早期小剂量尿激酶对跨窦硬膜外血肿致脑静脉窦回流障碍的治疗价值

Therapeutic significance of early-phase low-dose urokinase for cerebral venous flow obstruction secondary to trans-sinus acute epidural hematoma

目的探讨早期小剂量尿激酶干预对脑外伤后跨窦急性硬膜外血肿导致的静脉窦回流障碍的治疗价值。方法回顾分析该院2014年1月—2017年12月收治的跨窦急性硬膜外血肿导致的静脉窦回流障碍患者166例,分析小剂量尿激酶干预的临床疗效。结果纳入病例均依据神经查体和CT静脉成像(CTV)/磁共振静脉成像(MRV)联合诊断为脑静脉窦回流障碍。按是否早期给予尿激酶治疗分为尿激酶组(98例,入院早期即行影像学鉴别诊断)和常规组(68例,待颅内高压症状明显时完成影像学鉴别诊断)。所有病例在诊断后第3~7天和第10~14天时予CTV复查。首次复查时,尿激酶组55例再通良好,41例部分改善,2例无明显改变;常规组内32例再通良好,4例部分改善,32例无明显改变;两组治疗有效率比较,差异有统计学意义(P<0.05)。再次复查时,尿激酶组内所有病例均获得良好临床康复和影像学恢复,其中85例再通良好,12例部分改善,1例建立良好的侧支循环;常规组内47例再通良好,3例部分改善,4例建立良好的侧支循环,但仍有12例无明显改变和2例梗死加重且伴随明显的颅高压症状;两组治疗有效率比较,差异有统计学意义(P<0.05)。这14例患者在转而给予强化尿激酶溶栓治疗后静脉窦部分再通或对侧代偿,颅内高压症状逐渐缓解。结论跨窦硬膜外血肿患者伤后并发脑静脉窦回流障碍的风险较高,除及早行血肿外引流或手术清除外,早期小剂量尿激酶干预能有效避免继发性脑损伤进行性加重。

Objective To investigate the therapeutic significance of early-phase low-dose urokinase for cerebral venous flow obstruction secondary to transsinus acute epidural hematoma(EDH).Methods Clinical data of 166 patients with transsinus acute EDH who admitted in our center between Jan.2014 and Dec.2017 was retrospectively analyzed for the clinical efficacy of low-dose urokinase.Results Cerebral venous flow obstruction was jointly diagnosed according to neurological examinations and CT venous/MRV venous images in all the enrolled patients,and dichotomized to Urokinase group(n=98,radiographic differential diagnosis was established at early hours after admission)and Ordinary group(n=68,radiographic differential diagnosis was carried out until obvious symptom of intracranial hypertension).All the study population received CT venous re-examinations on day 3 to 7 and 10 to 14 after diagnosis.At the time of first reexamination,the involved cerebral sinuses were recanalized in 55 patients,partially improved in 41 patients,stabled in 2 patients in the Urokinase group.By contrast,they were recanalized in 32 patients,partially improved in 4 patients,stabled in 32 patients in the Ordinary group(P<0.05).At the time of second reexamination,all the patients in the Urokinase group received a satisfactory clinical and radiographic recovery,and the involved cerebral sinuses were recanalized in 85 patients,partially improved in 12 patients,collaterally compensated in 1 patient.By contrast,the involved cerebral sinuses were recanalized in 47 patients,partially improved in 3 patients,collaterally compensated in 4 patients in the Ordinary group(P<0.05).In addition,there were remaining 12 patients and 2 patients suffered from unimproved or deteriorated cerebral sinuses respectively which were partially recanalized or contralaterally compensated and accompanied with gradually alleviated symptoms of intracranial hypertension after a timely enforced urokinase-based thrombolytic therapy.Conclusion Transsinus epidural hematoma is associated with high risk of secondary cerebral venous flow obstruction.Early low-dose urokinase exhibits a good therapeutic efficacy on the cerebral venous flow obstruction and prevents progressive exacerbation of secondary brain injuries beside a timely surgical evacuation and drainage of epidural hematoma.