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      重癥高血壓腦出血患者手術(shù)時(shí)機(jī)選擇的實(shí)踐研究

      2019-05-24 14:24:32魏中興
      中外醫(yī)療 2019年6期
      關(guān)鍵詞:高血壓腦出血臨床療效

      魏中興

      [摘要] 目的 探討手術(shù)治療時(shí)機(jī)的選擇對(duì)于重癥高血壓腦出血病癥的臨床治療效果。方法 方便選取2016年1月—2018年1月間來(lái)院接受治療的高血壓腦出血患者作為研究對(duì)象,梳理分析病例資料,挑選出符合試驗(yàn)要求的60例納入試驗(yàn)研究序列,根據(jù)患者從發(fā)病至接受手術(shù)的時(shí)間間隔長(zhǎng)短進(jìn)行分組,將從發(fā)病至接受手術(shù)的時(shí)間間隔為6~24 h的患者分為早期組,共30例;將間隔時(shí)間小于6 h的患者作為超早期組,共30例。兩組受試個(gè)體均行去骨瓣減壓加血腫清除術(shù)治療,對(duì)比分析臨床療效的組間差異性。 結(jié)果 治療3周后,超早期組的治療總有效率高達(dá)96.67%,明顯高于早期組的73.33%(t=4.707,P<0.05);超早期組在接受為期1個(gè)月的治療后意識(shí)恢復(fù)率高達(dá)93.33%,明顯高于早期組的66.67%,超早期組致殘率為6.67%,明顯低于早期組的33.33%,組間差異有統(tǒng)計(jì)學(xué)意義(t=6.668,P<0.05);超早期組在進(jìn)行為期3個(gè)月的治療后,患者傷殘情況、運(yùn)動(dòng)功能及神經(jīng)功能缺損評(píng)分分別為(73.61±6.82)分、(68.89±11.96)分、(86.44±16.19)分,均明顯優(yōu)于早期組的(68.93±4.96)分、(62.93±9.87)分、(72.83±15.62)分,組間差異有統(tǒng)計(jì)學(xué)意義(t=3.040,2.105,3.314,P<0.05);在并發(fā)癥發(fā)生率方面,超早期組為16.67%,明顯低于早期組的43.33%,組間差異有統(tǒng)計(jì)學(xué)意義(t=5.078,P<0.05)。結(jié)論 超早期手術(shù)可有效提升高血壓腦出血患者的臨床治療效果,不僅有效改善了患者傷殘情況、運(yùn)動(dòng)功能及神經(jīng)功能缺損情況,而且對(duì)于并發(fā)癥也起到了顯著的控制作用,具有較好的臨床推廣應(yīng)用價(jià)值。

      [關(guān)鍵詞] 高血壓腦出血;超早期手術(shù);臨床療效

      [中圖分類(lèi)號(hào)] R5 [文獻(xiàn)標(biāo)識(shí)碼] A [文章編號(hào)] 1674-0742(2019)02(c)-0091-03

      [Abstract] Objective To explore the clinical treatment effect of the timing of surgical treatment for severe hypertensive cerebral hemorrhage. Methods Patients with hypertensive cerebral hemorrhage who were treated in the hospital from January 2016 to January 2018 were convenient selected as subjects for the study. The patient data were analyzed and selected, and 60 patients who met the test requirements were selected for inclusion in the trial study sequence. The time interval between the operation and the operation was divided into groups. The patients from the onset to the time of surgery were 6~24 h, and the patients were divided into the early group, a total of 30 cases. The patients with the interval of less than 6h were used as the ultra-early group, a total of 30 cases. All the subjects in the two groups underwent decompressive craniectomy plus hematoma evacuation, and the differences between the clinical effects were compared. Results After 3 weeks of treatment, the total effective rate of the ultra-early group was as high as 96.67%, which was significantly higher than that of the early group 73.33%(t=4.707, P<0.05). The ultra-early group received consciousness after 1 month of treatment. The recovery rate was as high as 93.33%, which was significantly higher than that of the early group (66.67%). The morbidity rate of the ultra-early group was 6.67%, which was significantly lower than that of the early group (33.33%). The difference between the groups was significant (t=6.668, P<0.05). In the early group, after 3 months of treatment, the patients' disability, motor function and neurological deficit scores were (73.61±6.82)points, (68.89±11.96)points, and (86.44±16.19)points, respectively better than the early group (68.93±4.96)points, (62.93±9.87)points, (72.83±15.62)points, the differences between the groups were significant (t=3.040, 2.105, 3.314, P<0.05); In terms of the incidence of symptoms, the ultra-early group was 16.67%, which was significantly lower than the 43.33% in the early group, and the difference between the groups was significant(t=5.078, P<0.05). Conclusion Ultra-early surgery can effectively improve the clinical treatment effect of patients with hypertensive intracerebral hemorrhage, not only effectively improve the patient's disability, motor function and neurological deficit, but also play a significant role in controlling the complications. The value of clinical promotion and application.

      [Key words] Hypertensive cerebral hemorrhage; Ultra-early surgery; Clinical efficacy

      高血壓腦出血是臨床較為常見(jiàn)的腦血管病癥,該病發(fā)病危急,若不能得到及時(shí)有效的治療,將危及患者生命[1]。有研究指出[2],高血壓是誘發(fā)腦出血的直接因素,臨床致殘率較高。目前臨床上多通過(guò)去骨瓣減壓加血腫清除術(shù)清除患者顱內(nèi)血腫,該種術(shù)式對(duì)于促進(jìn)患者神經(jīng)功能的恢復(fù)具有重要作用。近年來(lái),有學(xué)者指出手術(shù)時(shí)機(jī)的把握對(duì)于患者預(yù)后結(jié)局將產(chǎn)生重大影響,超早期手術(shù)對(duì)于恢復(fù)患者神經(jīng)功能具有積 [3]。該次研究方便選取2016年1月—2018年1月間的60例患者進(jìn)行研究,現(xiàn)報(bào)道如下。

      1 資料與方法

      1.1 一般資料

      方便選取來(lái)院接受治療的60例高血壓腦出血患者研究對(duì)象,隨機(jī)分為早期組、超早期組,均行去骨瓣減壓加血腫清除術(shù)治療。術(shù)前所有受試個(gè)體均經(jīng)倫理委員會(huì)批準(zhǔn),并征得家屬許可?;€資料組間差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。見(jiàn)表1。

      1.2 方法

      麻醉處理后均接受頭顱CT檢查,明確病灶部位,根據(jù)需去除骨瓣的大小進(jìn)行手術(shù)設(shè)計(jì),對(duì)切口部位、形狀進(jìn)行選擇并劃線標(biāo)記。對(duì)患者頭顱消毒,進(jìn)行全麻,沿標(biāo)記切開(kāi)頭皮,對(duì)顱骨進(jìn)行鉆孔,去除骨瓣,將穿刺針置入腦室進(jìn)行穿刺引導(dǎo),將引流管固定后對(duì)血腫進(jìn)行引流,血腫清除后通過(guò)顯微鏡檢查殘留情況,殘留物清除完畢后進(jìn)行止血處理,并用0.9%氯化鈉注射液對(duì)血腫部位進(jìn)行沖洗,引流后關(guān)閉顱骨[4]。

      1.3 觀察指標(biāo)

      術(shù)后神經(jīng)功能評(píng)分降幅高于90%,可視為完全恢復(fù),視為痊愈;得分降幅低于50%~90%,視為治療后有顯著進(jìn)步;評(píng)分降幅15%~50%,視為術(shù)后有進(jìn)步;神經(jīng)功能評(píng)分降幅低于15%,視為治療無(wú)效[5]?;颊咭庾R(shí)恢復(fù)的評(píng)價(jià)遵照GCS評(píng)分標(biāo)準(zhǔn),得分<8分視為處于昏迷狀態(tài),采用ESS積分法對(duì)患者的神經(jīng)功能缺損情況進(jìn)行評(píng)價(jià),傷殘情況評(píng)價(jià)采用Barthel指數(shù)法,總分為100分,<75分為傷殘,采用運(yùn)動(dòng)功能評(píng)分法(FMA)對(duì)運(yùn)動(dòng)功能進(jìn)行評(píng)價(jià),總分為100分,得分高視為運(yùn)動(dòng)功能好[6]。

      1.4 統(tǒng)計(jì)方法

      應(yīng)用SPSS 17.0統(tǒng)計(jì)學(xué)軟件數(shù)據(jù)處理,計(jì)量資料用(x±s)表示,行t檢驗(yàn),計(jì)數(shù)資料用[n(%)]表示,行χ2檢驗(yàn),P<0.05為差異有統(tǒng)計(jì)學(xué)意義。

      2 結(jié)果

      2.1 患者臨床療效比較

      在治療總有效率方面,經(jīng)過(guò)為期3周的治療后超早期組高達(dá)96.67% ,明顯高于早期組的73.33%(P<0.05),見(jiàn)表2。

      2.2 意識(shí)恢復(fù)及致殘率比較

      超早期組意識(shí)恢復(fù)率為93.33%,明顯高于早期組的33.33%(P<0.05),致殘率則明顯低于早期組的6.67%(P<0.05)。見(jiàn)表3。

      2.3 BI、FMA、ESS 評(píng)分組間比較

      治療后3個(gè)月,在BI、FMA及ESS評(píng)分方面,超早期組均高于早期組(P<0.05) 。見(jiàn)表4。

      2.4 并發(fā)癥發(fā)生情況

      在并發(fā)癥發(fā)生率方面,超早期組為16.67%,明顯低于早期組的43.33% (P<0.05)。見(jiàn)表5。

      3 討論

      高血壓患者往往在受到異常因素的影響下容易誘發(fā)腦出血,該病發(fā)病急切,一旦出現(xiàn)腦出血癥狀需要及時(shí)進(jìn)行救治,否則將給預(yù)后結(jié)局造成不利影響,臨床上具有較高的致殘率,甚至將危及患者生命[7-8]。目前臨床上在手術(shù)的時(shí)機(jī)選擇上卻存在較大的分歧,臨床認(rèn)為在患者發(fā)病后第一時(shí)間接受手術(shù)具有重要作用[9]。去骨瓣減壓治療可有效緩解顱內(nèi)壓力,對(duì)于改善顱內(nèi)水腫及神經(jīng)功能具有積極作用,逐步在腦血管病癥的治療中得到了應(yīng)用[10]。

      有研究指出,去骨瓣減壓加血腫清除術(shù)能夠減少血腫在顱內(nèi)的留存時(shí)間,對(duì)于緩解顱內(nèi)壓力,降低毒性物質(zhì)的產(chǎn)生具有積極意義。該次研究結(jié)果顯示,超早期組的治療總有效率高達(dá)96.67%,明顯高于早期組的73.33%(t=4.707,P<0.05),這與周?chē)?guó)林[8]的研究結(jié)果(超早期組的治療總有效率96.59%,早期組為73.40%)較為一致;超早期組的意識(shí)恢復(fù)率為93.33%,明顯高于早期組的66.67%,超早期組致殘率為6.67%,明顯低于早期組的33.33%,組間差異有統(tǒng)計(jì)學(xué)意義(t=6.668,P<0.05),這與劉宏浩[3]的研究結(jié)果(超早期組的意識(shí)恢復(fù)率、致殘率分別為93.41%、6.67%,早期組分別為66.53%、33.41%)較為一致。造成這種結(jié)果的原因可能是超早期手術(shù)縮短了血腫的存留時(shí)間,緩解了毒性物質(zhì)對(duì)腦神經(jīng)的損傷作用,縮短了患者意識(shí)恢復(fù)時(shí)間和并發(fā)癥發(fā)生率。而早期手術(shù)則由于血腫存留時(shí)間長(zhǎng),對(duì)腦組織造成了較大范圍的損傷。

      綜上所述,在手術(shù)的時(shí)機(jī)選擇方面,超早期手術(shù)可有效提升高血壓腦出血患者的臨床治療效果,促進(jìn)了患者病情轉(zhuǎn)歸,降低了并發(fā)癥發(fā)生率,具有較好的臨床推廣應(yīng)用價(jià)值。

      [參考文獻(xiàn)]

      [1] 張俊.高血壓腦出血患者不同手術(shù)時(shí)機(jī)治療與術(shù)后發(fā)生再出血及近期療效的關(guān)系研究[J].中華全科醫(yī)學(xué),2015(4):551-553.

      [2] 周長(zhǎng)元.不同手術(shù)時(shí)機(jī)治療高血壓腦出血與術(shù)后再出血相關(guān)性研究[J].河北醫(yī)學(xué),2015(7):1132-1134.

      [3] 劉宏浩.不同手術(shù)時(shí)機(jī)治療高血壓腦出血的對(duì)比分析研究[J]. 重慶醫(yī)學(xué),2016,45(22):2925-2927.

      [4] 呂釗.超早期手術(shù)結(jié)合增液承氣湯加減方治療高血壓腦出血臨床療效觀察[J].解放軍醫(yī)藥雜志,2017(6):78-82.

      [5] 褚光.超早期與早期小骨窗手術(shù)治療高血壓腦出血的臨床比較[J].中華全科醫(yī)學(xué),2016(5):735-736.

      [6] 胡振宇.老年高血壓腦出血患者超早期手術(shù)治療的臨床療效[J].醫(yī)學(xué)綜述,2017,23(5):1030-1033.

      [7] 劉清流.不同手術(shù)時(shí)機(jī)治療高血壓腦出血與術(shù)后再出血相關(guān)性分析[J].醫(yī)學(xué)理論與實(shí)踐,2017,30(21):3172-3173.

      [8] 周?chē)?guó)林.超早期手術(shù)與早期手術(shù)對(duì)高血壓腦出血患者的療效分析[J].中國(guó)實(shí)用神經(jīng)疾病雜志,2015,16(19):57-58.

      9] Noriyuki.Dysautoregulation in patients with hypertensive intracerebral hemorrhage. A SPECT study[J].Neurosurgical Review,2015,18(4):23-26.

      [10] Zhi Wang,Chao. Changes of TXA 2 and PGI 2 during postoperative hypertensive crisis in patients with hypert-ensive intracerebral hemorrhage[J].Journal of Huazh- ong University of Science and Technology[Medical Sciences],2016,28(1):52-58.

      (收稿日期:2018-11-23)

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