Nakagawa Atsuhiro, Karibe Hiroshi, Onuma Takehide, Hirano Takayuki, Kameyama Motonobu, Ishii Kiyoshi
Department of Neurosurgery, Sendai City Hospital, Japan.
No Shinkei Geka. 2011 Mar;39(3):287-92.
The authors have encountered a case of compound depressed skull fracture in a 59 year-old-man complicated by occlusion of the anterior 1/3 part of the superior sagittal sinus (SSS). He was hit by a hammer at the midline of the frontal region, and transferred to our emergency care unit. On admission, there was laceration of skin at the midline of the forehead, but the patient had no neurological deficit. Skull radiograph showed a depressed skull fracture over the SSS. Computed tomography (CT) scan showed a small brain contusion adjacent to the depressed fracture. Digital subtraction angiography (DSA) showed occlusion of the anterior 1/3 part of SSS, and extravasations of contrast medium from cortical arterioles and capillaries. CT taken at 4 hours after injury showed enlargement of the lesion with extravasations of contrast medium and the patient manifested consciousness disturbance at this point. Distribution of extravasations suggested the occurrence of hemorrhagic infarction. Elevation of the depressed skull was thus performed under general anesthesia. There was laceration of the dura 5 mm away from the SSS and lacerations of cortical vessels, but there was no apparent damage to SSS itself. The depressed bone was replaced with artificial bone. The patient was discharged without any neurological deficit. Preoperative angiography was helpful to understand the hemodynamics and risk of massive bleeding during the operation.
作者遇到一例59岁男性的复合性凹陷性颅骨骨折，并发上矢状窦（SSS）前三分之一部分闭塞。他在额部中线被锤子击中，随后被转至我们的急诊护理单元。入院时，前额中线处有皮肤裂伤，但患者没有神经功能缺损。颅骨X线片显示SSS上方有凹陷性颅骨骨折。计算机断层扫描（CT）显示凹陷骨折附近有小面积脑挫伤。数字减影血管造影（DSA）显示SSS前三分之一部分闭塞，造影剂从皮质小动脉和毛细血管外渗。受伤后4小时进行的CT显示病变扩大，有造影剂外渗，此时患者出现意识障碍。外渗分布提示发生了出血性梗死。因此在全身麻醉下对凹陷颅骨进行了抬高。在距SSS 5毫米处有硬脑膜裂伤和皮质血管裂伤，但SSS本身没有明显损伤。用人工骨替换了凹陷的骨头。患者出院时没有任何神经功能缺损。术前血管造影有助于了解手术过程中的血流动力学和大出血风险。
