만성 경막하 혈종의 성장에 대한 뇌 CT 소견 및 치료 방침

이영배 ( Young Bae Lee ) 대한외상학회 2012 大韓外傷學會誌 Vol.25 No.4

Purpose: The objectives of this study are to classify chronic subdural hematomas based on brain computerized tomographic scan (CT scan) findings and to determine the mechanism of evolution and treatment methods. Methods: One hundred thirty-nine patients who were diagnosed with a chronic subdural hematoma and who available for follow up assessment 6 months post-surgery were analyzed retrospectively. The presence of trauma and past medical history were reviewed and evaluation criteria based on brain CT scan findings were examined. Results: Initial brain CT scans revealed a chronic subdural hematoma in 106 patients, a subdural hygroma in 24 patients, and an acute subdural hematoma in 9 patients. In all cases where the initial acute subdural hematoma had progressed to a chronic subdural hematoma, final was a hypo-density chronic subdural hematoma. In case where the initial subdural hygroma had progressed to a chronic subdural hematoma, the most cases of hematoma were hyper-density and mixed-density chronic subdural hematoma. In total, 173 surgeries were performed, and they consisted of 97 one burr-hole drainages, 70 two burr-hole drainages and 6 craniotomies. Conclusion: This study demonstrates that rebleeding and osmotic effects are mechanisms for enlarging of a chronic subdural hematoma. In most cases, one burr-hole drainage is a sufficient for treatment. However, in cases of mixed or acute-on-chronic subdural hematomas, other appropriate treatment strategies are required. (J Trauma Inj 2012;25:209-216)

Cauda Equina Syndrome from Subdural Hematoma after Caudal Epidural Injection

Oh Jung Jae,Park Jong-Hyeok,Kim Jong-Tae 대한말초신경학회 2021 The Nerve Vol.7 No.2

Caudal epidural injection (CEI) is commonly used to manage patients with low back or leg pain, but cauda equine syndrome (CES) rarely results from epidural and/or subdural hematoma occurred after the procedure. A 71-year-old man presented at our outpatient department with voiding difficulty and radiating pain in both legs 8 days ago after CEI. The patient also complained pain and numbness of saddle area, CES. He had taken clopidogrel for 8 years after cardiac stent insertion. Lumbar magnetic resonance imaging (MRI) revealed subdural hematoma at the L5-S1-S2 level. The patient underwent urgent surgical treatment for hematoma evacuation. We finally recognized that subdural hematoma in lumbar MRI was found to subdural-extra arachnoid hematoma as considering intraoperative findings. To the best of our knowledge, few cases of this complication have been reported after CEI. Subdural hematoma often is concomitant with subarachnoid hematoma. Subdural and subarachnoid hematoma is associated with poor clinical outcomes due to severe edema of nerve rootlets. However, no evidence of edema and swelling of nerve rootlets was observed during surgery in our case. As a result, the patient achieved full recovery more than we expected unlike the case of subdural and subarachnoid hematoma.

Chronic Subdural Hematoma in the Aged, Trauma or Degeneration?

Lee, Kyeong-Seok The Korean Neurosurgical Society 2016 Journal of Korean neurosurgical society Vol.59 No.1

Chronic subdural hematomas (CSHs) are generally regarded to be a traumatic lesion. It was regarded as a stroke in 17th century, an inflammatory disease in 19th century. From 20th century, it became a traumatic lesion. CSH frequently occur after a trauma, however, it cannot occur when there is no enough subdural space even after a severe head injury. CSH may occur without trauma, when there is sufficient subdural space. The author tried to investigate trends in the causation of CSH. By a review of literature, the author suggested a different view on the causation of CSH. CSH usually originated from either a subdural hygroma or an acute subdural hematoma. Development of CSH starts from the separation of the dural border cell (DBC) layer, which induces proliferation of DBCs with production of neomembrane. Capillaries will follow along the neomembrane. Hemorrhage would occur into the subdural fluid either by tearing of bridge veins or repeated microhemorrhage from the neomembrane. That is the mechanism of hematoma enlargement. Trauma or bleeding tendency may precipitate development of CSH, however, it cannot lead CSH, if there is no sufficient subdural space. The key determinant for development of CSH is a sufficient subdural space, in other words, brain atrophy. The most common and universal cause of brain atrophy is the aging. Modifying Virchow's description, CSH is sometimes traumatic, but most often caused by degeneration of the brain. Now, it is reasonable that degeneration of brain might play pivotal role in development of CSH in the aged persons.

Superimposed Propionibacterium Acnes Subdural Empyema in a Patient with Chronic Subdural Hematoma

Kim, Jong-Hun,Lee, Chul-Hee,Hwang, Soo-Hyun,Kang, Dong-Ho The Korean Neurosurgical Society 2009 Journal of Korean neurosurgical society Vol.45 No.1

The authors present a case of subdural empyema in a macrocephalic patient. A 23-year-old male was admitted due to headache and fever. One month ago, he had mild head injury by his coworkers. Physical examination showed a macrocephaly and laboratory findings suggested purulent meningitis. Neuroimaging studies revealed a huge size of epidural space-occupying lesion. Under the impression of epidural abscess, operation was performed. Eventually, the lesion was located at subdural space and was proven to be subdural empyema. Later, histological examination of the specimen obtained by surgery demonstrated finings consistent with the capsule of the chronic subdural hematoma. Two weeks after operation, Propionibacterium acnes was isolated. The intravenous antibiotics were used for total of eight weeks under monitoring of the serum level of the C-reactive protein. Follow-up brain computed tomography (CT) scan showed the presence of significant amount of remaining subdural lesion. However, he has complained of minimal discomfort. It is suggested that the subdural empyema occurred with preexisting chronic subdural hematoma after head injury about one month prior to admission and it took a long time to treat Propionibacterium acnes subdural empyema with systemic antibiotics, at least over eight weeks.

Twist-Drill or Burr Hole Craniostomy for Draining Chronic Subdural Hematomas: How to Choose It for Chronic Subdural Hematoma Drainage

이성종,황선철,임수빈 대한신경손상학회 2016 Korean Journal of Neurotrauma Vol.12 No.2

Objective: Although twist-drill craniostomy (TDC) has a number of procedural advantages and an equivalent outcome compared to burr hole craniostomy (BHC) for the treatment of chronic subdural hematomas (CSDHs), the latter technique remains the preferred method. We analyzed symptomatic CSDHs in whom TDC at the pre-coronal suture entry point (PCSEP) was the primary method for hematoma drainage and BHC on the parietal was the secondary option. Methods: CSDHs in 86 consecutive patients were included. TDC at the PCSEP, which is 1 cm anterior to coronal suture at the level of the superior temporal line, was the primary operational technique when the hematoma thickness was suitable, and BHC was performed via the parietal when TDC was unreasonable or failed. The clinical feasibility and outcomes of these approaches were analyzed. Results: Of the 86 patients, 68 (79.1%) were treated by TDC, and 18 (20.9%) by BHC. All patients showed improvements in their symptoms after hematoma drainage. Neither morbidity nor mortality was associated with either technique, and there were no differences in drainage days between the groups. Ten patients had bilateral hematomas and were treated using TDC. Two patients were not sufficiently treated by TDC and, as a result, BHC was applied. Only six hematomas (7% of 86 hematomas) exhibited insufficient thickness on the computed tomography to perform TDC. Conclusion: When the hematoma was thick enough, a majority of the CSDHs were drained using TDC at the PCSEP as the first procedure, which was especially useful for bilateral hematomas and in elderly patients.

급성 뇌경막하 혈종 수술중 반대측에 발생한 뇌경막하 혈종 : Case Report

임좌혁 대한신경외과학회 1991 Journal of Korean neurosurgical society Vol.20 No.4

A case of traumatic acute bilateral subdural hematoma with different times is expierenced. The contralateral subural hematoma was developed during the evacuation of an acute subdural hematoma. The reduction of intracranial pressure after removal of subdural hematoma was postulated to be contributing factor to formation of the contralateral subdural hematoma.

외상후 뇌경막하 수종에 동반된 만성 뇌경막하 혈종 : 3례 증례 보고 A Report of Three Cases

박한배,이충렬,김상철 대한신경외과학회 1990 Journal of Korean neurosurgical society Vol.19 No.1

Three cases of chronic subdural hematoma superimposed on posttraumatic subdural hygroma are presented, with discussion of the development of the chronic subdural hematoma particularly. In all of these three cases the chronic subdural hematoma had occured consequently to the posttraumatic subdural hygroma, but these diagnoses were done in variable periods of 20 days to 60 days. Therefore, it is suggested that the posttraumatic subdural hygroma have, at least, some relation to the genesis of the chronic subdural hematoma.

Predictive Factors for Recurrence after Burr-Hole Craniostomy of Chronic Subdural Hematoma

Kim, Sang Uk,Lee, Dong Hoon,Kim, Young Il,Yang, Seung Ho,Sung, Jae Hoon,Cho, Chul Bum The Korean Neurosurgical Society 2017 Journal of Korean neurosurgical society Vol.60 No.6

Objective : Chronic subdural hematoma is a common and relatively benign disease. However, recurrence is common after surgical treatment, and the recurrence rate varies from 5% to 33%. The aim of this study was to investigate the predictive factors for recurrence of chronic subdural hematoma. Methods : We analyzed data from 248 patients with chronic subdural hematoma who were treated by burr-hole craniostomy with a closed drainage system for hematoma evacuation in this five-year retrospective study. Results : Thirty-one (12.6%) patients underwent re-operation for recurrence of chronic subdural hematoma. Univariate analysis revealed that anticoagulation (p=0.0279), headache (p=0.0323), and preoperative midline shifting (p=0.0321) showed significant differences with respect to recurrent chronic subdural hematoma. We performed a multivariate logistic regression analysis and found that diabetes mellitus (odds ratio [OR], 2.618; 95% confidence interval [CI], 1.0899-6.2898; p=0.0314), anticoagulation (OR, 6.739; 95% CI, 1.1287-40.2369; p=0.0364), headache (OR, 2.951; 95% CI, 1.1464-7.5964; p=0.0249), and preoperative midline shifting (OR, 1.0838; 95% CI, 1.0040-1.1699; p=0.0391) were independent predictive factors for recurrence of chronic subdural hematoma. Conclusion : We showed that diabetes mellitus, anticoagulation, headache, and preoperative midline shifting were independent predictors of recurrence of chronic subdural hematoma.

급성 허혈성 뇌졸중으로 오인된 자발성 경추 경막외 혈종: 증례 보고

송상윤,이은창,김동출,김동희 대한척추외과학회 2021 대한척추외과학회지 Vol.28 No.4

Study Design: Case report. Objectives: To report a case of spontaneous spinal epidural hematoma (SSEH) mimicking acute ischemic stroke in an 80-year-old woman. Summary of Literature Review: SSEH is a rare condition. Its initial presentation can vary, but generally involves neck pain, headache, gait disorder, and quadriplegia. These initial symptoms are sometimes mistaken for acute ischemic stroke or spontaneous spinal subdural hematoma. SSEH mimicking acute ischemic stroke or spontaneous spinal subdural hematoma is unique. Materials and Methods: An 80-year-old woman was referred to our center with symptoms of headache and left-side hemiparesis (motor grade 1/5). After 2 hours, the neurologic deficit spontaneously improved (3/5). The neurology department initially diagnosed the patient with acute ischemic stroke and began treatment with anticoagulants. Cervical magnetic resonance imaging (MRI) demonstrated that the diagnosis was spinal subdural hematoma, presenting with acute hematoma at the level of C2-3. Results: Decompression surgery was performed for hematoma, and pathologic findings confirmed it to be SSEH. One month after the operation, the patient's motor strength recovered to a normal level. Conclusions: SSEH is difficult to diagnose because its initial clinical presentation mimics that of acute ischemic stroke. Therefore, medical staff should first suspect SSEH, rather than acute ischemic stroke and transient ischemic stroke, in cases of hemiparesis accompanied by pain. Cervical MRI is a standard diagnostic tool for spinal hematoma. However, differentiation between epidural and subdural hematoma is sometimes difficult. Therefore, if the patient's neurological symptoms do not improve despite conservative treatment, surgical decompression should be performed for diagnostic and therapeutic purposes. 연구계획: 증례보고목적: 80세 여성에서 급성 허혈성 뇌졸중으로 오인된 자발성 척추 경막외 혈종 증례를 보고한다. 선행 연구문헌의 요약: 자발성 척추 경막외 혈종은 드물지만 신경 증상이 동반된 경우 응급 수술이 필요한 질환이다. 초기 패턴은 다양할 수 있지만 일반적으로 목 통증, 두통, 보행 장애 및 사지 마비 증상으로 나타난다. 이러한 초기 증상은 때때로 급성 허혈성 뇌졸중 또는 자발성 척추 경막하 혈종으로 오인된다. 급성 허혈성 뇌졸중으로 오인된 자발성 척추 경막외 혈종은 드물다. 대상 및 방법: 80세 여성이 두통과 좌측 하지 마비(운동 등급 1/5)를 호소하며 내원하였다. 2시간 후 신경학적 결손이 저절로 일부 호전되었다(3/5). 응급실 내원 직후 시행한 뇌자기공명영상 상 저명한 병변이 관찰되지는 않았으나 신경학적 증상이 시간이 지남에 따라 일부 호전이 있었다는 점, 그리고 증상발현 초기에 촬영한 자기공명영상 상에서는 급성 병변이 관찰되지 않을 수 있다는 점으로 처음에 급성 허혈성 뇌졸중으로 진단하고 항응고제로 치료를시작하였다. 하지만 급성 허혈성 확진을 위해 10시간 후 재촬영한 뇌자기공명영상 상 급성 병변이 관찰되지 않았다. 이에 환자의 증상이 뇌에서 기인하는 증상으로 보기 어렵다고 판단하였고 경추 자기공명영상 검사를 진행하였다. 초기 영상의학과적 진단은 급성 혈종을 보여주는 척추 경막하 혈종이었다. 결과: 혈종에 대해 감압 수술을 시행하였고 병리학적 소견으로 자발성 척추 경막외 혈종로 확인되었다. 수술 1개월 후 환자의 근력은 정상 수준으로 회복되었다. 결론: 척추 경막하 혈종은 초기 임상 양상이 급성 허혈성 뇌졸중과 유사하므로 진단하기 쉽지 않다. 따라서 통증을 동반한 편마비의 경우 급성 허혈성 뇌졸중과 일과성 허혈성 뇌졸중보다 척추 경막하 혈종을 먼저 의심해야 한다. 경추 자기공명영상은 척추관 내 혈종의 표준 진단 도구이지만 경막외 혈종과경막하 혈종의 감별이 어려운 경우가 있어 보존적 치료에도 불구하고 환자의 신경학적 증상이 호전되지 않거나 진행하면 진단 및 치료 목적으로 조기에수술적 감압을 고려해야 한다.

만성 경막하 혈종을 동반한 중두개와 지주막낭종 4례에 대한 임상분석

황의장,홍승철,김문간,성우현,임창수,심기범,김하영 대한신경외과학회 1991 Journal of Korean neurosurgical society Vol.20 No.8

Since the arachnoid cyst was first described by Bright in 1831, its natural history and exact incidence of arachnoid cyst associated with chronic subdural hematoma were not well understood. Authors analyzed 4 cases of arachnoid cysts in middle cranial fossa, associated with chronic subdural hematoma. So, the following results were obtained : 1) Headche and vomiting were presenting symptoms and its symptoms were due to chronic subdural hematoma rather than that of arachnoid cyst 2) Trauma, though trivial, may have triggered the development of chronic subdural hematoma 3) All cases showed bony abnormality on plain skull X-ray. 4) CT scan is very useful for the demonstration of shape, extent of lesion, membrane enhancement, and communication between hematoma and arachnoid cyst. 5) Every case was type Ⅱ arachnoid cyst. 6) Chronic subdural hematoma was most frequent intracystic type, showing rupture into the arachnoid cyst. 7) Surgery treating both the chronic subdural hematoma and arachnoid cyst produced good result.