自发性脑出血是一种毁灭性的疾病,占所有类型中风的10%至15%;但是,它与不成比例的更高的死亡率和残疾率有关。尽管这些患者的急性治疗取得了重大进展,理想的手术治疗仍有待确定。手术血肿引流术有许多理论上的好处,例如预防肿块效应和脑疝,颅内压降低,降低血液制品的兴奋性毒性和神经毒性。已经考虑了几种手术技术,比如开颅手术,去骨瓣减压术,神经内镜,微创置管后溶栓。开颅手术是这种临床情况下研究最多的方法,1960年代初的第一项随机对照试验。从那以后,已经发表了大量研究,其中包括两个大的,精心设计,动力很好,多中心,跨国公司,随机临床试验。这些研究,脑出血国际外科试验(STICH),与最佳医疗管理和必要时的延迟手术相比,STICHII对自发性幕上出血患者的早期手术清除脑实质内血肿没有临床益处。然而,STICH试验的结果可能无法推广,因为从医疗管理到手术组的患者交叉率很高。如果没有这些高交叉百分比,保守治疗的不良结局和死亡率会更高.此外,昏迷患者和有脑疝风险的患者不包括在内.在这些情况下,手术可以挽救生命,这阻止了这些患者参加此类试验。本文回顾了手术血肿清除术的临床证据,及其在降低自发性脑出血后死亡率和改善长期功能预后方面的作用。
Spontaneous intracerebral hemorrhage is a devastating disease, accounting for 10 to 15% of all types of stroke; however, it is associated with disproportionally higher rates of mortality and disability. Despite significant progress in the acute management of these patients, the ideal surgical management is still to be determined. Surgical hematoma drainage has many theoretical benefits, such as the prevention of mass effect and cerebral herniation, reduction in intracranial pressure, and the decrease of excitotoxicity and neurotoxicity of blood products.Several surgical techniques have been considered, such as open craniotomy, decompressive craniectomy, neuroendoscopy, and minimally invasive catheter evacuation followed by thrombolysis. Open craniotomy is the most studied approach in this clinical scenario, the first randomized controlled trial dating from the early 1960s. Since then, a large number of studies have been published, which included two large, well-designed, well-powered, multicenter, multinational, randomized clinical trials. These studies, The International Surgical Trial in Intracerebral Hemorrhage (
STICH), and the
STICH II have shown no clinical benefit for early surgical evacuation of intraparenchymal hematoma in patients with spontaneous supratentorial hemorrhage when compared with best medical management plus delayed surgery if necessary. However, the results of
STICH trials may not be generalizable, because of the high rates of patients\' crossover from medical management to the surgical group. Without these high crossover percentages, the rates of unfavorable outcome and death with conservative management would have been higher. Additionally, comatose patients and patients at risk of cerebral herniation were not included. In these cases, surgery may be lifesaving, which prevented those patients of being enrolled in such trials. This article reviews the clinical evidence of surgical hematoma evacuation, and its role to decrease mortality and improve long-term functional outcome after spontaneous intracerebral hemorrhage.