高血圧性脳出血の外科:-基底核部出血脳室穿破型を中心に-

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The recent progress of the operative intervention for hypertensive intracerebral hemorrhage has proven a marked improvement both in mortality and morbidity. Upon our 5 years surgical experience of 123 consecutive cases of hypertensive intracerebral hemorrhage, the lobar type of putaminal hemorrhage and subcortical hemorrhage are of good indication for craniotomy as was reported by Moriyama et al. in 1974, however the hemorrhage ruptured into ventricle from either putaminal or thalamic still requires further discussion as for the indication and the operative procedure. The over mortality of 45 cases of putaminal-internal capsule-ventricle type hemorrhage in our series is 28.8% whereas the lobar type of the putaminal hemorrhage recorded 8.7%. The prognosis of the putaminal-ventricle type hemorrhage is apparently influenced by hematoma localization, lesion and site and the progress of hemorrhage velocity which need detail analysis by preopetative serial angiography and contrast-medium ventriculography. In some cases. wider front-temporal decompressive craniotomy together with continuous ventricular drainage is necessary for controlling the post-operative intra-ventricular pressure which occasionally reached unbelievable 600 mmH2O level sporadically. In addition the hematoma spreads into the ventricle extensively, the remainder of the hematoma causes diffuse cerebral expansion and the external decompression is of importance in such cases. Also the intermit-tent coagula irrigation with urokinase agent via poly-hole intraventricular tube is advisable in cases of persisting coagula mixed c s f producing hemorrhage via drainage. The operative mortality of the venticle-ruptured thalamic hemorrhage is 40%(4 out of 10) andmorbidity is also unfavorable such as 4 cases are bed-ridden, 1 is able to stand by parallel crutch and 1 is ambulatory with caine. The lesion caused by the thalamic hemorrhage is fatal in most cases and the direct approch to the lesion has additional damage to the thalamus apparently. Our policy for the ventricle-ruptured thalamic hemorrhage in acute stage is only drainage via ventricular tube and irrigation until the intraventricular pressure reaches 200mm H2O with clear c s f and additional ventricular peritonial shunt is added if necessary. In summary, the lobar type of putaminal hemorrhage not involved the internal capsule should be evaluated carefully and the conservative therapy is also purposeful if the patient's consciousness and motor weakness have progressive improvement in the early stage. The putaminal-internal capsule type and the subcortical type are the best operative indication and the prognosis is, the earlier the timimg the better the result. The ventricle-ruptured hemorrhage either putaminal or thalamic requires careful approach and the former needs extensive front-temporal craniotomy consisting of utmost removal of hematoma, external decompression and post-operative continuous ventricular drainage. However the latter has only the ventricular drainage indication and multi-drainage is sometimes advisable.
The Japanese Society on Surgery for Cerebral Strokeの論文

高血圧性脳出血の外科:-基底核部出血脳室穿破型を中心に-

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