高血压脑出血各种不同手术方法效果的探讨及体会

高血压脑出血(hypertensive cerebral hemorrhage,HTCH)是我国中老年人的主要致死疾病之一.为了对高血压脑出血患者选择何种手术方法治疗,笔者总结了本院1999年1月至2004年1月收治资料完整的68例高血压脑出血患者进行比较分析,现报告如下.     

Factors determining the side of approach for clipping ruptured anterior communicating artery aneurysm via supraorbital eyebrow keyhole approach

Purpose:The purpose of this study was to review the microsurgical anatomy and clipping of ruptured anterior communicating artery(AComA)aneurysms and to plan and avoid complications before operation.Methods:A total of 523 cases of cerebral aneurysms admitted to the neurosurgery department of the Third Affiliated Hospital of Sun Yat-Sen University from September 2010 to October 2018 were analyzed retrospectively.Among them,85 patients had ruptured AComA aneurysms.This study was limited to 85 of these cases,whose satisfactory preoperative angiographic diagnostic films can be retrieved from the hospital database system because of the need for detailed review.Results:We performed supraorbital eyebrow keyhole approach(SOEK)craniotomy in 85 patients to clip 85 AComA aneurysms,in the setting of subarachnoid hemorrhage(SAH).Patients’mean age was(52.69±9.94)years(range,28e78 years).The proportions of small,medium and large aneurysms were 83.5%,15.3%,and 1.2%,respectively.The average size of the aneurysms was(5.07±2.36)mm.There were 77.8% of patients with inferior aneurysms and 81.3% of patients with superior aneurysms achieved good results.There was a significant correlation between A1 dominance and operation method(p<0.001).There was no significant relationship between surgical approach and aneurysm projection or A2 plane(p=0.157&p=0.318).Conclusion:Regardless of whether the A2 plane is open or closed,the A1 dominant side is still a better choice for accessing AComA aneurysms to avoid dangerous premature bleeding.     

锁孔入路显微手术治疗高血压性脑出血

外科手术是治疗高血压性脑出血（hypertensive intra cerebral hemorrhage,HICH）的有效方法,尽管目前有许多手术用于治疗HICH,但各种微创手术正逐渐成为主流。我院2006年5月~2010年4月对75例有手术指征的HICH采用锁孔入路显微镜下治疗,取得满意疗效,现报道如下。1临床资料与方法     

小骨窗微创手术治疗高血压脑出血68例分析

目的:探讨高血压脑出血小骨窗微创手术治疗的适应证及疗效。方法:对68例高血压脑出血患者采取小骨窗在显微镜下行血肿清除治疗,对并发血肿破入脑室者加行侧脑室穿刺引流治疗。结果:68例患者,术后24h内复查头颅CT,血肿清除率达90%以上24例,50%以上33例,30%以上5例。6例血肿复发,其中4例行二次手术。术后存活61例,死亡7例。获随访55例,生活质量按ADL评价:Ⅰ级15例(27.3%),Ⅱ级21例(38.2%),Ⅲ级8例(14.5%),Ⅳ级9例(16.4%),Ⅴ级2例(3.6%)。结论:小骨窗开颅显微手术治疗高血压脑出血是一种安全有效的方法,合理掌握手术适应证及手术技巧,可明显提高疗效。     

翼点入路经岛叶显微手术治疗基底节区高血压脑出血

【摘要】〓目的〓探讨基底节区高血压脑出血显微手术疗效。方法〓回顾性分析23例翼点入路经岛叶显微手术治疗的基底节区高血压脑出血患者的临床资料。 结果〓术后24 h复查头颅CT,血肿清除率 > 90%者21例(91.3%)。术后随访6~36个月,根据日常生活能力分级,Ⅰ级8例,Ⅱ级9例,Ⅲ级3例,Ⅳ级2例。Ⅴ级1例。 结论〓翼点入路经岛叶显微手术治疗基底节区高血压脑出血,血肿清除率高、神经功能恢复较好。     

脑基底节区出血的显微手术治疗

目的 报道显微手术治疗老年人高血脑基底节区出血的临床疗效.方法 回顾性分析58例老年人高血压脑基底节区出血的临床表现、显微手术过程及预后.结果 清除血肿量均达75%以上;术后48 h意识状态好转45例,无改善13例;6例72 h再出血,3例死亡.术后6个月随访(按ADL分级法):Ⅰ级18例,Ⅱ级23例,Ⅲ级11例,Ⅳ级3例.结论 显微手术创伤小、清除血肿充分,对于老年高血压脑出血的病例比较实用.手术中的微创是高血压脑出血手术成功的关键.     

脑沟入路显微手术治疗高血压脑出血

目的 探讨高血压脑出血手术方法及疗效. 方法 回顾分析本院2010年1月至2011年10月高血压脑出血经脑沟入路显微手术46例. 结果 术后随访6～12月,按ADL分级:Ⅰ级7例,Ⅱ级16例,Ⅲ级14例,Ⅳ级8例,Ⅴ级1例. 结论 脑沟入路显微手术清除高血压脑出血所减少不必要的损伤,改善患者的预后和生存质量.     

高血压脑出血的微创手术治疗

目的:探讨微创(锁孔技术)治疗高血压脑出血的手术指征(如GCS评分、出血量)问题.方法:对106例(幕上)+27例(幕下)高血压脑出血患者实施微创手术,后按GCS评分、出血量分组,进行同期疗效对比.结果:不同组别患者术后GOS、ADL结果差异显著.结论: 高血压脑出血手术指征可以适当放宽,能有效地提高生存质量,降低死亡率.     

锁孔显微手术治疗高血压基底节区脑出血41例探讨

目的 :探讨锁孔显微手术治疗高血压基底节区脑出血的方法及疗效。方法 :41例均在全麻下手术 ,作颞部长5cm斜切口 ,直径 3cm的圆形骨窗 (环钻 ) ,显微镜下分开侧裂池或脑沟、皮质 ,清除血肿并彻底止血 ,复位固定骨瓣。结果 :存活 3 6例 ,根据ADL(日常生活能力 )分级 :Ⅰ级 6例 ,Ⅱ级 17例 ,Ⅲ级 9例 ,Ⅳ级 3例 ,Ⅴ级 1例。结论 :此术式副损伤小 ,止血及清除血肿彻底 ,手术路径短、视野清晰。     

高血压性脑出血的显微外科手术治疗

目的 探讨超急性期和急性期显微手术治疗高血压性基底节区脑出血的临床疗效.方法 回顾性分析高血压性脑出血超急性期显微手术(发病后6h内)199例和急性期显微手术271例患者的康复情况. 结果超急性期手术患者住院期间并发症发生率低,出院时GOS评分及中长期随访日常生活能力(ADL)评定均优于急性期手术者,其中344例随访6个月～5年,超急性期组恢复良好(ADL Ⅰ-Ⅱ级)为72.5％(111/153),急性期组为45.5％(87/191). 结论超急性期显微手术治疗高血压性基底节区脑出血的临床康复疗效显著,有手术指征的病例应积极争取超急性期手术.     

Surgical experience with frontolateral keyhole craniotomy through a superciliary skin incision

OBJECTIVE: The purpose of this study was to evaluate the results of 173 frontolateral keyhole minicraniotomies performed on 155 patients with aneurysms of the anterior or posterior cerebral circulation and for supratentorial tumors. METHODS: The frontolateral keyhole craniotomy is a modification of the generally used pterional approach. Of the 155 patients studied, 102 harbored saccular arterial aneurysms in the vessels of the anterior or posterior cerebral circulation, and 53 had various tumors in the frontal base, suprasellar, or parasellar region. The operations were carried out through an approximately 2.5- x 3-cm frontolateral miniaturized craniotomy after a skin incision just above the eyebrow. RESULTS: Despite the small size of the craniotomy, the exploration allows enough room for intracranial manipulation with maximal protection of the brain and other intracranial structures. The presented series of patients did not have any craniotomy-related complications. CONCLUSION: In our experience, the frontolateral keyhole craniotomy, together with the advent of the modern neuroanesthesia, cerebrospinal fluid drainage, and microsurgical techniques, is a safe approach for an experienced neurosurgeon to use in the treatment of supratentorial aneurysms or tumors of the anterior fossa and sellar regions.     

The keyhole concept in aneurysm surgery--a comparative study: keyhole versus standard craniotomy.

OBJECTIVE: The purpose of the study is to compare the results of minimally invasive keyhole craniotomy and standard larger craniotomies in the surgical treatment of patients with intracranial aneurysms. METHODS: In the past eight years 628 patients were operated by two experienced neurosurgical teams. The first group of 482 patients with 565 aneurysms were operated through a small keyhole craniotomy, using the eyebrow keyhole approach in particular. The remaining 146 patients with 167 aneurysms were operated using a standard craniotomy that included pterional/frontotemporal, frontoparietal parasagittal, and retrosigmoid suboccipital craniotomies. All operations were performed in the standard microsurgical technique using intraoperative evoked potential monitoring and endoscopic assistance in selected cases. RESULTS: Most supratentorial aneurysms and basilar tip aneurysms were successfully operated through an eyebrow keyhole craniotomy. Distal MCA aneurysms as well as aneurysms on the MCA with a long M1 segment were operated through a temporal keyhole, and aneurysms of the distal PCA (P2-P3) segment subtemporally. The frontoparietal parasagittal keyhole approach was used only for pericallosal artery aneurysms. Infratentorial aneurysms of the VA/PICA complex were operated via a retrosigmoid approach. On comparing the surgery results in patients with a keyhole craniotomy and those with standard craniotomy, similar outcomes were found for both groups, with excellent or very good outcomes (GOS 5 and 4) in 398 (82.57%) patients from the keyhole craniotomy group, and in 116 (79.45%) patients from the standard craniotomy group. The mortality rate in the keyhole group was 0.83% (4 patients) and 2.05% (3 patients) in the standard craniotomy group. CONCLUSION: Parallel treatment results in using two options--keyhole craniotomy and standard larger craniotomy--were analysed in the past eight years. Two experienced neurosurgical teams in performing both surgical approaches have reached almost similar morbidity and mortality rates, and overall surgical results. The type of craniotomy is selected according to the experience of the surgical team, and familiarity with certain approach. The authors have good experience with the minimally invasive approach for different intracranial pathology and recommend it especially in neurovascular surgery.     

内镜辅助眶上锁孔入路切除鞍上区肿瘤

目的 探讨内镜辅助眶上锁孔入路切除鞍上区肿瘤的显微手术技术,以最大限度地切除肿瘤,减少手术创伤。方法 16例鞍上区肿瘤患者依据手术前影像学检查结果,制订个体化手术方案,采用眉部皮肤切口,在眶上行直径2cm左右开颅,应用内镜辅助的显微手术技术切除病变。结果 16例患者经眶上锁孔入路技术获肿瘤全部切除,无手术并发症发生。结论 眶上锁孔入路可明显减少手术创伤、提供鞍上区足够的手术空间,有利于肿瘤的全切除。     

锁孔入路显微手术的临床应用

目的探讨锁孔入路显微手术在神经外科的应用. 方法采用相应锁孔入路对鞍区占位13例,脑膜瘤6例,高血压性脑出血5例,胼胝体区胶质瘤2例,听神经瘤2例,脑转移瘤、硬膜外血肿和C2椎管内占位各1例实施手术. 结果 25例肿瘤全切19例,次全切除6例;脑出血5例和硬膜外血肿1例均彻底清除.1例听神经瘤术后第3天因瘤腔再次出血死亡,切口下皮下积液2例,一过性尿崩3例. 结论锁孔手术具有脑暴露少,损伤小,并发症少,恢复快等优点.     

超早期小骨窗外侧裂入路显微手术治疗高血压性基底节脑出血

目的总结超早期小骨窗外侧裂入路显微手术治疗高血压性基底节脑出血经验。方法2001年3月～2005年2月，我科对33例高血压性基底节脑出血6h内超早期手术，采用小骨窗开颅，经外侧裂、岛叶入路，显微镜下清除血肿，去骨瓣减压，不放引流，术后严格控制高血压。结果术后CT复查血肿清除彻底。术后肺炎2例。按格拉斯哥预后评分标准随访3个月，良好23例，中残10例。结论超早期小骨窗外侧裂入路显微手术治疗高血压性基底节脑出血，具有创伤小，清除血肿彻底，并发症和致残率低，恢复功能快等优点。     

Trans-supraorbital approach to supratentorial aneurysms

OBJECTIVE: The trans-supraorbital approach has the advantage of combining the keyhole principle with cranial base surgery. The anatomic fields that can be visualized with the use of this procedure have been demonstrated in cadavers, and the advantages and potential surgical applications of this procedure are described in this report. This article is the first to describe a group of intracranial supratentorial aneurysms. METHODS: We used the trans-supraorbital approach in 22 cases of supratentorial aneurysms. In this technique, an incision is made through the eyebrow, then a 3.5-cm craniotomy is performed with en bloc extension to the orbital arch, complemented by different drilling extensions of the orbital roof according to the surgical objective. We describe the anatomic details of the experimental work as well as the clinical results. RESULTS: The trans-supraorbital technique offers an unlimited wide exposure of neurovascular structures in this microsurgical corridor. The craniotomy extension allows greater exposure than the conventional keyhole supraorbital approach, which makes the technique safe for the patient and comfortable for the surgeon. All patient outcomes were successful; no serious complications from the surgical technique occurred. Our success was achieved through better microscopic illumination in the deep field and by gaining access to the complete supratentorial vascular territory with minimal cerebral retraction and an acceptable cosmetic result. CONCLUSION: The trans-supraorbital approach is effective for gaining access to and treating supratentorial aneurysms. Also, the microsurgical field is more convenient in microscope-assisted surgery because total reliance on the endoscope is not required, and minimal brain retraction is needed. This modification of the keyhole procedure also provides multiple surgical options in this microsurgical corridor, using the principles of minimal invasiveness in cranial base surgery.     

两种术式治疗脑室型丘脑出血的对比研究

目的探讨显微技术小骨窗开颅行丘脑血肿清除术＋脑室外引流术与丘脑血肿穿刺引流术＋脑室外引流术治疗脑室型丘脑出血的疗效。方法46例脑室型丘脑出血（大于20ml）患者随机分成A、B两组，A组22例，采用显微技术小骨窗开颅丘脑血肿清除术＋脑室外引流术；B组24例，在CT定位下行丘脑血肿穿刺引流术＋脑室外引流术。结果A组治疗在意识恢复时间、死亡率、GOS评分与B组比较差异有统计学意义（P〈0．05）。结论丘脑血肿大于20ml的脑室型丘脑出血宜采用显微外科小骨窗开颅行丘脑血肿清除术＋脑室外引流术。     

锁孔微创入路手术治疗颅内动脉瘤的风险因素及对策分析

目的 探讨颅内动脉瘤在锁孔手术中破裂的风险因素、适应证选择、手术难点、预防动脉瘤破裂的方法及应急处理措施.方法 回顾性分析1999年至2005年115例动脉瘤患者的临床资料.将动脉瘤破裂风险较低的43例患者通过锁孔微创入路手术治疗（锁孔组）,其余72例患者采用常规开颅手术治疗（常规组）.锁孔组43例患者手术中翼点锁孔入路20例,眶上锁孔入路18例,纵裂锁孔入路5例.常规组72例患者风险高而采用常规翼点开颅31例,额下开颅11例,纵裂开颅7例,翼点-额下联合10例,翼点-纵裂联合6例,额下-纵裂联合4例,翼点-额下-纵裂联合3例.结果 锁孔组术中动脉瘤渗漏6例,破裂出血3例,发生率为7%,无手术死亡.2例在锁孔手术中无法夹闭动脉瘤而改为常规开颅.常规组术中发生动脉瘤渗漏18例,破裂出血9例,发生率为13%,手术后死亡2例.结论 尽管锁孔手术有微创、伤口美观、术后恢复快等优点,但在风险低的患者中动脉瘤渗漏和破裂的风险仍然不能忽视.     

Bilateral supraorbital keyhole approach for multiple aneurysms via superciliary skin incisions

BACKGROUND: Considering that multiple aneurysms carry a high risk for fatal rupture, there is a need for complete treatment of all lesions in one surgical session using either unilateral-contralateral or bilateral approaches. Contralateral approaches have been used mainly for small anteriorly projecting middle cerebral and medially expanding ophthalmic types of aneurysms. They are limited by the narrow space for surgical manipulation, forced elevation of frontal lobes, and stretching of the olfactory nerves. These problems might result in damage to structures along the unusually long intracranial way of the approach. The complications associated with the unnecessarily large conventional fronto-temporal and bifrontal craniotomies, and the developments in visualization, neuroanaesthesia, microneurosurgery, cerebrospinal fluid (CSF) drainage, and brain protection have led to less invasive methods in cerebral base surgery. These achievements have supplied the background for the supraorbital keyhole approach to aneurysms of the anterior circulation or basilar tip. Because the supraorbital keyhole approach offers several advantages over the classic fronto-temporal craniotomies to the anterior skull base, it was extended for both sides in one surgical session to treat bilateral multiple aneurysms as well. METHODS: Out of a series of 150 patients harboring 188 saccular aneurysms operated on via a supraorbital keyhole approach with a superciliar skin incision, 36 had multiple aneurysms. Thirty patients with multiple aneurysms underwent surgery for their ruptured aneurysms (17 cases in the acute phase and 13 patients during the chronic stage); in 6 cases silent aneurysms were operated on. The multiple aneurysms were managed from one side in 18 cases. A bilateral supraorbital keyhole approach was performed during one surgical session in 11 patients, and in 7 cases the unilateral supraorbital keyhole approach was combined with contralateral fronto-temporal (3 cases), suboccipital (2 cases), or frontal-parasagittal (2 cases) exploration. The operations were carried out through an approximately 2.5 x 3 cm supraorbital keyhole craniotomy following a skin incision just above the eyebrow. The roughly 4 cm superciliar skin incision begins medial to the supraorbital nerve and ends 3 to 10 mm beyond the lateral edge of the eyebrow. The technical details of the method are presented, and the benefits, limitations, and complications are discussed. RESULTS: In the 36 patients operated on via the supraorbital keyhole approach 74 aneurysms were clipped successfully. In 2 cases premature intraoperative rupture of the aneurysms occurred, but these events were managed successfully. Despite the small size of the craniotomy the approach allows enough room for intracranial manipulation with maximal protection of the brain and other intracranial structures. One patient died because of pulmonary embolism. There were no craniotomy-related complications in the present series. CONCLUSION: The supraorbital keyhole approach together with the advent of the modern neuroanaesthesia, CSF drainage, and microsurgical techniques is a safe approach in the hands of experienced neurosurgeons for the treatment of supratentorial or basilar tip aneurysms. Because the approach is simple and swift, the bilateral single-session craniotomy does not have any disadvantages compared to two-stage procedures. However, the one-sitting surgery reduces the high risk of fatal rupture in the perioperative period associated with multiple aneurysms.     

显微手术治疗幕上高血压性脑出血的体会

目的探讨显微镜下清除幕上高血压性脑出血的疗效。方法我院2010年1月-2013年1月显微手术治疗30例幕上高血压性脑出血,根据头颅CT影像定位确定手术切口,游离骨瓣开颅,做一长2-3am皮层瘘口,用自动牵开器由浅入深显露血肿,显微镜下清除血肿。结果30例手术均获得成功。术后次日复查头颅CT,14例血肿完全清除,11例血肿清除率达到90％,5例清除率达到80％。术后死亡4例（13．3％）：均于术后4周内死亡：2例死于脑疝所致脑干功能衰竭,1例死于肺部感染,1例死于多脏器功能衰竭。术后3个月ADL分级：I级7例,Ⅱ级9例,Ⅲ级6例,Ⅳ级3例,V级1例。结论显微镜下血肿清除并直视下止血,对脑组织损伤小,止血彻底,疗效满意。