With the sudden change of temperature at the junction of autumn and winter and the arrival of cold winter season, it is again the time of high incidence of hypertensive cerebral hemorrhage. With the increasing popularity of medical knowledge, many people have learned that patients with cerebral hemorrhage can be treated conservatively with drugs if the bleeding is small and they are conscious; however, if the bleeding is large and they are unconscious, surgery is needed as soon as possible to save their lives.
There are currently four types of surgical approaches summarized as follows.
(1) Open bone flap formation hematoma removal.
(2) Minimally invasive small bone window method or “Keyhole” surgical hematoma removal.
(3) Stereotactic puncture hematoma removal.
(4) Ventriculoperitoneal external drainage. When a doctor recommends surgery, most families are at a loss as to which surgical procedure to choose when they listen to the doctor’s explanation;
Let’s understand the principles of each surgical procedure!
(1) Open bone flap formation hematoma removal.
Surgical method: The physician selects a suitable scalp incision according to the location of the CT hematoma in the brain. Usually a “U” shaped incision (about 15-500px long) is used to cut the scalp, and then special instruments are used to saw open the skull to form a square bone flap, the size of the bone flap in 8 × 250px2, after opening the bone flap, the physician will be under the operating microscope, cut “like tofu After opening the bone flap, the surgeon will cut the “tofu-like” tender brain tissue about 25px under the operating microscope and slowly enter the hematoma cavity to remove the hematoma. Generally, the surgeon will decide whether to remove the bone flap depending on the degree of swelling of the brain tissue after the hematoma is removed.
The advantages of this procedure are.
(1) direct vision surgery under the microscope, good illumination of the operative field, clear display, and more complete hematoma removal;
(2) Intraoperative hemostasis is complete, and the chance of postoperative rebleeding is low;
③The intraoperative bone flap can be removed as appropriate, especially in patients with large bleeding volume (more than 60 ml of hemorrhage in the cerebral hemisphere), which may have severe cerebral edema after surgery, and good decompression effect;
③The timing of surgery is more flexible, and the surgery is usually performed as early as possible.
Disadvantages are.
①Higher requirements for the equipment of the operating room and the surgical skills of the operator, which are difficult to carry out in primary hospitals;
②The surgery itself is very traumatic and takes a long time, which makes it difficult for patients with important organ (heart, lung, kidney) insufficiency to tolerate the surgery. ③After the condition is stabilized, the skull defect repair needs to be performed again.
This type of surgery is suitable for patients with huge bleeding volume (60ml of bleeding in cerebral hemisphere and 20ml or more in cerebellar hemisphere), obvious occupying effect of intracranial hematoma, patients with severe coma and dilated pupils, who need to remove the hematoma as soon as possible to release the occupancy.
(2)Minimally invasive small bone window method or “Keyhole” surgical hematoma removal
Surgical method: According to the location of the CT hematoma in the brain, the physician selects a suitable scalp incision, usually a straight incision (about 6-200 px), and then drills a bone hole (about 25 px in diameter) in the skull with special instruments, and then expands it into a small bone window (about 75 px in diameter). Next, the skull is entered and the hematoma is removed under the microscope.
The advantages are.
①The operation time is shorter than the former, the operation is rapid, and the hematoma is more completely removed;
②The hemostasis is more complete;
(3) Because of the smaller bone window, it is not necessary to perform another skull defect repair.
Disadvantages are.
①requirement for operating room equipment and operator’s surgical skills are higher, and it is difficult to carry out in primary hospitals;
②If the patient’s preoperative condition is severe, with a large amount of cerebral hemorrhage (more than 60ml of hemispheric hemorrhage) and significant cerebral edema, the decompression effect is less obvious than the former due to the small bone window.
This type of surgery is suitable for patients with average bleeding volume (30-60 ml of cerebral hemisphere bleeding and 10-20 ml of cerebellar hemisphere bleeding) and patients in coma or shallow coma.
(3) Stereotactic puncture hematoma removal.
The surgeon will use a special stereotactic instrument or scalp marker to select the center of the hematoma as the target point under CT, then locate the scalp projection of the target point, make a small incision (2-75 px) in the scalp, drill a hole with a special fine-tipped drill, and place a “signature pencil” thick hose (material can be silicone) in the direction and distance of the preoperative design of the puncture. tube (silicone material!). The tube is made of silicone.
After successful puncture, the first aspiration of about 20-30 ml is appropriate, and the rest of the residual hematoma can be drained by injecting a drug (urokinase) into the hematoma cavity through an extracorporeal hose that can dissolve the stagnant blood, little by little, 24 hours after the operation, after reviewing the head CT.
The advantages are.
① Minimal damage to the patient;
②It can be applied to bleeding in various areas, especially deep brain bleeding, such as thalamic bleeding, brain parenchymal bleeding with ventricular bleeding, slow progressing brainstem bleeding, etc.
③The operation can be completed under local anesthesia, and the operation time is short (about 0.5-1 hour).
Main disadvantages.
①Intraoperative hemostasis cannot be stopped, and the damage to the patient is usually fatal once active bleeding occurs intraoperatively;
②The removal of the hematoma is not complete, and the presence of residual blood can still lead to more serious secondary damage, and rapid decompression is not possible in patients with large bleeding volumes.
③ Postoperatively, it is easy to cause intracranial infection and new intracranial hemorrhage because of the need to repeatedly administer drugs to the hematoma cavity several times to make the stasis dissolve.
This type of surgery is suitable for elderly patients with average bleeding (30-60 ml in the cerebral hemisphere and 10-20 ml in the cerebellar hemisphere), comatose or shallow coma state, and important organ insufficiency.
(4) Ventricular puncture external drainage.
Procedure: The surgeon will make an incision of about 50px after the hairline of the patient’s scalp and 62.5px next to the midline, drill a hole in the skull with a special thin-tipped drill, and then put a silicone drainage tube into the direction of the ipsilateral external auditory canal about 125px, and the outflow of bloody cerebrospinal pages will be visible to indicate successful puncture, and after fixing the drainage tube properly, continue to drain bloody cerebrospinal fluid about 100-150 ml, or serious ventricular blood accumulation, through the drainage tube to the intracerebroventricular stasis dissolution of drugs (urokinase), dissolve and gradually drain out, keep the drainage tube unobstructed, drainage after a week to remove the drainage tube.
It is mainly for patients with hypertensive cerebral hemorrhage breaking into the ventricular system and causing intraventricular hemorrhage, and is used as a complementary surgical treatment for cerebral hemorrhage.
In practice, experienced neurosurgeons will follow the principle of individualization and advise the patient’s family on which specific surgical procedure to use or the combination of several surgical procedures to make the procedure safer, less traumatic and with the best surgical results, based on many factors such as the patient’s age, organ function tolerance, the location of the cerebral hemorrhage, and the amount of bleeding.