脑外伤：硬膜外血肿

　　A 65-year-old right-handed man was transferred to the hospital   approximately 16 hours after suffering head trauma with loss of consciousness in a motor-vehicle accident.

　　Examination. General examination was remarkable for a left parietal scalp laceration, left hemotympanum, and right periorbital hematoma（眶周血肿）.  Funduscopic  examination（眼底检查） was within normal limits. Neurological examination revealed an alert patient oriented to time and person but not to place. A mixed aphasia was present with expressive and conductive elements. Sensory examination was normal. There was left-sided weakness; however; the patient did have a positive Babinski sign on the left. The remainder of the neurological examination was normal. Skull films revealed a left parietal linear skull fracture.

　　Course.   The patient was admitted to the hospital for observation, and over the next 24 hours had modest but definite improvement in his aphasia. A CT scan was obtained approximately 24 hours after injury, and this reveals a left epidural hematoma with a 3-mm shift of midline structures from left to right, and effacement of the left lateral ventricle. Because the patient had been improving neurologically, surgery was withheld pending any evidence of neurological deterioration. By the 2nd day, the patient had complete resolution of his aphasia except for a very mild dysnomic component. Follow-up CT scan on the 4th hospital day demonstrated no significant change from the performed 24 hours after admission. The patient continued to improve and was discharged asymptomatic following complete resolution of his neurological deficits and headaches on the 6th hospital day. Repeat CT scans were obtained on the 17th and 30th postinjury day. These showed gradual but complete resolution of the epidural hematoma.

　　

脑外伤：硬膜外血肿

　　A 21-year-old man was transferred to the hospital 3 days after suffering a closed-head injury with loss of consciousness. On admission, the patient was complaining of severe right-sided headaches.

　　Examination. The general examination demonstrated a right parietal laceration. Neurological examination showed a mild abnormality of recent memory， but was otherwise within normal limits. Plain films demonstrated a linear right temporal-parietal skull fracture.

　　Course. The patient underwent CT scan on the day of admission. This revealed a right temporal-parietal epidural hematoma associated with a 4-to 4. 5-mm  shift from right to left. Because the patient demonstrated no neurological deficit, he was treated nonoperatively. During the hospital course, the patient had steady and complete resolution of his headache. Repeat CT scan, 1 week after admission, demonstrated persistent right epidural hematoma, with less shift than noted previously. The patient was discharged without neurological deficit, A third scan, repeated 7 weeks after injury, demonstrated complete resolution of the epidural hematoma.

 

脑外伤：慢性硬膜下血肿

　　You are asked to see a 27-year-old woman, a successful corporate lawyer, because of increasing headaches which began approximately 1 month ago. She first noted headache several days after returning from a ski t** with her husband and two children. The headaches are bifrontal, throbbing, and increasing in severity. During the past week she has awaked from sleep on several occasions with headache and vomiting. In addition, her husband describes her as more apathetic and less "sharp" at work than usual. One week ago she saw a local physician who prescribed Valium. There have been no visual, motor, or sensory complaints. She is not on any medications, has no other medical illnesses, and has suffered no recent trauma. On  examination , she was tearful and complained of severe steady headache and an inability to sleep for several days. She relied on her husband for most of the details of her illness. On several occasions, she did not respond to questions asked directly to her and the questions had to be repeated. There was no aphasia, but detailed mental status testing was impossible because of her agitated state.

　　Examination of the optic fundi revealed an absence of venous pulsations and blurring of the disc margins. The remainder of the cranial nerve examination was normal. There was a mild pronator drift of the right arm but power was otherwise normal.  There was reflex asymmetry (3/5 on the right, 2/5 on the left) and plantar responses were flexor on the left and equivocal on the right. Tone, sensory, and cerebellar examinations were within normal limits, and her gait was normal. A CT scan was performed.The scan shows a large, left-sided, isodense? chronic subdural hematoma. On the nonenhanced scan,  the subdural hematoma itself was not visible because of its isodense character, but a shift of the lateral ventricles due to mass effect was seen. With contrast enhancement 9 the membranous wall of the subdural hematoma can be  seen and the size of the subdural collection is clearly outlined.The treatment for symptomatic, chronic subdural hematomas is surgical evacuation. In patients with small, stable subdural hematomas, or in those for whom surgery is  contraindicated, medical management with corticosteroids and dehydrating agents(mannitol) may be successful. In this patient surgical evacuation was performed with excellent results.