Ernestus R I, Beldzinski P, Lanfermann H, Klug N
Department of Neurosurgery, University of Cologne, Germany.
Surg Neurol. 1997 Sep;48(3):220-5. doi: 10.1016/s0090-3019(97)80031-6.
The common occurrence of chronic subdural hematoma (CSDH) in older patients raises some diagnostic and therapeutic difficulties. Despite general agreement about the indication of operation, the extent of surgery is still discussed controversially. We have, therefore, reviewed operative findings and outcome in 104 patients with CSDH.
Retrospective analysis was performed by differentiating age < or = 60 years (n = 28) versus age > 60 years (n = 76) and burr hole craniostomy with a size range from 12-30 mm (n = 94) versus larger craniotomy (n = 10). All patients received closed-system drainage of the subdural space for 2-4 days.
Four patients older than 60 years died within 30 days after surgery, two in each operative group. Excluding these postoperative deaths, 17 out of 92 patients (18.5%) after burr hole trepanation and one out of eight patients (12.5%) after craniotomy required reoperation due to rebleeding (n = 6), residual subdural fluid (n = 4), and residual thick hematoma membranes (n = 8). Eight patients, who had been initially treated by burr hole craniostomy despite preoperative detection of neomembranes by contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI), recovered without further intervention. Clinical outcome was good in both operative groups. The percentage of patients without or with only mild neurologic deficits at the time of discharge from the hospital was 72.3% in the burr hole and 70.0% in the craniotomy group, respectively.
The clinical data of the present study suggest that burr hole craniostomy with closed-system drainage should be the method of choice for the initial treatment of CSDH, even in cases with preoperative detection of neomembranes. Craniotomy should be carried out only in patients with reaccumulating hematoma or residual hematoma membranes, which prevent reexpansion of the brain.
老年患者慢性硬膜下血肿（CSDH）较为常见，这带来了一些诊断和治疗上的困难。尽管对于手术指征已基本达成共识，但手术范围仍存在争议。因此，我们回顾了104例CSDH患者的手术发现及预后情况。
进行回顾性分析，将年龄≤60岁（n = 28）与年龄＞60岁（n = 76）进行区分，同时将钻孔开颅术（钻孔大小范围为12 - 30 mm，n = 94）与较大的开颅手术（n = 10）进行区分。所有患者均接受硬膜下腔闭式引流2 - 4天。
60岁以上的4例患者在术后30天内死亡，每个手术组各2例。排除这些术后死亡病例后，钻孔开颅术后的92例患者中有17例（18.5%）、开颅术后的8例患者中有1例（12.5%）因再出血（n = 6）、硬膜下积液残留（n = 4）和血肿厚膜残留（n = 8）而需要再次手术。8例患者尽管术前通过对比增强计算机断层扫描（CT）或磁共振成像（MRI）检测到新膜，但最初接受了钻孔开颅术治疗，最终未进行进一步干预即康复。两个手术组的临床结局均良好。出院时无神经功能缺损或仅有轻度神经功能缺损的患者百分比，钻孔开颅组为72.3%，开颅手术组为70.0%。
本研究的临床数据表明，即使在术前检测到新膜的情况下，钻孔开颅术加闭式引流也应是CSDH初始治疗的首选方法。仅在血肿复发或存在残留血肿膜且妨碍脑再扩张的患者中进行开颅手术。
