Ishikawa Toshihito, Endo Katsuhiro, Endo Yuji, Sato Naoki, Ohta Mamoru
Department of Neurosurgery, Masu Memorial Hospital.
No Shinkei Geka. 2017 Aug;45(8):667-675. doi: 10.11477/mf.1436203572.
Chronic subdural hematoma(CSDH)generally occurs in the elderly, and is usually treated by burr-hole craniotomy with closed-system drainage. Treatment of recurrent CSDH is more challenging, especially when the hematoma is multi-lobular. A variety of approaches to the management of multi-lobular CSDH have been described, including evacuation through a wide craniotomy, placement of an Ommaya reservoir, subdural peritoneal shunting, and embolization of the middle meningeal artery. We have previously reported a method of evacuating multi-lobular CSDH through a small craniotomy using a rigid endoscope and aspiration tube. The objective of this study was to compare our operative method with others from the literature.
Between January 2012 and October 2016, eight patients diagnosed with multi-lobular CSDH using computed tomography(CT)imaging underwent endoscopic evacuation. First, we established a 3×3cm craniotomy at a position where a rigid endoscope and aspiration tube would be able to reach as much of the hematoma cavity as possible in the longitudinal plane. Second, after identifying and removing the outer membrane of the CSDH with the scope, we evacuated the hematoma longitudinally, keeping the inner membrane intact. We also applied monopolar diathermy to any obvious bleeding points and the capillary network on the outer membrane of the CSDH, using the aspiration tube.
The mean duration of surgery was 42 minutes. Follow-up CT scan revealed no recurrence in any of the cases, and neurologic function improved in all patients postoperatively.
A multi-lobular CSDH can be drained quickly and effectively using a rigid endoscope and aspiration tube through a small craniotomy. In a cohort of eight patients, postoperative neurologic recovery was observed in all cases with no evidence of recurrence. This technique could be used in any facility with ready access to CT imaging and a rigid endoscope.
慢性硬膜下血肿（CSDH）通常发生于老年人，通常采用钻孔开颅闭式引流治疗。复发性CSDH的治疗更具挑战性，尤其是当血肿为多叶性时。已经描述了多种处理多叶性CSDH的方法，包括通过广泛开颅清除血肿、放置Ommaya储液器、硬膜下-腹腔分流术以及脑膜中动脉栓塞术。我们之前报道了一种使用硬式内镜和吸引管通过小骨窗清除多叶性CSDH的方法。本研究的目的是将我们的手术方法与文献中的其他方法进行比较。
2012年1月至2016年10月期间，8例经计算机断层扫描（CT）成像诊断为多叶性CSDH的患者接受了内镜下血肿清除术。首先，在硬式内镜和吸引管在纵向上能够尽可能多地到达血肿腔的位置建立一个3×3cm的骨窗。其次，用内镜识别并切除CSDH的外层包膜后，纵向清除血肿，保持内层包膜完整。我们还使用吸引管对CSDH外层包膜上任何明显的出血点和毛细血管网进行单极电凝。
平均手术时间为42分钟。术后CT随访扫描显示所有病例均无复发，所有患者术后神经功能均有改善。
使用硬式内镜和吸引管通过小骨窗可以快速有效地引流多叶性CSDH。在一组8例患者中，所有病例术后均观察到神经功能恢复且无复发迹象。该技术可在任何具备CT成像设备和硬式内镜的医疗机构中使用。
