高血圧性脳内出血における内視鏡下血腫吸引術急性期手術のポイント : 止血の重要性について  [in Japanese] Endoscopic Evacuation of Hypertensive Intracerebral Hemorrhage The Importance of Hemostasis in Ultra : early Surgery  [in Japanese]

高血圧性脳内出血に対する急性期手術は, 発症早期であるほど効果が高く, 多くの血腫を吸引除去し確実な止血を行うことがポイントである.そこで発症3時間以内の超急性期手術に適した手術である透過性外筒を用いた内視鏡下血腫吸引術を, 止血方法を中心に概説する.本手術は, (1)穿頭手術, (2)血腫腔内での広い視野の確保が可能, (3)血腫内または脳室内に透過性外筒を挿入した後はフリーハンドで手術を行うことにより三次元的な手術操作が可能, (4)電気凝固による確実な止血操作が可能, (5)全身麻酔導入や手術機器の準備に要する時間が短時間などの特徴を持つ.85例の脳内出血・脳室内出血に本手術を行い, 85例中24例では, 発症後3時間以内に手術施行した.その結果, 血腫吸引率は平均で96%であり, 明らかな術後出血はなかった.

Ultra-early surgical treatments are expected to be established, in which the associated brain injury is minimized and a maximal volume of hematoma is removed shortly after onset with secure hemostasis. We developed a transparent guiding sheath and other surgical instruments for endoscopic surgery, and we established a novel surgical procedure in the ultra-early stage using those instruments. This procedure has the following characteristics : (1) the capability of burr hole opening under local anesthesia, (2) a transparent sheath improves the surgical field visualization of the parenchyma and the hematoma, (3) free-hand surgery without fixing an endoscope and a sheath to a frame facilitates three-dimensional operation, (4) the capability of secure hemostasis by electric coagulation (When bleeding from a perforating artery occurs, a suction tube is placed at the bleeding point and hemostasis is achieved by electric coagulation), (5) easy preparation of relatively simple surgical instruments. We have performed this procedure on 85 patients with intracerebral or intraventricular hemorrhage. Among these 85 patients, 24 patients received our treatment in the ultra-early stage, or within 3 hours after onset. The mean duration of surgery was 63 minutes, the mean hematoma reduction rate was 96%, and no perioperative hemorrhage with deterioration of symptoms and/or signs occurred. Thus, we believe that endoscopic hematoma evacuation with our surgical procedure is a promising ultra-early-stage treatment for intracerebral hemorrhage, and that it may improve the long-term prognosis of patents with intracerebral hemorrhage.