A.V. Efimov, V.V. Klyuchevsky, I.V. Filippov
Chair of Nervous Diseases with a Neurosurgery Course, Chair of Normal Physiology, Chair of Traumatology, Orthopedics and Field Surgery Yaroslavl, Russia
Spontaneous intracerebral hematomas (SICH) are the last stage of hypertension in the majority of cases. Conservative treatment of their course, complicated by penetration of blood into cerebral ventricles and especially hemotamponade, deprive patients of any chance of survival. Penetration of blood into the III, IV ventricles is accompanied by aspiration or reflex pneumonia, pathologic vascular responses, which have a considerable negative effect on prognosis. Thus, a proposition on early operations in such patients is valid. Removal of an intraventricular component of hematoma is a difficult and traumatic stage, conditioning high postoperative mortality and casting doubt on operation expediency, which becomes a disputable problem.
The goal of the present study was estimation of efficacy of SICH removal with subsequent local fibrinolysis in patients with penetration of blood into cerebral ventricles.
Materials and Methods. Patients with SICH were operated with the help of two methods. The first group underwent stereotactic intervention (9 cases); a conventional puncture method was used in the second group (10 cases). The OREOL manipulator (Russia) was used for stereotactic removal. Preoperative calculations were carried out with the help of the diagonal RCT localizer (Russia) and the Sytec SRi spiral computer tomograph (General Electric). Conventional puncture removal was performed after that. A hematoma volume, including its intraventricular component, was determined in compliance with a generally accepted formula. Removal was completed by external drainage with subsequent repeated local fibrinolysis of hematoma residues. Operations were performed 6-12 days after SICH onset. Hematomas were located in the right (14) and left (5) hemispheres. Total hemotamponade of ventricles was watched in 2 patients. A level of consciousness was estimated on the basis of Glasgow Coma Scale (the score of 8-10 in both groups). Indications for stereotactic aspiration were as follows: a stable state in a preoperative period, a SICH volume of less than 60 ml. Lateral hematomas of more than 60 ml and augmentation of brain compression were operated by using a conventional puncture method. A risk of anesthesiologic support was no less important in choosing a type of intervention. All the patients had bronchopneumonia and signs of occlusive hydrocephalus at the moment of operation. One female case was operated in an acute period of myocardial infarction. Intervention in one more female patient was performed against a background of a decompensated phase of diabetes mellitus, diagnosed for the first time.
Results. Subtotal removal of hematomas was made. Subsequent postoperative RCT control allowed to estimate a volume of residual hematoma. Streptokinase solution (15 000 U) was injected into hematoma residues, communicating with an intraventricular component, during 1-3 days. It did not cause development of repeated hemorrhage in any patient. Two cases of group I (23%) died during the first postoperative month; 7 cases survived; at present 3 of them can take routine care of themselves. As for group II, 3 cases (30%) died after operation; 7 patients survived. Today 3 of them are in a satisfactory state and 4 cases need care and help. Regression of focal symptoms took more time in patients with hematomas, localized on the right side.
Discussion. Use of streptokinase in a postoperative period results in quick elimination of blood from the ventricular system, including the III and IV ventricles, and prevents development of occlusive hydrocephalus. Stereotactic removal is more preferable in patients with small hematomas, breaking into ventricles. At the same time, stereotactic total removal of hematomas of more than 60 ml is problematic. As for our study, hematoma relapse was watched very soon after operation in 1 patient and subsequent craniotomy led to his death. Repeated SCIH developed in 2 operated cases of Group II in some hours; they became a cause of fatal outcomes. We want to emphasize usage simplicity, high reliability and precision of pointing of the OREL stereotactic manipulator, which can be used in urgent neurosurgery quite easily too.
Conventional puncture aspiration of SICH with external drainage and subsequent local fibrinolysis can be an alternative of a stereotactic method. Large hematomas of mixed localization, characterized by negative dynamics, are indications for its use.
Taking into account results of surgical treatment of patients with SICH, complicated by breaking of blood into cerebral ventricles, one can come to the following conclusion: use of a conventional puncture method of hematoma removal, combined with repeated local fibrinolysis is justified in the absence of endoscopic and stereotactic equipment. The results of these operations are promising.