导论章节：脑内出血的神经外科管理Introductory Chapter: Neurosurgical Management of Intracerebral Hemorrhage | IntechOpen

1. 引言

原发性自发性脑内出血(SICH)可导致致命后果，在幸存者中也会造成显著发病率和长期残疾[1]。高达90%的患者，动脉高血压或淀粉样血管病被认为是出血原因[2]。区分原发性SICH与继发性SICH的关键点包括：原发性SICH通常累及有高血压病史患者的基底节和丘脑[2, 3, 4, 5]。随着预期寿命延长和老龄人口增长，SICH负担预计将持续增加[6, 7]，同时管理这些患者的总体终身成本也将上升[8]。神经外科干预及其可用选项在自发性SICH管理中的作用不仅在扩大，而且能够改善总体预后。本文不讨论自发性小脑血肿的管理，因其属于特殊亚型且临床预后相对较好[2]。

2. 临床特征

每位患者都需要进行详细评估，包括详细的临床病史和临床检查，特别是神经功能缺损及其程度[2]。SICH的临床特征取决于出血的大小、位置以及是否存在脑积水。一般表现为颅内压升高的症状，如头痛、呕吐、癫痫发作和意识水平改变（严重情况下包括昏迷）[2]。SICH的两个常见危险因素包括全身性动脉高血压和脑淀粉样血管病[9, 10]。

3. 诊断

原发性SICH需要与其他出血原因区分开来，即与继发性SICH（例如创伤性脑内出血、伴有出血的肿瘤、血管畸形和SICH的药物原因）[2]。当怀疑SICH时，脑部CT扫描将提供关于血液存在及其位置的详细信息，敏感性超过95%；但在某些患者中[11, 12]，CT扫描可能无法显示血液，此时MRI可帮助发现血液，特别是使用T2*和质子加权序列[12, 13]。在怀疑脑内出血有继发原因的情况下，CT和MRI可补充进行MR血管造影、CT血管造影，或必要时进行常规数字减影血管造影[11]。

4. 管理

管理方法可能从单纯药物治疗和观察到包括血肿清除和/或减压性颅骨切除术在内的积极外科干预不等[14-26]。标准保守治疗和适合手术患者的管理包括气道、呼吸和循环的稳定、血压控制，随后采取措施降低颅内压（如抗水肿治疗或血肿手术清除）以及预防继发性并发症（肺炎、深静脉血栓、尿路感染、压疮）[27]。例如，对于丘脑大出血或出血延伸至脑干且神经功能评分差的患者，手术可能不适宜[2]。

5. 外科管理

除药物治疗外，已描述多种用于清除血凝块和减少占位效应的侵入性神经外科方法。这些方法包括开颅手术清除血肿（伴或不伴减压性颅骨切除术）、影像引导的立体定向内镜抽吸、用于溶栓的微创方法以及放置外部脑室引流（在血凝块延伸至脑室或伴有脑积水的情况下）[27]。手术决策可能受可用设施、专业知识和患者相关因素影响，手术选项包括开颅手术和血肿清除、内镜下血肿清除、立体定向血肿清除，以及若血肿延伸至脑室或伴有梗阻性脑积水，可采用脑脊液分流手术，如外部脑室引流(EVD)或脑室-腹腔分流(VP shunt)。

6. 神经外科干预范围

神经外科干预在SICH管理中的作用正在扩大，但前方仍有许多挑战需要解决。例如，任何后续干预都无法逆转原发性损伤[27]，但同时可帮助最小化继发性损伤。清除血肿可以是救命的手术，但我们需要进一步了解如何改善幸存者的生活质量。手术清除的决定可在个案基础上进行权衡。例如Reichart[2]指出：

• 累及基底节的小出血，伴有最小或无神经功能缺损，可以保守治疗
• 对于累及整个半球的大血肿，患者为神经功能评分差的老年患者，手术可能是救命的，但预后仍然很差，因此手术可能不适宜
• 意识清醒的患者，血肿体积在30-50毫升之间，位于深部且无占位效应，可以保守治疗。然而，如果发生继发性神经功能恶化，血肿体积增加至50-60毫升，可以考虑开颅手术和清除血肿
• 临床状况恶化的年轻患者，伴有中度或大型脑叶出血，可能需要手术干预
• 与结构病变（如动脉瘤、动静脉畸形或海绵状血管瘤）相关的SICH可能需要手术干预

7. 挑战

尽管最近在这些患者的医疗和外科管理方面的进展已提高生存率，但总体功能预后仍然受损[27-34]。许多研究已探讨手术在自发性脑内血肿管理中的作用[35]。然而，研究结果的推广和个体患者的管理仍存在争议和挑战。

8. 结论

需要基于证据的算法，以更好地解决管理选项及患者的整体功能预后问题，使个体患者能够恢复功能独立性并融入社会。作为研究者，除开发事件后管理方案和促进神经元恢复的因素外，还应关注能够检测SICH高风险患者的技巧，以及通过风险因素调整等策略预防可能致命或导致患者严重残疾的SICH发作。

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