两种术式救治高血压脑出血临床疗效探讨

目的探讨高血压脑出血大骨瓣和小骨窗开颅血肿清除术两种手术方式的临床疗效。方法将62例高血压脑出血开颅血肿清除术患者分为2组:大骨瓣组31例,小骨窗组31例。对两组患者的近远期疗效、血肿清除率、再出血情况等进行比较。结果术后21d后患者生活能力评定(按ADL分级)显示小骨窗组明显优于大骨瓣组(P0.05);术后小骨窗组残留血肿量平均约8ml,明显少于大骨瓣组15ml;术后12h小骨窗组有1例(3.23%)再出血,大骨瓣组有6例(19.35%)发生再出血,两者有显著性差异(P0.05)。结论小骨窗开颅血肿清除术能提高高血压脑出血患者疗效,降低再出血率。     

立体定向术与小骨窗开颅术治疗高血压脑出血的疗效分析

目的 探讨立体定向血肿抽吸术与小骨窗开颅血肿清除术治疗高血压脑出血的疗效.方法 分别对33例和29例高血压脑出血患者采用立体定向血肿抽吸术及小骨窗开颅血肿清除术治疗.结果 立体定向血肿抽吸术与小骨窗开颅血肿清除术患者术后偏瘫开始恢复时间分别为12±3.2天、18±4.5天,差异有显著性意义(P＜0.05);术后肺部感染(P＞0.05)、上消化道出血(P＞0.05)差异无统计学意义;立体定向血肿抽吸术预后(Activity of daily living,ADL)优于小骨窗开颅血肿清除术(P＜0.05).结论 与小骨窗开颅术相比,立体定向血肿抽吸术具有创伤小、偏瘫恢复快的优点,是治疗高血压脑出血的理想方法.     

大骨瓣开颅术治疗重症高血压脑出血的疗效分析

目的探讨大骨瓣开颅术在重症高血压脑出血治疗中与单纯开颅血肿清除术的疗效比较。方法选取安徽省合肥市滨湖医院2014年1月—2018年11月手术治疗的66例高血压脑出血患者。根据患者的病情分为开颅血肿清除+大骨瓣减压组(去骨瓣组,骨窗减压范围至少为10 cm×12 cm)和单纯开颅血肿清除组(单纯开颅组,小骨窗开颅血肿清除)。术后1个月时进行格拉斯哥预后量表(Glasgow outcome scale,GOS)评分,比较两种手术患者的近期疗效。结果去骨瓣组恢复良好(GOS评分4～5分)、恢复较差(GOS评分2～3分)、死亡的患者分别为12例(36. 4%)、16例(48. 5%)、5例(15. 1%);单纯开颅组分别为16例(48. 5%)、7例(21. 2%)、10例(30. 3%)。两组间预后的差异有统计学意义(χ~2值17. 28,P=0. 000 2)。结论单纯血肿清除术对重症高血压脑出血的减压效果不显著。而大骨瓣减压术与其相比,则能取得较好的效果,可明显降低重症高血压脑出血的死亡率。     

69例高血压脑出血小骨窗手术治疗效果观察

目的观察69例高血压脑出血的小骨窗手术治疗效果。方法选取69例高血压脑出血者为观察组,给予小骨窗开颅术;同时选取传统去骨瓣开颅术的65例高血压脑出血者为对照组,对2组患者手术效果和并发症等进行观察。结果 2组患者恢复率与重残率、手术时间和住院时间、手术并发症发生率相比差异均有统计学意义(P<0.05)。结论小骨窗开颅术是处理高血压脑出血安全且可行的手术方案。     

标准外伤大骨瓣与常规骨瓣治疗重型颅脑损伤多中心前瞻性临床对照研究

目的比较标准外伤大骨瓣与常规颞顶瓣开颅术在治疗447例重型颅脑损伤合并脑挫裂伤脑水肿、恶性颅内高压病人的效果。方法6家医院神经外科共收治符合标准的重型颅脑损伤病人447例,分为两组:(1)标准外伤大骨瓣组217例;(2)常规骨瓣组230例。所有病人都经CT扫描证实颅内损伤状况。结果伤后6个月临床随访结果:标准外伤大骨瓣组:76例预后较好(35.0%),其中恢复良好42例、中残34例;141例预后较差(65.0%),其中重残69例、植物生存9例、死亡63例;常规骨瓣组:58例预后较好(25.2%),其中恢复良好31例、中残27例;172例预后较差(74.8%),其中重残80例、植物生存7例、死亡85例(P<0.05)。标准外伤大骨瓣治疗组病人颅内压下降速度和程度优于常规骨瓣对照组(P<0.05)。标准外伤大骨瓣治疗组病人的迟发性血肿、再次手术、切口疝和脑脊液漏发生率明显低于常规骨瓣对照组(P<0.05),但两组病人术后急性脑膨出、术后外伤性癫痫和颅内感染发生率均无显著差异(P>0.05)。结论临床前瞻性多中心对照研究证明标准外伤大骨瓣开颅术治疗严重脑挫裂伤脑水肿、恶性颅内高压病人的疗效优于常规颞顶瓣开颅术。     

颞顶直切口骨瓣成形治疗高血压壳核出血

目的探讨一种简便有效的治疗高血压脑出血的手术方式。方法高血压壳核出血56例，采用颞顶直切口、小骨窗开颅手术清除血肿。结果术中无死亡病例，术后3d血肿完全消失49例，术后10d意识完全恢复45例。术后随访3～4个月，根据GOS评分，恢复良好26例，轻残15例，重残11例，植物生存2例，死亡2例。结论颞顶直切15骨瓣成形血肿清除术治疗高血压壳核出血方法简便，创伤小，效果好，值得推广。     

小骨窗开颅血肿清除率对高血压脑出血的预后影响

目的评价小骨窗开颅术血肿清除率对高血压脑出血(hypertensive intracerebral hemorrhage,HICH)的预后影响。方法241例施行小骨窗开颅术的HICH病例,根据血肿清除率分为A组(血肿清除率≤60%~<75%,70例)、B组(血肿清除率≥75%~<90%,117例)、C组(血肿清除率>90%,54例),对三组的术后再出血率、颅内感染率、血肿完全吸收时间及术后28天神经功能缺损评分进行对比研究。结果随着血肿清除率的增加,病人术后清醒时间及血肿完全吸收时间明显缩短(P<0.01),神经功能明显改善(P<0.05),治疗有效率显著提高,C组最有效(P<0.01)。死亡率C组较A组明显降低(P<0.01)。结论血肿清除率是影响小骨窗开颅术治疗HICH预后的重要因素。     

小骨窗显微开颅术与传统开颅术治疗高血压脑出血的临床疗效比较

目的对比分析小骨窗显微开颅术和传统开颅术在治疗高血压脑出血患者临床疗效的差异。方法选取2011年1月~2014年12月我院收入治疗的61例高血压脑出血患者,根据其所选择的手术方法分为小骨窗显微开颅组(n=29)和传统开颅组,其中小骨窗显微开颅组有32例患者,大骨瓣开颅组有29例患者,比较两组患者的平均手术时间,术中出血量,再出血发生率,住院时间,术后死亡率,以及远期疗效等相关指标差异。结果小骨窗显微组与传统开颅组在手术时间,死亡率方面未见明显统计学差异(P0.05)。但在术中出血量,住院时间,再出血率以及远期疗效方面小骨窗显微组明显优于大骨瓣开颅组(P0.05)。结论小骨窗显微血肿清除术治疗高血压脑出血较大骨瓣开颅血肿清除术具有更为优异的临床疗效,术后恢复快且再出血发生率较低,远期疗效好。     

小骨窗显微手术治疗基底节高血压脑出血30例临床观察

目的探讨小骨窗显微手术治疗基底节高血压脑出血的手术方法。方法我院收治基底节区高血压脑出血患者60例,随机分为实验组和对照组各30例,实验组采取小骨窗显微手术治疗,对照组采用标准大骨瓣开颅手术治疗,对比2组临床疗效。结果 2组手术时间、术后并发症、术后清醒时间、术后恢复率对比,差异有统计学意义(P<0.05)。结论小骨窗显微手术治疗基底节高血压脑出血损伤小,血肿清除效果好,术后并发症发生率低。     

幕上高血压性脑出血162例手术治疗分析

目的 总结幕上高血压性脑出血手术治疗经验。方法 回顾性分析2016年6月至2018年12月手术治疗的162例高血压性脑出血的临床资料。85例采用小骨窗手术治疗（小骨窗组）,77例采用常规大骨瓣开颅手术（大骨瓣组）。结果 ①脑出血量≥60 ml的69例中,小骨窗组21例,大骨瓣组48例;小骨窗组组手术时间、术中出血量、二次手术率均明显优于大骨瓣组（P<0.05）;两组术后5 d脑水肿体积、住院时间及术后3个月GOS评分均无统计学差异（P>0.05）。②脑出血量30~60 ml的93例中,小骨窗组64例,大骨瓣组29例;小骨窗组手术时间、术中出血量、住院时间及术后3个月GOS评分均明显优于大骨瓣组（P<0.05）;两组术后5 d脑水肿体积及二次手术率均无统计学差异（P>0.05）。结论 对于高血压性脑出血,如果血肿量≥60 ml或脑疝中晚期,以大骨瓣开颅手术为妥;脑出血量在30~60 ml、无脑疝形成或脑疝形成早期,宜选择小骨窗手术,可以明显缩短手术及住院时间,减少术中出血,改善预后。不同手术方式,各有适应证,遵循个体化原则选择最合理的手术方式。     

微创开颅术

“微创手术”。即以最小的医源性损伤,达到最好的治疗效果,争取使病人尽早恢复健康。 神经外科早期手术是以打开较大直径的骨瓣为特点的。其原因是:(1)由于诊断方法不先进,经济财力不足或健康意识不足,以致肿瘤长得相当大时才被发现;(2)手术照明条件差,只有较大的开口,才能使光线射入术野深部;(3)器械粗大;(4)手术人员多,通常3人上台,6只手同时在术野操作,需要一个大的手术野。     

Patient acceptance of awake craniotomy

Objectives

The aim of this study was to objectively assess the patients’ acceptance for awake craniotomy in a group of neurosurgical patients, who underwent this procedure for removal of lesions in or close to eloquent brain areas.

Patients and methods

Patients acceptance for awake craniotomy under local anesthesia and conscious sedation was assessed by a formal questionnaire (PPP33), initially developed for general surgery patients. The results are compared to a group of patients who had brain surgery under general anesthesia and to previously published data.

Results

The awake craniotomy (AC) group consisted of 37 male and 9 female patients (48 craniotomies) with age ranging from 18 to 71 years. The general anesthesia (GA) group consisted of 26 male and 15 female patients (43 craniotomies) with age ranging from 26 to 83 years. All patients in the study were included in the questionnaire analysis. In comparison to GA the overall PPP33 score for AC was higher (p = 0.07), suggesting better overall acceptance for AC. The subscale scores for AC were also significantly better compared to GA for the two subscales “postoperative pain” (p = 0.02) and “physical disorders” (p = 0.01) and equal for the other 6 subscales. The results of the overall mean score and the scores for the subscales of the PPP33 questionnaire verify good patients’ acceptance for AC.

Conclusion

Previous studies have shown good patients’ acceptance for awake craniotomy, but only a few times using formal approaches. By utilizing a formal questionnaire we could verify good patient acceptance for awake craniotomy for the treatment of brain tumors in or close to eloquent areas. This is a novel approach that substantiates previously published experiences.     

New orbitozygomatic approach by craniotomy

Introduction The orbitozygomatic extension technique described by Sekhar and Wright requires a temporal basal craniectomy that must be done in order to make osteotomy dissections. In the present work, a technique that includes the base and squamous temporal bone and a craniotomy instead of a craniectomy is shown.Method The temporal and masseter muscles are dissected and separated from the temporal and zygomatic bones to facilitate passing them through the zygomatic arch in a caudal direction, which allows a frontotemporal basal craniotomy. Intracranially, a trepan that communicates to the glenoid cavity is done, which permits a temporal basal cut using the pneumatic drill saw. This is done in order to join with the orbital wall osteotomies, which were done in this approach with the craniotomy.     

Free craniotomy versus osteoplastic craniotomy,assessment of flap viability using 99mTC MDP SPECT

There are currently two accepted neurosurgical methods to perform a bony flap. In an osteoplastic flap, the flap is attached to surrounding muscle. In a free flap, the flap is not attached to adjacent tissues. The former is less common due to its complexity and the extensive time required for the surgery; yet the rate of infection is significantly lower, a clear explanation for which is unknown. The objective of this study was to test the hypothesis that the osteoplastic flap acts as a live implant that resumes its blood flow and metabolic activity; contrasting with the free flap, which does not have sufficient blood flow, and therefore acts as a foreign body. Seven patients who underwent craniotomy with osteoplastic flaps and five with free flaps had planar bone and single photon emission computed tomography (SPECT) scans of the skull at 3–7 days postoperative, after injection of the radioisotope, 99m-technetium-methylene diphosphonate (99m-Tc-MDP). We compared radioactive uptake as a measure of metabolic activity between osteoplastic and free flaps. Mean normalized radioactive uptakes in the centers of the flaps, calculated as the ratios of uptakes in the flap centers to uptakes in normal contralateral bone, were [mean: 1.7 (SD: 0.8)] and [0.6 (0.1)] for the osteoplastic and free flap groups respectively and were [2.4 (0.8)] and [1.3 (0.4)] in the borders of the flaps. Our analyses suggest that in craniotomy, the use of an osteoplastic flap, in contrast to free flap, retains bone viability.     

Unilateral craniotomy for bilateral cerebral aneurysms

Multiple intracranial aneurysms located bilaterally in the anterior circulation are usually clipped sequentially by separate craniotomies or a bilateral craniotomy. However, in selected patients, bilateral aneurysms can be clipped on both sides in a single sitting through a unilateral approach and unilateral craniotomy without causing morbidity. We present our technique and results of bilateral aneurysms clipped through a unilateral craniotomy from the ruptured aneurysm side. Ten patients (between 2006 and 2008) aged 20 years to 67 years with bilateral supratentorial anterior circulation saccular aneurysms, World Federation of Neurological Surgeons Scale (WFNS) score subarachnoid hemorrhage (SAH) grades 1 and 3, Fisher grades 2 and 3, were operated with unilateral orbito–pterional craniotomy and clipping of bilateral aneurysms. A total of 23 aneurysms, 12 located contralaterally, were successfully clipped with a good outcome in nine patients and no mortality at all. We therefore conclude that the unilateral orbito–pterional approach can be safely employed in selected patients harboring bilateral supratentorial saccular aneurysms and presenting with SAH, having WFNS grade 1 to 3, Fisher grade up to grade 3. The brain must be lax intra-operatively. Wide opening of the basal cisterns, 3rd ventriculostomy, and clipping of ruptured aneurysms are the important steps to be performed first before clipping the contralateral aneurysm thus avoiding a second craniotomy.     

Awake craniotomy and multilingualism: Language testing during anaesthesia for awake craniotomy in a bilingual patient

An awake craniotomy for epilepsy surgery is presented where a bilingual patient post-operatively reported temporary aphasia of his first language (Spanish). This case report discusses the potential causes for this clinical presentation and methods to prevent the occurrence of this in future patients undergoing this form of surgery.     

传统骨瓣开颅与小骨窗开颅微创治疗高血压脑出血患者的疗效分析

目的探讨传统骨瓣开颅与小骨窗微创手术治疗高血压脑出血患者的临床效果并对比分析。 方法选择高密市人民医院神经外二科自2016年5月至2018年3月收治的高血压脑出血患者72例,根据患者自身病情及家属意见进行手术分组,40例行小骨窗微创开颅（骨窗组）,32例行传统骨瓣开颅减压组（骨瓣组）。对比2组患者的术中手术时间、出血量、住院时间及术后6、24、72 h和1周的颅内压值,并于3个月后随访进行日常生活能力（ADL）评分。 结果骨窗组相对于骨瓣组术中出血量少、手术时间短;2组术后6、24 h颅内压力值比较,差异无统计学意义（P>0.05）;骨窗组72 h、1周颅内压力值高于骨瓣组,差异具有统计学意义（P<0.05）,但经脱水或释放部分脑脊液后,颅内压值均可控制在正常范围之内。术后3个月按照ADL评分：骨窗组Ⅰ~Ⅲ级良好率85.0%,骨瓣组Ⅰ~Ⅲ级良好率62.50%,差异具有统计学意义（P<0.05）。 结论与传统骨瓣开颅术相比,小骨窗微创术医源性创伤小,近期预后好,临床效果显著。     

Remote cerebellar hemorrhage following supratentorial craniotomy

Abstract

Objective: Cerebellar hemorrhage remote from the site of surgery may complicate neurosurgical procedure. The exact pathophysiology of this type of hemorrhage is poorly understood. We retrospectively compared 16 patients who had remote cerebellar hemorrhage (RCH) with a case-matched control cohort, to determine the significance of perisurgical and surgical factors that may predispose patients to such bleeding events.

Methods: From 1 June 2005 to 31 December 2008, postoperative routine head computed tomographic (CT) scan was performed in our institution and 16 patients with RCH after supratentorial neurosurgical procedure were identified. The medical charts of these 16 cases and a control cohort of 64 patients were recorded. All parameters were analyzed with regards to various variables.

Results: The incidence RCH after supratentorial craniotomy increased after postoperative computed tomographic scan. The mechanism of cerebellar hemorrhage in this series of patients is most likely multifactorial. Several variables showed a significant association with the occurrence of RCH. Multivariate analysis indicated that the following two factors independently correlated with occurrence of RCH: (1) postoperative epidural drainage amount; and (2) history of previous cerebrovascular accident (CVA) with cerebral atrophy. All cases with RCH underwent medical treatment and no neurological sequelae associated with RCH.

Conclusions: Postoperative epidural drainage amount and history of previous CVA with cerebral atrophy can reliably predict the occurrence of cerebellar hemorrhage after supratentorial craniotomy. One of the most important strategies to minimize hazardous complications is to be aware of these potential risk factors and to take action to prevent them.