Asian Case Reports in Emergency Medicine
Vol.06 No.03(2018), Article ID:26368,5 pages
10.12677/ACREM.2018.63003

Diagnosis and Surgical Treatment of Craniocerebral Injury Combined with Intracranial Aneurysm Rupture—Case Report

Peng Zhao, Wusi Qiu, Weiming Wang, Qizhou Jiang, Jun Cheng, Haisong Xu

Department of Neurosurgery, Affiliated Hospital of Hangzhou Normal University, Hangzhou Zhejiang

Received: Jul. 21st, 2018; accepted: Aug. 6th, 2018; published: Aug. 13th, 2018

ABSTRACT

Purpose: To study the diagnosis and therapeutic method of craniocerebral injury combined with intracranial aneurysm rupture and hemorrhage. Method: A 61-year-old female patient was hospitalized for sexual awareness disorder after a head trauma four hours earlier. Head CT showed subdural hemorrhage, left parietal cerebral hemorrhage, subarachnoid hemorrhage, and obvious displacement of the midline structure of the brain (Figure 1). Cephalic CTA shows distal branch aneurysm of left posterior cerebral artery (Figure 2). Results: Postoperative CTA examination indicated satisfactory aneurysm occlusion and patency of aneurysmal artery (Figure 3). Conclusion: Aneurysmal brain hematoma after craniocerebral injury, traumatic brain injury with intracranial aneurysm rupture should be considered. At the same time, combining with the history and the image is ruptured intracranial aneurysm in traumatic brain injury, or traumatic brain injury in intracranial aneurysm rupture. At this time, cephalic CTA is preferred to help definite diagnosis and reduce preoperative waiting time, timely craniotomy and decompression, and intraoperative treatment of ruptured aneurysms can reduce the risk of aneurysm rupture again.

Keywords:Brain Injury, Intracranial Hematoma, The Aneurysm

颅脑损伤合并颅内动脉瘤破裂诊断及手术 治疗—病例报告

赵鹏,裘五四,王卫民,姜启周,程军,徐海松

杭州师范大学附属医院(杭州市第二人民医院)神经外科,浙江 杭州

收稿日期:2018年7月21日;录用日期:2018年8月6日;发布日期:2018年8月13日

摘 要

目的:结合病例探讨颅脑损伤合并颅内动脉瘤破裂出血的诊断及治疗策略。方法:1例61岁女性患者因“头部外伤后进行性意识障碍4小时”入院,头颅CT显示左额颞顶部硬膜下出血,左顶叶脑出血,蛛网膜下腔出血,中线结构明显移位(图1)。头颅CTA显示左侧大脑后动脉远端分支动脉瘤(图2)。结果:术后CTA检查提示动脉瘤夹闭满意,载瘤动脉通畅(图3)。结论:颅脑损伤后出现动脉瘤性脑内血肿者,应考虑颅脑损伤合并颅内动脉瘤破裂的可能性,同时结合病史及影像判断是颅内动脉瘤破裂导致颅脑损伤,还是颅脑损伤导致颅内动脉瘤破裂。此时首选头颅CTA有助于明确诊断且减少术前等待时间,及时行开颅减压,术中同时处理破裂动脉瘤可降低动脉瘤再次破裂风险。

关键词 :颅脑损伤,颅内血肿,动脉瘤

Copyright © 2018 by authors and Hans Publishers Inc.

This work is licensed under the Creative Commons Attribution International License (CC BY).

http://creativecommons.org/licenses/by/4.0/

1. 引言

颅脑损伤合并颅内动脉瘤破裂出血,临床上容易被误诊、漏诊,应与创伤性蛛网膜下腔出血,创伤性硬膜下血肿或者脑内血肿鉴别。不能做到早期发现、处理会导致颅内动脉瘤发生二次破裂 [1] 。我科近期成功救治了1例重型颅脑损伤伴后交通动脉瘤破裂出血患者。现回顾其临床资料,并复习文献,报告如下。

2. 病例报告

患者,女性,61岁。因头部外伤后进行性意识障碍4小时入院。患者4小时前活动时摔倒在地,头部着地(具体不详)。约发病1小时后送至我院急诊,呈昏迷状,呼之不应,GCS:E1VTM1,查血压:135/80 mmHg,左/右瞳孔5 mm/4.5 mm,对光消失,呼吸微弱,急诊行头颅CT示左额颞顶部硬膜下出血,左顶叶脑出血,蛛网膜下腔出血,中线结构明显移位(图1)。行头颅CTA示左侧大脑后动脉远端分支动脉瘤(图2)。患者既往体健,否认高血压史,否认糖尿病史,否认结核、伤寒、疟疾等病史,无重大外伤史,无过敏史,无输血史。

患者入院后诊断为:脑疝(头部外伤合并动脉瘤破裂),完善相关检查后急诊在全麻下行额颞顶枕去骨瓣减压术 + 开颅血肿清除术 + 脑室穿刺引流术 + 动脉瘤夹闭术,手术顺利,术后患者安返ICU监护。术后24 h复查头颅CT提示血肿基本清除,中线移位较前改善(图3)。术后5天复查CTA提示动脉瘤夹闭妥,无明显再出血(图4)。

3. 讨论

颅脑损伤合并颅内动脉瘤破裂出血在临床上少见,Cummings等报道颅内动脉瘤破裂出血在创伤性蛛网膜下腔出血中约占8% [2] 。颅内动脉瘤破裂在CT影像上表现为颅内血肿较罕见,约占15% [3] 。患者

Figure 1. Top left frontal temporal subdural hemorrhage, left parietal lobe of the cerebral hemorrhage, subarachnoid hemorrhage, midline structure shift obviously

图1. 头颅CT:左额颞顶部硬膜下出血,左顶叶脑出血,蛛网膜下腔出血

Figure 2. Distal branch aneurysm of left posterior cerebral artery

图2. 头颅CTA:左侧大脑后动脉远端分支动脉瘤

Figure 3. Satisfactory aneurysm occlusion and patency of aneurysmal artery

图3. 头颅CT:血肿基本清除,中线移位较前改善

Figure 4. The aneurysm was clipped and there was no obvious re-hemorrhage

图4. 头颅CTA:动脉瘤夹闭妥,无明显再出血

均以颅脑损伤就诊。但颅脑损伤在先,伤时诱发颅内动脉瘤破裂,还是颅内动脉瘤破裂出血后导致头部受伤往往难以鉴别。由于两者的治疗方式不同,难度不同,预后不同,故早期诊断尤为重要。本病例因颅脑损伤就诊,急诊CT影像提示颅内血肿。综合考虑病史及CT表现怀疑是颅内动脉瘤破裂导致的颅脑损伤。遂急诊再次行头颅CTA,提示左侧大脑后动脉远端分支动脉瘤。证实此患者存在颅内动脉瘤破裂。最终拟颅内动脉瘤破裂导致颅脑损伤行手术治疗。

查阅相关资料文献并结合此病例,本研究认为以下情况应高度怀疑存在颅脑损伤合并颅内动脉瘤破裂的可能性:1) 蛛网膜下腔出血广泛且主要位于颅底蛛网膜池如鞍上池、环池、侧裂池等。2) 蛛网膜下腔出血位置与受伤部位无明显联系,脑挫裂伤多远离出血部位;3) 蛛网膜下腔出血并脑内血肿,且脑内血肿与蛛网膜下腔出血相连者。本病例术前CT提示左额颞顶部硬膜下出血,左顶叶脑出血,蛛网膜下腔出血。考虑脑内血肿与蛛网膜下腔出血相连。4) 既往有高血压病史,或有类似突发头痛和蛛网膜下腔出血病史者 [4] 。

此类病例的首选检查是CTA,DSA虽然是动脉瘤破裂的金标准,对判明动脉瘤的位置、数目、形态、内径、瘤蒂宽窄、有无血管痉挛、痉挛范围及程度和确定手术方案十分重要 [5] 。但DSA的局限性也很明显,检查费时、费力、有创,并且部分病例可能诱发再出血可能,这些都是DSA的局限性。而CTA具有费用较低,扫描便捷等特点,CTA扫描后的图像重建可以更好的将颅内血管的解剖结构显示出来,同时还能够任意旋转角度来观察颅内大管。同时,动脉瘤的位置、大小和形态、瘤颈、破裂口位置及与载瘤动脉的关系也能很好的显示出来,神经外科医生可以借助这些信息更好的设计手术 [6] [7] 。因此CTA有助于手术医生的手术设计,满足此类病例对影像的要求,是诊断此类病例的首选。

本病例入院时病情危重,脑疝形成,颅内血肿量大,CTA提示左侧大脑后动脉远端分支动脉瘤诊断明确,急诊手术指征明确,且文献报道2%~4%颅内动脉瘤发病后24 h内再次破裂出血,15%~20%动脉瘤在发病后14 d内再次破裂,再次破裂出血的病死率高达65% [8] 。本病例术中主刀医生并不考虑二次手术处理动脉瘤,而是术中清除脑内血肿的同时夹闭动脉瘤。

回顾本例患者的诊治,结合文献复习,我们认为,对于颅脑损伤后出现动脉瘤性脑内血肿者,应考虑颅脑损伤合并颅内动脉瘤破裂的可能,同时结合病史及影像判断是颅内动脉瘤破裂导致颅脑损伤,还是颅脑损伤导致颅内动脉瘤破裂。此时首选头颅CTA有助于明确诊断且减少术前等待时间,及时行开颅减压,术中同时处理破裂动脉瘤可降低动脉瘤再次破裂风险。

文章引用

赵 鹏,裘五四,王卫民,姜启周,程 军,徐海松. 颅脑损伤合并颅内动脉瘤破裂诊断及手术治疗—病例报告
Diagnosis and Surgical Treatment of Craniocerebral Injury Combined with Intracranial Aneurysm Rupture—Case Report[J]. 亚洲急诊医学病例研究, 2018, 06(03): 9-13. https://doi.org/10.12677/ACREM.2018.63003

参考文献

  1. 1. 方军康, 郭晓竑, 许金刚, 许国锋, 刘子明. 颅脑损伤合并颅内动脉瘤破裂出血10例[J]. 浙江创伤外科, 2017, 22(5): 842-843.

  2. 2. Cummings, T.J., Johnson, R.R., Diaz, F.G., et al. (2000) The Relationship of Blunt Head Trauma, Subarachoid Hem-orrhage, and Rupture of Pre-Existing Intracranial Saccular Aneurysms. Neurological Research, 22, 165. https://doi.org/10.1080/01616412.2000.11741055

  3. 3. 王忠诚. 王忠诚神经外科学[M]. 武汉: 湖北科学技术出版社, 2005: 763.

  4. 4. Skowronek, R., Kobek, M., Jankowski, Z., Zielińska-Pająk, E., Pałasz, A., Pilch-Kowalczyk, J., Kwarta, R., Rygol, K., Szczepański, M. and Chowaniec, C. (2016) Traumatic Basal Subarachnoid Haemorrhage or Ruptured Brain Aneurysm in 16-Year-Old Boy?—Case Report. Archiwum Medycyny Sądowej i Kryminologii, 66, 32-40. https://doi.org/10.5114/amsik.2016.62333

  5. 5. 赵继宗, 周良辅, 周定标, 等. 神经外科学[M]. 北京: 人民卫生出版社, 2007: 492.

  6. 6. Vaphiades, M.S., Cure, J. and Kline, L. (2008) Management of Intracranial Aneurysm Causing a Third Cranial Nerve Palsy: MRA, CTA or DSA? Seminars in Ophthalmology, 23, 143-150. https://doi.org/10.1080/08820530801978534

  7. 7. Matsumoto, M., Kasuya, H., Sato, T., et al. (2007) Can 3D-CT Angiography (3D-CTA) Replace Conventional Catheter Angiography in Ruptured Aneurysm Surgery? Our Experience with 162 Cases. Fukushima Journal of Medical Science, 53, 85-94. https://doi.org/10.5387/fms.53.85

  8. 8. 蔺玉昌, 冷冰, 苗增利, 等. 复发性颅内动脉瘤治疗方法的选择[J]. 中华神经外科杂志, 2006, 22(8): 497-498.

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