外伤性急性硬膜下血肿的治疗体会

急性硬膜下血肿是颅脑损伤较为常见的继发性损害,死亡率及致残率均较高.本院1999年1月至2002年5月,共收治外伤性急性硬膜下血肿患者198例,根据患者不同情况,分别采用了不同的治疗方案,取得了较好的疗效.现报道如下.     

Cardiovascualr changes with acute subdural hematoma.

Of 100 consecutive patients with acute subdural hematoma, 53 survived. Blood pressure and heart rate changes were not reliable indicators of increased intracranial pressure or cerebral disaster. Electrocardiographic changes in these patients were dramatic. Forty-one patients developed a new cardiac arrhythmia. Increased intracranial pressure and brain lesions adversely affect the heart. These effects must be recognized and appropriately treated.     

A model of acute subdural hematoma in the mouse.

The availability of genetically modified mice has allowed the study of genetic influences on acute brain injury. An animal model of acute subdural hematoma (ASDH) has been previously described in the rat but not the mouse. We describe a method for producing ASDH in the mouse. Subdural injections of 50 and 30 microL of nonheparinized autologous blood were associated with excessive mortality. Injections of 10 and 20 microL were associated with mean percentage volumes of damage of 1.804% and 4.019%, respectively. Sham subdural injections of saline were associated with minimal hemisphere damage (0.152%). This mouse model provides a means of investigating the effects of genotype on the brain's response to ASDH.     

急性硬膜下血肿清除术后迟发性硬膜下积液的诊治

目的 探讨急性硬膜下血肿清除术后硬膜下积液的原因、早期诊断、手术治疗方法和疗效。方法 对急性硬膜下血肿后硬膜下积液29例进行回顾性分析。结果 痊愈14例，占48．7％；轻残5例，占17．2％；重残4例，占13．8％；植物状态3例，占10．3％，死亡3例，占10．3％。引流效果良好，无一例颅内感染。结论 急性硬膜下血肿清除后可能发生硬膜下积液；术后意识无改善或意识好转后又加重、出现颅内压增高征象、神经系统定位体征、减压区膨隆、瞳孔及生命体征改变应予CT检查可明确诊断：积液区颅骨钻孔或减压区小切口置管引流简便易行，有效满意疗效。     

Role of dural fenestrations in acute subdural hematoma.

OBJECT: Patients with acute subdural hematomas (ASDHs) have higher mortality and lower functional recovery rates compared with those of other head-injured patients. Early surgical decompression and active intensive care treatment represent, so far, the best way to assist these patients. Paradoxically, one of the factors contributing to poor outcomes in cases of ASDHs could be rapid surgical decompression, owing to the severe extrusion of the brain through the craniotomy defect in response to acute brain swelling. To avoid the deleterious consequences of abrupt decompression of the subdural space with disruption of brain tissue, the authors have adopted a new surgical technique for evacuation of ASDHs. This procedure consists of creating multiple fenestrations of the dura (MFD) in a meshlike fashion and removing clots through the small dural openings that are left open, avoiding the creation of a wide dural opening and the disruption of and additional damage to brain tissue. METHODS: Thirty-one patients (26 male and five female patients with a mean age of 32.5 years) harboring ASDHs were treated using this method. On admission there were 16 patients (51.5%) with Glasgow Coma Scale (GCS) scores of 3 to 5, 11 patients (35.5%) with GCS scores of 6 to 8, and four patients (12.9%) with GCS scores of 9 to 12. Postoperative computerized tomography scans of the brain revealed evacuation of more than 80% of the hematoma in 29 of 31 patients. The overall mortality rate in this group was 51.6%. CONCLUSIONS: This preliminary report of a new surgical approach for patients who have sustained ASDHs should be considered to avoid abrupt disruption of the brain and to allow the gradual and gentle release of subdural clots. This is especially important in cases in which there are severe midline shifts and a tight brain. Further clinical studies should be conducted in a more selected series to estimate the impact of this new procedure on morbidity and mortality rates.     

Successful surgical treatment of a hemophiliac infant with nontraumatic acute subdural hematoma

BACKGROUND: The moderate hemophiliacs usually have no spontaneous bleeding, but bleed after minor or major trauma. The proper management of intracranial hemorrhage in hemophiliac children is a challenge. CASE DESCRIPTION: An 18-month-old male infant with moderate hemophilia A was admitted with fever, vomiting, and hypersomnia. There was no history of trauma or seizure. The CT scans showed an acute subdural hematoma in the right temporoparietooccipital region with midline shift and a coincidental right cerebellar arachnoid cyst. After bolus factor VIII replacement, a right temporoparietal craniotomy was performed, and the subdural hematoma was evacuated. The postoperative CT scans demonstrated no hematoma. CONCLUSIONS: The possibility of intracranial hemorrhage in a moderate hemophiliac infant should be considered even if the patient has no history of trauma. The surgical treatment results in a successful outcome in hemophiliac children with subdural hematomas provided that an aggressive factor replacement therapy is initiated before surgery.     

Chronic subdural hematoma: pathophysiological basis for treatment.

Fifty-three consecutive adult patients treated surgically for chronic subdural hematoma are reviewed. The current understanding of the pathogenesis of chronic subdural hematoma is discussed. In the current neurosurgical literature, wide discrepancies exist, in patients treated by burr-hole evacuation, regarding the rate of subdural recollection. Possible factors responsible for these discrepancies include (1) failure to recognize and properly treat multiloculated chronic subdural hematomas, (2) too aggressive a surgical approach toward persistent CT-demonstrated but asymptomatic subdural residual or recurrent collections, and (3) failure to use corticosteroids in the post-operative management of patients with persistent or recurrent symptoms as a step prior to re-operation. A prospective controlled clinical trial of glucocorticoids in chronic subdural hematoma is needed to establish their place in the management of this condition.     

External subdural drainage in the treatment of infantile chronic subdural hematoma

BACKGROUND: The management of chronic subdural hematoma (CSDH) in infants remains controversial. The purpose of this study was to analyze the clinical characteristics of CSDH in infancy and evaluate the efficacy of continuous external subdural drainage in the treatment of infantile CSDH. METHODS: We prospectively collected 36 consecutive infants with CSDH, to receive continuous external subdural drainage as the initial management. Medical records were reviewed for comparison of age, gender, cause of injury, clinical presentation, surgical management, and outcome. Diagnosis was made by computed tomography and/or magnetic resonance imaging. RESULTS: There were 20 boys and 16 girls, with ages ranging from 1 to 11 months (average, 5.9 months). The most common cause of CSDH was head injury (44.5%), followed by shaken baby syndrome (36.1%). The most common clinical presentations were seizure, bulging fontanel, and consciousness disturbance. Continuous external subdural drainage was the definite treatment in 34 patients (94.4%). The drains were left in place for no more than 9 days. Only two (5.6%) patients needed permanent subduroperitoneal shunting. No obvious complication was found. At follow-up (17-160 months; mean, 86.6 months), 23 (63.9%) had good recovery, 5 (13.9%) had moderate disability, 3 (8.3%) had severe disability, 4 (11.1%) were in a vegetative state, and 1 (2.8%) died. CONCLUSION: Continuous external subdural drainage was an effective treatment in infantile CSDH, with a low complication rate and good clinical outcome. It might be considered as a strategy before subduroperitoneal shunting in the treatment of CSDH in infants.     

Transient glucose hypermetabolism after acute subdural hematoma in the rat.

Ischemic brain damage occurs in most patients with acute subdural hematoma, yet many aspects of the distribution and extent of this damage remain unexplained. Previous studies in rat model, which produces a region of infarction under the hematoma, have implicated an "excitotoxic" mechanism, suggesting that high concentrations of excitatory amino acids may exacerbate ischemic damage. A study is described in which local glucose utilization is measured 2 or 4 hours after induction of acute subdural hematoma in the rat. These changes are compared to those produced by introducing the same volume of inert silicone gel into the subdural space. Massive increases (up to 142%) in glucose utilization occurred throughout both hippocampi and in a variable zone around the ischemic core, but these had normalized by 4 hours after blood injection. Hippocampal hypermetabolism was not seen after introduction of the silicone mass, suggesting that diffusible substances from the clotted blood may be responsible for these changes. This transient hypermetabolism accords with an excitotoxic process, which may amplify brain damage after acute subdural hematoma.     

Ischemic brain damage in a model of acute subdural hematoma

Ischemic brain damage is the most important neuropathological finding in humans who die after acute subdural hematoma; however, its causes are poorly understood. We have produced acute subdural hematoma in the rat by injecting 400 microliters of autologous blood (approximately 20% of intracranial volume) into the subdural space. Extensive areas of ischemic damage, involving 14 to 16% of the volume of the hemisphere, developed in this model at 4 and 24 hours after the lesion. The hematomas were associated with a brief peak in intracranial pressure (51 mm Hg), which remained at three times normal levels (14 mm Hg) for 3 hours. In this model, therefore, ischemic damage appears to be due to the local effects of blood overlying the cortex at 4 hours after the ictus, rather than to globally raised intracranial pressure. The implications for the pathophysiology of acute subdural hematomas in humans are discussed.     

Falx meningioma presenting as acute subdural hematoma: case report.

BACKGROUND: Acute subdural hematomas caused by meningiomas have been rarely encountered. Pathophysiologic mechanisms and clinical considerations in these patients have not been sufficiently explored. We addressed the possible mechanism of spontaneous hemorrhage in our case and briefly discuss the optimal treatment. CASE DESCRIPTION: This case of falx meningioma presenting as an acute subdural hematoma in a 78-year-old woman is described. On initial computed tomography (CT), an enhancing tumor of the falx appeared to be the cause of hemorrhage. Only faint contrast staining in the periphery of the tumor was seen on right external carotid arteriograms, with no evidence of other vascular supply. Extravasation of contrast material during the procedure occurred suddenly and was successfully treated by endovascular embolization using a microcatheter. The hematoma was emergently evacuated with gross total removal of the tumor. Pathologic examination confirmed a transitional meningioma with abundant hyalinized structures. Disruption of a thin-walled vessel adjacent to the tumor capsule was assumed to be the site of hemorrhage. CONCLUSIONS: The longstanding ischemia of the tumor was considered to have produced the deposition of hyalin in the tissue, which changed the hemodynamics within the tumor, producing vascular stress leading to rupture. The prognosis of patients with meningiomas complicated by acute subdural hematoma is generally poor, with mortality reported in approximately one-half of such patients. Surgical exploration is the most effective treatment and should be conducted before irreversible brain damage has occurred.     

Acute epidural hematoma developing during twist-drill craniostomy: a complication of percutaneous subdural tapping for the treatment of chronic subdural hematoma

BACKGROUND

This case illustrates that although percutaneous subdural tapping for patients with chronic subdural hematoma (CSDH) is successful and minimally invasive, it can be complicated by acute epidural hematoma.

CASE PRESENTATION

A 62-year-old woman presented with headache two months after minor head trauma. Computed tomography (CT) scanning revealed CSDH with mixed density on the right side. Prior to percutaneous subdural tapping, twist-drill craniostomy was performed at the parietal tuber. When the drill-needle reached the dura mater, the patient began to complain of headache, which was followed by altered consciousness. CT scanning disclosed acute epidural hematoma abutting the CSDH; both hematomas were evacuated by emergency craniotomy. At surgery, no definite bleeding source was identified apart from oozing on the dura mater.

CONCLUSION

Hemorrhagic complications after percutaneous subdural tapping are rare. The formation of acute epidural hematoma during twist-drill craniostomy has not been reported in the literature. This complication can occur when the blunt tip of the drill-needle remains on the dura mater without penetrating into the subdural hematoma cavity.     

Percutaneous subdural tapping and subdural peritoneal drainage for the treatment of subdural hematoma

Different therapeutic approaches may be used in the treatment of chronic subdural hematoma because it is more fluid. Age-dependent characteristics of the calvarium allow for different treatment in children and adults. Treatment options are discussed.     

Three cases of acute interhemispheric subdural hematoma

Traumatic acute subdural hematomas over the convexity of the cerebral hemispheres are often encountered, but acute interhemispheric subdural hematomas are rare. Fourty-eight cases of acute subdural hematomas was admitted to our hospital between 1977 and 1986, and three cases of them (6%) were located in the interhemispheric subdural space. In this paper, these three cases are reported with 20 documented cases. Case 1: an 81-year-old female was admitted to our hospital because of headache, nausea and vomiting. She hit her occiput a week ago. CT scan demonstrated contusion in the right frontal lobe and a high density in the interhemispheric space of the right frontal region. Her complaints disappeared gradually by conservative therapy and she returned to her social life. Case 2: a 50-year-old male fell downstairs and hit his vertex. As he lost consciousness, he was admitted to our hospital. He was stuporous and had left-hemiparesis. Skull X-ray film showed fracture line extending from the right temporal bone to the left parietal bone across the midline. CT scan revealed intracerebral hematoma in both frontal lobe and right parietal lobe and subarachnoid hemorrhage in the basal cistern and Sylvian fissure of the right side. And interhemispheric subdural hematoma in the right parietal region was visualized. Angiography demonstrated a lateral displacement of the right callosomarginal artery and an avascular area between the falx and the callosomarginal artery. After admission his consciousness recovered and convulsion was controlled by drug. Left-hemiparesis was improved by conservative therapy and he was discharged on foot.(ABSTRACT TRUNCATED AT 250 WORDS)     

Nonoperative treatment of chronic subdural hematoma

Chronic subdural hematomas that are asymptomatic or producing only mild symptoms are occasionally found with current neuroimaging methods. Some do not progress, and spontaneous resolution can occur. In addition, successful medical treatment of more significant hematomas has been reported. The indications for nonoperative management of these lesions are reviewed in this article.