037 Pathophysiology of subdural hematoma
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Transcript of 037 Pathophysiology of subdural hematoma
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Pathophysiology of subdural hematomas
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Pathophysiology of the development of CSDH
• Clear yellow to dark, thin liquid to semisolid• Gardner 1932,Osmotic gradient theory
– Increase protein content increase oncotic pressure
• Weir– CSDH fluid to be isosmotic to blood and CSF
• Microscopic examination of fluid from CSDHs of any age reveals fresh erythrocytes
• CSDH membrane
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Pathophysiology of the development of CSDH
• Neovasculature at outer membrane of CSDH• Abnormal sinusoidal dilate• Both vessel types are composed of endothelial cells• Erythrocytes and platelets found in perivascular
space• Gap junction 8 um leakage of plasma and RBC
into hematoma cavity
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Pathophysiology of the development of CSDH
• Kallikrein, bradykinin, and platelet-activating factor (PAF) vasodilatation, increase vascular permeability, prolong the clotting time, release t-PA
• Eosinophil degranulation in the outer membrane fibrinolytic factor, inflammatory mediator local coagulopathy and cell destruction
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Evolution of chronic subdural hematomas
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Evolution of chronic subdural hematomas
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Surgical Treatment ofchronic subdural hematomas
• 1925, Putnam and Cushing : craniotomy with complete removal of the outer membrane and hematoma contents
• 1964, Svien and Gelety : bur hole better outcome than craniotomy (lower reoperation)
• 1977, Tabaddor and Shulmon : study comparing craniotomy had the highest mortality rate
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Surgical Treatment ofchronic subdural hematomas
• Suzuki and associates : closed system drainage without irrigation to be as effective as closed system drainage with irrigation
• Smely and coauthors : twist drill drainage without irrigation was superior to bur hole drainage with irrigation
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Medical Treatment ofchronic subdural hematomas
• Corticosteroid : decreases leukocyte chemotaxis, inhibits degranulation, inhibit neomembrane formation, prevent clot enlargement
• Bender and Christoff : more rapid neurologic improvement after introducing corticosteroids to the treatment regimen, thereby allowing shorter hospitalization
• ACEI : interrupt neovascularization by inhibiting endothelial vascular growth factor
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Medical and Surgical Management
of Chronic Subdural Hematomas
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Definition• Fluid collection within the layers of dura matter• DDx : subdural hygroma (subdural hydroma,
external hydrocephalus)• Subdural hygroma can transform into CSDH
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Epidemiology• Peak incidence , 80th • Male• Trauma most important risk factor• Postsurgical communication of the subarachnoid
space• CSF shunting• Primart coagulopathy in children• Anticoagulant treatment in adult• Chronic alcoholism
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Patient history• No pathognomonic sign and symptoms• Asymptomatic• Coma from increase ICP• Refractory headache• Lack of concentration
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Imaging• Preoperative CT scan
– sickle-shaped lesion– midline shift– High risk for recurrence : mixed-density or layer
type
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Imaging
• Postoperative CT scan– Recurrence : BHC 29 %, TDC 76 %– Residual fluid : 78% of case on day 10, 15% in
the 6th week– Intracranial air : tension pneumocephalus– Bilateral CSDH : Mount Fuji sign
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Imaging• MRI
– Hyperintense on T2 , proton-weightes image– Variability in signal intensity on T1 : 50 %
hyperintense– DDx : Subdural hygroma : Hypointense on
proton-weightes image
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Contemporary treatment• Corticosteroid : anti-inflammatory, antiangiogenic• Mannitol• ACEI : antiangiogenic• Anticonvulsant : posttraumatic and postoperative
epilepsy have low incidence in Pt c CSDH• Patient posture after surgey : RDCT,flat position in
the first 3 day after surgery for reduce recurrence• Hydration : increase brain volume• Postoperative hyperemia
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Surgical treatment• Gold standard• TDC : up to diameter 5 mm• BHC : 5-30 mm diameter• Craniotomay : larger than 30 mm diameter• Hematoma cavity be filled with 100% Oxygen or
carbon dioxide
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Twist drill craniotomy : TDC
• Decompress brain slowly and avoid the presume rapid pressure shift that occur ICH
• 0.5 cm incision• Twist drill hole is place 45 angle,aim direction in
longitudinal axis of the collection• Ventricular catherter insert to subdural space
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Surgical treatment
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Surgical treatment
• Irrigation : remove hematoma completely
• Drainage :• Recurrence : BHC
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Thank you