RU2414173C1 - Method of treating subdural hematoma - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to field of medicine, namely to neurosurgery. Localisation of hematoma is determined by means of tomography, transcranial access to hematoma cavity is performed and subdural space is drained with placement of reservoir for collection of hematoma contents below head level. Transcranial access is performed by microperforation of skull, for instance, be means of intraosteal needle, in projection of more extensional part of hematoma, and for drainage through perforation hole catheter with diametre not more than 3 mm is used. ^ EFFECT: method makes it possible to reduce risk of infectious, hemorrhagic and embolic complications. ^ 4 dwg, 1 ex

Description

The present invention relates to medicine, namely to neurosurgery, and can be used in the treatment of traumatic brain injury, namely, subacute subdural hematoma.

A known method of treating subacute subdural hematoma, including craniotomy and open removal of the hematoma. Craniotomy (resection or osteoplastic) is performed depending on the location of the hematoma. Dissect the dura mater. After opening the dura mater, the hematoma in the form of clots or the liquid part is removed. After open removal of intracranial hemorrhages in the subacute period, the risk of repeated hemorrhage usually remains, which can lead to further dislocation of the brain and its infringement in the trepanation window, and a coma can occur (1).

Closest to the proposed method is the method of using for the treatment of subacute subdural hematoma of open drainage of the subdural space. Under local anesthesia, the contents of the hematoma are evacuated through the milling hole, washing its cavities, followed by closed external drainage. In this case, the patient’s head is positioned so that the milling hole is the top point on the surface of the skull. The milling hole is applied according to the generally accepted technique, mainly one is used, rarely two milling holes. Skin incisions focus on the possibility of their continuation with craniotomy. After opening the dura mater and capsule of the hematoma, the catheter is immersed into its cavity simultaneously to a depth of 5.0 cm, its free end is fixed to the skin of the skull. Controlled drainage is carried out both in passive and in active modes. Passive drainage with spontaneous outflow of the contents of the hematoma cavity is achieved by the position of the tank below the head level by 20-30 cm. The duration of drainage depends on the volume of hematoma separated from the cavity (up to 3 days). Given the undulating nature of the increase in intracranial pressure, timely drainage of the subdural space is necessary in the treatment of brain damage (2).

However, known methods of treatment have significant disadvantages, namely:

1) the presence in the subdural space of a bulky foreign body often causes epileptic convulsions, which can provoke swelling and dislocation of the brain (2),

2) an open drainage installation can provoke re-hemorrhage due to separation of a blood clot at an alleged source of bleeding (1),

3) have a high risk of infectious, embolic complications and liquorrhea with prolonged use (3, 4).

Based on the current level of treatment for intracranial hemorrhage, as well as eliminating the disadvantages of known technologies, the task was set: to increase the effectiveness of the treatment of subdural hemorrhages due to internal decompression of the brain without extensive craniotomy and to reduce the risk of infectious, embolic complications and cerebrospinal fluid with minimal surgical aggression.

The task is achieved as follows.

Treatment of a subdural hematoma includes determining the location of the hematoma using tomography, transosseous access to the hematoma cavity, and draining the subdural space with a container for collecting hematoma contents below head level. New in solving this problem is that they perform percutaneous microperforation of the skull, for example, with an intraosseous needle in the projection of a more voluminous part of the hematoma. Then install drainage through the perforation hole, while the catheter has a diameter of not more than 3 mm

We explain the essential distinguishing features of the proposed "Method for the treatment of subdural hematoma."

Percutaneous microperforation of the skull, for example, with an intraosseous needle in the projection of a larger part of the hematoma with subsequent installation of drainage through the perforation, the catheter having a diameter of not more than 3 mm, allows maximum removal of blood decay products with minimal impact, and also eliminates the negative effect of the installation of extensive foreign drainage into the subdural space and the risk of repeated subdural hemorrhage. Elimination of brain compression using microperforation and control tomographic examinations confirm the high efficiency of the technology with minimally invasive effects. At the same time, the risk of complications from the installation of microdrainage is minimal; in the postoperative period, the patient maintains the integrity of the skull bones (without defect), which eliminates infectious and other complications.

The patent studies on subclasses A61M 27/00, as well as the analysis of scientific and medical information reflecting the current level of technology for the treatment of subacute subdural hematoma, did not reveal identical technologies. Thus, the proposed method of treatment is new.

The interconnection and interaction of the essential methods of the proposed method ensure the achievement of a new medical result in solving the problem, namely, increasing the effectiveness of treatment by adequately eliminating brain compression without open craniotomy, radical treatment of subdural hemorrhage with minimal surgical aggression, and reducing the risk of hemorrhagic, embolic and infectious complications. Thus, the proposed technical solution has an "inventive step".

The proposed method for the treatment of subacute subdural hematoma with traumatic brain injury causing compression of the brain can be widely and successfully applied in practical health care, since it does not require exceptional means for use.

The essence of the proposed "Method of treatment of subdural hematoma" is as follows.

Computed tomography of the brain is performed, the location of the hematoma and the projection of its most voluminous part are revealed. Then microperforation of the bones of the skull is carried out by percutaneous puncture, using, for example, modern bone needles. After controlling the puncture of the dura mater, a microdrainage is introduced into the subdural space through a perforation hole (catheter up to 3 mm in diameter), the distal end is fixed with a ligature to the skin and connected to the reservoir, which is set below the head position by 20-30 cm. The proximal end of the drainage catheter located in the projection of a more voluminous part of the hematoma. The average duration of microdrainage in the hematoma cavity for stopping brain compression is 3-5 days.

The essence of the proposed method of treatment is illustrated by illustrations.

Figure 1. - Computed tomography of the brain of patient Sh. Before surgical treatment, 2 days after the injury.

Figure 2. - Computed tomography of the brain of patient Sh. Before surgical treatment on day 14.

Figure 3. Computed tomography of the brain of patient C. after surgical treatment for 2 days.

Figure 4. - Computed tomography of the brain of patient S. on the 5th day after surgical treatment.

The proposed method for the treatment of subdural hematoma is illustrated by a clinical example.

Patient Sh., 23 years old, was admitted on 10.08.2009 to the city clinical hospital (GKB) No. 3 of Irkutsk after being beaten in serious condition with a convulsive syndrome. Upon admission: deep stunning (9 points for GK), contact is difficult, does not follow instructions, answers questions in a monosyllabic way. The pupils are equal, the photoreaction is preserved, the corneal reflexes are alive, the reflex gaze upward is limited. Spontaneous breathing, rhythmic, frequency - 23 per minute, adequate, pulse 140 beats / min, rhythmic, blood pressure 150/60 mm Hg Muscle tone is increased in the flexors of the arms and extensors of the legs, higher on the left. Spontaneous unilateral symptom of Babinsky on the left. Moderately pronounced meningeal signs.

Computed tomography (CT) of the head is a subdural hematoma of the frontotemporal region on the left with a volume of up to 40 ml, a lesion focus of type 1 of the frontal lobe on the right. Middle structures are not displaced. Bypass tank saved. Fracture of the occipital, temporal bones on the right with the transition to the base of the skull (see figure 1).

Diagnosis: Penetrating traumatic brain injury. Medium brain contusion with compression of the acute subdural hematoma on the left. Fracture of the arch with the transition to the base of the skull. Otogemolikvorea on the right.

The department has been prescribed vasoactive, anticonvulsant, nootropic therapy, antibiotics, Actovegin, Gordox in appropriate dosages.

On the control tomograms in dynamics, the displacement of the median structures from left to right by 7 mm, an increase in the volume of the subdural hematoma in the left frontotemporal region to 70 ml was visualized, however, a decrease in density to 35 uN (see figure 2).

According to the proposed method, the patient performed percutaneous microtrefaction with an intraosseous needle in the projection of the left frontotemporal region, i.e. the most voluminous part of the subdural hematoma. Lysed blood was removed, a subdural hematoma was drained using a 3 mm catheter. Performed control CT of the brain on the 2nd and 5th day after the operation (see figure 3, 4, respectively). On day 2, with computed tomography, there is no displacement of the median structures, a decrease in the hematoma to 2/3 of the contents, and the microdrainage position is satisfactory. On the 5th day, there was no displacement of the median structures, the drainage was removed, and at the site of the hematoma there was a slight hypo-intensive strip of up to 2 mm. In the postoperative period, the patient experienced a regression of neurological disorders, restoration of impaired speech articulation. Decreased meningeal signs, reduced headaches. Decreased weakness in the right limbs.

Discharged 24 days after injury. By the time of discharge - the patient's condition is satisfactory, ordered behavior. In neurological status, there is some instability when walking.

Thus, the proposed “Method for the treatment of subdural hematoma”, which causes compression of the brain, allows, in comparison with known technologies, to increase the effectiveness of treatment, reduce its time, reduce the risk of infectious, hemorrhagic and embolic complications, avoid trepanation defects of the skull and thereby exclude the transfer of patients to disability, the need to perform further plastic surgery of the skull defect.

According to the proposed technology, 9 patients were treated. Good near and long-term results were obtained. In all cases, compression of the brain was eliminated. A partial regression of neurological symptoms has been achieved. Infectious, embolic and other complications were not observed.

Sources of information taken into account

1. Lebedev, V.V. Guidelines for emergency neurosurgery / V.V. Lebedev, V.V. Krylov // - M., Medicine, 2000. - 336 p.

2. Clinical guidelines for traumatic brain injury. // Edited by A.N. Konovalov, L.B. Likhterman, A.A. Potapov. 2 t., 2001, p. 58-60.

3. Hirsh, L.F. Delayed traumatic intracerebral hematomas after surgical decompression / L.F. Hirsh // Neurosurgery. l979 - V.5. P.653-655.

4. Shenkin, H.A. Acute subdural hematoma / H. A. Shenkin // J. Neurosurg. - 1982, - 7.57, N2. - P.254-257.

Claims (1)

A method of treating a subdural hematoma, including determining the location of the hematoma using tomography, transosseous access to the hematoma cavity and draining the subdural space with a container for collecting hematoma contents below the head level, characterized in that they perform percutaneous microperforation of the skull, for example, with an intraosseous needle in a projection of a more voluminous parts of the hematoma with subsequent installation of drainage through the perforation hole, while the catheter has a diameter of not more than 3 mm.

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