Arai Nobuhiko, Mine Yutaka, Kagami Hiroshi, Inaba Makoto
Department of Neurosurgery, Tobu Hospital, Yokohama, Japan.
J Craniofac Surg. 2019 Jan;30(1):196-199. doi: 10.1097/SCS.0000000000004908.
In primary intracerebral hemorrhage, several studies showed that contrast extravasation (CEV) is reported to be an indicator of delayed hematoma expansion, emergent hematoma removal and poor prognosis. On the contrary in head trauma, few researches validated the effectiveness of CEV because of other influences such as subarachnoid hemorrhage (SAH), contusion or brain swelling. The authors experienced a patient showing diffuse SAH caused by traumatic mechanism with acute subdural hematoma (ASDH). In the angiography, a notable rare image of CEV was found and emergency operation mainly to cease the bleeding points was performed.
A 70-year-old man was found being comatose and brought to emergency room. Computed tomography (CT) revealed diffuse SAH with left ASDH. Computed tomography angiography (CTA) also did not clarify any abnormal vessel structure except for slightly dilatation at the part of internal carotid artery, suggesting tiny ruptured aneurysm. The authors performed a cerebral angiography and resulted in no aneurysm or arteriovenous shunt detection but revealed the extravasation from middle cerebral artery and middle meningeal artery. Follow-up CT revealed increased left ASDH though 5 hours have already elapsed. The authors performed surgical intervention to halt the bleeding.
The authors experienced a notably rare image of the extravasation from middle cerebral artery and middle meningeal artery in the cerebral angiography. When an obscure arterial abnormality is suspected on CTA for the unknown origin SAH with ASDH, the authors may have an affirmative attitude toward performing conventional cerebral angiography, which is most promising modality to detect the source of bleeding including CEV.
在原发性脑出血中，多项研究表明，造影剂外渗（CEV）被认为是血肿延迟扩大、急诊血肿清除及预后不良的一个指标。相反，在头部创伤中，由于蛛网膜下腔出血（SAH）、挫伤或脑肿胀等其他影响因素，很少有研究证实CEV的有效性。作者遇到一名因创伤机制导致弥漫性SAH并伴有急性硬膜下血肿（ASDH）的患者。在血管造影中，发现了一个显著罕见的CEV图像，并进行了主要为止血点的急诊手术。
一名70岁男性被发现昏迷并被送往急诊室。计算机断层扫描（CT）显示弥漫性SAH伴左侧ASDH。计算机断层扫描血管造影（CTA）除颈内动脉部分轻度扩张外，未发现任何异常血管结构，提示微小破裂动脉瘤。作者进行了脑血管造影，未检测到动脉瘤或动静脉分流，但显示了大脑中动脉和脑膜中动脉的外渗。随访CT显示，尽管已经过去了5个小时，但左侧ASDH仍有增加。作者进行了手术干预以止血。
作者在脑血管造影中遇到了大脑中动脉和脑膜中动脉外渗的显著罕见图像。当CTA怀疑不明来源SAH伴ASDH存在隐匿性动脉异常时，作者可能对进行传统脑血管造影持肯定态度，这是检测包括CEV在内的出血源最有前景的方式。
