低成本增强现实技术在高血压脑出血神经内镜治疗中的应用

目的探讨应用低成本增强现实技术在高血压脑出血神经内镜微创治疗中的可行性和可靠性。方法采集17例高血压脑出血拟行神经内镜微创手术治疗患者头颅CT数据,运用3D-slicer免费软件进行虚拟现实重建并设置标记物后,将重建图片导入智能手机,应用相机功能程序进行头皮与重建图片准确融合,精确描画脑内血肿体表投影,实现增强现实技术,个体化选择手术入路,进而在神经内镜辅助下行脑内血肿清除手术。结果运用低成本增强现实技术17例高血压脑出血患者均可成功完成脑内深部血肿穿刺,并经神经内镜观察证实到达目标部位。结论低成本增强现实技术可以为高血压脑出血的神经内镜微创手术治疗提供准确可靠的定位指导。     

介绍一种简易体表标记头颅CT定位法

单纯依靠头颅 CT轴位扫描进行手术或穿刺定位时 ,因为有扫描基线做参照 ,故颅内病变在体表所处的高度易确定 ,但病变前后方向上的体表定位缺少可靠的参照点 ,因此常引起一定程度的偏差 ,影响手术操作。为此 ,作者设计了一种简易体表标记头颅 CT定位法 ,用于某些幕上开颅手术切口设计和穿刺点定位。定位法如下 :( 1 )取内径 3mm塑料管一段约 1 5cm,管内注满按 1∶ 1 0稀释的 76%泛影葡胺溶液 ,两端热封闭制成标记物备用。 ( 2 )病人剃头后标记出 OM线 (听眦线 ) ,然后在耳屏前作一条 OM线垂直线 ,将标记物沿此线放置 ,并用胶布膏固定于头…     

3D-Slicer辅助定位微创软通道引流术治疗中等量高血压脑出血的疗效观察

目的探讨3D-Slicer辅助定位下微创软通道置管外引流术治疗中等量高血压脑出血的临床疗效。方法阜阳市第二人民医院神经外科2016年5月—2018年5月行微创软通道置管外引流术治疗的,出血量在30～60 m L的幕上高血压脑出血患者52例。依据确定脑血肿体表穿刺点的方法不同,将患者分为3D-Slicer辅助定位组(3D-Slicer定位组)和CT定位组(对照组),每组各26例。对比两组患者脑血肿穿刺满意率、尿激酶冲洗次数、术后1 d、3 d血肿清除率、拔管时间、术后并发症及神经功能恢复状况。结果 3DSlicer定位组患者的血肿穿刺满意率、血肿清除率明显高于对照组,尿激酶冲洗次数及拔管时间小于对照组,差异均有统计学意义(均P 0. 05)。两组再出血及颅内感染方面并发症之间差异无统计学意义(均P0. 05)。术后3个月时,3D-Slicer定位组患者的日常生活能力显著优于对照组(P 0. 05)。结论 3D-Slicer可为高血压脑出血微创软通道置管血肿引流手术,提供更加精准的体表定位;并可在术后较短时间内彻底引流血肿,临床疗效显著。     

幕上脑内血肿简易定位穿刺引流法

目的 介绍一种简单易行可靠的幕上脑内血肿定位穿刺方法。方法 回顾性分析2016年1月至2017年12月收治的58例幕上大脑半球出血的临床资料,根据头颅CT平扫轴位相,首先确定穿刺平面,然后测量拟穿刺点到中线的皮肤表面距离和穿刺深度,换算为实际距离和深度,确定头部血肿穿刺点行钻孔引流术。结果 58例经此法行血肿穿刺引流术,术后CT证实,穿刺位置准确,穿刺成功率100%。结论 此种幕上脑内血肿定位穿刺法,简单易行,经济,准确率较高。     

Mimics软件在高血压性脑出血穿刺引流术中的应用价值

目的 探讨mimics软件在高血压性脑出血穿刺引流术中的临床应用价值。方法 将15例高血压性脑出血的CT影像数据导入mimics软件并对血肿进行三维重建,根据重建血肿大小、形态及其中心距颅骨内板距离设计穿刺位点及路径,对比分析手术前后CT影像,对治疗效果进行综合评估。结果 15例均成功穿刺,且全部引流管均置入理想靶点。手术时间仅（30.9±4.1）min,术中失血量（44.7±8.3）ml。整个手术过程及围手术期无须输血。结论 运用mimics软件辅助高血压性脑出血穿刺引流术,不仅操作简单、定位准确,且更符合微创外科理念。     

增强现实技术辅助神经内镜微创手术治疗高血压脑出血

目的探讨增强现实技术在神经内镜微创手术治疗高血压脑出血(HICH)的临床应用价值。方法分析20例增强现实技术辅助神经内镜精准手术治疗HICH的临床资料。术前手术穿刺部位和血肿侧颞部贴电极片,CT扫描并用3D-Slicer软件对头颅CT DICOM格式数据资料进行三维重建,模拟穿刺路径、测量穿刺深度、血肿体积。投影三维重建模型(包括电极片和血肿模型)与患者预贴电极片位置吻后,标记血肿体表投影、穿刺路径投影,术中激光指导穿刺方向,应用神经内镜微创清除血肿。结果根据术前3D-Slicer软件重建结果投影,结合激光定位,均成功穿刺血肿达目标位置,并在神经内镜辅助下顺利完成手术操作。本组病例手术时间18~85min,平均(32±3.5)min;术中失血5~15ml,平均(8±2.6)ml;术后CT复查提示血肿残留平均约(2.12±2.00)ml,血肿清除率达95.67%±4.07%;住院时间8~35d,平均(19.40±7.65)d;未发现颅内再出血及与手术相关并发症。结论增强现实技术结合激光定位可为HICH内镜微创手术提供精确的穿刺定位,提高手术成功率。     

颞下入路的显微解剖学研究

目的研究颞下入路中小脑幕中切迹间隙的解剖结构，指导临床手术入路的选择。方法在手术显微镜下模拟颞下入路对10例经甲醛溶液固定的国人成人尸头标本进行逐层解剖，并观察、测量重要神经解剖结构之间的关系，描述颞下手术入路所暴露的视野范围，然后切开小脑幕，观察增加的暴露范围。结果颧弓至脑干和小脑幕游离缘的最短距离分别为（46.83±3.52）mm和（39.00±2.65）mm；天幕游离缘与滑车神经、小脑上动脉、大脑后动脉和三叉神经后根的距离分别为（1.90±0.55）mm、（5.12±2.20）mm、（3.28±1.67）mm、（0.80±0.20）mm。结论颞下入路手术治疗小脑幕中切迹间隙病变具有手术操作距离短、垂直视角大、对中切迹间隙的暴露范围广泛等优点。     

简易平面定位器在高血压脑出血穿刺引流术的应用

1对象与方法 （图1~3）2013年1月-2013年12月京山县人民医院神经外科以自制简易平面定位仪,行血肿腔置管引流[1]治疗25例适合行血肿腔软通道引流的幕上中等量高血压脑出血病人。简易平面定位仪制作：取1个具有2个相交垂直面的高分子塑料材料,下缘切割打磨,形成适合颅骨球形表面弧形,2个垂直平面交线处做1个穿刺针管可顺利进出的孔道,直径约4 mm,此为穿刺角。     

神经导航下经乙状窦后入路术中打开内听道及内听道的解剖研究

目的探讨基于显微镜的神经导航系统在乙状窦后入路中打开内听道中的作用,为经乙状窦后入路中安全打开内听道提供解剖研究。方法对8具16侧成人汉族尸头标本在神经导航指引下完成乙状窦后入路中到达内听道,观测内听道的解剖及其与重要结构的关系。结果均成功导航,到达内听道的导航平均定位误差是(0.71±0.20)mm,到达后半规管的解剖定位误差是(0.68±0.42)mm。内耳门后下缘到乙状窦后缘中点的距离左侧为(32.15±1.76)mm,右侧为(33.34 ±1.57)mm,内耳门后下缘到后半规管后缘中点的距离左侧为(12.51±2.15)mm,右侧为(13.26±2.44)mm。结论神经导航辅助下打开内听道有肯定的价值;熟悉内耳门及周围结构的显微解剖有助于手术中保护重要结构,     

颅内血肿微创手术及亚低温脑保护的临床研究

目的 探讨颅内血肿微创手术的优越性及围手术期亚低温脑保护的临床效果。方法 对１００例内血肿病人转手术期亚低温脑保护同时予以微创血肿清除术。其中外伤性颅内血肿５３例，高血压性脑内血肿４０例，自发性脑内血肿（脑动静脉畸形或脑动脉瘤）７例。结果术后半年随访内血肿ＡＤＬ１（社会生活能力正常）３７例，ＡＤＬ２（有自理生活能力）２５例，ＡＤＬ３（部分生活处理）２６例，ＡＤＬ４（卧床）７例，ＡＤＬ５（植物生存     

应用简化增强现实技术辅助定位引流术治疗老年幕上脑出血的临床研究

目的 通过对比分析评价利用智能手机简化增强现实(AR)技术辅助定位引流术治疗老年幕上脑出血的应用价值.方法 回顾性分析221例引流手术治疗的老年幕上脑出血患者(出血量20～ 40 mL)的临床资料,其中行简化AR技术辅助定位引流术(观察组)108例,行立体定向引流术(对照组)113例.对比两组患者手术时间,置管位置准确...     

Clinical application of 3DSlicer and Sina in minimally invasive puncture drainage of elderly patients with spontaneous intracerebral hemorrhage under local anesthesia

BackgroundDecreased organ function and poor physical compensatory capacity in elderly patients diagnosed with spontaneous intracerebral hemorrhage (ICH) can make surgical treatment procedures challenging and risky. Minimally invasive puncture drainage (MIPD) combined with urokinase infusion therapy is a safe and feasible method of treating ICH. This study aimed to compare the treatment efficacy of MIPD conducted under local anesthesia using either 3DSlicer + Sina application or computer tomography (CT)–guided stereotactic localization of hematomas in elderly patients diagnosed with ICH.MethodsThe study sample included 78 elderly patients (≥ 65 years of age) diagnosed with ICH for the first time. All patients exhibited stable vital signs and underwent surgical treatment. The study sample was randomly divided into two groups, either receiving 3DSlicer+Sina or CT-guided stereotactic assistance. The preoperative preparation time; hematoma localization accuracy rate; satisfactory hematoma puncture rate; hematoma clearance rate; postoperative rebleeding rate; Glasgow Coma Scale (GCS) score after 7 days; and modified Rankin scale (mRS) score 6 months after surgery were compared between the two groups.ResultsNo significant differences in gender, age, preoperative GCS score, preoperative hematoma volume (HV), and surgical duration were observed between the two groups (all p-values > 0.05). However, the preoperative preparation time was shorter in the group receiving 3DSlicer + Sina assistance compared to that receiving CT-guided stereotactic assistance (p-value < 0.001). Both groups exhibited significant improvement in GCS scores and reduction in HV after surgery (all p-values < 0.001). The accuracy of hematoma localization and puncture was 100% in both groups. There were no significant differences in surgical duration, postoperative hematoma clearance rate, rebleeding rate, postoperative GCS and mRS scores between the two groups (all p-values > 0.05).ConclusionsA combination of 3DSlicer and Sina is effective in accurately identifying hematomas in elderly patients with ICH exhibiting stable vital signs, thus simplifying MIPD surgeries conducted under local anesthesia. This procedure may also be preferred over CT-guided stereotactic localization in clinical practice due to its ease of use and accuracy in hematoma localization.     

Prognosis for patients treated conservatively for spontaneous intracerebral hematomas

The long-term clinical and CT-outcome of 53 conservatively treated patients with spontaneous intracerebral hematomas (ICH) was studied in relation to the acute findings. The acute mortality of ICH was 27%. Determinant for the immediate prognosis was the level of consciousness and the volume of the hematoma. The crucial size was 50 ml with a mortality of 90% for hematomas larger and 10% for hematomas smaller than that. Intraventricular hemorrhage was a bad prognostic sign only in the ganglionic-thalamic hematomas. At follow-up at a median of 4 1/2 years after ICH, 30% of the total series had a completely normal neurological examination and 28% had resumed work. Thirteen per cent had minor neurological deficits and 17% had debilitating sequelae. During the follow-up period 7 patients had died, which indicates an excess mortality for ICH survivors. The CT findings at follow-up consisted of low density areas smaller than the original hematomas, focal atrophy, calcifications and porencephalic cysts. In 10% the CT scan revealed no trace of the previous hematoma.     

Intracerebral Hematoma Caused by Ruptured Traumatic Pseudoaneurysm of the Middle Meningeal Artery : A Case Report

Hematomas caused by ruptured traumatic pseudoaneurysms of the middle meningeal artery (MMA) usually present with extradural hematomas, whereas intradural intraparenchymal hematomas are extremely rare. We report a case of traumatic pseudoaneurysm of the MMA giving rise to an intracerebral hematoma after head trauma. A 70-year-old man suffered a massive intracerebral temporoparietal hemorrhage after a head injury. CT angiogram of the brain revealed a large hematoma in the right middle cranial fossa extending to the right sylvian fissure. Cerebral angiogram also revealed a pseudoaneurysm of the MMA, which was successfully treated surgically. Although traumatic MMA pseudoaneurysm producing intracerebral hematoma (ICH) is rare, it should be considered as a possible cause of intracerebral hematoma.     

便携式神经内镜在脑内血肿清除术和开放性颅脑损伤有限清创术中的应用

目的 探讨便携式神经内镜在脑内血肿清除术和开放性颅脑损伤有限清创术中的应用价值。方法 在头颅模型内注入硅胶作为脑实质,用垂物法投入模拟血包,制作脑内血肿,应用便携式神经内镜模拟清除脑内血肿;取10只比格犬制作开放性颅脑损伤模型,应用便携式神经内镜模拟进行有限清创术。结果 5例脑内血肿模拟清除术均顺利完成,血肿量为（30.00±7.91）ml,血肿清除时间为（1.28±0.45）min,血肿清除效率为（24.05±2.51）ml/min,血肿清除体积为（27.20±6.83）ml,血肿清除率为（90.98±2.73）%。10只比格犬开放性颅脑损伤模型在便携式超声实时引导下完成有限清创术,异物数量为（4.00±1.49）个,手术时间为（25.20±9.66）min,异物取出数量为（2.90±1.10）个,单个异物清除时间为（9.50±2.83）min,异物清除率为（73.17±16.22）%;手术前后CT示颅内无继发性出血,但是积气增多。结论 利用便携式神经内镜对脑内血肿进行血肿清除术,或对开放性颅脑损伤进行有限清创术,都是可行、有效的。     

急诊手术治疗大脑中动脉动脉瘤破裂合并脑内血肿

目的 总结大脑中动脉动脉瘤破裂合并脑内血肿的急诊手术方法 及疗效.方法 急诊手术治疗大脑中动脉动脉瘤破裂合并脑内血肿患者13 例,术中均先清除部分血肿减压,然后采用经侧裂近端-远端入路行动脉瘤夹闭术.8 例患者术前行CTA 检查明确动脉瘤,5 例患者直接手术探查发现动脉瘤.结果 13例患者均在血肿清除同时成功夹闭动脉...     

The prognostic value of the CT scan in conservatively treated patients with intracerebral hematoma

Prognostic factors for survival and neurological recovery were assessed in 42 patients with nontraumatic intracerebral hematoma (ICH) diagnosed by CT scan. None underwent surgical evacuation of hematoma. CT scans were used to determine location and volume of ICH and presence or absence of intraventricular hemorrhage (IVH). Only 11 patients (26%) died and 17 patients (40.5%) recovered fully. Mortality was associated with: 1) loss of consciousness as a presenting symptom (63.5% mortality rate versus 13% when there was no loss of consciousness at the onset; p less than 0.01). 2) extension of the bleeding into the ventricular system (45% mortality rate versus 9% when hemorrhages were confined to brain parenchyma; p less than 0.01). 3) location of hematoma in the posterior fossa (mortality rate of 43% versus 23% for intrahemispheric hematomas). Mortality was unaffected by age of patients and size of ICH. Full neurological and functional recovery occurred mainly when estimated volume of hematomas was less than 15 cc and with lobar hematomas regardless of size. In survivors there is CT evidence of complete resolution of ICH. Our data indicates a favourable outcome in a relatively large percentage of patients with ICH treated conservatively and therefore questions the need for surgical evacuation of hematoma.     

Demonstration of hypoperfusion surrounding intracerebral hematoma in humans.

We undertook this study to determine whether ischemic regions are present that may contribute to poor outcome after intracerebral hemorrhage (ICH) in humans. Hypoperfusion around an ICH has not been reported in humans. Brain computed tomography (CT) and (99m)Tc-HMPAO brain single photon emission computed tomography (SPECT) perfusion studies were carried out 51 +/- 12 hours after supratentorial ICH in seven patients selected from a referral hospital over an 8-month period. The widest diameters of the hematoma on CT and of reduced perfusion on SPECT were measured and compared. The diameters of reduced perfusion were measured at the 40% and 20% reduced count levels compared with the contralateral side. Reduced perfusion in and around the hematoma was seen in all seven cases. The diameters of ICH on CT (mean, 53 +/- 12 mm) were comparable to the diameters of 40% reduction of counts (mean, 61 +/- 14 mm) measured by SPECT. The mean diameter of brain demonstrating 20% reduction in counts was 76+/-19 mm, which was 43% greater than the hematoma diameter on CT (p = .004). In conclusion, substantial regions of reduced perfusion surround ICH in humans, which might contribute to poor outcome and be amenable to anti-ischemic therapy.     

Surgery for Bilateral Large Intracranial Traumatic Hematomas: Evacuation in a Single Session

Objective

Management guidelines for single intracranial hematomas have been established, but the optimal management of multiple hematomas has little known. We present bilateral traumatic supratentorial hematomas that each has enough volume to be evacuated and discuss how to operate effectively it in a single anesthesia.

Methods

In total, 203 patients underwent evacuation and/or decompressive craniectomies for acute intracranial hematomas over 5 years. Among them, only eight cases (3.9%) underwent operations for bilateral intracranial hematomas in a single session. Injury mechanism, initial Glasgow Coma Scale score, types of intracranial lesions, surgical methods, and Glasgow outcome scale were evaluated.

Results

The most common injury mechanism was a fall (four cases). The types of intracranial lesions were epidural hematoma (EDH)/intracerebral hematoma (ICH) in five, EDH/EDH in one, EDH/subdural hematoma (SDH) in one, and ICH/SDH in one. All cases except one had an EDH. The EDH was addressed first in all cases. Then, the evacuation of the ICH was performed through a small craniotomy or burr hole. All patients except one survived.

Conclusion

Bilateral intracranial hematomas that should be removed in a single-session operation are rare. Epidural hematomas almost always occur in these cases and should be removed first to prevent the hematoma from growing during the surgery. Then, the other hematoma, contralateral to the EDH, can be evacuated with a small craniotomy.     

Endoscopic treatment of the spontaneous intracerebral hematomas

BACKGROUND AND PURPOSE: Surgical evacuation of spontaneous intracerebral hematomas (ICH) performed in a traditional way usually increases primary brain tissue damage due to the hemorrhage. On the other hand, symptoms of the intracerebral pressure and secondary brain tissue destruction close to the hematoma are the basis for making a decision about surgical treatment. In order to limit surgical trauma we started research to evaluate the usefulness of endoscopic surgery in the treatment of ICH. MATERIAL AND METHODS: Twenty three cases were included in the study. Patients with consciousness disorders and/or focal neurological deficit and different systemic diseases were qualified for endoscopic evacuation. The diagnosis of hematoma was based on computed tomography (CT). ICHs were lobar and in certain cases they extended to the basal ganglia. All patients were operated on within one week from the onset of symptoms. Neuroendoscope was introduced to the hematoma cavity through the burr hole and the puncture of the cerebral surface over the hematoma. The hematoma was evacuated by fractionated rinsing. Bigger clots were fragmentized but those which were adjacent to the cavity wall were left. Postoperative assessment of the hematoma evacuation was based on CT performed immediately and in the second week after surgery. RESULTS: Total evacuation of the ICH was achieved in 6 patients, and its volume was reduced in 17 cases. Symptoms of brain edema resolved in all patients. A significant trend to reduce focal neurological deficits was observed: 16 patients improved and 3 remained unchanged. Four patients died. CONCLUSIONS: Endoscopic surgery allows a complete hematoma evacuation or reduction of its volume, reduces symptoms of brain edema and accelerates the improvement of focal neurological deficits.