多次复发难治性慢性硬膜下血肿21例的原因及治疗

目的　探讨反复复发、两次或两次手术以上难治性慢性硬膜下血肿（chronic subdural hematoma, CSDH）的原因及治疗方法。方法　总结分析21例患者的临床资料，结合有关文献进行相关分析。结果　21例难治性CSDH患者中，血肿钻孔引流手术史2次者15例，3次者4例，4次者2例。治疗前CT/MRI扫描发现明显脑萎缩12例，血肿包膜形成8例，血肿分隔多房5例，血肿机化3例。对5例无血肿分房分隔、包膜明显强化及血肿机化的患者仅再行血肿穿刺冲洗引流术，余16例行骨瓣开颅血肿清除+包膜切除术。术后均给予1~2疗程高压氧治疗。随访3~6个月，症状明显改善或消失，无围手术期死亡。术后3个月CT或MRI检查，5例呈硬膜下积液表现，其中2例有占位效应再次行钻孔引流+高压氧治疗；术后6个月，4例有少量硬膜下积液，较前好转，无新复发病例。结论　高龄脑萎缩、包膜形成、血肿分隔多房、血肿机化为难治性CSDH的主要原因；根据不同原因采用开颅血肿和包膜切除或钻孔冲洗引流术+高压氧等治疗可提高治疗效果。

Causes and treatment of multiple recurrent reflactory chronic subdural hematoma in 21 cases

Objective To investigate the reasons and treatment of multiple recurrent in chronic subdural hematoma.Methods A clinical date of 21 patients with multiple recurrent chronic subdural hematoma were analyzed.Results Of 21 cases,16 were male and 5 female,the ages was 42-83 year old and 15 patients were over 60 year old.Burr hole drainage were performed twice in 15 patients and more than 3 times in 6 patients.Strengthen CT and/or MRI scan showed encephalatrophy in 12 patents,hemotoma envelope formation in 8 patients,septal hemotoma cavity in 5 patients and organized hemotoma in 3 patients.16 cases were treated with clearance of hematoma and envelope by craniotomy with bone flap and other 5 cases were received combined burr hole drainage with hyperbaric oxygenation.Follow-up was between 3-6 months.A small amount of subdural effusion was found in 4 cases.No death happened.Conclusion Old folk,encephalatrophy,hemotoma envelope formation,septal hemotoma cavity and organized hemotoma are the major reasones in multiple recurrent of chronic subdural hematoma.Depending on the different reasones,choice clearance of hematoma and envelope by craniotomy with bone flap or treated combined burr hole drainage again with hyperbaric oxygenation can improve the treatment effect.