Knuckey N W, Gelbard S, Epstein M H
Department of Clinical Neuroscience, Brown University, Providence, Rhode Island.
J Neurosurg. 1989 Mar;70(3):392-6. doi: 10.3171/jns.1989.70.3.0392.
Standard neurosurgical management mandates prompt evacuation of all epidural hematomas to obtain a low incidence of mortality and morbidity. This dogma has recently been challenged. A number of authors have suggested that in selected cases small and moderate epidural hematomas may be managed conservatively with a normal outcome and without risk to the patient. The goal of this study was to define the clinical parameters that may aide in the management of patients with small epidural hematomas who were clinically asymptomatic at initial presentation because there was no clinical evidence of raised intracranial pressure or focal compression. A prospective study was conducted of 22 patients (17 males and five females) aged from 1 to 71 years, who had a small epidural hematoma diagnosed within 24 hours of trauma and were managed expectantly. Of these, 32% subsequently required evacuation of the epidural hematoma 1 to 10 days after the initial trauma. Analysis of the patients revealed that age, sex, Glasgow Coma Scale score, and initial size of the hematoma are not risk factors for deterioration. However, deterioration was seen in 55% of patients with a skull fracture transversing a meningeal artery, vein, or major sinus, and in 43% of those undergoing computerized tomography (CT) within 6 hours of trauma. In contrast, only 13% of patients in whom the diagnosis of a small epidural hematoma was delayed over 6 hours subsequently required evacuation of the epidural collection. Of patients with both risk factors, 71% required evacuation of the epidural hematoma. None of the patients suffered neurological sequelae attributable to this management protocol. It was concluded that patients with a small epidural hematoma, a fracture overlaying a major vessel or major sinus, and/or who are diagnosed less than 6 hours after trauma are at risk of subsequent deterioration and may require evacuation. Conversely, patients without these risk factors may be managed conservatively with repeat CT and careful neurological observation, because of the low risk of delayed deterioration.
标准的神经外科治疗要求迅速清除所有硬膜外血肿，以降低死亡率和发病率。这一教条最近受到了挑战。一些作者认为，在某些情况下，小型和中型硬膜外血肿可以保守治疗，预后正常，且对患者无风险。本研究的目的是确定有助于管理初次就诊时临床无症状的小型硬膜外血肿患者的临床参数，因为没有颅内压升高或局灶性压迫的临床证据。对22例年龄在1至71岁之间的患者（17例男性和5例女性）进行了一项前瞻性研究，这些患者在创伤后24小时内被诊断为小型硬膜外血肿，并进行了保守治疗。其中，32%的患者在初次创伤后1至10天随后需要清除硬膜外血肿。对这些患者的分析显示，年龄、性别、格拉斯哥昏迷量表评分和血肿的初始大小不是病情恶化的危险因素。然而，55%横跨脑膜动脉、静脉或主要窦的颅骨骨折患者以及43%在创伤后6小时内接受计算机断层扫描（CT）的患者出现了病情恶化。相比之下，小型硬膜外血肿诊断延迟超过6小时的患者中，只有13%随后需要清除硬膜外血肿。同时具有这两个危险因素的患者中，71%需要清除硬膜外血肿。没有患者因该治疗方案出现神经后遗症。研究得出结论，患有小型硬膜外血肿、覆盖主要血管或主要窦的骨折和/或创伤后6小时内被诊断的患者有随后病情恶化的风险，可能需要清除血肿。相反，没有这些危险因素的患者可以通过重复CT和仔细的神经观察进行保守治疗，因为延迟恶化的风险较低。
