RU2792563C1 - Method for drainage of chronic subdural hematoma in children - Google Patents

Abstract

FIELD: medicine; neurosurgery.

SUBSTANCE: two tubular drains are installed through one oval-shaped burr hole, superimposed in the projection of the deepest part of the subdural hematoma. At the same time, through the dissected dura mater, tubular drains are installed at an acute angle into the subdural cavity in opposite directions opposite each other. One of the drains is immersed in the ventral part of the hematoma cavity. Another drain is immersed in the dorsal part of the hematoma cavity. The outer ends of the drains are brought out through the skin counter-openings. In advance, additional holes are made at the intracranial ends of the tubular drains for 20–30 mm.

EFFECT: method allows to remove chronic subdural hematoma in children, minimize the risk of recurrence and complications, speed up recovery, improve the quality of life of patients, reduce the duration of inpatient treatment, eliminate the need for a second operation.

1 cl, 11 dwg, 1 ex

Description

The invention relates to medicine, namely to neurosurgery. Advantageously, the invention can be used for chronic subdural hematomas (CSH) in children by removing the compression of this hematoma of the brain parenchyma temporarily installed through one superimposed burr hole into the subdural space into the hematoma cavity of two external drainage systems.

The problem of surgical treatment of chronic subdural hematomas remains relevant today. Every year the number of children with cerebral pathology increases, where it is often caused by chronic subdural hematoma. Subdural hematoma is diagnosed in 20-25 per 100,000 children under the age of 1 year. [Melashenko T.V., Fomina M.Yu., Usenko I.N., Rodionov Yu.V., Pavlova O.I. Subdural hematomas of early age: clinical and electrophysiological features // Pediatrician. - 2019. - Vol. 10. - No. 6. - S. 93-99; Jayawant S, Parr J. Outcome following subdural haemorrhages in infancy. Arch DisChild. 2007; 92(4): P. 343-347].

Chronic subdural hematoma is formed from 1 week to 3 months. [Likhterman L.B. Traumatic brain injury. Diagnosis and treatment // M: GEOTAR-Media, 2014. - 488 p.; Moskala M. et al. Morphological Aspects of the Traumatic Chronic Subdural Hematoma Capsule: SEM Studies // Microscopy and icroanalysis. - 2007. - Vol. 13, No. 3. - P. 211-219].

Due to the presence of a sufficient number of compensatory possibilities in children under 1 year of age (the presence of a large fontanelle, plasticity of bone sutures, expansion of subarachnoid spaces, immaturity of brain structures), an acute period of subdural hematoma, even if the child has recurrent behavioral abnormalities and changes in neurological status , often skipped by parents. Given the lack of timely medical care over the above specified time, a capsule is formed that surrounds a completely subdural hematoma. The volume of this hematoma, due to its complex pathomorphological structure, increases, which creates a life-threatening situation.

The clinical course in children with CSH is manifested by general cerebral and hypertensive symptoms (the child is restless, refuses to eat, sleeps poorly, often burps, vomiting occurs periodically, there is an increase in the vascular pattern of the skin of the head, tension of the large fontanelle, an increase in the diameter of the head), there are frequent cases of epileptic seizures, up to the status course, the development of a neurological deficit (hemi-/tetraparesis, a positive symptom of Graefe, a positive meningeal syndrome, more often converging strabismus), when examining the fundus, stagnation of the visual disc is determined.

More often, children with a similar pathology come to inpatient treatment from grades I-III on the T.M. Markwalder [Markwalder T.M., Steinsieppe K.F., Rohner M. Et al. The course of chronic subdural hematoma after burr-hole craniostomy and closed-system drainage. J. Neurosurg 1981; 55(3):390-6.].

In all neurosurgical recommendations for the surgical treatment of CSH, its tactics and techniques are described only in adulthood, while these aspects are absent in children's recommendations. Surgical treatment of this pathology is still relevant.

Indications for surgical treatment of CSH are:

- the presence of a neurological deficit;

- oppression of the level of consciousness;

- hematoma thickness >1 cm;

- volume >50 cm ³ .

A known method of surgical treatment of chronic subdural hematoma by performing osteoplastic craniotomy with its complete removal. This method allows you to completely solve the problem intraoperatively, remove the hematoma and eliminate the zone of impression of the brain parenchyma, but given the duration, large blood loss of surgical treatment in childhood, this method is traumatic and carries a high risk of intra / postoperative complications [Kravchuk A.D., Likhterman L. .B., Maryakhin A.D. Clinical guidelines for the diagnosis and treatment of chronic subdural hematomas. - Moscow, 2015 - 49 p.].

Endoscopic evacuation of CSH requires the insertion of an endoscope sheath and adequate manipulation of the endoscopic system by making a burr hole of sufficient size, with a diameter of 15-20 mm; after completion of the main endoscopic stage of surgical treatment, a tubular drainage is installed in conclusion. To carry out this type of surgical treatment, expensive specialized equipment and an appropriate skill in the endoscopic system are required, which makes it difficult to use this technique in all regions of the Russian Federation, and also lengthens the time of surgical intervention [Krylov V.V. Endoscopic neurosurgery: a guide for doctors / ed. acad. RAS V.V. Krylov. - M.: ABS-press, 2020. - 416 p.].

There is a known method of installing two drainage tubes through two milling holes in order to create an inflow-outflow system, followed by washing with saline solution of the CSH cavity, the drainage tubes are installed below the level of the head to improve the outflow of hematoma contents [Mirzabaev M.Zh., Dyusembekov E.K., Aliev M.A., Khalimov A.R., Akhanov G.Zh., Nikolaeva A.V. Chronic subdural hematoma in elderly and senile patients // Bulletin of the AGIUV No. 1, 2018].

In childhood, the age of up to 1 year often prevails with CSH; in order to minimize trauma, it is desirable to use one burr hole for adequate drainage. It should also be noted that cases of occlusion by dense clots of the outflow drainage system are not uncommon, and if there is an untimely response to the activity of the inflow drainage, the risk of developing complications is high. As a result of hyperdrainage, there is a sharp decrease in intracranial pressure, which can affect the formation of recurrent hemorrhage.

Also known is a method for the treatment of subdural hematoma, carried out by transosseous access, performed using microperforation of the skull with an intraosseous needle to the hematoma cavity and drainage of the subdural space with a single catheter with a diameter of not more than 3 mm [Onysko O.V., Rychkov A.V., Smirnov B.V. , Zhigailov E.A. Method for the treatment of subdural hematoma. RF patent No. 2414173, publ. 03/20/2011].

This method does not allow for visual control over the course of surgical treatment during the implantation of the drainage system, judging by the claimed technique, the drainage is installed perpendicularly, which creates a risk of implanting a tubular catheter into the brain parenchyma both during installation and after reducing the volume of the subdural hematoma and straightening brain matter, which has negative consequences.

The objective of the claimed invention is to create a simplified method for the treatment of CSH - at the same time through the superimposed one burr hole, two drainage systems are implanted in opposite sides of the hematoma, thereby draining the hematoma throughout its entire length, and also due to the incoming air through one of the drainages, it allows to exclude the formation of a vacuum, which is the main reason for the unsatisfactory functional performance of the drainage system, which reduces the time of drainage, reduces the number of pyemic and hemorrhagic complications, thereby improving the results of surgical treatment.

The technical result of the claimed method is expressed in the complete regression of CSH without the risk of recurrence and minimizing the development of complications.

The technical result is achieved by the fact that through one burr hole of the skull, superimposed in the projection of the deepest part of the subdural hematoma and expanded to an oval shape, while two tubular drains are installed through the dissected dura mater with pre-cut holes in the implanted part with a length (length) within from 20 mm to 30 mm. One of the drains is immersed in the ventral part of the hematoma cavity, the other drain is immersed in the dorsal part of the hematoma cavity. The drains are implanted in opposite directions opposite each other, and the outer ends of the drains are brought out through the skin counter-openings.

The advantage of the claimed method is as follows.

1. It is possible to completely drain the CSH cavity throughout its entire length, without the formation of a vacuum.

2. Due to the presence of two drainage systems, it is possible to quickly achieve a decrease in the volume and sanitation of the hematoma cavity without the use of additional washing with physiological solutions.

3. The oval shape of the burr hole eliminates the risk of developing a kink in the drainage tube, and also allows you to introduce subdural drainage into the hematoma cavity at an acute angle.

4. The method does not require reoperation (it is used at any childhood), due to good consolidation, the bone defect in most cases heals.

5. Ease of use.

6. Absence of relapses when using this method of drainage of CSH.

The invention is illustrated by illustrations, where photo 1 shows a chronic subdural hematoma on a computed tomography image in the axial projection; photo 2 - chronic subdural hematoma on a computed tomographic image in the frontal projection; photo 3 - chronic subdural hematoma on a computed tomographic image in the sagittal projection; photo 4 shows an oval burr hole through which two tubular drains are implanted; photo 5 shows the installed drainage tubes into the hematoma cavity, one - into the frontal part of the hematoma for a length of 30 mm, the second - into the dorsal part by 20 mm; photo 6 shows the installed drain pipes in an approximate foreshortening; photo 7 - drainage tubes are brought out through the cutter hole to the outside with a total of four drains, two on each side; photo 8 - postoperative study, shows a total regression of chronic subdural hematoma on a computed tomographic image in the axial projection; photo 9 - postoperative study, shows a total regression of chronic subdural hematoma on a computed tomographic image in the frontal projection; photo 10 postoperative study, shows a total regression of chronic subdural hematoma on a computed tomographic image in the sagittal projection; photo 11 - the gradual disappearance of trepanion holes during the growth of the child, the study was carried out after 6 months. from the time of the operation.

Positions in photographs indicate the following:

1 - cavity of chronic subdural hematoma,

2 - oval-shaped milling hole,

3 - frontal implantable part of the first external drainage for a length of 30 mm,

4 - dorsal implantable part of the first external drainage for a length of 20 mm,

5 - substance of the brain,

6 - the outer part of the tubular drains, brought out through the milling hole,

7 - large fontanel,

8 - regression of chronic subdural hematoma,

9 - gradual tightening of the burr holes by the bone tissue.

The method is carried out as follows.

In the projection of the deepest part of the CSH, a linear incision is made, up to 30 mm long, soft tissues are separated in layers (skin-aponeurotic flap, then muscle-periosteal flap). A burr hole with a diameter of 7 mm is applied, which is expanded with bone cutters, giving the hole an oval shape. The dura mater (DM) is opened in an X-shape. Further, retreating from the operating area at a distance of 30 mm from the ventral and dorsal sides, counter-openings are created in the skin - additional linear incisions 5 mm long. On tubular drains, before implantation into the subdural cavity, additional holes are made at the intracranial end of the tube over a length of 20 mm to 30 mm, and only then one drain is immersed into the cavity of chronic subdural hematoma, directing the intracranial end to the ventral part of the hematoma, and the outer end is brought out through the dorsal counteropening. The intracranial end of the second drain is directed and immersed in the dorsal part of the hematoma, and the outer end is brought out through the ventral contra-opening. The surgical wound is sutured in layers. Drainage tubes are fixed and sutured to the skin with interrupted sutures. Apply an aseptic bandage. A sterile reservoir is connected to the drainage tubes to drain the lysed part of the hematoma. The drains are kept until the complete evacuation of the contents of the CSG.

Example. Patient T., 3 months was admitted to the neurosurgical department of the Regional Children's Clinical Hospital, in moderate condition, level of consciousness - stunning I, Graefe's symptom is sharply positive, intense large fontanel, pronounced vascular pattern of the skin of the head, divergence of bone sutures on the right with diastasis by 10 mm , asymmetry of the cranial vault D>S. Parents complain of frequent drowsiness of the child, refusal to eat, periodic anxiety in behavior. From the anamnesis it is known that for 3 weeks the child vomited once a day, the child became capricious, began to sleep poorly, often shudders with his limbs, freezes, within 3 days before admission, the child's condition began to noticeably worsen.

According to the X-ray computed tomography (CT) study, the diagnosis was made: “Chronic subdural hematoma of the right hemisphere. Hypertension-hydrocephalic syndrome. Dislocation syndrome (by 10 mm).

Surgical treatment was carried out: "drainage of the cavity of chronic subdural hematoma of the right hemisphere of the brain."

Operation protocol: under endotracheal anesthesia, in the position of the child lying on his back with an additional turn of the head to the left in the parietal region in the projection of the parietal tubercle, a linear incision up to 30 mm long was made, layer-by-layer separation of soft tissues, after which the parietal bone was visualized. A burr hole with a diameter of 7 mm was placed; after visualization of the dura mater, this hole was expanded with wire cutters to an oval shape, expanding it in its anterior-posterior sections. Before implantation of two tubular drains, additional holes were created on their itracranial parts over a length of 30 mm. On the skin, retreating from the surgical wound by 30 mm in order to form counter-opening, additional linear incisions 5 mm long were made in the dorsal and ventral parts. One drain is directed with its intracranial end to the ventral part of the hematoma, and the outer end is brought out through the dorsal counter-opening, the second drain is directed and immersed in the dorsal part of the hematoma with its intracranial end, and its outer end is brought out through the ventral counter-opening. A lysed hematoma was evacuated through the drains under high pressure, the brown hematoma functioned satisfactorily. The surgical wound was sutured in layers. The drainage tubes are fixed and sutured to the skin with interrupted sutures. An aseptic bandage was applied. A sterile reservoir is connected to the drainage tubes to drain the lysed part of the hematoma.

The drains were installed for three days. After this time, an CT scan of the brain was performed, according to which there was a positive trend in the form of regression of the dislocation of the median structures, restoration of liquorodynamics, the absence of a mass effect from the remaining CSH cavity, this cavity noticeably decreased in size. Xanthochromic contents are evacuated through the drains, without admixture of fresh blood, within the tubes, which made it possible to remove these drainage systems. The patient was discharged in a satisfactory condition from the moment of the operation on the 10th day after the removal of p/o sutures with regression of the neurological deficit and regression of cerebral symptoms.

In the course of dynamic CT examination of the brain (after 3 months, 6 months, 12 months), complete expansion of the brain parenchyma was noted, there were no signs of CSH recurrence, the bone defect in the area of the superimposed burr hole was consolidated.

In this way, 24 patients were operated on in the neurosurgical department of the Regional Children's Clinical Hospital, all of them had a good functional, therapeutic and cosmetic result, complications in the surgical treatment of this category of patients using the developed method were not observed.

The inventive method accelerates recovery and improves the quality of life of patients, reduces the duration of hospital treatment, does not require a second operation, there were no functional disorders during the operation of the installed drains. There are no complications during the operations, technical intraoperative difficulties do not arise.

Claims (1)

A method for draining chronic subdural hematoma in children, characterized in that through one burr hole of the skull, superimposed in the projection of the deepest part of the subdural hematoma, two tubular drains are installed through the dissected dura mater, while one of them is immersed in the ventral part of the hematoma cavity, the other - into the dorsal part of the hematoma cavity, characterized in that the burr hole is expanded to an oval shape, the tubular drains are placed at an acute angle into the subdural cavity in opposite directions opposite each other, and the outer ends of the drains are brought out through the skin counter-openings, while in advance at the intracranial ends of the tubular drainages make additional holes for 20-30 mm.

Images