Yatsushige Hiroshi
Department of Neurosurgery, National Hospital Organization Disaster Medical Center.
No Shinkei Geka. 2021 Sep;49(5):977-985. doi: 10.11477/mf.1436204480.
Surgery is one of the primary options for the management of traumatic brain injury(TBI). We focused on operative techniques, additional options, and potential pitfalls of surgical intervention for intracranial hematomas, such as acute subdural hematoma(ASDH), acute epidural hematoma(AEDH), cerebral contusion, and intracerebral hematoma. A wide craniotomy covering the hematoma was recommended for a case of AEDH to evacuate the hematoma, control bleeding, and prevent blood reaccumulation. Combined multiple craniotomies leaving a bone bridge over the sinus for dural tenting sutures enabled safe surgical intervention in a case of AEDH with sinus injuries. Different surgical techniques have been advocated for the evacuation of ASDH. Large craniotomy is often chosen as it can easily be shifted to decompressive craniectomy in case of brain swelling. It is important to pay attention to injuries of dural sinuses and bridging veins, and to expose the floor of the middle cranial fossa. Small craniotomy or endoscopic burr-hole evacuation of ASDH has been accepted as a way to avoid large craniotomies and additional morbidity, particularly for patients who are poor surgical candidates. Contusion necrotomy is performed for satisfactory control of progressive elevation in intracranial pressure and clinical deterioration.
手术是创伤性脑损伤（TBI）治疗的主要选择之一。我们重点关注了颅内血肿手术干预的操作技术、其他选择及潜在陷阱，如急性硬膜下血肿（ASDH）、急性硬膜外血肿（AEDH）、脑挫裂伤和脑内血肿。对于AEDH病例，建议采用覆盖血肿的大骨瓣开颅术以清除血肿、控制出血并防止血液再次积聚。对于伴有窦损伤的AEDH病例，采用联合多个开颅术并在窦上方保留骨桥以进行硬脑膜帐篷缝合可实现安全的手术干预。对于ASDH的清除，人们提倡采用不同的手术技术。大骨瓣开颅术常被选用，因为在脑肿胀的情况下它可轻松转换为去骨瓣减压术。注意硬脑膜窦和桥静脉的损伤并暴露中颅窝底很重要。ASDH的小骨瓣开颅术或内镜钻孔血肿清除术已被认可为避免大骨瓣开颅术及额外并发症的一种方法，特别是对于手术条件较差的患者。进行挫伤坏死组织切除术以满意地控制颅内压的进行性升高和临床病情恶化。
