Stereotactic intracranial hematoma evacuation

Cerebral hemorrhage caused by hypertension arteriosclerosis, the problem that has been debated for many years is the indications and contraindications for surgery, the timing and surgical methods of surgery. The mortality rate after deep coma intrathoracic hemorrhage or intracerebral hemorrhage can be as high as 60% to 80%. However, if these critically ill patients can perform early surgery, not only can the patient's life be saved, but also the brain function can be improved. There is no technical difficulty in clearing the hematoma by conventional craniotomy. However, due to the high risk of surgery, the patients of many patients do not have family members. Willing to undergo surgery, and many doctors believe that deep coma is a surgical contraindication. Over the years, people have tried to find a simple way to remove the hematoma without aggravating the condition, such as puncture blood or a similar method of fragmentation, but because of the short time after the onset of stroke, about 80% of the hematoma is It is rarely successful to use blood clots to puncture blood, so it is widely sought after to find a less traumatic surgery to remove brain hematoma. The development of CT scans has enabled neurosurgery to uncover the possibility of using stereotactic techniques to remove intracerebral hematoma. In 1978, Backlund and Vonholst proposed a newly designed stereotactic hematoma ejector and successfully performed hematoma evacuation for patients with cerebral hemorrhage. . Higgins (1980, 1982), Chen Xiguang et al. (1990), Zhang Yanqing et al. (1998) have also improved this method to make this technology widely used. Liu Zonghui et al (1999) reported the use of CT guided stereotactic removal of 208 cases of hypertensive intracerebral hematoma, the operative mortality rate fell to 8.7%. Treatment of diseases: hypertensive cerebral hemorrhage Indication 1. Hematoma in various parts of the cerebral hemisphere, hematoma in the cerebellum and brainstem are suitable for directional surgical removal. 2. This procedure is also feasible in elderly patients with intracerebral hematoma and critically ill patients with stable cardiopulmonary resuscitation. 3. This method can be used in the early stage of cerebral palsy to quickly remove the hematoma. Contraindications 1. Age is too large, each organ is depleted, or is already in the brain. 2. Family members or patients are unwilling to undergo surgery. 3. Heart and lung failure, may be breathing during the operation, heartbeat stop. Preoperative preparation 1. Rapid CT scan to determine the location, size, and extent of the intracranial hematoma, and calculate the amount of hematoma. 2. For patients with airway obstruction, tracheal intubation or tracheotomy can be performed first to improve respiratory function. 3. Prepare according to general craniotomy. Surgical procedure 1. Install the orientation frame Place the patient's head on the pillow holder and mark the sagittal midline and coronal suture with gentian violet. The two fixed earplugs on the orientation frame reach the patient's external auditory canal at the same distance, and the orientation instrument is fixed by one person to keep the frame horizontally and in the middle position to prevent deflection. Then, the four metal spikes are placed diagonally. Both sides of the forehead and occipital scalp. After partial infiltration anesthesia with 0.5% procaine solution, the spike was pierced into the scalp, deep into the periosteum, and then the spike was sent to the skull barrier with an electric drill, and the electric drill automatically stopped. Replace the metal nail into the hole of the barrier with a nylon tip or carbon fiber tip and tighten it with a spiral jacket. After confirming that the frame is in the correct position and firm, remove the earplug, and the sterile towel wraps the orienter frame to the CT room for preoperative positioning scan. 2. Brain CT scan The patient lies flat on the examination table and the headband frame is placed on the coupler at the end of the CT bed. The combiner has three magnetic caps that can be coupled to the frame to be firmly attached to ensure correct position and no movement during CT scanning. Patients with cerebral hemorrhage usually have a flat scan to see the location and size of the hematoma, without the need for enhanced scanning. One or two enlarged CT slices were washed out at the target level required for directional surgery. 3. Identify stereotactic surgical targets Place the required CT film on a special calculation disk, and select the target to discharge the hematoma. Generally, take 1/3 of the center point of the hematoma as the target point, and record the three-dimensional coordinate coefficients of X, Y and Z. 4. Calculation of hematoma volume The CT scan computer can directly measure the hemorrhage volume, that is, the area of the hematoma at each level × layer thickness, and then add the hematoma volume of each layer is the total amount of hematoma. It is also possible to convert the hematoma volume of the CT slice onto the X-ray film and convert it with a special calculation disk, but it is important that the slice of the CT slice must be parallel to the plane of the skull base line, that is, the CT scan and the stereotactic frame mark line. In the same plane, in order to get the accuracy factor. 5. Scalp incision and skull drilling The patient was placed in the supine position, and the stereotactic frame was placed on the pillow holder of the operating table. A 3 cm coronal suture was placed on both sides of the sagittal line to draw a cranial line, and a skull auger (diameter 4 mm) was drilled. The sharp needle pierces the dura mater, and a small (diameter 4mm) auger drills a bone hole on the opposite side of the operation for continuous drainage of the ventricle. 6. Install the stereotactic guide device According to the three-dimensional coefficient of the stereotactic target obtained, the Y, Z, and X coefficients are sequentially aligned, and the side ring rod and the curved bow are installed. Adjust the angle of the curved bow, point the main rod of the guide to the drilled part of the skull of the hematoma, and then send it to the fine puncture needle for pumping. If it is liquid hematoma, you can slowly draw 3/4 of the amount of hemorrhage, and replace the inner diameter of 2mm. After the silicone tube reaches the target, it is fixed, and the hematoma cavity is repeatedly washed with thrombin-containing saline until the liquid is clear. If the puncture proves that the hematoma is a clot, a hemostatic reducer with an outer diameter of 4 mm and a length of 17 mm is placed from the guide, and a trocar with a side hole at the tip is provided on the outside, and a screw shaft is arranged inside, and the trocar end is connected. The vacuum suction bottle and the screw shaft inside the sleeve can be used to crush the clot and suck it out. Higgin-modified ejector can also be used, that is, the side hole of the trocar is changed to the tip, the screw shaft is shortened by 1.5 mm, two tubes are placed inside the trocar, one screw shaft, one irrigation tube, and the rest are the same (Fig. 4.10) .6-1). During operation, the rotation speed of the screw shaft is controlled at 100 rpm, the two atmospheric pressures are attractive, and the hematoma discharge is controlled at 2 to 4 ml per minute. The hematoma is recovered into the suction bottle, and the scale on the bottle can be used to calculate the exclusion amount. The general exclusion amount should be 3 to 5 ml less than the estimated amount. After the hematoma is removed, it should be observed for 10 to 15 minutes. When there is no fresh bleeding, the hemorrhage can be removed and the drainage tube with cuff should be left. Then, a drainage tube was sent to the anterior horn of the lateral ventricle on the opposite side of the operation, and the cerebrospinal fluid was discharged and connected to the brain pressure monitor to observe and record the intracranial pressure. 7. Stitching The drainage tube was fixed with a suture, the scalp was sutured layer by layer, the stereotactic instrument frame was removed, and the operation was completed by aseptic dressing. complication Postoperative hemorrhage accounted for about 2% to 5%. Dynamic observation of CT scans. Once a new hematoma is found, hematoma should be removed again.