硬膜外麻醉继发的硬膜下血肿—一种罕见的并发症

Subdural haematoma secondary to epidural anaesthesia. A rare complication
   《Neurologia》, 2015, 28(6):380-382

硬膜外麻醉继发的硬膜下血肿—一种罕见的并发症

 

Intracranial subdural haematoma (SH) rarely presents as a complication of epidural anaesthesia, although we do find cases in the literature. If the dura mater is punctured during this procedure, there is a risk that SH will occur, and that risk may be related to cerebrospinal fluid (CSF) hypotension syndrome.

颅内硬膜下血肿（SH）很少做为硬膜外麻醉的并发症出现，虽然在文献中的确有过相关的报道。如果在硬膜外麻醉的过程中硬脑膜被刺破，这将成为发生SH的危险因素，并且该风险可能与脑脊髓液（CSF）低压综合症相关。

We present the case of a patient with no relevant personal history who presented a SH secondary to the epidural anaesthesia received during childbirth.

此例病例中的患者之前并没有相关的病史，在分娩期间接受硬膜外麻醉后出现了SH.

 

Symptoms of SH are linked to the mass effect and displacement of structures, and they depend on the patient’s age; haematoma location, size, and speed of onset; the patient’s prior clinical condition; and the compression of intracranial structures. Distinguishing CSF hypotension syndrome from SH due to intracranial hypertension may be difficult in differential diagnosis, and this can be an obstacle to diagnosing the condition early.

SH的症状与血量的作用和解剖结构的移位相关，并且它们取决于病人的年龄，血肿位置，大小，和发病的速度;患者的入院状况;颅内结构的压缩的情况。鉴别诊断脑脊液低压综合征和SH是困难的，这可能是一个早期诊断的障碍。

 

A 27-year-old woman came to our hospital’s emergency department on 2 consecutive occasions due to a frontal and occipital headache that increased while standing and improved upon lying down.These visits took place 4 days after a normal vaginal delivery without complications.Epiduralanaesthesia had been administered during childbirth by means of an 18 gauge Weiss needle used to inject levobupivacaine into the L2-L3 intervertebral disc space.Blood pressure (BP) was 148/73 mm Hg and heart rate (HR) was 70 bpm.Physical examination did not reveal any pathological signs, marfanoid/leptosomatic habitus, or articularhypermobility/skin hyperlaxity.Neurological examination showed no focal signs.

1名27岁的女性患者在正常分娩后的4天.由于额部和枕部疼痛接连2次来我们医院的急诊科,疼痛在站立时加剧，平卧位减轻。分娩过程中应用了硬膜外麻醉,用18号weiss针穿刺L2-L3椎间盘间隙,注入布比卡因.血压148/73mmHg和心脏速率是70次/分。体检未发现任何病理征象（患者无类似马凡的瘦长体型，或关节的过度活动及皮肤过度松弛），神经系统检查未见阳性体征。

 

The patient was discharged with analgesic and anti-inflammatory treatment. In the following weeks, she experienced a postural headache that did not prevent her from performing her daily activities and that resolved or lessened with the analgesic treatment rescribed.Approximately one month later, she returned to our department due to an intense headache which did not respond to postural change or improve with habitual analgesics. It was accompanied by vomiting and a state of anxiety and agitation. BP was 136/86 mm Hg and HR was 37 bpm.

患者继续应用镇痛药及抗炎药出院,接下来的几周,他出现了体位性头痛,镇痛药物无法缓解头痛,日常活动未受限.一个月后,该患者由于剧烈的头痛回到我们科,改变体位和习惯性应用镇痛药并没有改善症状.疼痛时常伴有呕吐.焦虑和情绪激动等症状,血压136/86毫米汞柱和HR为37次/分。

 

Neurological examination revealed no pathological findings. The blood count, biochemical and coagulation study, venous blood gas values, and urine analyses provided no significant findings. The ECG detected sinus bradycardia with no other findings. The chest radiography was normal.The brain CT showed an extensive subacute left fronto-temporo-parietal SH with significant mass effect shifting the midline and ventricular system 14 mm to the right (Fig. 1).

神经系统检查未发现病理结果。血常规，生化，凝血研究，静脉血气值，尿液分析没有提供显著的发现。心电图检测窦性心动过缓，没有其他发现。该胸片正常。头颅CT呈亚急性广泛左额颞顶叶SH,有显著位移,中线偏向右侧脑室系统14毫米（图1）。

 

After the case was discussed with the neurology department at the referral hospital, the patient was transferred to that centre. While in the emergency room prior to being transferred, she experienced an abrupt decrease in level of consciousness (GCS score of 3) and anisocoria. Doctors therefore decided to administer sedatives, relaxants, and anti-oedema drugs, as well as orotracheal intubation and mechanical ventilation.

此案与转诊医院神经科讨论后，患者由之前的急诊室被转移到该中心。她出现了意识水平急剧下降（GCS3分）和瞳孔不等大。因此医生决定施用镇静剂，肌松药，以及抗水肿药，以及气管插管和机械通气。

 

Upon her arrival at the referral hospital, doctors performed emergency evacuation of the haematoma using 2 burr holes (one in the parietal and frontal lobe and the other in the left parietal and posterior lobe). Fluid exited under considerable pressure. The patient made good clinical progress; fluid output was abundant and her level of consciousness increased (GCS 15). Brain CT was then performed, revealing re-expansion of the cerebral parenchyma and resolution of the midline shift (Fig. 1). The patient was subsequently discharged and monitored by her primary care doctor and local neurologist; she will also require check-ups in the neurosurgery outpatient unit.

转院后，医生进行了急诊钻孔引流术（一个位于顶叶和额叶，另一个位于左顶叶和枕叶）。引流流出的压力相当大。患者术后明显好转，由于充分的引流，她的意识状态改善达到GCS15分.头部CT显示脑实质复张和中线移位消失（Fig.1）.随后病人出院由之前的医生和当地神经科医生监管，她仍需要在神经外科门诊接受检查。

 

SH is defined as a collection of blood in the cranial cavity between the dura and arachnoid mater. Its most common aetiology is trauma. Chronic SH was first described by Wepfer (1658) and Morgani (1761). In 1857, Virchow wrote that the aetiology of what he called ‘pachymeningitis hemorrhagica interna’ was not traumatic. In 1914, Trotter considered the possibility of SH being caused by the rupture of small veins in the arachnoid mater. SH as a result of epidural anaesthesia is rare, with a prevalence ranging from .

SH被定义为硬膜和蛛网膜之间的血肿，通常是由外伤引起。慢性SH最早是由Wepfer和Morgani提出。1857年，Virchow 描述硬脑膜炎性内出血的病因并非是外伤性的。1914年，Trotter认为SH可能是由于蛛网膜上的小静脉破裂引起。硬膜外麻醉导致的SH极罕见，只有1/500 000 to 1/1 000 000.

 

Post-dural puncture headache (PDPH) is the most frequent complication of epidural anaesthesia. It is associated with CSF hypotension syndrome, since CSF extravasation by lumbar puncture decreases the intracranial pressure.According to the  diagnostic criteria (2004, ICHD-II),the characteristic feature of PDPH is postural headache that appears or intensifies after 15 minutes of standing and improves upon lying down for a similar time period. Studies show that symptoms last no more than 5 days in most cases.

穿刺后头痛是硬膜外麻醉最常见的并发症，并且和脑脊液低压力综合征相关，这是由于腰穿导致的脑脊液外渗减低了颅内压。根据International Headache Society’s 的诊断标准，穿刺后头痛是站立后15分钟加重平卧15分钟后减轻的枕部疼痛，研究表明在大多数病例中，疼痛不会持续超过5天。

 

When CSF pressure decreases suddenly, the displacement of brain structures may cause intracranial subdural veins to tear, giving rise to SH. Many authors have linked the appearance of SH to the technique and material used in lumbar puncture, stating that larger needle diameter, pencil-point type needle tips, and the angle of the bevel are associated with a higher probability of vascular lesion. However, the solution to the problem does not seem to reside in the type of needle, since there are also documented cases of SH secondary to epidural anaesthesia with fine gauge needles.

当脑脊液压力突然降低时，脑组织的移位可能会导致硬膜下静脉的撕裂，引起SH.一些学者认为SH的发生同腰穿技术及使用的材料有关联，声称粗的穿刺针，铅笔尖样的针尖以及锥形的角度会带来更大可能的血管损伤。然而，问题的解决之道似乎并不在于穿刺针的类型，因为在应用改良的穿刺针进行的硬膜外麻醉中仍有SH的病例报道。

 

We should highlight that during the acute phase of SH, intracranial pressure (ICP) increases due to the larger brain volume. In advanced stages, this phenomenon leads to hypoperfusion and ischaemia of the brainstem, which increases the activity of the sympathetic and parasympathetic autonomous nervous system in an attempt to increase the stroke volume and the BP to a level exceeding the pressure on the brainstem.The purpose of this process is to overcome the vascular resistance to cerebral blood flow caused by increased ICP。This physiological response to elevated ICP is called the Cushing reflex and it is described clinically by the triad of arterial hypertension, bradycardia, and irregular breathing, indicators of poor clinical prognosis. In the case we describe, doctors detected bradycardia, but no arterial hypertension or irregular breathing.

值得我们重视的是在SH的急性期，由于脑容量增加引起的高颅压。在进展期，高颅压会导致脑干的低灌注和缺血，从而激活交感和副交感系统，增加每搏量和提升血压是为了对抗升高的颅内压保证脑灌注。我们称这种对抗高颅压的生理性反应为库欣反应，临床上表现为高血压，心动过缓和不规则呼吸三联征，通常提示预后较差。此例病例中，只出现了心动过缓，并没有高血压和不规则呼吸。

 

Headaches that last more than one week after lumbar administration of epidural anaesthesia, stop responding to postural change, or appear with focal neurological signs should alert us to the possibility of an acute intracranial process. Symptoms of such processes no longer reflect CSF hypotension — the typical feature of PDPH — but rather intracranial hypertension, mass effect, and displacement of intracranial structures caused by SH.

硬膜外麻醉一周后仍持续的头痛，体位变动对头痛无影响，或者是出现对应的神经系统症状，这些提示我们可能出现了急性的颅内病情进展。这些症状反应的不再是引起硬膜外穿刺后头痛的脑脊液的低压力，而是硬膜下血肿引起的颅内压升高，血肿压迫和颅内结构的移位。

来源： 舒适化麻醉论坛