43±1.851)次,差异有统计学意义(P<0.05);内镜组拔管时间(2.52±0.795)d,钻孔组(5.5±1.167)d,差异有统计学意义(P<0.05);术后内镜组发生颅内感染1例(3.03%),钻孔组5例(16.67%),差异无统计学意义(P>0.05)。内镜组出现脑积水1例(3.03%),钻孔组 6例(20%),差异有统计学意义(P<0.05)。内镜组mRS评分优于钻孔组,差异有统计学意义(P<0.05)。结论 应用神经内镜清除脑室血肿+三脑室底造瘘术治疗脑室出血能够快速清除脑室血肿,减少尿激酶脑室内注射次数、缩短拔管时间、减少术后颅内感染及脑积水的发生,能够改善患者的预后,提高患者生活质量。
【关键词】 脑室出血;神经内镜;三脑室底造瘘;血肿清除;颅内感染;脑积水
【中图分类号】 R743.34 【文献标识码】 A 【文章编号】 1673-5110(2019)02-0171-05 DOI:10.12083/SYSJ.2019.02.033
Treatment of intraventricular hemorrhage by neuroendoscopic removal of hematoma and tri-ventriculostomy
ZHAO Chongqing
Zhengzhou Central Hospital Affiliated to Zhengzhou University,Zhengzhou 450007,China
【Abstract】 Objective To observe the therapeutic effect of neuroendoscopic removal of hematoma and tri-ventriculostomy in intraventricular hemorrhage.Methods 63 patients with ventricular hemorrhage who were diagnosed and treated in Zhengzhou central hospital affiliated to zhengzhou university from June 2016 to June 2017 were selected as research objects.The patients were divided into endoscopic group and drilling group according to different treatment methods.The Graeb score at 8h postoperative,times of urokinase injections,extubation time,incidence of intracranial infection,hydrocephalus rate,and neurological function (mRS) of postoperative half a year of the patients in the two groups were observed and compared.The therapeutic effect of neuroendoscopic removal of hematoma and triventriculostomy in ventricular hemorrhage were analyzed.Results Postoperative 8hGraeb score (4.060 6±1.390 6) in the endoscopic group and (9.5±1.634 8) in the drilling group showed statistically significant difference (P<0.05).The Times of drug injection in the endoscopic group (1.39±1.029) and those in the drilling group (6.43±1.851) were statistically significant (P<0.05).The extubation time (2.52±0.795)d of the endoscopic group and the time (5.5±1.167)d of the drilling group,the difference was statistically significant (P<0.05).Intracranial infection occurred in 1 case (3.03%) in the endoscopic group and 5 cases (16.67%) in the drilling group,and the difference was not statistically significant (P>0.05).Hydrocephalus occurred in 1 case (3.03%) in the endoscopic group and 6 cases (20%) in the drilling group,and the difference was statistically significant (P<0.05).The mRS score of the endoscopic group was better than that of the drilling group,and the difference was statistically significant (P<0.05).Conclusion The treatment of intraventricular hemorrhage with neuroendoscopic removal of intraventricular hematoma + triple ventriculostomy can rapidly clear ventricular hematoma,reduce the number of urokinase intracranial injections,shorten the time of extubation,reduce postoperative intracranial infection and hydrocephalus,and improve the prognosis and quality of life of patients.
【Key words】 Neuroendoscopy;Triventriculostomy;Intraventricular hemorrhage;Hematoma removal;Intracranial infection;Hydrocephalus
脑室出血是临床常见的神经科急危重症,起病急、进展快,容易发生颅内高压、脑积水和脑血管痉挛等并发症,病死率高[1-3]。快速清除脑室内血肿是治疗脑室出血的根本措施[4],常用治疗方法是侧脑室钻孔外引流术,术后脑室内注射尿激酶等溶解血肿,持续引流脑室内积血,可较快缓解颅内压增高,但脑室内血肿仍需较长时间才能清除,不利于患者神经功能的恢复,反复注药、持续引流会增加感染的风险。本文通过分析神经内镜清除血肿及三脑室底造瘘治疗脑室出血前后2组的术后8 h血肿清除情况、注射尿激酶次数、拔管时间、术后颅内感染发生率、术后脑积水率、术后6个月患者神经功能恢复的状况(mRS)等,认为应用神经内镜清除血肿及三脑室底造瘘治疗脑室出血可取得更好的效果。
1 资料与方法
1.1 临床资料 选取 2016-06-2017-06在郑州大学附属郑州中心医院诊治的脑室出血患者 63例为研究对象,其中钻孔组(脑室钻孔外引流组)30例,内镜组(使用神经内镜治疗)33例,排除有外伤史、严重肝肾功能不足、免疫类疾病以及血液类疾病等,所有患者均符合以下标准:有高血压病史,发病前无外伤史;出血位于脑室系统内;发病24 h内。所有患者均经头颅CT扫描,且幕上脑实质内血肿量>20 mL或幕下小脑血肿量>10 mL者不纳入本研究。1982年由GRAEB等提出Graeb脑室内出血评分,主要用于CT影像学上对脑室内出血量进行测评,是一种便捷的临床测评方式[5-6]。Graeb脑室内出血评分方法如下:侧脑室:1分:出现血迹或轻度出血;2分:一半以下的脑室内充血;3分:一半以上的脑室内充血;4分:全脑室充血膨胀。第三或第四脑室:1分:脑室内出血,但脑室未膨胀;2分:全脑室充血膨胀。Graeb总分=左侧脑室评分+右侧脑室评分+第三脑室评分+第四脑室评分 (最高12分)。2组病例一般资料比较差异无统计学意义(P>0.05)。见表1。
1.2 方法 钻孔组行侧脑室钻孔外引流术。在冠状缝前2.5 cm,中线旁边开 2.5 cm做长约3 cm切口,钻孔后十字切开硬膜,行双侧侧脑室额角穿刺,穿刺成功见有血性脑脊液流出后引流管再置入颅内 1 cm,另做切口固定引流管,连接引流装置。为避免出血增加,术中不常规抽吸血肿。术后8 h复查头颅CT,向引流管内注入尿激酶5万U (加生理盐水5 mL),夹闭4 h后开放,2次/d,根据引流情况及时复查头颅CT,脑脊液循环通畅后拔管,拔管后行腰大池持续引流至脑脊液清亮。
内镜组应用脑室镜清除血肿+三脑室底造瘘术。在冠状缝前2.5 cm,中线旁边开 2.5 cm做长约3 cm切口,钻孔后形成直径为 2 cm 骨窗,十字切开硬膜,向侧脑室放置脑室镜,清除一侧侧脑室血肿,行透明隔造瘘,清除对侧侧脑室血肿。经过脑室孔进入第三脑室清除血肿。找到乳头体,行三脑室底造瘘。放置引流管,另做切口固定引流管,连接引流装置。术后8 h复查头颅CT,根据复查结果选择相应的处理措施,血肿残余较多或导水管、四脑室不通,且无明显出血者向引流管内注入尿激酶 5万U (加生理盐水5 mL),夹闭4 h后开放,2次/d,根据引流情况及时复查头颅CT,脑脊液通畅后拔管,拔管后行腰大池持续引流至脑脊液清亮。
1.3 观察指标 分别对比2组术后8 h CT的Graeb评分、注射尿激酶次数、拔管时间、术后颅内感染发生率、术后脑积水率、术后6个月患者的神经功能恢复的状况(mRS)。
1.4 统计学分析 采用SPSS 22.0进行数据分析,术后8 h Graeb评分、术后6月mRS采用两独立样本t检验,注药次数、拔管时间采用两独立样本秩和检验,脑积水和颅内感染率采用Fisher确切概率法分析,P<0.05为差异有统计学意义。
2 结果
2.1 2组血肿清除情况、尿激酶注射次数、拔管时间比较 术后8 h复查头颅CT,行Graeb评分,了解患者术后血肿消除情况,结果表明内镜组术后8 h Graeb评分、注药次数、拔管时间均明显优于钻孔组,差异有统计学意义(P<0.05)。见表2。
2.2 脑积水以及颅内感染发生率 术后内镜组发生颅内感染1例(3.03%),钻孔组5例(16.67%),差异无统计学意义(P>0.05)。内镜组出现脑积水1例(3.03%),钻孔组 6例(20%),差异有统计学意义(P<0.05)。
2.3 2组术后6个月改良RANKIN量表(mRS)评分比较 内镜组术后6个月mRS评分(2.45±1.438)分,钻孔组为(3.5±1.432)分,内镜组优于钻孔组,差异有统计学意义(P>0.05)。
表1 2组一般资料 (x±s)
Table 1 General information of 2 groups (x±s)
组别 |
n |
性别 |
年龄/岁 |
术前Graeb评分 |
术前GCS评分 |
男 |
女 |
内镜组 |
33 |
19 |
14 |
63.09±7.63 |
9.9394±1.7667 |
6.91±2.255 |
钻孔组 |
30 |
16 |
14 |
62.67±7.369 |
10.1±1.4704 |
7.47±2.209 |
P值 |
|
0.735 |
0.823 |
0.698 |
0.326 |
表2 2组血肿清除情况、尿激酶注射次数、拔管时间比较 (x±s)
Table 2 Comparison of hematoma clearance,urokinase injection times
and extubation time between the two groups (x±s)
组别 |
n |
术后8 h Graeb评分 |
注药次数(次) |
拔管时间(d) |
内镜组 |
33 |
4.060 6±1.390 6 |
1.39±1.029 |
2.52±0.795 |
钻孔组 |
30 |
9.500 0±1.634 8 |
6.43±1.851 |
5.5±1.167 |
P值 |
|
0.000 |
0.000 |
0.000 |
3 讨论
脑出血在脑卒中各亚型中发病率仅次于缺血性脑卒中,居第2位[1,2]。脑室出血可见于45% 的自发性脑出血患者,可以是原发性或继发性,原发性脑室出血指出血来源于脑室脉络丛、脑室内和脑室壁以及脑室旁区的血管 (室管膜下区1.5cm以内)的一类脑室出血类型。脑室出血发病急,变化快,致死致残率高,病死率高达50%~80%[3,4]。
脑室内大量积血压迫深部结构,产生占位效应;室间孔、导水管、第四脑室梗阻造成脑脊液循环障碍,形成急性梗阻性脑积水,颅内压急剧升高,严重时引发脑疝,危及生命[7]。脑室内积血会释放凝血酶、细胞因子、血细胞崩解产物等多种毒性物质,对脑组织造成继发性损害,导致下丘脑功能紊乱,出现糖代谢紊乱、中枢性高热、应激性溃疡、心肌缺血、心律失常;自由基、内皮素、儿茶酚胺同舒血管递质比例失调导致脑血管痉挛,脑缺血缺氧,甚至脑梗死等[7-11]。
在脑室出血后期形成的脑积水多为交通性脑积水,脑积水的发生率与脑室出血的量正相关[12-15]。随着对脑脊液循环动力学认识的深入,发现第三脑室底造瘘术可借助基底动脉的搏动改变脑脊液循环动力,改善脑组织顺应性,对于脑脊液循环动力障碍导致的正常压力脑积水和交通性脑积水具有良好治疗效果[15-16],据相关报道,第三脑室底造瘘术治疗交通性脑积水术后症状改善率达66.5%,其中步态不稳的改善率高达75%[17-20]。本文结果显示,在内镜治疗脑室出血时行三脑室底造瘘后脑积水的发生率较钻孔组下降,说明此方法可以减少脑室出血后脑积水的发生,避免再次手术和植入脑室腹腔分流管,减少治疗周期及费用。
神经内镜有侧方视角,可扩大手术视野,近距离照明,清晰度明显增加,利于辨认病变周围重要的神经和血管结构,增加手术操作的精确性和安全性[21-22]。神经内镜可通过狭长的腔隙和孔道进行操作,减少对脑组织的牵拉及神经、血管的损伤,手术创伤小[23-25]。使用神经内镜可快速清除脑室内血肿,减轻血肿压迫,消除室间孔梗阻[26],恢复脑脊液循环通畅,利于患者术后神经功能恢复,早期清醒可减少肺部感染、下肢静脉血栓形成等严重并发症的发生。本文结果显示在血肿清除率、尿激酶注射次数、拔管时间方面内镜组均具有明显优势。
术后继发颅内感染是脑室外引流严重并发症之一,明显增加病死率,即使感染控制,致残率及远期脑积水的发生率亦明显增高,导致患者预后明显不佳[27-28]。脑室出血外引流后颅内感染文献报道发生率2%~27%[29-30]。脑室炎与原发疾病明显相关,可能与脑室出血后引流时间长、反复向脑室内注射尿激酶、脑室内积血成为细菌良好的培养基有关[31-32]。有学者认为脑室炎与导管放置时间有关,导管放置>5 d明显增加感染风险,在9~11 d感染达高峰[33-35]。脑室内注药可能是细菌进入颅内的一个途径,反复注射可能增加颅内感染的发生。本文结果显示,2组颅内感染率差异无统计学意义,这可能与样本量较小有关。内镜组颅内感染率低,可能与脑室引流管放置时间明显缩短和脑室内注药次数明显减少有关。严格的无菌操作是避免颅内感染的关键[36]。
本文通过对2组病人术后6个月的mRS分析,内镜组术后mRS较钻孔组明显降低,说明应用神经内镜清除脑室血肿+三脑室底造瘘能够改善患者的预后、提高患者生活质量,与文献报道一致[37-38]。
应用神经内镜清除脑室血肿+三脑室底造瘘术治疗脑室出血能够快速清除脑室血肿,减少尿激酶脑室内注射次数、缩短拔管时间、减少术后颅内感染及脑积水的发生,能够改善患者预后,提高患者生活质量。
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(收稿2019-01-07)
本文责编:张喜民
本文引用信息:赵重庆.神经内镜清除血肿及三脑室底造瘘治疗脑室出血的疗效分析[J].中国实用神经疾病杂志,2019,22(2):171-175.DOI:10.12083/SYSJ.2019.02.033
Reference information:ZHAO Chongqing.Treatment of intraventricular hemorrhage by neuroendoscopic removal of hematoma and tri-ventriculostomy[J].Chinese Journal of Practical Nervous Diseases,2019,22(2):171-175.DOI:10.12083/SYSJ.2019.02.033