Clinical Study On The Treatment Of Hypertensive Intracerebral Hemorrhage With Minimally Invasive Surgery

Hypertensive cerebral hemorrhage is a non traumatic intracerebral hemorrhage in patients with hypertension cased by the arteriolar hemorrhage when the blood pressure suddenly increased, which causes a series of neurological symptoms. Pathophysiological mechanism can be divided into the following two aspects after cerebral hemorrhage. The first aspect is acute neuronal injury of hematoma center because of bleeding and hematoma enlargement. The final enlargemen volume of hematoma and hematoma location is one of the indicators to predict the prognosis of patients with cerebral hemorrhage. The second aspect is the duration of the presence of hematoma. The iron, protein, erythrocyte degradation product, free radicals hematoma persists produce sustained damage in surrounding tissue that lead to peripheral edema and ischemia necrosis. The mechanism of sustained perihematoma damage is complex, duing to peripheral edema and various chemical substances produced in the process of the hematoma contraction. Animal experiments showed that the persistence of intracerebral hematoma caused cerebral edema progresses, cell metabolic disorders and long-term paralysis. In theory, the early evacuation of intracranial hematom can relieve the secondary injury and promote the recovery of neural function.In present, there is no other effective methods to remove intracerebral hemorrhage in addition to surgical strategy. The traditional surgery include craniotomy and hematoma clearance. Although the previous meta-analysis and randomized controlled trials failed to demonstrate the effectiveness of craniotomy. And the traditional craniotomy may damage normal brain tissue, and there is no sufficient evidence to prove that the craniotomy can reduce the mortality of patients with cerebral hemorrhage. According to the relevant research, patients underwent craniotomy,the 3 months mortality is 25%, and 58.9% of this patients had poor prognosis. However, the craniotomy surgery is still one of the most important methods in treating the cerebral hemorrhage in clinical. Minimally invasive surgery including endoscopic surgery and stereotactic hematoma aspiration. Minimally invasive surgery has various advantages including small injury, short operation time and can be did under local anesthesia. Minimally invasive hematoma puncture drainage is a surgical method refers to precise position through the imaging method, drill a hole on the skull, dissect the dura, put a catheter into the hematoma, slowly aspirate and drainage the hematoma. Stereotactic hematoma aspiration in the treatment of deep location such as basal ganglia has been accepted by the vast number of physicians. The American Heart and Stroke Association published the latest guidelines for cerebral hemorrhage in 2015 years pointed out that hematoma can be used as a method to save life in patients with supratentorial cerebral hemorrhage. Decompressive craniectomy may reduce mortality in patients with coma and a large amount of hematoma in cerebral hemorrhage. China cerebral hemorrhage guidelines in 2015 years proposed that patients with the following signs such as tentorial hernia, a midline deviation of more than 5mm diagnosed by imaging examination, the ipsilateral lateral ventricle compressed more than half, cisterns and sulci disappeared or fuzzy has operation indication. The two guidelines did not give a clear advice for surgical choice of cerebral hemorrhage. Domestic and foreign literature have compared the efficacy of craniotomy surgery with conservative treatment, and minimally invasive hematoma puncture drainage surgery with conservative treatment. However there were less comparative study about the craniotomy surgery and minimally invasive surgery, and analysising of these studies found that, there is little research matching the characteristics of the hematoma or patients in accordance with their own characteristics. At the same time, there is no uniform standard about how to carry out the operation and what the aspiration proportion of hematoma at home and abroad.This paper is a retrospective study analysed previous clinical data in patients with minimally invasive hematoma puncture drainage and craniotomy. Analysed the efficacy and safety of patients with different ages, hematoma volume and conscious state. Analysed the safety and effectiveness of these two kinds of surgical method in treating with different conditions of hypertensive cerebral hemorrhage patient, to provide a reference in selecting the two kinds of surgical for clinical work. This paper also analysed the effect of different hematoma aspiration rate on the residual hematoma absorption and liquid drainage, peripheral edema and postoperative neurological function recovery in hypertensive cerebral hemorrhage patients, providing a reference for clinical practice.Part 1 The efficacy and safety of minimally invasive surgery and craniotomy in treating patients with different age, hematoma volume and conscious statusContents and methods:We compared minimally invasive surgery with craniotomy treatment in patients with different age, hematoma volume, status of consciousness, analysed the efficacy and safety of this two methods, to conclude the advantages of this two operation in treating with different condition hypertensive cerebral hemorrhage patients.209 cases with hypertensive cerebral hemorrhage were included. Patients were divided into minimally invasive group and craniotomy group according to different surgery method. This tow groups were redivided into several subgroups according to age, hematoma volume and Glasgow coma score. For age, the two groups were divided into<45 years old group,45-59years old group and≥60 years old group; For hematoma volume, the two groups were divide into 30-49ml group,50-70ml group and>70ml group; For Glasgow coma score, the two groups were divide into≤6 group,7-10 group,11-15 group. The postoperative bleeding rate, postoperative infection rate, mortality rate during hospitalization and Glasgow prognosis score 3 months after surgery were compared between minimally invasive group and craniotomy group under different condition.Result1、Comparison of the general data between subjects:209 patients were included: craniotomy (101 cases), minimally invasive(108 cases). The age, gender strictures, hypertension, diabetes, GCS score when admitted to hospital ematoma volume and time to surgery in two groups had no statistical significance (P>0.05).2、The rebleeding rate, postoperative infection rate and GOS score between craniotomy and the minimally invasive group had statistically significant differences (χ2=5.12, p=0.02;χ2=5.28,p=0.02). The mortality rate during hospitalization between the two groups had no difference. The postoperative bleeding rate, postoperative infection rate and Glasgow prognosis score of craniotomy group was lower than minimally invasive group.3、Age subgroup<45 years old:The postoperative bleeding rate,postoperative infection rate,mortality rate during hospitalization and Glasgow prognosis score had no significant difference in minimally invasive group and craniotomy group (χ2= 0.06,p=0.79;χ2=0.19,p=0.66;χ2=0.01,p=0.89;Z=-1.16,P=0.24).(1)45-59years old:The postoperative bleeding rate and mortality rate during hospitalization between minimally invasive group and craniotomy group had significant difference(χ2=5.35,P=0.02;χ2=4.36,P=0.03).Minimally invasive group patients had higher bleeding rate and mortality rate than craniotomy group patients. The postoperative infection rate and Glasgow prognosis score had no significant difference in minimally invasive group and craniotomy group(χ2=1.27,p= 0.26;Z=-1.79,P=0.07).(2)age≥60 years old The postoperative infection rate and Glasgow prognosis score in minimally invasive group and craniotomy group had significant difference(x2=6.85,P=0.00;Z=-2.0,P=0.04),minimally invasive group patients had lower infection rate and higher Glasgow prognosis score than craniotomy group patients.The postoperative bleeding rate and mortality rate during hospitalization between the two groups had no significant difference(χ2=1.68,p= 0.19;χ2=1.02, p=0.26).4、Consciousness subgroup(1) GCS≤6 The mortality rate between minimally invasive group and craniotomy group had significant difference(χ2=5.49, P=0.01), craniotomy group was lower than minimally invasive group. The postoperative bleeding rate, mortality rate during hospitalization and Glasgow prognosis score had no difference in the two group.(2) GCS7-10 The postoperative rebleeding rate and infection rate had statistically significant difference(χ2=6.86, P=0.00; χ2=6.04, P=0.02), minimally invasive patients had higher rebleeding rate and lower infection. The mortality rate and Glasgow prognosis score had no difference in the two group(x2=1.60, P=0.20; Z=-1.15,P=0.25).(3) GCS11-15 The rebleeding rate, postoperative infection rate, GOS score and mortality rate had no significant difference (χ2=0.01,P=0.90;χ2=0.66, P=0.41; χ2=0.09, P=0.75; Z=-1.35,P=0.17).5、Hematoma volume(1)30-49ml The rebleeding rate, postoperative infection rate and mortality rate had no significant difference between the two groups(x2=0.04, P=0.82; x2=3.49, P=0.06; χ2=0.04, P=0.82). The difference of GOS score between craniotomy group and minimally invasive group had statistically significant (Z=-2.13,P=0.03), the minimally invasive patients had higher GOS score than craniotomy patients.(2)50-70ml The rebleeding rate, postoperative infection rate and mortality rate had no significant difference between the two groups(x2=0.01, P=0.90; χ2=0.66, P=0.41; χ2=0.09, P=0.75). The difference of GOS score in between craniotomy group and minimally invasive group had statistically significant (Z=-2.10,P=0.03), the minimally invasive patients had higher GOS score than craniotomy patients.(3)≥70ml The postoperative bleeding rate and mortality rate during hospitalization between minimally invasive group and craniotomy group had significant difference (χ2=4.66,P=0.04;χ2=6.78, P=0.00). Minimally invasive group patients had higher bleeding rate and mortality rate than craniotomy group patients. The postoperative infection rate and Glasgow prognosis score had no significant difference in minimally invasive group and craniotomy group(χ2=1.60,P=0.20;Z=-0.17,P=0.85).Summary:1、The two surgery method had different efficacy and safety when treated with patients with different age,hematoma volume and consciousness states.2、Minimally invasive hematoma aspiration and drainage may have better efficacy and safety in treating with age lower than 45 years old or higher than 60 years old, GCS score≥11, hematoma volume less than 70ml.3、45-59 years old patients with hematoma volume more than 70ml and GCS score less than 10 choose craniotomy surgery may have better efficacy and safety than minimally invasive hematoma aspiration and drainage.Part 2 Discussing the initial aspiration rate in minimally invasive surgeryContents and methods:To study the best initial aspiration rate in minimally invasive procedures for intracerebral hematoma evacuation.88 cases with hypertensive cerebral hemorrhage who underwent hematoma puncture drainage during January 2008 -September 2015 in our hospital were included. According to the the first hematoma aspiration rate,all cases were divided into 3 groups:A group (<20%), B group(20%-40%), C group (40%-60%). The residual hematoma clearance rate, rebleeding rate, edema volume and NIHSS score were compared in three groups in unit time after surgery.Result1、Comparison of the general data between subjects:83 cerebral hemorrhage patients metting inclusion criteria, male 63 cases of,female 20 cases, mean age 57.84± 10.51 years(mean±SD)onset to treatment time is from 1 to 12 hours,83 patients are cerebral hemorrhage in basal ganglia, preoperative average volume of hematoma is 42.58 ± 8.44 ml. A group (29 cases), B group (28 cases), C group (28 cases). The gender, age, history of hypertension, time of onset to surgery, preoperative NIHSS score, hematoma volume and edema volume in three groups had no significant difference.2、Comparison of residual hematoma absorption rate, residual hematoma volume, postoperative NIHSS score and edema in the three group.(1)Comparison of postoperative residual hematoma clearance rate among three groups:The residual hematoma of A,B,C groups were 36.88±5.88 ml,3.221± 6.17 ml and 21.66±5.94 ml. The differences of hematoma absorption clearance rate among three groups on the 3rd day,7th day and 14th day after surgery were statistically significant (F=737.70, P=0.00; F=763.14, P=0.00; F=161.40, P= 0.00).(2)The comparison of postoperative edema volume among three groups:The perihematomal edema volume differences of three groups on the 3rd,7th,14th day after surgery had statistically significant (F=54.35, P=0.00; F=63.59, P=0.00; F=23.55, P=0.00).(3)Comparison of postoperative NIHSS score among three groups:The postoperative NIHSS score of three groups on the 3rd,7th,14th day had statistically significant F =7.97,P=0.00; F=11.77, P=0.00;F=19.24, P=0.00).3、The pairwise comparison of residual hematoma absorption rate, postoperative NIHSS score and perihematomal edema in three group.(1)The pairwise comparison of residual hematoma absorption rate:①The residual hematoma absorption rate of this 3 groups on the third day after operation are (x±s) 0.13±0.33,0.24±0.33,0.42±0.02, the difference in the three groups had statistical significance (P=0.00, P=0.00, P=0.00).②The residual hematoma absorption rate of this 3 groups on the 7th day are (x±s) 0.56±0.03,0.58±0.05,0.88±0.03,The residual hematoma absorption rate on the 7th day after operation between A and B group had no significant difference(P= 0.09).The residual hematoma absorption rate between A and C, B and C had statistically significant difference(P=0.00, P=0.00).③The residual hematoma absorption rate on the 14th day are (x±s) 0.82±0.04, 0.88±0.05,0.99±0.01, the difference among three groups had statistical significance (P=0.00).(2)The pairwise comparison of perihematomal edema.①The postoperative perihematomal edema on the 3rd and 14th days of the 3 groups are (x±s) 31.52±1.06,26.59±1.10,15.90±1.09;32.75±5.77,27.83±7.10, 15.10±4.97.The postoperative perihematomal edema difference among the three groups in the two days had significant difference(P=0.00).②The postoperative perihematomal edema on the 14th day are (x±s) 19.88±5.70, 16.25±7.12,9.55±3.73, A and B groups had no significant difference (P=0.06). The postoperative perihematomal edema between A and C groups, B and C groups had statistically significant difference (P=0.00, P=0.00).(3)The pairwise comparison of postoperative NIHSS score.①The postoperative NIHSS score on the 3rd day after operation are (x±s) 16.69 ±2.95,14.74±3.29,13.41±3.05.A and B group had statistically significant difference(P=0.00). The postoperative NIHSS score between A and C groups, B and C groups had no significant difference(P=0.06, P=0.35).②The postoperative NIHSS score on the 7th day after operation are(x±s) 15.24±3.0,13.0±3.23,11.63±2.08. A had statistically significant difference from B and C(P=0.01, P=0.00). The postoperative NIHSS score between B and C group had no significant difference(P=0.23).③The postoperative NIHSS score on the 14th day are (x±s) 12.28±2.7, 9.44±2.68,8.56±1.42. A had statistically significant difference from B and C(P= 0.00,P=0.00). The postoperative NIHSS score between B and C group had no significant difference(P=0.51).4、The hematoma aspiration rate and were positively correlated with residual hematoma clearance rate,and negatively correlated with NIHSS score and postoperative edema volume.5、The correlation analysis among residual hematoma absorption rate, postoperative NIHSS score and perihematomal edema:The NIHSS score and residual hematoma absorption rate had negatively correlated on the 3rd,7th and 14th day after surgery (r =-0.34, P=0.00; r=-0.39, P=0.00; r=-0.47, P=0.00). There was a positive correlation between NIHSS score and perihematomal edema on the 3rd,7th and 14th day after surgery (r=0.31, P=0.00; r=0.32, P=0.00; r=0.31, P=0.00). There was a negative correlation between perihematomal edema and residual hematoma absorption rate (r=-0.71, P=0.00; r=-0.93, P=0.00; r=-0.62, P=0.00).6、The comparison of rebleeding rate in three groups:There was 1 rebleeding case in A group (3.4%),B and C group had 2 cases respectively (7.4%). The rebleeding rate in three groups had no significant difference(χ2=0.39, P=0.53).Summary:1、The hematoma aspiration rate for the first time in minimally invasive intracranial hematoma puncture and drainage has effect on residual hematoma absorption, the edema around the hematoma and nerve function recovery and without increasing the risk of rebleeding.2、The initial hematoma clearance rate is higher, the edema around the hematoma increased less, even edema volume decreases, neurological function recovered faster under 60%.Conclusion:1、We should focus on not only efficacy but also safety when choosing different surgery method.The two surgery method had different efficacy and safety when treated with patients with different age, hematoma volume and consciousness states,and different initial hematoma aspiration rate has effect on patients’ recovery.2、Minimally invasive hematoma aspiration and drainage may have better efficacy and safety in treating with age lower than 45 years old or higher than 60 years old,3、 GCS score≥11, hematoma volume less than 70ml. For 45-59 years old patients with hematoma volume more than 70ml and GCS score less than 11 choose craniotomy surgery may have better efficacy and safety than minimally invasive hematoma aspiration and drainage.3、For patients with initial hematoma aspiration rate below 60%, the aspiration rate higher,the faster postoperative recovery will be and without increasing the risk of rebleeding. In this study, patient with initial hematoma aspiration rate at 40%-60% had a better short-term recovery than lower.