创伤性脑血管损伤的识别和治疗

doi:10.11817/j.issn.1673-9248.2023.06.011

目的

探讨创伤性脑血管损伤（TCVI）的危险因素、临床表现及救治方法。

方法

回顾性分析2012年1月至2022年12月苏州大学附属张家港医院收治的39例TCVI患者的临床资料，统计其临床表现及治疗方法。

结果

创伤性脑动脉狭窄或闭塞19例患者中，12例予以抗栓治疗，8例血管管腔完全恢复正常，4例未再通，7例予以支架植入开通血管，死亡1例；创伤性脑动脉瘤8例患者，均行手术治疗，死亡2例；创伤性颈内动脉海绵窦瘘9例患者，均行手术治疗，术后相关症状消失，均恢复良好；脑动脉横断3例患者中，行手术治疗后死亡1例，2例恢复良好。

结论

对于头颅CT无法解释的神经系统症状、格拉斯哥昏迷评分3~8分、局限性或弥漫性较厚的蛛网膜下腔出血、口鼻腔或外耳道大量出血、颈椎C1~3骨折、颈椎骨折半脱位、穿透性损伤、损伤后出现新的神经系统症状或体征的外伤患者要高度警惕TCVI的存在，可行头颈部CT血管成像或数字减影血管造影明确，针对不同类型的TCVI患者采取个体化治疗方案，有助于改善患者神经功能及预后。

关键词: 颅脑损伤, 穿透性脑血管损伤, 钝性脑血管损伤, 创伤性颅内动脉瘤

Objective

To explore the risk factors, clinical manifestations, and treatment of traumatic cerebrovascular injury.

Methods

The clinical data of 39 patients with traumatic cerebrovascular injury admitted to Zhangjiagang Hospital Affiliated to Soochow University from January 2012 to December 2022 were analyzed retrospectively. The clinical manifestations and treatment methods were analyzed.

Results

Among 19 patients with traumatic cerebral artery stenosis or occlusion, 12 patients were treated with antithrombotic therapy, withe 8 patients with normal vascular lumen and the other 4 patients without recanalization, and 7 patients were opened with stent implantation, with 1 patient died. Among 8 patients with traumatic aneurysm who underwent surgical treatment, 2 patients died. The symptoms of 9 cases of traumatic carotid cavernous fistula disappeared after surgical treatment, with all recovered well. One patient died and 2 patients recovered well after surgical treatment in 3 patients with cerebral artery transection.

Conclusion

The patients with neurological symptoms, which cannot be explained by head CT, GCS scores of 3-8 points, localized or diffuse thick subarachnoid hemorrhage, massive hemorrhage in the oral and nasal cavity or external ear canal, cervical vertebra C1-3 fracture, cervical vertebra fracture subluxation, penetrating injury, and new neurological symptoms or signs after injury, should be paid high attension to traumatic cerebrovascular injury, and can be identified by head and neck CT angiography or digital substraction angiography. Individualized treatment for different types of TCVI patients is helpful to improve the neurological function and prognosis of patients.

Key words: Traumatic brain injury, Penetrative cerebrovascular injury, Blunt cerebrovascular injury, Traumatic intracranial aneurysms

图1 例1患者（31岁）的影像资料。图a 入院头颅CT显示左侧额颞顶部硬膜下血肿伴脑疝形成；图b、c 去骨瓣减压术后复查头颅CT显示左侧颅骨缺损，左侧额颞顶叶及基底节区梗死，中线偏移好转；图d 头颅CT血管成像显示左侧颈内动脉未显影；图e、f 左侧颈总动脉数字减影血管造影（DSA）正位和侧位像显示左侧颈内动脉起始部夹层伴闭塞；图g 右侧颈内动脉DSA侧位像显示右侧颈内动脉通过前交通动脉向左侧大脑半球代偿供血；图h 左侧椎动脉DSA侧位像显示椎动脉通过左侧后交通动脉向左侧大脑半球代偿供血

图2 例2患者（16岁）的影像资料。图a 入院头颅CT显示额骨骨折伴右额部硬膜外血肿、气颅；图b 右颈部皮下血肿（箭头所示）；图c 入院颈椎CT显示右颈部软组织肿胀（箭头所示），颈椎未见骨折；图d 伤后1 d头颅CT显示右侧大脑中动脉供血区大面积脑梗死；图e 右侧颈总动脉数字减影血管造影（DSA）侧位像显示右侧颈内动脉起始部夹层伴闭塞；图f 左侧颈内动脉DSA正位像显示左侧颈内动脉通过前交通动脉向左侧大脑前动脉供血，右侧大脑前动脉A1段纤细向右侧大脑中动脉少量代偿供血；图g 左侧椎动脉DSA侧位像显示右侧后交通动脉未开放；图h 去骨瓣减压术后复查头颅CT，示右侧颅骨缺损，右侧脑梗死，中线偏移好转；图i：术后3个月复查右侧颈总动脉DSA侧位像显示，右侧颈内动脉起始部闭塞；图j、k 左侧颈内动脉造影显示右侧大脑前动脉A1段较前明显增粗，左侧颈内动脉通过前交通动脉向右侧大脑半球代偿供血；图l 颅骨修补术后

图3 例3患者（35岁）的影像资料。图a、b 入院头颅CT显示胼胝体及蛛网膜下腔出血，左侧颞骨及枕骨骨折；图c、d 头颅CT血管成像及左侧颈内动脉数字减影血管造影（DSA）显示左侧大脑前动脉A4段创伤性动脉瘤（箭头所示）；图e 予以弹簧圈及Onyx胶闭塞动脉瘤及载瘤动脉；图f 栓塞术后左侧颈内动脉DSA显示左侧大脑前动脉A4段闭塞（箭头所示）；图g 左侧椎动脉DSA侧位像显示后胼周动脉代偿供血（箭头所示）；图h 术后复查头颅CT，示颅内未见新鲜出血及大片脑梗死

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Diagnosis and treatment of traumatic cerebrovascular injury

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Diagnosis and treatment of traumatic cerebrovascular injury