急性外伤性颅内血肿二次手术16例临床分析

急性外伤性颅内血肿手术后迟发性颅内出血的比例虽然较小,但死亡率高,因此越来越受到神经外科医师的重视.本院2001年3月至2003年11月,收治手术治疗的外伤性颅内血肿138例中,16例在急性颅内血肿清除术后出现颅内迟发出血而行第2次手术.现报告如下.     

外伤性迟发性颅内血肿的临床观察与护理

目的总结外伤性迟发性颅内血肿的护理经验。方法对36例外伤性迟发性颅内血肿患者进行严密观察与细心护理。结果治愈30例,中等残疾3例,重残2例,死亡1例。未发生与护理不当有关的并发症。结论严密观察与细心护理是降低外伤性迟发性颅内血肿病死率、病残率和改善预后的关键。     

外伤性迟发性颅内血肿临床分析

目的:探讨外伤性迟发性颅内血肿的早期诊断及治疗效果。方法:回顾分析本院收治的121例外伤性迟发性颅内血肿的发生机理、早期诊断和治疗效果。结果:对幕下血肿大于10ml,幕上血肿大于30ml且中线移位明显者75例施行开颅血肿清除加去骨瓣减压术,效果良好53例,重残5例,死亡17例,死亡率22.7%。而46例血肿较小、中线移位不明显者行非手术治疗,效果良好35例,重残8例,死亡3例,死亡率6.5%。结论:早期诊断能明显提高外伤性迟发性颅内血肿的治疗效果,而动态CT监测是早期诊断外伤性迟发性颅内血肿的关键。     

外伤性颅内血肿手术后并发迟发性血肿分析

目的分析外伤性颅内血肿手术后并发迟发性颅内血肿,探讨其与诸多因素的关系。方法回顾性调查1994年1月至2002年12月期,间本院收住的764例外伤性颅内血肿手术病人熏术后并发迟发性颅内血肿共98例,对其年龄、受伤机制、血肿厚度与中线移位的关系、血肿量、血肿部位、脑挫裂伤、手术时机以及术后骨窗的压力与发生迟发性血肿的关系,进行研究分析。结果诸多因素与并发迟发性血肿之间的存在相关关系。结论迟发性颅内血肿是颅脑外伤手术后较常见和严重的并发症,对其的发生应有足够的预见性,早期诊治是降低其死亡率和致残率的关键。     

外伤性迟发性颅内血肿临床特点及首次CT的影像学特征分析

目的分析外伤性迟发性颅内血肿临床特点及首次CT影像学特征,早期诊断外伤性迟发性颅内血肿,提高疗效。方法回顾性分析我院2005年至2009年经CT证实的外伤性迟发性颅内血肿患者的临床资料,总结临床特点和首次CT影像学特征。结果迟发性血肿多发生在伤后3d内,额颞部好发,老年人容易发生,进行性的意识水平下降或出现新的神经系统体征往往意味着迟发性血肿;首次CT发现头皮血肿、颅骨骨折、气颅、脑挫伤、蛛网膜下腔出血、外侧裂血肿等预警征象时,要警惕迟发性血肿的发生。结论如果首次CT扫描有头皮血肿、颅骨骨折、脑挫伤、蛛网膜下腔出血、外侧裂血肿者,或颅内血肿成功清除后,但临床症状和特征未改善甚至加重者,进行性的意识水平下降者,伤后应将头部CT动态扫描作为常规检查,做到早期诊断、及时治疗。     

一侧急性颅内血肿清除术中继发对侧迟发性颅内血肿的治疗体会

目的 探讨一侧急性颅内血肿清除术中继发对侧迟发性颅内血肿的治疗方法.方法 回顾性分析13例急性颅内血肿术中继发对侧迟发性颅内血肿患者的临床资料,采用一次开颅清除双侧血肿.结果 术后按Glasgow(COS)评定预后,其中良好4例,中残4例,重残2例,植物生存1例,死亡2例.结论 采用一次开颅治疗一侧急性颅内血肿清除术中继发对侧迟发性颅内血肿的效果显著,可以提高患者的生存率和生活质量.     

微创穿刺术与开颅清除术治疗老年迟发外伤性颅内血肿的临床疗效比较研究

目的研究分析老年迟发外伤性颅内血肿行微创穿刺术治疗后的临床疗效。方法选取2012年1月至2017年1月本院收治疗的老年迟发性外伤性颅内血肿患者70例,治疗医师根据手术方法不同将所有患者分为A组(24例)、B组(46例)。A组患者行微创血肿穿刺术治疗,B组患者行常规开颅血肿清除术治疗,观察两组患者治疗时清除血肿操作时间及治疗后的并发症情况。应用GOS(格拉斯哥颈后评分表)评分对两组患者治疗后的整体疗效进行评估。结果 A组患者血肿清除操作时间明显短于B组,且A组治疗后的并发症发生率显著低于B组,差异具有统计学意义(P0.05);A组患者治疗后的临床疗效有效率明显高于B组患者,差异具有统计学意义(P0.05)。结论微创血肿穿刺引流术治疗迟发性外伤性颅内血肿具有更好的临床疗效。效果显著,优点明显,适合临床医师选择应用。     

一侧急性颅内血肿清除术中继发对侧迟发性颅内血肿的治疗体会

目的 探讨一侧急性颅内血肿清除术中继发对侧迟发性颅内血肿的治疗方法.方法 回顾性分析13例急性颅内血肿术中继发对侧迟发性颅内血肿患者的临床资料,采用一次开颅清除双侧血肿.结果 术后按Glasgow(COS)评定预后,其中良好4例,中残4例,重残2例,植物生存1例,死亡2例.结论 采用一次开颅治疗一侧急性颅内血肿清除术中继发对侧迟发性颅内血肿的效果显著,可以提高患者的生存率和生活质量.     

颅脑损伤手术中即时诊治对侧迟发性颅内血肿

外伤性迟发性颅内血肿的早期诊治,是影响预后的关键因素。我院自1995．3～2000．10在急性颅脑损伤手术中怀疑对侧出现迟发性血肿即行钻颅探查,确诊并行血肿清除37例,疗效良好。现分析报告如下。     

急性颅内血肿清除后继发对侧迟发性血肿

目的 探讨急性外伤性颅内血肿清除的术中及术后，及时发现对侧迟发性血肿并治疗的意义。方法 在术中发生急性脑肿胀时应在对侧钻颅探查或术后病人恶化时行CT检查。结果 治疗15例对侧迟发血肿病人其中2例死亡，手术死亡率为6％。结论 在清除急性外伤性颅内血肿时发生急性脑肿胀，或术后病情恶化，应想到对侧可能是迟发性血肿形成，宜尽早复查CT及钻颅探查，早诊早治可改善预后。     

慢性扩展性脑内血肿18例临床分析

目的 总结慢性扩展性脑内血肿的诊断与治疗经验。方法 对18例慢性扩展性脑内血肿的临床资料进行回顾性分析。结果 多数病变术前误诊为脑肿瘤。术后15例痊愈，2例重残，1例死亡。结论 脑内有包膜的占位性病变应考虑慢性扩展性脑内血肿的可能，最后诊断需手术及病理证实。     

表现为慢性脑内血肿的脑血管畸形诊断与治疗

目的：探索CT表现为慢性脑内血肿的脑血管畸形的诊断和外科治疗。方法：回顾性分析10例CT表现为慢性脑内血肿的脑血管畸形，主要症状表现为癫痫，轻瘫和头痛，所有病例均经CT检查，5例经MRI检查，4例经全脑DSA检查，所有病人均经手术治疗，并取得相应资料。结果：术前6例误诊囊性胶质瘤或肿瘤卒中，术后是诊断均为脑血管畸形伴慢性脑内血肿，全组无死亡，除1例轻瘫外均恢复正常；8例临床和影像学随访5月－6年无异常发现。结论：表现慢性脑内血肿的脑血管畸形易误诊为脑胶质瘤，MRI，DSA检查对确诊和治疗有重要意义。     

Conservative treatment of traumatic intracerebral hematoma

In the previous report, it was insisted that traumatic intracerebral hematoma should be regarded as a variety of cerebral confusion and that conservative treatment would be therapy of choice in these situations. Adversely, unjudicious operation would sometimes result in more expansion of hematoma by untamponade effect of decompressive craniectomy. In the present investigation, it was attempted to provide therapeutic policy in the management of traumatic intracerebral hematoma. Consecutive thirty two cases of traumatic intracerebral hematomas were selected for this study. Those cases with other hematoma such as epidural or subdural hematoma were excluded. These 32 cases were divided into two groups, operative (15 cases) and non-operative (17 cases). Whether to be operated or not was arbitrarily decided by the surgeons who were faced to the patients. Disturbance of consciousness of the patients were divided into three categories, namely severe (III-100 to 200 level), moderate (II-10 to 30 level), and mild (I-1 to 3 level). They were 8 cases, 5 cases, 1 case in operative cases and 6 cases, 10 cases, 1 case in non-operative cases respectively. Mortality rates were 13.3% (2 cases) in operative cases and none in non-operative ones. Concerning the patients of severely disturbed consciousness, there were no difference in their final outcomes between the two groups. On the other hand, 7 out of 10 cases of moderately disturbed consciousness recovered completely without operation, whereas all operative cases of the same category were, more or less, handicapped.     

中小骨瓣开颅辅以冷光源冲照吸引管治疗脑内血肿

目的探讨脑内血肿的手术方法和技巧。方法根据CT扫描结果设计合适大小的骨瓣,联合应用冲照吸引管和双极电凝清除脑内血肿。采用该方法治疗脑内血肿29例,其中26例为高血压脑出血,2例为外伤性脑内血肿,1例为动静脉畸形脑内出血。结果术后随访6～12月,26例存活,其中完全恢复日常生活6例;部分恢复或可独立生活11例;需他人帮助,扶拐可行5例;卧床,但保持意识清醒3例;植物生存1例。结论中小骨瓣开颅辅以冲照吸引管清除脑内血肿具有组织创伤小,手术时间短,明显降低脑出血病人的死亡率和致残率,提高生存质量,特别适用于深部脑内血肿的治疗。     

Intracerebral hematoma surgically treated under x-ray computed tomography with Backlund's needle. A series of 15 cases

15 cases of supratentorial intracerebral hematomas (12 cases of primary hematomas and 3 post-traumatic cases) were operated under C.T. scan control, using the screw and suction technique (Backlund's needle). 10 cases of primary hematomas were operated early, before the 24th hour. The patients were selected for intervention on the following criteria: 1) Patients aged less than 70 years old; 2) initial Glasgow coma scale between 6 and 10; 3) cases with involvement of the mesencephalon by the hematoma were excluded. In the 3 cases of post-traumatic hematomas, intervention was decided in reference to the clinical course. The volume of the hematomas ranged from 40 to 160 cc. Putaminal or thalamic hematomas were observed in 9 cases. The percentage of aspirated hematoma volume ranged from 50 to 91%, the average being 70.5%. Dramatic improvement of the consciousness was observed in all cases. Improvement of the motor deficit was incomplete, for the most part. 1 patient rebled and 1 patient died (6.6% mortality). In 26% of the cases (4 patients) the development of a brain oedema, in the surrounding of the residual hematoma site, was observed during the post operative follow up. There was no post operative infection. Intervention under direct C.T. control allows an accurate guidance of the needle. Efficacity of the evacuation is attested by an immediate improvement of the mass effect on C.T. scan. Under C.T. control the risk to aspirate the adjacent brain is avoided. The technique proposed here has been easily performed in emergency condition.     

显微手术治疗幕上高血压性脑出血的体会

目的探讨显微镜下清除幕上高血压性脑出血的疗效。方法我院2010年1月-2013年1月显微手术治疗30例幕上高血压性脑出血,根据头颅CT影像定位确定手术切口,游离骨瓣开颅,做一长2-3am皮层瘘口,用自动牵开器由浅入深显露血肿,显微镜下清除血肿。结果30例手术均获得成功。术后次日复查头颅CT,14例血肿完全清除,11例血肿清除率达到90％,5例清除率达到80％。术后死亡4例（13．3％）：均于术后4周内死亡：2例死于脑疝所致脑干功能衰竭,1例死于肺部感染,1例死于多脏器功能衰竭。术后3个月ADL分级：I级7例,Ⅱ级9例,Ⅲ级6例,Ⅳ级3例,V级1例。结论显微镜下血肿清除并直视下止血,对脑组织损伤小,止血彻底,疗效满意。     

Analysis of 53 ruptured middle cerebral artery aneurysms

In spite of a recent remarkable progress in operative results of ruptured middle cerebral artery aneurysms, a mortality rate of 2-8% appears to be unavoidable. In the present study, 53 ruptured MCA aneurysms were retrospectively analyzed to determine causative factors of unfortunate outcome (fair, poor and dead). Surgical results of 53 ruptured MCA aneurysms are shown in Table 1, where the outcome was unfortunate in 7 cases (17%). Intracerebral hematoma was responsible for 4 cases, two of which were fatal and postoperative vasospasm for 3 cases. There were 13 cases with intracerebral hematomas (25%) ranging from 21 mm to 68 mm in diameter. Although hematomas less than 40 mm in diameter localized in temporal or frontal subcortical areas and yielded no neurological deficits, those more than 60mm extended to the caudate nucleus or thalamus through the internal capsule and led to deep coma (Table 2, Fig. 1). Intracerebral hematoma with the diameter between 50 to 60 mm seems to be critical in regard to postoperative outcome. Repeated rupture caused intracerebral hematoma (50%) more frequently than single rupture (21%) and aneurysm with intracerebral hematoma was liable to bleed (27%), resulting in acute deterioration of neurological conditions by marked enlargement of the hematoma (Fig. 2). Accordingly it is essential for the cases with intracerebral hematoma to prevent rerupture. Subarachnoid hemorrhage and symptomatic vasospasm were observed less frequently in hematoma group than in non-hematoma group. However, prophylactic treatment of vasospasm is important even in the cases with intracerebral hematoma since more than half of them suffer from relatively thicker subarachnoid clot.     

Endoscopic evacuation of intraventricular hematoma and third ventriculostomy

We described our experience of three cases treated with endoscopic evacuation of intraventricular hematoma and third ventriculostomy for a tight intraventricular hematoma associated with intracerebral hemorrhage. A steerable endoscope was introduced into the anterior horn of the lateral ventricle contralaterally to the intracerebral hemorrhage, through a 14 Fr. peel-away sheath. First, the hematoma in the lateral ventricle contralateral to the hemorrhage was evacuated by direct aspiration using a syringe connected to the operative channel of the endoscope, and evacuation of the hematoma was subsequently carried on the third ventricle, aqueduct and the fourth ventricle. After the evacuation of the intraventricular hematoma, third ventriculostomy was performed for acute obstructive hydrocephalus. Finally, the procedure was completed with septostomy and evacuation of the hematoma in the lateral ventricle ipsilateral to the hemorrhage. Sufficient evacuation of the hematoma was obtained in all cases and no major complications were encountered. We conclude that for patients with intraventricular hematoma associated with intracerebral hemorrhage endoscopic evacuation of intraventricular hematoma brings about sufficient removal of hematoma, reduction of hospitalization time and prevention of subsequent hydrocephalus.     

Computerized tomography (CT), EMI scanner, in the diagnosis of acute traumatic intracranial hematomas (author's transl)

Eighteen examinations of acute head trauma have been performed using computerized tomography (CT), EMI scanner, before and after operation in our department since September, 1975. Diagnostic findings in CT before emergency operations of 5 cases including epidural hematoma (1), subdural hematoma (2), intracerebral hematoma (1), and combined hematoma (1) were presented and the diagnostic value of this new method was compared with that of cerebral angiography. CT was proved to be highly valuable in the diagnosis of not only intracranial hematomas but also cerebral edema, cerebral contusion and other abnormalities of the brain structures in head injury.     

Multiple intracranial lesions in head injury: clinical considerations, prognostic factors, management, and results in 95 patients

BACKGROUND: The goal of this study was to identify clinical and radiological predictors of prognosis in patients with multiple post-traumatic intracranial lesions. METHODS: We reviewed 95 patients (75 male and 20 female) between the ages of 18 and 70 (average 38) admitted between 1993 and 2000 with multiple post-traumatic intracranial lesions. Intracranial pressure (ICP) monitoring was carried out in 67 patients (70%); 77 received intensive care unit (ICU) treatment. Since in all cases it was possible to identify a clearly predominant lesion, 3 groups of patients emerged from the data: the first with extradural hematoma (EDH), the second with a combination of homolateral subdural (SDH) and intracerebral hematoma (ICH), and the third with pure focal intracerebral hematoma (ICH). RESULTS: Twenty-seven patients were treated conservatively, 2 of whom died (7.4%); both had bilateral ICH and compression of the basal cisterns. Sixty-eight patients underwent one or more surgeries; 8 died (11.7%). In the group with EDH-predominant lesions (27 cases) all patients were operated (16 for multiple lesions); no one died. In the group with SDH+ICH-predominant lesions, 26 of 32 patients were operated (10 had multiple procedures); 6 died (18.7%), 3 were vegetative. In the group with ICH-predominant lesion, 15 of 36 patients were operated (7 bilaterally); 4 died (11%).Decompressive craniectomy proved to be a useful means to control ICP. Bilateral lobectomy is not recommended because of poor results. Immediate postoperative computed tomography (CT) scan proved to be mandatory to detect additional surgically treatable lesions (16 cases).Statistical analysis was performed by means of chi(2) analysis and multiple linear regression model. The multiple linear regression model was used to ascertain risk factors independently associated with the outcome. The type of lesion (presence of SDH+ICH predominant lesion), the worst recorded Glasgow Coma Scale (GCS) score, the presence of prolonged increased ICP, and the absence of pupillary reflexes were all statistically significant predictors of a bad outcome (dead or vegetative state). CONCLUSIONS: Multiple lesions have the same prognosis as the corresponding single lesions; therefore, their management should be guided by the predominant pathology.