Treatment Strategies For Hypertensive Supraten-torial Cerebral Hemorrhage And Related Factors Of EVD For Severe Intraventricular Hemorrhage

Background and objectivesHypertensive supratentorial intracerebral hemorrhage is the most common type of primary intracerebral hemorrhage and surgical treatment has become one of the most important methods, which includes bone flap craniotomy and decompression, small bone window craniotomy hematoma evacuation, burr hole drilling and drainage, stereotactic hematoma evacuation, neuro-endoscopic hematoma evacuation, etc. While the necessity for surgery, choice of surgical methods and time is still of the questions at issue. In recent years, with the development of endoscopic technology and related equipments, endoscopic hematoma evacuation is recognized by more and more neurosurgeons, but the indications and clinical effectiveness of neuroendoscopic surgery is still controversial. So, the clinical materials, such as conservative treatment and surgical treatment, different surgical methods, different surgical time, prognosis and so on, were analized and compared with those of patients who were given conservative treatment during the same period. Make sense, better strategies could be provided for clinical treatment of hypertensive intracerebral hemorrhage.Methods223 cases of hypertensive supratentorial cerebral hemorrhage patients under our criteria were admitted in our department from June 2012 to June 2014.136 cases were performed surgical methods including neuro-endoscopic craniotomy and craniectomy hematoma evacuation, which contained 65 cases and 71 cases respectively. According to the volume of hematoma, they were divided into small hemorrhage Group (<40ml) and massive hemorrhage Group(≥40ml), which contained 45 cases and 91 cases respectively.87 cases were performed conservative treatment, which contained 36 cases of small hemorrhag(<40ml)e and 51 cases of massive hemorrhage (≥40ml). Evaluation criterions include preoperative GCS score, hematoma clearance, rehaemorrhagia, complete hematoma absorption time, length of stay, time of operation, activity of daily living (ADL)assessment etc, ADL of grade Ⅰ-Ⅲ means effective,while grade Ⅳ-Ⅴ means failure.The difference of curative effect between conservative and operative treatment, endoscopic surgery and routine craniotomy operation were evaluated.78 cases were performed operation within 6 hours after the onset (super-early operation group), while the other 58 cases 7-72 hours after the onset (early operation group). In order to evaluate the effect of prognosis of different operation methods, postoperative mortality, complication rates, activity of daily living were compared.Results1.Comparison between conservative treatment group and surgical methods group.Mean hematoma absorption time of conservative treatment group was 29.2±5.4 days, average length of stay was 28.4±7.1 days,21 cases occurred rebleeding (24.1%),21 cases occurred other complications,11 cases died (12.6%). The assessment of activity of daily living (ADL)in Ⅰ-Ⅲ level and Ⅳ-Ⅴ level contained 64 cases (73.6%) and 23 cases (26.4%) respectively. Mean hematoma absorption time of the surgery group was 4.7±1.4 days, average length of stay was 19.1±3.2 days,10 cases occurred rebleeding (7.3%),12 cases occurred other complications (8.8%),7 cases died (5.1%). The assessment of activity of daily living (ADL) in I-III level and Ⅳ-Ⅴ level contained 122 cases (89.7%) and 14 cases (10.3%) respectively.2. Comparison between endoscopic surgery group and craniectomy surgery groupFor endoscopic surgery group, the average hematoma cleared rate was 89.7±4.7%, average operation time was 123.6±32.1minutes, average blood loss was 110±43.1 ml, average time of stay was 17.2±4.1 days,4 cases occurred rebleeding (6.2%),2 cases died (3.1%),51 cases’(78.4%)postoperation GCS scores improved more than 2 points. The assessment of activity of daily living (ADL)in I-III level and IV-V level contained 59 cases (90.8%) and 6 cases (9.2%. Average hematoma clearance rate in craniectomy surgery group was 87.8±6.7%, average surgery time was 190.1±41 minutes, average blood loss was 480±81.1 ml, average time of stay was 21.1±3.4 days,6 cases occurred rebleeding(8.4%),3 cases died(4.2%),60(84.5%) cases ’postoperation GCS scores improved more than 2 points. The assessment of activity of daily living (ADL) in I-III level and Ⅳ-Ⅴ level contained 63 cases (88.7%) and 8 cases (11.3%) respectively.Postoperative complications of the endoscopic operation:1 cases of pulmonary infection,5 cases of urinary tract infection,4 cases of rebleeding,3 cases died. The first case died of rebleeding,6 hours after the endoscopic operation, who was performed craniectomy again; the second case died of MODS caused by pulmonary infection of multidrug resistant Pseudomonas aeruginosa and baumanii, which finally develop into fungemia, one died for acute kidney failure.Postoperative complication of craniectomy group:10 cases of pulmonary infection, 6 cases of rebleeding,4 cases died. One died for postoperative rebleeding and secondary MODS, two for pulmonary infection, one died of pulmonary embolism.3. Comparison of groups with different surgical opportunity.Super-early surgery group had 1 case(1.3%) died, and 8 cases(10.3%) with complications after operation. The assessment of activity of daily living (ADL) in I-III level and Ⅳ-Ⅴ -level contained 72 cases(92.3%) and 6 cases(7.7%) respectively.Early surgery group had 6 cases(10.3%) of died, and 14 cases(24.1%) with complications after operation. The assessment of activity of daily living (ADL) in I-III level and Ⅳ-Ⅴ level contained 50 cases (86.2%) and 8 cases (13.8%) respectively.4. Comparison of surgery groups with differernt amount of hematoma.In terms of hematoma volume<40 ml, there is no death in the endoscopic surgery group which include 22 cases, the assessment of activity of daily living (ADL) in (Ⅰ-Ⅲ level)and(Ⅳ-Ⅴ level) contained 24 cases (100%) and 0 cases respectively; there are no deaths in craniectomy surgery group which include 23 case. The assessment of activity of daily living (ADL) in Ⅰ-Ⅲ level and Ⅳ-Ⅴ level contained 23cases (100%) and 0 cases respectively.In terms of hematoma volume≥40 ml, there are 3 deathes in the endoscopic surgery group which include 43 cases. The assessment of activity of daily living (ADL) in Ⅰ-Ⅲ level and Ⅳ-Ⅴ level contained 35 cases (81.4%) and 8 cases(18.6%)respectively; there are 4 deaths in craniectomy surgery group which include 48 cases, The assessment of activity of daily living (ADL) in Ⅰ-Ⅲ level and Ⅳ-Ⅴ level contained 37 cases (77.1%) and 11 cases (22.9%)respectively.Conclusions1. Cases with hypertensive cerebral hemorrhage performed craniotomy surgery have a lower rate on mortality, invalidity, hematoma absorption time, time of stay and complication rate compared with conservative treatment.2. Endoscopic surgery may shorten the operation time, time of stay and blood loss, the differences had statistical significance.Though endoscopic surgery with higher hematoma clearance rate, the difference had no statistical significance.3. Super-early operation(<6 hours) had lower mortality and complication rates than early operation (6-72 hours), while there’s no sigificant rate of good outcome.4. In terms of hematoma volume<40 ml, endoscopic surgery group and craniectomy group had no differences in mortality rate and morbidity rate (ADL assessment Ⅳ-Ⅴ level); when hematoma volume≥40 ml, endoscopic surgery group had higher efficiency than craniectomy group, while there’s no statistical significance.Background and objectivesIntraventricular hemorrhage (IVH) was one of the most common emergency dieases of neurosurgery, which develops quickly with high mortality rate and poor prognosis. External ventricular drainage (EVD) was one of the most important means of treatment of This diease and its validity has been widely recognized. The machine, invented by professor Zhang Qinglin and Zhang Cheng, was widely used since a patient suffering late cerebral hernia was successfully rescued in 1977. But systematic and comprehensive study of influential factors of rapid pore cranial drilling was still not sufficient. This study was to provide more references for the use of this technique by carrying retrospective study of it’s use in the treatment of severe intraventricular hemorrhage, related factors affecting the prognosis.Materials and methodsThis study lasted from January 2006 to December 2013, collecting 396 cases from four hospitals. All the cases were severe or extremely severe types of intraventricular hemorrhage with GCS score≤9 points. GOS score of the 3rd month after the operation was evaluated as prognostic outcome,1-2 points defined poor while 3-5 points fine. Differences of prognosis effects with different factors was analized.Results1. General conditionsAge≤40y group contained 79 cases,40-60y group contained 198 cases, age≥60y group contained 119 cases; 272 cases belong to the group who were given rapid pore cranial drilling within 6 hours from the onset, while 124 cases over 6 hours; preoperative GCS score marked between 3 to 5 points included 179 cases, while 6 to 9 points 217 cases; 87 cases occurred rebleeding within 24 hours; 18 cases occurred intracranial infection, with a infection rate of 4.5%; 211 cases had their tube remained more than 10 days, while only 185 cases less than 10 days, while the average time was 12.4±6.7 days; 206 cases treated with bilateral drainage, while 190 cases with unilateral drainage; 301 cases used urokinase, while 95 cases with simply drainage for treatment; 71 cases’tube blocked during the treatment,7 cases infected(9.9%).All the cases were followed up for 3 months at least.95 cases died (GOS 1point), 114 cases were being plant survival (GOS 2 points),107 cases were full restoration (GOS 5 points),80 cases had incomplete recovery (GOS 3-4 points). GOS 1-2 points considered as unfavourable prognosis; GOS 3-5 points considered as favourable prognosis.2. The influence of different factors on the prognosis2.1 The age of 79 cases was less than 40 years old,16 cases of them died, mortality rate was 20.3%,39 cases had fine prognosis, effective rate was 49.4%; 198 cases were 40-60 years old,52cases of them died, mortality rate was 26.3%,97 cases had fine prognosis with effective rate of 48.9%; 27 cases over 60 year old died, mortality rate was 22.7%,51 cases had fine prognosis and the effective rate was 42.9%. Through layering Chi-square test, there was no statastical significance between the mortality rate and effective rate, identifing that age was not a determine factors on prognosis of patients with severe intraventricular hemorrhage.2.2179 cases had GCS score 3-5 points,51 cases of them died, mortality rate was 28.5%,89 cases had fine prognosis with the effective rate of 49.7%; 217 cases had GCS score 6-9 points,44 of them died, mortality rate was 20.2%,98 cases had a fine prognosis, the effective rate was 45.2%. The mortality rate and the effective rate between the two groups showed P>0.05, identifing the difference possessed no statistical significance. The GCS score had no significant influence on the prognosis of severe intraventricular hemorrhage.2.3272 cases performed surgery within 6 hours,36 cases died, with mortality rate of 13.2%,151 cases had fine prognosis with an effective rate of 55.5%; 124 cases performed surgery after more than 6 hours,59 cases died, mortality rate was 47.6%, 36 cases had fine prognosis and effective rate was 29.0%. Mortality rate and the effective rate of the two groups possessed statistical significance respectively.2.4 There were 87casess orrurred rebleeding within 24 hours after the operation, and 31 cases of them died, mortality rate was 35.6%,22 cases had fine prognosis whit an effective rate of 25.2%; 309 cases didn’t occur rebleeding within 24 hours,64 cases of them died, mortality rate was 20.7%,165 cases had fine prognosis with the effective rate of 53.4%. Mortality rate and the effective rate of the two groups possessed statistical significance respectively.2.5 Bilateral and unilateral EVD Comparison between drainage tube stay time and hematoma clearance timeMean time of bilateral drainage placeing was 8.2±3.2 days, while average time of intraventricular hematoma absorption was 7.1±2.7 days; however, mean time of one-side drainage placeing was 14.3±5.7 days, and average time of intraventricular hematoma absorption was 11.4±3.2 days. Comparing the two results, there’s statwastic indication(P<0.05), indicating bilateral drainage was faster than unilateral drainage on hematoma clearance with shorter drainage time.2.6301 cases had application of urokinase,59 cases of them died and mortality rate was 19.6%,149 cases had fine prognosis, the effective rate was 49.5%; 95 cases didn’t use urokinase,36 cases of them died and mortality rate was 37.8%,38 cases had fine prognosis, the effective rate was 40%. Compared the two results, mortality rate possess a statistical significance while not the effective rate, identifing that early application of urokinase could reduce the mortality rate of patients with severe intraventricular hemorrhage, but would not significantly improve the overall prognosis.2.7 The average stay time of catheter of cases using urokinase was 7.9±3.2 days, mean time of hematoma absorption was 5.2±3.7 days; Those who didn’t use urokinase, the mean time of catheter placing was 15.2±6.1 days, mean time of hematoma absorption was 11.2±4.2 days. Tube placing time and hematoma absorption time both possessed statistical significance (P<0.05).2.8 Intracranial infection occurred in 18 cases,3 cases of them died, mortality was 16.7%,4 cases had fine prognosis with the effective rate of 22.2%; 378 cases did not occur intracranial infection,15 cases of them died, mortality rate was 3.9%,182 cases had fine prognosis with the effective rate of 48.1%. Mortality rate and the effective rate of the two groups possessed statistical significance respectively.3.Comparason of influencing factors of intracranial infection and bacterias3.1 Relationship between stay time of the tube and intracranial infectionAccording to the time of drainage, cases were divided into 4 groups (≤7 days,8-14 days,15-20 days and≥21 days) and their incidence rate of intracranial infection was recorded. Results showed that≤7 days group and≥21 days group had higher intracranial infection rate than the other two groups. But there’s no identifing difference among the 4 groups.3.2 Relationship between tube blockage and intracranial infection71 cases occurred drainage tube blockage during treatment, in which 7 cases attacked intracranial infection with infection rate of 9.9%; 325 cases’ drainage tube without blockage and only 11 cases occurred intracranial infection with infection rate of 3.4%. There’s significant difference btween the two group(P<0.05), identifing blocked tube may increase the occurrence of intracranial infection. 3.3. Cultivate results of intracranial infecionThere were 18 cases of intracranial infection totally, overall infection rate was 4.5%. Which include 11 cases of positive results,4 cases of Staphylococcus epidermidas,2 cases of Staphylococcus aureus,1 case of Hemolytic staphylococcus,2 cases of Escherichia,1 case of Klebsiella pneumoniae,1 case of single Pseudomonas maltophilia.Conclusions1. Rapid pore cranial drilling external ventricular draniage was time saving, simple, instant implementation and it was an effective means to cure patients with severe intraventricular hemorrhage.2. Different age patients with no significant difference in mortality and response rate, there’s no significant effect between age and prognosis to patients with severe intraventricular hemorrhage.3. There’s no sigificant relationship between preoperative GCS and outcome for severe intraventricular hemorrhage.4. Placing lateral ventricle drainage as early as possible after the onset(within 6h) to reduce the mortality rate and improve the prognosis.5. Postoperative rebleeding within 24 hours may increase mortality rate, affecting patients’prognosis.6. Bilateral ventricular drainage was faster in hematoma clearance and shorter on tube remaining time than unilateral drainage.7. Urokinase Infusing into the cerebral ventricle could accelerate the hematoma absorption, reduce the intubation time and lower the death rate, but the overall improvement on prognosis was not clear.8. Tube blockage occuring in the treatment could increase the occurrence of intracranial infection which could increase the mortality rate and influence patients’prognosis. Staphylococci was the common type of bacteria leading intracranial infection and it may always be multi-drug resistant bacteria.