Recurrent hematomas following craniotomy for traumatic intracranial mass

Of 850 patients who underwent craniotomy for evacuation of a traumatic intracranial mass, 59 (6.9%) developed a second hematoma at the operation site, which required a second operation. Compared to those who did not, patients who developed postcraniotomy hematoma (PCH) had a significantly higher incidence of evidence of alcohol intake and preoperative mannitol administration; a higher percentage had a bad outcome. Coagulopathy was frequent in PCH patients. Although three-quarters of the initial hematomas were intradural, 69% of the PCH's were predominantly extradural. The large potential space underlying a craniotomy bone flap may predispose to development of a PCH. Intracranial pressure (ICP) was monitored in 39 of the 59 PCH patients, which allowed earlier detection of the PCH in 22 (56%). In 17 patients, the ICP failed to rise despite clinical deterioration, and detection of the PCH was delayed, significantly worsening the outcome in this group.     

小儿急性外伤性颅内血肿的诊疗

小儿急性外伤性颅内血肿除具一般颅内血肿的发生发展规律外,还具有其特殊性。本院自1990年1月至2000年12月,共收治小儿急性外伤性颅内血肿96例。本文根据小儿急性外伤性颅内血肿的临床特点,总结分析如下。1临床资料1.1一般资料:男66例,女30例;2岁以下7例,3～6岁37例,7～15岁51例,平均年龄7.9岁。坠落伤46例,跌伤28例,车祸伤19例,打击伤3例。1.2伤情分类及临床表现:入院时意识状态按格拉斯哥计分(GCS):3～5分5例,6～8分18例,9～12分31例,13～15分42例。伤后有原发昏迷史39例,入院时昏迷且意识阻碍进行加重23例。入院时单侧瞳孔散大伴对侧偏…     

Surgical management of traumatic intracerebral hematomas

Intraparenchymal lesions continue to contribute significantly to poor outcome in patients with head injury. This article elucidates the problems that must be dealt with in the management of these patients and develops guidelines that may be useful in making surgical decisions.     

Surgical treatment of multiple intracranial aneurysms

Summary A retrospective review of 126 patients with multiple aneurysms seen over a 10 year period was undertaken. They had a total of 302 aneurysms. Thirty-seven percent of the patients were males, and 63% were females. Direct operations were performed on 97 cases. Both the ruptured and unruptured aneurysms were treated in 71% (69 of the 97 cases), and only the ruptured aneurysms were treated in 29% (28). In 69 cases in whom both ruptured and unruptured aneurysms were treated, one-stage operations were used for 48 cases, and two-stage operations were used for 21 cases. Thirty-four of the 48 cases, who were treated in one-stage operations, were operated on by day 4 after subarachnoid haemorrhage. In 12 cases, a total of 13 small unruptured aneurysms, which had not been found by preoperative angiograms, were discovered during surgery, and 9 of the 13 were discovered while removing blood clots to reduce cerebral vasospasm. Regardless of the operative method selected and the timing of operations, the surgical outcome of patients with multiple aneurysms was comparable to that of the 228 cases with single aneurysms treated during the same period at the same hospital.The analysis of this study suggests that surgical results for multiple aneurysms are satisfactory, even for early operations. Further, the actual incidence of multiple aneurysms may be higher than has been reported to date because small unruptured aneurysms which have been discovered during clot removal may not have been reported.     

颅内多发动脉瘤的手术治疗

目的 探讨颅内多发动脉瘤的手术策略并分析临床疗效.方法 回顾性分析2009年1月至2013年12月手术治疗49例颅内多发动脉瘤患者的临床资料.49例患者中,男性12例,女性37例;平均年龄(49±11)岁;35例动脉瘤破裂,14例未破裂;治疗策略有一期手术(一侧入路夹闭所有动脉瘤),二期治疗(分期处理所有动脉瘤)和部分治疗(只处理责任动脉瘤).随访中复查脑CT血管造影(CTA)或数字减影血管造影(DSA),用格拉斯哥预后量表(GOS)评估预后.结果 一期手术32例(65.3％),二期治疗9例(18.4％),部分治疗8例(16.3％).47例随访4 ～ 49个月,平均(22 ±7)个月.术后CTA或DSA均未见动脉瘤复发.根据GOS评分,患者预后良好(4～5分)41例(83.7％),残疾(2～3分)6例(12.2％),死亡(1分)2例(4.1％).结论 在具有娴熟手术技术的前提下选择合适的患者,根据动脉瘤和患者的特征制定个性化的手术策略,能提高颅内多发动脉瘤的手术疗效.     

Surgical treatment of multiple intracranial aneurysms

Summary Patients with multiple intracranial aneurysms present a great challenge to neurosurgical practice. The presence of one or more additional aneurysms, whether recognized or unrecognized, along with the source of the haemorrhage profoundly changes the outcome. It also alters the timing and strategy of surgery. In this study the experiences gained from 138 cases with a total of 317 aneurysms are discussed. The analysis of the clinical data, our results and the factors influencing the outcome suggest that the risk of clipping all aneurysms simultaneously are less than the risk of a rebleed from an untreated, previously silent sac even in the early postoperative period.     

Surgical outcome for multiple intracranial aneurysms

Summary The surgical outcome of 221 cases with multiple intracranial aneurysms operated upon during the years 1988 to 1994 were reviewed. The patients were classified into three groups according to the locations of the aneurysms; group 1: multiple aneurysms located unilaterally in the anterior circulation only (147 cases); group 2: multiple aneurysms located bilaterally in the anterior circulation only (44 cases) and group 3: multiple aneurysms located in both anterior and posterior circulation or in the posterior circulation alone (30 cases). In 132 cases of group 1 (89.8%) all aneurysms were treated in one-stage operations. Twenty-eight patients from group 2 (63.6%) received partial treatment, where only the ruptured or the symptomatic aneurysms were treated. In 12 other cases from group 2 (27.3%) all multiple aneurysms were treated in two-stage operations. In group 3 patients, one-stage operations were performed in 18 cases (60%), while 9 patients (30%) received partial treatment only. Of the 221 multiple aneurysm cases, 162 (73.3%) presented with manifestations of subarachnoid haemorrhage (SAH). The remaining 59 multiple aneurysms cases (26.7%) presented with manifestations other than SAH (unruptured aneurysms). In the postoperative follow-up, of the 221 multiple aneurysms cases, 113 (51.1%) were free of neurological deficit (excellent), 48 cases (21.7%) were capable of leading an independent life (good), 32 cases (14.5%) were not independent and needed to be assisted (fair), and 28 patients (12.7%) died. These results were comparable to the results of patients with single aneurysms operated on during the same period.Based on our results, we recommend that whenever possible all multiple aneurysms should be treated in one-stage operations. In unruptured multiple aneurysm cases surgical management is the recommended treatment. In poor grade SAH patients or unruptured multiple aneurysms in old patients, two-stage operations or partial treatment of only the ruptured or the symptomatic aneurysms may be adopted.     

The significance of skull fracture in acute traumatic intracranial hematomas in adolescents: a prospective study

A prospective study was conducted to validate the retrospective finding that adolescents (11 to 15 years old) with skull fractures were prone to develop acute traumatic intracranial hematoma (ICH). Over a 4-year period, 1178 consecutive adolescents attended the emergency room directly, of whom 760 were discharged well and 418 were admitted. All underwent skull x-ray studies. Immediate computerized tomography (CT) scans were performed in patients with Glasgow Coma Scale (GCS) scores of less than 15, in those with radiological and/or clinical evidence of skull fracture, and whenever clinically indicated. Of the 418 admitted patients, only 26 had skull fractures; 13 of these developed ICH. Four patients without skull fracture developed diffuse brain swelling. The remaining 401 patients were discharged after observation periods of up to 48 hours. Of the 13 patients with ICH, 10 had admission GCS scores of 15; however, four deteriorated rapidly and required urgent operation, and four remained stable but were operated on due to their large ICH. Two required conservative treatment only and both made good recovery. Three patients were in coma (GCS score less than or equal to 8) on admission. One patient had an epidural hematoma and made good recovery after surgery. Two developed delayed ICH after operations for associated systemic injuries despite initial CT showing diffuse brain swelling only, and both died despite evacuation of the ICH. Multivariate analysis showed that skull fracture was the only independent significant risk factor in predicting ICH in adolescents (sensitivity of 100% and specificity of 97%). A routine skull x-ray study is therefore mandatory in all head-injured adolescents and, if a skull fracture is detected, immediate CT may be performed for early detection of ICH.     

Neurosurgical treatment of spontaneous and traumatic intracerebral hematomas

In the period from 01.01.2000 until 31.12.2002 34 patients with spontaneous intracerebral hematoma (ICH) and with deeply disturbed state of consciousness were operated in the Department of neurosurgery of the Urgent Center, Clinical Center of Serbia. In all operated patients the indication for surgery was given on the basis of CT scan of the brain, state of consciousness, defined Glasgow coma score (GCS) and neurological status, but due to existing or threatening incarceration not even one patient was submitted to angiography of the blood vessels at the cerebral base, thus preoperatively we did not know the cause of the hemorrhage. Of 34 operated patients 22 or 64.7% died, and 12 or 35.3% survived. 14 patients were in the deepest phase of coma, where the preoperative GCS is from 3 to 5 points, and in the postoperative course only one survived, aged 25. The other survivors had somewhat less disturbed state of consciousness, they also were younger, CT scan of the brain was without blood in the chamber system. In the same period, in the Department of Neurosurgery of the Urgent Center, Clinical Center of Serbia 43 patients with traumatic intracerebral hematoma (TIH) were operated; 9 patients survived, 34 died. Only 4 patients had acute TIH. All of them were in the terminal stage of incarceration, and despite being immediately submitted to surgery all of them died. The remaining 39 patients had, the so called delayed TIH where the secondary CT scan of the brain showed development of the traumatic intracerebral haematoma that was not verified on the incipient scanner. Indication for a repeated CT scan was given in 19 patients due to focal or general neurological deterioration. However in 20 patients subsequent neurological disturbances were not registered. Those that survived were younger patients, and they were not in the deepest stage of coma, most often they had a temporal localization of hematoma.     

Surgical treatment for traumatic tracheobronchial injuries

Tracheobronchial injury is a relatively rare but often fatal condition due to the injury from the neck to the chest. Different clinical features depend on the site of injury. We experienced 5 cases of tracheobronchial injury; cervical trachea in 2, thoracic trachea in 1, tracheal carina in 1, left main bronchus in 1. Three cases were caused by blunt trauma by traffic accident and 2 cases were due to penetrating injury (stab wound and gunshot wound). Thoracotomy with primary repair for 3 (simple repair, bronchoplasty, pneumonectomy) and cervicotomy for 2 (end-to-end anastomosis) were performed. One patient with severe associated injury died of multiple organ failure after surgery. Accurate diagnosis and the appropriate treatment in the early stage is essential in the treatment of tracheobronchial injury.     

Cerebral atrophy after acute traumatic subdural orextradural hematomas in adults

Cerebral atrophy is one of the serious sequelae ofsevere head injury. 1 Neuropathologicalinvestigation has revealed that cerebral atrophy iscaused by either diffuse axonal injury or cerebralhypoxia and ischemia. Secondary ipsilateral cerebralatrophy caused by acute subdural hematomas in infantshas been reported recently, but this unilateral cerebralatrophy after head injury in adult patients has rarelybeen reported.     

创伤性枢椎滑脱的外科治疗

目的：探讨手术治疗创伤性枢椎滑税的方法和疗效。方法：自1992年1月～2001年9月对17例创伤性枢椎滑税患者进行手术治疗。其中前路C2/3椎体螺钉固定9例；后路枕颈融合5例，C2椎弓根螺钉直接固定3例。结果：所有患者未出现与内固定有关的并发症。17例患者的C2椎弓均取得骨性融合，无畸形愈合，临床效果满意。结论：手术治疗创伤性枢椎滑税具有治疗周期短，疗效确实，并发症少的优点，可以在有条件的大医院实施。