内視鏡下血腫除去術における出血性合併症の検討と改善策

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  • Review and Prevention of Hemorrhagic Complications of Endoscopic Surgery for Intracerebral Hematomas

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Hemorrhagic complication is a major concern in performing endoscopic surgery for cerebral hemorrhage. Here, we summarize the recent improvements and review the procedural details and risks of endoscopic operation. At our institution, there were 12 cases (10.5%) with surgical complications among all cases of endoscopic surgery (N = 111). All complications were categorized into the following three groups: (1) difficulty in achieving robust hemostasis during surgery (n = 3), (2) rebleeding after surgery (n = 8), and (3) cerebral infarction after surgery at the ipsilateral side of the hemisphere (n = 1). After dividing the review period into an early period of 3 years (n = 48) and a late period of 3 years (n = 66), half of the complications were found to be related to problems in hemostasis in the early period, with the following suspected causes: undiscovered dural arteriovenous fistula, oral medication with an anticoagulant before the surgery, and rough handling of the apparatus including the transparent sheath and the metal suction during the operation. Therefore, we incorporated the following improvements in operational procedures preceding the remaining half of the periods: (1) adjusting the intensity of aspiration carefully so as not to injure the blood vessels; (2) avoiding removing a hardened hematoma that often has contact with the ruptured artery unless the hematoma cavity becomes near bloodless; (3) ensuring complete hemostasis before moving deeper into the hematoma cavity; (4) enlarging the tract leading to the hematoma by using a Nelaton catheter before inserting a sheath; (5) stuffing the hematoma cavity with oxidized cellulose just before removing the sheath; (6) mandatory infusion of fresh frozen plasma before surgery in patients taking an anticoagulant; and (7) mandatory application of general anesthesia to stabilize blood pressure and prevent accidental body movements. In the latter period, no more difficulties in hemostasis were encountered during the operation, whereas rebleeding after surgery became the only surgical complication. We compared the statistical importance of risk factors between cases with complication and those without complication, where only vascular anomaly, but not other factors, including anticoagulant medication, cerebral amyloid angiopathy (CAA), or lower platelet counts had a statistically significant role in the development of hemorrhagic complications. In the latter period, a higher incidence of CAA and anticoagulant medication were involved, which also suggests that the above-mentioned improvements might have had a major impact. Endoscopic surgery may become an established method in the treatment of cerebral hemorrhage by virtue of its inherent simplicity, low invasiveness, and effectiveness, for which minimizing surgical complications is important. In this light, we hope this review will prove valuable in the improvement of this surgery.

収録刊行物

  • 脳卒中の外科

    脳卒中の外科 43 (1), 39-44, 2015

    一般社団法人 日本脳卒中の外科学会

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