| Background and objectiveHypertensive hemorrhage remains one of the four most usual diseases that threating our health in China, carrying rapid onset and extremely high morbidity (approximately 40%) and also a high rate of mutilation. The most common site of hypertensive hemorrhage is the basal ganglion (mainly the arteriorrhexis of cerebral hemorrhage), which accounts for two thirds of all hemorrhage in brain. Regarding the therapy for basal ganglia hematoma, various approaches are available depending on the different conditions. For example, in case of the conscious suffers with little volume of blood in basal ganglia (less than 20 ml), surgery offers no benefit, and such patients should be treated conservatively. What's more, either surgery or not is meaningless for the deep coma ones with corectasis or severe disorder in vital signs. Alternatively, it has been recognized to make more profits for patients with GCS≥6 and the volume of hematoma either≥20 ml superior or≥10 ml inferior curtain, respectively,who receive surgery rather than conserve treatment. In the last decade, minimal invasiveness has become the trends of neurosurgery with the development of micro-invasive techniques in this field and the pervasion of CT in clinic, which in turn bring amelioration in the functional impairment and improvement in life quality for patients suffering from hemorrhage in basal ganglia to some degree, resulting in satisfying effects. Ultimately, accumulating evidences verify the microsurgery to tackle hemotoma in the brain as one of the effective approaches to basal ganglia hematoma. Being the key point of various minimal invasive surgery of hematoma in basal ganglia, precise localization before operation has already got widely effective investigation. Unfortunately, its unexpected lower precision might lead to the clearance rate of hematoma, which in turn cause more puncturation, urokinase, and higher rates of rehaemorrhagia, intracranial infection. The underlying causes may be that as follows:1. The surgery under simple CT localization has easy procedures on one hand; on the other hand, it owns untackleable disadvantages of lower precise and more rehaemorrhagia post-operation.2. The CT-guided surgery and stereotaxis ones are more precise in localization, but neither suit for the widely application in the primary hospitals due to their high requirements for apparatus and complex procedures. In present paper, we aimed to evaluate role of the the brain-CT-location-paste in minimal invasive therapy for hematoma in basal ganglia in terms of surgical effects, safety and complications, in detail:1. To test the brain-CT-location-paste in minimal invasive treatment for hematoma in basal ganglia, concerning the hematoma clearance rate, amounts of rehaemorrhagia, score of SSS after 4 weeks administration, and the postoperative GCS scores at 6 months post-operation.2. To investigate the CT-metal mark-guided in the treatment process in terms of the amounts of puncturation, injection of urokinase and rates of intracranial infects.3.To compare the CT-metal mark-guided in minimal invasive therapy and classical microsurgery in treatment of basal ganglia haemorrhage, regarding advantages, safty and complications via taking into consideration of conditions 1 and 2. Gladly, preliminary clinical research has been done with satisfied effects:1. A simple, safe and effective surgical method has been provided for the minimal invasive treatment for basal ganglia haemorrhage.2. To some extent, improvement in prevention has been attained due to higher clearance rate of hematoma, less modulation of puncturation and urokinase, also fewer damagement to the brain tissue.3. Cost of hospitalization per patient would be lessened massively because of the shorter length of patient stay. In addition, it may bring some economical benefits to generalize the CT-metal mark-guided wide utility. Materials and methodsThere are 93 patiens of Basis festival area cerebral hemorrhage in our department from July 2006 to September 2009,49 cases in the CT slice positioning taken minimally invasive puncture (invasive group) and the other 44 cases of CT-metal mark-guided Posts Positioning taken minimally invasive puncture (positioning paste group).1.1 The criteria for patient selection:①Have the history of hypertension or high blood pressure When morbidity and been exclusion of other causes of spontaneous intracerebral hemorrhage;②The bleeding≥30ml according to Tada formula,which is cerebral hemorrhage in the basal ganglia area showed by CT③preoperative GCS score 5-8 points;④Have a complete treatment and follow-up data;⑤several conditions were not included in this study,including rapid progression,4-6 hours in a deep coma, two-dilated pupils and respiratory arrest1.2 Clinical situation of patiensGeneral conditions of patien were shown in table 1 consist of age, blood loss, broken into the ventricle, GCS of preoperative,SSS of preoperative, surgical opportunity and surgical time. Note: There were no obvious statistical difference between minimally invasive group and positioning affixed group by statistic analysis in age, bleeding volume, broken into ventricles, GCS of preoperative, SSS of preoperative, surgery opportunity and time (Pa-g> 0.05.)1.3 Manufacture of the CT-metal mark-guidedThe patented home-made the CT-metal mark-guided is composed of two different medal buttons and rectangle coated fabric (13cm x8 cm), with the larger buttons and the smaller ones aligned on the later fabric orderly and along bias, respectively. (Fig 1 A,1B row x c:2 cm x 1 cm)2 Surgical ProcedureGroup of minimal invasiveness:the hematoma was under punctuation by means of a type YL-1 puncture pin (produced by Beijing WanTeFu Medical Apparatus Co., Ltd), according to the classical scribing position determined by pre-surgical CT scan. Then the core of pin was pulled out, followed by the slow suction of liquid hematoma and the normal sodium douche of drainage tube, once the olden blood flowed out. Finally,7 out 10 ml normal sodium containing 100 thousand Units urokinase were injected into the canal to dissolve the residual part of hematoma, with injection of the left 3 ml urokinase into the tube, which was closed immediately and opened again after approximately 6 to 8 hours,3 times daily. During the next 18 to 24 h and 48 h after surgery, two CT scan of brain had been taken to determine and modulate the distance between the center of hematoma and the pin tip, via modulation of the pin according to the degree of drainage, meaning also drawing out of the pin when more than 90% of blood had been sucked from the hematoma. After the operation, the patient got combined therapy including medicine for diastoleing brain vessel, haemostasis, anhydration, fluid expansion and strict controlment of blood pressure, preventive application of antibiotic, prevention and cure stress ulcer, adjusting electrolyte balance, as well as drugs for neurotrophy.Group of the CT-metal mark-guided: having his/her hair shaved in pre-operation, the patient was received the CT-metal mark-guided attaching on his/her brain surface, with the inferior border on the superior edge of ipsilateral ear and the longitude axis paralleling to canthomeatal line (OM line), which was used as baseline in the latter brain CT scan. After the scan with slice thickness of 0.5 or 1.0 cm, the max slice of hematoma to be punctured and the vertical line between its center and the skull were determined, followed by the finding of the CT-metal mark-guided position responding to point on the skull. Simultaneously, the slice with the shortest distance between the hematoma and skull was selected. Then following the record of depth of punctuation and thickness of skull, scribing on the brain surface was applied to avoid blood vessel in the lateral cleft and arteria meningea media. Finally, the punctuation processed with the type YL-1 pin pushing in vertical to the skull at the position determined by the the CT-metal mark-guided after local anesthesia. The surgical procedure of this group was identical to the one applied in the minimal invasiveness.(Fig 1 B-G)The hematoma clearance rate at 48h, amounts of rehaemorrhagia, score of SSS after 4 weeks administration, and follow-up of the survive to evaluate the postoperative GCS scores at 6 months postoperation were carried out. Data were analysised using SPPSS 16.0. Chi-Square test was used to conpare enumeration data,the different between measurementdata which followed normal distribution was compared by t-test and exprssed as mean±SD.A significance was defined as P value<0.05.3. ResultsThe condition of the patiens at two groups was marked in table 2 in terms of intracranial hematoma rateafter 48 hours,postoperative bleeding, SSS scores after 4 weeks hospital admission and GOS scores at 6 months post-operation. there were 49 patiens in Minimally invasive group,8 died at 4 weeks after admission,10 died at 6 months after operation.44 patiens in Location paste group:6 died in 4 weeks after admission,7 died after 6 months operation.1 case in intraoperative rebleeding,4 patients rebleeding after operation,the rate of recurrent bleeding was 11.36%.4. Conclusions.①Among most minimally invasive therapies of cerebral hemorrhage in the basal ganglia area, this method,compared with simple brain-CT Location, has a high evacuation rate (90%), may be improve neural function in future at a greater extent.②The minimally invasive surgery under the CT-metal mark-guided has the following advantages:1. Surgery done under local anesthesia, low requiring in the patient's age and general condition which including the function of heart, lung,liver and kidney; 2. Less damage on normal brain tissue with small diameter needle (2mm), low rate of re-bleeding; 3. The surgery may popularize to the primary hospital for its simplicity of surgical procedure,safe effective;4. it has improved the quality of life of patients, reduced the damage of these diseases on people and achieved satisfactory effct.③his operation type still has deficiency in ultra-early hematoma removal under direct vision which is related to the operation type itself and operative opportunity. As for postoperative hemorrhage,this type can not stop bleeding in a short time.Then,enlargement of hematoma and even the second opening cranium may be caused for puncture by blindly approach.And whether it effects Short-term neurological function and prognosis needs further study...
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