The Treatment Of Minimally Invasive Hematoma Aspiration Combined With Intracranial Pressure Monitoring To Hypertensive Cerebral Hemorrhage

BackgroundHypertensive intracerebral hemorrhage(HIH)is one of the most severe complications of hypertension,with a higher incidence in male than female,which are more frequently seen in old people between 50 to 60 years old.But in recent years it shows a younger trend.HIH is a common clinical disease and is characterized as rapid onset,severe and complicated progressing,high mortality and disability rate.Sometimes,especially while the hematoma volume is large,the drug curative effect is not very satisfactory and a craniotomy is in demand.In recent years,the micro-traumatic hematomas cleaning operation has been widely carried out,and opened up a new field for HIH with the advantages of simple manipulation,less trauma,short-term operation and low cost.Since the 80's,with the development of science and technology,CT was generally popularized,and opened up a new era for the development of neurosurgery.Brain tumors,trauma and HIH could be diagnosed correctly in time.Then,the micro-traumatic operation on HIH was begun to study.To open a bone window on the skull by drill or bone awl by means of stereotactic or CT localization,then to puncture and draw in the hematoma by needle or tube with different diameters,the trauma is less than craniotomy,but the effect was not satisfactory,the clearance rate,rehaemorrhagia rate,mortality and disability rate was significantly worse than craniotomy.At that time,the mortality reported by Davidoff reached highly to 63.3%,which was not a satisfactory surgical approach.Since the 60's in China,Jia Baoxiang et.used puncture needles and remained the needle into the hematoma cavity,then melted it by hematoma liquefier and drainage it out.The application of this technology is a major advance in the treatment of HIH.After continuous development and perfection,this tech turned out to be simpler and safer.A,By improving the puncture needles,the soft tube puncture can reduce the damage to the brain and become safer.B.It's unnecessary to use the stereotaxic apparatus or surgical aspirator,just mark on CT,and use common neurosurgical instruments,which is more adaptable to primary hospital.C.Urokinase was used multiply to dissolve the hematoma,which is safe to avoid the sudden pressure drop or rehaemorrhagia.D.The surgical trauma is relatively small,the surgery time is short and most patients can tolerate the surgery including some patients with cardiopulmonary insufficiency.Since the reform and opening policy,the Chinese way of life is changing rapidly including the shifting of eating habit,lack of exercise,smoking and drinking,the Chinese population is generally aging,and the population of old people is getting larger.So the incidence of cerebral hemorrhage is increasing year by year.Acute Hypertensive Intracerebral Hemorrhage(ICH)is one of the most severe complications of hypertension,and many happen on elderly.ICH is a disease that highly threatens human health with high mortality.In China,the incidence rate is as high as 40%-60%,and some patients leave sequelae.Based on the above factors,our hospital is searching for a simple and easy way to treat HIH,and the micro-traumatic opened up a new field.This study was conducted in a randomized controlled study of 115 cases of patients with hypertensive cerebral hemorrhage and clinical effect of the treatment of hypertensive cerebral hemorrhage of minimally invasive hematoma puncture combined with intracranial pressure monitoring and traditional craniotomy treatment,in order to improve the hypertensive cerebral hemorrhage patients the treatment effect of reference.Objectives:By analyzing the data of 115 cases of hypertensive cerebral hemorrhage were analyzed to investigate the clinical significance of minimally invasive hematoma puncture combined with intracranial pressure monitoring.in treatment of hypertensive cerebral hemorrhage.Equipment:Outside the Korea sewun intraventricular hematoma puncture drainage and intracranial pressure monitoring the Codman ICP monitor and routine surgical instruments and materials,such as neurosurgery dedicated bipolar coagulation,meidun strength drill and milling cutter system,Hitachi electric drill,attract and washing equipment,scissors,hemostatic gauze,cotton piece,gelatin sponge etc..Object:1.Inclusion criteria:(1)aged 40 to 80 years of age;(2)the volume of hematoma 30-60 ml;(3)confirmed by CT for cerebral parenchymal hemorrhage;(4)have a clear history of hypertension;(5)was approved by the hospital ethics committee and signed informed consent.2 exclusion criteria:(1)does not meet the above criteria;(2)intracranial arteriovenous malformations or aneurysms bleeding;(3)the coagulation dysfunction leading to bleeding;(4)combined with heart,liver,kidney and other functional abnormalities;(5)patients with mental disorders;(6)Preoperative mydriasis and other manifestations of cerebral hernia occurred.Operation mode:ICP+ hematoma puncture group:Hole-putamen hemorrhage ipsilateral forehead,straight incision,scalp and muscle retractor,open bone drill hole 1 gold,size of about 1 cm x 1 cm bone hole,electrocoagulation epidural,"+",select the type of the ventricular catheter intracranial pressure probe,along the CT showed hematoma center direction of puncture,with 30 ml syringe slowly out hematoma,about 40%-80%,indwelling hematoma cavity drainage tube,at the same time,the detector zero.The connection of intracranial pressure monitor,continuous monitoring of intracranial pressure.Postoperative cranial CT,observe whether there is no hemorrhage or hematoma.According to the adjustment of the drainage system of the intracranial pressure like height or open(closed),the use of dehydrating agent,cranial CT.ICP value>20mmHg immediately open the tube or the use of dehydration drugs drainage of malignant intracranial hypertension were quick check of head CT.Intracranial pressure tended to be stable,the review of the brain CT showed that the hematoma was reduced by more than 80%or more than 7 days of drainage to pull out the drainage tube.Thalamic hemorrhage broken into ventricles of brain using "double tube drainage",namely hematoma cavity drainage and the medial ventricular intracranial pressure probe ventricle puncture drainage.Conventional craniotomy group:Take the forehead and temporal "question mark"cut,cut scalp,temporal muscle,after drilling the bone flap,"U" shaped cut open,the middle and lower back in the temporal lobe cortex,into the hematoma,hematoma,hematoma cavity completely stop bleeding,open.Bone flap to determine whether the extent of brain swelling is also satisfied that the flap under the drainage tube.Hematoma puncture group:operation mode with ICP+ hematoma puncture group hematoma puncture way.Evaluation index:Re bleeding rate,operation time,mortality rate,activities daily living and of ADL(ICP)were assessed by grading method.Methods:To analyze the resources of 115cases with medium dose HIH in our hospital from July 2012 to November 2014.36 cases with HIH were selected as experimental group and were treated by micro-traumatic hematoma puncture operation combined with intracranial pressure monitoring.Meanwhile 41 case and 38 case with HIH were selected as control and were treated by conventional craniotomy and hematoma puncture.Postoperative clinical observation and a 6-month follow-up were carried out on the above patients after operation,and relevant data were recorded.To further evaluate the clinical effect of micro-traumatic hematoma puncture operation combined with intracranial pressure monitoring on medium dose HIH through comparing the rehaemorrhagia rate,duration of operation,mortality,complication occurrence,mannitol dosage,postoperative ICP and activities of daily living(ADL)in the 3 groups.Results:1.ICP+ puncture group after operation bleeding in 3 cases,was 8.33%and routine craniotomy group postoperative bleeding in 2 cases,4.88%,puncture group postoperative rebleeding in 2 cases,5.26%,?2 =0.45,P = 0.80,the difference among the three groups no statistical significance.The mean ICP+ puncture group operation time for 54.86 ±8.82 minutes and routine craniotomy group,the operation time was minutes 109.27±30.26 and operation time of puncture group mean 41.71 ±7.65 minute,t1=10.99,P1=0.00,t2=6.87,P2=0.00,t3=13.83,P3=0.00,the difference is statistically significant.2.ICP+ puncture group postoperative follow-up scores of ADL grade I in 5 cases,10 cases in grade ?,14 cases of grade ?,IV in 5 cases,2 cases of grade ?,the good rate was 80.56%,the mortality rate of 2.78%;after craniotomy group ADL score ? divided into Level 2,6 cases of grade ?,? grade 15 cases,12 cases of grade ?,?points 4.The effective rate was 56.10%,the mortality rate of 4.88%.Hematoma puncture group postoperative ADL score ? divided into Level 2,8 cases of grade ?,? level in 17 cases,8 cases of grade ? ? points 2 grade,1 cases died,mortality was 2.63%,the good rate was 71.05%.The good rate was compared between the three groups,x2 =5.48,P =0.06,there was no significant difference between the three groups was good.Comparison of three groups of the good rate of two two,?21=5.23,P1 =0.02,?22=0.90,P 2=0.42,?23 =1.89,P3 =0.24.Hematoma puncture group and the difference between the conventional craniotomy group were statistically significant,ICP+ hematoma puncture group and hematoma puncture group and conventional craniotomy group and hematoma puncture group had no significant difference.ICP+ hematoma puncture group died in 1 cases,died of pulmonary infection.In the craniotomy group,2 cases died,1 cases were postoperative hemorrhage,and the other died of multiple organ failure.1 cases of hematoma puncture group died of coronary heart disease.Comparing the three groups of mortality,?2 =0.35,P =0.83,there was no significant difference in mortality between the three groups.3.Mannitol dosage:ICP+ puncture group after operation the average doses of mannitol for 1465.28 ± 426.36ml and routine craniotomy group average dosage for 2783.54 ± 539.11 ml,hematoma puncture group after operation the average doses of mannitol for 2592.11 ? 831.54ml,x2=50.79,P=0.00.Three groups of mannitol dosage compared difference system have statistical significance.ICP+ hematoma puncture group compared with the hematoma puncture group,the average per patient was reduced by mannitol 1086.83ml,that is,42.93%.4.Complications:ICP+ puncture operation in group after renal functional lesion in 1 cases and routine craniotomy group for 6 cases,hematoma puncture group for 3 cases,?2=3.65,P =0.16.Three groups of renal damage difference system without meter significance.2 cases of water and electrolyte disorders ICP+ puncture group after operation and routine craniotomy group(9 cases),hematoma puncture group(9 cases),?2=5.51,P = 0.07,three groups of water electrolyte disorder compared,difference system without meter significance.Three groups of water and electrolyte disorders pairwise comparison,?21 =4.89,P1= 0.04,?22 = 0.80,P 2=0.35,? 23 = 2.39,P3 was,ICP+ hematoma puncture group and routine craniotomy group differences have statistical significance.ICP+ hematoma in the puncture group and hematoma puncture group and routine craniotomy and hematoma puncture group differences without statistical significance.Compared with the hematoma puncture group,the incidence of renal damage and water electrolyte were decreased by 2.78%and 16.79%,respectively,compared with the ICP+ hematoma puncture group.5.ICP value of the ICP+ hematoma puncture group was first day 9.94 ±2.37,second day 11.03 ± 2.56,third day 12.17±3.45,fourth day 12.56 ± 1.89,fifth day 13.12 ±2.17,sixth days 11.78±3.07,seventh days 9.27 ±3.17.6.After ICP+ hematoma puncture group 24 hours of CT,hematoma clearance rate of 42.55-80.65%,average 65.36%.After injection of urokinase and continuous drainage after extubation of hematoma clearance rate is more than 80%of a 34,reached 60-80%of 2 cases.Craniotomy group 24 hours after cranial CT hematoma removal rate of 65.87-100%,an average of 85.65%.Hematoma puncture group 24 hours after the review of head CT,hematoma clearance rate of 43.45-82.76%,with an average of 63.42%,after urokinase injection and continuous drainage,removal rate of 80%cases of hematoma removal rate is greater than 35,3 cases of 60-80%.7.ICP+ hematoma puncture drainage of intracranial pressure maximum value<20mmHg3 cases,greater than or equal to 20-30mmHg31 cases,>30mmHg2 and drainage of intracranial pressure after continuous<20mmHg35.Postoperative intracranial pressure continued to 30mmHg1.No cerebral hernia before CT scan found recurrent intracerebral hemorrhage(ICH)in,emergency craniotomy clearance hematoma and decompressive craniectomy.Conclusions:1.Minimally invasive hematoma puncture surgery in non cerebral hernia patients with cerebral hemorrhage,craniotomy has obvious advantages compared with the.But the surgery must strict surgical indications,for obvious hypertension history,imaging examination without cerebrovascular diseases,no bleeding,no manifestations of cerebral hernia patients,minimally invasive hematoma puncture surgery is safe and effective,is advanced.2.Compared with the traditional craniotomy,minimally invasive hematoma puncture surgery short operation time,low incidence of complications,postoperative recovery was good.3.The micro-traumatic hematoma puncture operation may also effectively reduce the ICP for patients with non-hernia,and there are no significant difference compared with conventional craniotomy.4.Intracranial pressure monitoring can detect early rebleeding,can reduce the dosage of mannitol,can reduce the incidence of complications,can stabilize the intracranial pressure,and improve the prognosis.