不同方式治疗高血压脑出血的疗效对比

目的比较小骨窗显微手术、软通道血肿碎吸术及内科保守治疗3种方式治疗中等量高血压脑出血的疗效。方法连续选取血肿量20～40ml、格拉斯哥昏迷评分9～12分的单侧基底核区高血压性脑出血患者106例，按住院号尾数，随机将其分为小骨窗组31例、软通道组36例，内科保守治疗组39例。观察住院期间再出血率、病死率及术后3个月的致残率。其中软通道组3例、内科保守治疗组6例因病情变化，中途改为小骨窗手术治疗。结果①小骨窗组血肿清除量均〉75％，其中9例基本全部被清除；软通道组中，除1例血肿清除量约为65％外，其余均〈50％。②小骨窗组、软通道组、内科保守治疗组再出血率分别为6．5％（2／31）、30．3％（10／33）及45．5％（15／33）；病死率为3．2％（1／31）、24．2％（8／33）及48．5％（16／33）；致残率为35．7％（10／28）、68．0％（17／25）及73．3％（11／15）。小骨窗组的再出血率、病死率及致残率与软通道组和内科保守治疗组比较，差异均有统计学意义（P〈0．01，P〈0．05）；软通道组与内科保守治疗组比较，再出血率和致残率差异无统计学意义（P〉0．05），病死率差异有统计学意义（P〈0．05）。结论3种治疗方式中，小骨窗显微手术疗效最安全、有效；软通道血肿碎吸术能降低患者的病死率，但不能改善再出血率和致残率；内科保守治疗仅适用于出血量小，无意识障碍和神经功能缺损不明显的患者。

Three treatments for moderate hypertensive intracerebral hemorrhage: a comparative therapeusis

Objective To compare the therapeutic efficacy of small skull window microsurgery, minimally invasive surgery for crashing and aspirating of hematoma （ MISCAH）, and conservative management for moderate hypertensive intracerebral hemorrhage treatment. Methods A total of 106 consecutive patients with moderate hypertensive intracerebral hemorrhage （hematoma volume 20 -40 mL; Glasgow coma scaleGCS] scores 9 -12） in unilateral basal ganglion regions were selected. They were randomly assigned to small skull window microsurgery group （ n = 31 ） , MISCAH group （ n = 36 ）, and conservative treatment groups （n = 39）. The recurrent rehemorrhage rate, mortality rate, and disability rate 3 months after the procedure were observed. Three patients in the MISCAH group and six patients in the conservative treatment group eventually underwent microsurgery through small skull window for evacuation of hematoma. Results ①The volume of hematoma evacuated in the small skull window microsurgery group was 〉 75%. Among them, 9 were almost evacuated completely. The volume of hematoma evacuated in the MISCAH group was 〈 50%. ②The recurrent hemorrhage rates in the small skull window microsurgery group, MISCAH group, and conservative treatment group were 6.5% （2/31）, 30.3% （10/33）, and 45.5% （15/33）, respectively. Their mortality rates were 3.2% （ 1/31 ）, 24.2% （8/33） , and 48.5% （ 16/ 33）, respectively. The disability rates were 35.7% （ 10/28）, 68.0% （ 17/25）, and 73.3% （ 11/15）, respectively. There were significant differences of the recurrent hemorrhage rate, mor：ahty rate, and disability rate between the small skull window microsurgery group and both the MISCAH group and conservative treatment groups（P 〈 0.01, P 〈0.05）. There was no significant significance in the recurrent hemorrhage rate and disability rate between the MISCAH group and the conservative treatment group（P 〉 0.05 ） ,except the mortality rate （P 〈 0.05）. Conclusion Microsurgery through small skull window for evacuation of hematoma is the most safe and effective method for treatment of hypertensive intracerebral hemorrhage. The MISCAH can decrease the mortality rate of the patients, but it can not reduce the recurrent hemorrhage rate and disability rate. The conservative treatment was only suitable for patients with small amount of bleeding, without disturbance of consciousness, and with mild neurological deficits.