Stroke is a common disease that threatens human life and health, of which 20-30% manifest as cerebral hemorrhage, with a high mortality and disability rate. Among hypertensive cerebral hemorrhage, basal ganglion hemorrhage accounts for nearly 80% of hypertensive cerebral hemorrhage, because it is located deep in the brain, and most of them are middle-aged and elderly who have suffered from hypertension for several years, with poor systemic organ function and their own cerebrovascular foundation, and poor tolerance to surgery and anesthesia, while many patients have been taking anticoagulant drugs such as aspirin for many years. This further increases the high risk of craniotomy, and in addition, retrospective studies in some foreign centers have shown that craniotomy for complete removal of hematoma under direct vision is not superior to conservative medical treatment in terms of improving brain function and reducing morbidity and mortality. Then it is an important task for neurologists to investigate a minimally invasive treatment method that is less invasive, has lower surgical risk, is easy to perform, and has positive efficacy. In recent years, I have used rapid fine hole drilling cranial hematoma puncture and drainage to treat cerebral hemorrhage with good clinical efficacy, as reported below: Wei Lin, Department of Neurosurgery, Shandong Qianfo Mountain Hospital
I. Applied surgical instruments and drainage devices
1. Surgical instruments–fast cranial drilling device
The cranial drilling device with fine holes was originally conceived and designed by Zhang Qinglin and Zhang Cheng of the Department of Neurosurgery of the Affiliated Hospital of Shandong Medical College in 1963, and cooperated with Cao Shangde of Shandong Xinhua Medical Equipment Factory to produce samples for clinical trial in 1964, and now it has been widely used in hospitals at all levels in China. The most important feature of this cranial drill is that it does not need to cut the scalp, and it can be done at the bedside of the emergency room or ward in only 3-5 minutes without the use of operating room equipment such as shadowless lamp, suction device and electrocoagulation. After clinical trial in many hospitals in South China, Beijing, Shanghai and Tianjin, it fully achieved the early conception and its performance reached the expected effect of safety, effectiveness, time saving, simplicity, money saving and practicality. In 1965, it was formally used in clinical practice, and was soon popularized. In the 1970s, the cranial drilling device was named as “rapid fine hole drilling device”. Academician Wang Loyal and Professor Shi Yuquan, the leading neurosurgeons in China, commented on the device: “……40 years of clinical application, fully reflects the cranial drill apparatus has the characteristics of safe, effective, minimally invasive, simple, fast, practical, economic, etc., is an independent innovation with intellectual property rights in China It is a medical device with independent innovation and intellectual property rights in China (it has been awarded the national invention patent certificate and confirmed by literature search for 50 years from 1952 to 2002). …… has enabled many endangered patients to save their lives by using the cranial drill in the shortest time (3-5 minutes) to complete cranial drilling and extracorporeal drainage of the ventricles without the need of operating room conditions …….”
2. Drainage device
The external cranial drainage device produced by Shandong Dazheng Medical Equipment Co.
II. Surgical method.
According to the priority of the patient’s condition, treatment can be chosen in the emergency room resuscitation room, CT room, operating room, or ward bedside. Generally, the largest level of the hematoma volume on the CT scan image is chosen, and the puncture point is along the long axis of the hematoma via the frontal area, and the distance of its side opening to the midline is the distance from the center of the hematoma to the midline, and the range is mostly 2.5-4.5 cm, and the puncture direction is both parallel to the sagittal plane and pointing to the hematoma at the same time The length of the hematoma and the length of the puncture point from the front of the hematoma are measured separately by CT images, and the sum of the two is the depth of entry of the entire puncture drainage tube, and the position of the trimmed lateral holes on the drainage tube is calculated according to the length of the hematoma. All the lateral holes should be in the hematoma cavity so that urokinase can be injected into the hematoma cavity after surgery to drain the hematoma as soon as possible. The patient is placed in the supine position, routinely disinfected, sheeted and anesthetized with local infiltration of the scalp puncture site to form a skin mound, and pulled out after puncturing the whole layer of the scalp with a thin-bore cranial drill, and the drill is reimplanted in the direction of drainage tube placement for cranial drilling, to drill through the skull and puncture the dura at one time, and puncture the hematoma cavity with a 12F or 14F silicone drainage tube with a needle core, and enter the hematoma cavity with a slight breakthrough sensation and see dark red bloody When entering the hematoma cavity, there is a slight breakthrough sensation, and dark red bloody fluid is seen when the fluid overflows, indicating entry into the hematoma cavity. Scalp suture is fixed with a stitch to fix the drainage tube, and a tee tube (lateral passages are blocked with heparin caps) and a special cranio-cerebral drainage apparatus are attached to drain the cranium. Immediately after surgery, the cranial CT was reviewed to understand the position of the tube, the amount of residual hematoma after aspiration and the presence of bleeding, and the position of the drainage tube could be adjusted if necessary. In patients in the acute phase, urokinase is slowly injected into the hematoma cavity through a tee tube with a dilute amount of urokinase 30-50,000 U + 3 ml saline cap puncture after 8-12 h of tube placement, and the continuous drainage is released after 0.5-1 h of tube closure, and the operation is repeated every 8 h. In patients whose bleeding has exceeded 10 h, the hematoma cavity can be treated with urokinase injection after the hematoma is aspirated by drainage tube placement. The patient’s condition and hematoma drainage (drainage flow, color, presence of cerebrospinal fluid outflow, etc.) should be closely observed daily. When there is no large amount of dark red old blood outflow and the total drainage flow is similar to the hematoma volume calculated by preoperative CT scan, the cranial CT should be reviewed, and extubation can be considered if there is little residual hematoma (less than 10 ml). If fresh blood is induced during drainage and judged to be intracranial rebleeding, immediate laparoscopic hemostasis of 1 KU is given and retained for 3 min, and the drainage tube is opened and confirmed by review of CT. For patients with hematoma breaking into the ventricular system or combined with acute hydrocephalus, unilateral or bilateral extraventricular drainage is required.
Drainage of the patient (photo not successfully uploaded here)
Typical case 1: Cerebral hemorrhage in the left basal ganglia region.
Patient, male, 70 years old, 2011.2.10.9:15am CT (about 1 hour after onset), continuous aspirin for more than 2 years
Patient in deep coma, left pupil 3.5 mm, right pupil 2.5 mm, light reaction present
The patient was admitted to the hospital and underwent emergency hematoma puncture and drainage, and immediately after the operation, the patient was rechecked at 10:56am CT on 2011.2.10. The patient was in a shallow coma, with orbital pressure response, bilateral pupils equal in size 2.5mm, and sensitive to light reaction.
2011.2.12 8:46am CT was repeated, the patient was able to open his eyes on call and followed the instructions.
2011.2.15 CT was rechecked and the drainage tube was removed after the recheck. The patient is fully conscious, with partial motor aphasia, muscle strength of right lower limb grade 2-3, right upper limb grade 1-2
Typical case II. Right basal ganglia hemorrhage breaking into the ventricle
Patient, female, 74 years old, 2011.2.15 16.:56 pm CT (40 minutes after onset), patient was comatose was recommended to be transferred to a provincial hospital, with a history of continuous aspirin use
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2011.2.16.9:34am CT review at a provincial hospital, conservative treatment, hydrocephalus
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The patient was transferred to our hospital, and on 2011.2.17.18:01pm CT review, the patient was in deep coma, the right pupil was 4mm, the light response was blunted, the left pupil was 3mm, the light response existed
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The patient was admitted to the hospital for emergency cranial hematoma drainage by drilling the right side of the hole and left ventricular puncture and drainage, and immediately after the operation, the CT was reviewed at 2011.2.17.19:13 PM.
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2011.2.21.8:10am Four days after puncture and drainage, the CT was rechecked and the drainage tube was removed on the same day. The patient was fully awake, with left-sided hemiparesis and muscle strength of 0-1.
DISCUSSION
The main cause of hypertensive basal ganglia area cerebral hemorrhage is the rupture of the doublestem artery, which usually forms the maximum extent of the hematoma in 20-30 min, and the hemorrhagic state mostly stops by itself, while the secondary brain damage caused by high cranial pressure due to the occupying effect of the hematoma itself, brain herniation and various neurotoxic substances released during blood coagulation, liquefaction and lysis are the main causes of its disability and death. The pathogenesis determines that the main purpose of surgical treatment is not to stop the bleeding, but to reduce the intracranial pressure and secondary brain damage by removing the drained hematoma as soon as possible, so that the brain tissue can be protected to the greatest extent, thus improving the patient’s prognosis. In our second patient, although the surgical drainage of the hematoma was effective, the recovery of the hemiplegic limb after surgery was unsatisfactory because the surgery was performed fifty hours after the onset. More and more studies have shown that minimally invasive puncture and drainage can achieve better treatment results and is now commonly used in the treatment of hypertensive basal ganglia cerebral hemorrhage. Since minimally invasive drainage is a non-direct vision procedure, how to drain the hematoma, intracranial rebleeding, and intracranial infection as soon as possible is a fundamental issue that directly determines the efficacy of the procedure and the patient’s prognosis. Then how to avoid these risks in a timely and effective manner is the key. The rapid fine hole drilling cranial hematoma puncture and drainage we applied to treat hypertensive basal ganglia cerebral hemorrhage has accumulated a better experience, which is discussed as follows.
1. Timing of surgery.
In the past, it was believed that patients with cerebral hemorrhage were critically ill in the early stage, mostly elderly people with combined multi-organ dysfunction, with high risk of surgery and rebleeding, and surgery should be performed after 24 hours. The timing of surgery for hypertensive cerebral hemorrhage is generally divided into ultra-early (within 6h of onset), early (within 48h of onset), and deferred surgery (after 48h of onset). Recent studies have shown that intracranial hematoma forms 20-30 minutes after the onset of cerebral hemorrhage, and the formed hematoma can lead to lacerations and mechanical compression of brain tissue, i.e., primary injury. At the same time, the damaging effects of hematoma decomposition products cause edema, degeneration, hemorrhage and necrosis to occur in the brain tissue around the hematoma from near to far, and they are aggravated over time. Generally, the edema around the hematoma has not yet formed within 3 hours, and edema appears after 6 to 7 hours, with necrosis and irreversible damage to the brain tissue immediately surrounding the hematoma, reaching moderate edema at 12 hours and severe edema at 24 hours. The literature reports that brain tissue adjacent to the hematoma cavity was taken for pathological examination during surgery within 6 hours, and only about 1 mm of brain parenchyma was found to have edema and small patchy hemorrhage with degeneration. This shows that how to reduce secondary damage to brain tissue as soon as possible is very important to protect neurological function and reduce mortality and disability With the depth of research, most scholars advocate early surgery to remove the hematoma, release the compression of brain tissue by the hematoma, break the vicious cycle caused by a series of secondary changes such as blood cell decomposition and brain tissue edema after hemorrhage, and improve survival rate and quality of life. Therefore, ultra-early surgery to remove the hematoma and decompress the brain tissue before the surrounding brain tissue becomes edematous and degenerative necrosis occurs reduces the secondary damage to the brain tissue to a minimum and prevents the development of brain herniation, thus reducing the mortality and disability rate. We also found that the earlier the treatment, the lower the disability rate and the better the prognosis of the patients in the postoperative follow-up of patients who applied rapid fine hole drilling cranial hematoma puncture and drainage.
2. Postoperative bleeding problem
In order to minimize the occurrence of postoperative rebleeding, we have the following experiences in the animal experiments of early rapid fine hole drilling development process and later clinical application for many years: (1) The selected puncture point is the frontal part of 2.5-4.5cm in the midline of the paracentesis, so the site is a relatively functional dumb area, and the cortex The selected 12-14F “soft channel” silicone drainage tube, with a “smooth and rounded” head at its insertion end, can take advantage of the “avoidance mechanism” of the cerebral vessels with a certain degree of elasticity when it is submerged in the brain parenchyma. “When it is placed in the basal ganglia through the frontal direction, it is nearly parallel to the direction of the doublestem artery, so that it can “separate” the doublestem artery instead of “cut” it, and compared with the temporal puncture, it can avoid the important functional areas of the brain while avoiding damage to the lateral fissure vein. Compared with transtemporal puncture, it avoids damage to the lateral fissure vein and middle cerebral artery branches, which minimizes the risk of rebleeding due to damage to cerebral vessels during the puncture. (2) The direction and depth of puncture of the hematoma cavity should be calculated and planned accurately by CT images before surgery to ensure the accuracy of puncture and reduce the number of punctures as much as possible. For hematoma center within 2.5-4.5 cm from the midline, the puncture direction should be parallel to the sagittal plane while pointing to the hypothetical line between the center of the hematoma and its projection on the temporal body surface. The purpose is to reduce the chance of damaging large vessels during the puncture. Generally speaking, as long as the operator has successful experience in transfrontal puncture of the frontal horn of the ventricle, it is not difficult to puncture a hematoma cavity of more than 30 ml in the basal ganglia area, and a successful puncture can be achieved in most cases. (3) The thin-bore cranial drill should be gentle in the process of cranial drilling and drainage tube puncture, and the dura should be pierced with the guide core after the electric drill penetrates the inner plate of the skull, and the intracerebral puncture should be advanced slowly. (4) Since the chance of intracranial rebleeding decreases significantly after 6 hours of cerebral hemorrhage, and the brain tissue damage and cerebral edema around the hematoma are serious after more than 24 hours, it is necessary to choose ultra-early or early surgery. For patients with ultra-early surgery within 6 hours, if combined with brain herniation, consider the cause of brain herniation is direct compression of the hematoma occupying and acute hydrocephalus, perform rapid fine hole drilling cranial ventricular puncture and drainage as soon as possible to reduce cranial pressure and relieve hydrocephalus. This is not only helpful to relieve the brain herniation crisis, but also can prevent the bleeding artery from rebleeding and rebleeding due to the loss of the hematoma and the pulling of the rapidly resetting brain tissue. The occurrence of rapid decompression syndrome. For patients who undergo surgery at 6-24 h of hemorrhage, since the hematoma at this stage is mostly in a coagulated state and the liquid hematoma only accounts for about 30%, the first removal of the hematoma is usually 30-40% of the calculated volume, and strong high negative pressure aspiration to increase the first hematoma removal is not allowed. (5) The location of the largest central level of the hematoma is usually chosen for the puncture target, and multiple lateral holes of the drainage tube are required to be evenly distributed within the hematoma, with the lateral holes not being in the brain tissue to ensure that urokinase can be accurately injected into the hematoma cavity without being in the brain tissue, which can reduce the occurrence of postoperative rebleeding. (6) Regarding postoperative blood pressure control, we generally require the mean arterial pressure to be between 110-130 mmHg after surgery, both To ensure adequate cerebral tissue perfusion pressure, but also to prevent the risk of bleeding in due to high blood pressure, blood pressure is not allowed to exceed 180/100mmHg, and blood pressure is controlled by micro-pump injection of nitroglycerin or sodium nitroprusside in the acute stage, and changed to oral or nasal antihypertensive drugs after the condition is stabilized. Blood pressure is not well controlled after the first bleeding is an important cause of rebleeding. Some articles analyze the relationship between blood pressure and the occurrence of rebleeding, and believe that diastolic blood pressure over 90 mmHg is one of the important factors predicting the possibility of cerebral hemorrhage again, and diastolic blood pressure control less than 90 mmHg after the first cerebral hemorrhage is very important to reduce the reoccurrence of hypertensive cerebral hemorrhage. (7) Postoperative patients to be agitated can be moderately sedated, but attention should be paid to keep the airway open.
3.The problem of hematoma clearance speed and clearance rate
Since hematoma puncture and drainage surgery cannot immediately remove all hematomas, the question of how to increase the speed and rate of hematoma removal is directly related to the effect of surgery. We hope to clear most of the hematoma before the peak of severe cerebral edema, that is, to clear 80% of the hematoma around 50 hours after the onset of the disease, so as to minimize the high cranial pressure caused by the occupying effect of the hematoma itself, brain herniation and the secondary brain damage caused by the release of a variety of neurotoxic substances, which is the basis for a good recovery of the patient. The following measures can be taken to increase the speed and rate of hematoma removal: (1) Depending on whether the surgery is performed at an ultra-early or early stage, as much hematoma as possible can be aspirated intraoperatively without strong aspiration, as discussed in detail earlier and will not be repeated here. (2) According to the size and shape of the hematoma, the long axis of the hematoma is generally selected to cut a suitable lateral hole in the drainage tube to ensure that multiple lateral holes are evenly distributed within the hematoma. Because the puncture point of the drainage tube is the largest section of the selected hematoma, as the hematoma continues to drain and the pressure in the hematoma cavity decreases, the surrounding brain tissue will contribute to the centripetal reduction of the hematoma cavity, which can ensure that the drainage tube is always in the central part of the hematoma and accelerate the drainage speed. (3) In order to further accelerate the liquefaction and drainage of coagulated hematoma rich in neurotoxic substances, patients in the acute stage should be slowly injected into the hematoma cavity with urokinase 30-50,000 U + 3 ml saline dilution after 8-12 h of tube placement by puncturing the heparin cap through a three-way tube and releasing continuous drainage after 0.5-1 h of tube closure, and the operation should be repeated every 8 h. For patients whose bleeding has exceeded 10 h, after the hematoma is aspirated by drainage tube placement In patients who have been bleeding for more than 10 h, treatment with urokinase injection into the hematoma cavity can be performed. Most neurologists use a small single dose of urokinase because of concerns that it may cause intracranial rebleeding, which is detrimental to the liquefaction and drainage of the hematoma, because a dose of <30,000 U is significantly less effective in dissolving, liquefying, and coagulating the hematoma. Urokinase, as a non-specific direct activator of fibrinogen, has no harmful effects on brain tissue and no direct effects on the cerebral vascular wall itself, making it a safe and effective biological agent for lysing hematomas. However, we do not advocate a single application of very large doses, because of the risk of rebleeding due to the rapid liquefaction and drainage of the hematoma, which may lead to the pulling of the hemorrhagic artery by the rapidly resetting brain tissue. Our experience is that multiple small applications of urokinase are safe and effective, while 3 ml of saline as a diluent injection facilitates adequate infiltration and dissolution of the hematoma, and the amount injected is not sufficient to cause a rapid increase in intracranial pressure. (4) The height of the drainage bottle for hematoma cavity puncture and drainage is different from that of the ventricular drainage bottle, which can be placed at a position lower than the hematoma cavity, but not more than 10 cm, which is beneficial to hematoma drainage and will not cause excessive drainage. During the drainage process, the patient's condition and the drainage of the hematoma should be closely observed every day (drainage flow, color, presence or absence of cerebrospinal fluid outflow, etc.). If there is no obvious dark red bloody fluid drainage, the hematoma has generally been cleared by more than 80%; if bright red bloody fluid is found during the drainage process, it is generally due to intracranial rebleeding and should be given immediately to stop bleeding 1KU injection and kept for 3 min after opening the drainage. If the blood is found to be bright red during drainage, it is usually due to intracranial rebleeding. In these two cases, do not blindly inject urokinase, and promptly review the CT to understand the intracranial hematoma for the next step of treatment.
4. Intracranial infection
In order to prevent the occurrence of intracranial infection, in addition to the strict aseptic operation during surgery and drug injection in the hematoma cavity, the occurrence of intracranial infection can also be reduced by selecting a drainage device with an anti-reflux device, which is available from Shandong Dazheng Medical Devices Co. In addition, because there are intracranial infections caused by puncture drainage including ventricular puncture drainage, in addition to contamination during surgery and drug injection, the main source of infection is from bacteria (most commonly staphylococcus) hidden in the scalp follicles and sebaceous glands around the borehole, therefore, our experience is: (1) the borehole must match the drainage tube to avoid large boreholes and thin drainage tubes, which can easily cause retrograde infection. (2) Use 75% medical alcohol gauze to wet dress the skin around the drill hole 3cm every day. The fat-soluble alcohol can effectively control and prevent infection through the skin. We have very few intracranial infections in our clinical patients for many years, and one of our patients with ventricular drainage had no infection with the tube for one month.
In conclusion, rapid fine hole drilling cranial hematoma puncture and drainage combined with urokinase hematoma cavity injection to treat hypertensive basal ganglia cerebral hemorrhage has been proved by our clinical application for many years to be minimally invasive, fast, convenient, safe, effective, practical and economical, and minimizes the risks and complications of minimally invasive surgery, reduces the morbidity and mortality rate and disability rate, and early treatment is beneficial to patients’ neurological recovery. It is suitable to be promoted and applied in hospitals at all levels nationwide.
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