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| 題 名 | 硬腦膜外血腫:170例之臨床研究 |
|---|---|
| 作 者 | 高明見; 洪慶章; | 書刊名 | 中華民國外科醫學會雜誌 |
| 卷 期 | 9:1 民65.01-03 |
| 頁 次 | 頁24-39 |
| 關鍵詞 | 硬腦膜外血腫; |
| 語 文 | 中文(Chinese) |
| 中文摘要 | 自1968年1月至1975年1月七年間，在臺大醫院以外科手術治療，證明重逾30公克之硬腦膜外血腫共170例。年齡分佈以青少年最多，佔半數以上；性別以男性居多，男女之比例為8.5比1。造成本症之事故，以車禍為最多，佔62%，尤以機車事故為多，跌落摔倒者佔21%，被毆打者佔11%，為墜物擊傷者佔6%。受傷當初腦本身之損傷多為輕度或中等度，因170例中，10例受傷至手術始終清醒，123例受傷至開刀之間仍有一股清醒之時期，卽所謂之清明期，而後再惡化。因本症起因於外傷，往往無法確知清明期之長短，如概略分為一日以內以及一日以上兩羣，則前者有109例，後者有14例，無清明期者有30例(18%)。 關於顱骨骨折，145例可由X光片或手術所見確定有骨折，其餘25例，或無記錄或無骨折或未照X光者。大多數為顱頂(Calvarium)骨折，且以線狀骨折居多(130例)，複合性及凹陷性骨折有15例。骨折部位多於側頭部，波及枕骨者僅2例，13例為橫跨中央之兩側性骨折。純粹之顱底骨折，不易由普通X光檢查或手術確知。若為顱頂之骨折，則其外表頭皮多有撞擊傷痕。 雖然至少有133例(78%)，(包括始終清醒之10例)，於受傷至手術之間仍有一段清醒時期，但至開刀前，則有160例(94%)呈意識障礙，其中133例(78%)呈半昏睡或昏睡狀態，27例(16%)星嗜睡或木殭狀態。術前呈去皮質或去腦硬直者有80例(47%)。凡術前症狀嚴重，如昏睡或去腦硬直，則預後必不良，死亡率亦甚高，如幸而生存，則術後意識之恢復較慢，康復程度較差，而術前仍清醒之10例，術後均迅速清醒且完全康復。 有10例曾施行腦血管攝影檢查，均可發現無血管區影像，故此項檢查對血腫之正確診斷甚者價值。15例曾以超音波檢查中介反射波(Midline Echo)之偏位，但因經驗不足技術未熟，結果多不可靠。 因大多數病例，均先經就近醫院之診治，而後轉來本院，再經本院住院醫師之診治，始行手術，以致多數病例卽於該段時期被延誤，究其原因，在就近醫院，主因醫師之缺乏腦外科學智識及經驗，以致未能正確診斷及適切處置，且擔心輸送當中病情惡化而造成延誤。到達本院後，因醫師對本症之不正確觀念，以為本症必須具有清明期或顱骨骨折，或拘泥於典型症狀之出現，診斷困難時又不能施行緊急腦血管攝影檢查，因而延誤診斷及手術治療。 至於手術之方法，大多數先施行試驗穿孔，發現血腫後再擴大該洞以便清除血腫及止血，即所謂之破骨開顱術(Osteoclastic craniotomy)。少數病例，因病情較不緊急，且由腦外科專門醫師手術，則施行骨成形開顱術(Osteoplastic craniotomy)。如合併嚴重腦挫傷或腦浮腫，則併施顳下減壓術(Subtemporal decompression)。 血腫之大小時分為三型，大型者為120 c.c.以上，中型者為60 c.c.至120 c.c.，小型者為60 c.c.以下。半數以上之病例為大型血腫，但血腫之大小與致命率無明顯關系。多數之血腫位於側頭部，局限於額部者有14例，兩側性者5例，無一例於後顱窩。血腫與顱頂骨折皆於同一側，雖然兩者部位未必完全一致。遲發性血腫有6例，位於側頭部者有5例，大多術後結果良好。約有半數病例合併其他顱內損傷，如腦挫傷及硬腦膜下血腫，其死亡率比無合併者為高，前者為32%，後者為8%。 170例中34例於術後住院當中或自動出院不久死亡，手術死亡率為20%，51歲以上15例中8例死亡，高齡者死亡率較高。死亡例中約70%因車禍致命，但事故種類不影響其致命率。34例中8例無清明期，無一例其清明期超過一日。死亡34例中，合併硬腦膜內損傷者有27例，術前呈半昏睡或昏睡者有32例，呈去皮質或去腦硬直者有28例，兩側瞳孔均散大者有6例，呼吸暫停者有2例，18例併有明顯上消化道出血，數例曾因此而致命。總之，年齡，病情惡化速度，合併顱內損傷以及術前之意識與腦幹機能具常症狀，均可影響死亡率，而事故種類、骨折部位、血腫大小與手術方法，對死亡率無明顯影響。 |
| 英文摘要 | Extradural hemorrhage is an acute and serious complication of head injury. Most of the patients with extradural hematoma can be easily cured, provided that the diagnosis is promptly established and immediately followed by surgery. Otherwise, extradural hematoma will almost always be fatal. From January, 1968 to January, 1975, 170 cases of extradural (epidural) hematoma were surgically treated at the National Taiwan University Hospital. So far as we know, this is one of the largest clinical series of patients with extradural hematoma reported up to date. The age ranged from 8 months to 70 years, the peak being in the second decade. Males outnumbered females by 8.5 to 1. As to the causes of iniury, 62% were traffic accidents, especially those by motorcycles, 21% were falling upon the head, 11% were assaults and 6% were falling objects on the head. The initial injury to the brain was usually of minor or moderate degree, as there were 10 patients who remained entirely, conscious all the time, and about 70% of the cases had a lucid period of various duration after the accident. Fractures of the skull were identified either in x-ray films or during operation in 145 cases. Most of them were linear fractures and involved the lateral part of the calvarium. ln 18 cases there were bilateral fractures, which crossed the midline in 13 cases. The fracture of the calvarium was always associated with an extemal scalp wound over the fracture area. Although many patients had a lucid period after the accident, 160 patients (94%) had some disturbance of consciousness before the operation, 133 patients (78%) being semicomatose or comatose and 27 patients (16%) lethargic or stuporose. Decortication or decerebration was present in 80 cases (47%). The comatose and decerebrate states were associated with a serious prognosis and high mortality. No death occurred in the 24 patients who had a lucid period over 24 hours or who remained conscious all the time. Ten patients underwent cerebral angiographic examination, the diagnosis of extradural hematoma was invariably confirmed by surgery. The results of Echo encephalography in 15 cases were not always reliable. After the accidents, most patients were first sent to a local hospital and then transferred to our Emergancy Service after receiving some treatment. When the patients were brought to our Emergency Service, they were usually first seen and managed by our surgical residents. The diagnosis and treatment were usually delayed in these two periods. The lack of essential neurosurgical knowledge and experience as well as misconceptions about the treatment of intracranial bleeding among practitioners or general surgeons was the first major cause of delay. Undue concern about the transference of the patient to a neurosurgical center by the family or doctors was the second most important cause of delay. The failure by our surgical residents to recognize the clinical features which deviate from the classical course of epidural hemorrhage was the third leading cause. As to the types of operalion, usually exploratory bur-holes were followed by an osteoclastic craniotomy if a hematoma was found. A few patients underwent an osteoplastic craniotomy as their course was fairly benign and operation was performed by the neurosurgical staff. Subtemporal, lecompression was often performed if there was severe brain swelling. The hematoma was located beneath the lateral part of calvarium in most of the cases, at the frontal region in 14 cases, and was bilateral in 5 cases, but never in the posterior fossa. In this series, the hematoma was always found on the same side as the calvarial fracture. The size of hematoma was roughly divided into 3 groups: small hemato na less than 60 c.c., medium from 60 c.c. to 120 c.c. and large over 120 c.c. More than half of the cases had a large hemanoma, but there was no signifificant correlation between the size of hematoma and the mortality. Eighty-four of the 170 cases were associated with intradural lesions. Those cases associated with contusion or contusion and subdural bleeding had a higher mortality rate than those with "pure" extradural hematoma. Thirty-four patients died postoperatively either during the hospitalization or soon after discharge, the operative mortality being 20%. The contributing factors to the higher mortality rate were 1) old age, 2) shorter lucid interval with a rapid course of deterioration 3) a combination of intradural lesions, 4)presence of coma, and 5) decerebration before surgery. Bleeding from the upper gastrointestinal tract possibly related to the stress mechpaism was demonstrated in 18 of the 34 fatal cases. Based on this study, it is emphasized that the early diagnosis and prompt surgical intervention are essential to the reouction of the mortality and morbidity of extradural hematoma. The need of postgraduate training in traumatic neurosurgery for those practitioners and general surgeons responsible for primary management of acute head iniuries can not be overemphasized. A wider use of cerebral angiography is desirable, especially when the diagnosis is in doubt. Computerized axial tomography will be most ideal in the early diagnosis of this acute and serious complication. The establishment of head injury centers and organization of a modem ambulance system are urgently needed in this community. |
本系統中英文摘要資訊取自各篇刊載內容。