动脉瘤早期手术夹闭后术区继发性脑内血肿的分析

目的 探讨早期手术成功夹闭动脉瘤之后,术区形成继发性脑内血肿的原因.方法 134例颅内动脉瘤开颅夹闭的患者中5例(3.7%)形成术后继发脑内血肿需二次开颅处理,分析术中(包括减压后)额叶挫裂伤程度、创面渗血和术中止血情况、脑压板对脑组织造成的损伤程度.1例难以止血者先留取部分脑挫裂伤组织提前送病理检查;4例第二次开颅清除血肿同时留取出血脑组织送病理检查,综合了解出血的原因.结果 5例手术中均发现蛛网膜下腔出血,脑肿胀明显,脑组织外观呈"紫红色";术中均有不同程度脑压板造成的损伤;病理主要表现为局部出血.出血周围可见"异常血管集中区",主要为细小静脉及毛细血管,血管呈弥漫扩张,部分血栓形成,一些血管壁明显厚薄不一,壁内见有少量中性白细胞浸润.结论 这种脑内血肿的发生与动脉瘤出血所致的早期脑肿胀、患者本身存在脑组织内小血管畸形及术中脑压板牵拉伤有关,术后严密观察能够早期发现,及时处理,效果良好.

Analysis on secondary intracerebral hematoma in the operating area after clipping aneurysm in an early surgery

Objective Investigate the reasons for secondary intracranial hematoma, formed finally due to some rare refractory small hemorrhage of brain tissue in the initial operating area after successfully clipping anearysm in an early surgery. Method 134 cases with intracranial aneurysm underwent clipping through direct cranioctomy were retrospected,5 cases(3.7%) of which were subject to carofnl observation for contusion and laceration severity of frontal lobe (including those after decompression), exudation of wound surface, and hemostasis during the surgery, as well as injury severity of brain tissue due to brain spatula. For one case of them it was hard to control bleeding, a part of "cerebral contusion and laceration" tissue was collected and sent for pathological examination in advance; for the other 4 cases, hematonm was removed through a second cranioctomy, and a part of "hemorrhagic cerebral tissue" was sent for pathological examination, for the purpose of obtaining comprehensive knowledge of the reasons for hemorrhage from pathology, etc. Results Of the 5 cases, it was found that, subarachnoid hemorrhage, obvious brain swelling, and purplish' brain tissue appearance occurred, injury to different extent due to brain spatula occurred during the surgery, and the pathological manifestations were mainly of local hemorrhage. A concentrated area of irregular blood vessels was found around the hemorrhagic site, mainly including minute veins and capillaries; those blood vessels were diffusively dilated, and thrombosis occurred in some of them; the walls of some blood vessels were of inconsistent thickness, and a small neutrophil infiltration was found in the walls. Conclusions Occurrence of such intracerebral hematoma, and early hard cerebral swelling due to aneurysm hemorrhage are associated with patient's inherent small vascular malformation and brain spatula stretch injury during the surgery; it may be found through careful observation after the surgery, and timely treatment is effective.