Di Rienzo Alessandro, Iacoangeli Maurizio, Alvaro Lorenzo, Colasanti Roberto, Somma Lucia Giovanna Maria Di, Nocchi Niccolo, Gladi Maurizio, Scerrati Massimo
Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy.
J Neurol Surg A Cent Eur Neurosurg. 2017 Nov;78(6):535-540. doi: 10.1055/s-0037-1599054. Epub 2017 Mar 1.
Surgical treatment for acute subdural hematomas (ASDHs) in elderly patients is still considered unsatisfactory. Series focusing on the use of conventional craniotomy or decompressive craniectomy in such patients report discouraging results. Glasgow Coma Scale (GCS) score at admission seems to be crucial in the decision-making process. Deteriorating patients with a GCS score between 9 and 11 are those who would benefit most from the surgical treatment. Unfortunately, elderly patients often present other comorbidities that greatly increase the risk of severe complications after major neurosurgical procedures under general anesthesia. The aim of the present study was to evaluate the feasibility of performing a mini-craniotomy under local anesthesia to treat ASDHs in a select group of elderly patients who were somnolent but still breathing autonomously at admission (GCS 9-11). Twenty-eight elderly patients (age > 75 years) with ASDH and a GCS score at surgery ranging from 9 to 11 were surgically treated under local anesthesia by a single burr-hole mini-craniotomy (transverse diameter 3-5 cm) and hematoma evacuation. At the end of the procedure, an endoscopic inspection of the surgical cavity was performed to look for residual clots that were not visible under direct vision. The median operation time was 65 minutes. Hematoma evacuation was complete in 22 cases, complete consciousness recovery was observed in all patients but one, and reoperation was required for two patients. Historically, elderly patients with ASDH treated with a traditional craniotomy performed under general anesthesia have not had a good prognosis. Our preliminary experience with this less invasive surgical and anesthesiological approach suggests that somnolent but autonomously breathing elderly patients could benefit from this approach, achieving an adequate hematoma evacuation and bypassing the complications related to intubation and artificial respiratory assistance.
老年患者急性硬膜下血肿（ASDH）的外科治疗效果仍不尽人意。针对此类患者采用传统开颅手术或去骨瓣减压术的系列研究报告结果令人沮丧。入院时的格拉斯哥昏迷量表（GCS）评分在决策过程中似乎至关重要。GCS评分在9至11分之间且病情恶化的患者是最能从手术治疗中获益的人群。不幸的是，老年患者常伴有其他合并症，这大大增加了全身麻醉下进行大型神经外科手术后出现严重并发症的风险。本研究的目的是评估在局部麻醉下实施小骨窗开颅术治疗ASDH的可行性，该手术针对的是一组入院时嗜睡但仍自主呼吸（GCS 9 - 11）的老年患者。28例年龄大于75岁的ASDH且手术时GCS评分在9至11分之间的老年患者在局部麻醉下通过单骨孔小骨窗开颅术（横向直径3 - 5厘米）及血肿清除术进行手术治疗。手术结束时，对手术腔进行内镜检查以寻找直视下不可见的残留血块。中位手术时间为65分钟。22例血肿清除彻底，除1例患者外所有患者意识完全恢复，2例患者需要再次手术。从历史数据来看，接受全身麻醉下传统开颅手术治疗的老年ASDH患者预后不佳。我们采用这种侵入性较小的手术及麻醉方法的初步经验表明，嗜睡但自主呼吸的老年患者可能会从这种方法中获益，实现充分的血肿清除，并避免与插管及人工呼吸辅助相关的并发症。
