Schaller B, Radziwill A J, Wasner M, Gratzl O, Steck A J
Neurologische Klinik, Universitätskliniken, Kantonsspital Basel.
Schweiz Med Wochenschr. 1999 Jul 27;129(29-30):1067-72.
Chronic subdural haematomas are mainly related to slight or moderate head trauma with consecutive lesion of bridge or cortical veins and bleeding in the subdural space. Further predisposing factors are known impairment of coagulation (coagulopathies, treatment with anticoagulants, alcohol abuse), risk factors for degenerative disease of the arteries (diabetes mellitus, arterial hypertension), and development of pressure gradients (hydrocephalus, epileptic seizures, lumbar puncture, CSF drainage and cerebral atrophy). Chronic subdural haematomas appear bilaterally in 20 to 25% of cases. We report on a 69-year-old male with a 4-day history of intermittent, proximal, painless paraparesis (BMA grade M2-5) without a trigger event. Sensibility was normal in all qualities and vigilance was not disturbed. Computed tomography of the neurocranium revealed a bitemporally located chronic subdural haematoma with extension to parietal on both sides. Trepanation was performed over the tuber parietale and temporoparietally on both sides, with release of 150 ml fluid. The neurologic deficits regressed totally within 12 hours postoperatively. To the best of our knowledge, we are the first to describe the clinical paradox of intermittent, painless paraparesis with preserved sensibility and without disturbances of vigilance, as manifestation of a chronic subdural haematoma possibly leading to impairment of cerebral blood flow in the area of the middle cerebral artery. Small changes in systemic blood pressure lead to changes in cerebral perfusion pressure due to vessel compression by the haematoma, thus explaining the intermittent character of the clinical presentation.
慢性硬膜下血肿主要与轻度或中度头部外伤相关，伴有桥静脉或皮质静脉的连续性损伤以及硬膜下间隙出血。其他诱发因素包括已知的凝血功能障碍（凝血病、抗凝治疗、酗酒）、动脉退行性疾病的危险因素（糖尿病、动脉高血压）以及压力梯度的形成（脑积水、癫痫发作、腰椎穿刺、脑脊液引流和脑萎缩）。慢性硬膜下血肿在20%至25%的病例中双侧出现。我们报告一例69岁男性，有4天间歇性、近端、无痛性双下肢轻瘫病史（BMA分级M2 - 5级），无触发事件。各种感觉均正常，意识未受干扰。头颅计算机断层扫描显示双侧颞部慢性硬膜下血肿并累及顶叶。在双侧顶结节及颞顶部进行开颅手术，引出150毫升液体。术后12小时内神经功能缺损完全消退。据我们所知，我们是首个描述间歇性、无痛性双下肢轻瘫伴感觉保留且意识无干扰这一临床矛盾现象的，该现象为慢性硬膜下血肿的一种表现，可能导致大脑中动脉区域脑血流受损。由于血肿压迫血管，全身血压的微小变化会导致脑灌注压改变，从而解释了临床表现的间歇性特点。
