复合手术治疗急性进展性硬膜外血肿1例  

Hybrid surgery foRa patient with an acute progressive extraparenchymal hematoma

作　　者：刘成云 杨华 徐源 彭瀚 周兴旺 向欣 LIU Cheng-yun;YANG Hua;XU Yuan;PENG Han;ZHOU Xing-wang;XIANG Xin(Department of Neurosurgery,Affiliated Hospital of Guizhou Medical University,Guiyang 550004,China)

机构地区：[1]贵州医科大学附属医院神经外科,贵阳550004

出　　处：《中国临床神经外科杂志》2024年第5期318-320,共3页Chinese Journal of Clinical Neurosurgery

摘　　要：急性硬膜外血肿是神经外科常见急重症之一,具有起病急、病情发展迅速、致残率高等特点。尽管目前开颅手术及钻孔引流术等常见手术方式能有效清除血肿,但仍有部分病人由于缺乏针对责任血管的处理,导致血肿继续进展、病情恶化。本文报道1例75岁女性,因交通事故致意识障碍3 h入院,颅脑CT示右侧颞顶部急性硬膜外血肿,血肿量约28 ml。拟行介入栓塞控制出血,二期行钻孔引流术。在导管室完成股动脉穿刺后,突发右侧瞳孔渐散大至5 mm,考虑进展性血肿增大导致小脑幕切迹疝形成。立即行Dyna-CT确认血肿迅速扩大,随即行硬通道穿刺血肿,抽吸出65 ml活动性出血;造影见右侧脑膜中动脉后支造影剂外溢,证实其破裂活动性出血,予以Onyx胶栓塞后即刻造影见出血停止。Dyna-CT引导下于右侧颞枕部再次穿刺抽吸出205 ml血液。之后行开颅手术,取右侧颞顶枕部马蹄形切口,铣开约12 cm×10 cm骨窗,清除硬膜外血肿约80 ml;放射状剪开硬膜后,清除硬膜下血肿约20 ml,同时去除骨瓣。术后1 d复查CT示血肿基本清除,未见新发血肿。术后8个月随访,GCS评分15分,右侧肢体肌力Ⅴ级,左上肢肌力0级,左下肢肌力Ⅲ级。因此,对于急性硬膜外血肿,应准确判断血肿的部位、性质、出血来源和进展速度,充分了解各种治疗方法的优缺点,及时选择恰当的治疗方法,制定个体化的治疗方案,才能获得良好的治疗结果。Acute epidural hematoma is one of the common and critical conditions in neurosurgery,characterized by sudden onset,rapid progression of symptoms,and high rate of disability.Although common surgical procedures such as craniotomy and burRhole drainage can effectively remove the hematoma,some patients still suffeRfrom progression of the hematoma and deterioration of theiRcondition due to lack of treatment foRthe responsible blood vessel.This papeRreported a 75-year-old female who was admitted to the hospital with a 3-houRhistory of loss of consciousness due to a traffic accident.CT scan revealed an acute epidural hematoma that overlies the right frontal and parietal lobes,with a volume of approximately 28 ml.The patient was planned to undergo interventional embolization to control the bleeding and a second operation foRburRhole drainage.AfteRfemoral artery puncture in the angiography room,the patient's right pupil gradually dilated to 5 mm,which was considered to be the progression of the hematoma causing a herniation.A Dyna-CT scan confirmed the rapid expansion of the hematoma,and a volume of 65 ml hemotoma was immediately drainaged.Angiography revealed that the distal branches of the right middle meningeal artery(MMA)were leaking contrast agent,confirming its rupture and active bleeding,which was treated with Onyx glue embolization.Dyna-CT-guided puncture and drainage of 205 ml of blood was performed afteRthe embolization.Subsequently,a craniotomy was performed,with a right temporal-parietal-occipital horseshoe-shaped incision and a 12 cm×10 cm bone window,and approximately 80 ml of subdural hematoma was removed.Radial incision of the dura mateRwas performed afterward,and approximately 20 ml of subdural hematoma was removed.Then the bone flap was removed.One day afteRthe craniotomy,CT scan showed that the hematoma had been mostly removed,and no new hematoma was found.At the 8-month follow-up,the GCS score was 15,and the right limb had a muscle strength of grade V,while the left upper limb had a muscle strength of

关 键 词：急性硬膜外血肿 进展性硬膜外血肿 复合手术 血管内治疗 钻孔引流术 开颅血肿清除术 

分 类 号：R651.15[医药卫生—外科学] R651.11[医药卫生—临床医学]