Surgical treatment of hypertensive cerebellar hemorrhage; stereotactic aspiration surgery vs suboccipital craniectomy]

Patients with severe types of hypertensive cerebellar hemorrhage have been treated usually by suboccipital craniectomy and hematoma evacuation. However, since 1981, we have treated such patients with stereotactic aspiration surgery. The purpose of this study was to evaluate the prognosis of patients treated by stereotactic aspiration surgery for cerebellar hemorrhage in comparison with those who underwent suboccipital craniectomy. Between May 1976 and December 1989, 246 patients with hypertensive cerebellar hemorrhage were admitted to our university hospital and affiliated hospitals. The patients were classified into four categories according to the grading of hypertensive cerebellar hemorrhage proposed by Matsumoto in 1982; benign, moderate, severe, and fulminant. Then we decided the most appropriate therapy according to this grading. Fifty-nine patients (24.0%) underwent suboccipital craniectomy and 38 (15.4%) underwent stereotactic aspiration surgery. There was no significant difference in the postoperative outcome between suboccipital craniectomy and stereotactic aspiration surgery in the overall study. However prognosis of the fulminant type was significantly better with stereotactic aspiration surgery than with suboccipital craniectomy. Possible reasons for this include: 1) All patients of this type who underwent aspiration surgery had this procedure within 12 hours after the onset of cerebellar hemorrhage. 2) The hematoma volume of most patients of this type who had aspiration surgery was under 30ml. 3) The age of all patients of this type with aspiration surgery was under 70 years old. In conclusion, we suggest that aspiration surgery for hypertensive cerebellar hemorrhage is indicated for all patients with moderate, severe and fulminant types of hemorrhage.     

Relationship between motor disturbance and involvement of internal capsule in hypertensive thalamic hemorrhage

We treated a consecutive series of 309 patients with hypertensive thalamic hemorrhage from April 1981 to December 1987. In 99 cases of involvement of the internal capsule, the relationship between the extent of destruction of the internal capsule and motor disturbance was clinically investigated and discussed. First, these 99 cases were classified into three groups on the basis of the location of the hematoma in the internal capsule on the CT image. All the cases were confined to the anterior, middle and posterior portions of the posterior limb of the internal capsule. The correlation between hematoma extension and the severity of motor weakness, its improvement nd prognosis were discussed. The severity of motor weakness was found not to be related to hematoma extension. On the other hand, the prognosis was frequently poor when the hematoma was located at the posterior portion within the posterior limb of the internal capsule. In hypertensive thalamic hemorrhage, there seemed to be a narrow and significant area within the posterior limb of the internal capsule which determined morbidity. And, as a matter of course, the nearer the hematoma was located to the border between the middle and posterior portions, the worse the outcome was. Cases treated by aspiration surgery were evaluated to investigate the utility of aspiration surgery for thalamic hemorrhage. (Special attention was given to the ADL of those cases with severe motor weakness.) When the hematoma was located at the posterior portion of the posterior limb of the internal capsule, the percentage of patients with good outcome was significantly higher in the aspirated group than in the medical group (p less than 0.05).     

高血压小脑出血致呼吸骤停13例患者手术疗效分析

目的探讨高血压小脑出血致呼吸骤停患者的手术治疗价值。方法回顾性分析大连医科大学附属第一医院神经外科收治的13例高血压小脑出血致呼吸骤停患者的临床资料,13例患者均急行气管插管呼吸支持、脱水降颅内压等急诊干预后,立即行开颅血肿清除,后颅窝减压,枕骨大孔开放术,必要时联合侧脑室外引流术。用GOS评分评价治疗效果,将所有患者按年龄、血肿量、是否梗阻性脑积水、发病至呼吸骤停时间、呼吸骤停至手术时间分组统计分析。结果年龄在60岁以下,血肿量在30ml以下,发病至呼吸骤停时间不小于3．5h,呼吸骤停至手术小于1h,手术治疗效果较好,反之,手术效果差;是否有梗阻性脑积水无明显统计学意义。结论高血压小脑出血致呼吸骤停患者,只要在血压、心率平稳前提下,部分病人仍应尽快积极手术治疗,仍可获得较满意效果,保守治疗效果差。     

Emergency manual aspiration for severe hypertensive cerebellar hemorrhage]

We treated 16 patients with hypertensive cerebellar hemorrhage and coma, or deep coma. Their ages ranged from 44 to 79 years (mean age: 66.3 years). Manual aspiration was performed in 9 patients and suboccipital craniectomy was performed in 7 patients. The difference in outcome between the manual aspiration group and the suboccipital craniectomy group with severe hypertensive cerebellar hemorrhage was then evaluated. Manual aspiration was performed for 4 patients in coma, and 5 in deep coma, with a mean age of 69.0 years. The average size of the hematoma was 48.7mm and the mean volume was 31. 7ml on CT scan. The mean interval from admission to operation was about 60 minutes. The mean aspiration rate was 79.6% and 7 patients (77.8%) had a good response to drainage. The suboccipital craniectomy patients included 5 in coma, and 2 in deep coma, with a mean age of 63.4 years. The average size of the hematoma was 51.1 mm and the mean volume was 33.1 ml on CT scan. The mean interval from admission to operation was about 112 minutes and the mean evacuation rate was 86.4%. The results were as follows: 1) After manual aspiration, 5 patients (55.6%) had a good outcome and 2 patients (40%) with deep coma showed good recovery. In contrast, after suboccipital craniectomy only 2 patients (28.6%) had a good outcome and all of the deep coma patients showed poor recovery. 2) The outcome may be most strongly influenced by the duration from admission to operation. 3) All patients with a hematoma volume of over 30 ml had a poor outcome.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intracerebral hemorrhage from a metastatic brain tumor. Importance of differential diagnosis preceding stereotaxic hematoma aspiration

Three cases of sudden intracerebral hemorrhage, which were diagnosed as hemorrhage from metastatic brain tumors following stereotaxic aspiration of a hematoma, are reported. Two cases had subcortical hemorrhage and one had cerebellar hemorrhage. Neither contrast-enhanced computed tomography scans nor angiograms revealed any findings other than those indicating the hematoma in all three cases. However, retrospective study of the anamnesis showed very mild symptoms due to metastasis to the brain or spinal cord in one case each. In cases of intracerebral hematoma located at atypical sites, extreme care is required for the differential diagnosis.     

Stereotaxic evacuation of spontaneous intracerebral hematomas

The authors describe a new device for removal of intracerebral hematomas, based on the principle of stereotaxic evacuation of these lesions proposed in 1978 by Backlund and von Holst. The optimum parameters of stereotaxic aspiration, including speed of screw rotation and amount of suction, have been determined experimentally. Computerized tomography scanning was used to locate the hematoma site, to assess its volume, and to determine stereotaxic coordinates. A new method of preventing rebleeding is also described. This procedure was used to aspirate hematomas in 32 patients with spontaneous intracerebral hemorrhage, including one case caused by aneurysmal rupture and one secondary to rupture of an arteriovenous malformation. All patients were operated on in a severely comatose or semicomatose state. In all but four cases, the hematomas were almost totally removed. Three patients were operated on twice because of recurrent bleeding. The mortality rate for the series was 22%. A preliminary conclusion is made that this new method is safer and less traumatic than open surgery in most cases of severe intracerebral hematoma.     

高血压性基底节区脑出血的显微手术治疗

目的探讨经侧裂-岛叶入路显微手术治疗高血压性基底节区脑出血的效果。方法2008年8月～2012年8月对25例高血压性基底节区脑出血在显微镜下分离外侧裂,经岛叶无血管区进入血肿腔,行血肿清除术。术后按照严格的内科治疗,控制血压,神经营养,康复治疗,进行ADL评分。结果术后存活24例,死亡1例（4．0％）。24例术后3个月按ADL评分：Ⅱ级13例（54．2％）,Ⅲ级8例（33．3％）,Ⅳ级2例（8．3％）,Ⅴ级1例（4．2％）。结论经侧裂-岛叶人路显微手术治疗高血压性基底节区脑出血创伤小,疗效满意。     

Functional outcome of primary pontine hemorrhage: conservative treatment or stereotaxic surgery

In this study we compared the outcome of patients with primary pontine hemorrhage (PPH) in those who underwent stereotaxic aspiration and those treated non-surgically. Out of 75 PPHs, 37 patients were selected. Their consciousness on admission was somnolent to semicoma (alert and deeply comatose cases were excluded). Patients admitted between 1988 and 1990, and between 1995 and 1996 underwent CT guided stereotaxic aspiration (18 cases: Surgical Group), and those admitted between 1991 and 1994 were treated conservatively (19 cases: Conservative Group). The outcome was analyzed three months after the onset from the viewpoint of level of consciousness and severity of paresis, according to the location of the hemorrhage. With regard to consciousness, 13 of 18 cases in the Surgical Group showed remarkable improvement, while only 8 of 19 cases in the Conservative Group did. The severity of paresis was evaluated only among the patients who could obey commands three months after the onset. Paresis improved in 7 of 13 patients in the Surgical Group, vs. in 3 of 8 patients in the Conservative Group (p < 0.05). According to the location of hemorrhage (CT classification), in the Unilateral tegmental type and the Massive type, the Surgical Group and the Conservative Group showed no difference. On the other hand, in the Bilateral tegmental type and the Basal tegmental type, surgery seemed to be more effective than conservative treatment. In conclusion, CT guided stereotaxic aspiration may improve not only the consciousness level but also the functional outcome.     

高血压脑出血的微侵袭治疗

目的探讨高血压脑出血的术式选择策略及功能保护技巧。方法回顾性分析75例高血压脑出血手术治疗病例,其中传统骨瓣开颅31例;直切口小骨窗开颅19例;立体定向血肿穿刺引流25例。结果血肿完全清除18例,近全清除57例,术后1个月以内死亡5例（6.7%）。71例随访6～30个月,按ADL分级Ⅰ级15例（21.1%）,Ⅱ级20例（28.2%）,Ⅲ级21例（29.6%）,Ⅳ级10例（14.1%）,Ⅴ级5例（7.0%）。结论应根据术前病情分级、血肿CT分型、患者年龄等因素合理选择不同的手术方式。显微镜下微侵袭操作,三种手术方法均创伤小,术后神经功能恢复好且快。     

小骨窗开颅显微手术治疗基底节高血压脑出血

目的探讨小骨窗开颅微创治疗基底节高血压脑出血的临床疗效。方法对138例基底节区高血压脑出血患者采用小骨窗开颅,显微镜下清除血肿。结果术后24h内复查CT显示,117例血肿清除90%以上,21例血肿清除80%以上。死亡13例,其中5例死于术后再出血所致的脑疝,3例死于肺部感染,2例死于多器官衰竭,死于颅内感染、气道梗阻及消化道大出血各1例。术后生存125例,平均随访8(3～12)个月,日常生活能力(ADL)分级:Ⅰ级25例,Ⅱ级49例,Ⅲ级34例,Ⅳ级15例,Ⅴ级2例。结论小骨窗开颅显微手术创伤小,术野显露充分,血肿清除彻底,止血可靠,是治疗基底节高血压脑出血的有效手术方式之一。     

Spontaneous cerebellar hemorrhage: clinical remarks on 50 cases

BACKGROUND: Only during the past 10 years have spontaneous cerebellar hemorrhages became a well-defined nosological entity. The surgical indication remains debatable. Our primary objective in this study was to set the criteria for undertaking surgery by determining the critical diameter of the hematoma and considering the patients' neurological status (Glasgow Coma Scale). METHODS: During the 8-year period 1990 through 1997 a series of 50 consecutive patients with spontaneous cerebellar hemorrhage were admitted to the Emergency Neurosurgery Unit, University of Rome "La Sapienza" (Italy). On admission all patients underwent a standard neurological examination, (Glasgow Coma Scale) and a computed tomographic scan. The diameter and the site of the hematoma, a coexisting tight posterior fossa, and the presence of hypertensive hydrocephalus were the criteria, in association with the patients' neurological status, used as indications for surgery. RESULTS: Operative mortality was nil; and perioperative mortality eight patients (16%, increasing to 24% including the four patients who were deeply comatose on admission). Most patients who died (seven of eight) had two or more general medical risk factors (arterial hypertension and diabetes mellitus; arterial hypertension and liver disease; or liver disease and hematological disorders). CONCLUSION: In patients presenting with spontaneous cerebellar hemorrhage the essential criteria indicating surgery are a hematoma 40 mm x 30 mm on CT imaging in the cerebellar hemisphere or 35 mm x 25 mm on CT imaging in the vermis, the presence of a tight posterior fossa (critical size reduced by 10 mm), and a Glasgow Coma Score less than 13.     

自制球囊止血装置在高血压脑出血手术中的临床应用

目的探讨高血压脑出血术后再出血的防治方法。方法先后对102例高血压脑出血患者施行小骨窗直视下血肿清除手术,随机将其分为自制球囊引流组(观察组)和血肿腔常规引流组(对照组),分时段复查CT,按ADL分级观察术后1个月时预后情况,比较两组间再出血情况及近期疗效。结果观察组发生再出血2例,对照组发生再出血14例;观察组较常规对照组术后再出血明显减少(P<0.05);按ADL分级术后1个月预后情况:观察组优良率达87.18%,对照组为66.67%,观察组明显好于对照组(P<0.05)。结论自制球囊止血装置在高血压脑出血中的应用,对减少术后再出血有良好的防治作用,能明显改善患者的预后。     

微创幕上血肿抽吸引流术后患者死亡相关因素分析

目的探讨幕上脑出血患者行微创血肿抽吸引流术预后的影响因素。方法回顾性分析2009年1月~2013年1月我科采用微创颅内血肿抽吸引流术治疗的129例幕上脑出血患者的临床资料,并对可能影响其预后及死亡的相关因素进行单因素和多因素分析。结果术后死亡16例(12.4%)。单因素分析结果显示患者术前血肿体积(P=0.021或P=0.013)、GCS评分(P=0.011)、糖尿病史(P=0.045)及高血压病史(P=0.039)是影响预后的相关因素,多因素分析显示术前GCS评分(≤8)是患者术后死亡的独立危险因素。结论术前GCS评分≤8是预测幕上脑出血患者血肿抽吸引流术术后死亡风险的独立危险因素,应根据患者意识状态合理选择治疗方案。     

Grading and operative indication for hypertensive cerebellar hemorrhage

Fifty six patients with hypertensive cerebellar hemorrhage diagnosed by CT scan were hospitalized from November 1976 up to June 1984. The 35 male and 21 female patients ranged in age from 24 to 84 years, and 39 of them were operated on. The important factors related to prognosis of cerebellar hemorrhage were level of consciousness, size of hematoma on CT scan, and massive ventricular hemorrhage resulting in obstruction of the ventricular system. We classified the patient with cerebellar hemorrhage into 5 grades, according to the severity of these factors. Grade I indicates cerebellar signs without disturbance of consciousness and size of hematoma less than 25 mm measured by CT scan. Grade II indicates disturbance of consciousness (stupor), or progressive neurological deficits, and size of hematoma less than 50 mm without acute hydrocephalus. Grade III reveals disturbance of consciousness (stupor-semicoma), and size of hematoma less than 50 mm with acute hydrocephalus. Grade IV reveals severe disturbance of consciousness (semicoma), and size of hematoma less than 50 mm with massive ventricular hemorrhage. Grade V exhibits deep coma, and more than 50 mm diameter of hematoma. The prognosis of all of 9 patients in Grade I was good, Eleven out of 13 patients (85%) in Grade II and all of 9 patients in Grade III were alive. Fourteen out of 19 patients (74%) in Grade IV and all of 6 patients in Grade V expired in spite of operation. The patients of Grade I should be treated by conservative therapy. The patients of Grade II, Grade III, and Grade IV should be managed surgically. Surgical treatment for Grade V is not advisable.     

微侵袭血肿清除术对高血压脑出血患者术后神经功能恢复及并发症的影响

目的 分析微侵袭血肿清除术对高血压脑出血患者术后神经功能恢复及并发症的影响。方法 选取2017年6月至2020年5月期间我院38例高血压脑出血患者,按照手术方式不同将患者分为微侵袭组（n=12）和大骨瓣组（n=26）。微侵袭组给予微侵袭血肿清除术治疗;大骨瓣组采用基底节区改良翼点入路,骨窗大小约为6 cm×8 cm。比较两组患者临床疗效、手术情况、临床神经功能缺失量表（NDS）评分、日常生活能力量表（ADL）评分以及并发症发生情况。结果 微侵袭组患者总好转率为91.67%,高于大骨瓣组的73.07%,差异无统计学意义（P>0.05）;微侵袭组手术时间、术中出血量明显小于大骨瓣组（P<0.05）,两组血肿清除率、住院时间比较无明显差异（P>0.05）;手术后3个月,两组患者NDS评分均明显低于本组手术前（P<0.05）,ADL评分均明显高于本组手术前（P<0.05）,微侵袭组患者NDS评分明显低于大骨瓣组（P<0.05）,ADL评分明显高于大骨瓣组（P<0.05）;两组患者颅内感染、肺部感染以及再出血并发症总发生率对比无统计学差异（P>0.05）。结论 与传统大骨瓣开颅术相比,微侵袭血肿清除术治疗高血压脑出血更加安全有效,患者术后神经功能恢复更好,并发症更少。     

Clinical study of hypertensive cerebellar hemorrhage: surgical indication and measurement of volume of hematoma

There have been a few reports available for determining surgical indications in hypertensive cerebellar hemorrhage based on volume of hematoma on computerized tomography (CT). The authors then studied the clinical results of hypertensive cerebellar hemorrhage, and the surgical indication based on clinical findings and volume of hematoma on CT scan was considered. Forty-five patients with hypertensive cerebellar hemorrhage diagnosed by CT scan who were hospitalized to Matsue Red Cross Hospital from January 1980 up to December 1986 were studied. The 25 male and 20 female patients ranged in age from 52 to 85 years, and 16 of them were operated on. The results were as follows: 1) The Kanaya's neurological grading tended to be high in the patients with cerebellar vermis hemorrhage or a large volume of hematoma (greater than or equal to 30 ml). 2) In patients with grade I or II and a moderate volume of hematoma (15-30 ml), the patient complicated with hydrocephalus should be treated with ventricular drainage. The patients with grade III and IVa should be treated with surgical therapy (suboccipital craniectomy and evacuation of the hematoma). The patients with cerebellar vermis hemorrhage should be treated with surgical therapy. The patients with a large volume of hematoma (greater than or equal to 30 ml) should be treated with surgical therapy. The patients with grade IVb and V should not be treated actively because the prognosis is bad.(ABSTRACT TRUNCATED AT 250 WORDS)     

微创穿刺术治疗中等量高血压脑出血的疗效分析

目的 评价微创穿刺清除术与传统保守治疗中等量基底节区高血压脑出血的效果。方法：回顾性分析84例中等量（30~60 ml）高血压基底节区脑出血患者临床资料,分为微创穿刺血肿清除术（微创组,45例）和传统保守治疗（保守组39例）,评价两组患者1周时的意识恢复情况、治疗1个月时神经功能缺损程度(NID)和3个月时日常生活活动能力(ADL)。结果 治疗第7天时微创组的意识恢复率（75.6%）明显高于保守组（46.0%）;1个月后微创组患者的NID明显低于保守组（P<0.05）;治疗3个月后随访,患者ADL达自理水平的较好状态者（Barthel指数≥80）,两组有显著性差异（P<0.05）,微创组优于保守组。结论：与保守组相比,微创穿刺术可明显改善中等量基底节区脑出血患者早期的意识状况,改善神经功能缺失程度、提高患者日常生活活动能力,降低病残率。     

CT-guided stereotaxic evacuation of hypertensive intracerebral hematomas

Computerized tomography (CT) is now available for diagnosis and localization of intracerebral hematoma. Computerized tomography-guided stereotaxic evacuation of hypertensive intracerebral hematoma was performed in 51 cases: 34 basal ganglion hematomas with or without ventricular perforation, 11 subcortical hematomas, three thalamic hematomas, and three cerebellar hematomas. Three-dimensional CT images or biplane CT images were taken to determine the coordinates of the target point, which was the center of the hematoma. A silicone tube (3.5 mm in outer diameter and 2.1 mm in inner diameter) was then inserted into the center of the hematoma through a burr-hole under local anesthesia, and the liquefied or solid portion of the hematoma was aspirated with a syringe. Immediately after the first trial of hematoma aspiration, urokinase (6000 IU/5 ml saline) was administered through this silicone tube and the drain was clipped. Subsequently, aspiration and infusion of urokinase were repeated every 6 or 12 hours until the hematoma was completely evacuated. The silicone tube was removed when repeat CT scanning revealed no residual hematoma. The follow-up results indicate that this procedure is as good as conventional craniotomy and evacuation of hematoma under direct vision. This CT-guided stereotaxic approach for evacuation of the hematoma has the following advantages: 1) the procedure is simple and safe; 2) the operation can be performed under local anesthesia; and 3) the hematoma is completely drained with the aid of urokinase. This procedure seems indicated as an emergency treatment for elderly or high-risk patients who show no signs of cerebral herniation.     

Endoscopic hematoma evacuation for hypertensive cerebellar hemorrhage.

OBJECT: The management of spontaneous cerebral hemorrhage remains controversial, particularly the surgical indications. Endoscopic surgery was evaluated for the treatment of spontaneous cerebellar hemorrhage. METHODS: The records of 69 patients with hypertensive cerebral hemorrhage were retrospectively reviewed. Patients treated by endoscopic surgery (n = 10) were compared with patients treated by conventional surgical hematoma evacuation (n = 10) under the same surgical indications. RESULTS: The surgical procedure time, duration of ventricular drainage, extent of hematoma evacuation, necessity for cerebrospinal fluid (CSF) shunt, surgical complications, and outcome at discharge and at 3 months after onset were compared. The extent of hematoma evacuation was greater in the endoscopic group (95.2 %) than in the craniectomy group (90.6 %) but without significant difference. The endoscopic technique (64.5 min) took significantly less time than the craniectomy method (230.6 min, p < 0.0001). The period of ventricular drainage was significantly shorter in the endoscopic group (2.6 days) compared to the craniectomy group (12.3 days, p < 0.01). CSF shunt surgery was required in no patient in the endoscopic group compared to three in the craniectomy group. CONCLUSION: Endoscopic hematoma evacuation is a rapid, effective, and safe technique for the removal of hypertensive cerebellar hemorrhage. Reduction of the mass effect can be accomplished with low risk of recurrent hemorrhage. Release of obstructive hydrocephalus in the early stage may improve the patient's outcome and decrease the requirement for permanent shunt emplacement.     

颅内血肿微创清除术治疗高血压性脑出血(附32例报道)

目的：研究采用颅内血肿微创清除术治疗高血压性脑出血的效果。方法：回顾性分析采用血肿微创清除术治疗的32例高血压性脑出血患临床资料。结果：32例中，恢复良好19例，轻残6例，重残4例，死亡3例，治愈或基本治愈率达59．4％，致残率31．3％，死亡率9．4％。结论：颅内血肿微创清除术可有效地降低高血压性脑出血的死亡率和致残率。