Du Bo, Xu Jianzhong, Hu Jintao, Zhong Xianliang, Liang Jian, Lei Pengfei, Wang Hao, Li Weichun, Peng Yuping, Shan Aijun, Zhang Yujuan
Department of Emergency, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China.
Department of Pathology, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China.
Front Neurol. 2020 Jan 17;10:1408. doi: 10.3389/fneur.2019.01408. eCollection 2019.
The surgical technique, safety, efficacy, and clinical application value of the intra-neuroendoscopic technique (INET) for the treatment of subacute-chronic and chronic septal subdural hematoma was investigated based on the structure and pathological features of the hematoma wall, and the critical factors of hematoma growth and recurrence were determined, in order to provide reference for clinical drug treatment. This was non-randomized concurrent control study. A total of 94 patients who met the inclusion criteria were recruited between May 2015 and February 2019 and were divided into the INET treatment group (INET group, 45 cases) and the burr hole drainage (BHD) treatment group (control group, 49 cases). The hematoma fluid components and the morphological structure and pathological characteristics of the hematoma wall were analyzed, and the surgical duration, subdural drainage tube (SDT) placement duration, intracranial infection rate, Bender grade at the 1 month post-operative follow-up and hematoma recurrence rate within the 6 months of post-operative follow-up were compared between the two groups. A multiple logistic regression model was established to analyze the risk factors associated with recurrence within 6 months. Intraoperative endoscopy showed that the adhesion bands that formed early in the hematoma cavity were strip-like and that those that formed late were lock-column-like. The hematoma cavity was divided into different-sized chambers with by these strips/columns. Pathological sections of cyst wall reveled angiogenesis inside the cyst and mucus-like changes, rupture and hemorrhage in the vascular wall. Obvious inflammatory cell infiltration and fibrous connective tissue hyperplasia were observed in the cyst wall. The osmotic pressure of the hematoma fluid was not significantly different from that of the peripheral venous blood [(296.7 ± 10.3) mOsm/kg vs. (291.5 ± 12.4) mOsm/kg, = 0.68]. However, the D-dimer contents which reflect the severity of fibrinolysis in the hematoma and the proinflammatory cytokine interleukin 6 (IL-6) were significantly higher in the hematoma fluid than in the peripheral venous blood. The surgery duration for the INET group was significantly longer than that for the control group [(60.4 ± 10.6) min vs. (44.1 ± 9.8) min, = 0.00], but both the hematoma recurrence rate within 6 months of post-operative follow-up (4.4 vs. 24.5%, = 0.00) and the SDT placement duration [(2.1 ± 0.6) d vs. (3.9 ± 0.7) d, = 0.00] for the INET group were both lower than those for the control group. The intracranial infection rate did not differ significantly between the two groups (4.4 vs. 10.2%, = 0.50). The overall effective rate of the Bender grade at 1 month of follow-up did not differ significantly between the two groups (95.6 vs. 87.8%, = 0.32), but the proportion of patients who recovered to Bender grade 0 with no symptoms was significantly higher in the INET group than in the control group (86.7 vs. 67.3%, = 0.03). Multiple logistic regression analysis showed that INET surgery [odds ratio (OR) 3.71, 95% confidence interval (CI) 1.31-9.62, = 0.02], age of 65 years or younger (OR 1.51, 95% CI 1.05-2.87, = 0.03) and unilateral subdural hematoma (OR 1.76, 95% CI 1.05-3.41, = 0.02) were independent factors that reduced the post-operative recurrence rate. The INET surgical plan based on the structure and pathological features of the subacute-chronic and chronic subdural hematoma wall can reduce the recurrence rate and improve the clinical prognosis. ClinicalTrials.gov, NCT02515903. Registered 5 August, 2015.
基于血肿壁的结构和病理特征，研究神经内镜技术（INET）治疗亚急性 - 慢性和慢性硬膜下血肿的手术技术、安全性、有效性及临床应用价值，确定血肿生长和复发的关键因素，为临床药物治疗提供参考。这是一项非随机同期对照研究。2015年5月至2019年2月共招募94例符合纳入标准的患者，分为INET治疗组（INET组，45例）和钻孔引流（BHD）治疗组（对照组，49例）。分析血肿液成分以及血肿壁的形态结构和病理特征，比较两组的手术时长、硬膜下引流管（SDT）放置时长、颅内感染率、术后1个月随访时的Bender分级及术后6个月随访内的血肿复发率。建立多元逻辑回归模型分析与6个月内复发相关的危险因素。术中内镜显示，血肿腔内早期形成的粘连带呈条状，晚期形成的呈锁柱状。这些条带/柱状结构将血肿腔分隔成不同大小的腔室。囊肿壁病理切片显示囊肿内有血管生成及黏液样改变，血管壁破裂出血。囊肿壁可见明显的炎性细胞浸润和纤维结缔组织增生。血肿液的渗透压与外周静脉血无显著差异[（296.7±10.3）mOsm/kg vs.（291.5±12.4）mOsm/kg，P = 0.68]。然而，反映血肿内纤溶程度的D - 二聚体含量及促炎细胞因子白细胞介素6（IL - 6）在血肿液中显著高于外周静脉血。INET组的手术时长显著长于对照组[（60.4±10.6）分钟 vs.（44.1±9.8）分钟，P = 0.00]，但INET组术后6个月随访内的血肿复发率（4.4% vs. 2（此处原文有误，应为24.5%），P = 0.00）及SDT放置时长[（2.1±0.6）天 vs.（3.9±0.7）天，P = 0.00]均低于对照组。两组颅内感染率无显著差异（4.4% vs. 10.2%，P = 0.50）。术后1个月随访时Bender分级的总体有效率两组无显著差异（95.6% vs. 87.8%，P = 0.32），但INET组恢复至无症状的Bender 0级患者比例显著高于对照组（86.7% vs. 67.3%，P = 0.03）。多元逻辑回归分析显示，INET手术[比值比（OR）3.71，95%置信区间（CI）1.31 - 9.62，P = 0.02]、65岁及以下年龄（OR 1.51，95% CI 1.05 - 2.87，P = 0.03）和单侧硬膜下血肿（OR 1.76，95% CI 1.05 - 3.41，P = 0.02）是降低术后复发率的独立因素。基于亚急性 - 慢性和慢性硬膜下血肿壁结构和病理特征的INET手术方案可降低复发率并改善临床预后。ClinicalTrials.gov，NCT02515903。2015年8月5日注册。
