跨窦硬膜外血肿并骨折致脑静脉窦回流障碍:回顾性病例系列研究

摘要

目的 探讨跨窦硬膜外血肿并骨折致脑静脉窦回流障碍(cerebral venous flow obstruction,CVFO)的临床特点.方法 回顾性收集CVFO患者的临床资料.根据影像学表现和临床特征,将这些病例分为单纯外伤性静脉窦回流不畅(traumatic cerebral venous sinus stagnation,TCVSS)和静脉窦血栓形成(cerebral venous sinus thrombosis,CVST),对受伤机制、临床表现、颅内压监测、影像学检查、治疗方法和疗效进行比较.结果 共纳入194例CVFO患者,其中TCVSS患者167例,CVST患者27例.CVST组颅内压较TCVSS组显著性增高[(44.0 ±4.8)cm H2O对(28.0±2.8)cm H2O,1 cm H2O =0.098 kPa;t =24.518,P=0.000],常表现为剧烈头痛(77.8％)、频繁呕吐(33.3％)、视物模糊(18.5％)和进行性意识障碍(11.1％),而TCVSS常表现为轻度头痛(39.5％)、呕吐(13.8％)和畏光(4.8％).影像学检查显示,TCVSS好发于双侧横窦/乙状窦系统毗邻硬膜外血肿或骨折的部位(85.0％),呈局限性静脉窦变细(50.3％);而CVST好发于双侧横窦近窦汇端(81.5％)、上矢状窦后部及窦汇区(18.5％),呈局限性静脉窦充盈缺损或闭塞(81.5％)、窦旁脑实质继发性静脉性梗死伴出血(14.8％)甚至大面积脑水肿(7.4％).在治疗方面,CVST组尿激酶剂量[(24.2±7.8)万U/d对(12.4±4.5)万U/d;P=0.000]和用药时程[(10.8±5.3)d对(6.2 ±2.4)d;P =0.000]均显著性高于和长于TCVSS组.除1例上矢状窦CVST患者死亡外,其余患者的临床症状和颅内压均随静脉窦循环改善而显著缓解,转归良好.结论 外伤性CWO病理生理学变化的中心环节是持续性颅内高压,根据临床和影像学表现可分为2种不同亚型——TCVSS和CVST.动态颅内压监测可作为CVFO临床分型、个体化治疗方案选择和调整的依据.积极解除机械压迫和尿激酶治疗,TCVSS和CVST均预后良好,但后者的治疗强度明显更高.%Objective To investigate the clinical features of transsinus epidural hematoma with fracture-induced cerebral venous flow obstruction (CVFO).Methods The clinical data of patients with CVFO were collected retrospectively.They were divided into traumatic cerebral venous sinus stagnation (TCVSS) and cerebral venous sinus thrombosis (CVST) according to the imaging findings and clinical features.Their mechanism of injury,clinical manifestations,intracranial pressure monitoring,imaging examinations,treatment methods,and efficacy were compared.Results A total of 194 patients with CVSO were enrolled,167 of them were TCVSS and 27 of them were CVST.The intracranial pressure of the CVST group was significantly higher than that of the TCVSS group (44.0 ± 4.8 cm H2O vs.28.0 ± 2.8 cm H2O,1 cm H2O =0.098 kPa; t =24.518,P＜ 0.001).The patients often presented as severe headache (77.8％),frequent vomiting (33.3％),blurred vision (18.5％),and progressive disturbance of consciousness (11.1％),while their TCVSS often presented as mild headache (39.5％),vomiting (13.8％),and photophobia (4.8％).Imaging examinations showed that TCVSS commonly occurred in bilateral transverse sinus/sigmoid sinus system nearing epidural hematoma or fracture site (85.0％) showing venous sinus thinning (50.3％); while CVST commonly occurred in the bilateral proximal transverse sinus (81.5％),and the rear of the superior sagittal sinus and confluence of sinuses (18.5％) showing limited sinus filling defect or occlusion (81.5％),parasagittal parenchyma secondary venous infarction with hemorrhage (14.8％),and even massive cerebral edema (7.4％).In terms of treatment,urokinase dose ([24.2 ± 7.8] × 104U/d vs.[12.4 ± 4.5] × 104U/d; t ＜ 0.001) and administration duration (10.8 ± 5.3 d vs.6.2 ±2.4 d; P ＜0.001) of the CVST group were significantly higher and longer than those of the TCVSS group.The clinical symptoms and intracranial pressure of all the patients were significantly relieved with the improvement in sinus cycle except one died of CVST in superior sagittal sinus.Their outcomes are good.Conclusions The central link of the pathophysiological changes of traumatic CVFO is persistent intracranial hypertension and can be divided into two different subtypes according to clinical and imaging findings,including TCVSS and CVST.Dynamic monitoring of intracranial pressure can be used as the bases for the clinical classification of CVFO,individualized treatment options,and adjustments.The prognosis of both TCVSS and CVST are good after actively relieving mechanical pressure and urokinase therapy.However,the treatment intensity of the la1tter is significantly higher.