Luzzi Sabino, Elia Angela, Del Maestro Mattia, Morotti Andrea, Elbabaa Samer K, Cavallini Anna, Galzio Renato
Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; PhD Course in Tissues and Organs Transplantation and Cellular Therapies, D.E.O.T. Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy.
Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Polo Didattico "CesareBrusotti", Pavia, Italy.
World Neurosurg. 2019 Apr;124:e769-e778. doi: 10.1016/j.wneu.2019.01.016. Epub 2019 Jan 22.
To delineate the most recommendable treatment of spontaneous intracerebral hemorrhages and the indication for surgery, its timing, and the best surgical technique to be adopted case by case.
Based on PubMed/MEDLINE, Embase, and the Cochrane Library databases, a systematic review of the literature was performed using as keywords the terms "spontaneous intracerebral hemorrhage," "surgical management," "medical management," "supratentorial," and "infratentorial." Because of the highest level of evidence, only randomized and nonrandomized clinical trials, meta-analyses, and comparative cohort studies reported within the last 12 years were selected. An updated and evidence-based treatment algorithm was reported also.
The search initially returned 255 articles. After application of the exclusion criteria, only 19 studies were selected. According to the site and volume of the hematoma, admission Glasgow Coma Scale (GCS) score, and progressive neurologic decline, specific subgroups were identified. Surgery must be considered in patients with an admission GCS score ranging between 5 and 12 and a hematoma volume >30 mL. The best time-window has been reported to be 7-24 hours after ictus. Endoscopic surgery is recommendable for patients with a supratentorial hematoma >60 mL and with a poor GCS score (4-8). Alternative techniques, such as minimally invasive puncture and thrombolysis, may be considered for deeper hematoma.
Careful selection of patients eligible for surgery is mandatory. The optimal timing falls into a time-window ranging between 7 and 24 hours after ictus. Minimal invasive techniques are valuable surgical options for patients in a poor GCS score or harboring large deep-seated hemorrhages.
明确自发性脑出血最值得推荐的治疗方法以及手术指征、时机，还有针对具体病例应采用的最佳手术技术。
基于PubMed/MEDLINE、Embase和Cochrane图书馆数据库，以“自发性脑出血”“手术治疗”“药物治疗”“幕上”和“幕下”为关键词进行文献系统综述。由于证据水平最高，仅选取过去12年内报道的随机和非随机临床试验、荟萃分析及比较队列研究。还报告了一种更新的、基于证据的治疗算法。
检索最初返回255篇文章。应用排除标准后，仅选取19项研究。根据血肿部位和体积、入院时格拉斯哥昏迷量表（GCS）评分以及神经功能进行性减退情况，确定了特定亚组。入院GCS评分在5至12分且血肿体积>30 mL的患者必须考虑手术。据报道，最佳时间窗为发病后7 - 24小时。幕上血肿>60 mL且GCS评分较差（4 - 8分）的患者推荐采用内镜手术。对于深部血肿，可考虑采用微创穿刺和溶栓等替代技术。
必须仔细挑选适合手术的患者。最佳时机为发病后7至24小时的时间窗。对于GCS评分较差或有大型深部出血的患者，微创技术是有价值的手术选择。
