Salunke Pravin, Garg Ravi, Kapoor Ankur, Chhabra Rajesh, Mukherjee Kanchan K
Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
J Neurosurg. 2015 Mar;122(3):602-9. doi: 10.3171/2014.10.JNS14780. Epub 2014 Dec 12.
Contralateral subdural hygromas are occasionally observed after decompressive craniectomies (DCs). Some of these hygromas are symptomatic, and the etiology and management of these symptomatic contralateral subdural collections (CLDCs) present surgical challenges. The authors share their experience with managing symptomatic CLSDCs after a DC.
During a 10-month period, 306 patients underwent a DC. Of these patients, 266 had a head injury, 25 a middle cerebral artery infarction (that is, a thrombotic stroke), and 15 an infarction due to a vasospasm (resulting from an aneurysmal subarachnoid hemorrhage [SAH]). Seventeen patients (15 with a head injury and 2 with an SAH) developed a CLSDC, and 7 of these patients showed overt symptoms of the fluid collection. These patients were treated with a trial intervention consisting of bur hole drainage followed by cranioplasty. If required, a ventriculo- or thecoperitoneal shunt was inserted at a later time.
Seven patients developed a symptomatic CLSDC after a DC, 6 of whom had a head injury and 1 had an SAH. The average length of time between the DC and CLSDC formation was 24 days. Fluid drainage via a bur hole was attempted in the first 5 patients. However, symptoms in these patients improved only temporarily. All 7 patients (including the 5 in whom the bur hole drainage had failed and 2 directly after the DC) underwent a cranioplasty, and the CLSDC resolved in all of these patients. The average time it took for the CLSDC to resolve after the cranioplasty was 34 days. Three patients developed hydrocephalus after the cranioplasty, requiring a diversion procedure, and 1 patient contracted meningitis and died.
Arachnoid tears and blockage of arachnoid villi appear to be the underlying causes of a CLSDC. The absence of sufficient fluid pressure required for CSF absorption after a DC further aggravates such fluid collections. Underlying hydrocephalus may appear as subdural collections in some patients after the DC. Bur hole drainage appears to be only a temporary measure and leads to recurrence of a CLSDC. Therefore, cranioplasty is the definitive treatment for such collections and, if performed early, may even avert CLSDC formation. A temporary ventriculostomy or an external lumbar drainage may be added to aid the cranioplasty and may be removed postoperatively. Ventriculoperitoneal or thecoperitoneal shunting may be required for patients in whom a hydrocephalus manifests after cranioplasty and underlies the CLSDC.
减压性颅骨切除术（DC）后偶尔会观察到对侧硬膜下积液。其中一些积液有症状，这些有症状的对侧硬膜下积液（CLDC）的病因和处理对手术提出了挑战。作者分享他们处理DC后有症状的CLSDC的经验。
在10个月期间，306例患者接受了DC。这些患者中，266例有头部损伤，25例有大脑中动脉梗死（即血栓性中风），15例有血管痉挛导致的梗死（由动脉瘤性蛛网膜下腔出血[SAH]引起）。17例患者（15例头部损伤和2例SAH）出现了CLSDC，其中7例患者表现出明显的积液症状。这些患者接受了包括钻孔引流随后颅骨成形术的试验性干预。如有需要，随后会插入脑室或脑室腹腔分流管。
7例患者在DC后出现有症状的CLSDC，其中6例有头部损伤，1例有SAH。DC与CLSDC形成之间的平均时间为24天。前5例患者尝试通过钻孔引流积液。然而，这些患者的症状仅暂时改善。所有7例患者（包括钻孔引流失败的5例和DC后直接出现症状的2例）均接受了颅骨成形术，所有这些患者的CLSDC均消失。颅骨成形术后CLSDC消失的平均时间为34天。3例患者在颅骨成形术后出现脑积水，需要进行分流手术，1例患者发生脑膜炎并死亡。
蛛网膜撕裂和蛛网膜绒毛阻塞似乎是CLSDC的潜在原因。DC后脑脊液吸收所需的足够流体压力缺失进一步加重了这种积液。在一些DC后的患者中，潜在的脑积水可能表现为硬膜下积液。钻孔引流似乎只是一种临时措施，并会导致CLSDC复发。因此，颅骨成形术是治疗此类积液的确定性方法，如果早期进行，甚至可能避免CLSDC的形成。可增加临时脑室造瘘术或外部腰大池引流以辅助颅骨成形术，并可在术后拔除。对于颅骨成形术后出现脑积水且是CLSDC潜在原因的患者，可能需要进行脑室腹腔或硬脊膜腹腔分流术。
