脳室内穿破を伴う重症視床出血の急性期開頭血腫除去術―ｉｎｔｅｒｈｅｍｉｓｐｈｅｒｉｃ ｔｒａｎｓｃａｌｌｏｓａｌ ａｐｐｒｏａｃｈを用いて―

Abstract

When thalamic hemorrhage is accompanied by severe intraventricular casting, the prognosis is extremely poor. Although the ventricular drainage with thrombolysis agent is effective in some cases, the drainage occlusion and inadequate hematoma removal are often troublesome in actual daily clinical practice. For such severe cases, we performed direct hematoma evacuation through interhemispheric transcallosal route in recent years and compared the results with that of the ventricular drainage, which had been performed before. We operated on 15 cases (5 men and 10 women) using interhemispheric transcallosal approach (ITA) between June 2002 and May 2005. In all cases, emergent and minimal angiography was performed just to estimate ipsilateral bridging veins to decide the craniotomy site. ITA through the ipsilateral side of thalamic hemorrhage with 2-3 cm callosotomy between bilateral A3 enabled hematoma evacuation of the ipsilateral ventricle, contralateral ventricle through the septum, as well as the thalamus through perforated ventricular wall. The direct hemostasis of bleeding perforators of thalamus was accomplished in all cases. More than 90% hematoma removal was achieved, and the postoperative serial CT scans demonstrated no rebleeding in any of the cases. Two patients (13.3%) needed VP shunt due to hydrocephalus in the chronic stage. At the time of discharge (average hospital-days 48.1 days), 12 patients were Grade 4 and 2 patients were Grade 5 on the modified Rankin Scale. One sudden death (6.7%) due to pulmonary embolism occurred on the 28th day after surgery. In the previous treatment (ventricular drainage only) of 15 patients between 1997-2002, 1 patient was Grade 3, 8 were Grade 4, 2 were Grade 5 and 4 (26.7%) died. The direct hematoma removal using ITA might improve the prognosis of thalamic ICH with severe ventricular casting by relieving ventricular irritation and obstructive hydrocephalus quickly as well as by definite hemostasis through direct vision.