Study On Type And Choice Of Surgical Method Of Hypertensive Intracerebral Hemorrhage

Objective:Hypertensive intracerebral hemorrhage (HICH) accounted for about one in third in patients with cerebrovascular disease, but the mortality accounted for the top in cerebrovascular disease. The disease mostly occurs in the 50-60 year-old of hypertensive patients with cerebral arteriosclerosis, the mortality rate was up to 40%-70% while using non-surgical therapy, so it is extremely important for looking for effective surgical methods to improve the cure rate and reduce the mortality rate. After the application of CT in clinic, the diagnosis of cerebral hemorrhage is simple and rapid, but the location and characteristics of bleeding varied. With the advancement of science and technology, the treatment constantly updated, and the treatment modalities were endless. There are currently two types of surgical techniques:one is Craniotomy remove the hematoma.The craniotomy including conventional surgery and microsurgery; The other is minimally invasive surgery, including surgery stereotactic hematoma aspiration, endoscopic stereotactic evacuation of hematoma and under suction catheter drainage of hematoma+hemolysis operation (including under stereotactic localization and simple calculation through three-dimensional positioning). There were many views in the surgical method of treatment of the cerebral hemorrhage patients to get the desired results today. There is a tendency that promoted minimally invasive surgery to replace craniotomy, because of the large trauma in craniotomy and emphasizing the advantages of minimally invasive surgery. In fact every type of surgery has its own advantages and disadvantages. The treatment of cerebral hemorrhage should be individualized. The purpose of this study is to conduct a more comprehensive type on the HICH and to find the appropriate surgical treatment for each type.Methods:Retrospective analyzing the information of 352 cases of HICH patient we treated in two hospitals in the past three years. A hospital for the counties in the Upper Second Class Hospital which HICH patients admitted to medical therapy, than the other with the drainage tube suction+ hemolysis. The three-dimensional calculation according to CT placed the drainage tube since the hematoma from a recent department, its tip in the center or close to the hematoma center. Drainage tube is produced by a medical.device Co., Ltd. Beijing North san You of different lengths of 2.0mm diameter metal pipe that is hard channel. The operations were completed in the sterile operating room under local anesthesia by the deputy chief physician with many years of catheter experience. The hospital provided 149 cases, most of the surgery implemented 6 hours after the onset. Our Hospital is B for the three hospitals and carry out micro-surgery for 15 years.The treatment, methods of HICH have micro-surgery craniotomy hematoma removal, decide to decompressive craniectomy according to the preoperative condition. this group has 160 cases; treating 39 cases with hemolytic stereotactic catheter drainage tube and simple skull hemolytic drainage, conservative treatment in 5 cases. The inner diameter of drainage tube is 2.0mm standard shunt that soft passage. The group of patients has a strong randomness, the technology of surgery is mature and reliable. Evaluating preoperative condition with the five grading and GCS, drowsiness, confusion, light coma, moderate coma and deep coma, all cases were classified, according to bleeding site-in CT. Classification as follows:①lobar hemorrhage: hematoma in subcortical, the parts lighter;②basal ganglia hemorrhage:hemorrhage, including putaminal and caudate hemorrhage;③thalamic hemorrhage:include localized bleeding hypotha-lamus,thalamus-hemorrhage within the cystic and the hypothalamus-brain stem hemorrhage type;④mixed hemorrhage:hemorrhage covering two or more areas (such as the brain stem-the hypothalamus-in cystic hemorrhage, the hypothalamus-the internal capsule-putaminal hemorrhage and the capsule-putamen-lobar bleeding);⑤cerebellar hemorrhage;⑥brainstem hemorrhage;⑦intraventricular hemorrhage:intraventricular hemorrhage, including primary and secondary intraventricular hemorrhage;⑧multiple brain hemorrhage:bleeding while not adjacent to the site. Analysis the treatment and outcome of bleeding in each type, divided into minimally invasive surgery group and the control group of the most common brain hemorrhage and basal ganglia hemorrhage.Results:First,we contrast two methods of treatment over the same period hematoma in the cerebral lobes and basal ganglia area of the 190 eligible patients were each matched.Divided into two groups according to the degree of consciousness, analyzed the treatment results. Group I: patients with consciousness lethargy or hazy, GCS10-14 points, a total of 73 cases. Craniotomy group:32 cases, hematoma volume on average is 43ml.6 hours-48 hours operation time, average 16 hours.31 cases improved,1 died, mortality was 3.1%. Hematoma Cavity hard tunnel drainage pumping+ hemolysis group:41 cases, hematoma volume average of 41ml,11 cases breaking into the ventricle. The time from onset to surgery was 6-48 hours, average 18 hours.39 cases were improved,2 patients died, mortality was 4.9%. GroupⅡ:the patients' consciousness is light coma and moderate coma, GCS score of 4-9 points, a total of 117 cases. Craniotomy group:60 cases, hematoma volume average 62ml,40 cases of breaking into the ventricle,there were 15 cases of hernia, are unilateral hernia.2 hours-24 hours operation time, an average of 9 hours.53 cases were improved,7 patients died, mortality rate was 11.7%. Hematoma Cavity hard tunnel drainage pumping+hemolysis group:57 cases, hematoma volume average 56ml,38 cases of breaking into the ventricle,13 cases of cerebral herniation occurred.4-24 hours of operation time, average is 12 hours.43 cases were improved,14 cases of death, mortality rate was 24.6%. design two sample tests with SPSS13.0, the first group P> 0.05,there is no significant difference. The second group P<0.05, there is significant difference. Follow-up 6 months-3 years, the average is 18 months, activities of daily living (ADL) of the two sample test of P>0.05, there is no significant difference between two treatment methods. Second, the hypothalamus-in 48 cases of cystic hemorrhage, hematoma volume was 15-40ml, are breaking into the ventricle. Bleeding was less than 30ml in 19 patients, hemolytic ventricle drainage catheter which improved 16 cases,3 died. Large amount of bleeding in 30ml were 29 cases, ipsilateral to the temporal-parietal bone flap craniotomy decompression, hematoma+lateral ventricle under a microscope clear open drainage was 15 cases, of which 6 cases of hernia,4 patients died after surgery, the mortality rate was 26.7%; Hemolytic hematoma drainage+catheter tube lateral external drainage of cerebrospinal fluid was 14 cases,4 cases of cerebral herniation before surgery,6 died,the mortality rate was 42.9%. Third, mixed hemorrhage were 20 cases, more than a larger amount of bleeding, the hypothalamus-the internal capsule-the nuclear shell model bleeding often more than 40ml, putamen-cerebral hemorrhage blade often more than 80ml. Craniotomy was 10 cases,4 died. Minimally invasive surgery was 10 cases,8 patients died. The last,12 cases of cerebellar hemorrhage, the hematoma volume was 15-35ml, all were operated the microscope suboccipital craniotomy hematoma removal,11 cases improved,1 case of persistent vegetative state.Conclusion:①The hematoma cavity for aspiration+hemolysis tube drainage fit for the cerebral lobes and basal ganglia hemorrhage while the patient has not entered a coma, drowsiness or hazy consciousness, hematoma volume of more than in 30-50ml.The surgery implementation is appropriate after 12-24 hours of the onset; while craniotomy under a microscope to remove the hematoma surgery carried out as soon as possible fit for the patient has entered a coma, coma or moderate to light coma, hematoma volume of more than in 50ml, and according to the condition and surgery deciding whether to decompressive craniectomy.②thalamic hemorrhage:hematoma were less than 30ml,the fluid drainage outside ventricle puncture cerebrospinal;. the hematoma was more than 30ml, it should operate temporal-parietal craniotomy ipsilateral decompressive craniectomy, hematoma removal+lateral ventricle under the microscope.③Unless the deep coma and bilaterally dilated pupils,the mixed cerebellar hemorrhage and cerebral hemorrhage should operate craniotomy decompression and hematoma evacuation.