Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, University College London, London, UK.
J Neurosurg. 2012 Jan;116(1):84-94. doi: 10.3171/2011.8.JNS101407. Epub 2011 Sep 9.
Hemorrhagic complications carry by far the highest risk of devastating neurological outcome in functional neurosurgery. Literature published over the past 10 years suggests that hemorrhage, although relatively rare, remains a significant problem. Estimating the true incidence of and risk factors for hemorrhage in functional neurosurgery is a challenging issue.
The authors analyzed the hemorrhage rate in a consecutive series of 214 patients undergoing image-guided deep brain stimulation (DBS) lead placement without microelectrode recording (MER) and with routine postoperative MR imaging lead verification. They also conducted a systematic review of the literature on stereotactic ablative surgery and DBS over a 10-year period to determine the incidence and risk factors for hemorrhage as a complication of functional neurosurgery.
The total incidence of hemorrhage in our series of image-guided DBS was 0.9%: asymptomatic in 0.5%, symptomatic in 0.5%, and causing permanent deficit in 0.0% of patients. Weighted means calculated from the literature review suggest that the overall incidence of hemorrhage in functional neurosurgery is 5.0%, with asymptomatic hemorrhage occurring in 1.9% of patients, symptomatic hemorrhage in 2.1% and hemorrhage resulting in permanent deficit or death in 1.1%. Hypertension and age were the most important patient-related factors associated with an increased risk of hemorrhage. Risk factors related to surgical technique included use of MER, number of MER penetrations, as well as sulcal or ventricular involvement by the trajectory. The incidence of hemorrhage in studies adopting an image-guided and image-verified approach without MER was significantly lower than that reported with other operative techniques (p < 0.001 for total number of hemorrhages, p < 0.001 for asymptomatic hemorrhage, p < 0.004 for symptomatic hemorrhage, and p = 0.001 for hemorrhage leading to permanent deficit; Fisher exact test).
Age and a history of hypertension are associated with an increased risk of hemorrhage in functional neurosurgery. Surgical factors that increase the risk of hemorrhage include the use of MER and sulcal or ventricular incursion. The meticulous use of neuroimaging-both in planning the trajectory and for target verification-can avoid all of these surgery-related risk factors and appears to carry a significantly lower risk of hemorrhage and associated permanent deficit.
在功能神经外科中，出血并发症带来的神经功能损伤风险最高。过去 10 年的文献表明，出血虽然相对罕见，但仍是一个严重的问题。评估功能神经外科中出血的真实发生率和风险因素是一个具有挑战性的问题。
作者分析了 214 例连续接受无微电极记录（MER）的影像引导下深部脑刺激（DBS）导丝置入术和常规术后磁共振成像（MR）导丝验证的患者的出血率。他们还对过去 10 年立体定向消融手术和 DBS 的文献进行了系统回顾，以确定出血作为功能神经外科并发症的发生率和风险因素。
在我们的影像引导 DBS 系列中，出血的总发生率为 0.9%：无症状为 0.5%，有症状为 0.5%，导致永久性损伤为 0.0%。从文献综述中计算的加权平均值表明，功能神经外科中出血的总发生率为 5.0%，无症状出血发生在 1.9%的患者中，有症状出血发生在 2.1%的患者中，出血导致永久性损伤或死亡发生在 1.1%的患者中。高血压和年龄是与出血风险增加最相关的患者因素。与手术技术相关的危险因素包括使用 MER、MER 穿透次数以及轨迹穿过脑沟或脑室。采用无 MER 的影像引导和影像验证方法的研究中，出血的发生率明显低于其他手术技术（总出血数：p < 0.001，无症状出血：p < 0.001，有症状出血：p < 0.004，导致永久性损伤的出血：p = 0.001；Fisher 确切检验）。
年龄和高血压病史与功能神经外科出血风险增加相关。增加出血风险的手术因素包括使用 MER 和脑沟或脑室侵犯。神经影像学的精细使用——无论是在规划轨迹还是进行目标验证方面——都可以避免所有这些与手术相关的风险因素，并且出血和相关的永久性损伤风险明显降低。
