脑干血管畸形的外科治疗

目的：探讨脑干血管畸形的外科治疗方法、手术入路和治疗效果。方法：对10例脑干血管畸形患进行回顾性分析,男8例,女2例;平均年龄34.4岁。所有患均经CT和MRI检查确诊为脑干血管畸形。有6例患行DSA检查,但无异常发现。病变位于桥脑6例,桥脑中脑结合部3例,桥脑延髓结合部1例。结果：10例患平均的出血后第34d行开颅手术,其中经后颅窝中线小脑下蚓部第四脑室入路5例,于枕下乙状窦后经小脑外侧入路4例,经颞下切开天幕入路1例。术后病理学检查报告：毛细血管扩张症6例、海绵状血管瘤3例、动静脉畸形1例,无手术死亡病例。所有患术后症状均获改善,有6例患获得随访,最长随访时间6年,最短1年,无再出血。结论：应用显微外科手术治疗脑干血管畸形患安全有效,通过切除畸形的脑干血管可防止再次出血。     

脑干血管畸形的外科治疗

目的探讨脑干血管畸形的外科治疗方法、手术入路和治疗效果.方法对10例脑干血管畸形患者进行回顾性分析,男8例,女2例;平均年龄34.4岁.所有患者均经CT和MRI检查确诊为脑干血管畸形.有6例患者行DSA检查,但无异常发现.病变位于桥脑者6例,桥脑中脑结合部者3例,桥脑延髓结合部者1例.结果10例患者平均在出血后第34 d行开颅手术,其中经后颅窝中线小脑下蚓部第四脑室入路5例,于枕下乙状窦后经小脑外侧入路4例,经颞下切开天幕入路1例.术后病理学检查报告毛细血管扩张症6例、海绵状血管瘤3例、动静脉畸形1例,无手术死亡病例.所有患者术后症状均获改善,有6例患者获得随访,最长随访时间6年,最短1年,无再出血.结论应用显微外科手术治疗脑干血管畸形患者安全有效,通过切除畸形的脑干血管可防止再次出血.     

自发性脑干出血的手术治疗

目的 探讨自发性脑干出血的治疗方法及其效果。方法 回顾性分析2016年6月至2019年6月显微手术治疗23例自发性脑干出血的临床资料。采用颞下入路13例，枕下后正中入路10例。结果 术后复查CT显示，15例血肿全部清除，8例部分清除。术后3个月GCS评分平均（6.7±4.2）分，术后3个月GOS评分平均（1.9±0.8）分。病死率为34.8%（8/23）。结论 手术可以作为自发性脑干出血的一种治疗手段，大血肿或重型脑干出血短期可能有较好的获益。     

CTA在非高血压自发性脑内血肿急诊手术中的指导作用

目的 探讨头颅多层螺旋CT血管造影(CT angiography,CTA)检查在非高血压自发性脑内血肿急诊显微外科手术治疗中的应用价值.方法 对27例需行急诊手术血肿清除的非高血压自发性脑内血肿患者,术前行头颅CTA检查,根据CTA检查结果做急诊开颅显微外科手术治疗,并对CTA在手术中的指导作用进行分析.结果 27例头颅CTA检查中,动脉瘤6例,动静脉畸形14例,烟雾病3例,无明显血管异常4例.术中探查发现动脉瘤6例,均予瘤颈夹闭;动静脉畸形14例,其中全切除12例,部分切除2例;烟雾病3例,均单纯血肿清除;海绵状血管瘤3例,均全切除;无明显原发病变1例,单纯血肿清除.术后均行头颅DSA检查,动静脉畸形残留2例,予伽玛刀治疗,烟雾病3例,无明显血管异常22例.格拉斯哥预后评分(GOS):Ⅰ级8例,Ⅱ级14例,Ⅲ～Ⅳ级5例.随访0.5-2年无再出血.结论 头颅CTA能简便、快速、无创地明确非高血压自发性脑内血肿患者中的动脉瘤、动静脉畸形、烟雾病等病因,提供直观的三维形态及解剖定位,有利于一期手术清除血肿及消除病因,降低手术风险,对非高血压性自发性脑内血肿的急诊显微外科手术治疗具有重要的指导作用.     

原发性脑干出血60例临床分析

目的 :研究原发脑干出血的病因 ,临床症状、CT和 /或MR表现及治疗转归。方法 :总结分析 60例脑干出血患者的临床、CT和 /或MR资料。结果 :本病多见于 5 0岁以上 ,病因主要为高血压病 ,其次为脑干血管畸形 ,临床症状可复杂多样 ,必须结合头颅CT和 /或MR检查方可作出相同部位的定性定位诊断 ,预后与出血积压量的多少以及能否早期正确诊断治疗有密切的关系     

隐匿性脑血管畸形

本文报道了15例隐匿性脑血管畸形（Occult intracephalic vascular malformation,OIVM)，均经手术和病理证实。病变血管内机化，血肿压迫血管，畸形血管团太小以及在出血过程中病变血管被破坏等是造成脑血管造影难以发现畸形血管的常见原因。CT、MR、DSA是术前诊断的重要依据。     

隐匿性脑血管畸形的诊断和微侵袭治疗

目的：报告DSA未能显示的隐匿性脑血管畸形11例,并探讨其发生机理,误诊原因和诊治原则,方法：详细分析11例病人的临床资料。结果：该病变发生机理主要是病变输入运输太细,病灶内血栓形成,出血和血肿破坏了畸形血管以及出血后血管痉挛,其被误诊原因是一些病人的临床特点,CT表现与某些胶质瘤酷似,结论：MR对隐匿性脑血管畸形的诊断有重要意义,MRA可帮助确诊。该病变不宜行血管内治疗,应以显微手术和立体定向放射治疗为主。     

原发性脑干出血60例临床分析

目的：研究原发脑干出血的原因，临床症状、CT和／或MR表现及治疗转归。方法：总结分析60例脑干出血患者的临床、CT和／或MR资料。结果：本病多见于50岁以上，病因主要为高血压病，其次为脑干血管畸形，临床症状可复杂，必须结合头颅CT和／或MR检查方可作出相同部位的定性定位诊断，预后与出血积压量的多少以及能否早期正确诊断治疗有密切的关系。     

基底节区小型动静脉畸形出血的手术治疗

目的探讨基底节区小型动静脉畸形出血并脑内血肿病人的手术治疗问题。方法 32例CT示基底节区脑出血患者术中均行血肿清除和血管畸形切除。结果术后对切除的可疑畸形血管行病理切片检查,均证实为脑动静脉畸形。术后MRI及MRA检查均未见脑血管畸形。术后3个月随访ADL分级,Ⅰ级完全恢复日常生活7例;Ⅱ级部分恢复或可独立生活17例;Ⅲ级需他人帮助,扶拐可行8例;无卧床,植物生存病人;无术后再出血患者。结论基底节区小型动静脉畸形出血并脑内血肿病人行血肿清除和畸形血管切除可减少再出血发生,取得了较好预后。     

非高血压性自发性颅内血肿54例临床分析

报告５４例非高血压性自发性颅内血肿。常见病因为血管畸形（占４４％）。ＣＴ、ＭＲＩ是最好的定位诊断方法，ＭＲＩ还可显示畸形血管，脑血管造影常可作出病因诊断。手术治疗４７例，作者主张开颅显微手术，既可以清除血肿，又有可能提供病因诊断线索，及时采取治疗措施，预防再次发生出血。     

自发性脑干出血治疗探讨

目的探讨自发性脑干出血患者的治疗方法。方法回顾性分析36例入院时病情危重且接受手术治疗的脑干出血患者临床资料、治疗效果以及随访信息。根据血肿位置、深度不同,分别选择枕下后正中入路、颞下入路或枕下乙状窦后入路等清除血肿。结果发病一个月死亡10例,病死率为27.8%;术后格拉斯哥预后评分（GOS）平均为3.5分。结论手术清除血肿可以作为自发性脑干出血患者治疗的一种选择。     

Clinician's biases toward surgery in cerebellar hematomas: an analysis of decision-making in 94 patients

BACKGROUND AND PURPOSE: No studies have examined clinical decision-making in cerebellar hemorrhages. Clinical and CT features may influence surgery in patients with a spontaneous cerebellar hematoma. One commonly accepted adage is to remove a clot when 3 cm or larger in axial diameter on presentation CT scan. It is possible that certain preferences impact on outcome. METHODS: We analyzed 94 patients with spontaneous cerebellar hematomas between the years of 1973-1993. Thirty-one patients underwent suboccipital craniectomy and clot removal with or without ventriculostomy. Deterioration denoted worsening of consciousness, new brainstem signs, or presentation in coma. Statistical analysis was performed utilizing a tree-based model fitted by binary recursive partitioning. Ninety-five percent confidence intervals (CI) were calculated. RESULTS: The overall probability of surgical intervention was 33% (CI 23-43%). The chance of surgery in stable patients was 7% (CI 2-20%). Neurologic deterioration was seen in 54 patients (57%) and increased the prospects of a surgical procedure (52%, CI 38-66%). Surgery was performed in all deteriorating patients with small hematomas (size <3 cm), but large clots (size >3 cm) did not substantially influence surgical decision-making (45%, CI 30-60%) except in patients younger than 70 years old (57%, CI 41-82%). CONCLUSIONS: Clinicians at our institution usually wait for clinical deterioration to unfold prior to operating on patients with cerebellar hematomas. After deterioration occurs, they prefer small hematomas but will operate on large hematomas when patients are younger than 70, generally withholding surgery from older patients. These attitudes may impact on outcome and should be considered in future treatment trials.     

Diagnosis and treatment of cerebellar hemorrhage: comparison of hypertensive hemorrhage with hemorrhage caused by small angiomas, and CT findings (author's transl)]

In spontaneous cerebellar hemorrhage emergency surgical intervention is often life-saving. Clinical features and the operative results of hypertensive cerebellar hemorrhage (18 cases) were compared with those of hemorrhage caused by small angiomas (7 cases). Hypertensive hemorrhage occured most frequently in the seventh decades. Two thirds of the patients developed brainstem compression syndrome within a week from onset. One third remained awake or drowsy throughout their clinical course. Surgical removal of a hematoma was carried out in 13 patients with four deaths. Of note, two comatose patients regained consciousness after surgery, and were discharged with residual ataxia. Rupture of a small angioma occurred in younger patients. Their clinical course was sub-acute or chronic associated with focal cerebellar dysfunction. All seven surgically treated patients subsequently regained independent function. CT findings have been found helpful not only for diagnosis but also in defining appropriate therapy. Hematomas larger than 3 cm in diameter produced signs of rapidly progressing compression of the brainstem. Thereby, regardless of the cause of bleeding, emergency removal of a clot is indicated even in awake patients. Hematomas of 2 to 3 cm produced brainstem compression or prolonged cerebellar dysfunction, and occasionally require surgical decompression. Hematomas smaller than 2 cm can be managed conservatively, since they were absorbed spontaneously in three weeks without residual functional disturbances. However, in case of a young patient exploration should be performed for a probable "cryptic" angioma.     

Local fibrinolytic technique in surgery of traumatic inctracranial hemorrhages

The emergence of neuroimaging techniques and new surgical technologies (neuroendocopy, navigation systems) in neurosurgery has substantially changed views of surgery for traumatic intracranial hematomas. The local fibrinolytic technique that has been applied to 40 victims aged 18 to 67 years (mean age 42.1 +/- 2 years) who had 18-to-97-cm3 hematomas is a promising direction of mini-invasive surgery for traumatic intracranial hematomas in patients in the compensated and subcompensated state. There were 32 males and 8 females. The procedure of the surgical intervention involves drainage of intracranial hematoma, followed by clot lysis and liquid blood aspiration along the drainage. A good outcome with a complete hematoma removal and clinical symptom regression was observed in 26 patients, a fair result with preservation of moderate neurological symptoms at hospital discharge was noted in 2 patients; 3 victims died. Recurrent bleedings were seen in 4 patients with epidural hematomas. A morphological study revealed the typical features of the morphogenesis of traumatic hematomas and perifocal brain tissue during local fibrinolytic therapy, which suggests that the area of damaging effect of bleeding on the adjacent brain tissue is decreased. Local fibrinolysis in surgery of traumatic intracranial hematomas may be considered to be one of the promising lines of treatment policy along with the existing traditional and current techniques and may be used as the method of choice in surgery of traumatic intracranial hematomas in patients in the compensated state. Removal of epidural hematomas through local fibrinolysis should be limited due to a high risk of recurrent hemorrhage and may be made only in a restricted contingent of patients with severe concomitant injury and concurrent somatic diseases when the risk of combined anesthesia and that of a longer operation are rather high. Moreover, of promise is that subtentorial epidural hematomas may be aspirated without trepanation of the posterior cranial fossa and the surgery may be performed under local anesthesia.     

原发性基底节区脑出血手术策略的选择及疗效分析

目的探讨原发性基底节区脑出血手术策略的选择并对其疗效进行分析总结。方法2008年1月至2013年1月经手术治疗原发性基底节区脑出血病人120例。对于血肿量在30-60ml或者血肿量较大已形成脑疝者87例患者行开颅手术血肿清除术,其中未脑疝并且一般身体情况较好的56例行微创小骨窗经侧裂-岛叶入路血肿清除术;另31例血肿量较大已形成脑疝者行大骨瓣颅血肿清除术,12例由于术后脑压仍高加行去骨瓣减压术。对于合并有心,脑,肾严重疾病,以及年龄大于70岁的33例病人行血肿穿刺引流术。术后3天复查头颅CT,观察血肿清情况,术后半年按照COS量表对患者进行疗效评定。结果采用血肿穿刺引流术33例患者术后3天,再出血4例,术后6个月GOS预后评分5分0例,4分16例,3分100例,2分4例,1分3例;采用开颅血肿清除术87例患者,其中56例采用小骨窗经侧裂-岛叶入路,术后3天再出血4例,术后6个月COS预后评分5分0例,4分38例,3分14例,2分2例,1分2例;而行大骨瓣颅内清除31例患者,术后3天再出血8例,术后6个月GOS预后评分5分0例,4分11例,3分9例,2分6例,1分5例。结论对于血肿量在30-60ml,未脑疝并且一般身体情况较好的患者,行小骨窗经侧裂-岛叶入路血肿清除术,手术效果好,恢复快;对血肿量大于60ml或者脑疝的病人,建议行大骨瓣颅血肿清除术,必要时行去骨瓣减压术。合并有心,脑,肾严重疾病,以及年龄大于70岁的病人行血肿穿刺引流术。早期进行小骨窗开颅血肿清除术及积极处理并发症有助于降低基底节区脑出血患者的死亡率,改善其预后。     

Superatentorial intracerebral hemorrhage following infratentorial surgery.

Supratentorial hematoma following infratentorial surgery is rare. We present two such patients with remote site supratentorial hematoma after posterior fossa surgery. In one patient, a supratentorial hematoma developed following surgery for an acoustic tumor. The supratentorial hematoma was located near where a supratentorial meningioma was excised five days before. No hematoma was seen on the immediate postoperative CT scan. In another patient there were two tumors, one in the pons and the other in the basal ganglia. This patient developed a basal ganglia hematoma following brain stem surgery. In both the patients, hematological profile revealed a coagulation abnormality following the posterior fossa surgery. Our first case stabilized conservative management, whereas the second required surgical evacuation of the hematoma. The differential diagnosis of declining level of consciousness after posterior fossa surgery must include supratentorial intracerebral hemorrhage and CT scan of the head is the diagnostic test of choice.     

Childhood cerebrovascular diseases not associated with vascular malformations

Of 76 patients in the pediatric age group suffering from cerebrovascular diseases treated in the years 1970–1983, 26 patients (34%) did not harbor intracranial vascular malformations (aneurysms or arterovenous malformations). Two groups of patients were identified: (a) those suffering from a spontaneous intracranial hemorrhage (16 cases); (b) those suffering from an ischemic stroke (10 cases). Of those with spontaneous intracranial hemorrhage, 10 patients underwent surgery and evacuation of the hematoma. In 2 cases the hematoma was located in the posterior fossa, in 1 case in the upper brain stem, and in 3 cases in the basal ganglia; in the remainder the hematoma was supratentorial. Two patients died soon after the hemorrhage. Eight of the surviving patients completely recovered. In those with ischemic stroke, none suffered from congenital heart disease, a well-known predisposing factor. In this second group 1 patient died and 9 survived. Only one patient showed complete recovery. The data indicate that a hemorrhagic stroke is more common than an ischemic stroke in a child presenting with acute onset of hemiparesis and/or loss of conciousness: thus the value of CT scan as the first diagnostic procedure is clear, owing to the possibility of emergency surgical treatment. In children with ischemic strokes, a complete laboratory/clinical evaluation should be undertaken in order to exclude preexisting heart disease, coagulation disorders or lipoprotein abnormalities, and less common systemic diseases.     

The surgical management of intracranial hematomas in hemophiliac children

A prospective study was undertaken to treat all intracranial hematomas in hemophiliac A children under a uniform protocol. Patient selection was obtained by (1) early CT scan of all hemophiliacs presenting with neurological symptoms and (2) routine hematological screening for coagulopathies of all pediatric intracranial hematomas, spontaneous or traumatic. Nine patients, of whom seven came under category 1 and two under category 2, were entered into this study. There were eight subdural hematomas, one epidural hematoma, and one intracerebral hematoma. Surgery was required in every patient. Human factor VIII concentrate was used for replacement up to 100% just before and 3 days after surgery. Thereafter, it was maintained at 50% up to the 10th postoperative day. There was no operative or late mortality. At 6-month follow-up, eight of nine patients had recovered completely with no residual neurological deficit. We conclude that early diagnosis, prompt surgical intervention, and perfect normalization of hemostatic defect are essential in improving the outcome of these patients.     

CT引导立体定向神经内镜手术治疗高血压性脑出血

目的探讨CT引导立体定向神经内镜手术治疗高血压脑出血的方法和疗效。方法局麻下安装ASA601S型立体定向仪,CT扫描选择血肿最大层面为中心靶点测量坐标,设计手术切口和入路,全麻下环钻开颅,颅骨钻孔直径3 cm,导针穿刺放置导管引导,沿非功能区皮层径路到达血肿腔,应用神经内镜清除血肿,电凝出血点。结果按28例脑实质内出血血肿清除50%者3例,50%～70%者12例,70%～90%者13例；5例伴有出血破入脑室内者,清除均在90%以上；术后7 d死亡2例,未发现术后再出血。随访6月显著好转和好转20例,无变化4例,恶化2例。结论应用立体定向神经内镜清除脑内血肿,是一种定位精确、微创、安全、血肿清除率较高和疗效较好的治疗方法。     

影像引导下前额锁孔入路内镜基底核区血肿清除术：10例技术报告

目的探讨微创内镜技术清除基底核区JOL）的方法。方法分析连续10例自发性基底核区出血病人的临床资料,血肿量18。70ml,平均38．7ml;病人GCS评分5～14分,平均9．7分;病人均存在明确神经功能缺损但未发生脑疝。均行影像引导下前额锁孔入路内镜基底核区血肿清除术。,结果手术耗时45—105min,平均67min。残余血肿体积0—6ml,平均0．8m1：血肿清除率76．9％～100％,平均96．8％。住院时间5—50d,中位时间13d。术后GCS评分7～15分,平均14．1分。术后并发肺部感染4例,其中合并消化道出血和深静脉血栓1例;无切口感染和颅内感染,住院期间无死亡病例。术后1个月、3个月、1年平均GOS评分分别是2．9、3．2、3．0分,有2例左侧出血者术后完全恢复运动和语言功能,随访期间死亡3例。结论内镜技术前额锁孔入路处理基底核区血肿,血肿清除彻底,止血可靠,对脑功能区域影响小,术后并发症少,较经侧方人路显微镜下血肿清除手术有优势。