微创治疗外伤性硬膜外血肿

目的：探讨微创治疗外伤性硬膜外血肿的方法,适应证及其疗效,方法：回顾分析85例外伤性硬膜外血肿微创清除术病例。结果：18例无效,改行开颅血肿清除术;余67例血肿均于术后3d内引流干净,预后按GOS结果分类：良好77例,中残7例,重残1例,结论：微创清除血肿瘤30－80ml,GCS计分≥8分幕上硬膜外血肿及生命体征稳定,血肿量≤20ml幕下硬膜外血肿,其疗效确切,安全,可靠。     

外伤性进展性颅内血肿的诊断和治疗

目的探讨外伤性进展性颅内血肿的临床特点,总结其发病机制及诊断、治疗方法。 方法选取自2011年1月至2015年12月中国人民解放军第二五一医院神经外科收治的97例外伤性进展性颅内血肿的临床资料进行分析。 结果本组97例占同期外伤性颅内血肿的15.3%,手术63例,死亡7例;保守治疗34例,死亡1例,总死亡率8.2%。 结论外伤性进展性颅内血肿临床意义重大,绝不能仅仅依赖首次CT结果即制定一成不变的治疗方案,而应进行动态观察和CT监测,根据患者血肿量的变化及时调整治疗方案。     

Surgery for Bilateral Large Intracranial Traumatic Hematomas: Evacuation in a Single Session

Objective

Management guidelines for single intracranial hematomas have been established, but the optimal management of multiple hematomas has little known. We present bilateral traumatic supratentorial hematomas that each has enough volume to be evacuated and discuss how to operate effectively it in a single anesthesia.

Methods

In total, 203 patients underwent evacuation and/or decompressive craniectomies for acute intracranial hematomas over 5 years. Among them, only eight cases (3.9%) underwent operations for bilateral intracranial hematomas in a single session. Injury mechanism, initial Glasgow Coma Scale score, types of intracranial lesions, surgical methods, and Glasgow outcome scale were evaluated.

Results

The most common injury mechanism was a fall (four cases). The types of intracranial lesions were epidural hematoma (EDH)/intracerebral hematoma (ICH) in five, EDH/EDH in one, EDH/subdural hematoma (SDH) in one, and ICH/SDH in one. All cases except one had an EDH. The EDH was addressed first in all cases. Then, the evacuation of the ICH was performed through a small craniotomy or burr hole. All patients except one survived.

Conclusion

Bilateral intracranial hematomas that should be removed in a single-session operation are rare. Epidural hematomas almost always occur in these cases and should be removed first to prevent the hematoma from growing during the surgery. Then, the other hematoma, contralateral to the EDH, can be evacuated with a small craniotomy.     

Local fibrinolytic technique in surgery of traumatic inctracranial hemorrhages

The emergence of neuroimaging techniques and new surgical technologies (neuroendocopy, navigation systems) in neurosurgery has substantially changed views of surgery for traumatic intracranial hematomas. The local fibrinolytic technique that has been applied to 40 victims aged 18 to 67 years (mean age 42.1 +/- 2 years) who had 18-to-97-cm3 hematomas is a promising direction of mini-invasive surgery for traumatic intracranial hematomas in patients in the compensated and subcompensated state. There were 32 males and 8 females. The procedure of the surgical intervention involves drainage of intracranial hematoma, followed by clot lysis and liquid blood aspiration along the drainage. A good outcome with a complete hematoma removal and clinical symptom regression was observed in 26 patients, a fair result with preservation of moderate neurological symptoms at hospital discharge was noted in 2 patients; 3 victims died. Recurrent bleedings were seen in 4 patients with epidural hematomas. A morphological study revealed the typical features of the morphogenesis of traumatic hematomas and perifocal brain tissue during local fibrinolytic therapy, which suggests that the area of damaging effect of bleeding on the adjacent brain tissue is decreased. Local fibrinolysis in surgery of traumatic intracranial hematomas may be considered to be one of the promising lines of treatment policy along with the existing traditional and current techniques and may be used as the method of choice in surgery of traumatic intracranial hematomas in patients in the compensated state. Removal of epidural hematomas through local fibrinolysis should be limited due to a high risk of recurrent hemorrhage and may be made only in a restricted contingent of patients with severe concomitant injury and concurrent somatic diseases when the risk of combined anesthesia and that of a longer operation are rather high. Moreover, of promise is that subtentorial epidural hematomas may be aspirated without trepanation of the posterior cranial fossa and the surgery may be performed under local anesthesia.     

颅内血肿微创碎吸清除术临床分析

目的提高颅内出血的救治水平，降低死亡率及伤残率。方法作者对59例颅内出血患者进行CT定位，选用北京万特福公司生产的YL-Ⅰ型一次性颅内血肿粉碎穿刺针，进行微创血肿穿刺碎吸引流术及血肿生物酶溶解技术，根据出血是否破入脑室选用单侧或双侧侧脑室穿刺外引流术．术后配合康复治疗。结果本组高血压脑出血36例治疗好转率88．9％，死亡率11．1％，外伤性颅内出血23例治疗好转率100％，结论颅内血肿微创碎吸清除术救治重症颅内出血是日前降低死亡率及致残率，提高生存质量，缩短病程，减少医疗费用的一种理想方法。     

老年人外伤性颅内血肿的临床特点及治疗

目的　探讨老年人外伤性颅内血肿的治疗。　　方法　分析 60岁以上老年人外伤性颅内血肿 1 1 7例临床资料。致伤原因多为跌伤及交通事故 ,大多为对冲部位血肿 ( 55 6% )及多发血肿( 2 5 6% ) ,手术治疗 87例 ,非手术治疗 3 0例。　　结果　按GOS评定 :良好 46 1 % ,中残 1 2 8% ,重残 4 3 % ,植物生存 2 6% ,死亡 3 4 2 %。　　结论　指出意识状态、是否合并脑疝、颅内血肿大小和部位等对预后有直接影响 ,提出颅内血肿手术与非手术治疗的适应证 ,强调积极防治并发症是降低死亡率的有效措施     

重型颅脑损伤术中B超对迟发性颅内血肿的诊治

目的探讨重型颅脑损伤术中B超对迟发性颅内血肿诊治的效果。方法回顾性分析重型颅脑损伤开颅手术中出现急性脑膨出的39例患者采用实时术中B超探查的方法,并根据检查结果采取相应的治疗方法。结果术中B超发现迟发性颅内血肿23例,其中同侧脑挫裂伤灶脑内血肿5例,对侧硬膜外血肿14例,对侧脑内血肿3例,对侧硬膜下血肿1例;多发性血肿11例。患者治愈12例,中残3例,重残4例,死亡4例,死亡率17.4%(4/23)。结论重型颅脑损伤开颅术中出现急性脑膨出应首先考虑迟发颅内血肿的存在,并行术中B超扫描,迅速定位血肿的部位,及时手术治疗,可改善其预后。     

颅脑损伤术后迟发性颅内血肿的形成机制

目的 探讨颅脑损伤术后非手术区迟发性颅内血肿的临床特征及形成机制。方法 回顾性分析29例颅脑损伤术后经CT扫描或再次开颅探查证实为飞黄腾达这发性血肿的发生部位，发生时间，及其与脑挫裂伤，颅骨骨折等原发伤的关系。结果 血肿发生部位与手术部位关系；邻近型8例，远隔型12例，对侧型9例；发生在脑内9例，硬膜外12例，硬膜下7例。脑室内1例；12例术后硬膜外血肿中有9例可见颅骨骨折；9例术后脑内血肿中有7例可见脑挫裂伤。结论 颅脑损伤术后迟发性颅内血肿中，硬膜外，硬膜下与脑内血肿形成机制不尽相同，颅骨骨折，脑挫裂伤，脑膜或皮质血管破裂，桥静脉断裂等局部损伤影响不同类型血肿的形成，脑血管麻痹，低氧血症等是非手术区迟发性血肿形成的病理基础。     

血肿清除术后并发迟发性颅内血肿的临床分析

目的 :探讨外伤性颅内血肿清除术后并发迟发性颅内血肿 (DPIH)的原因、发病机制及防治措施。方法 :790例急性外伤性颅内血肿清除术后 ,4 5例出现术后迟发性颅内血肿 ,将DPIH与未出现术后血肿 (WRIH)者在某些临床特征方面进行比较。结果 :两组比较 ,在术前出现脑疝征象、血肿的类型、凝血功能异常、手术方式、术中低血压及治疗结果等方面均存在显著性差异。结论 :DPIH的发生与颅脑损伤的程度、类型、治疗方式及全身因素密切相关 ,其预后很差。血肿清除术后症状不能改善或病情恶化时应行动态CT检查 ,可尽早发现DPIH。一些预防措施可有助于减少DPIH的发生     

Traumatic extradural hematomas of the posterior fossa in children

The most favorable type of traumatic intracranial bleeding in childhood is the extradural hemorrage (EDH). The posterior fossa location is less frequent than the supratentorial site. In the period from January 1989 to January 1994 we treated 2,372 patients with craniocerebral trauma; 31 had extradural hematomas (1.3%); 3 of them were located in the posterior fossa (9.7%): 1 boy and 2 girls aged from 6 to 16 years. The traumatic mechanism was an occipital fall in all cases. Diagnosis was made by computed tomography scan (CT). Two of them had a rapidly deteriorating course. The three patients were operated on without mortality and there was no morbidity. The role of CT in the early detection of lesions and prompt surgical evacuation may reduce the mortality and morbidity from this lesion. The interaction between these factors is discussed.     

Extradural hematoma: comparative radiological study between comatose and non-comatose patients]

A series of 129 patients harbouring extradural hematomas was analysed considering the neurological state immediately before operation as the most consistent variable. Seventy eight patients were considered to be comatose (Group I) and 51 were noncomatose. Among the comatose group, 30 were investigated with computerized tomography (23.3% mortality, 50% good results), 31 were submitted to angiography (48.3% mortality, 38.7% good results), and 17 were operated based on the neurological examination and skull radiography (47% mortality, 35.2% good results). The presence or absence of skull fracture and the density of hematoma did not change the final outcome. Associated intracranial lesions increased the mortality and lowered the good results in both groups. Frontal hematomas (10 cases) in the comatose group were associated with high mortality (52.6%) due to bad neurological state (Glasgow 3-5) and to isolated or multiple intracranial associated lesions (6 patients).     

迟发性外伤性颅内血肿临床分析

目的探讨迟发性外伤性颅内血肿患者的临床特点,以提高疗效.方法回顾分析1998年1月～2000年7月收治的17例迟发性外伤性颅内血肿患者的临床资料,其中脑内血肿9例,硬膜外血肿5例,硬膜下血肿3例.结果在17例迟发性外伤性颅内血肿患者中,经治疗恢复良好者9例,中残4例,重残2例,死亡2例.结论迟发性外伤性颅内血肿的发生同外伤部位、脑挫伤、颅骨骨折等因素有关.降低迟发性外伤性颅内血肿的死亡率和致残率的关键在于及时诊断和及时治疗     

无框架立体定向下微创穿刺联合尿激酶治疗外伤性脑内血肿

目的探讨在无框架立体定向仪下行微创穿刺联合尿激酶在外伤性颅内血肿中的应用。方法对2012年02月~2013年01月37例外伤性颅内血肿患者的微创治疗疗效进行回顾分析。首先外伤性颅内血肿经CT检查确诊后在24小时内,行无框架立体定向微创穿刺后连接一次性颅内血肿清除套装引流,术后每日两次经套装注入尿激酶并引流积血。结果 37例患者均治愈出院,肢体活动恢复正常29例（73.38%）,轻度残疾6例（16.22%）,2例出现重度对侧肢体偏瘫（5.4%）;13例出现失语症状（35.14%）,余患者恢复良好。住院时间最短7天,最长18天,平均住院时间为10.7天。结论立体定向下微创穿刺定位准、疗效确切、创伤小,术后并发症低,有效地减轻了患者的经济负担。     

急性外伤性颅内血肿清除术后继发血肿再手术的原因分析

目的探讨急性外伤性颅内血肿清除术后再次手术的原因、预防及处理措施。方法2001年11月至2006年11月我科共对561例颅脑损伤病人急诊行开颅血肿清除术，术后31例发生迟发性血肿行再次手术治疗。结果本组31例再次手术后恢复良好7例，中残7例，重残8例，植物生存3例，死亡6例。结论急性外伤性颅内血肿清除术后继发血肿包括：①原血肿手术部位再出血；②多发性血肿的非手术部位血肿形成。临床应采取相应的有效预防措施，并强调严密观察病情变化、及时复查CT，以便及时发现并再次手术清除继发性血肿、缓解颅内压。     

185例小儿外伤性颅内出血的临床分析

目的探讨小儿外伤性颅内出血的临床特点。方法将我院神经外科住院治疗的185例小儿外伤性颅内出血的临床资料进行分析和总结。硬膜外血肿为68例,硬膜下血肿37例,脑挫裂伤75例,脑内血肿3例,外伤性蛛网膜下腔出血2例。颅内出血患儿14例出现抽搐,149例有颅骨骨折,12例脑梗塞,5例脑积水,32例出现贫血。结果 47例行手术治疗,3例死亡,死亡率为1.62%。结论小儿脑出血发展迅速,应密切观察病情,及时做出诊断进行治疗,可有效地降低致残率和死亡率。     

表现为侧裂区血肿的颅内动脉瘤的诊断和治疗

目的探讨颅内动脉瘤破裂导致侧裂区血肿的诊断和处理原则。方法本组男7例,女5例,年龄18～63岁,平均49岁。12例侧裂区血肿均经脑血管造影（DSA）或CT脑血管造影（CTA）检查确诊,其中大脑中动脉瘤9例,后交通动脉瘤2例,后交通动脉瘤合并大脑中动脉瘤1例。本研究对其临床表现、影像学特点及处理原则分别进行了分析。结果12例患者中有10例经开颅动脉瘤夹闭及血肿清除术,1例行经股动脉穿刺血管内弹簧圈栓塞治疗,1例经DSA检查明确动脉瘤后术前准备时再出血,抢救无效死亡。术后1例患者出现脑梗死,经对症治疗好转,3例遗留神经功能障碍,其余病人恢复良好。结论表现为侧裂区的自发性脑内血肿,很有可能是动脉瘤破裂出血所致,需尽早行DSA或CTA检查明确诊断,治疗以手术为首选,术中夹闭动脉瘤并将血肿清除。     

Expanding traumatic intracerebral contusion/hematoma

BACKGROUND AND AIMS: Delayed traumatic hematomas and expansion of already detected hematomas are not uncommon. Only few studies are available on risk factors of expanding hematomas. A prospective study was aimed to find out risk factors associated with such traumatic lesions. MATERIALS AND METHODS: Present study is based on 262 cases of intracerebral hematomas / contusions out of which 43 (16.4%) hematomas expanded in size. computerized tomography (CT) scan was done in all the patients at the time of admission and within 24 hours of injury. Repeat CT scan was done within 24 hours, 4 days and 7 days. Midline shift if any, prothrombin time, activated partial thromboplastin time, bleeding time, clotting time and platelet counts, Glasgow coma scale at admission and discharge and Glasgow outcome score at 6 months follow up were recorded. RESULTS: Twenty six percent, 11.3 and 0% patients developed expanding hematoma in Glasgow Coma scale (GCS) of 8 and below, 9-12 and 13-15 respectively. The chances of expanding hematomas were higher in patients with other associated hematomas (17.4%) as compared to isolated hematoma (4.8%) (Fisher's exact results P =0.216). All the cases of expanding hematoma had some degree of midline shift and considerably higher proportion had presence of coagulopathy. The results of logistic regression analysis showed GCS, midline shift and coagulopathy as significant predictors for the expanding hematoma. Thirty nine patients (90.7%) of the total expanding hematomas developed within 24 hours of injury. CONCLUSIONS: Enlargement of intracerebral hematomas is quite common and majority of them expand early after the injury. These lesions were common in patients with poor GCS, associated hematomas, associated coagulopathy and midline shift.     

CT导引下立体定向脑血肿抽吸术

目的评价CT导引下立体定向脑血肿抽吸术的临床应用价值。方法选择1989年10月～2001年11月入院治疗的脑血肿患者1020例,应用CJF型和Fischer2D型立体定向仪于CT导引下施行脑血肿抽吸治疗。根据CT扫描图像直接测算出脑血肿靶点的X,Y,Z轴坐标,标出靶点位置、抽吸针的行径和进针深度,确保抽吸针到达预定的靶点。1020例患者中基底节区血肿618例、丘脑血肿160例、脑叶血肿182例、小脑血肿6例、脑干血肿40例和脑室出血14例。结果686例患者血肿抽吸量>80%,248例为50%～80%,72例<50%,14例因血肿未液化难以抽出积血。手术后再次出血是主要并发症,发生率为1.17%。1020例中存活835例(81.9%),死亡185例(18.1%)。手术后1个月和3个月进行随访,评估患者预后。根据日常生活能力(activitiesofdailyliving,ADL)评价标准,在随访的819例中1～2级者450例(54.9%),3级者196例(23.9%),4级者131例(16.0%),5级者42例(5.1%)。结论CT导引下立体定向脑血肿抽吸术是一种创伤小、安全、精确和简便的治疗方法。     

Intracerebral Hematoma Caused by Ruptured Traumatic Pseudoaneurysm of the Middle Meningeal Artery : A Case Report

Hematomas caused by ruptured traumatic pseudoaneurysms of the middle meningeal artery (MMA) usually present with extradural hematomas, whereas intradural intraparenchymal hematomas are extremely rare. We report a case of traumatic pseudoaneurysm of the MMA giving rise to an intracerebral hematoma after head trauma. A 70-year-old man suffered a massive intracerebral temporoparietal hemorrhage after a head injury. CT angiogram of the brain revealed a large hematoma in the right middle cranial fossa extending to the right sylvian fissure. Cerebral angiogram also revealed a pseudoaneurysm of the MMA, which was successfully treated surgically. Although traumatic MMA pseudoaneurysm producing intracerebral hematoma (ICH) is rare, it should be considered as a possible cause of intracerebral hematoma.     

Early dynamics of acute extradural and subdural hematomas

Abstract

In a retrospective study volumes of 42 extradural and 702 subdural traumatic hematomas were evaluated. Results were related with the time interval between injury and initial CT scan, outcome, coma grade and subject age. Mean volumes were found to increase with time after the injury. In the first bour volumes of 8 intracranial hematomas were hardly space consuming, while they became clearly space consuming in the second and in later hours after the injury. It was therefore concluded that it should not take longer than one hour until a CT scan be performed when an intracranial post-traumatic hematoma is suspected in the comatose patient. [Neural Res 1997; 19: 257–260]