1.Brief case information
Patient Zhao Mouqiang, male, 93 years old. He was admitted to the emergency room mainly due to sudden onset of unconsciousness with right-sided limb weakness for 4 hours. Past: hypertension, diabetes mellitus, hypothyroidism. On examination: Glasgow coma score of 6, bilateral pupils are equal in size and round, with a diameter of about 2.5 mm and blunted reflex to light. The right limb muscle strength was grade 2, with low muscle tone. Pathological signs were positive. Bilateral physiological reflexes were present and pathological reflexes were not elicited. Auxiliary examination: CT (2013-12-11): hemorrhage in the left basal ganglia area, volume 80 ml. right deviation of the midline 5 mm, deformation of the ipsilateral ventricle by compression, and compression of the cricoid pool.
Figure 5-2-6-1 Preoperative images
Admission diagnosis: left basal ganglia region lateral type cerebral hemorrhage; hypertensive disease grade 3 (very high risk group)
Diabetic hypothyroidism management: emergency general anesthesia endoscopic left middle frontal gyral foramen approach for intracerebral hematoma removal.
2.Surgical procedure
(1) Anesthesia: Intravenous complex anesthesia with tracheal intubation.
(2) Position: The patient is placed in a supine position with the upper body elevated by 30°, and the head is fixed with a head rest.
(3) Incision design: take the left middle frontal gyrus approach, inside the hairline, 87.5px before the coronal suture, and open a 100px horseshoe-shaped incision next to the midline about 125px long, (the cortical entry point is located approximately in the anterior part of the middle frontal gyrus).
Figure 5-2-6-2 Surgical incision
(4) Exposure of the cortex: routine disinfection, laying of towels. The scalp, capitellum and periosteum are dissected in layers. Sutures are pulled to reveal the incision. One bone hole with a diameter of about 37.5 px was drilled, and the dura was cross-cut to expose the cortex and hemostasis was achieved by electrocoagulation.
Figure 5-2-6-3 Dural incision and draping
(5) Working sleeve placement: The hematoma is first punctured with a cerebral puncture needle oriented to the vertical cortex, aligned with the binaural line, and the needle is advanced 5-175 px, and the old hematoma is seen on retraction. Then the puncture tunnel was dilated for the first time with a 1 ml syringe and the stale hematoma was aspirated, after which a 5 ml syringe was applied to remove the head end and plunger, and a pediatric ureteral flushing capsule was fixed to the head end of the syringe for secondary dilatation, and finally the ureter was removed and the working channel was left in the hematoma.
Figure 5-2-1-3 Simple working sleeve and placement
(6) Endoscopic removal of the hematoma: The operator holds a 5-mm diameter 0° pterygoid sinus scope or ventriculoscope in the left hand to expose the operative field, and a 3-5 mm fine head suction device in the right hand to operate, paying attention to the main points of operation within the hematoma and avoiding the suction device touching the hematoma wall. Operate gently and use the suction device to cut the hematoma when encountering hematoma mechanization. Swing the transparent working sleeve appropriately to find and squeeze the hematoma into the operative field to facilitate removal. When active bleeding is encountered, the suction is applied to the bleeding point, and monopolar electrocoagulation is applied to the suction to stop the hematoma, taking care to withdraw the suction gently to confirm reliable electrocoagulation. If bleeding is available cotton pad compression and covered with hemostatic gauze can stop bleeding. After satisfactory hematoma removal, slowly withdraw the working sleeve. Close the sinus tract with a gel sponge roll. Gentamic saline is used to flush the operative field. Cortical collapse and recovery of cerebral pulsation can be seen.
Figure 5-2-1-4 Endoscopic removal of hematoma
(7) Cranial closure: the periosteum covers the bone hole, the scalp is sutured in layers, and one drainage tube is left in place.
3. Pre-operative and post-operative imaging
Figure 5-2-1-5 Axial cranial CT scan before and after surgery
4.Surgical points
Minimally invasive
Minimally invasive treatment concept: to deal with the lesion to the maximum extent, while preventing or reducing the medical damage to brain tissue and preserving brain function to the maximum extent.
Endoscopic frontocentral foramen approach to remove cerebral hemorrhage in the nucleus accumbens can be completed within one hour. The incision is 125 px small, with a minimally invasive horseshoe incision covering the bone foramen to avoid cerebrospinal fluid leakage. The surgical incision is located within the hairline taking into account the cosmetic aspect. The working sleeve was placed in the hematoma cavity during the operation, and the field was well exposed endoscopically, and the hematoma could be completely removed and decompressed by adjusting the direction of the sleeve. The middle frontal gyrus is less vascularized than the lateral fissure, and the working sleeve has a diameter of 37.5 px, so the brain tissue is less damaged after placement, and the medically induced damage to the brain tissue is minimal. The frontal middle gyrus is a relatively functional subregion of the brain, so the hematoma wall and the electrocoagulated vessels can be avoided as much as possible during the surgery, thus protecting the brain function to the greatest extent.
Surgical techniques
Gentle operation: to operate inside the hematoma, avoid the suction device touching the hematoma wall, and have the spirit of ants gnawing on the bones; the hematoma is mostly a few tens of milliliters, and it is not difficult to remove it completely with patient aspiration; do not be irritable.
Exposure of the operative field: moderate swinging of the working sleeve. Satisfactory exposure of the operative field can be obtained by moderate swinging of the working sleeve. So that the hematoma is completely removed. Excessive oscillation of the working sleeve can increase medically induced brain damage.
Hemostasis: monopolar electrocoagulation is used to stop the hemorrhage. The diameter of the blood supplying arteries in the basal ganglia region is mostly 300-800 μm, and hemorrhage can mostly be stopped by compression. The narrow working sleeve in this procedure, coupled with the endoscope in one hand and the suction in the other hand of the operator. In case of obvious bleeding point, the suction device can be used to aspirate the bleeding point, preferably with a distance of about 1 mm. Satisfactory hemostasis can be obtained by applying a monopolar electrode electrocoagulation aspirator. Cotton piece and hemostatic gauze sequential hemostasis. First use cotton piece to compress the hemostasis, then lay hemostatic gauze, and then use hemostatic gauze to compress. Satisfactory hemostasis can be achieved. Note that hemostatic gauze should be used sparingly.
Perioperative management
Strictly control blood pressure for 6 hours. Systolic blood pressure is required to be controlled between 110-130 mmHg. This can be achieved by sedation, analgesia, and antihypertensive drugs. Patients should preferably be treated in the ICU.
Imaging review: head CT is performed at 6 hours postoperatively. The rate of hematoma clearance is the criterion for the success of the procedure. The hematoma clearance rate is generally considered excellent above 90% to promote awakening and extubation and a smooth course of disease. 70-90% is OK. below 70% is failing and may require difficult ICU treatment or diaphoresis.
Neurocritical support therapy in the perioperative period: secondary brain injury after cerebral hemorrhage includes cerebral edema, cerebral ischemia and hypoxia, hydrocephalus, cerebral swelling, epilepsy, abnormal energy metabolism, and systemic inflammatory response syndrome. Neurocritical support therapy is required. This includes intracranial pressure monitoring and management; respiratory and circulatory management; nutritional support; infection prevention; and maintenance of acid-base balance and internal environmental stability.
5.Review
Advantages.
1, in line with the development of neurosurgery – minimally invasive concept: to maximize the treatment of lesions, while preventing or reducing the medical damage to brain tissue, and maximizing the preservation of brain function.
2. Short operation time, low bleeding, fast recovery of patients, most patients awake and extubated on the next day of operation, few perioperative complications.
3.It can replace classical craniotomy.