Hematoma subdural agudo traumático: estudo de 110 pacientes

Figueiredo Neto, Nicandro de; Martins, Johnny Wesley G.; Parage Filho, Miguel; Motta, Luiz Augusto Casulari Roxo da; Mello, Paulo Andrade de; Pereira, Ronaldo Sérgio Santana

doi:10.1590/S0004-282X1996000200011

Resumos

Apresentamos uma série consecutiva de 110 pacientes com hematoma subdural agudo traumático (HSDA) admitidos no serviço de emergência do HBDF no período de 1°-janeiro a 1°-dezembro-1994. Todos os pacientes foram atendidos de acordo com o mesmo protocolo. Houve predominância do sexo masculino (79%), com idade variando entre 14 e 70 anos, sendo os atropelamentos (34%) e os acidentes automobilísticos (20%) as causas mais comuns. A maioria dos pacientes (85,7%) foi admitida muito grave, com 8 pontos ou menos na Escala de Coma Glasgow (ECG), o que influenciou diretamente na mortalidade. A tomografia computadorizada de crânio foi o exame diagnóstico de escolha que mostrou serem as contusões e o inchaço cerebral ("swelling") as lesões intracranianas associadas mais freqüentes. A cirurgia foi realizada em 45,1% dos pacientes, e, em sua maioria, através de craniotomia fronto-têmporo-parietal ampla, com drenagem do hematoma, seguida de plástica da dura-mater. Em 54,9% as condições clínicas não permitiram a realização da cirurgia; neste grupo, cerca de 69,6% estavam em coma profundo à admissão, com 3 pontos na ECG. A letalidade cirúrgica foi de 61,2% e esteve diretamente relacionada à condição clínica inicial e à idade do paciente. A letalidade, incluindo todos os pacientes cirúrgicos e não cirúrgicos com HSDA, mesmo aqueles admitidos já com sinais de falência de tronco cerebral, foi de 79,5%. Além destes pacientes que faleceram, cerca de 7% evoluíram sem seqüelas ou com seqüelas mínimas; outros 11,4% com seqüelas de moderadas a paves e 2,1 % permaneceram em estado vegetativo persistente. Nossos dados estão de acordo com os da literatura no que se refere a elevada taxa de morbidade e mortalidade dos pacientes com HSDA.

traumatismo cranioencefálico; hematoma subdural agudo traumático; epidemiologia; diagnóstico; conduta

We report a series of 110 patients with acute traumatic subdural hematoma (ASDH) admitted at HBDF emergency within 1994 (January Is1 to December PJ.All patients were treated according to the same protocol. There was a predominance of males (79%), with ages ranging from 14 to 70, being car accidents (20%) and car-pedestrian accidents (34%) the most frequent causes The majority of patients (85.7%) was admitted in very serious condition, with a score of 8 points on the Glasgow Coma Scale (GCS) or lesser, which directly influenced the mortality rates. CT scan was the diagnostic procedure of choice, and it showed contusion and brain swelling to be the most frequent associated intracranial lesions. Surgery was carried out in 45.1% of cases and, in most instances, through an ample fronto-temporo-parietal craniotomy, with hematoma drainage and dural reconstitution. In 54.9% of cases, clinical conditions did not allow surgery and in this group, 69.6%

cranioencephalic trauma; acute traumatic subdural hematoma; epidemiology; diagnostics; management

Hematoma subdural agudo traumático: estudo de 110 pacientes

Acute traumatic subdural haematomas: study of 110 cases

Nicandro de Figueiredo Neto^I; Johnny Wesley G. Martins^I; Miguel Parage Filho^II; Luiz Augusto Casulari Roxo da Motta^III; Paulo Andrade de Mello^IV; Ronaldo Sérgio Santana Pereira^II

^IMédico Residente da Unidade de Neurocirurgia do HBDF

^IIMédico staffs e preceptores da Unidade de Neurocirurgia do HBDF

^IIIMédico staff do HBDF e Professor de Endocrinologia da Universidade de Brasília

^IVProfessor de Neurocirurgia da Universidade de Brasília

RESUMO

Apresentamos uma série consecutiva de 110 pacientes com hematoma subdural agudo traumático (HSDA) admitidos no serviço de emergência do HBDF no período de 1°-janeiro a 1°-dezembro-1994. Todos os pacientes foram atendidos de acordo com o mesmo protocolo. Houve predominância do sexo masculino (79%), com idade variando entre 14 e 70 anos, sendo os atropelamentos (34%) e os acidentes automobilísticos (20%) as causas mais comuns. A maioria dos pacientes (85,7%) foi admitida muito grave, com 8 pontos ou menos na Escala de Coma Glasgow (ECG), o que influenciou diretamente na mortalidade. A tomografia computadorizada de crânio foi o exame diagnóstico de escolha que mostrou serem as contusões e o inchaço cerebral ("swelling") as lesões intracranianas associadas mais freqüentes. A cirurgia foi realizada em 45,1% dos pacientes, e, em sua maioria, através de craniotomia fronto-têmporo-parietal ampla, com drenagem do hematoma, seguida de plástica da dura-mater. Em 54,9% as condições clínicas não permitiram a realização da cirurgia; neste grupo, cerca de 69,6% estavam em coma profundo à admissão, com 3 pontos na ECG. A letalidade cirúrgica foi de 61,2% e esteve diretamente relacionada à condição clínica inicial e à idade do paciente. A letalidade, incluindo todos os pacientes cirúrgicos e não cirúrgicos com HSDA, mesmo aqueles admitidos já com sinais de falência de tronco cerebral, foi de 79,5%. Além destes pacientes que faleceram, cerca de 7% evoluíram sem seqüelas ou com seqüelas mínimas; outros 11,4% com seqüelas de moderadas a paves e 2,1 % permaneceram em estado vegetativo persistente. Nossos dados estão de acordo com os da literatura no que se refere a elevada taxa de morbidade e mortalidade dos pacientes com HSDA.

Palavras-chave: traumatismo cranioencefálico, hematoma subdural agudo traumático, epidemiologia, diagnóstico, conduta.

ABSTRACT

We report a series of 110 patients with acute traumatic subdural hematoma (ASDH) admitted at HBDF emergency within 1994 (January I^s1 to December PJ.All patients were treated according to the same protocol. There was a predominance of males (79%), with ages ranging from 14 to 70, being car accidents (20%) and car-pedestrian accidents (34%) the most frequent causes The majority of patients (85.7%) was admitted in very serious condition, with a score of 8 points on the Glasgow Coma Scale (GCS) or lesser, which directly influenced the mortality rates. CT scan was the diagnostic procedure of choice, and it showed contusion and brain swelling to be the most frequent associated intracranial lesions. Surgery was carried out in 45.1% of cases and, in most instances, through an ample fronto-temporo-parietal craniotomy, with hematoma drainage and dural reconstitution. In 54.9% of cases, clinical conditions did not allow surgery and in this group, 69.6%

Key words:cranioencephalic trauma, acute traumatic subdural hematoma, epidemiology, diagnostics, management.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

Agradecimentos - Ao Dr. Mário Zan Morello e ao Sr. João Arruda Falcão pela importante colaboração no preparo do manuscrito.

Aceite: 23-janeiro-1996.

Unidade de Neurocirurgia do Hospital de Base do Distrito Federal (HBDF)

Dr. Nicandro de Figueiredo Neto - SQS 113 Bloco C Apto 106 - 70376-030 Brasília DF - Brasil

1. Alberico AM, Ward JD, Choi SC, Marmarou A, Young Mf. Outcome after servere head injury: relationship to mass lesion, diffuse injury and ICP course in pediatric and adult patient. J Neurosurg 1987;67:648-656.
2. Becker D.P.Comentário de: Miller JD, Bullock R, Graham Dl et al. Ischemic brain damage in a model of acute subdural hematoma. Neurosurgery. 1990;27,433-439.
3. Cagetti B, Cossu M, Pau A et al. The outcome from acute subdural and epidural hematoma in very elderly patients. Br J Neurosurg 1992;6:227-231.
4. Candon E. Indentation sign in the sylvian sulcus and the arterial origin of an acute subdural hematoma: contribution of computerized tomography. Ann Radiol (Paris) 1993;36:269-274.
5. Cantore GP, Delfini R, Neri J.Contribution to the surgical treatment of acute subdural hematomas. Acta Neurochir (Wien) 1987;41:349-353.
6. Ciembroniewicz JE. Subdural hematoma of the posterior fossa: review literature with additional 3 cases. J Neurosurg 1965;22:465-473.
7. Cooper RP. Post-traumatic intracranial mass lesion. Head injury. Ed 2. Baltimore: Willians & Wilkins,1987;238-284.
8. Croce MA, Dent DL, Menke PG, Robertson JT, Hison MS, Young BH, Donovan TB, Pritchard FE, Minard G, Kudsk KA. Acute subdural hematoma: nonsurgical management of selected patients. J Trauma. 1994;36: 820-826.
9. Eisenberg MH, Aldrich EF. Extra-cerebral lesions. Management of head injury. Neurosurg Clin N Am 1991;358-632.
10. Estridge MN. Acute subdural hemorrage of posterior fossa: report of a case and review of the literature. J Neurosurg 1961;18:248-249.
11. Fell DA, Fitzgerald S, Moiel RH, Caram P. Acute subdural hematoma: review of 144 cases. J Neurosurg 1975;42:37-42.
12. Gennarelli TA, Spielman GM, Langfitt TW, Gildenberg PL, Harrington T, Jane JA, Marshall JD, Pitts LH. Influence of the type of intracranial lesion on outcome from severe head injury: a multicenter study using a new classification system. J Neurosurg 1982;56:26-32.
13. Gennarelli TA, Thibault LE. Biomechanics of acute subdural hematoma. J Trauma. 1982;22:680-686.
14. Hans JS. Head trauma evaluated magnetic resonance and computed tomography: a comparison. Radiology 1984;150:71-77.
15. Haselberger K, Rucher R, Auer LM. Prognosis after acute subdural and extradural hematoma. ActaNeurochir (Wien) 1988;90:111-116.
16. Hernesniemi J. Outcome following acute subdural hematoma. ActaNeurochir (Wien). 1979;49:191-198.
17. Howard MA, Gross AS, Dacey RG, Win HR. Acute subdural hematoma: an age dependent clinical entity. J Neurosurgl989;71:858-863.
18. Janieson KG, Yelland JDN. Surgically treated traumatic subdural hematomas. J Neurosurg. 1968;29:13-23.
19. Klun B, Fettich M. Factors influencing the outcome in acute subdural hematoma: a review of 330 cases. ActaNeurochir (Wien). 1984;71:171-178.
20. Kotwica Z, Brzezi'nski J. Acute subdural hematoma in adults: an analysis of outcome in comatose patients. Acta Neurochir (Wien) 1993;121: 95-99.
21. Long DM. Aging in the nervous system. Neurosurgery 1985;17:348-354.
22. Mc Kissock W, Richardson A, Bloom WH. Acute subdural hematoma: a review of 389 cases. Lancet 1960;1:1365-1369.
23. Mc Laurin RL, Tutor FT. Acute subdural hematoma: review of 90 cases. J Neurosurg 1961;18:61-67.
24. Mendelow AD, Bullock R, Nath FP, Jinkins A, Kingman T, Teasdale GM: Experimental intracerebral haemorrage: intracranial pressure changes and cerebral blood flow. Intracranial pressure. Proceedings of the 6th International Symposium on Intracranial Pressure. Berlin: Springer-Verlag, 1986: 515-520.
25. Miller JD. Ischemic brain damage in a model of acute subdural hematoma. Neurosurgery 1990;27,433-439.
26. O'Brien PK, Norris JW, Tator CH. Acute subdural hematomas of arterial origin. J Neurosurg. 1974; 41: 435-439.
27. Richards T, Hoff J. Factors affecting survival from acute subdural hematoma. Surgery 1974;75:253-258.
28. Schroder ML, Muizelaar JP, Kuta AJ. Documented reversal of global ischaemia immediately after removal of an acute subdural hematoma. J Neurosurg 1994;80:324-327.
29. Seelig JM. Traumatic acute subdural hematoma. Major mortality reduction in comatose patients treated within 4 hours. N Engl J Med 1981;304:1511-1518.
30. Shmidek HH. Operative neurosurgical techniques. Ed 3. Philadelphia: Saunders 1995:50-54.
31. Sonne NM, Tonnessen H. Course after surgery of subdural hematoma in alcohol abusers. Ugeskr Lauger 1994; 17:156; 295-297.
32. Stone JL. Acute subdural hematomas: progress in definition, clinical pathology, and therapy. Surg Neurol 1983;19:216-231.
33. Tallala A. Acute traumatic subdural hematoma: a review of 100 consecutive cases. J Trauma 1971;11:771-777.
34. Vielvoye GJ. Acute infratentorial subdural hematoma associated with a torn tentorium cerebelli in a 1 year old boy. Neuroradiology 1982;22:259-261.
35. Whittmore SR, Nieto-Sampiedro M, Needles DL et al. Neuronotrophic factors for mammalian brain neurons: injury inductions in neonatal, adult and aged rat brain. Dev Brain Res. 1985; 20: 169-178.
36. Wilberger JE Jr, Harris M, Diamond DL. Acute subdural hematoma : morbidity, mortality, and operative timing. J Neurosurg.l991;74:212-218.
37. Youmans, JR. Neurological surgery. Ed 3. Philadelphia: Saunders 1990: 1962, 1977-1980, 2046-2049, 2077-2078, 2083-2085, 2204-2205.

Datas de Publicação

Publicação nesta coleção
06 Dez 2010
Data do Fascículo
Jun 1996

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Alberico AM, Ward JD, Choi SC, Marmarou A, Young Mf. Outcome after servere head injury: relationship to mass lesion, diffuse injury and ICP course in pediatric and adult patient. J Neurosurg 1987;67:648-656.

[2] 2. Becker D.P.Comentário de: Miller JD, Bullock R, Graham Dl et al. Ischemic brain damage in a model of acute subdural hematoma. Neurosurgery. 1990;27,433-439.

[3] 3. Cagetti B, Cossu M, Pau A et al. The outcome from acute subdural and epidural hematoma in very elderly patients. Br J Neurosurg 1992;6:227-231.

[4] 4. Candon E. Indentation sign in the sylvian sulcus and the arterial origin of an acute subdural hematoma: contribution of computerized tomography. Ann Radiol (Paris) 1993;36:269-274.

[5] 5. Cantore GP, Delfini R, Neri J.Contribution to the surgical treatment of acute subdural hematomas. Acta Neurochir (Wien) 1987;41:349-353.

[6] 6. Ciembroniewicz JE. Subdural hematoma of the posterior fossa: review literature with additional 3 cases. J Neurosurg 1965;22:465-473.

[7] 7. Cooper RP. Post-traumatic intracranial mass lesion. Head injury. Ed 2. Baltimore: Willians & Wilkins,1987;238-284.

[8] 8. Croce MA, Dent DL, Menke PG, Robertson JT, Hison MS, Young BH, Donovan TB, Pritchard FE, Minard G, Kudsk KA. Acute subdural hematoma: nonsurgical management of selected patients. J Trauma. 1994;36: 820-826.

[9] 9. Eisenberg MH, Aldrich EF. Extra-cerebral lesions. Management of head injury. Neurosurg Clin N Am 1991;358-632.

[10] 10. Estridge MN. Acute subdural hemorrage of posterior fossa: report of a case and review of the literature. J Neurosurg 1961;18:248-249.

[11] 11. Fell DA, Fitzgerald S, Moiel RH, Caram P. Acute subdural hematoma: review of 144 cases. J Neurosurg 1975;42:37-42.

[12] 12. Gennarelli TA, Spielman GM, Langfitt TW, Gildenberg PL, Harrington T, Jane JA, Marshall JD, Pitts LH. Influence of the type of intracranial lesion on outcome from severe head injury: a multicenter study using a new classification system. J Neurosurg 1982;56:26-32.

[13] 13. Gennarelli TA, Thibault LE. Biomechanics of acute subdural hematoma. J Trauma. 1982;22:680-686.

[14] 14. Hans JS. Head trauma evaluated magnetic resonance and computed tomography: a comparison. Radiology 1984;150:71-77.

[15] 15. Haselberger K, Rucher R, Auer LM. Prognosis after acute subdural and extradural hematoma. ActaNeurochir (Wien) 1988;90:111-116.

[16] 16. Hernesniemi J. Outcome following acute subdural hematoma. ActaNeurochir (Wien). 1979;49:191-198.

[17] 17. Howard MA, Gross AS, Dacey RG, Win HR. Acute subdural hematoma: an age dependent clinical entity. J Neurosurgl989;71:858-863.

[18] 18. Janieson KG, Yelland JDN. Surgically treated traumatic subdural hematomas. J Neurosurg. 1968;29:13-23.

[19] 19. Klun B, Fettich M. Factors influencing the outcome in acute subdural hematoma: a review of 330 cases. ActaNeurochir (Wien). 1984;71:171-178.

[20] 20. Kotwica Z, Brzezi'nski J. Acute subdural hematoma in adults: an analysis of outcome in comatose patients. Acta Neurochir (Wien) 1993;121: 95-99.

[21] 21. Long DM. Aging in the nervous system. Neurosurgery 1985;17:348-354.

[22] 22. Mc Kissock W, Richardson A, Bloom WH. Acute subdural hematoma: a review of 389 cases. Lancet 1960;1:1365-1369.

[23] 23. Mc Laurin RL, Tutor FT. Acute subdural hematoma: review of 90 cases. J Neurosurg 1961;18:61-67.

[24] 24. Mendelow AD, Bullock R, Nath FP, Jinkins A, Kingman T, Teasdale GM: Experimental intracerebral haemorrage: intracranial pressure changes and cerebral blood flow. Intracranial pressure. Proceedings of the 6th International Symposium on Intracranial Pressure. Berlin: Springer-Verlag, 1986: 515-520.

[25] 25. Miller JD. Ischemic brain damage in a model of acute subdural hematoma. Neurosurgery 1990;27,433-439.

[26] 26. O'Brien PK, Norris JW, Tator CH. Acute subdural hematomas of arterial origin. J Neurosurg. 1974; 41: 435-439.

[27] 27. Richards T, Hoff J. Factors affecting survival from acute subdural hematoma. Surgery 1974;75:253-258.

[28] 28. Schroder ML, Muizelaar JP, Kuta AJ. Documented reversal of global ischaemia immediately after removal of an acute subdural hematoma. J Neurosurg 1994;80:324-327.

[29] 29. Seelig JM. Traumatic acute subdural hematoma. Major mortality reduction in comatose patients treated within 4 hours. N Engl J Med 1981;304:1511-1518.

[30] 30. Shmidek HH. Operative neurosurgical techniques. Ed 3. Philadelphia: Saunders 1995:50-54.

[31] 31. Sonne NM, Tonnessen H. Course after surgery of subdural hematoma in alcohol abusers. Ugeskr Lauger 1994; 17:156; 295-297.

[32] 32. Stone JL. Acute subdural hematomas: progress in definition, clinical pathology, and therapy. Surg Neurol 1983;19:216-231.

[33] 33. Tallala A. Acute traumatic subdural hematoma: a review of 100 consecutive cases. J Trauma 1971;11:771-777.

[34] 34. Vielvoye GJ. Acute infratentorial subdural hematoma associated with a torn tentorium cerebelli in a 1 year old boy. Neuroradiology 1982;22:259-261.

[35] 35. Whittmore SR, Nieto-Sampiedro M, Needles DL et al. Neuronotrophic factors for mammalian brain neurons: injury inductions in neonatal, adult and aged rat brain. Dev Brain Res. 1985; 20: 169-178.

[36] 36. Wilberger JE Jr, Harris M, Diamond DL. Acute subdural hematoma : morbidity, mortality, and operative timing. J Neurosurg.l991;74:212-218.

[37] 37. Youmans, JR. Neurological surgery. Ed 3. Philadelphia: Saunders 1990: 1962, 1977-1980, 2046-2049, 2077-2078, 2083-2085, 2204-2205.