高血圧性脳内血腫—内包付近に発生した血腫への手術接近法

HYPERTENSIVE INTRACEREBRAL HEMATOMA : A NEW OPERATIVE APPROACH TO THE HEMATOMA IN THE VICINITY OF THE INTERNAL CAPSULE

はじめに

　高血圧性脳内出血は脳卒中の主要原因であり^1），最近その開頭手術例は次々に報告されている。しかしその手術成績は必ずしも満足すべきものではなく^2）3），一部には外科的治療を疑問視しているものもある^4）。高血圧性脳内血腫では，出血により破壊された脳に，更に開頭手術によつて新たに健康な脳実質の損傷を加えれば^5），たとえ血腫を全摘し得たにせよ，予後に悪影響を及ぼすことは十分に考えられることである。一方，高血圧性脳内出血の好発部位は，被殻，視床，尾状核などの内包，外包付近が大部分である^1）6）。従つてこの部血腫への脳損傷の最も少ない接近方法を考え，これを6例に施行したので，この方法について述べ，その適応などについて考案を加える。

It has been reported that hypertensive intracerebral hemorrhage occurs most frequently near the thala-mus, internal or external capsule. From the point of view, we describe, in this paper, a new operative method which seems to be the nearest approach to these hematoma.

A linear skin incision about 6 cm long on the temporal region is made backwards from the border of the hair (fig. 1). The skull is opened extensively, especialy at the sphenoidal ridge, and the dure is opened. The arachnoidea near the veins on the Sylvian fissure is incised carefully (fig. 3), and then the fissure is dissected bluntly not to damage the brain substance as far as the insula (fig. 4). Branches of the middle cerebral artery can be seen on the surface of the insula (fig. 5), where probe puncture is performed to the hematoma cavity, and dark blackish fluid blood will spurt out of it. Then, old blood and clots is evacuated through the small in-cision at the cortex of the insula (fig. 6). Finally, the wound is primarily closed without drainage.

By our operative procedure, we have experienced six cases of hypertensive intracerebral hematoma, in which five cases are improved satisfactorily, while another one died six days after operation because of rebleeding into the hematoma cavity and com-bined large duodenal ulcer. Severe hemiplegia im-proved in a relatively early stage after operation in all cases, and other additional neurological deficit is not found after operative treatment except one death case.

In the traditional way, burr hole aspiration of hematoma is incomplete, while craniotomy and eva-cuation may necessitate a comparatively large inci-sion at the cortex and also the possibility that the destruction of healthy brain substance may occur because of great distance between the hematoma cavity and brain surface. On the other hand, how-ever, our approach through the Sylvian fissure is nearer to the hematoma cavity and is less brain damage except for the small part of the insula.