高血圧性脳出血治療の変遷と将来
2004 年 26 巻 3 号 p. 465-471
詳細
2004 年 26 巻 3 号 p. 465-471
The recent development for a treatment of hypertensive brain hemorrhage (ICH) is described.
1) Patients with brain hemorrhage are selected for surgical treatment on the basis of their response to hyperbaric oxygen (H.B.O). Patients who show clinical improvement with hyperbaric oxygen therapy and undergo surgery show a significantly improved outcome. On the other hand, patients who do not show any clinical improvement with hyperbaric oxygen demonstrate a poor outcome even if surgery is performed.
There are some similarities between the effects of H.B.O and hematoma evacuation. Both these procedures decrease intracranial pressure and improve the marginal regional cerebral blood flow (r-CBF) and acidosis. However, there is one significant difference. The effect of H.B.O therapy does not last for longer than 24 hrs. Any clinical improvement returns to the pretreatment level the following mornig. Therefore, H.B.O does not offer a permanent treatment for hypertensive ICH. On the other hand, the effect of hematoma evacuation is more permanet. We therefore, postulated that patients who demonstrate clinical improvement with H.B.O would benefit more permanently from surgery.
The long-term outcome of 216 patients verified this approach. Patients with moderate brain hemorrhage for surgery based on H.B.O clearly showed a significantly better long-term outcome compared with control.
This comparative study verified the usefulness of hyperbaric oxygen therapy for selection of patients with ICH selection for surgery.
2) CT-guided intervention has been a common procedure for the last 10 years, but the real-time monitoring with CT image has not been available yet. We have developed the real-time CT-fuluoroscopy of which initial trial was reported in 1993. This paper deals with the clinical experience with its system in surgery for brain hemorrhage. A third-generation scanner equipped with a slip-ring (TOSHIBA) was used. Images were reconstructed and displayed at a rate of 6 per second with 0.83-second delay time using a newly designed array processor. These results suggest that CT-fuluoroscopy offers improved accuracy and safety in surgery for brain hemorrhage as a new neuro-navigation system and makes it possible to do free-hand puncture without stereotactic procedures.
3) Neuroendoscopy has become more popular in neurosurgery. It used to be difficult to use it for hematoma evacuation, because the surgical field was bloody which made the complete evacuation more difficult. However, since a new sheath around the tip of the endoscopy was developed, the evacuation becomes easier, and more accurate.
