微创手术治疗高血压幕下脑出血28例

目的探讨微创手术治疗高血压幕下脑出血的效果。方法1998年3月~2008年12月,对11例脑干出血及17例小脑出血应用立体定向技术行血肿腔内置管抽吸、尿激酶灌洗引流治疗。病例选择标准：脑干出血病例选择桥脑出血呈基底型或被盖型,双侧侧脑室及第三、四脑室轻度扩张或无扩张,GCS评分≥6分;小脑出血病例选择小脑半球或蚓部,出血量不超过40 ml,未出现枕骨大孔疝,GCS评分8分以上。结果28例手术均获成功,手术时间50~100 min,平均70 min。术后存活21例,经盐水尿激酶溶液冲洗引流3 d拔除引流管12例,5 d拔管7例,7 d拔管2例。术后随访1~5年,平均3年。日常生活能力评定（ADL）Ⅰ级12例,Ⅱ级4例,Ⅲ级3例,Ⅳ级1例,植物生存1例。脑干出血术后死亡4例,小脑出血术后死亡3例。结论应用立体定向技术行血肿腔内置管抽吸、尿激酶灌洗引流治疗高血压幕下脑出血效果良好,病死率低。     

标准大骨瓣开颅治疗高血压脑出血的临床分析

高血压脑出血是急性脑血管疾病中死亡率和伤残率最高疾病。约有70％左右的出血发生于基底节区。目前对高血压脑出血的手术方式主要包括标准大骨瓣开颅血肿清除术、小骨窗开颅血肿清除术及（立体）定向穿刺血肿引流术等。本院自2000年1月至2005年6月共采用标准大骨瓣开颅手术高血压脑出血35例，现将治疗体会报告如下。     

MRI三维定向神经内镜手术治疗高血压脑出血

目的 应用神经内镜手术治疗高血压脑出血,探讨治疗脑出血的一种微创有效的方法. 方法 2007年10月至2011年2月,37例高血压脑出血患者选择经血肿中央长轴枕外侧入路在MRI三维立体定位引导下确定血肿靶点并穿刺,沿穿刺通道于神经内镜下清除血肿,血肿腔内置管引流,术后注入尿激酶溶解残留血肿并引流. 结果术后随访37例,随访时间为3～24个月(平均7.6个月).术后6个月生存质量采用ADL评分,Ⅰ级10例,Ⅱ级10例,Ⅲ级11例,Ⅳ级4例,Ⅴ级2例.Ⅰ～Ⅲ级为疗效满意,Ⅳ、Ⅴ级为疗效不佳,良好率达83.8％,不佳率为16.2％. 结论 MRI能显示出被挤压、移位的外侧裂血管,提供了全面清晰的三维结构影像信息,MRI三维引导下神经内镜手术治疗高血压脑出血是一种安全、有效的微创手术方法,最大限度地减少手术损伤.     

CT引导立体定向手术治疗高血压脑出血

1997．5～2000．5我们采用CT引导立体定向手术对40例高血压脑出血病人进行血肿碎吸加尿激酶血肿腔引流治疗，疗效满意。现报告如下：     

立体定向穿刺置管引流术治疗中少量高血压性脑出血的临床观察

目的探讨立体定向穿刺置管引流术治疗中少量高血压性脑出血的临床疗效和并发症发生情况。方法将88例中少量高血压性脑出血患者随机分为立体定向手术组和常规手术组,各44例。立体定向手术组患者住院6 h后在CT引导下进行立体定向穿刺置管引流术。所有患者手术后随访6个月~12个月。结果立体定向手术组术后第7、14、21天神经功能缺损评分均较常规手术组明显减少,术后并发症发生率、病死率显著低于常规手术组,两组比较差异均有统计学意义(P0.05)。结论立体定向穿刺置管引流术治疗中少量高血压性脑出血疗效显著,安全简便,值得在临床上应用。     

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。     

经侧裂-岛叶入路显微手术治疗基底节区高血压脑出血

目的探讨经外侧裂-岛叶入路显微手术治疗基底节区高血压脑出血的临床疗效。方法对32例基底节区高血压脑出血的患者采取额颞部扩大翼点入路切口经外侧裂-岛叶入路清除血肿。结果本组32例患者,术中显露血肿腔良好,在显微镜下血肿清除较彻底,止血效果良好,减压充分。患者出院时按GOS评价治疗效果：恢复良好：14例（43．8％）;中重残：12例（37．5％）;植物生存：2例（6．25％）;死亡：4例（12．5％）。结论经外侧裂-岛叶入路显微手术治疗基底节区高血压脑出血具有创伤小、清除血肿彻底、疗效佳等优点。可以在有条件的基层医院开展。     

高血压脑出血CT模拟定位置双管血肿腔内尿激酶引流术27例治疗体会

本文报告了我院自1995年8月至1996年12月间对27例高血压脑出血病人，根据CT片模拟定位血肿中心靶点，颅骨钻孔，置双导管血肿腔内．早期抽吸血肿的液体部分，解除颅内急性机械压迫，后期应用尿激酶（uk）溶解凝血块引流残余血肿。作者体会其优点是：（1）能经常冲洗导管，保持引流通畅；（2）能动态监测颅内压（ICP）．指导使用脱水药物：（3）每日定时向血肿腔内注身尿激酶，能将血肿完全溶解排尽；（4）根据ICP变化，开放或关闭引流管，控制颅内液体的排放，能调控ICP在正常范围。本治疗方法操作简单．不需要立体定向系统，创伤小．疗效满意。     

立体定向手术与内科治疗中小量基底核区高血压性脑出血的对比研究

目的研究中小量（15～40m1）基底核区高血压性脑出血应用立体定向治疗与内科保守治疗对患者病死率、运动功能及预后的影响。方法2003年1月～2013年1月,我院收治中小量基底核区高血压性脑出血164例,其中82例行立体定向手术抽吸结合尿激酶引流治疗,另82例行内科保守治疗。比较2组血肿清除时间、30d病死率、患侧肢体运动功能和90d格拉斯哥预后评分（Glasgow outcome score,GOS）。结果立体定向治疗组血肿消散时间（3.8±1.1）d,明显短于内科治疗组的（19.9±3.5）d（t=-39.463,P=0.000）。2组30d病死率差异无显著性。立体定向组治疗30d病肢肌力4～5级[43.9％（36／82）vs.28.0％（23／82）,X^2=4.474,P=0.034]和90 d GOS 5分者的比例明显高于内科治疗组[53.7％（44／82）vs.36.6％（30／82）,X^2=4.826,P=0.028]。结论对于中小量高血压性脑出血,行立体定向手术治疗比内科治疗能明显加快血肿清除时间,改善患者的功能预后。     

早期微创钻孔引流治疗高血压脑出血66例临床研究

目的探讨早期血肿腔钻孔引流治疗高血压脑出血的临床疗效。方法总结采用早期血肿腔钻孔引流治疗66例高血压脑出血病人的体会。根据CT定位,选择无血管及无功能区定位,尽可能在血肿最大层面钻孔,迅速引流。结果随访0.5～1.5a,痊愈15例,生活自理21例,生活部分自理20例,放弃治疗5例,死亡5例。结论早期血肿腔钻孔引流治疗高血压脑出血能比较彻底清除血肿,在基层医院(无立体定向设备)进行,损伤小,及早引流,解除压迫,简便有效,费用低,并发症少,有效防止脑疝形成,能较好的改善预后。     

开颅术与钻孔引流术治疗高血压脑出血后颅内压的影响比较

目的：探讨开颅术与钻孔引流术治疗高血压脑出血（HICH）后颅内压的影响,为临床HICH后选择合理的手术治疗提供依据。方法选择HICH患者120例,随机分为开颅组（n=60）和钻孔组（n=60）,开颅组采用开颅手术治疗,钻孔组采用钻孔引流术结合尿激酶溶解术治疗,比较两组患者术后即时、24h、72h和1周时颅内压变化情况。结果两组患者术后即时颅内压均增高,术后72h达峰值,术后1周开始下降。开颅组颅内压在各时间点均低于钻孔组（P＜0.05）。结论开颅手术治疗HICH在降低颅内压力,减少脑组织损害方面优于钻孔引流术。但开颅手术由于存在创伤大等缺点,因此应在术前综合考虑患者全身状况、出血部位、血肿量等因素,再选择合适的术式,但不管何种术式,均以降低脑出血患者病死、病残率,改善生存质量为最终目的。     

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。     

Rapid expansion of hypertensive intracerebral hemorrhage.

We report a series of 10 patients who had a rapid expansion of a hypertensive intracerebral hemorrhage (HICH). It occurred in approximately 3% of 320 patients who sought treatment for HICH during the past 2 years. The site of hemorrhage was the putamen in 6 patients and the thalamus in 4 patients. Neurological deterioration occurred in a mean time of 40 hours after the onset of symptoms (range, 5.5-109 h). Fifty percent of all patients deteriorated within 24 hours. Persistent hypertension was recorded in all patients. Repeat computed tomography showed an increase of hematoma volume that was twice as large in thalamic hemorrhage and about three times as large in putaminal hemorrhage. Six patients died, whereas 3 survived with severe disability and 1 survived with moderate disability. This study indicates that continued or subsequent bleeding can occur in HICH. If those lesions are not detected early and microsurgically evacuated, they are almost always fatal. Early stereotactic evacuation with urokinase irrigation is considered more dangerous than open craniotomy by microsurgical techniques. We stress the need for attention to this problem during the acute phase of HICH.     

立体定向穿刺引流与显微镜下小骨窗血肿清除术治疗基底节区脑出血的疗效比较

目的探讨立体定向穿刺引流治疗基底节区脑出血的临床疗效。方法本院2011年9月~2013年9月立体定向穿刺引流治疗基底节区脑出血患者50例(观察组),与同期行显微镜下小骨窗血肿清除术的50例患者进行对比(对照组)。结果观察组4例患者术后出现并发症,并发症发生率为8%(4/50),3例死亡,死亡率6%(3/50)。对照组12例患者术后出现并发症,并发症发生率为24%(12/50),死亡4例,死亡率为8%(4/50)。两组患者术后并发症发生率差异有统计学意义(P0.05),但死亡率比较差异无统计学意义(P0.05)。结论采用立体定向穿刺引流治疗基底节区脑出血具有创伤小、并发症少、恢复快的优点,值得在临床推广应用。     

腹腔镜术穿刺孔出血的原因分析及其对策

目的探讨腹腔镜术穿刺孔出血的原因及其对策。方法对自1992年5月至2006年8月间腹腔镜穿刺孔出血21例病例进行回顾性分析。结果21例穿刺孔出血均发生在1.1cm穿刺孔,其中腹膜层出血5例,肌层出血7例,皮下层出血9例;术中发现并处理8例,术后发现并处理13例,均治愈出院。结论术前准备不充分,穿刺部位选择不当,穿刺操作不规范及标本取出时盲目扩张等是穿刺孔出血的根本原因;术中应对各穿刺孔仔细观察从而及时发现穿刺孔出血;术中应对穿刺孔出血彻底止血;术后出现穿刺孔出血,应根据不同原因合理选择治疗方式。     

The effect of hematoma puncture drainage before decompressive craniectomy on the prognosis of hypertensive intracerebral hemorrhage with cerebral hernia at a high altitude

PurposeRapid decompressive craniectomy (DC) was the most effective method for the treatment of hypertensive intracerebral hemorrhage (HICH) with cerebral hernia, but the mortality and disability rate is still high. We suspected that hematoma puncture drainage (PD) + DC may improve the therapeutic effect and thus compared the combined surgery with DC alone.MethodsFrom December 2013 to July 2019, patients with HICH from Linzhi, Tibet and Honghe, Yunnan Province were retrospectively analyzed. The selection criteria were as follows: (1) altitude ≥1500 m; (2) HICH patients with cerebral hernia; (3) Glascow coma scale score of 4–8 and time from onset to admission ≤3 h; (4) good liver and kidney function; and (5) complete case data. The included patients were divided into DC group and PD + DC group. The patients were followed up for 6 months. The outcome was assessed by Glasgow outcome scale (GOS) score, Kaplan-Meier survival curve and correlation between time from admission to operation and prognosis. A good outcome was defined as independent (GOS score, 4-5) and poor outcome defined as dependent (GOS score, 3-1). All data analyses were performed using SPSS 19, and comparison between two groups was conducted using separate t-tests or Chi-square tests.ResultsA total of 65 patients was included. The age ranged 34-90 years (mean, 63.00 ± 14.04 years). Among them, 31 patients had the operation of PD + DC, whereas 34 patients underwent DC. The two groups had no significant difference in the basic characteristics. After 6 months of follow-up, in the PD + DC group there were 8 death, 4 vegetative state, 4 severe disability (GOS score 1-3, poor outcome 51.6 %); 8 moderate disability, and 7 good recovery (GOS score 4-5, good outcome 48.4 %); while in the DC group the result was 15 death, 6 vegetative state, 5 severe disability (poor outcome 76.5 %), 4 moderate disability and 4 good recovery (good outcome 23.5 %). The GOS score and good outcome were significantly less in DC group than in PD + DC group (Z = −1.993, p = 0.046; χ² = 4.38, p = 0.043). However, there was no significant difference regarding the survival curve between PD + DC group and DC group. The correlation between the time from admission to operation and GOS at 6 months (r = −0.41, R² = 0.002, p = 0.829) was not significant in the PD + DC group, but significant in the DC group (r = −0.357, R² = 0.128, p = 0.038).ConclusionPD + DC treatment can improve the good outcomes better than DC treatment for HICH with cerebral hernia at a high altitude.     

非胰腺手术后胰腺假性囊肿的治疗

目的探讨非胰腺手术后胰腺假性囊肿的治疗方法。方法对近11年来治疗的28例非胰腺手术后胰腺假性囊肿进行回顾性临床分析。结果保守治疗4例。B超引导下经皮多次穿刺10例(其中穿刺后置管外引流3例)。手术行外引流6例,内引流8例。1例外引流无效后,改行内引流。28例均痊愈出院。结论手术后胰腺假性囊肿应采用个体化的治疗原则,早期应采取保守治疗、穿刺抽液或外引流,内引流可作为治疗的最后选择。     

The influence of traumatic subarachnoid hemorrhage on prognosis of head injury

OBJECTIVE: To study the influence of traumatic subarachnoid hemorrhage on secondary intracranial damage in GCS 13-15 head injuries and prognosis. METHODS: One hundred and twenty-eight patients with mild head injury, including 64 with subarachnoid hemorrhage and 64 without subarachnoid hemorrhage, were selected and analyzed according to the changes of their conditions after injury. RESULTS: Intracranial abnormality was found in 14 patients (21.87%) with subarachnoid hemorrhage and only in 4 patients (6.25%) without subarachnoid hemorrhage (P<0.01). In the 14 patients, 4 were given surgical treatment. Mild disability was in 2 patients and 2 completely recovered. The rest were conservatively treated and achieved complete recovery at last. CONCLUSIONS: Traumatic subarachnoid hemorrhage, as a factor of intracranial complications in mild head injury should be given much attention. Early drainage of bloody cerebrospinal fluid by lumbar puncture is an effective method for prevention and treatment of complications in mild head injury.     

Percutaneous transhepatic biliary drainage for acute cholangitis

Percutaneous Transhepatic Biliary Drainage (PTHBD) was performed in 56 consecutive patients with severe acute cholangitis, during a period of one year. An immediate decompression effect with a "good" response was achieved in 46 (82.2%), who usually became afebrile within 18 to 24 hours, and "poor" response in 10 (17.8%). Five died (8.93%) in a subsequent operation. No mortality was associated with the use of PTHBD. Complications related to the procedure occurred in 12 of the 56 patients (21.4%). Hemobilia was the major complication. The other complications were intraabdominal hemorrhage, bleeding from the puncture site, transient hypotension, catheter occlusion and/or dislodgement, bile leak, pneumothorax and hemothorax. Two with hemobilia, one with intraabdominal hemorrhage and the other with bile leak required an emergency operation. PTHBD procedures can be lifesaving in biliary sepsis. Once infection and hyperbilirubinemia are controlled, rational subsequent therapy can be formulated for the underlying disease.     

腰穿置管持续引流在神经外科患者中的应用

目的探讨腰穿置管引流在神经外科各种疾病中的辅助治疗作用。方法对采用腰穿置管引流方法的46例患者进行回顾性研究,观察其疗效及并发症情况。结果所有脑脊液漏患者除一例需手术修补漏口外,余32例患者漏口均自行愈合。颅内感染患者3例中有2例感染得到控制。蛛网膜下腔出血和脑室内出血患者10例经此法引流血性脑脊液后,仅有2例出现脑积水,无硬脊膜外血肿、感染等严重并发症。结论腰穿置管引流具有操作简便、安全可靠、创伤小、效果确切、并发症少等优点,是神经外科一种有效的辅助治疗方法。