2 English references Epidural hematoma
3 classification of diseases neurosurgery
4 disease overview Epidural hematoma is a very common hematoma located between the skull inner plate and the dura mater, accounting for about 30% of traumatic intracranial hematoma. It can be divided into chronic and acute epidural hematoma.
Causes and pathology of injury: Typical acute epidural hematoma is common in young and middle-aged male patients with linear skull fracture, especially in frontotemporal region and parietal region, which is related to the fact that the temporal region contains middle meningeal artery and vein and is easily torn by fracture. The size of hematoma is closely related to the severity of the disease, and the bigger it is, the heavier it is.
Symptoms and signs: unconsciousness leads to increased intracranial pressure: with the increase of intracranial pressure, patients often have headache, vomiting, restlessness and typical changes of four curves, namely Cushing reaction, compensatory reactions such as increased blood pressure, increased pulse pressure difference, increased body temperature, slowed heart rate and respiration, and blood pressure drops, weak pulse and respiratory depression when they fail.
Signs of nervous system: Only when hematoma forms and oppresses brain functional areas, there are corresponding positive signs: facial paralysis, hemiplegia or aphasia.
Diagnosis: When the patient has increased headache and vomiting, restlessness, increased blood pressure, increased pulse pressure difference and/or new signs, he should highly suspect intracranial hematoma and give necessary imaging examination in time, including X-ray plain film, A-mode ultrasound, cerebral angiography or ct scan.
Treatment: For the treatment of acute epidural hematoma, in principle, surgical treatment should be performed as soon as the diagnosis is made, and the hematoma should be excluded to relieve intracranial hypertension, and appropriate non-surgical treatment should be given according to the condition after operation.
Symptoms and signs 1. Consciousness disorder? The disturbance of consciousness caused by hematoma itself is caused by cerebral hernia, which usually occurs from a few hours to 1-2 days after injury. Due to the influence of primary brain injury, there are three kinds of consciousness disorders:
(1) When the primary brain injury is very mild (concussion or mild brain contusion), the initial coma time is short, and the hematoma formation is not rapid, there is a period of consciousness between the initial coma and the cerebral hernia coma, which is mostly a few hours or a little longer, and rarely exceeds 24 hours, which is called the "intermediate awake period";
(2) If the primary brain injury is serious or the hematoma is formed quickly, and there is no intermediate waking period, there may be a "consciousness improvement period", which will be aggravated when you are not awake, or it may be manifested as continuous and progressive aggravation of consciousness disorder;
(3) A small amount of hematoma occurred, with no primary brain injury or localized brain contusion and laceration, and early unconsciousness, which only occurred when hematoma caused brain hernia. Most of the wounded had symptoms such as headache, vomiting, irritability or indifference, lethargy, disorientation, enuresis, etc. before entering the coma of cerebral hernia, which was enough to indicate the occurrence of cerebral hernia.
2. Pupil changes? In the early stage of tentorial notch hernia, the oculomotor nerve of the affected side is affected by traction, which can first narrow the pupil of the affected side and be slow to respond to light. With the compression of oculomotor nerve and midbrain, the pupil of this side immediately expanded progressively, the light reaction disappeared, the ptosis and the opposite pupil increased. It should be differentiated from the primary oculomotor nerve injury caused by simple anterior cranial fossa fracture, and its mydriasis appeared at the time of injury without progressive deterioration. Pupils with optic nerve damage are dilated and have an indirect reaction to light.
3. Cone beam sign? Early myasthenia of one limb without progressive aggravation may be the focus sign of brain contusion and laceration; If it appears later or earlier and gets worse progressively, we should consider that hematoma causes cerebral hernia or hematoma compresses the motor area. Intracranial rigidity is the late manifestation of cerebral hernia.
4. Vital signs? It is usually a gradual increase in blood pressure, a slow heart rate and an increase in body temperature. Because most of the hematoma in the temporal region first appears tentorial notch hernia, and then combined with foramen magnum hernia, after a period of consciousness disorder and pupil change, serious respiratory and circulatory disorders often appear; Hematoma in frontal area or occipital area can directly cause foramen magnum hernia without experiencing tentorial notch hernia. Once there is disturbance of consciousness, it can almost simultaneously manifest as pupil change and respiratory arrest.
Etiology of trauma history: direct violent injury to the skull, especially to the temporal area, local scar or scalp hematoma, and X-ray film of the head found that the fracture line crossed the middle meningeal artery groove; Or occipital bone injury, soft tissue swelling, subcutaneous congestion, skull X-ray clamp found that the fracture line crossed the transverse sinus; We should attach great importance to the possibility of epidural hematoma.
7 pathophysiological formation mechanism: closely related to skull injury. Skull fracture or short-term deformation tears the dural artery or venous sinus located in the bone groove, causing bleeding, or fracture bleeding. Blood accumulates between the skull and the dura mater. In the process of separating the dura mater from the skull, some small blood vessels can be torn, making the hematoma bigger. Because the dura mater attached to the skull in the skull cover is loose and easy to separate, and the dura mater attached to the skull at the bottom of the skull is tight, epidural hematoma is generally more common in the skull cover. The amount of bleeding required to cause intracranial hypertension and cerebral hernia may vary with bleeding speed, compensatory function and severity of primary brain injury. When the average adult reaches 20ml above the awning and 10ml below the awning, it may cause, mostly acute. The middle meningeal artery is the most common source of bleeding, and its main or anterior bleeding is rapid, and symptoms can appear within 6- 12 hours or less. A small amount of hematoma caused by venous sinus or baffle bleeding may have symptoms in the future, which may be subacute or chronic. Hematomas most often occur in the temporal region, most of which are single hematoma, and a few can be multiple hematoma, located in one or both cerebral hemispheres, or above and below the tentorium cerebelli.
8 Diagnostic examination CT examination: If there is a biconvex lenticular or arcuate density enhancement image between the skull inner plate and the brain surface, it will help to make a definite diagnosis. CT examination can also clearly locate and calculate the amount of bleeding, understand the compression of ventricle and the displacement of midline structure, as well as the coexistence of brain contusion, brain edema and multiple or multiple hematomas.
It is especially suggested that 1, as long as the epidural hematoma is diagnosed early, the operation and the prognosis of the patient are good.
2. Observe the abnormal changes of vital signs, report to the doctor in time, and remove the hematoma as soon as possible. The disturbance of consciousness appears in the middle of waking or improvement, which is often one of the typical symptoms of epidural hematoma.
3. Patients with hematoma in motor area have hemiplegia and aphasia. It is necessary to strengthen physical and language training after operation to promote their early recovery.
4. The prognosis of epidural hematoma is mostly good. As long as it is diagnosed and treated in time, the hematoma can be completely removed, the patient can completely recover, and the headache can be gradually relieved until it disappears. Patients don't have to worry too much, otherwise it will increase mental burden, aggravate headache symptoms and delay the recovery process of patients.
10 related sources: internal medicine 5th edition, surgery 5th edition, pediatrics 6th edition, internal medicine 6th edition.
Acupoint Ying Zheng for Treating Epidural Hematoma