内镜辅助经侧脑室额角入路手术治疗重型脑室型丘脑出血

2020-05-26 王晓军 于涛 周林强 中国微侵袭神经外科杂志

苏州市相城人民医院神经外科2016年5月-2018年5月采用内镜辅助下经侧脑室额角入路手术治疗重型脑室型丘脑出血病人12例,现总结经验报告如下。

苏州市相城人民医院神经外科2016年5月-2018年5月采用内镜辅助下经侧脑室额角入路手术治疗重型脑室型丘脑出血病人12例,现总结经验报告如下。

1.对象与方法

1.1临床资料

男9例,女3例;年龄52~79岁,平均年龄63.5岁;从发病到本院急诊科就诊的时间0.5~16.0h。入院GCS评分:9~13分2例,7~8分8例,4~6分2例。临床表现:瞳孔不等大3例,颅内出血对侧肢体肌力0~Ⅲ级不等。术前CT示丘脑出血且破入脑室,脑内血肿量均≥15ml;继发性脑室出血并铸型,第三脑室扩大,中脑导水管及第四脑室积血,Graeb评分≥6分;西门子MMWP工作站精确测算出术前颅内血肿量为(97.5±6.7)ml,第三、四脑室积血为(25.9±4.6)ml。

1.2手术方法

病人全身麻醉,取丘脑出血同侧发际内弧形切口,铣取直径2.5 cm骨瓣,额叶皮质造瘘沿脑室额角穿刺方向4~5 cm即进入侧脑室,置入内镜镜鞘固定,使用Storz高清硬质观察镜,吸除同侧脑室内血肿,再沿脑室外侧壁找到丘脑血肿破口处,向外清除丘脑内血肿,并确切止血,然后交替使用0°和30°内镜吸除堵塞室间孔的凝血块、清除对侧侧脑室内血凝块,内镜直视下置10号硅胶管于第三脑室内,反复使用生理盐水充分灌洗,尽量冲洗出第三脑室和中脑导水管内的积血,放置脑室引流管,骨瓣复位缝合切口。

1.3术后处理

根据病情或行气管切开,在术后第1天、(4±1)天、(7±1)天复查头部CT,评估颅内出血吸收情况,3~5d后复查头部CT未见非交通性脑积水征象即拔除脑室引流管,经抗感染、高压氧仓及康复训练等综合治疗,4周后行MRI及DTI成像检查。

2.结果(图1)

12例病人术后24h内第1次复查CT:通过西门子MMWP工作站精确测算,丘脑内血肿全部清除9例,大部清除(残余超过3ml)3例;脑室内血肿病人颅内残留血肿量为(19.9±5.2)ml,血肿清除率为70.9%~85.8%,平均78.9%±4.73%;术后第1天第三、四脑室积血体积为(17.8±3.8)ml,较术前减少30.2%~37.5%。术后24h意识好转率58.3%(7/12),1周内意识好转率83.3%(10/12)。术后病人出现肺部感染、电解质紊乱和消化道出血分别为11例、11例和1例;术区再出血1例,经保守治疗后恢复;无一例发生颅内感染;术后1个月发生交通性脑积水1例,经脑室-腹腔分流手术治疗好转。所有病例随访3~6个月,GOS评分4~5分6例,2~3分5例,1分(死亡)1例。


图1内镜辅助经侧脑室额角入路手术治疗右侧重型脑室型丘脑出血。1A术前CT示右侧丘脑出血破入脑室并铸型;1B术后24h复查头部CT示颅内血肿清除满意;1C内镜辅助下经侧脑室额角入路手术后DTI检查提示血肿手术侧锥体传导束完整;1D颞叶造瘘手术病人DTI示手术侧锥体传导束中断破坏

3.讨论

重型脑室型丘脑出血导致脑室铸型,引起脑室急性扩张,阻塞脑脊液循环,形成非交通性脑积水,甚至出现脑疝,病死率较高。尽早清除丘脑及脑室内血肿,最大限度保留残存丘脑功能,恢复脑脊液循环,缓解颅高压,被认为是重型脑室型丘脑出血的早期治疗目标,其对提高病人的生存率及生活质量有重要意义。

丘脑出血由于其部位特殊,传统开颅手术,无论是经侧裂-岛叶入路、外侧裂与角回入路、三角区入路或者颞叶造瘘手术,手术路径均会不同程度破坏内囊等重要部位的神经传导束,加重病人术后神经功能障碍;加之丘脑供血动脉穿支复杂,位置深,止血困难,术后再出血概率大,且脑室内血肿也难以清除满意。神经内镜手术近年在微创神经外科发展迅猛,被广泛应用于脑出血手术中。

作者所在科室采用内镜辅助下经侧脑室额角入路手术治疗重型脑室型丘脑出血病人,一期手术同时清除丘脑和脑室内的血肿,临床效果明显。相比其他手术方法有以下优势:

①血肿清除率高。调整内镜角度,轻松廓清同侧和对侧脑室内的血块,直视下第三脑室内置管冲洗抽吸,可清除第三脑室和中脑导水管内血肿,甚至第四脑室内血肿,并通过侧脑室壁丘脑出血破溃口一期同时清除丘脑内血肿,使丘脑和脑室内的血肿清除率达到最大化,脑室扩张得以短时间内恢复,及早解除对丘脑及脑干重要核团的压迫,使病人在术后更短时间内改善意识障碍,而术前意识障碍时间长短与预后良好程度成反比。

②手术创伤小。该入路通过侧脑室、室间孔等生理间隙进行操作,对脑组织的损害较小,脑室外侧壁丘脑出血自然破溃口由内侧进入丘脑,不经过内囊,尽可能地避开皮质脊髓束等重要神经传导束,始终在血肿腔内操作,降低清除血肿过程中对丘脑组织的二次损伤。

③止血确切。充分发挥神经内镜手持显微镜近距离放大效应,以及角度镜多视角及绕角观察功能,为手术操作提供更清晰术野,确切止血,减少盲目操作。

④术后并发症少。术后意识障碍持续时间越短,发生并发症的概率越小。而手术清除脑室内大量的血凝块,脑室外引流时间明显缩短,无需再使用尿激酶,减少颅内感染的机会,本组无一例发生颅内感染。清除第三脑室和中脑导水管内的血肿,早期恢复脑室系统脑脊液循环,降低交通性脑积水的发生率。重型脑室型丘脑出血预后不佳,内镜辅助下经侧脑室额角入路切口易定位,血肿清除效率高,副损伤小,止血确切,并发症少,可进一步推广应用。

原始出处:

王晓军,于涛,周林强,石磊,蒋才奇,顾宇佳,卞杰勇.内镜辅助经侧脑室额角入路手术治疗重型脑室型丘脑出血[J].中国微侵袭神经外科杂志,2019(04):172-173.

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    2020-08-02 kcb069
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    2020-05-28 xlwang2696
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    2020-05-28 xlwang2696
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    2020-05-28 tastas

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