双侧慢性硬膜下血肿合并自发性低颅压综合征的诊断和治疗

Diagnosis and treatment of bilateral chronic subdural hematomas complicated by spontaneous intracranial hypotension

目的探讨合并自发性低颅压综合征的双侧慢性硬膜下血肿患者的临床、影像学特征及治疗。方法回顾性分析2016年1月至2020年1月同济大学上海第十人民医院神经外科收治的14例合并自发性低颅压综合征的双侧硬膜下血肿患者的临床资料。14例患者首诊时的格拉斯哥昏迷评分(GCS)均≥13分。术前均行头颅CT及MRI检查,5例患者行腰椎穿刺测压。治疗方法包括保守治疗(6例)和手术治疗(8例),手术治疗采取钻孔引流术。预后评估采用格拉斯哥预后评级(GOS)。结果14例患者中,直立性头痛是最主要的临床症状(10例);头颅MRI增强扫描显示硬膜弥漫性强化是最典型的影像学特征(12例)。6例采取保守治疗的患者,治疗后症状均显著改善,复查CT或MRI显示血肿消失或明显缩小。8例行钻孔引流术的患者中,3例术后神经系统功能状态迅速恶化,1例术后死亡。13例患者按自发性低颅压综合征治疗后,病情均明显改善,出院时的GOS均为Ⅴ级。13例患者的随访时间为(24.6±14.9)个月(4~52个月),均未见血肿或症状复发。结论双侧慢性硬膜下血肿合并自发性低颅压综合征患者的主要临床表现及影像学特征分别为直立性头痛和硬膜弥漫性强化。临床应根据患者的个体情况选择保守治疗或钻孔引流术。

Objective To elucidate the clinical and radiologic features and treatment of patients with bilateral chronic subdural hematomas(CSDH)complicated by spontaneous intracranial hypotension(SIH).Methods A retrospective study was conducted on the data of 14 patients with bilateral CSDH combined with SIH who were admitted to Neurosurgery Department,Shanghai Tenth Hospital,Tongji University from January 2016 to January 2020.All the patients had an initial Glasgow Coma Score(GCS)greater than or equal to 13.All patients underwent CT and MRI examination of the skull before operation,and 5 patients underwent cerebrospinal fluid(CSF)pressure measurement through lumbar puncture.Treatment methods included conservative treatment(6 cases)and surgical operation(8 cases).For surgical operation,burr hole drainage was performed.Glasgow Outcome Scale(GOS)was used for the outcome assessment.Results Among the 14 patients,orthostatic headache was the most common characteristic symptom of SIH(10 cases).Diffuse dura enhancement on contrast-enhanced MRI was the most typical imaging feature(12 cases).The symptoms of all 6 patients undergoing conservative treatment were signiciantly improved post medication.Re-examination of CT or MRI showed that the hematoma disappeared or shrank significantly.Of the 8 patients undergoing burr-hole drainage,3 experienced a rapid postoperative deterioration of neurological functions,and 1 died post operation.At the time of discharge,the conditions of 13 patients were all significantly improved after treatment according to the diagnosis of SIH,and the GOS ratings were all gradeⅤ.The follow-up time of 13 patients was 24.6±14.9 months(4-52 months).No recurrence of hematoma or related symptoms was reported.Conclusions The major clinical and imaging features of bilateral CSDH complicated by SIH are orthostatic headache and diffuse enhancement of the dura mater respectively.Clinically,conservative treatment or drilling and drainage should be selected according to the individual situation of the patient.