神经内镜下不同出血部位高血压脑出血血肿清除手术技巧探讨

Investigation on surgical techniques for hematoma evacuation in hypertensive cerebral hemorrhage at different bleeding sites under neuroendoscopy

摘要:

目的 探讨神经内镜下不同出血部位高血压脑出血（HCH）血肿清除手术技巧及其治疗效果。方法 选取2022年5月－2024年1月该院收治的HCH患者101例，根据CT结果，将患者按照脑出血部位分为脑叶出血组（n = 43）和基底节区出血组（n = 58）。该研究采用Pearson法，分析脑微循环指标与美国国立卫生研究院卒中量表（NIHSS）评分、简易智能精神状态检查量表（MMSE）评分和日常生活能力Barthel指数（BI）评分间的相关性；基于广义估计方程，分析神经内镜下血肿清除术对不同出血部位患者脑微循环指标的改善效果。基于双重差分方程模型，分析神经内镜下血肿清除术对不同出血部位患者NIHSS评分、MMSE评分和BI评分的改善效果，并将基线指标纳入模型作为控制变量。结果 基底节区出血组手术时间明显长于脑叶出血组，NIHSS评分、MMSE评分、BI评分、平均通过时间（MTT）、脑血流量（CBF）、脑血容量（CBV）和平均动脉压（MAP）治疗前后差值变化明显小于脑叶出血组，差异均有统计学意义（P < 0.05）；两组患者并发症发生率比较，差异无统计学意义（P > 0.05）；相关分析结果显示，MTT与NIHSS评分呈正相关，MTT与BI评分和MMSE评分呈负相关，CBF、CBV和MAP与NIHSS评分呈负相关，CBF、CBV和MAP与BI评分和MMSE评分呈正相关，差异均有统计学意义（P < 0.05）；广义估计方程分析结果显示，脑叶出血组MTT、CBF、CBV和MAP改善情况明显优于基底节区出血组，差异均有统计学意义（P < 0.05）；双重差分方程模型分析结果显示，年龄增大、MTT延长和发病到手术时间的延长对NIHSS评分产生正影响（B = 0.884、1.291和0.758，P < 0.05），对MMSE评分产生负影响（B = -1.014、-1.569和-0.821，P < 0.05）；MTT延长对BI评分产生负影响（B = -0.973，P < 0.05）；CBV、CBF和MAP的升高对NIHSS评分产生负影响（B = -0.841、-0.767和-1.213，P < 0.05），对MMSE评分和BI评分产生正影响（MMSE：B = 0.932、0.738和0.874；BI：B = 0.897、0.751和0.842，P < 0.05）。结论 神经内镜下血肿清除术通过调节HCH患者的MTT、CBF、CBV和MAP等指标，可改善HCH患者的NIHSS评分、MMSE评分和BI评分，且脑叶出血患者改善效果明显优于基底节区出血患者。

Abstract:

Objective To explore the surgical techniques and therapeutic effects of hematoma evacuation for hypertensive cerebral hemorrhage (HCH) with different bleeding sites under neuroendoscopy.Methods This study enrolled 101 patients with HCH treated in our hospital from May 2022 to January 2024. Based on CT imaging results, patients were divided into lobar cerebral hemorrhage group (n = 43) and basal ganglia hemorrhage group (n = 58). The Pearson was used to analyze the correlations between cerebral microcirculation indicators and the scores of national institutes of health stroke scale (NIHSS), mini mental state examination (MMSE), and the Barthel index (BI) of activities of daily living. The generalized estimating equation was employed to analyze the improvement effects of neuroendoscopic hematoma evacuation on cerebral microcirculation indicators in patients with different hemorrhage locations. A difference-in-differences equation model with full specifications was applied to analyze the improvement effects of neuroendoscopic hematoma evacuation on NIHSS score, MMSE score, and BI score in patients with different hemorrhage locations, incorporating baseline indicators as control variables.Results The operative time of basal ganglia hemorrhage group was significantly longer than those of lobar cerebral hemorrhage group, and the differences of NIHSS, MMSE, BI, mean transit time (MTT), cerebral blood flow (CBF), cerebral blood volume (CBV) and mean arterial pressure (MAP) before and after treatment were significantly smaller than those of lobar cerebral hemorrhage group, the differences were statistically significant (P < 0.05). There was no significant difference in the incidence of complications between the two groups (P > 0.05). The correlation analysis results showed that MTT was positively correlated with NIHSS, and negatively correlated with BI and MMSE; CBF, CBV and MAP were negatively correlated with NIHSS, but positively correlated with BI and MMSE, the differences were statistically significant (P < 0.05). The result of generalized estimating equation analysis showed that the improvement of MTT, CBF, CBV and MAP in patients with lobar cerebral hemorrhage group was better than those in patients with basal ganglia hemorrhage group, the differences were statistically significant (P < 0.05). The result of difference-in-differences equation model analysis showed that increase of age, prolongation of MTT and prolongation of the time from onset to operation had positive effects on NIHSS score (B = 0.884, 1.291, 0.758, P < 0.05), and had negative effects on MMSE score (B = -1.014, -1.569, -0.821, P < 0.05). The prolongation of MTT had a negative effect on BI score (B = -0.973, P < 0.05). The increase of CBV, CBF and MAP had a negative effect on NIHSS score (B = -0.841, -0.767, -1.213, P < 0.05), and had a positive effect on MMSE and BI score (MMSE: B = 0.932, 0.738, 0.874; BI: B = 0.897, 0.751, 0.842, P < 0.05).Conclusion Neuroendoscopic hematoma evacuation can improve the NIHSS score, MMSE score, BI score of patients with HCH by adjusting MTT, CBF, CBV and MAP, and the improvement effect of patients with lobar cerebral hemorrhage is significantly better than that of patients with basal ganglia hemorrhage.