With the application of microoperation techniques and stereotactic puncture techniques in neurosurgery, surgery is again developing in the direction of fine and minimally invasive. However, how to determine the surgical indications and give the most reasonable treatment to patients is the topic facing every neurologist; and because hypertension is a systemic disease and cerebral hemorrhage is only one of its many complications, it is also necessary to focus on comprehensive treatment after surgery to prevent various complications such as rebleeding. The following is a brief review of the surgical treatment of hypertensive cerebral hemorrhage based on a review of the literature, combined with the author’s clinical practice.
What is the site of hemorrhage and the indication for surgery?
Hypertensive cerebral hemorrhage can occur in the basal ganglia, thalamus, lobes, brainstem and cerebellum, with hemorrhage from the doublestem artery in the basal ganglia being the most common. In clinical practice, based on anatomical basis, the cranial cavity is divided into supratentorial and infratentorial cavities for the convenience of application, using the cerebellar curtain as the boundary. The supratentorial contains the lobes of the brain and the bilateral thalamus, etc. The volume is larger, so the compensatory space is also larger; the infratentorial contains the cerebellum and brainstem, the space is narrow, so the compensatory space is also small. This determines that there are different surgical indications for supratentorial and infratentorial hemorrhage, and then combined with the patient’s head CT reading and the patient’s state of consciousness and pupillary changes, the surgical indications are as follows.
(1) supratentorial hemorrhage ≥ 30 ml, subatentorial hemorrhage ≥ 10 ml;
②Midline cerebral structures displaced by ≥1cm;
③ ventricles, cerebral pool pressure deformation or disappearance, especially the cricoid pool, the fourth ventricle should be more attention;
(④) Bilateral pupils are unequal in size, pupillary light reflexes are blunted, or even pupils are dilated and reflexes disappear;
⑤ Patients with deterioration of consciousness, such as restlessness, drowsiness, or even coma. The above ①, ②, ③ are the results of the cranial CT, ④, ⑤ are the symptoms and signs; if the condition ① is satisfied, and any of the conditions ② to ⑤ are present, then it is an absolute indication for surgery.
What is the choice of surgical method?
Due to the progress of modern neurosurgery technology and the continuous application of advanced surgical instruments in the clinic, the surgical treatment of hypertensive cerebral hemorrhage has become more abundant and diversified, and developed in the direction of fine and minimally invasive, with the original direction of preserving survival to the more demanding direction of preserving survival and function. Nowadays, early and ultra-early hematoma removal surgery has become a consensus, which has become a powerful guarantee to improve survival and reduce disability rate.
Bone flap craniotomy for hematoma removal: It is suitable for patients with large hematoma, rapid progression of patient’s disease or brain herniation, and analysis of possible active bleeding. The advantage is that the surgical field of view is open, and the hematoma can be removed under direct vision, and the pressure can be reduced by removing the bone flap when the cranial pressure is high; the disadvantage is that the craniotomy is time-consuming and the brain tissue is damaged by the operation. The application of microscopic operation can improve the fineness and reduce the damage.
Small bone window craniotomy for hematoma removal: It is suitable for patients with various kinds of cerebral hemorrhage, and requires good microscopic operation skills, microscopic operation, direct vision hemostasis, small trauma and reliable results. The disadvantage is that it is more demanding for the operator, and due to the narrow field, it sometimes causes some difficulties for the operation, which should be avoided.
Stereotactic hematoma puncture and drainage: It is a technique supported by computer-aided design, combined with cranial CT, which can precisely locate the target point of bleeding, and after puncture and extraction of part of the hematoma to achieve intracranial decompression, a tube can be placed to continuously drain the residual hematoma, and urokinase can be injected to accelerate the dissolution of the hematoma, which is less traumatic and has good effect, especially suitable for surgery in important functional areas of the brain, brain stem, deep brain tissue bleeding and other parts of the brain. The disadvantage is that there is no hemostatic effect and there is a possibility of rebleeding.
Drilling or cone cranial hematoma puncture: According to the cranial CT results, the maximum level of the hematoma is measured, and under the premise of avoiding important blood vessels and functional areas, the maximum level of the hematoma is taken as the closest distance to the center of the hematoma as the entry point of cranial puncture, and a drainage tube is placed by drilling or cone cranial method, after aspirating and decompressing part of the hematoma, a drainage tube is left in place to continuously drain the residual hematoma, and urokinase can be injected to accelerate hematoma dissolution. This method is less invasive and has good results when applied properly. The advantage is that it is simple and easy to perform, and can even be performed at the bedside, which is especially valuable in hospitals that do not have neurosurgical specialties; the disadvantage is that the positioning is not precise enough, and there is no hemostasis. The problem of inaccurate localization can be solved by determining the puncture site under CT localization.
Analysis and avoidance of recent postoperative rebleeding factors?
Postoperative blood pressure control is extremely important. Patients’ original basal blood pressure is high, plus the postoperative patients are more agitated, which makes the blood pressure rise and increases the pressure gradient between cerebral vessels and brain tissues, causing the original coagulated small vessels to rupture and bleed again. Therefore, postoperative blood pressure must be stabilized at 170-140 mmHg systolic pressure and 110-90 mmHg diastolic pressure, and blood pressure can be controlled by intravenous application of sodium nitroprusside, nitroglycerin, and uradil, etc. Sedative drugs are applied when patients are irritable.
Intraoperative blood pressure control under general anesthesia is low, and postoperative blood pressure rebound can easily induce bleeding. Therefore, it is important to elevate the blood pressure before cranial closure and observe whether hemostasis is reliable after reaching the daily basal pressure level, and close the cranium after complete hemostasis. If the daily basal pressure is not known, the systolic blood pressure should be raised to above 100 mmHg for observation.
Hypertension accompanied by other systemic diseases, such as disorders of coagulation mechanism, diabetes mellitus, atherosclerosis, etc., or plainly taking anticoagulant drugs or drugs affecting coagulation mechanism, are prone to postoperative rebleeding. Therefore, preoperative medical history should be carefully understood, and careful physical examination should be conducted to solve the problem in a targeted manner to reduce the chance of rebleeding.
Cerebral hemorrhage compresses the surrounding brain tissue ischemia and hypoxia, and the combined pulmonary infection has poor blood oxygen exchange capacity, which aggravates brain tissue edema and makes the normal function of cerebral vessels around the trauma destroyed and bleeds again. Therefore, postoperative ventilation should be improved and hypoxemia should be corrected to reduce the chance of secondary bleeding.
Injury of drainage tube causes rebleeding. Intraoperative placement of drainage tube is too deep, and the end of the tube pokes into the brain tissue outside the wall of the contralateral hematoma after midline repositioning, which can induce rebleeding. Therefore, a blunt-ended drainage tube with moderate diameter and hardness should be chosen and placed in the center of the hematoma cavity.
Treatment and guidance during recovery?
For patients who survive the surgery period, functional recovery becomes the primary issue. In addition to neurotrophic drugs, hyperbaric oxygen therapy is an effective method to eliminate brain edema and protect the normal function of brain cells, and should be applied as early as possible. Functional exercise should also be started early, usually after the removal of stitches, and gradually increase the intensity without overexertion. The recovery of language function and limb function are closely related to the good or bad functional exercise.
It is still advisable for patients to receive guidance from doctors after discharge, especially to insist on taking effective antihypertensive drugs to control blood pressure at the ideal level. Two years after surgery is a high-risk period for recurrence of bleeding, and most patients who recur are those who do not adhere to antihypertensive drugs. These patients can be referred to community hospitals or the corresponding hypertension control associations where available, which will be beneficial in reducing recurrence.