Patients sudden vomiting with confusion, brain stem bleeding 10 ml, how to treat?

If the brain is the command, the brain stem is the commander-in-chief of the command, because it is the cardiovascular and respiratory centerbrain stem is located below the brain, a smaller part of the brain and spinal cord, in an irregular column shapeThe brain stem is composed of three parts from top to bottomThe spinal cord is attached under the myelinbrain stem haemorrhage accounts for about 10% of spontaneous brain haemorrhage, and is one of the most dangerous strokesIt has been reported in the literature that the death rate of cerebral stem hematoma is very high, the death rate of bleeding less than 5 ml is about 70%, the blood volume is more than 5 ml mortality rate of 90%, the blood bleeding amount is almost 100% mortality ratethe current surgical treatment of cerebral stem haemorrhage is still controversial, for spongiform vascular malformation caused by brain stem bleeding more active surgical treatment, and for high blood pressure brain stem hemorrhage patients are not recommended for surgical treatmentHowever, patients with severe lysion stoic severity (bleeding volume of 5mL, GCS 9) often have irreversible neurological defects and high mortalityIn recent years, with the progress of modern neuroimaging methods and microscopy, as well as the emergence and application of three-dimensional imaging, augmented reality and other positioning techniques, brain stem haemorrhage can selectively carry out surgical interventionthat is, although cerebral stem bleeding is extremely dangerous, but also through a certain surgical intervention to pull the patient back from the hands of deathcurrently, for the treatment principle of cerebral stem bleeding: the amount of hemorrhage 5 ml, conservative treatment; How canbe treated? Let's look at a case of brain stem hematoma up to 10 ml of patients:patient Deng a certain, male, 50 years old, to "sudden vomiting with confusion, urinating incontinence for 1 hour" as the main complaint emergency hospitalHead CT test shows: the right brain stem bridge brain haemorrhage 3 ml into the fourth ventricle and the two sides of the base section area cavity, given glycol and other symptoms after treatment rushed to the higher hospital, to accept neurosurgerya long history of hypertensionPhysical examination: body temperature 36 degrees C, blood pressure 210/132mmHg, pulse 85 times / minute, 17 times / minute of breathing Confusion, restlessness, pressure and pain stimulation have a reaction, passive body position Two-sided pupils and other large equiene, diameter of about 3.0mm, dull reflection of light hearing two lung squeals and wet and dry sound The hearing double lung breathing movement is symmetrical, breathing is stable, the rhythm is neat, and the double lung is clear The muscle tone of the limbs was high and the two-sided papidal character was positive diagnosed as: 1 acute cerebral hemorrhage; 2 Level 3 of hypertension (extremely high risk); 3 inhalation pneumonia After admission to 25h, patients gradually appear edatight shortness of breath, blood oxygen saturation significantly decreased, immediately to the trachea intubation, review of the skull CT found that the brain stem bleeding increased to 10 ml (see Figure 1) after active preoperative preparation, emergency room sent to the operating room, under the bureau under the implementation of the square-directed tube cerebral stem puncture, the operation to pump old hematoma 4 ml, the next day after surgery urinary kinase injection, continuous drainage cerebral stem hematoma, review CT see hematoma most of the removal (see Figure 2) on the 5th day after , the mind was hazy and the stimulus was reactive 10 days after surgery, the call can be made, by EICU transfer treatment Half a month later, he was conscious and transferred to rehab (see Figure 3) 5 months after , the left limb muscle strength near v grade, in addition to the left hand five fingers difficult to stretch, can stand walking and riding a motorcycle, life self-care (see Figure 4) The minimally invasive operation successfully pulled the patient back from the hands of death To know that brain stem haemorrhage surgery was previously a no-go area, such patients fatality rate is almost 100%, but now there is a breakthrough - the use of minimally invasive treatment of brain stem bleeding But this surgery to strictly abide by the adaptation certificate, to avoid surgery, people save is the state of plants, to the family and society caused a heavy burden next, let's go into detail about the surgery directional tube attraction to treat hypertension brain stem bleeding is determined according to the three-dimensional positioning parameters of brain stem bleeding provided by THE CT scan to determine the vertical projection line and face in the forehead, stolic, top and pillow, and to determine the central target of cerebral stem hematoma according to the three-sided intersection The straight lines formed by the intersection of three planes perpendicular to each other and three two planes perpendicular to each other can be used as a path to pierce the tube into the skull, while the position of the other plane is used as a sign of the depth of the hematoma target point of the brain stem, so that the hematoma target point can be reached accurately surgery there is currently no brain stem hemorrhage minimally invasive puncture surgery indication stoic surgery indication of the uniform standards, it is generally believed that the following circumstances can be considered to choose brain stem hematoma puncture surgery treatment: 1 2.GCS score of 8 points; 3 Bleeding amount of 5 ml; 4 Vital signs such as body temperature, pupil, breathing, etc all have different degrees of disorder; 5 Family informed consent surgery surgical contraindication 1 Brain stem bleeding amount of 5 ml; 2 Deep coma, double-sided pupil dispersion, after the onset of autonomic breathing stop blood pressure below 60mmHg more than 30min ; 3 confirmed by CTA/DSA tumor stroke, aneurysm, venous malformation, spongiform hemangioma; 4 clotting dysfunction and blood disease; 5 signs of brain failure ; surgical method
positioning method
is divided into the forehead top, pillow and lower pillow body directional tube attraction according to the skin puncture point The most commonly used method under the pillow, introduced as follows: 1) draw the basic positioning line: after the patient skin, quiet state lying on the ground, with the midpoint between the eyebrows as the starting point, the cranial brain stereoscopic locator short plate, middle plate, long plate respectively close to the forehead, the top, select the middle hole through the starting point, with a drawing wire cotton wool or straight-in-the-middle bar-shaped line back to the back of the pillow Align the edge of the long plate on one side of the stereoscopic locator at the connection between the surgical side and the outer ear canal, draw the OM line, and extend to the opposite side of the neck 2) marker hematoma target projection and path: side lying, according to the ct image hematoma target distance from the OM line, projected on the side of the head surgery side (bridge brain bleeding target on the outer ear canal around 2cm), to determine the puncture point under the pillow (open 5 from the center line) -6cm, cross-sinus body table projection line 2-3cm), the cranial brain stereoscopic locator short plate perpendicular to the positive center of the avowed line, with a drawing wire cotton swab or pen to draw the side point and the pillow puncture point of the line, establish the horizontal surface of the hematoma (see Figure 1, 2) According to the position of the hematoma target at the top or forehead projection point, the hemorrhagic syllable line is drawn with the locator to establish the hematoma's face (see Figure 3 and 4) The vertical intersection of the above-mentioned target and horizontal faces is the path of cerebral stem hematoma puncture, with a depth of 9-10cm Surgical operation 1) will be the patient into the minimally invasive operating room or compound operating room (rescue patients can also be carried out in the critical ward bed), placement of patients in the appropriate position, connect ingestay tube, electrocardiogram, establish venous channels, observe and record the size of pupils and vital signs, and pay attention to the continuous observation of its changes in the operation 2) head drawing line positioning, routine disinfection, spread surgical towel 3) the same side ventricle puncture tube, the intracranial pressure Place the brain outdoor flow device 4) anaesthetic method using bureau hemp or whole hemp, with a scalpel in the pillow puncture point cut about 0.5cm, with a concave drill to build a subcutaneous passage of the pillow bone, directional skull drill through the pillow bone (see Figure 5), with concave drilling expansion drilling and removal of residual bone debris Installing a collarbone device, a meninges needle punctures the meninges, and the stick ruler expands the meninges incision to establish a pre-channel to the target First with a brain needle to the hematoma center target point test pumping a small amount of old blood, placed in the brain stem hematoma attracttube, pumped old blood 2-5ml (see figure 6), left the tube in the hematoma residual blood cavity, connected to the outer end of the tube hematoma drainage bag, bandaged back to the ward or review to understand the post-operative intracranial hematoma drainage situation Surgical precautions 1) cerebral stem hematoma positioning drawing line, we must adhere to the principle of square positioning, to ensure that all intersections are right angles; 2) when using the skull stereoscopic locator short plate, it is necessary to pay attention to the cranial brain radius distance line overlaps with the target
line when projecting the drawing line on the side of the skull; 4) according to the thickness of the skull, adjust the length of the drill to prevent the drill bit from getting into deep damage to the epidural; 5) does not seek a one-time thorough removal of hematoma, pumping process emphasizes slow, intermittent, non-resistance, blood discharge, not damage brain tissue; 6) when the skull is pierced, do not injure and lower pillow sinuses, sinuses and s
inuses, sinuses and sinuses, etc 7) Brain stem puncture do not hurt the brain stem mesh upward agitation system and cerebellum tooth-like nucleus, brain stem nerve nucleus, trigeminal nerve core, kinetic eye nerve nucleus and other important nerve nucleus And pay attention to the tube too deep, there is a risk of damage to the brain stem, 8) in the operation of blood pressure drop, significant changes in life signs, need to stop the operation, waiting for the life indication slower after the continuation of surgery; 9) first through the side ventricle, then through the brain stem hematoma; such as side ventricle, pull the drainage tube to follow the principle of first pull the brain stem drainage tube, pull out the side ventricle drainage tube
; Avoid long-term tube placement, retention time of 1 week, 11) emphasize the cerebrstemal hemorrhage puncture tube treatment operation of the normative and sterile, to prevent mis-wearing, brain stem damage bleeding and infection finally, let's conclude: preoperative positioning of cerebral stem hematoma is very important, the direction of puncture in surgery is the foundation of success, puncture into the hematoma position to determine the role after the healing, within 72h is the best time for surgery, the worst prognosis of myelin hemorrhage Expert sin professor tang Chauping
professor, chief physician, doctoral tutor, professor, professor Vice-Chancellor of The International Medical Center of Huazhong University of Science and Technology, Vice President of Guanggu Hospital District of Tongji Medical College affiliated with Tongji Medical College of Huazhong University of Science and Technology, Deputy Director of The Department of Neurology and Research of Tongji Hospital affiliated with Tongji Medical College of Huazhong University of Science and Technology, academic posts: Vice Chairman of the National Health And Health Commission's Hemorrhagic Neurology Committee, Deputy Chairman of the Chinese Physicians Association's Special Committee for Neuroremediation, Vice Chairman of the Chinese Physicians Association academic contribution: host the national natural surface project, Hubei Provincial Health Department Fund a total of 14 items, including brain haemorrhagic minimally invasive treatment related to 5; published more than 200 related scientific research papers, was directed nearly 1800 times, including in NEUROLOGY, MOL NEUROBIOL and other international authoritative journals published SCI papers 50, a total impact factor of 120; Brain Haemorrhage magazine and editor-in-chief, "Brain Hemorrhages" executive editor, as the person in charge or member of the Ministry of Education has won the second prize of scientific and technological progress, Guizhou Medical Science and Technology First Prize, Shanghai Science and Technology 3rd Prize, Tongji Hospital New Technology New Business Award 3 times; Author: Sun Shujie Tang Zhouping Source: medical neurology channel highlights: wxl882001 on 2020-4-18 Comment: to learn about the (from: MedSci Medicine APP