Fernández-Carballal C, Muñoz-Fernández E, García-Salazar F, Cancela-Caro P, Mateo-Sierra O, Pinilla-Arias D, Mosqueira-Centurión B
Departamento de Neurocirugía, Hospital General Gregorio Marañón, Madrid, Spain.
Rev Neurol. 2004;39(4):335-8.
Ruptured aneurysms on rare occasions cause subdural hematomas as described in literature. Sudden deterioration and coma is a common feature in those patients and a emergent surgical attitude is prompt required, even without confirmation with angiography.
We described three cases with acute subdural hematomas and little or no subarachnoid hemorrhage caused by ruptured aneurisms who presented with rapid neurologic deterioration. Urgent craniotomy and evacuation of the hematoma was performed without previous angiography in the three patients. In two patients the aneurysm was found during surgical exploration and subsequently clipped; in the remaining patient the aneurysm was embolized postoperatively.
The occurrence of a subdural hematoma caused by the rupture of an intracranial aneurysm must be suspected in spontaneous subdural hematomas, especially in association with disproportioned conscious deterioration. All the three patients we report debuted with sudden conscious deterioration. If a ruptured aneurysm causing subdural hematoma is suspected, early surgical intervention is required even if angiography is not available. Severe neurological deficit and uncal herniation might still be reversible if provided decompression can be carried out in promptly. Angiography availability should not postpone surgery. Aneurysm presence should be ruled out whether by surgical exploration or by delayed angiography. Posterior communicating aneurysm are related to formation of subdural hematoma.
如文献所述，破裂的动脉瘤在极少数情况下会导致硬膜下血肿。这些患者的常见特征是突然病情恶化并昏迷，即使未经血管造影确认，也需要迅速采取紧急手术治疗。
我们描述了3例由破裂动脉瘤导致急性硬膜下血肿且蛛网膜下腔出血很少或无出血的病例，这些患者均出现快速神经功能恶化。3例患者均未进行血管造影就紧急实施了开颅手术并清除血肿。2例患者在手术探查时发现动脉瘤并随后夹闭；其余1例患者在术后进行了动脉瘤栓塞。
对于自发性硬膜下血肿，尤其是伴有意识恶化程度不成比例的情况，必须怀疑颅内动脉瘤破裂导致硬膜下血肿的发生。我们报告的所有3例患者均以突然意识恶化起病。如果怀疑是破裂动脉瘤导致硬膜下血肿，即使没有血管造影检查，也需要早期手术干预。如果能及时进行减压，严重神经功能缺损和钩回疝仍可能可逆。血管造影检查不应推迟手术。应通过手术探查或延迟血管造影排除动脉瘤的存在。后交通动脉瘤与硬膜下血肿的形成有关。
