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硬膜下血腫

著者: 池上史郎1) 千葉大学大学院医学研究院脳神経外科

著者: 佐伯直勝2) 脳神経内科 津田沼

監修: 甲村英二 公立学校共済組合 近畿中央病院

著者校正/監修レビュー済:2021/03/24
参考ガイドライン:
  1. 日本脳神経外科学会/日本脳神経外傷学会:頭部外傷治療・管理のガイドライン 第4版
患者向け説明資料

概要・推奨   

  1. 急性硬膜下血腫は、頭部外傷後の意識障害や片麻痺などの原因となり重症例では致命的となるため、頭部CT評価や外科的介入などの迅速な対応が必要である(推奨度1)。
  1. 慢性硬膜下血腫は、軽微な頭部外傷後に緩徐に進行する頭痛、認知障害や片麻痺などの神経症状で発症する疾患で、想定される場合には頭部CTなどの画像評価を行う(推奨度1)。
  1. 硬膜下血腫を認める場合には外科的治療の適応などの評価を目的に脳神経外科の専門医に相談する。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
池上史郎 : 特に申告事項無し[2021年]
佐伯直勝 : 未申告[2021年]
監修:甲村英二 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、保存的加療について加筆修正を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
急性硬膜下血腫:
  1. 急性硬膜下血腫とは、頭部外傷急性期に硬膜と脳を覆うクモ膜の間に血腫を形成する外傷性頭蓋内血腫の一種である。
  1. 急性硬膜下血腫の典型画像(1):<図表>
  1. 急性硬膜下血腫の典型画像(2):<図表>
  1. 受傷時の回旋力による脳表の橋静脈の破綻や脳の直接損傷部からの出血が原因となる。
  1. 脳挫傷などの一次損傷に引き続き、脳浮腫・脳腫脹などの二次損傷を生じやすく、血腫の増大により重篤となることも多い。
 
慢性硬膜下血腫:
  1. 慢性硬膜下血腫とは、硬膜と脳表との間に被膜に包まれた血腫を形成する疾患である。
  1. 慢性硬膜下血腫の典型画像(1):<図表>
  1. 慢性硬膜下血腫の典型画像(2):<図表>
  1. 中高年男性に多く、多飲酒歴、肝機能障害、血液疾患や担癌状態などによる凝固線溶系異常、抗凝固・抗血小板薬内服、透析患者などに合併することもある。
  1. ごく軽微な頭部外傷後の数週間から数カ月で頭痛・精神症状、片麻痺などで発症することが多いとされるが、その発生機序は完全には解明されていない。
問診・診察のポイント  
  1. 呼吸・循環状態の評価、意識障害(グラスゴー・コーマ・スケール[GCS]やジャパン・コーマ・スケール[JCS])、局所症状の有無を確認する。

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文献 

著者: R D Lobato, J J Rivas, P A Gomez, M Castañeda, J M Cañizal, R Sarabia, A Cabrera, M J Muñoz
雑誌名: J Neurosurg. 1991 Aug;75(2):256-61. doi: 10.3171/jns.1991.75.2.0256.
Abstract/Text Of 838 patients with severe head injuries admitted since the introduction of computerized tomography, 211 (25.1%) talked at some time between trauma and subsequent deterioration into coma. Of these 211 patients, 89 (42.2%) had brain contusion/hematoma, 46 (21.8%) an epidural hematoma, 35 (16.6%) a subdural hematoma, and 41 (19.4%) did not show focal mass lesions. Thus, four of every five patients who deteriorated into coma after suffering an apparently nonsevere head injury had a mass lesion potentially requiring surgery: the mass was intracerebral in 52.3% of the cases and extracerebral in 47.6%. Patients aged 20 years or less had a 39% chance of having a nonfocal mass lesion (diffuse brain damage), a 29% chance of having an epidural hematoma, and a 32% chance of having an intradural mass lesion; patients over 40 years had only a 3% chance of having a nonfocal mass lesion, an 18% chance of having an epidural hematoma, and a 79% chance of having a intradural mass lesion. Sixty-eight (32.2%) patients died and 143 (67.8%) survived. The following were independent outcome predictors (in order of significance): Glasgow Coma Scale score following deterioration into coma, the highest intracranial pressure during the patient's course, the degree of midline shift, the type of intracranial lesion, and the age of the patient. In contrast, the mechanism of injury, the verbal Glasgow Coma Scale score during the lucid interval, and the length of time until deterioration or until operative intervention did not influence the final result.

PMID 2072163  J Neurosurg. 1991 Aug;75(2):256-61. doi: 10.3171/jns.19・・・
著者: K G Jamieson, J D Yelland
雑誌名: J Neurosurg. 1972 Aug;37(2):137-49. doi: 10.3171/jns.1972.37.2.0137.
Abstract/Text
PMID 5046082  J Neurosurg. 1972 Aug;37(2):137-49. doi: 10.3171/jns.19・・・
著者: J L Stone, M H Rifai, O Sugar, R G Lang, J B Oldershaw, R A Moody
雑誌名: Surg Neurol. 1983 Mar;19(3):216-31.
Abstract/Text A series of 206 patients with clotted subdural hematomas operated within 3 days of closed head injury is presented. Sixty-two percent (128) were operated within 24 hours of trauma (acute subdural hematoma) carrying a high incidence of sterotypic motor posturing, impaired oculomotor reflexes, and unilateral dilated fixed pupil. A functional recovery occurred in 27% and a vegetative state or death resulted in 62%. The remaining 38% were operated after 24 but within 72 hours from injury (early subacute subdural hematoma) and generally had less severe neurologic dysfunction. A functional recovery occurred in 54% and vegetative state or death in 34%. The 128 acute cases are presented in detail to establish a logical basis for time differential. The cases requiring operation within 12 hours of injury were the most challenging. Improved outcome is felt to result from prompt referral and large craniotomy in the earliest hours after injury, combined with careful postoperative monitoring. Clinical, operative and autopsy findings are presented and discussed in relation to pathogenesis.

PMID 6836474  Surg Neurol. 1983 Mar;19(3):216-31.
著者: CRASH-3 trial collaborators
雑誌名: Lancet. 2019 Nov 9;394(10210):1713-1723. doi: 10.1016/S0140-6736(19)32233-0. Epub 2019 Oct 14.
Abstract/Text BACKGROUND: Tranexamic acid reduces surgical bleeding and decreases mortality in patients with traumatic extracranial bleeding. Intracranial bleeding is common after traumatic brain injury (TBI) and can cause brain herniation and death. We aimed to assess the effects of tranexamic acid in patients with TBI.
METHODS: This randomised, placebo-controlled trial was done in 175 hospitals in 29 countries. Adults with TBI who were within 3 h of injury, had a Glasgow Coma Scale (GCS) score of 12 or lower or any intracranial bleeding on CT scan, and no major extracranial bleeding were eligible. The time window for eligibility was originally 8 h but in 2016 the protocol was changed to limit recruitment to patients within 3 h of injury. This change was made blind to the trial data, in response to external evidence suggesting that delayed treatment is unlikely to be effective. We randomly assigned (1:1) patients to receive tranexamic acid (loading dose 1 g over 10 min then infusion of 1 g over 8 h) or matching placebo. Patients were assigned by selecting a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was head injury-related death in hospital within 28 days of injury in patients treated within 3 h of injury. We prespecified a sensitivity analysis that excluded patients with a GCS score of 3 and those with bilateral unreactive pupils at baseline. All analyses were done by intention to treat. This trial was registered with ISRCTN (ISRCTN15088122), ClinicalTrials.gov (NCT01402882), EudraCT (2011-003669-14), and the Pan African Clinical Trial Registry (PACTR20121000441277).
RESULTS: Between July 20, 2012, and Jan 31, 2019, we randomly allocated 12 737 patients with TBI to receive tranexamic acid (6406 [50·3%] or placebo [6331 [49·7%], of whom 9202 (72·2%) patients were treated within 3 h of injury. Among patients treated within 3 h of injury, the risk of head injury-related death was 18·5% in the tranexamic acid group versus 19·8% in the placebo group (855 vs 892 events; risk ratio [RR] 0·94 [95% CI 0·86-1·02]). In the prespecified sensitivity analysis that excluded patients with a GCS score of 3 or bilateral unreactive pupils at baseline, the risk of head injury-related death was 12·5% in the tranexamic acid group versus 14·0% in the placebo group (485 vs 525 events; RR 0·89 [95% CI 0·80-1·00]). The risk of head injury-related death reduced with tranexamic acid in patients with mild-to-moderate head injury (RR 0·78 [95% CI 0·64-0·95]) but not in patients with severe head injury (0·99 [95% CI 0·91-1·07]; p value for heterogeneity 0·030). Early treatment was more effective than was later treatment in patients with mild and moderate head injury (p=0·005) but time to treatment had no obvious effect in patients with severe head injury (p=0·73). The risk of vascular occlusive events was similar in the tranexamic acid and placebo groups (RR 0·98 (0·74-1·28). The risk of seizures was also similar between groups (1·09 [95% CI 0·90-1·33]).
INTERPRETATION: Our results show that tranexamic acid is safe in patients with TBI and that treatment within 3 h of injury reduces head injury-related death. Patients should be treated as soon as possible after injury.
FUNDING: National Institute for Health Research Health Technology Assessment, JP Moulton Charitable Trust, Department of Health and Social Care, Department for International Development, Global Challenges Research Fund, Medical Research Council, and Wellcome Trust (Joint Global Health Trials scheme).
TRANSLATIONS: For the Arabic, Chinese, French, Hindi, Japanese, Spanish and Urdu translations of the abstract see Supplementary Material.

Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.
PMID 31623894  Lancet. 2019 Nov 9;394(10210):1713-1723. doi: 10.1016/S・・・
著者: Sae-Yeon Won, Juergen Konczalla, Daniel Dubinski, Adriano Cattani, Colleen Cuca, Volker Seifert, Felix Rosenow, Adam Strzelczyk, Thomas M Freiman
雑誌名: Seizure. 2016 Nov 25;45:28-35. doi: 10.1016/j.seizure.2016.11.017. Epub 2016 Nov 25.
Abstract/Text BACKGROUND: Posttraumatic epileptic seizures (PTS) are a serious complication in patients with subdural haematoma (SDH). However, to date, several studies have shown discordances about SDH-associated seizures in terms of incidence, risk factors and prophylactic antiepileptic treatment.
OBJECTIVE: The aim of this study was to analyse the incidence, risk factors of PTS and the role of prophylactic antiepileptic treatment in patients with SDH.
DATA SOURCES: A systematic literature review examining PTS in patients with SDH was performed using PubMed gateway, Cochrane Central Register of Controlled Trials, and Excerpta Medica dataBASE between September 1961 and February 2016. Search terms included subdural haematoma, seizure, epilepsy, prophylactic antiepileptic drugs, anticonvulsive medication, and risk factors.
DATA SELECTION: Human-based clinical studies focusing on epileptic seizures in patients with SDH.
DATA EXTRACTION AND SYNTHESIS: PRISMA statements were used for assessing data quality. Two independent reviewers extracted data from included studies and disagreement was solved by consensus. Twenty-four studies were identified for inclusion into the study.
RESULTS: Overall incidence of early PTS (ePTS) and late PTS (lPTS)/2 years was 28% and 43% in acute SDH (aSDH) whereas the incidence of e- and lPTS was lower in chronic SDH (cSDH; 5.3% vs. 10%). Overall risk factors for PTS in patients with aSDH were: 24h postoperative Glasgow Coma Score (GCS) score below 9 (OR 10.5), craniotomy (OR 3.9), preoperative GCS below 8 (OR 3.1). In patients with cSDH the risk factors were alcohol abuse (OR 14.3), change of mental status (OR 7.2), previous stroke (OR 5.3) and density of haematoma in computer tomography (OR 3.8). Age, sex, haematoma size/side and midline shifts were not significant risk factors for PTS in both types of SDH. In prevention of PTS phenytoin and levetiracetam showed similar efficacy (OR 1.3), whereas levetiracetam was associated with significantly lower adverse effects (OR 0.1).
LIMITATIONS: Most of the studies were of retrospective nature with a small sample size. Due to the inclusion criteria, some studies had to be excluded and that might lead to selection bias.
CONCLUSIONS: PTS are a serious complication in patients with SDH, particularly in aSDH. The "prophylactic use" of antiepileptic drugs might be beneficial in patients with cumulative risk factors.

Copyright © 2016 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.
PMID 27914224  Seizure. 2016 Nov 25;45:28-35. doi: 10.1016/j.seizure.2・・・
著者: Mitsusuke Miyagami, Yukihide Kagawa
雑誌名: No Shinkei Geka. 2009 Aug;37(8):765-70.
Abstract/Text Chronic subdural hematomas (CSDHs) are basically treated by surgery. In some cases with no or minimum symptoms, however, they may be treated conservatively. In the present study, we evaluated the therapeutic effect of a Kampo medicine (Japanese traditional herbal medicine), Gorei-san, in the treatment of those CSDHs. Gorei-san 7.5 g t.i.d. was orally administered for 4 weeks in 22 patients with 27 CSDHs. Maximum thickness of the hematoma was followed up on CT scan for 4 to 29 weeks after administration of Gorei-san. In 7 of 22 patients, tranexamic acid and/or carbazochrome sodium sulfonate were also administrated. Gorei-san was effective in 23 of 27 CSDHs. In 12 of them, the hematoma was completely disappeared within 14 weeks after administration. In the other 11 CSDHs, the thickness was decreased. In those effective cases, thickness began to decrease 3 to 4 weeks after administration of Gorei-san. It was more effective in CSDHs with iso-/high or mixed density than with low density on CT. It was not effective in 4 out of 27 CSDHs. No apparent adverse effect was noted in the present series of patients. The present study suggests that a Kampo medicine, Gorei-san, is a useful option in the conservative treatment of CSDHs with no or minimum symptoms.

PMID 19663334  No Shinkei Geka. 2009 Aug;37(8):765-70.
著者: L M E Berghauser Pont, C M F Dirven, D W J Dippel, B H Verweij, R Dammers
雑誌名: Eur J Neurol. 2012 Nov;19(11):1397-403. doi: 10.1111/j.1468-1331.2012.03768.x. Epub 2012 May 29.
Abstract/Text The role of corticosteroids in the management of chronic subdural hematoma (CSDH) remains a matter of debate. Standard surgical treatment has recurrence rates reported between 4 and 26%. We reviewed the safety and effectiveness of corticosteroids both as a monotherapy and as an adjunct to surgery in patients with CSDH. PubMed-MEDLINE, EMBASE and Cochrane databases were searched in July 2011 for randomized controlled trials and for prospective and retrospective cohort studies, reporting on 10 or more adult patients with CSDH. Quality was assessed according to the STROBE checklist. Corticosteroid monotherapy and surgery with corticosteroids as an adjunct were compared with no treatment or surgery only, with regard to lethality, neurological outcome, secondary intervention and complications. Five observational studies were included in this review. There was no randomized allocation of treatment in any study. Secondary intervention rates ranged from 3 to 28%, lethality rates ranged from 0 to 13%, and good outcome was seen in 83-100%. Hyperglycemia occurred more often in patients treated with corticosteroids. In only two studies, one case of gastrointestinal bleeding was observed. Five observational studies suggest that corticosteroids might be beneficial in the treatment of CSDH; however, there is a lack of well-designed trials that support or refute the use of corticosteroids in CSDH. These results encourage further randomized clinical trials to establish the role of corticosteroids in CSDH.

© 2012 Erasmus MC European Journal of Neurology © 2012 EFNS.
PMID 22642223  Eur J Neurol. 2012 Nov;19(11):1397-403. doi: 10.1111/j.・・・
著者: Raja K Kutty, Sureshkumar Kunjuni Leela, Sunilkumar Balakrishnan Sreemathyamma, Jyothish Laila Sivanandapanicker, Prasanth Asher, Anilkumar Peethambaran, Rajmohan Bhanu Prabhakar
雑誌名: J Stroke Cerebrovasc Dis. 2020 Nov;29(11):105273. doi: 10.1016/j.jstrokecerebrovasdis.2020.105273. Epub 2020 Sep 4.
Abstract/Text INTRODUCTION: The conservative management of Chronic subdural hematoma (CSDH) is controversial. Many drugs have been tried in the conservative management of CSDH. Tranexamic acid (Txa) is one such drug in the armamentarium for conservative management of CSDH. We conducted a prospective observational study about treatment of CSDH with Txa.
MATERIAL AND METHODS: The study was conducted over three years. The clinical grading was assessed by the Markwalder grading system. All patients who were relatively and mildly symptomatic and willing for conservative management were recruited for the study. All patients were given Txa in the dosage of 750 mg/day in divided doses. The patients were followed up in the neurosurgery out-patient department.
RESULTS: There were 27 patients with 30 CSDH during this period who were treated with Txa. There were 20 cases of primary CSDHs and 7 cases of recurrent CSDHs following surgery that were enrolled in the Txa group. The mean volume of treated CSDH was 135.62 ± 92.90 SD. The mean thickness of CSDH enrolled in the study was 14.31 ± 5.47 SD. The mean number of days the patients treated with Txa was 64.83 ± 24.8 SD. There were no complications in any of the patients. All patients had good resolution of the hematomas, and none of the hematomas progressed during conservative treatment.
CONCLUSION: The conservative management of CSDH with Txa is both a safe and effective alternative in the absence of life-threatening symptoms.

Copyright © 2020 Elsevier Inc. All rights reserved.
PMID 33066896  J Stroke Cerebrovasc Dis. 2020 Nov;29(11):105273. doi: ・・・
著者: S Wakai, K Hashimoto, N Watanabe, S Inoh, C Ochiai, M Nagai
雑誌名: Neurosurgery. 1990 May;26(5):771-3.
Abstract/Text The authors conducted a prospective comparative study on the recurrence rate of chronic subdural hematoma after the use of two different treatment modalities: burr-hole irrigation of the hematoma cavity with (Group A) and without closed-system drainage (Group B). Thirty-eight patients were studied. Patients were assigned to groups sequentially upon admission. There were no significant differences between the two groups for age, sex, preoperative hematoma volume, and density on computed tomographic scan. One patient in Group A (5%) suffered a recurrence as opposed to 6 in Group B (33%). The difference in recurrence rate between the two groups was statistically significant (P less than 0.05). The authors conclude that closed-system drainage after burr-hole irrigation reduces the recurrence rate of chronic subdural hematoma.

PMID 2352594  Neurosurgery. 1990 May;26(5):771-3.
著者: Y Iwadate, N Ishige, Y Hosoi
雑誌名: Neurol Med Chir (Tokyo). 1989 Feb;29(2):117-21.
Abstract/Text The surgical treatment of chronic subdural hematoma has evolved from membranectomy through craniotomy to burr hole irrigation. The latter approach is based on utilization of the natural absorptive process that is thought to be part of the life cycle of the hematoma. To test this theory, the authors treated fifty-nine patients with chronic subdural hematoma according to the following protocol. Local anesthesia was induced with a modified neuroleptanalgesic procedure. A single burr hole was drilled, usually in the posterior frontal region, and irrigation was carried out until the washing was clear. Subdural drainage was not employed. Patients were permitted to walk about on the following day. The outcome was better than that achieved with conventional treatment. Such complications as tension pneumocephalus and intracranial hematoma were not observed, and only one patient (1.7%) had a recurrence. The results of this study indicate that single burr hole irrigation without drainage is a very simple and effective treatment for chronic subdural hematoma. The absence of subdural drainage may be an important feature, since drainage may contribute to the development of certain postoperative complications. Also, the simplified procedure allows patients early mobility, which may be of particular benefit to the elderly.

PMID 2475800  Neurol Med Chir (Tokyo). 1989 Feb;29(2):117-21.
著者: Akihiko Adachi, Yoshinori Higuchi, Atsushi Fujikawa, Toshio Machida, Shigeo Sueyoshi, Kenichi Harigaya, Junichi Ono, Naokatsu Saeki
雑誌名: PLoS One. 2014;9(8):e103703. doi: 10.1371/journal.pone.0103703. Epub 2014 Aug 4.
Abstract/Text BACKGROUND: Chronic subdural hematoma (CSDH) is known to have a substantial recurrence rate. Artificial cerebrospinal fluid (ACF) is an effective irrigation solution in general open craniotomy and endoneurosurgery, but no evidence of its use in burr-hole surgery exists.
OBJECTIVE: To identify the potential of ACF irrigation to prevent CSDH recurrence. More specifically, to investigate the perioperative and intraoperative prognostic factors, and to identify controllable ones.
METHODS: To examine various prognostic factors, 120 consecutive patients with unilateral CSDH treated with burr-hole drainage between September 2007 and March 2013 were analyzed. Intraoperative irrigation was performed with one of two irrigation solutions: normal saline (NS; n = 60) or ACF (n = 60). All patients were followed-up for at least 6 months postoperatively. We also examined the morphological alternations of the hematoma outer membranes after incubation with different solutions.
RESULTS: Eleven patients (9.2%) had recurrence. Nine patients (15%) required additional surgery in the NS group, whereas only 2 patients (3.3%) in the ACF group required additional surgery. Among preoperative and intraoperative data, age (<80 years old, P = .044), thrombocyte (>22.0, P = .037), laterality (right, P = .03), and irrigation solution (ACF, P = .027) were related to smaller recurrence rates by log-rank tests. Only the type of irrigation solution used significantly correlated with recurrence in favor of ACF in both Cox proportional hazards (relative hazard: 0.20, 95% confidence interval (CI): 0.04-0.99; P = .049) and logistic regression models (odds ratio, 0.17, 95% CI: 0.03-0.92; P = .04) using these factors. Histological examinations of the hematoma membranes showed that the membranes incubated with NS were loose and infiltrated by inflammatory cells compared with those incubated with ACF.
CONCLUSION: Irrigation with ACF decreased the rate of CSDH recurrence.

PMID 25089621  PLoS One. 2014;9(8):e103703. doi: 10.1371/journal.pone.・・・
著者: Hiroyuki Toi, Yukihiko Fujii, Toru Iwama, Hiroyuki Kinouchi, Hiroyuki Nakase, Kazuhiko Nozaki, Hiroki Ohkuma, Hajime Ohta, Hideo Takeshima, Hironobu Tokumasu, Yuhei Yoshimoto, Masaaki Uno
雑誌名: J Neurotrauma. 2018 Jun 14;. doi: 10.1089/neu.2018.5821. Epub 2018 Jun 14.
Abstract/Text BACKGROUND Over the decades, postoperative recurrence of chronic subdural hematoma (CSDH) has not been resolved. OBJECT The objective of our study was to investigate whether the recurrence rate of CSDH is decreased when artificial cerebrospinal fluid (ACF) is used as irrigation solution for CSDH surgery. METHODS The present study was a multi-center, prospective, randomized, open parallel group comparison test of patients enrolled from 10 hospitals in Japan. Eligible patients with CSDH were randomly assigned to undergo burr hole drainage with either normal saline (NS) or ACF irrigation. The primary endpoint was postoperative recurrence of ipsilateral CSDH. RESULTS A total of 402 patients with newly diagnosed CSDH were enrolled during the study period. After applying inclusion and exclusion criteria, considering lost cases, our final study cohorts consisted of 177 ACF patients and 165 NS patients, representing 85.7% of the initial cohort. The overall recurrence rate was 11.4%, occurring in 39 of the 342 analyzed patients during 90 days of follow-up. Recurrence rates in the ACF and NS groups were 11.9% (21 of 177) and 10.9% (18 of 165), respectively. No significant difference was evident between groups (p=0.87). In addition, no significant difference in time to recurrence was seen between groups (p=0.74). No serious adverse effects related to irrigation fluid were seen in either group. CONCLUSIONS Regarding the irrigation fluid for CSDH surgery, no differences in recurrence rate or time to recurrence were seen between ACF and NS. However, ACF offers sufficient safety as irrigation fluid for CSDH.

PMID 29901422  J Neurotrauma. 2018 Jun 14;. doi: 10.1089/neu.2018.5821・・・
著者: K Mori, M Maeda
雑誌名: Neurol Med Chir (Tokyo). 2001 Aug;41(8):371-81.
Abstract/Text Chronic subdural hematoma (CSDH) is one of the most common clinical entities in daily neurosurgical practice. The diagnosis and treatment are well established, but recurrence, complications, and factors related to these problems, especially in the elderly, are not completely understood. This study evaluated the clinical features, radiological findings, and surgical results in a large series of the patients treated at the same institution. 500 consecutive patients (359 men and 141 women) with CSDH were treated by burr hole craniostomy with closed system drainage from January 1987 through February 1999. Causes, clinical and computed tomographic findings, surgical results, re-expansion of brain after surgery, and hematoma recurrence were statistically analyzed to elucidate the potential risks of CSDH. Most patients (89.4%) had good recovery, 8.4% showed no change, and 2.2% worsened. Six patients (1.2%) died, three due to disseminated intravascular coagulation. Recurrence of hematoma was recognized in 49 patients (9.8%), at 1 to 8 weeks (3.5 +/- 1.9 weeks) after the first operation. The brain re-expansion rate at one week after operation was 45.0 +/- 21.4% in patients with hematoma recurrence and significantly lower than 55.3 +/- 19.1% in patients without recurrence (p < 0.001). Old age, pre-existing cerebral infarction, and persistence of subdural air after surgery were significantly correlated with poor brain re-expansion (p < 0.001). Twenty-seven patients (5.4%) suffered postoperative complications, of which 13 cases were acute subdural hematoma caused by incomplete hemostasis of the scalp wound and four cases were tension pneumocephalus. Careful hemostasis and complete replacement of subdural hematoma by normal saline to prevent influx of air into the subdural space will further improve the surgical outcome for patients with CSDH.

PMID 11561347  Neurol Med Chir (Tokyo). 2001 Aug;41(8):371-81.

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