本文選題：腦出血 + 微創(chuàng)術(shù)��； 參考：《華中科技大學(xué)》2015年博士論文

【摘要】：第一部分：穿刺準(zhǔn)確度對微創(chuàng)術(shù)治療自發(fā)性腦出血療效的影響 目的：介紹一種評估微創(chuàng)術(shù)穿刺準(zhǔn)確度的方法——相對偏離度(RE),評估其對血腫清除效果的影響,并比較徒手穿刺法和立體定向法定位準(zhǔn)確度的差異。 方法：回顧性分析我科電子資料庫中2012.7～2014.6接受微創(chuàng)術(shù)聯(lián)合重組組織型纖溶酶原激活劑(rt-PA)治療的自發(fā)性腦出血患者,納入其中應(yīng)用徒手穿刺法或立體定向法定位,單針穿刺,且并無再出血的患者。采用計算機輔助的容量分析方法計算ICH體積,利用頭顱CT平掃圖像,以引流管在軸位及冠狀位兩個平面上偏離血腫中心的比例的和,即RE,來評估穿刺準(zhǔn)確度。 結(jié)果：共納入80例患者,應(yīng)用多重回歸分析,僅有RE對血腫清除率有顯著影響(P0.001)。當(dāng)RE0.6時,剩余血腫量≤15m1的比例為45.0%,而RE0.6時則分別為81.7%。徒手穿刺組的RE為0.5±0.24(0.03-1.03),立體定向組的RE為0.284±0.17(0-0.66),差異顯著(P0.001)。前者的血腫清除率為69.34±14.4%,剩余血腫量為11.81±6.50ml,而后者的血腫清除率為71.2±14.5%,剩余血腫量為10.17±6.38ml,均無顯著差異(血腫清除率,P=0.584；剩余血腫量,P=0.288)。在徒手穿刺組,RE與血腫清除率顯著相關(guān)(rs=-0.551,P0.001),而立體定向組RE與血腫清除率無顯著相關(guān)性(rs=-0.004,P=0.983)。 結(jié)論：RE是評估穿刺準(zhǔn)確度簡便易行的方法。穿刺準(zhǔn)確度與血腫清除效果高度相關(guān),RE≤0.6是較為理想的穿刺準(zhǔn)確度。相比徒手穿刺法,立體定向法可有效提高穿刺的準(zhǔn)確,同時提高血腫清除效果的穩(wěn)定性。徒手穿刺也有較高的穿刺準(zhǔn)確度和血腫清除率,而且操作簡單,對于推廣微創(chuàng)術(shù)救治腦出血患者有重要的作用。 第二部分：微創(chuàng)術(shù)聯(lián)合重組組織型纖溶酶原激活劑治療自發(fā)性腦出血：劑量探討 目的：探討重組組織型纖溶酶原激活劑(rt-PA)在微創(chuàng)術(shù)(MIS)中用于治療腦出血(ICH)時,rt-PA劑量與血腫清除效果的關(guān)系。 方法：回顧性分析我科電子資料庫中2012.7～2014.12接受微創(chuàng)術(shù)聯(lián)合重組組織型纖溶酶原激活劑(rt-PA)治療的自發(fā)性腦出血患者,納入其中無再出血且單針穿刺的患者,采用計算機輔助的容量分析方法計算ICH體積,以每次治療后ICH體積的變化,即液化清除量,代表清除效果。應(yīng)用協(xié)方差分析單次用藥時,不同劑量rt-PA對液化清除量的影響。同時比較不同劑量rt-PA對再出血率的差異。 結(jié)果：共納入單針治療者126例,共進行液化193次,59.5%用藥1次,30.2%用藥2次,7.9%用藥3次,2.4%用藥4次。rt-PA單劑用量為0.54±0.30mg,范圍從0.1～2.0mg,其中主要的劑量方案為0.3mg(19.7%).0.5mg(51.3%)與1.0mg(19.1%),共占90.1%。液化前血腫量(P0.001)是影響首次液化清除量的主要因素,rt-PA劑量對清除量無顯著影響(P=0.123)。液化清除量均隨液化前血腫量的增大而增大,但血腫量≥30m1后,清除量增加幅度較小。三組劑量間第二次液化清除量亦無顯著差異(P=0.577)。用藥次數(shù)≥3次的患者,三組劑量間液化清除率隨液化次序遞增(除第4次液化)的變化趨勢無顯著差異(P=0.511)。共8例液化后再出血,不同劑量間液化后再出血率無顯著差異(P=0.400)。 結(jié)論：應(yīng)用微創(chuàng)術(shù)聯(lián)合rt-PA是清除ICH的有效治療手段,但至少在rt-PA0.3-1.Omg范圍內(nèi),藥物劑量與液化效果不存在顯著的量效關(guān)系。液化前血腫量是影響液化效果主要因素。 第三部分：自發(fā)性腦出血微創(chuàng)術(shù)后出血并發(fā)癥危險因素分析 目的：評估微創(chuàng)術(shù)治療自發(fā)性腦出血發(fā)生出血并發(fā)癥的風(fēng)險及安全性,探討出血并發(fā)癥發(fā)生的危險因素。 方法：回顧性分析我科電子資料庫中2012.7～2014.12接受微創(chuàng)術(shù)聯(lián)合重組組織型纖溶酶原激活劑(rt-PA)治療的自發(fā)性腦出血患者,記錄患者每天癥狀及頭顱CT上出血特征隨治療的變化,以再出血、穿刺損傷(穿刺道出血及蛛網(wǎng)膜下腔出血)發(fā)生率評估微創(chuàng)術(shù)的安全性并分析手術(shù)時機、抽吸術(shù)、rt-PA方案及穿刺損傷與再出血的關(guān)系,以重癥監(jiān)護病房(ICU)住院時間及起病30d死亡率判斷預(yù)后,并評估再出血及穿刺損傷對預(yù)后的影響。 結(jié)果：共納入182例患者,再出血發(fā)生率為8.7%,僅2例(1.1%)癥狀性再出血,共發(fā)生8次術(shù)后再出血,11次液化后再出血。穿刺損傷率為19.8%,包括28例穿刺道出血及17例蛛網(wǎng)膜下腔出血。穿刺損傷(P=0.001)、液化前調(diào)整穿刺針(P=0.030)增加再出血風(fēng)險。rt-PA應(yīng)用時機,非劑量,與液化后再出血相關(guān),發(fā)現(xiàn)穿刺損傷、抽吸術(shù)后及再出血后早期應(yīng)用rt-PA可導(dǎo)致再出血。再出血及穿刺損傷未增加ICU住院時間及30d死亡率。 結(jié)論：本研究發(fā)現(xiàn)微創(chuàng)術(shù)聯(lián)合rt-PA治療ICH有良好的安全性,再出血率,特別是癥狀性再出血率較低,穿刺損傷率亦較低。發(fā)現(xiàn)穿刺損傷、抽吸術(shù)后及再出血后穩(wěn)定至少12h再行后續(xù)液化治療,液化治療期問避免調(diào)整穿刺針?biāo)坪跤兄诮档驮俪鲅省?總結(jié)
[Abstract]:Part I : Effect of puncture accuracy on the efficacy of minimally invasive surgery in the treatment of spontaneous cerebral hemorrhage

Objective : To introduce a method _ relative deviation ( RE ) for evaluating the accuracy of puncture accuracy of minimally invasive procedure , to evaluate its effect on hematoma removal , and to compare the difference of accuracy of positioning accuracy with the method of manual puncture and stereotaxic method .

Methods : The patients with spontaneous cerebral hemorrhage treated with rt - PA were retrospectively analyzed in the electronic database of our department . The patients with spontaneous intracerebral hemorrhage treated with either hand puncture or stereotactic method were included . The ICH volume was calculated by computer - assisted volumetric analysis method . The CT plain scan was used to measure the accuracy of puncture by using the CT plain scan image and the ratio of the drainage tube to the center of the hematoma on both the axial and coronal planes .

Results : A total of 80 patients were enrolled and multiple regression analysis was applied . Only RE had a significant effect on the clearance of hematoma ( P 0.001 ) . When RE0.6 , the ratio of residual hematoma to 15ml was 45.0 % , while RE was 0.284 鹵 0.17 ( 0 - 0.66 ) , and the remaining hematoma volume was 11.81 鹵 6.50 ml , while the remaining hematoma was 10.17 鹵 6.38ml . There was no significant difference ( hematoma clearance , P = 0.584 ) .
Residual hematoma volume , P = 0.288 ) . There was no significant correlation between RE and hematoma clearance ( rs = - 0.551 , P0.001 ) , but there was no significant correlation between RE and hematoma clearance ( rs = - 0.004 , P = 0.983 ) .

Conclusion : RE is a simple and easy method to assess the accuracy of puncture . The accuracy of puncture is highly correlated with hematoma clearance effect . RE 鈮，

本文編號：2104901