基底节区高血压脑出血手术治疗术式选择

目的总结选择不同的手术方式外科治疗基底节区高血压脑出血的临床经验。方法回顾142例基底节区高血压脑出血手术治疗病例,根据病情严重程度、出血部位、出血量选择不同的手术术式,传统开颅46例,选择额颞大骨瓣颞中回入路;选择直切口小骨窗微创开颅96例,一般根据头颅CT定位血肿量最大径处的皮层入路。结果本组有36例小骨窗微创开颅患者术后因再出血、或难以度过脑水肿期,而出现病情加重。选择额颞大骨瓣的患者中,术后仅有5例因为再出血、或难以度过脑水肿期,出现病情恶化（P〈0.05）。结论应根据病情的严重程度、血肿部位、血肿量、脑组织受损范围等选择相应的手术方式。     

左侧基底节区高血压脑出血的术式选择及功能保护

目的探索左侧基底节区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65例左侧基底节区高血压脑出血手术治疗病例。其中传统颞瓣开颅经皮质入路34例;翼点开颅经外侧裂-岛叶入路19例;直切口小骨窗开颅12例。结果血肿完全清除19例,近全清除31例,大部清除13例,再出血后两次手术清除2例。随访6个月～2年,GOS评分优18例,轻残29例,重残12例,植物状态3例,死亡3例。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。术中微侵袭操作、充分减压以及重要血管保护是取得良好预后的关键因素。     

不同术式对自发性脑出血周围水肿带的影响

目的通过比较微创脑内血肿穿刺外引流术与开颅血肿清除术对自发性基底节区脑出血周围水肿带大小的比较,为脑出血的治疗寻找较为理想的治疗方案。方法对51例自发性基底节区脑出血病人进行回顾性分析,其中26例接受微创脑内血肿外引流术,25例接受开颅手术清除血肿。将手术前后两组病人血肿周围脑水肿带体积进行比较。结果微创手术组术后7天血肿周围水肿体积小于开颅血肿清除手术组(P<0.05)。结论微创手术组对血肿周围脑组织损伤小,可作为高血压性脑出血手术治疗的首选术式。     

经外侧裂-岛叶与颞叶上回入路清除基底节区出血的疗效对比分析

目的分析经外侧裂-岛叶入路清除高血压基底节区脑出血的疗效。方法回顾分析49例单纯基底节区内囊以外的血肿患者,其中经外侧裂-岛叶入路显微手术治疗21例,经颞叶皮质入路手术治疗28例。从手术方法、血肿暴露、血肿清除难易、术中止血、术中脑组织损伤、术后复查、患者恢复方面进行对比分析。结果经外侧裂-岛叶与经颞上回入路清除高血压基底节区脑出血组比较,在72 h再出血率及术后3个月日常生活能力评分(ADL)中的Barthel指数评分比较,差异有统计学意义(均P0.05)。结论经外侧裂-岛叶入路清除高血压基底节区脑出血的效果优于经颞上回入路。     

高血压性基底节区脑出血25例手术治疗

目的探讨开颅手术治疗高血压性基底节区脑出血的方法及经验。方法回顾性分析25例采用额颞开颅手术治疗基底节区高血压脑出血患者的结果。结果 25例中,19例患者单纯行血肿清除,6例行血肿清除加去骨瓣减压术;3例手术后再岀血(再岀血率12.0%),1例行再手术后死亡,2例家属放弃治疗;术后至术后3月,16例患者意识清楚但遗留有对侧肢体偏瘫,4例呈植物生存状态,5例死于并发症或自动出院后死亡。结论对于有手术指征的基底节区高血压脑岀血患者,采用开颅血肿清除术具有快速缓解颅内压、止血确切等优点。     

基底节区高血压脑出血手术适应症的探讨及疗效分析

目的探讨基底节区高血压脑出血手术适应症,并对手术疗效进行分析。方法回顾性分析58例采用额颞开颅经颞中回皮层造瘘及经外侧裂岛叶入路显微手术治疗的基底节区高血压脑出血患者的临床资料及手术效果。结果 58例患者单纯行血肿清除41例,17例行血肿清除加去骨瓣减压术;4例手术后再岀血,其中2例家属自动放弃治疗后死亡,另外2例行原切口入路血肿清除。术后长期昏迷死于并发症或自动出院后死亡5例。余患者术后随访3个月,意识清楚但遗留有对侧肢体偏瘫,其中语言障碍者6例,植物生存状态7例。结论对于有手术指征的基底节区高血压脑岀血患者,采用开颅血肿清除术具有快速缓解颅内压、止血确切等优点。     

颞部直切口小骨窗微创清除基底节区血肿的临床观察

目的研究显微镜下颞部直切口小骨窗微创清除脑基底节区血肿术的有效性和安全性,为高血压脑出血手术治疗开辟新的途径。方法 2010-07—2012-08我们对102例出血量25～100mL的基底节区脑出血患者行早期血肿清除术:53例(治疗组)采用颞部直切口镜下小骨窗微创术,与49例应用去大骨瓣开颅清除并减压术患者(对照组)进行回顾性比较。结果治疗组术后并发症少(24.52%<对照组的81.63%)、恢复快、住院时间短、费用低,且不需后期二次手术颅骨修补;预后良好率57.3%,优于对照组的30.2%,2组比较差异有统计学意义(P<0.05)。结论颞部直切口小骨窗镜下微创清除术是急诊治疗高血压性脑出血安全可靠的外科方法,对减少脑基底节区血肿治疗中的并发症及提高预后具有重要临床意义。     

脑梗死溶栓后基底节区脑出血手术方法探讨

目的探讨脑梗死溶栓后继发基底节区出血的手术方法及疗效。方法 22例不同部位脑梗死溶栓后基底节区脑出血病人,其中早期开颅血肿清除+去骨瓣减压术8例,单纯经额定位锥颅软通道抽吸引流治疗基底节区脑出血5例,经额定位锥颅软通道抽吸引流治疗基底节区脑出血减压后再开颅9例。结果开颅血肿清除+去骨瓣减压术8例患者全部死亡,单纯经额定位锥颅软通道抽吸引流治疗基底节区脑出血患者5例全部存活,经额定位锥颅软通道抽吸引流治疗基底节区脑出血减压后再开颅9例患者,6例存活,死亡3例。结论早期经额定位锥颅软通道抽吸引流治疗基底节区脑出血减压后,经积极纠正凝血后,再开颅血肿清除及去骨瓣减压术是治疗脑梗死溶栓后大量基底节脑出血良好方法。     

经侧裂-岛叶入路显微手术治疗基底节区高血压脑出血

目的探讨经侧裂-岛叶入路显微手术治疗基底节区高血压脑出血的疗效。方法回顾性分析取2011-04—2016-01收治的经侧裂-岛叶入路手术治疗的38例基底节区高血压脑出血患者的病例资料并探讨疗效。结果术后次日复查CT示血肿清除率达90%以上26例,75%~90%者12例,无再出血及死亡病例。结论经侧裂-岛叶入路治疗基底节区高血压脑出血具有创伤较小、血肿清除较彻底、止血安全可靠、术后神经功能恢复好等特点。     

经外侧裂入路基底节区血肿清除术的切口改良探索及临床效果分析

目的 探讨经外侧裂入路基底节区高血压脑出血手术U型切口的改良方法及临床意义. 方法 自2007年8月至2012年7月解放军第四二一医院神经外科采用经外侧裂岛叶入路清除基底节区高血压脑出血患者共52例(发病后7h内手术28例,7～24 h手术18例,大于24 h手术6例),手术中为更好暴露外侧裂长度,采取前斜30°U型皮瓣形成椭圆形骨窗,骨窗后部过外侧裂中部之后. 结果 术后24 h内复查头颅CT示血肿彻底清除42例,血肿残留量＜10mL 6例,血肿残留量＞10 mL4例.术后7d内死亡6例,均为严重肺部感染.存活的46例患者术后6个月GOS评分为良好28例、中残11例、重残3例、植物生存2例、死亡2例. 结论 对基底节区高血压脑出血患者采取改良切口经外侧裂入路清除血肿,可以减少手术时间,提高血肿清除率.     

Cerebral artery thrombosis as a cause of striatocapsular infarction. a histopathological case study

Striatocapsular infarction is a distinct form of stroke, but few histopathological studies have been performed concerning acute lesions. We report the postmortem findings of a patient with an infarct who died shortly after onset. A 72-year-old man died of acute myocardial infarction 6 days after the onset of left-sided striatocapsular infarction. Autopsy revealed thrombus formation of the left middle cerebral artery (MCA) trunk. The lateral striate arteries irrigating the area of the infarct branched off distal to the arterial segment occluded with a thrombus. The cortical vessels were perfused by leptomeningeal collaterals. This report histopathologically confirmed thrombus formation of the MCA resulting in striatocapsular infarction.     

The arterial lesions underlying cerebral infarction

The arterial lesions underlying cerebral infarction were reviewed by studying the pathological materials in the National Cardiovascular Center. The major clinical cate-gories of arterial lesion (i.e. atherothrombotic, cardio-embolic and lacunar strokes) were reviewed. Arterial lesions underlying striatocapsular infarction were reviewed separately. In order to analyze the mechanisms of the development of cerebral infarction, full postmortem ex-amination of patients dying shortly after the onset of stroke is necessary. Therefore, arterial lesions observed in acute stroke patients were the topic of this review. Two mech-anisms are responsible for atherothrombotic stroke: re-duced perfusion due to obstructive changes in the arteries and embolism. Cardioembolic stroke includes a special clinicopathological entity, cerebral infarction associated with non-bacterial thrombotic endocarditis. The mechan-isms of development of lacunar stroke are not studied sufficiently because the analysis of arterial lesions respons-ible for lacunes requires meticulous effort to examine serial sections of specially prepared specimens. Embolism of the middle cerebral artery (MCA) and abnormalities of the internal carotid artery (ICA) and MCA are responsible for striatocapsular infarction. The author emphasizes the need for postmortem examination of stroke patients, especially those dying shortly after the onset of stroke.     

降纤酶治疗脑梗死的实验研究

目的观察降纤酶对光化学模型诱导的大鼠大脑中动脉血栓的溶栓作用及对脑梗死灶的影响.方法应用光化学方法造成60只易卒中型肾血管性高血压大鼠(RHRSP)大脑中动脉(MCA)血栓形成,在3h、6h、9h、12h、1d不同的时间点对大鼠静脉注射3种产地的降纤酶8U/kg,对照组注射等容生理盐水,观察2d,对大鼠进行行为学评分、MCA血流测定、梗死灶体积测定、病理改变及出血情况观察.结果降纤酶组3小时以内的血栓全部溶解,6小时内的部分溶解.降纤酶组各时间点无论血栓溶解与否,大鼠的行为学评分、梗死灶体积均较生理盐水组低,梗死灶周围微血管闭塞较生理盐水组少.但在降纤酶组中有2例发生出血,分别发生于血栓后6h、12h用药组.结论降纤酶对6小时以内的血栓有溶栓作用,对3小时以内的血栓溶解率最高.降纤酶除溶栓作用外,还可减少梗死灶体积,抑制微血管的血栓形成,改善微循环,改善卒中的预后.与其他溶栓剂相比并不增加出血并发症的发生.     

大脑中脑动脉供血区急性脑梗死病灶类型与进展性脑梗死的关系

目的 探讨大脑中动脉供血区急性脑梗死病灶类型及其与进展性脑梗死的关系.方法 回顾性分析140例大脑中动脉供血区急性脑梗死患者病历资料及脑MRI、DWI、MRA影像资料,其中进展组71例,非进展组69例.结果 2组脑梗死类型均可见流域性脑梗死、分水岭脑梗死、纹状体内囊梗死、腔隙性梗死,进展组以分水岭脑梗死(45.1%)、纹状体内囊梗死(46.5%)为主,非进展组以流域性脑梗死(44.9%)为主,2组脑梗死病灶类型比较,差异有统计学意义(χ2=24.829,P<0.01).结论 大脑中动脉供血区急性分水岭脑梗死、纹状体内囊梗死易表现为进展性脑梗死.     

大脑中动脉狭窄脑深部小梗死发病机制的研究

目的 研究大脑中动脉粥样硬化性狭窄患者脑深部小梗死的发生频率和发病机制。方法86例发病时间〈1周的急件脑梗死患者，行经颅多普勒超声、彩色超声、磁共振血管造影及功能磁共振成像等检查方法被明确诊断为症状性大脑中动脉粥样硬化性狭窄，并排除颈内动脉病变、心源性栓塞以及非动脉粥样硬化性狭窄。利用磁共振扩散加权成像观察梗死灶的形态学表现及特点，分析其发病机制。结果37例（43．02％）症状性大脑中动脉粥样硬化性狭窄患者存在深部小梗死，多呈孤立性单发病灶。其中内囊纹状体梗死及巨大腔隙者18例（20．93％），梗死灶体积多超过两个层面，少数病灶呈多灶分布的特点；直径较小的腔隙性梗死19例（22．09％），梗死灶体积〈15mm，多位于一个层面内。伴有大脑中动脉粥样硬化性狭窄的深部小梗死的患者，病情多不稳定，预后较差。所有脑深部小梗死患者均伴有大脑中动脉主干支狭窄，且梗死灶体积与大脑中动脉粥样硬化性狭窄程度有关，内囊纹状体梗死多见于大脑中动脉重度狭窄者。结论约50％大脑中动脉粥样硬化性狭窄患者存在脑深部小梗死，其发病机制与大脑中动脉粥样硬化斑块或斑块残端血栓蔓延堵塞深穿支动脉入口有关。对此类患者的治疗不同于经典的腔隙性脑梗死。     

Reduction of tissue plasminogen activator-induced hemorrhage and brain injury by free radical spin trapping after embolic focal cerebral ischemia in rats.

Thrombolytic stroke therapy with tissue plasminogen activator (tPA) remains complicated by serious risks of cerebral hemorrhage and brain injury. In this study, a novel model of tPA-induced hemorrhage was used in spontaneously hypertensive rats to examine the correlates of hemorrhage, and test methods of reducing hemorrhage and brain injury. Homologous blood clot emboli were used to occlude the middle cerebral artery in spontaneously hypertensive rats, and delayed administration of tPA (6 hours postischemia) resulted in high rates of cerebral hemorrhage 24 hours later. Compared with untreated rats, tPA significantly increased hemorrhage volumes by almost 85%. Concomitantly, infarction and neurological deficits were worsened by tPA. A parallel experiment in normotensive Wistar-Kyoto rats showed markedly reduced rates of hemorrhage, and tPA did not significantly increase hemorrhage volumes. To examine whether tPA-induced hemorrhage was caused by the delayed onset of reperfusion per se, another group of spontaneously hypertensive rats was subjected to focal ischemia using a mechanical method of arterial occlusion. Delayed (6 hours) reperfusion via mechanical means did not induce hemorrhage. However, administration of tPA plus delayed mechanical reperfusion significantly increased hemorrhage volumes. Since reperfusion injury was implicated, a final experiment compared outcomes in spontaneously hypertensive rats treated with tPA plus the free radical spin trap alpha-phenyl tert butyl nitrone (alpha-PBN) versus tPA alone. tPA-induced hemorrhage volumes were reduced by 40% with alpha-PBN, and infarction and neurological deficits were also decreased. These results indicate that (1) blood pressure is an important correlate of tPA-induced hemorrhage, (2) tPA interacts negatively with reperfusion injury to promote hemorrhage, and (3) combination therapies with anti-free radical treatments may reduce the severity of tPA-induced hemorrhage and brain injury after cerebral ischemia.     

Distinct clinical expressions of striatocapsular infarction according to cortical manifestations

Striatocapsular infarction is known to have various neurologic manifestations including cortical symptoms. However, striatocapsular infarction patients without cortical dysfunctions can be easily found. Therefore, we tried to evaluate the properties and pathogenesis of two distinct expressions of striatocapsular infarction, striatocapsular infarction with and without cortical dysfunctions respectively. Forty-eight patients were divided into two groups according to their initial manifestations. Forty-eight patients with striatocapsular infarction were divided into cortical type of striatocapsular infarction (CSCI) and non-cortical type (NCSCI) according to their initial manifestations. We compared the properties such as stroke risk factors, laboratory data, and clinical features and assessed magnetic resonance imaging (MRI) and MR angiography for possible mechanisms in each type of striatocapsular infarction. Patients with CSCI and those with NCSCI had similar characteristics, laboratory data and morphologic findings in MRI. CSCI patients had more profound initial neurologic manifestations [Both National Institutes of Health Stroke Scale (NIHSS) score and Barthel index]. In MR angiography, patients with CSCI showed more frequent single middle cerebral artery (MCA) stenosis, whereas NCSCI patients had findings that were more heterogeneous. In conclusion, we found that not all the patients with striatocapsular infarction had cortical dysfunctions. It is possible for lesions with similar size and location to have different manifestations (cortical or non-cortical) according to their vascular integrity.     

脑穿支动脉病变梗死类型和神经影像学研究进展

大脑前动脉、大脑中动脉及后循环血管的穿支动脉,如豆纹动脉、脉络膜前动脉（anterior choroidal artery,AChA）和髓质动脉等,阻塞会导致脑深部缺血性病变。不同穿支动脉梗死类型不 同：豆纹动脉供血区域的梗死类型为腔隙性梗死、穿支动脉粥样硬化病型梗死和纹状体内囊梗死; AChA病变可导致AChA综合征;髓质分支梗死会导致半卵圆中心、放射冠部位的边界区梗死。7T二维 相位对比MRI、三维时间飞跃法MRA和三维快速自旋回波T1WI序列等神经影像学新技术有助于确定穿 支动脉早期病变,并可早期发现疾病的发生发展。     

纹状体内囊区域内不同面积梗死的病因机制的探讨

目的通过对纹状体内囊区域大小不同面积梗死患者的临床表现与磁共振(MRI)影像特点的对比性分析,探究其发病的病因和机制。方法分析根据发病48h内磁共振弥散加权像(DWI)的结果,确定梗死的部位及大小,按照纹状体内囊梗死(SCI)的影像诊断标准,将58例患者分为(SCI组)26例和(非SCI组)32例。并分别进行临床表现与影像特点的分组对比。结果临床资料显示,两组在NIHSS评分、血压、血糖及CRP等动脉粥样硬化危险因素指标均有显著差异。影像资料显示,病灶分布情况、白质病变在2组对比差异有统计学意义,颈内动脉颅内段、大脑中动脉受累无显著差异。结论 (SCI组)动脉源性或心源性栓塞是主要病因之一,(非SCI组)病因考虑动脉粥样硬化血栓形成。     

A case of aneurysm of the peripheral middle cerebral artery presenting putaminal hemorrhage--pitfall in diagnosis]

A case mimicking hypertensive putaminal hemorrhage which was first treated by CT-guided stereotactic aspiration and eventually diagnosed as a sequence of the ruptured aneurysm of the left peripheral middle cerebral artery on postoperative angiography is presented. This 41 old, right-handed, hypertensive female suffered sudden onset of headache and right hemiparesis. Next day hematoma was evacuated by the CT-guided stereotactic aspiration because of progressive deterioration of the consciousness and patient recovered well. Fourteen days after the evacuation when she presented mild right hand weakness and motor aphasia, angiography revealed a saccular aneurysm with broad neck derived from left posterior parietal artery. A neck clipping necessitated an additional anastomosis between superficial temporal artery and distal middle cerebral artery because of parent artery stenosis. Postoperatively she is doing well with slight motor aphasia. Among the typical hypertensive putaminal hemorrhage diagnosed on CT scan, it is stressed that there may be a possibility of ruptured aneurysm situated on the peripheral middle cerebral artery.