Sousa Énia, Pestana Ricardo, Caleia Ana, Barreira Catarina, Lima Pedro
Neurological Surgery, Hospital Central do Funchal, Funchal, PRT.
Cureus. 2024 Nov 25;16(11):e74387. doi: 10.7759/cureus.74387. eCollection 2024 Nov.
Pure acute subdural hematoma (ASDH) is an uncommon clinical presentation of ruptured intracranial aneurysms, and only rarely, the culprit is a cortical microaneurysm.Mortality can be high; thus, appropriate diagnosis and treatment are crucial. Due to its extreme rarity, there are no available guidelines.We aimed to describe two clinical cases of pure ASDH due to cortical microaneurysm rupture, and a literature review was performed. A 33-year-old man, with no history of head trauma, was admitted with headache and left hemiparesis. Computed tomography (CT) showed right convexity ASDH, and CT angiography excluded intracranial vascular malformations. An emergent craniotomy was performed, and a microaneurysm was identified; the lesion was electrocoagulated and wrapped in muslin. The patient was discharged three weeks after with a modified Rankin Scale (mRS) of 1. A 58-year-old woman was admitted to the emergency room (ER) with a presumed history of head trauma. The Glasgow Coma Scale (GCS) was 4, and the left pupil was mydriatic. A CT scan showed a left convexity ASDH. Emergent decompressive craniotomy was performed, and the cortical surface beneath the hematoma revealed a microaneurysm that was clipped. The neurological status improved, but she perished 14 days after the procedure for nosocomial pneumoniae. To date, few cases of pure ASDH due to cortical non-mycotic microaneurysm rupture were reported, including the two described in this article. Digital subtraction angiography (DSA) continues to be the gold standard for diagnosis. Nevertheless, the possibility of angiographically unvisualized lesions should be considered. The risk of rebleeding is high, and it foresees a worse outcome. Prompt diagnosis and treatment are imperative to achieve better outcomes, and the craniotomy must be extensive to expose a large area of the brain surface beneath the hematoma to assess a possible bleeding source. After treatment, the outcome is good in most published cases. In patients presenting with nontraumatic ASDH, after the imageological exclusion of vascular intracranial malformations, the craniotomy for hematoma evacuation should be large to visualize all the brain surface beneath the hematoma to identify possible microaneurysm as the source of bleeding. To improve the outcome, the microaneurysm should be treated to prevent rebleeding.
单纯急性硬膜下血肿（ASDH）是颅内动脉瘤破裂的一种罕见临床表现，而罪魁祸首为皮质微动脉瘤的情况则更为罕见。死亡率可能很高，因此，恰当的诊断和治疗至关重要。由于其极为罕见，目前尚无可用的指南。我们旨在描述两例因皮质微动脉瘤破裂导致的单纯ASDH临床病例，并进行了文献综述。一名33岁男性，无头部外伤史，因头痛和左侧偏瘫入院。计算机断层扫描（CT）显示右侧凸面ASDH，CT血管造影排除了颅内血管畸形。紧急进行了开颅手术，发现了一个微动脉瘤；对病变进行了电凝并包裹在纱布中。患者三周后出院，改良Rankin量表（mRS）评分为1分。一名58岁女性因疑似有头部外伤史被送入急诊室（ER）。格拉斯哥昏迷量表（GCS）评分为4分，左侧瞳孔散大。CT扫描显示左侧凸面ASDH。紧急进行了减压开颅手术，血肿下方的皮质表面发现一个微动脉瘤并进行了夹闭。神经功能状态有所改善，但她在术后14天因医院获得性肺炎死亡。迄今为止，因皮质非霉菌性微动脉瘤破裂导致的单纯ASDH病例报道较少，包括本文所述的两例。数字减影血管造影（DSA）仍然是诊断的金标准。然而，应考虑血管造影未显示病变的可能性。再出血风险很高，且预后较差。迅速诊断和治疗对于取得更好的结果至关重要，开颅手术必须广泛，以暴露血肿下方大面积的脑表面，评估可能的出血源。在大多数已发表的病例中，治疗后的结果良好。对于出现非创伤性ASDH的患者，在影像学排除颅内血管畸形后，用于血肿清除的开颅手术应足够大，以观察血肿下方所有的脑表面，识别可能作为出血源的微动脉瘤。为了改善预后，应治疗微动脉瘤以防止再出血。
