Fewel Matthew E, Thompson B Gregory, Hoff Julian T
Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan 48109-0338, USA.
Neurosurg Focus. 2003 Oct 15;15(4):E1.
Spontaneous intracerebral hemorrhage (SICH) is a blood clot that arises in the brain parenchyma in the absence of trauma or surgery. This entity accounts for 10 to 15% of all strokes and is associated with a higher mortality rate than either ischemic stroke or subarachnoid hemorrhage. Common causes include hypertension, amyloid angiopathy, coagulopathy, vascular anomalies, tumors, and various drugs. Hypertension, however, remains the single greatest modifiable risk factor for SICH. Computerized tomography scanning is the initial diagnostic modality of choice in SICH, and angiography should be considered in all cases except those involving older patients with preexisting hypertension in thalamic, putaminal, or cerebellar hemorrhage. Medical management includes venous thrombosis prophylaxis, gastric cytoprotection, and aggressive rehabilitation. Anticonvulsant agents should be prescribed in supratentorial SICH, whereas the management of hypertension is controversial. To date, nine prospective randomized controlled studies have been conducted to compare surgical and medical management of SICH. Although definitive evidence favoring surgical intervention is lacking, there is good theoretical rationale for early surgical intervention. Surgery should be considered in patients with moderate to large lobar or basal ganglia hemorrhages and those suffering progressive neurological deterioration. Elderly patients in whom the Glasgow Coma Scale score is less than 5, those with brainstem hemorrhages, and those with small hemorrhages do not typically benefit from surgery. Patients with cerebellar hemorrhages larger than 3 cm, those with brainstem compression and hydrocephalus, or those exhibiting neurological deterioration should undergo surgical evacuation of the clot. It is hoped that the forthcoming results of the International Surgical Trial in IntraCerebral Hemorrhage will help formulate evidence-based recommendations regarding the role of surgery in SICH.
自发性脑出血（SICH）是指在无创伤或手术情况下，脑实质内形成的血凝块。该病症占所有中风病例的10%至15%，且与高于缺血性中风或蛛网膜下腔出血的死亡率相关。常见病因包括高血压、淀粉样血管病、凝血病、血管异常、肿瘤以及各种药物。然而，高血压仍是SICH唯一最大的可改变风险因素。计算机断层扫描是SICH首选的初始诊断方式，除涉及患有丘脑、壳核或小脑出血且有高血压病史的老年患者外，所有病例均应考虑进行血管造影。药物治疗包括预防静脉血栓形成、胃黏膜保护以及积极的康复治疗。幕上SICH患者应开具抗惊厥药物，而高血压的治疗存在争议。迄今为止，已开展了九项前瞻性随机对照研究，以比较SICH的手术治疗和药物治疗。尽管缺乏支持手术干预的确切证据，但早期手术干预有充分的理论依据。对于中度至大量的脑叶或基底节出血患者以及出现进行性神经功能恶化的患者，应考虑手术治疗。格拉斯哥昏迷量表评分低于5分的老年患者、脑干出血患者以及小量出血患者通常无法从手术中获益。小脑血肿大于3 cm的患者、出现脑干受压和脑积水的患者或出现神经功能恶化的患者应接受手术清除血凝块。希望即将公布的脑出血国际外科试验结果将有助于就手术在SICH中的作用制定基于证据的建议。
