微创术联合重组组织型纤溶酶原激活剂治疗自发性脑出血的临床研究

发布时间：2018-07-07 12:02

  本文选题：脑出血 + 微创术　； 参考：《华中科技大学》2015年博士论文

【摘要】：第一部分：穿刺准确度对微创术治疗自发性脑出血疗效的影响 目的：介绍一种评估微创术穿刺准确度的方法——相对偏离度(RE),评估其对血肿清除效果的影响,并比较徒手穿刺法和立体定向法定位准确度的差异。 方法：回顾性分析我科电子资料库中2012.7～2014.6接受微创术联合重组组织型纤溶酶原激活剂(rt-PA)治疗的自发性脑出血患者,纳入其中应用徒手穿刺法或立体定向法定位,单针穿刺,且并无再出血的患者。采用计算机辅助的容量分析方法计算ICH体积,利用头颅CT平扫图像,以引流管在轴位及冠状位两个平面上偏离血肿中心的比例的和,即RE,来评估穿刺准确度。 结果：共纳入80例患者,应用多重回归分析,仅有RE对血肿清除率有显著影响(P0.001)。当RE0.6时,剩余血肿量≤15m1的比例为45.0%,而RE0.6时则分别为81.7%。徒手穿刺组的RE为0.5±0.24(0.03-1.03),立体定向组的RE为0.284±0.17(0-0.66),差异显著(P0.001)。前者的血肿清除率为69.34±14.4%,剩余血肿量为11.81±6.50ml,而后者的血肿清除率为71.2±14.5%,剩余血肿量为10.17±6.38ml,均无显著差异(血肿清除率,P=0.584；剩余血肿量,P=0.288)。在徒手穿刺组,RE与血肿清除率显著相关(rs=-0.551,P0.001),而立体定向组RE与血肿清除率无显著相关性(rs=-0.004,P=0.983)。 结论：RE是评估穿刺准确度简便易行的方法。穿刺准确度与血肿清除效果高度相关,RE≤0.6是较为理想的穿刺准确度。相比徒手穿刺法,立体定向法可有效提高穿刺的准确,同时提高血肿清除效果的稳定性。徒手穿刺也有较高的穿刺准确度和血肿清除率,而且操作简单,对于推广微创术救治脑出血患者有重要的作用。 第二部分：微创术联合重组组织型纤溶酶原激活剂治疗自发性脑出血：剂量探讨 目的：探讨重组组织型纤溶酶原激活剂(rt-PA)在微创术(MIS)中用于治疗脑出血(ICH)时,rt-PA剂量与血肿清除效果的关系。 方法：回顾性分析我科电子资料库中2012.7～2014.12接受微创术联合重组组织型纤溶酶原激活剂(rt-PA)治疗的自发性脑出血患者,纳入其中无再出血且单针穿刺的患者,采用计算机辅助的容量分析方法计算ICH体积,以每次治疗后ICH体积的变化,即液化清除量,代表清除效果。应用协方差分析单次用药时,不同剂量rt-PA对液化清除量的影响。同时比较不同剂量rt-PA对再出血率的差异。 结果：共纳入单针治疗者126例,共进行液化193次,59.5%用药1次,30.2%用药2次,7.9%用药3次,2.4%用药4次。rt-PA单剂用量为0.54±0.30mg,范围从0.1～2.0mg,其中主要的剂量方案为0.3mg(19.7%).0.5mg(51.3%)与1.0mg(19.1%),共占90.1%。液化前血肿量(P0.001)是影响首次液化清除量的主要因素,rt-PA剂量对清除量无显著影响(P=0.123)。液化清除量均随液化前血肿量的增大而增大,但血肿量≥30m1后,清除量增加幅度较小。三组剂量间第二次液化清除量亦无显著差异(P=0.577)。用药次数≥3次的患者,三组剂量间液化清除率随液化次序递增(除第4次液化)的变化趋势无显著差异(P=0.511)。共8例液化后再出血,不同剂量间液化后再出血率无显著差异(P=0.400)。 结论：应用微创术联合rt-PA是清除ICH的有效治疗手段,但至少在rt-PA0.3-1.Omg范围内,药物剂量与液化效果不存在显著的量效关系。液化前血肿量是影响液化效果主要因素。 第三部分：自发性脑出血微创术后出血并发症危险因素分析 目的：评估微创术治疗自发性脑出血发生出血并发症的风险及安全性,探讨出血并发症发生的危险因素。 方法：回顾性分析我科电子资料库中2012.7～2014.12接受微创术联合重组组织型纤溶酶原激活剂(rt-PA)治疗的自发性脑出血患者,记录患者每天症状及头颅CT上出血特征随治疗的变化,以再出血、穿刺损伤(穿刺道出血及蛛网膜下腔出血)发生率评估微创术的安全性并分析手术时机、抽吸术、rt-PA方案及穿刺损伤与再出血的关系,以重症监护病房(ICU)住院时间及起病30d死亡率判断预后,并评估再出血及穿刺损伤对预后的影响。 结果：共纳入182例患者,再出血发生率为8.7%,仅2例(1.1%)症状性再出血,共发生8次术后再出血,11次液化后再出血。穿刺损伤率为19.8%,包括28例穿刺道出血及17例蛛网膜下腔出血。穿刺损伤(P=0.001)、液化前调整穿刺针(P=0.030)增加再出血风险。rt-PA应用时机,非剂量,与液化后再出血相关,发现穿刺损伤、抽吸术后及再出血后早期应用rt-PA可导致再出血。再出血及穿刺损伤未增加ICU住院时间及30d死亡率。 结论：本研究发现微创术联合rt-PA治疗ICH有良好的安全性,再出血率,特别是症状性再出血率较低,穿刺损伤率亦较低。发现穿刺损伤、抽吸术后及再出血后稳定至少12h再行后续液化治疗,液化治疗期问避免调整穿刺针似乎有助于降低再出血率。 总结
[Abstract]:Part I : Effect of puncture accuracy on the efficacy of minimally invasive surgery in the treatment of spontaneous cerebral hemorrhage

Objective : To introduce a method _ relative deviation ( RE ) for evaluating the accuracy of puncture accuracy of minimally invasive procedure , to evaluate its effect on hematoma removal , and to compare the difference of accuracy of positioning accuracy with the method of manual puncture and stereotaxic method .

Methods : The patients with spontaneous cerebral hemorrhage treated with rt - PA were retrospectively analyzed in the electronic database of our department . The patients with spontaneous intracerebral hemorrhage treated with either hand puncture or stereotactic method were included . The ICH volume was calculated by computer - assisted volumetric analysis method . The CT plain scan was used to measure the accuracy of puncture by using the CT plain scan image and the ratio of the drainage tube to the center of the hematoma on both the axial and coronal planes .

Results : A total of 80 patients were enrolled and multiple regression analysis was applied . Only RE had a significant effect on the clearance of hematoma ( P 0.001 ) . When RE0.6 , the ratio of residual hematoma to 15ml was 45.0 % , while RE was 0.284 卤 0.17 ( 0 - 0.66 ) , and the remaining hematoma volume was 11.81 卤 6.50 ml , while the remaining hematoma was 10.17 卤 6.38ml . There was no significant difference ( hematoma clearance , P = 0.584 ) .
Residual hematoma volume , P = 0.288 ) . There was no significant correlation between RE and hematoma clearance ( rs = - 0.551 , P0.001 ) , but there was no significant correlation between RE and hematoma clearance ( rs = - 0.004 , P = 0.983 ) .

Conclusion : RE is a simple and easy method to assess the accuracy of puncture . The accuracy of puncture is highly correlated with hematoma clearance effect . RE 鈮，

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