切换至 "中华医学电子期刊资源库"
高级检索
中华神经创伤外科电子杂志

中华神经创伤外科电子杂志 ›› 2019, Vol. 05 ›› Issue (05) : 269 -275. doi: 10.3877/cma.j.issn.2095-9141.2019.05.004

所属专题： 文献；

临床研究

不同手术方式治疗高血压性脑出血的疗效比较及术后再出血影响因素分析
温玉东1,†(), 黄振山1, 张永明1, 刘家传1, 王春琳1   
  1. 1. 230031　合肥，解放军联勤保障部队第九一医院神经外科
  • 收稿日期:2019-06-24 出版日期:2019-10-15
  • 通信作者: 温玉东

Therapeutic effects comparison of different surgical methods for hypertensive intracerebral hemorrhage and logistic regression analysis of postoperative rebleeding influencing factors

Yudong Wen1,†(), Zhenshan Huang1, Yongming Zhang1, Jiachuan Liu1, Chunlin Wang1   

  1. 1. Department of Neurosurgery, 901th Hospital of PLA Joint Logistics Support Force, Hefei 230031, China
  • Received:2019-06-24 Published:2019-10-15
  • Corresponding author: Yudong Wen
  • About author:
    Corresponding author: Wen Yudong, Email:
全文 ( ) 下载PDF ( ) 导出引用
引用本文：

温玉东, 黄振山, 张永明, 刘家传, 王春琳. 不同手术方式治疗高血压性脑出血的疗效比较及术后再出血影响因素分析[J]. 中华神经创伤外科电子杂志, 2019, 05(05): 269-275.

Yudong Wen, Zhenshan Huang, Yongming Zhang, Jiachuan Liu, Chunlin Wang. Therapeutic effects comparison of different surgical methods for hypertensive intracerebral hemorrhage and logistic regression analysis of postoperative rebleeding influencing factors[J]. Chinese Journal of Neurotraumatic Surgery(Electronic Edition), 2019, 05(05): 269-275.

目的

探讨神经导航辅助微创穿刺血肿引流术（NAMIEH）、小骨窗开颅血肿清除术（SWCEH）与大骨瓣开颅血肿清除术（LBFEH）治疗高血压性脑出血的疗效及术后再出血影响因素Logistic回归分析。

方法

回顾性分析自2016年9月至2019年3月解放军联勤保障部队第九一医院神经外科收治的134例高血压性脑出血患者的临床资料，根据手术治疗方式的不同将其分为NAMIEH组38例、SWCEH组45例与LBFEH组51例。记录2组患者术前及术后7、14 d出血量、GCS评分、NIHSS评分、Barthel指数以及治疗后临床疗效并进行比较，并将高血压性脑出血患者术后再出血影响因素采用Logistic回归分析。

结果

3组患者术前出血量、GCS评分、NIHSS评分及Barthel指数比较，差异无统计学意义（P>0.05）；3组患者术后7、14 d出血量、GCS评分、NIHSS评分及Barthel指数比较，差异均有统计学意义（P<0.05）；3组患者术前及术后7、14 d出血量及NIHSS评分均依次明显降低，GCS评分及Barthel指数均依次明显升高，且组内任意两时间点比较差异均有统计学意义（P<0.05）。NAMIEH组、SWCEH组再出血、血肿残留及并发症发生率均分别明显低于LBFEH组，NAMIEH组再出血发生率（10.53%）、血肿残留发生率（5.26%）及术后并发症发生率（15.79%）均明显低于SWCEH组（P<0.05）。以高血压性脑出血患者术后再出血为因变量，对单因素分析中的可能术后再出血影响因素进行Logistic回归分析，结果显示合并糖尿病、术前收缩压、发病至手术时间、血肿形状、破入脑室、术前出血量、术前GCS评分、术前NIHSS评分、术前Barthel指数、凝血功能异常、术后并发症及总住院时间为高血压性脑出血患者术后再出血的独立影响因素（均P<0.05）。

结论

NAMIEH治疗高血压性脑出血的临床效果明显优于SWCEH及LBFEH，可有效促进神经功能的恢复，明显降低再出血及术后并发症的发生率，且合并糖尿病、术前收缩压、发病至手术时间等为高血压性脑出血患者术后再出血的独立影响因素。

关键词: 神经导航辅助微创穿刺血肿引流术, 小骨窗血肿清除术, 大骨瓣开颅血肿清除术, 高血压性脑出血
Objective

To discuss the therapeutic effects of neuronavigation assisted minimally invasive puncture hematomas drainage (NAMIEH), small-window craniotomy evacuation of hematoma (SWCEH) and large bone flap evacuation of hematoma (LBFEH) for hypertensive intracerebral hemorrhage and logistic regression analysis of postoperative rebleeding influencing factors.

Methods

The clinical data of 134 patients with hypertensive intracerebral hemorrhage admitted to Department of neurosurgery, 901th Hospital of PLA Joint Logistics Support Force from September 2016 to March 2019 were retrospectively analyzed, and divided into NAMIEH group (38 cases), SWCEH group (45 cases) and LBFEH group (51 cases) according to the different surgical treatment methods. Compared the preoperative and postoperative 7, 14 d bleeding volume, GCS scores, NIHSS scores, Barthel indexes and the clinical effects after treatment, the Logistic regression analysis was used to analysis the postoperative rebleeding influencing factors of patients with hypertensive intracerebral hemorrhage.

Results

The preoperative bleeding volume, GCS score, NIHSS score and Barthel index of the 3 groups had no significant statistical differences (P<0.05); The postoperative 7, 14 d bleeding volume, GCS scores, NIHSS scores and Barthel indexes of the three groups had significant statistical differences (P<0.05); The preoperative and postoperative 7, 14 d bleeding volume and NIHSS scores of the NAMIEH group, SWCEH group and LBFEH group decreased significantly in turn, GCS score and Barthel index increased significantly in turn, and there were significant statistical differences at any two time points in the group (P<0.05). The incidence of rebleeding, residual hematoma and postoperative complications of the NAMIEH group and SWCEH group were significantly lower than the LBFEH group, and the rebleeding (10.53%), residual hematoma (5.26%) and postoperative complications (15.79%) were significantly lower than the SWCEH group respectively (P<0.05). Regarding the postoperative rebleeding of hypertensive cerebral hemorrhage patients as dependent variable, logistic regression analysis was carried out on the possible influencing factors of postoperative rebleeding in univariate analysis. The results showed that associated with diabetes, preoperative systolic blood pressure, the operative occasion, hematoma shape, break into the ventricle, preoperative bleeding volume, preoperative GCS score, preoperative NIHSS score, preoperative Barthel index, abnormal coagulation function, postoperative complications and total duration of hospitalization were independent influencing factors of postoperative rebleeding in patients with hypertensive intracerebral hemorrhage (P<0.05).

Conclusion

The clinical effect of MIEH in treating hypertensive cerebral hemorrhage is better than SWCEH and LBFEH, can effectively promote the recovery of nerve function and reduce the incidence of rebleeding and postoperative complications; Moreover, associated with diabetes, preoperative systolic blood pressure, time from onset to operation et al were independent influencing factors of postoperative rebleeding in patients with hypertensive intracerebral hemorrhage.

Key words: Neuronavigation assisted minimally invasive puncture hematomas drainage, Small-window craniotomy evacuation of hematoma, Large bone flap evacuation of hematoma, Hypertensive cerebral hemorrhage
表1 3组患者基线资料比较
项目 NAMIEH组(n=38) SWCEH组(n=45) LBFEH组(n=51) χ2/F值 P值
男/女 22/16 25/20 28/23 0.795 0.413
平均年龄（岁） 52.24±13.02 53.82±12.81 51.17±11.63 1.145 0.231
高血压病程（年） 9.58±1.82 9.74±1.93 9.66±2.02 1.316 0.178
术前收缩压(mmHg) 173.85±20.18 171.98±19.33 172.29±19.88 0.621 0.442
术前舒张压(mmHg) 97.45±12.34 96.82±11.96 97.26±12.01 0.734 0.364
发病至手术时间(h) 8.87±1.81 8.95±1.79 9.06±1.87 1.237 0.185
出血部位[例(%)] ? ? ? 1.017 0.356
? 脑叶出血 9(23.68) 11(24.44) 13(25.49) ? ?
? 基底节区出血 17(44.74) 19(42.22) 23(45.10) ? ?
? 丘脑出血 12(31.58) 15(33.33) 15(29.41) ? ?
破入脑室[例(%)] 16(42.11) 20(44.44) 25(49.02) 1.582 0.217
表2 3组患者手术前后出血量、GCS评分、NIHSS评分及Barthel指数比较（±s）
项目 NAMIEH组(n=38) SWCEH组(n=45) LBFEH组(n=51) F值 P值
出血量(mL) ? ? ? ? ?
? 术前 56.39±12.45 54.02±11.62 55.84±13.07 0.603 0.459
? 术后7 d 5.74±1.59abc 7.87±2.05ac 11.06±2.34c 5.179 0.000
? 术后14 d 1.39±0.71abcd 2.21±0.93acd 2.95±1.26cd 6.361 0.000
GCS评分（分） ? ? ? ? ?
? 术前 6.19±1.36 6.11±1.29 6.23±1.38 1.152 0.206
? 术后7 d 10.14±1.84abc 9.02±1.61ac 8.22±1.47c 3.081 0.037
? 术后14 d 12.91±2.07abcd 10.39±1.93acd 9.44±1.72cd 3.976 0.025
NIHSS评分（分） ? ? ? ? ?
? 术前 12.71±2.59 12.36±2.52 12.78±2.49 0.911 0.293
? 术后7 d 8.37±1.85abc 9.55±2.07ac 10.33±2.17c 3.165 0.032
? 术后14 d 4.02±1.03abcd 4.96±1.38acd 5.77±1.81cd 4.402 0.011
Barthel指数（分） ? ? ? ? ?
? 术前 34.87±4.22 33.64±4.37 34.05±4.41 0.725 0.377
? 术后7 d 47.29±6.11abc 41.35±5.78ac 38.16±5.23c 2.947 0.042
? 术后14 d 60.58±7.08abcd 52.48±6.19acd 45.28±5.51cd 4.171 0.015
表3 3组患者临床疗效比较[例（%）]
组别 例数 再出血 血肿残留 术后并发症
颅内感染 肺部感染 应激性溃疡 发生率
NAMIEH组 38 4(10.53) 2(5.26) 2(5.26) 3(7.89) 1(2.63) 6(15.79)
SWCEH组 45 8(17.78)a 5(11.11)a 2(4.44) 5(11.55) 3(6.67) 10(22.22)a
LBFEH组 51 17(33.33)ab 8(15.69)ab 3(5.88) 7(13.73) 5(9.80) 15(29.41)ab
χ2值 ? 12.864 10.217 ? ? ? 3.492
P值 ? 0.000 0.000 ? ? ? 0.029
表4 高血压性脑出血患者术后再出血的单因素分析
项目 未再出血组(n=105) 再出血组(n=29) χ2/t值 P值
性别比（男/女） 57/48 18/11 0.736 0.421
平均年龄（岁） 51.93±12.64 54.05±12.29 1.352 0.169
? 高血压病程（年） 8.22±1.78 11.46±2.01 5.146 0.000
? 合并糖尿病（是/否） 31/74 14/15 3.761 0.033
术前收缩压(mmHg) 162.17±18.55 191.35±21.64 3.589 0.027
术前舒张压(mmHg) 88.33±10.72 112.05±13.16 4.705 0.003
发病至手术时间(h) 6.57±1.61 10.42±1.95 5.911 0.000
血肿形状[例(%)] ? ? 4.022 0.028
? 规则 82(78.10) 16(55.17) ? ?
? 不规则 23(21.90) 13(44.83) ? ?
出血部位[例(%)] ? ? 1.463 0.249
? 脑叶出血 24(22.86) 7(24.14) ? ?
? 基底节区出血 43(40.95) 13(44.83) ? ?
? 丘脑出血 38(36.19) 9(31.03) ? ?
破入脑室（是/否） 19/86 17/12 7.316 0.000
术前出血量(mL) 49.93±10.59 63.85±12.74 3.157 0.036
术前GCS评分（分） 6.71±1.51 5.69±1.04 3.429 0.031
术前NIHSS评分（分） 12.18±2.21 13.95±2.39 2.925 0.042
术前Barthel指数（分） 36.01±4.53 31.25±4.11 3.218 0.035
凝血功能异常（是/否） 7/98 10/19 12.234 0.000
手术方式[例(%)] ? ? 2.868 0.046
? NAMIEH 34(32.38) 4(13.79) ? ?
? SWCEH 33(31.43) 12(41.38) ? ?
? LBFEH 38(36.19) 13(44.83) ? ?
使用甘露醇[例(%)] 13(12.38) 4(13.79) 1.401 0.257
术后并发症[例(%)] 19(18.10) 12(41.38) 6.054 0.000
总住院时间(d) 11.93±1.41 18.37±2.11 6.123 0.000
表5 高血压性脑出血患者术后再出血影响因素Logistic回归分析
自变量 β SE（β） Wald P值 OR 95%CI
高血压病程 1.158 0.537 1.635 0.104 1.923 1.158~2.861
合并糖尿病 0.215 0.402 4.533 0.002 1.851 1.243~3.048
术前收缩压 0.632 0.395 5.128 0.001 2.371 1.635~3.184
术前舒张压 0.197 0.156 1.506 0.121 1.475 1.143~2.614
发病至手术时间 0.546 0.312 3.465 0.023 1.962 1.204~3.596
血肿形状 0.336 0.425 3.627 0.021 1.546 1.012~2.135
破入脑室 0.702 0.299 4.081 0.009 2.893 2.137~4.226
术前出血量 0.431 0.365 4.897 0.001 2.012 1.958~3.482
术前GCS评分 1.274 0.613 5.545 0.000 1.612 1.151~1.852
术前NIHSS评分 0.807 0.593 3.914 0.010 2.576 2.068~3.779
术前Barthel指数 0.371 0.528 4.427 0.003 1.765 1.368~2.363
凝血功能异常 0.345 0.471 3.034 0.029 1.317 1.214~1.799
手术方式 0.592 0.385 1.257 0.237 1.641 1.242~2.513
术后并发症 0.742 0.423 5.629 0.000 1.972 1.182~3.985
总住院时间 0.451 0.394 3.378 0.026 1.394 1.378~2.827
[1]
Luan L,Li M,Sui H, et al. Efficacies of minimally invasive puncture and small bone window craniotomy for hypertensive intracerebral hemorrhage, evaluation of motor-evoked potentials and comparison of postoperative rehemorrhage between the two methods[J]. Exp Ther Med, 2019, 17(2): 1256-1261.
[2]
贾彬.立体定向联合显微手术治疗高血压性脑出血疗效及再出血危险因素分析[J].中风与神经疾病杂志, 2015, 32(5): 455-457.
[3]
Yan KX,Gao H,Wang QP, et al. Endoscopic surgery to chronic subdural hematoma with neovessel septation: technical notes and literature review[J]. Neurol Res, 2016, 38(5): 467-476.
[4]
Tsai HH,Pasi M,Tsai LK, et al. Microangiopathy underlying mixed-location intracerebral hemorrhages/microbleeds[J]. Neurology, 2019, 92(8): 774-781.
[5]
陈果,董伟.颅内微创穿刺血肿引流术治疗老年高血压脑出血的效果及对NT-proBNP、HMGB-1和GM-CSF水平的影响[J].中国医药导报, 2016, 13(2): 41-45.
[6]
Luan L,Li ML,Sui H, et al. Efficacies of minimally invasive puncture and small bone window craniotomy for hypertensive intracerebral hemorrhage, evaluation of motor-evoked potentials and comparison of postoperative rehemorrhage between the two methods[J]. Exp Ther Med, 2019, 17(2): 1256-1261.
[7]
康慧莉,詹维伟,丁勇,等.超声在高血压性脑出血微创清除术中的应用[J].介入放射学杂志, 2016, 25(1): 74-77.
[8]
龚良,钱忠心,刘卫东,等.神经导航精准定位微创治疗中小量高血压性基底节脑出血[J].兰州大学学报(医学版), 2016, 42(5): 36-39.
[9]
唐忠,陈启富,廖广生,等.微创穿刺血肿引流术与小骨窗血肿清除术治疗高血压脑出血的疗效及术后再出血的影响因素[J].海南医学, 2017, 28(19): 3128-3130.
[10]
Rivera-Lara L,Murthy SB,Nekoovaght-Tak S, et al. Influence of bleeding pattern on ischemic lesions after spontaneous hypertensive intracerebral hemorrhage with intraventricular hemorrhage[J]. Neurocrit Care, 2018, 29(2): 180-188.
[11]
Matz O,Arndt A,Litmathe J, et al. Risk factors for hypertensive and cerebral amyloid angiopathy associated intracerebral hemorrhage: a retrospective comparison[J]. Fortschr Neurol Psyc, 2018, 86(12): 763-769.
[12]
白磊,陈晨,李军,等.微创穿刺引流术治疗高血压性基底节区脑出血的效果[J].中华老年心脑血管病杂志, 2018, 20(12): 1290-1293.
[13]
Li F,Chen QX,Xiang SG, et al. N-terminal pro-brain natriuretic peptide concentrations after hypertensive intracerebral hemorrhage: relationship with hematoma size, hyponatremia, and intracranial pressure[J]. Intensive Care Med, 2018, 33(12): 663-670.
[14]
Zhao J,Mao Q,Qian Z, et al. Effect of mild hypothermia on expression of inflammatory factors in surrounding tissue after minimally invasive hematoma evacuation in the treatment of hypertensive intracerebral hemorrhage[J]. Exp Ther Med, 2018, 15(6): 4906-4910.
[15]
农胜德,陆明雄,李廷阳,等.颅内微创穿刺血肿引流术对高血压脑出血患者炎性因子及血清铁蛋白、血清P物质的影响[J].海南医学院学报, 2017, 23(1): 104-106, 109.
[16]
Scaggiante J,Zhang XN,Mocco J, et al. Minimally invasive surgery for intracerebral hemorrhage: an updated Meta-analysis of randomized controlled trials[J]. Stroke, 2018, 49(11): 2612-2620.
[17]
赵明媚,袁少勇,陈瑶刚,等.小骨窗微创血肿清除术联合甘露醇对高血压脑出血患者炎性因子、血清铁蛋白和血清P物质的影响[J].疑难病杂志, 2018, 17(8): 776-780.
[18]
Liang KS,Ding J,Yin CB, et al. Clinical study on minimally invasive liquefaction and drainage of intracerebral hematoma in the treatment of hypertensive putamen hemorrhage[J]. Technol Health Care, 2017, 25(6): 1061-1071.
[19]
聂晓枫,杨军,吕智龙.醒脑静注射液联合微创穿刺引流术治疗对中等量高血压性基底节区脑出血患者脑水肿及血清AQP4的影响[J].临床和实验医学杂志, 2017, 16(18): 1838-1841.
[20]
唐小虎,刘家传,张星,等.不同手术方式治疗高血压脑出血的疗效对比观察[J].安徽医药, 2018, 22(5): 843-847.
[21]
仝兆锋,皇甫蓓蓓.微创穿刺血肿引流术与小骨窗血肿清除术治疗高血压性脑出血的效果比较及再出血影响因素分析[J].中国当代医药, 2018, 25(31): 15-17.
[22]
刘宇.微创穿刺引流与小骨窗血肿清除治疗高血压脑出血的临床效果及术后再出血危险因素分析[J].临床误诊误治, 2018, 31(6): 64-67.
[1] 刘政委, 仪立志, 尹夕龙, 孔文龙, 纠智松, 张文源. 锥颅血肿外引流与神经内镜手术治疗老年基底节区高血压性脑出血的疗效分析[J]. 中华脑科疾病与康复杂志(电子版), 2023, 13(05): 299-303.
[2] 运陌, 李茂芳, 王浩, 刘东远. 微创穿刺引流联合吡拉西坦、乌拉地尔治疗基底节区高血压性脑出血的临床研究[J]. 中华脑科疾病与康复杂志(电子版), 2023, 13(05): 278-285.
[3] 王立忠, 初君盛, 赵立辉, 孙慧渊, 侯青, 丁奇, 闫俊飞, 侯源, 袁武, 王唯. 神经内镜与显微镜手术治疗早期基底节区高血压性脑出血的临床疗效对比[J]. 中华脑科疾病与康复杂志(电子版), 2022, 12(02): 69-73.
[4] 刘桂欣, 陈秀杰. 急诊护理干预对高血压脑出血患者的预后的影响[J]. 中华卫生应急电子杂志, 2016, 02(03): 186-189.
[5] 赵希宇, 凌菱, 张超, 卢珊, 相蕾, 岳伟. 不同出血部位及年龄阶段高血压性脑出血的危险因素特点分析[J]. 中华脑血管病杂志(电子版), 2022, 16(03): 165-171.
[6] 刘永生, 申明峰, 郭士琨. 颅内血肿微创清除技术与保守治疗高血压脑出血的临床疗效分析[J]. 中华脑血管病杂志(电子版), 2014, 08(02): 1-3.
阅读次数
全文


摘要

版权所有 中华医学会 中华医学电子音像出版社有限责任公司  京ICP备14006079号-1  网络出版服务许可证：(署)网出证(京)字第075号