I.V. Korypaeva, V.V. Lebedev, V.V. Krylov
Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
The last years are characterized by an increase of the rate of severe craniocerebral trauma (SCCT), which includes large traumatic intracranial hematomas (100 cm3 and more). According to the data of the above Institute, a quota of patients, operated for large traumatic intracranial hematomas (LTIH), in a total number of cases with traumatic intracranial hematomas is more than 35%. These large hematomas are characterized by peculiarities of a clinical picture. Moreover, they are accompanied by high mortality despite performing timely surgical intervention.
The goal of the present study was more precise determination of peculiarities of a clinical picture, diagnosis and surgical treatment of patients with LTIH.
Materials and Methods. There were 653 casualties with intracranial hematomas, operated in the Sklifosovsky Research Institute of Emergency Care during 3 years (2000-2002). LTIH were watched in 183 (35.7%) of them. There were 110 males and 18 females. Their mean age was 42 years. Hematoma distribution was as follows: acute subdural hematomas - 70 cases (54.7%), subacute subdural hematomas - 26 cases (20.3%), acute epidural hematomas - 21 cases (16.4%), episubdural hematomas - 11 cases (8.6%). A hematoma volume did not exceed 160 cm3 in the majority of patients, but it reached 260 cm3 in some casualties. All the cases were subject to complex examination. It included not only general and neurologic examination, but also compulsory use of craniography, echoencephaloscopy, CT (102 cases), cerebral angiography (10 cases). Decompressive and osteoplastic trephination were performed in 67 and 61 patients respectively.
Results and Discussion. There were two versions of a clinical course of acute LTIH: decompensated and subcompensated. A decompensated version was observed in 71.9% of casualties. It was characterized by development of severe, extremely severe and terminal (1/3 of cases) states, depressed consciousness (the score of 8 and less according to Glasgow Coma Scale), predominance of gross dislocation syndrome, which leveled hemispheric symptoms. Mortality reached 73.9%. A subcompensated version of a clinical course was present in 28.1% of cases. A state was either satisfactory or could be characterized by severe consciousness disorders (the score of 9-15 according to Glasgow Coma Scale). Focal hemispheric symptoms were watched in a half of patients against a background of general cerebral and dislocation symptoms. Mortality in a subcompensated version was equal to 33.3%.
Peculiarities of dislocation syndromes in LTIH were as follows: considerable dislocation of median cerebral structures of 10-28 mm, gross deformity and compression of basal cisterns, ventricles deformity with manifestations of vicarious hydrocephalus, dislocation and deformity of the posterior and anterior cerebral arteries with subsequent ischemia of the brain.
Severity of a state and manifestations of dislocation syndrome, typical of patients with large acute subdural hematomas correlated with a volume and thickness of hematoma proper, a value of transverse dislocation, a degree of deformity of basal cisterns and a change of density of brain stem structures. A value of transverse dislocation was dependent not only on a hematoma volume, but also on a volume of all pathologic focus, i.e. brain contusion, a zone of perifocal edema, surrounding it, and an area of secondary ischemia.
Risk factors in acute LTIH included depressed consciousness (Glasgow Coma Scale score of 8), age of more than 70 years, a hematoma volume of more than 180 cm3, dislocation of median structures of more than 21 mm, no visualization of basal cisterns, lower density of brain stem structures.
Surgical intervention, performed no later than 6 hours since the moment of trauma, allowed to achieve favorable results of treatment of large acute subdural hematomas even in patients in a terminal state.
Osteoplastic trephination tended to improve results of treatment of large acute subdural hematomas. However, there was no statistically reliable difference in outcomes of treatment with the help of decompressive or osteoplastic trephination. Decompressive trephination is justified, when the brain prolapses into a trephination defect by the end of operation after hematoma removal. Decompressive trephination, made in such cases, was life-saving in 22% of cases.