软通道微骨窗开颅血肿清除术...BGCH合并脑疝患者的效果_吕远.pdf

-41-Chinese and Foreign Medical Research Vol.21,No.3 January,2023中外医学研究第 21 卷 第 3 期（总第 551 期）2023 年 1月临床与实践 Linchuangyushijian钟祥市人民医院湖北钟祥431900软通道微骨窗开颅血肿清除术治疗BGCH合并脑疝患者的效果吕远【摘要】目的：分析软通道微骨窗开颅血肿清除术（软通道术）治疗基底节区脑出血（basal ganglia cerebral hemorrhage，BGCH）合并脑疝患者的效果。方法：回顾性选取 2018 年 3 月2020 年 10 月钟祥市人民医院 84 例 BGCH 合并脑疝患者。根据治疗方案的不同将其分为对照组（41 例）和观察组（43 例）。对照组接受大骨瓣开颅血肿清除术，观察组接受软通道术治疗。比较两组围手术期指标，术前、术后 7 d 神经功能缺损程度、意识状态、炎症因子及并发症。结果：与对照组对比，观察组颅骨缺损面积小，手术时长、住院时间短，术中失血量少（P80%占比比较差异无统计学意义（P0.05）。术后 7 d，两组改良爱丁堡-斯堪的纳维亚评分（modified Edinburgh Scandinavian stroke scale，MESSS）评分、格拉斯哥昏迷量表（Glasgow coma scale，GCS）评分均得到改善，且观察组 MESSS 评分低于对照组，GCS 评分高于对照组（P0.05）。术后 7 d，两组肿瘤坏死因子-（tumor necrosis factor-，TNF-）、C 反应蛋白（C-reactive protein，CRP）水平均低于术前，且观察组 TNF-、CRP 水平均低于对照组（P0.05）。与对照组术后并发症发生率（19.51%）相比，观察组术后并发症发生率（2.33%）更低（P0.05）。结论：软通道术治疗 BGCH 合并脑疝患者，效果确切，能优化手术相关指标水平，改善神经功能，降低炎症因子水平，促进恢复。【关键词】软通道微骨窗开颅血肿清除术基底节区脑出血脑疝doi：10.14033/ki.cfmr.2023.03.010 文献标识码B 文章编号1674-6805（2023）03-0041-04Effect of Soft Channel Micro Bone Window Craniotomy for Hematoma Removal in the Treatment of Patients with BGCH Complicated with Cerebral Hernia/LYU Yuan./Chinese and Foreign Medical Research,2023,21(3):41-44AbstractObjective:To analyze the effect of soft channel micro bone window craniotomy for hematoma removal(soft channel operation)in the treatment of patients with basal ganglia cerebral hemorrhage(BGCH)complicated with cerebral hernia.Method:A total of 84 patients with BGCH complicated with cerebral hernia in Zhongxiang Peoples Hospital from March 2018 to October 2020 were retrospectively selected.The patients were divided into control group(41 cases)and observation group(43 cases)according to different treatment programs.The control group received large bone flap craniotomy for hematoma removal,and the observation group received soft channel operation treatment.Perioperative indexes,degree of neurological function impairment,state of consciousness,inflammatory factors before and 7 d after operation and complications were compared between the two groups.Result:Compared with the control group,the skull defect area was smaller,the operation time and the hospital stay were shorter,and the intraoperative blood loss volume was smaller of the observation group(P80%(P0.05).Seven days after operation,the modified Edinburgh Scandinavian stroke scale(MESSS)score and Glasgow coma scale(GCS)score were improved in both groups,and the MESSS score in the observation group was lower than that in the control group,while the GCS score was higher than that in the control group(P0.05).Seven days after operation,the levels of tumor necrosis factor-(TNF-)and C-reactive protein(CRP)in both groups were lower than those before operation,and the levels of TNF-and CRP in the observation group were lower than those in the control group(P0.05).Compared with the incidence of postoperative complication in the control group(19.51%),the incidence of postoperative complication in the observation group(2.33%)was lower(P0.05），有可比性。1.2方法1.2.1对照组接受大骨瓣开颅血肿清除术。气管插管，全麻，作颅脑切口，于颧弓上耳屏前，至耳廓上端，之后斜行向上至顶结节下，其后转向前，最终止于前额发际线处；于相对无功能区切开脑皮质，入血肿腔，清除血肿；止血，弃骨瓣减压，硬膜外放置引流管，缝合。1.2.2观察组接受软通道术治疗。气管插管，全麻，根据术前 CT 等影像学结果，以最大血肿量层面为中心，于颞骨上做 57 cm 切口，切口需平行于外侧裂投影线，至骨膜，钻孔颞骨，扩大，形成小骨窗，切开硬膜，经导引钢丝，将特殊硅胶导管经颞上回或颞中回插入颅内，至血肿腔预计靶点，退出导引钢丝；连接注射器，抽吸血肿，确定脑组织压力降低后，沿穿刺通道，行皮质造瘘，大小 12 cm，沿硅胶导管软通道向深部继续分离，于直视下清除残留血肿，术毕后留置软通道导管，连接外引流装置，术后根据残留血肿量、继发出血量，给予尿激酶注射，连续引流 37 d。1.3观察指标及评价标准（1）围手术期指标：比较两组颅骨缺损面积、手术时长、住院时间、术中失血量、术后 24 h 血肿清除率 80%血肿清除率=（术前血肿量-术后残余血肿量）/术前血肿量 100%的情况。（2）神经功能缺损程度：于术前、术后 7 d 采用改良爱丁堡-斯堪的纳维亚评分（modified Edinburgh Scandinavian stroke scale，MESSS）评估两组神经功能缺损程度，量表总分 45 分，得分越高表示神经功能缺损越严重，术前评分由专业医师代为评估3。（3）意识状态：格拉斯哥昏迷量表（Glasgow coma scale，GCS）评分：于术前、术后 7 d 评估，分值范围 315 分，得分越高表示意识状态越好4。（4）炎症因子：术前、术后 7 d，分别采集两组患者 5 mL 静脉血，离心分离，使用酶标仪（Bio-Rad Model 550 型）、采用酶联免疫吸附法测定血清肿瘤坏死因子-（tumor necrosis factor-，TNF-）、C 反应蛋白（C-reactive protein，CRP）。（5）并发症：比较两组术后住院期间颅内感染、再出血、硬膜外血肿等发生情况。1.4统计学处理本研究数据采用 SPSS 22.0 统计学软件进行分析和处理，计量资料以（x-s）表示，采用 t 检验，计数资料以率（%）表示，采用 2检验，以 P0.05为差异有统计学意义。2结果2.1两组围手术期指标比较与对照组对比，观察组颅骨缺损面积小，手术时长、住院时间短，术中失血量少（P80%占比比较差异无统计学意义（P0.05），见表 1。2.2两组神经功能缺损程度、意识状态比较术前，两组 MESSS、GCS 评分比较差异均无统计学意义（P0.05）；术后 7 d，两组 MESSS 评分、GCS 评分均得到改善，且观察组 MESSS 评分低于对-43-Chinese and Foreign Medical Research Vol.21,No.3 January,2023中外医学研究第 21 卷 第 3 期（总第 551 期）2023 年 1月临床与实践 Linchuangyushijian照组，GCS 评分高于对照组（P0.05）；术后 7 d，两组 TNF-、CRP 水平均低于术前，且观察组 TNF-、CRP 水平均低于对照组（P80%例（%）观察组（n=43）9.501.87148.6614.9712.972.14241.5325.9032（74.42）对照组（n=41）123.445.61210.3520.8219.683.20329.7130.4632（78.05）t/2值126.07115.64711.34614.3170.153P 值 0.0010.0010.0010.0010.696表2两组神经功能缺损程度、意识状态比较分，（x-s）组别MESSS 评分GCS 评分术前术后 7 dt 值P 值术前术后 7 dt 值P 值观察组（n=43）44.1810.2316.374.2216.4790.0016.912.0410.351.818.2710.001对照组（n=41）42.069.8520.595.1812.3530.0017.232.57 9.021.433.8970.001t 值0.967 4.1020.634 3.725P 值0.3370.0010.5280.001表3两组炎症因子比较（x-s）组别TNF-（pg/mL）CRP（mg/L）术前术后 7 dt 值P 值术前术后 7 dt 值P 值观察组（n=43）87.2010.6330.987.2128.8020.00131.245.83 8.971.4224.3370.001对照组（n=41）84.1210.5941.769.3519.2000.00129.785.2