骑跨横窦硬膜外血肿58例临床分析

Surgical strategies for epidural hematoma straddling the transverse sinus： clinical analysis of 58 cases

目的探讨骑跨横窦硬膜外血肿的临床处理、手术指征及方法。方法收集自2001年9月至2007年12月收治住院的58例骑跨横窦硬膜外血肿患者的临床资料，其中门诊第一次常规头颅CT平扫发现血肿者42例，迟发性血肿者10例，开颅手术中出现迟发性血肿者6例。所有患者均采用16排螺旋CT行冠状面、矢状面三维重建，计算血肿总量、幕下和幕上血肿量，其中血肿总量t〉30mL或幕下血肿≥15mL者有42例，均采取手术治疗，方法为依据血肿范围，跨过横窦一次性骨瓣成形，血肿清除后骨瓣复位，蛇牌颅骨锁固定；对伴有其他部位血肿或严重颅高压者8例行另外部位血肿清除或去骨瓣减压术。结果本组54例患者术后恢复正常，3例生活能自理，1例重残，无死亡病例。结论对血肿总量〈30mL或幕下血肿〈15mL者可采取保守治疗，血肿总量〉／30mL或幕下血肿≥15mL者应积极手术治疗。应用跨过横窦一次性骨瓣成形方法安全可行，骨瓣复位后要采取牢固的内固定。

Objective To analyze the clinical management, surgical indications and surgical approaches for epidural hematoma straddling the transverse sinus. Methods The clinical data were collected from 58 patients with epidural hematoma straddling the transverse sinus treated between September, 2001 and December, 2007. Of these patients, the hematoma was found by the initial head CT scan in 42 cases; 10 patients had delayed hematoma, and 6 showed delayed hematoma during craniotomy. All the patients were scanned using 16-slice spiral CT for coronal and sagittal three-dimensional reconstruction, and the total hematoma volume and the supratentorial and infratentorial hematoma volumes were calculated. Forty-two patients were found to have the straddling hematoma volume no less than 30 mL or infratentorial hematoma volume over 15 mL. According to the extension of the hemotoma, a bone flap spanning the transverse sinus was taken, and after hematoma removal, the bone flap was reduced and fixed with cranial screws. In 8 patients with other hematomas or severe intracranial hypertension, routine removal of the hematoma or decompressive craniectomy was performed. Results Fifty-four of the patients recovered, 3 were capable of independent living, and 1 sustained severe disabilities after the operations. No death occurred in these patients. Conclusion In patients with epidural hematoma straddling the transverse sinus, conservative treatment can be administered in cases with the straddling hematoma volume 〈 30 mL or infratentorial hematoma volume 〈 15 mL, otherwise timely surgical interventions should be performed. One-step preparation of the bone flap spanning the transverse sinus is safe but secure internal fixation is necessitated after reduction of the bone flap.