| BackgroundSecondary Intraventricular hemorrhage (IVH), especially severe IVH with blood in all four ventricles, continues to present a challenge to neurosurgeons, often being accompanied by significant morbidity and mortality. When an intracerebral hematoma extends into a portion of the ventricular system, the mortality has been reported to be32to44%. When hemorrhage extends into all four ventricles, the mortality has been60to91%. It was once believed that the poor prognosis was because of elevated intracranial pressure because of impaired CSF circulation—i.e., the occurrence of obstructive hydrocephalus. In addition to this mechanism, it is now known that the blood clot itself exerts a mass effect on the ventricular walls, and may also cause damage by means of an inflammatory cascade reaction. Traditionally, treatment of IVH has entailed the placement of one or more external ventricular drains (EVDs) for drainage of blood and CSF from the ventricular system and normalization of intracranial pressure. However, this approach alone is often not sufficiently effective in improving the poor prognosis for severe IVH. EVD is sometimes complicated by infection or catheter blockage, unresolved hematoma and protracted hydrocephalus, and problems may persist, ultimately requiring ventriculoperitoneal shunting. Therefore, how to seek a better approach for ventricular cast bleeding is the starting point of this study. Our study adopted a modified ventricular puncture external drainage to the treatment of severe secondary intraventricular cast hemorrhage. The goals of this study are to maintain EVD patency, dissolve intraventricular blood clots, reduce ICP and mass effect on the ventricular walls, help clear potentially deleterious blood breakdown products, accelerate patient recovery, decrease the incidence of hydrocephalus, and improve overall outcome.MethodsThis study is prospective and randomized.60cases of secondary intraventricular cast hemorrhage patients were randomly divided into two groups, modified ventricular puncture (MVP) group and control group. Each group was of30cases. The MVP group improved ventricular puncture drainage, postoperative combined with urokinase therapy. Another group for the control group, using the traditional external ventricular drainage combined with intraventricular injection of urokinase. Compared to preoperative Glasgow coma scale (GCS) and Graeb score, we could determine whether the two groups are the same on the severity of the disease. Then the postoperative data of two groups were analyzed and compared statistically, including evacuation rate of intraventricular hematoma in24hours, the time with drainage tube, rebleeding, complicated by infection, shunt-dependent hydrocephalus and Glasgow outcome scale at3months.Results1. There was no significant difference in preoperative GCS score and the Graeb score between two groups (P>0.05). 2. In the MVP group via frontal tuber approach, a substantial removal of intraventricular hematoma was achieved in all cases, the average evacuation rate of intraventricular hematoma reached (80.10±10.16)%, the average time of catheter drainage was (3.17±0.87) days, the average GOS was3.80±0.92, and no intracranial infection and secondary hemorrhage were observed following surgery in all cases, shunt-dependent hydrocephalus occurred in2cases. In the control group, the hematoma evacuation rate was an average of (21.21±7.81)%, the time of drainage was an average of (7.63±2.87) days, and the GOS was an average of3.20±1.12, intracranial infection after surgery occurred in5cases, secondary hemorrhage was observed in1case, shunt-dependent hydrocephalus occurred in8cases. Between two groups there were significantly statistical difference in the hematoma evacuation rate, drainage duration, infection rate and GOS (all P<0.05).ConclusionsThe new approach of modified ventricular puncture external drainage combined with urokinase to the treatment of severe secondary intraventricular cast hemorrhage is safe, quickly removes the hematoma, and significantly shortens the time with a pipe, reduces the occurrence of infection and hydrocephalus, improves overall outcome of patients. So it is worth promoting. BackgroundThe first part of our study is "modified ventricular puncture combined with urokinase in the treatment of secondary intraventricular cast hemorrhage" The new approach of modified ventricular puncture external drainage to the treatment of severe secondary intraventricular cast hemorrhage is safe, quickly removes the hematoma, and significantly shortens the time with a pipe, reduces the occurrence of infection and hydrocephalus, improves overall outcome of patients and reduces mortality. However, the safety of trans-frontal tuber punctrue needs further anatomical evidence to support. In particular, the distribution and anatomical characteristics of cortical venous of the puncture site have a great impact on the establishment of the puncture point and drilling. The second part of the study is about the imaging characteristics of frontal cortical veins as branches of the superior sagittal sinus, and discusses the security of the approach trans-frontal tuber puncture.Methods61cases (122sides) normal adult MRV image data were analyzed. The numbers of the frontal cortical veins enter the superior sagittal sinus and the angles at which the veins join the sinus were recorded and measured. The distance between the frontal pole and the point where each frontal cortical vein enter the superior sagittal sinus was also measured. Calculate and establish the scope of the security zone of the trans-frontal tuber puncture.ResultsThe front of the superior sagittal sinus accepts the frontopolar, anterior, and middle frontal veins. The frontopolar vein is variable to the probability of53%,57%of the side of the missing,18%bilateral absence. The distance between the frontal pole and the point where the frontopolar vein enter the superior sagittal sinus is an average1.45±0.46cm. The emergences of the anterior and middle frontal veins are greater chances of81%,83%, respectively. The distances between the frontal pole and the point where the anterior and middle frontal veins enter the superior sagittal sinus are average2.97±0.55cm,6.03±1.26cm, respectively. The latter two veins are closer with the puncture point of our study among the three veins. There is about3cm wide security zone between the anterior frontal vein and the middle frontal vein. This security zone is located above the frontal pole of about3cm to6cm. our puncture point is located in2.5cm at the top of supraorbital ridge (corresponding to the frontal pole above4cm). So the puncture point lies in the safe range.ConclusionsThe trans-frontal tuber puncture point is located in the security zone between the anterior frontal vein and the middle frontal vein, and less likely to cause vein damage of the frontal cortex. However, this safe range is relatively small, and the variability of the frontal cortical veins is large. So a large hole that we use it in drilling cranial is recommended. Try to avoid using a small hole, so as not to cause cortical vein iniurv resulting in rebleeding. BackgroundHypertensive intracerebral hemorrhage (HICH) is responsible for10to30%of stroke presentations1and is responsible for greater morbidity and mortality compared to ischemic stroke. Hematoma expansion within the first few hours following ictus is recognized as a poor prognostic marker. Recent studies of intracerebral hemorrhage (ICH) treatments have highlighted the need to identify reliable predictors of hematoma expansion. Computed tomography angiography (CTA) is a rapid, noninvasive investigation for patients with ICH and has proven useful for identifying potentially treatable entities such as aneurysms and other vascular lesions. In some reports, people describe the CTA finding of tiny, enhancing foci, or the "spot sign," within hematomas, with or without clear contrast extravasation. We hypothesized that this sign is associated with hematoma expansion and poor clinical outcomes. The recently reported computed tomogram angiography (CTA)spot sign'describes foci of enhancement within the acute hematoma on CTA that are associated with hematoma expansion. The purpose of this part of our research is to validate the CTA and contrast-enhanced CT "spot sign" can accurately predict hematoma expansion in hypertensive intracerebral hemorrhage.MethodsWe prospectively studied42consecutive patients with spontaneous ICH by computed tomography angiography and contrast-enhanced CT within3hours of symptom onset. Precontrast head imaging is followed by a CTA study and immediately thereafter a postcontrast study1to2minutes after contrast injection. Hematoma volumes were calculated on the initial and follow-up CTs within24hours with the previously validated ABC/2method. An increase of hematoma size30%or6mL was considered significant enlargement.Results12patients (29%) demonstrated23enhancing foci. Baseline clinical variables were similar in both groups. Hematoma expansion occurred in13patients (31%) on follow-up. Seventy-seven percent of patients with and4%without hematoma expansion demonstrated the spot sign. Sensitivity, specificity, positive predictive value and negative predictive value for expansion were92%,100%,100%,97%, respectively. In patients with the spot sign, mean volume change was greater, extravasation more common. ConclusionsIntravenous contrast material should be administered to patients with ICH not only to evaluate underlying sources of hemorrhage but also to identify patients at risk for hematoma expansion. Assessing a simple radiologic feature such as contrast extravasation on CT may serve as a very efficient and straightforward method of risk-stratifying patients on admission. This should be confirmed in prospective studies in which all patients with ICH would systematically undergo CTA and CECT.
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