Wakai S, Kumakura N, Nagai M
Department of Neurosurgery, Dokkyo University School of Medicine, Tochigi, Japan.
J Neurosurg. 1992 Feb;76(2):231-8. doi: 10.3171/jns.1992.76.2.0231.
The authors operated consecutively on 50 patients with lobar intracerebral hemorrhage during a prospectively designed study period from January, 1986, to March, 1990. They investigated the correlations between the underlying causes and the clinicoradiographic features in 29 patients who showed no angiographic vascular abnormalities, in order to elucidate the operative indication for such cases. Patients with ruptured saccular aneurysm or trauma were not included in this study. There were 15 males and 14 females, ranging in age from 7 to 76 years (mean 52.4 years). Histological diagnoses of the surgical specimens were as follows: vascular malformation in nine cases (arteriovenous malformation (AVM) in six and cavernous malformation in three), microaneurysm in 11, cerebral amyloid angiopathy in six, and brain tumor in two; in the remaining case the cause was not verified histologically. The underlying cause was determined in 96.5% of cases. The mean patient age was lowest in the cavernous malformation group (27.0 years), followed by the AVM (45.8 years), microaneurysm (59.8 years), and cerebral amyloid angiopathy (70.0 years) groups. Four patients with vascular malformation (three AVM's and one cavernous malformation) had previous episodes of bleeding at the same site, whereas none of those with microaneurysms or cerebral amyloid angiopathy had such episodes. On computerized tomography (CT) scans, the round to oval hematoma was related to the presence of an AVM or cavernous malformation in contrast to microaneurysms and cerebral amyloid angiopathy. Upon infusion of contrast material, variable enhancement was seen in five (two AVM's and three cavernous malformations) of the nine vascular malformations while no enhancement was noted in any patient with microaneurysm or cerebral amyloid angiopathy at the acute stage. Subarachnoid extension of the hematoma was associated with cerebral amyloid angiopathy significantly more frequently than with AVM's (p less than 0.05) and microaneurysms (p less than 0.01). The results suggest that clinicoradiographic pictures in cases with negative angiography are quite different among the three major pathological categories; namely, vascular malformation (AVM and cavernous malformation), microaneurysm, and cerebral amyloid angiopathy. It is suggested that the underlying etiology of a given lobar intracerebral hemorrhage with negative angiography may be predicted by a combination of patient age, history of previous bleeding at the same site, hematoma shape, and subarachnoid extension of the hematoma on CT scans. Based upon these findings, the authors discuss operative indications for such cases.
在1986年1月至1990年3月这一前瞻性设计的研究期间，作者连续对50例脑叶脑出血患者进行了手术。他们调查了29例血管造影未显示血管异常患者的潜在病因与临床影像学特征之间的相关性，以阐明此类病例的手术指征。本研究未纳入囊状动脉瘤破裂或外伤患者。患者共29例，男性15例，女性14例，年龄7至76岁（平均52.4岁）。手术标本的组织学诊断如下：血管畸形9例（动静脉畸形6例，海绵状畸形3例），微动脉瘤11例，脑淀粉样血管病6例，脑肿瘤2例；其余1例的病因未通过组织学证实。96.5%的病例确定了潜在病因。海绵状畸形组患者的平均年龄最低（27.0岁），其次是动静脉畸形组（45.8岁）、微动脉瘤组（59.8岁）和脑淀粉样血管病组（70.0岁）。4例血管畸形患者（3例动静脉畸形和1例海绵状畸形）既往有同一部位出血史，而微动脉瘤或脑淀粉样血管病患者均无此类病史。在计算机断层扫描（CT）上，圆形至椭圆形血肿与动静脉畸形或海绵状畸形有关，与微动脉瘤和脑淀粉样血管病不同。注入造影剂后，9例血管畸形中有5例（2例动静脉畸形和3例海绵状畸形）出现不同程度的强化，而急性期微动脉瘤或脑淀粉样血管病患者均未出现强化。血肿蛛网膜下腔扩展在脑淀粉样血管病患者中比在动静脉畸形患者中更常见（p<0.05），比在微动脉瘤患者中更常见（p<0.01）。结果表明，血管造影阴性病例的临床影像学表现在三种主要病理类型中差异很大；即血管畸形（动静脉畸形和海绵状畸形）、微动脉瘤和脑淀粉样血管病。提示结合患者年龄、既往同一部位出血史、血肿形态以及CT扫描上血肿的蛛网膜下腔扩展情况，可预测血管造影阴性的脑叶脑出血的潜在病因。基于这些发现，作者讨论了此类病例的手术指征。
