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Advances in Clinical Medicine
Vol. 14  No. 01 ( 2024 ), Article ID: 79344 , 5 pages
10.12677/ACM.2024.141100

蛛网膜囊肿合并慢性硬膜下血肿10例临床 分析

刘自衡1，杨宇浩2，李照建3*

1青岛大学医学部，山东 青岛

2胶州中心医院神经外科，山东 青岛

3青岛大学附属医院神经外科，山东 青岛

收稿日期：2023年12月17日；录用日期：2024年1月10日；发布日期：2024年1月17日

摘要

目的：探讨蛛网膜囊肿合并慢性硬膜下血肿的诱因及治疗方案。方法：青岛大学附属医院2014年4月至2020年5月收治蛛网膜囊肿合并慢性硬膜下血肿患者10例，2例保守治疗，3例行单纯钻孔引流术，1例行囊肿–腹腔分流术 + 钻孔引流术，1例行钻孔引流术 + 开颅血肿清除术，3例行开颅血肿清除术 + 囊肿切除术，回顾性分析其临床资料和治疗效果。结果：10例患者均恢复良好，无不适，3~24个月随访未见血肿或囊肿复发。结论：蛛网膜囊肿患者受头部外伤、运动等刺激易致囊肿破裂出血；蛛网膜囊肿合并慢性硬膜下血肿首选钻孔引流术；血肿复发或囊肿伴相应症状者可在行血肿清除时一并切除囊肿。

关键词

蛛网膜囊肿，慢性硬膜下血肿，病因分析，治疗效果

Clinical Analysis of Arachnoid Cysts with Chronic Subdural Hematoma—10 Case Reports

Ziheng Liu1, Yuhao Yang2, Zhaojian Li3*

1Medical College, Qingdao University, Qingdao Shandong

2Department of Neurosurgery, Jiaozhou Central Hospital, Qingdao Shandong

3Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao Shandong

Received: Dec. 17th, 2023; accepted: Jan. 10th, 2024; published: Jan. 17th, 2024

ABSTRACT

Objective: To investigate the pathogenesis and treatment of intracranial arachnoid cyst. Methods: Retrospectively analyze 10 patients with arachnoid cysts and intracranial hematoma admitted from April 2014 to May 2020. 2 patients were managed conservatively, 3 patients were performed with trepanation and drainage, 1 patient was performed with borehole drainage and cystic-peritoneal shunt, 1 patient was performed with borehole drainage and hematoma evacuation, 3 patients were performed with hematoma evacuation and cyst resection. Results: All the patients in this study were in good recovery and respectively followed up for 3 to 24 months. No complications or recurrence had occurred. Conclusion: Patients with intracranial arachnoid cysts are vulnerable to intracranial hemorrhage after head injury or sports. Trepanation and drainage should be the first treatment of arachnoid cysts with chronic subdural hematoma. Craniotomy evacuation of hematoma and cyst resection are preferred to the patients who have high risk of bleeding recurrence or obvious symptom of arachnoid cysts.

Keywords:Arachnoid Cysts, Chronic Subdural Hematoma, Etiology Analyses, Treatment Effect

Copyright © 2024 by author(s) and Hans Publishers Inc.

This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).

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

1. 引言

颅内蛛网膜囊肿(intracranial arachnoid cyst, IAC)是一种位于脑实质外、蛛网膜内的囊性占位病变，好发于中颅窝(外侧裂)，约占颅内占位性病变的1%。可发生于任何年龄，但在儿童中更为常见，大约有75%的病例出现于儿童，男女比例为3:1 [1] 。蛛网膜囊肿因外伤或自发破裂时可继发慢性硬膜下血肿(chronic subdural hematoma, CSDH)，其机制复杂仍无定论，因此指导患者规避IAC破裂相关风险便显得更加重要；多数IAC继发CSDH患者因出现颅内高压症状而需要处理，但治疗方式尚不统一 [2] ，以上问题值得讨论。本文对10例IAC合并CSDH患者进行回顾性研究，以增强对蛛网膜囊肿出血的认识和诊疗。

2. 资料与方法

青岛大学附属医院2014年4月至2020年5月确诊收治蛛网膜囊肿合并慢性硬膜下血肿患者10例，男性9例，女性1例，平均年龄17.7岁。

临床症状：9例患者有明显头痛，其中4例伴恶心呕吐；1例有外耳道流液；1例有视物模糊。5例患者出现症状前2个月内有明确外伤史。

影像表现：颅脑CT (图1)、MR (图2)示10例患者囊肿均位于中颅窝，伴同侧慢性硬膜下血肿。

诊疗经过：2例患者行保守治疗；3例行单纯钻孔引流术；1例行钻孔引流术后另行囊肿–腹腔分流术；1例于外院行钻孔引流术后血肿复发，于我院行开颅血肿清除术 + 囊肿切除术，3例行开颅血肿清除术 + 囊肿切除术，手术过程：彻底清除血肿后冲洗至流出液清亮，探查蛛网膜囊肿，剪开囊壁释放囊液，反复冲洗干净后尽可能切除壁层囊壁及脏层囊壁，剪开侧裂及基底池蛛网膜，使囊肿与蛛网膜下腔沟通，术中仔细止血，避免损伤神经及重要血管。

Figure 1. Brain CT imaging

图1. 患者颅脑CT影像

Figure 2. Brain MRI imaging

图2. 患者颅脑MRI影像

回顾性研究以上资料，汇总如下(表1)。

Table 1. General information of 10 patients with IAC and CSDH

表1. 10例IAC合并CSDH患者一般资料

3. 结果

10例患者均恢复良好，术后复查CT未见明显异常(图3)，临床症状明显缓解后出院。出院后10例患者分别行为期3至24个月随访，一般情况可，正常生活未受影响，复查影像未见复发出血或囊肿增大(图4)。

Figure 3. Postoperative follow-up imaging

图3. 术后复查影像

Figure 4. Long term follow-up imaging

图4. 长期随访影像

4. 讨论

IAC多属于先天性良性囊肿性病变，颅脑感染、外伤、出血等亦可引起继发性IAC，大多数IAC无明显症状，部分Galassi 2型及3型巨大IAC可压迫周围脑组织及颅骨，引起神经症状及颅骨改变。IAC破裂引起的CSDH临床并不常见，但Mori Kentaro等 [3] 对541例CSDH患者临床分析发现青年CSDH患者合并IAC的比例为62.5%，明显高于中老年CSDH患者。本组10例患者最大年龄为28岁，平均年龄17.7岁，验证了IAC是青年人群发生硬膜下血肿的常见危险因素之一。

IAC患者更容易因头部外伤、剧烈活动而发生CSDH [4] ，Lee Chang-Hyun等 [5] 研究发现位于外侧裂的IAC较正常情况承受了更多来自头部活动或受冲击的剪切力，因囊壁破裂而导致硬膜下血肿或积液的风险更高。患者起病前一般有近期头部外伤史或剧烈活动史 [6] [7] [8] ，因此对于IAC患者应注意宣教尽量避免会增加头部外伤风险的活动，如足球、篮球、拳击等。此外，部分患者的轻微外伤史常被忽略 [9] ，且临床症状轻微 [10] ，易发生误诊或漏诊。无外伤史的IAC自发破裂机制尚不明确，其诊疗措施没有明显改变 [11] 。

钻孔引流术是IAC合并CSDH的常用治疗手段，具有创伤小、术后并发症少等优点，手术效果满意，随访中患者临床症状明显改善 [12] ，本文3例行单纯钻孔引流患者术后恢复良好，证实其疗效可靠。对于囊肿本身引起压迫症状或钻孔引流术后复发血肿的患者，应在清除血肿的同时一并处理囊肿，可行开颅囊肿切除术或囊肿–腹腔分流术。囊肿–腹腔分流术后并发症发生率较高，但在治疗Galassi 3型IAC时具有疗效稳定、术后无巨大空腔残留的优点；本文4例开颅囊肿切除患者术后未出现严重手术并发症，长期随访手术效果理想，是目前常用方案之一。此外，较晚开展的神经内镜下囊肿造瘘术 [13] 具有微创、无异物植入的优点，长期效果有待于继续观察。对于一般情况可、血肿量不大的患者也可行保守治疗，若无新发出血，患者临床症状可逐渐改善，长期随访满意，应用药物如阿托伐他汀对IAC出血亦有一定疗效 [14] 。综上所述，对于IAC合并CSDH的患者优先选择钻孔引流术，复发血肿及囊肿伴神经症状者可一并处理囊肿，根据患者具体情况对手术方案进行个体化调整。

文章引用

刘自衡,杨宇浩,李照建. 蛛网膜囊肿合并慢性硬膜下血肿10例临床分析
Clinical Analysis of Arachnoid Cysts with Chronic Subdural Hematoma—10 Case Reports[J]. 临床医学进展, 2024, 14(01): 722-726. https://doi.org/10.12677/ACM.2024.141100

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    15. NOTES

    *通讯作者。

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