RU2230497C2 - Method for removing intracerebral hematomas of nontraumatic origin - Google Patents

Abstract

FIELD: medicine, neurosurgery.

SUBSTANCE: one should carry out encephalotomy of 2.0 cm size to penetrate hematoma's cavity. Liquid part of blood should be removed along with centrally located clots, then come unfixed parietal blood clots. Then one should fenestrate the wall of lateral ventricle of 7-9 mm length. Drainage should be applied into hematoma's bottom, where during 2-3 d the rest parietally located blood clots are lysed and completely washed out due to the flow of cerebrospinal liquid. Encephalotomy is conducted in silent cerebral area. In postoperative period it is necessary to perform the withdrawal of 200-300 ml liquor/d to normalize intracranial pressure and for sanitation of cerebrospinal liquid. The method enables to decrease traumaticity level and the number of postoperational complications.

EFFECT: higher efficiency.

2 cl, 2 dwg, 1 ex

Description

The invention relates to medicine, namely to neurosurgery, and can be used to improve the clinical results of surgical treatment of patients with intracerebral hematomas of non-traumatic origin of hemispheric localization.

A surgical method is known for the treatment of intracerebral hematomas of hemispheric localization, consisting in an open craniotomy with a wide dissection of the brain substance and subsequent removal of the intracerebral hematoma (Saribekyan A.S., Ponomarev V.A., Nikolaev A.G., Sharifurin R.A. // Tactics surgical treatment of patients with hypertensive intracerebral hematomas / 1st Congress of Russian Neurosurgeons: Abstracts - Ekaterinburg. - 1995. - P.272-273).

A significant disadvantage of this method is that this method of removing the hematoma is traumatic, often accompanied by blood loss, prolonged anesthesia, which adversely affects the further course of the disease in elderly patients, as a rule, having a concomitant pathology. The approach and removal of extensive and deep intracerebral hematomas with this method is always accompanied by significant brain trauma and leads to gross neurological symptoms, since it is necessary to dissect the brain over a large length in functionally important areas of the brain. In addition, a straightforward visual review does not always allow you to see and completely remove not all blood clots from the hematoma cavity.

There is a known method of removing intracerebral hematoma using endoscopic techniques, allowing through a small craniotomy access to examine the hematoma cavity and remove its contents (Danchin A.G. // Application of endoscopic technique at some stages of the removal of intracerebral hematomas caused by arterial hypertension, limited craniotomy access. / Materials VI international conference Surgical hepatol. CIS countries / Actual problems surgeon hepatol. - Kiev. - 1998. - S.365-366).

The disadvantage of this method is that when intracerebral hematomas are removed, access is often provided through areas of the brain that are functionally important (motor zones of the cerebral cortex), which in the postoperative period, as a rule, leads to a deepening of focal neurological symptoms. Using this method does not guarantee the complete removal of blood clots, especially those located near the wall, not visible against the background of hemorrhagically impregnated brain tissue. This method does not involve drainage of the hematoma cavity. But not removed blood clots in the hematoma cavity contribute to the long-term maintenance of the volume of this cavity, which adversely affects the pathways of the white matter of the brain and prevents the regression of focal neurological symptoms.

Closest to the claimed is the surgical access described by A. Golovko. and Lyubishchev N.S. (Comparative analysis of endoscopic removal of intracerebral hematomas in hemorrhagic strokes // Materials of the VI international symposium. Modern minimally invasive technologies. - St. Petersburg. - 2001. - P.138). The author uses a milling hole as a surgical access through which the brain cannula "blindly" punctures and aspirates the liquid part of the hematoma. Then, after dissecting the brain, a rigid diagnostic endoscope was inserted through the brain into the hematoma cavity, and the surgical intervention was carried out with a vacuum aspirator and micro-instruments introduced axially to an endoscope immersed in the cavity formed.

This method is quite traumatic: firstly, you must first puncture the hematoma cavity with a thick cannula, which is not always the first time. Secondly, a diagnostic rather than a manipulation endoscope is immersed in the cavity and the removal of the hematoma occurs with instruments inserted not inside, but outside the endoscope, which also leads to additional brain injury. In addition, the initial stage of the operation, performed “blindly”, can lead to damage to the cerebral vessels, increased cerebral edema and deepening of focal and cerebral symptoms. According to the authors themselves, this method does not give a good visualization of the deep structures of the brain due to the decay of swollen brain tissue and parietal bundles of blood, therefore, the radical removal of hemispheric intracerebral hemorrhages is only 60-90%.

In addition to all of the above, this method does not involve drainage of the hematoma cavity. The lack of a full outflow from the hematoma cavity can lead not only to the occurrence of repeated hemorrhage, but also to a prolonged lysis of the remaining blood clots and the maintenance of the formed intracerebral cavity, which always adversely affects the regression of focal symptoms and worsens the clinical results of treatment.

The objective of the proposed method is the radical removal of intracerebral hematoma with minimal brain trauma due to the use of endovideocontrol, opening the walls of the lateral ventricle, draining the hematoma cavity and washing the parietal blood bundles with cerebrospinal fluid flow.

The solution of this problem allows you to achieve a positive therapeutic effect - to save the patient’s life, reduce his stay in bed and significantly improve the postoperative results of treatment of this group of patients.

The problem is solved due to the fact that they carry out an encephalotomy of 2.0 cm in size and penetrate the hematoma cavity, remove the liquid part of the blood and centrally located convolutions, then unfixed parietal blood clots, after which the wall of the lateral ventricle 7-9 mm long is fenestrated in the bed hematomas lay a drainage, according to which within two to three days a flow of cerebrospinal fluid is lysed and completely washed off the parietally located blood clots. Encephalotomy is performed in the “silent” area of the brain. In the postoperative period, 250-300 ml of cerebrospinal fluid are excreted per day to normalize intracranial pressure, rehabilitation of cerebrospinal fluid.

The method is as follows.

Upon admission of the patient with suspected intracerebral hematoma, a thorough clinical and tomographic examination was carried out and surgical confirmation upon diagnosis.

For this, after minimal trepanation and dissection of the dura mater in the least physiologically significant (“mute”) zone of the brain, a 2.0 cm long section of the cortex was dissected. With minimal retraction, the brain matter was moved apart with spatulas fixed by spring retractors and penetrated into the hematoma cavity. After removal of liquid blood and repeated washing, sufficient space was created for the introduction of a hard diagnostic endoscope into the cavity. Further removal of the intracerebral hematoma was carried out under endovideo control with micro-instruments (vacuum aspirator, loop, konhotom) coaxially with the direction of movement of the endoscope. Endovideocontrol makes it possible to conduct a detailed and sequential visual inspection of the cavity and remove centrally located blood clots. Then the hematoma cavity was once again well washed from the blood and the walls of the hematoma cavity were visualized with an endoscope. As a rule, the brain tissue over the entire area was imbibed with blood and we removed only the parietally located unfixed blood clots. Tightly fixed parietal bundles of blood were left because of the risk of rebleeding.

At the last stage of the operation, after careful hemostasis, the wall of the lateral ventricle was perforated for 7–9 mm in order for the cerebrospinal fluid to freely drain from the ventricle and wash the left parietal blood clots. After ascertaining the flow of cerebrospinal fluid, a silicone drainage tube 3-4 mm in diameter was inserted into the hematoma cavity for 2-3 days. This ended the surgery. A bone flap was placed in place, layered stitches were placed on the wound.

In the postoperative period, dosed evacuation of cerebrospinal fluid was performed through drainage for 2–3 days after the operation. Withdrawal of 250-300 ml of cerebrospinal fluid per day led to normalization of intracranial pressure, rehabilitation of cerebrospinal fluid, complete washing off of parietal bundles of blood and restoration of normal cerebrospinal fluid flow. Drainage from the ventricular cavity was removed as the cerebrospinal fluid was rehabilitated for 2-3 days.

Concrete example

Patient K., born in 1966, and / b 7337 was admitted to the neurosurgery department of the State Clinical Hospital of the City Clinical Hospital in Barnaul with a diagnosis of Stage II hypertension. Acute cerebrovascular accident as a hemorrhagic stroke with the formation of intracerebral hematoma in the left parietal-temporal region.

From the anamnesis it was found that for 7 years he suffers from hypertension. Discovered at home in an unconscious state. Delivered to the nerve compartment of the KKB with a help machine. Pulse 84 per minute. Blood pressure 150/90 mm RT. Art. There is no speech contact, does not respond to pain. Spontaneous motor activity in the left limbs, right hemiplegia.

For diagnostic purposes, CG and MRI of the brain were performed. Intracerebral extensive hematoma 8 × 4 × 3 cm in size, deep localization in the left temporal-parietal region, with a density of 69 units was revealed. (figure 1).

After 34 hours from the time of the disease, an operation was performed. Operational access to the hematoma was carried out as follows. Under endotracheal anesthesia with controlled hypotension, a free bone flap with a diameter of 4 cm was cut to the left in the posterior parietal region. At the border of the parietal and occipital lobes in the functionally insignificant area of the brain, the cortex was dissected for 2.0 cm. The brain substance was diluted with spatulas inserted into the hematoma cavity which are fixed by spring retractors. A 25 ml liquid portion was removed from the hematoma cavity using a vacuum aspirator. The resulting cavity is thoroughly washed with saline and a hard diagnostic endoscope is immersed in it. Coaxially injected with a vacuum aspirator. Under video control, centrally located blood convolutions (V = 50 ml) were removed with a vacuum aspirator. Then repeatedly repeatedly washed out the hematoma cavity with saline. A thoroughly conducted endovideocontrol showed that the walls of the brain throughout the cavity are imbibed with blood and many small parietal bundles of blood remain in them. Only those parietal convolutions that were easily aspirated (V = 5 ml) were removed. Tightly fixed clots were not removed due to the high probability of rebleeding. The total volume of the removed hematoma was 80 ml. After the removal of blood, the hematoma cavity “in the eyes” significantly decreased in volume, the brain slightly sunken and pulsed well. A thorough hemostasis was carried out in the resulting brain cavity.

At the last stage of the operation, the posterior horn of the lateral ventricle was opened for 7-8 mm. After ascertaining the flow of cerebrospinal fluid into the hematoma cavity, the operation ended with the installation of silicone drainage 3 mm in diameter. The dura mater is sutured tightly, the bone flap is in place, soft tissues are sutured in layers.

The condition of the patient after surgery has improved significantly. He was awake. In neurological status, gross right-sided hemiparesis was noted. Through a selikon catheter, up to 300 ml of cerebrospinal fluid separated per day. On the third day after complete rehabilitation of the cerebrospinal fluid, the drainage was removed.

The patient was in the department for 22 days, then was transferred to the neurological department for further rehabilitation. He moved with outside help, since rather rude, but gradually regressing hemiparesis and the phenomena of partial motor aphasia remained.

On the control computer tomograms performed 3 weeks after the operation, there is no data for the hematoma (figure 2). The lateral ventricles are slightly enlarged, located in the midline. To the left, there is a paraventricular atrophic cavity 3 × 2 × 1 cm in size, filled with cerebrospinal fluid and communicating with the lateral ventricle.

4 months after the operation, moderate-right hemiparesis, minor motor aphasia symptoms, persist. There are no violations of the higher nervous activity.

Thus, the removal of intracerebral hematoma was carried out by microsurgical access through functionally insignificant ("dumb") parts of the brain due to the use of endovideo technology. The use of endovideocontrol and the method we developed for removing intracerebral hematoma allowed us to completely remove blood from the hematoma cavity, not to deepen neurological symptoms and to get a good clinical result.

Claims (3)

1. A method for removing intracerebral hematomas of non-traumatic origin by applying craniotomy and using endovideo equipment, characterized in that they carry out an encephalotomy of 2.0 cm in size and penetrate the hematoma cavity, remove the liquid part of the blood and centrally located convolutions, then unfixed parietal blood clots, after which it is fenestrated the wall of the lateral ventricle is 7-9 mm long; a drainage is placed in the hematoma bed, according to which, within two to three days, the cerebrospinal fluid is lysed and completely blurs out the left Parietal located blood clots. 2. The method according to claim 1, characterized in that the encephalotomy is carried out in the "silent" area of the brain. 3. The method according to claim 1, characterized in that in the postoperative period, 250-300 ml of cerebrospinal fluid are excreted per day to normalize intracranial pressure, rehabilitation of the cerebrospinal fluid.

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