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微创钻孔引流与阿托伐他汀钙治疗慢性硬膜下血肿临床分析

作者 / Author:王衍廷 王小刚 王天助 黄建睿 刘 强 袁绍纪

摘要 / Abstract:

目的 探讨微创钻孔引流加阿托伐他汀钙治疗慢性硬膜下血肿的疗效。方法 对67例慢性硬膜下血肿的临床资料进行回顾性分析。结果 65例临床治愈,随访3~6个月,复发2例。结论 阿托伐他汀钙可以一定程度降低慢性硬膜下血肿手术后复发率;加速血肿吸收,减少住院时间。

关键词 / KeyWords:

慢性硬膜下血肿,微创钻孔引流,阿托伐他汀钙,颅内出血,复发
微创钻孔引流与阿托伐他汀钙治疗慢性硬膜下血肿临床分析
王衍廷  王小刚  王天助  黄建睿  刘  强  袁绍纪
中国人民解放军济南军区总医院神经外科,山东 济南 250031
作者简介:王衍廷,Email:awangyt__197657@126.com
通信作者:袁绍纪,Email:round90@163.com
 
摘要  目的  探讨微创钻孔引流加阿托伐他汀钙治疗慢性硬膜下血肿的疗效。方法  对67例慢性硬膜下血肿的临床资料进行回顾性分析。结果  65例临床治愈,随访3~6个月,复发2例。结论  阿托伐他汀钙可以一定程度降低慢性硬膜下血肿手术后复发率;加速血肿吸收,减少住院时间。
关键词】  慢性硬膜下血肿;微创钻孔引流;阿托伐他汀钙;颅内出血;复发
中图分类号】  R651.15    【文献标识码】  A    【文章编号】  1673-5110(2019)05-0479-08  DOI:10.12083/SYSJ.2019.05.065
 
Clinical analysis of minimally invasive drainage and atorvastatin calcium in the treatment of chronic subdural hematoma
WANG YantingWANG XiaogangWANG TianzhuHUANG JianruiLIU QiangYUAN Shaoji
Department of NeurosurgeryJinan military region General Hospital of the Chinese Peoples Liberation ArmyJinan 250031,China
Abstract】  Objective  To investigate the effect of minimally invasive drilling drainage combined with Atorvastatin calcium in the treatment of chronic subdural hematoma.Methods  The clinical data of 67 cases of chronic subdural hematoma were retrospectively analyzed.Results  65 cases were cured clinically,followed up for 3 to 6 months,and 2 cases recurred.Conclusion  Atorvastatin calcium can reduce the recurrence rate of chronic subdural hematoma after operation,accelerate the absorption of hematoma and reduce the number of hospital stays.
Key words】  Chronic subdural hematoma;Minimally invasive borehole drainage;Atorvastatin calcium;Intracranial bleeding;Recurrence  
 
        慢性硬膜下血肿(chronic subdural hematoma,CSDH)是指出颅内出血并聚集于硬脑膜下腔,在颅脑损伤3周以后出现的症状[1-2],占颅内血肿的10%[3-5],是神经外科的常见疾病,病因主要有外伤性和自发性。自发性主要来自慢性硬膜下积液的演变[6],常发生于额顶颞半球凸面,血肿量可达100~300 mL。该病多见于老年人和6个月以下的婴幼儿,常表现为头晕、头痛、肢体乏力、嗜睡、精神差等,临床表现无特异性[7-8]。临床治疗方式主要包括钻孔引流术、锥钻引流术、内窥镜辅助钻孔引流术、开颅血肿清除术等。与开颅血肿清除术相比,微创钻孔引流术具有更高的安全性和使用性[9],目前是慢性硬膜下血肿治疗的首选方法[10-14]。尽管其手术方法简便、术后并发症少,最常见的是再出血[15-19],但术后依然有2.3%~33.0%的复发率[20-24]。因此,有效降低术后复发率尤为重要。本研究选取中国人民解放军济南军区总医院神经外科2015-02—2017-03收治的67例慢性硬膜下血肿,采用微创钻孔引流加口服阿托伐他汀钙治疗,明显降低了复发率,加快血肿的吸收,减少了住院时间。
 
1  资料与方法
1.1  一般资料  本组67例患者中,男52例,女15例;年龄40~89岁,平均61.3岁;有明确外伤史50例;病程1~6个月,平均2.1个月;头痛、头晕44例,记忆力减退、理解力差、计算力差,反应迟钝35例,肢体不同程度偏瘫30例。全部病例经头颅CT平扫或MRI检查或增强扫描确诊,单侧血肿62例,双侧血肿5例。血肿量50~180 mL,平均82 mL;低密度10例,略高密度18例为混合密度,等密度30例,混杂密度9例;脑室受压45例,中线结构明显移位38例。
1.2  手术方法  术前根据头颅CT定位,选择血肿最大层面为钻孔层面,避开大血管及脑重要功能区的体表投影,能配合的患者局部浸润麻醉,病情不能配合的气管插管全身麻醉,以血肿最厚处中心作纵形直切口3~4 cm,全层切开头皮,乳突撑开器撑开切口暴露颅骨,动力装置钻孔1枚,止血满意,十字切开硬脑膜,立即电凝扩大硬膜切口,使用8~10号尿管置入硬膜下腔[25-26],用适量生理盐水反复多方向冲洗血肿腔,将陈旧性血块及积血冲洗出来,直至冲洗液清亮无血色,留置引流管,缝合切口。术后引流2~4 d后,复查头颅CT扫描,若血肿腔液体明显减少,颅内占位减小,可拔除引流管[27-28]
1.3  阿托伐他汀钙的应用  确诊为CSDH后即给予阿托伐他汀钙片(辉瑞制药有限公司,规格:20 mg)20 mg口服,qn;根据术后头颅CT,如患者达到治愈标准再服药1个月后停药观察,服药注意事项:定期复查肝肾功能,同时观察服药期间是否有肌肉酸痛、肌酸激酶升高等异常,若有及时停药。
 
2  结果
        术后3~5 d复查颅脑CT,见血肿引流比较彻底,脑组织大部分膨起复位,一般前额部膨起稍差,或残余少量积液或积气,拔出引流管,继续服用阿托伐他汀钙。术后随访3~6个月,复发率2例,其中1例中途因肝功能异常,停服药物;1例因年龄大,脑组织不能膨起,形成硬膜下积液。较原先单独微创钻孔引流明显降低了复发率,加速了血肿吸收,减少了并发症及住院时间。见图1~图3。术后4个月MRI显示,硬膜下血肿几乎全部吸收。见图4。  
王衍廷10.jpg 
王衍廷20.jpg
图1  患者术前CT及MRI表现  A:右侧额颞顶硬膜下血肿CT;B:MRI T1像;C:MRI T2像表现;D.MRI DWI像;E:MRI T1矢状位像
Figure 1  preoperative CT and MRI findings A:CT findings of right,B:MRI T1 image,C MRI T2 image,D:MRI DWI image,E:MRI T1 sagittal image
王衍廷30.jpg 
图2  患者术后CT及MRI 表现  A:术后1 d CT表现;B:术后3 d CT表现;C:术后10 d MRI T1像表现;D:MRI T2像;E:DWI像;F:MRI T1矢状位T1像
Figure 2  CT and MRI findings after surgery  A:CT findings 1 day after operation;B:CT findings 3 days after operation;C:The subdural hematoma was obviously reduced;D:MRI T2 image;E:DWI image;F:MRI T1 sagittal image
王衍廷40.jpg 
图3  术后2个月MRI表现可见硬膜下血肿明显减少,脑组织无明显受压表现  A:MRI T2像;B:MRI T1像;C:MRI DWI像;D:MRI T1矢状位像
Figure 3  MRI showed that the subdural hematoma was decreased significantly,and no obvious compression was found in brain tissue 2 months after operation  A:MRI T2 image;B:MRI T1 image;C:MRI DWI image;D:MRI T1 sagittal image
王衍廷50.jpg 
图4  术后4个月MRI表现,硬膜下血肿几乎全部吸收  A:MRI T2像;B:MRI T1像;C:MRI DWI像;D:MRI T1矢状位像
Figure 4  MRI subdural hematoma almost completely absorbed 4 months after operation  A:MRI T2 image;B:MRI T1 image;C:MRI DWI image;D:MRI T1 sagittal image
 
3  讨论
        慢性硬膜下血肿是一种炎症血管生成性疾病[29-31]。该病有内层和外层共两层完整的膜,外层包膜中含有大量的新生病理性血管,通过血管源源不断的向患者血肿腔内渗透血液[32-35]。研究表明,术后服用阿司匹林与硬膜下血肿的复发并无相关性[36-38]。目前,手术治疗是CSDH的常规治疗方法,钻孔引流术又是一线手术方案[39-51],因其操作简单,风险小,创伤小,费用较低等临床应用十分普遍。但近年来发现,CSDH术后常出现引流不彻底或残留,存留时间长复发率高[52-53]等。因此,根据CSDH的发病机制联合他汀类药物阿托伐他汀钙治疗可降低上述并发症的发生率。
        阿托伐他汀钙是抑制3-羟基-3-甲基戊二酰辅酶A还原酶,并通过降低低密度脂蛋白胆固醇水平起作用的他汀类药物[54]。阿托伐他汀已被证明不仅是局部炎症抑制剂,而且是血管生成成熟剂[55-57]。大鼠模型发现,低剂量阿托伐他汀可以增加血管生成素和血管内皮生长因子的表达,可能增强血管成熟[58]。研究发现,阿托伐他汀治疗慢性硬膜下血肿1~6个月,可加速血肿吸收,降低钻孔引流的风险[59-62]。研究[63]表明,阿托伐他汀可以降低慢性硬膜下血肿手术后复发的风险或延长复发的时间,可能会加速血肿吸收,降低复发率。
        微创钻孔引流加阿托伐他汀钙治疗慢性硬膜下血肿,可一定程度上提升临床治疗效果,降低慢性硬膜下血肿术后复发率,加速血肿吸收,减少住院时间。
 
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(收稿2018-05-13)
本文责编:张喜民
本文引用信息:王衍廷,王小刚,王天助,黄建睿,刘强,袁绍纪.微创钻孔引流与阿托伐他汀钙治疗慢性硬膜下血肿临床分析[J].中国实用神经疾病杂志,2019,22(5):479-486.DOI:10.12083/SYSJ.2019.05.065
Reference information:WANG Yanting,WANG Xiaogang,WANG Tianzhu,HUANG Jianrui,LIU Qiang,YUAN Shaoji.Clinical analysis of minimally invasive drainage and atorvastatin calcium in the treatment of chronic subdural hematoma[J].Chinese Journal of Practical Nervous Diseases,2019,22(5):479-486.DOI:10.12083/SYSJ.2019.05.065
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