CHẤN THƯƠNG SỌ NÃO..........................................................................................................................................................................................................................................................
Cranial meninges Rajasri Manimaran Group Protection of the Brain • • • • The Skull Cranial meninges Cerebrospinal fluid Blood brain barrier The Meninges Cranial Meninges - layer protective membrane Dura Mater - Composed of two layers: a) Periosteal – outer layer, attaches to bone b) Meningeal – inner layer, closer to brain Two layers fused, except to enclose the dural sinuses Arachnoid Layer - ‘spider’ web like Pia Mater - delicate, follows convolutions Superior sagittal sinus (Dural venous sinus) Dura mater Endosteal layer Meningeal layer They are closely united except along certain lines; they are separated to form venous sinuses Subdural space Coronal section of the upper part of the head 1) Falx cerebri 2) Tentorium cerebelli 4) Diaphragma sellae 3) Falx cerebelli Sagittal section showing the duramater Dural Nerve Supply Branches of the trigeminal, vagus, and first three cervical nerves and branches from the sympathetic system pass to the dura The dura is sensitive to stretching, which produces the sensation of headache Dural blood supply The middle meningeal artery supplies most of the blood for the dura mater, though the meningeal branches of the posterior and anterior ethmoidal artery also contribute Arachnoid mater Hunt and Hess classification Grade Signs and symptoms Asymptomatic or minimal headache and slight neck stiffness Moderate to severe headache; neck stiffness; no neurologic deficit except cranial nerve plasy Drowsy; minimal neurologic deficit Stuporous; moderate to severe hemiparesis; possibly early decerebrate rigidity and vegetative disturbances Deep coma; decerebrate rigidity; moribund Survival 70% 60% 50% 20% 10% Treatment Stabilizing patient Prevention of rebleeding by obliterating the bleeding source prevention of a phenomenon known as vasospasm and, prevention and treatment of complications the initial hemorrhage Re-bleeding was more common in those with a systolic blood pressure >160mm Hg Anti-fibrinolytic therapy may reduce re-bleeding but has not been shown to improve outcomes 3/1/17© 2009, American Heart Up to 14% of SAH patients may experience re-bleeding within hours of Association All rights reserved Preventing Re-bleeding Endovascular – coiling Should be performed within days of hemorrhage 3/1/17© 2009, American Heart Surgery – clip aneurysm base Association All rights reserved Surgical and Endovascular Management of SAH 3/1/17© 2009, American Heart Association All rights reserved Clipping Angio Image Courtsey: The University of Texas Health Science Center at San Antonio – Department of Neurosurgery 3/1/17© 2009, American Heart Right image arrow – Angio showing aneurysm post clipping Association All rights reserved Left image arrow -Angio with Large aneurysm treated patients than in those treated with endovascular techniques (30.9% vs 23.5%; absolute risk reduction 7.4%) During the short follow-up period, the re-bleeding rate for coiling was 2.9% versus 0.9% for surgery There have been no randomized comparisons of coiling versus clipping for unruptured aneurysms 3/1/17© 2009, American Heart Combined morbidity and mortality was significantly greater in surgically Association All rights reserved Surgical and Endovascular Management of SAH 3/1/17© 2009, American Heart Association All rights reserved Coiling Same aneurysm - Post GDC Coiling Angio Image Courtsey: The University of Texas Health Science Center at San Antonio – Department of Neurosurgery 3/1/17© 2009, American Heart Angio showing large ICA aneurysm Association All rights reserved Coil system embolization: immediate result Preventing vasospasm The use of calcium channel blockers, thought to be able to prevent the spasm of blood vessels by preventing calcium from entering smooth muscle cells, has been proposed for the prevention of vasospasm The oral calcium channel blocker nimodipine improves outcome if administered between the fourth and twenty-first day after the hemorrhage Preventing other complications If medication don’t help, then angiography may be attempted to identify the sites of vasospasms and administer vasodilator medication (drugs that relax the blood vessel wall) directly into the artery. Angioplasty (opening the constricted area with a balloon) may also be performed endovascular coiling of the aneurysm neck whenever possible Treatment morbidity is determined by numerous factors, including patient, aneurysm, and institutional factors 3/1/17© 2009, American Heart The current standard of practice calls for microsurgical clipping or Association All rights reserved Summary and Conclusions volumes of patients with SAH, in institutions that offer endovascular services, and in selected patients whose aneurysms are coiled rather than clipped Optimal treatment requires availability of both experienced cerebrovascular surgeons and endovascular surgeons working in a collaborative effort to evaluate each case of SAH 3/1/17© 2009, American Heart Favorable outcomes are more likely in institutions that treat high Association All rights reserved Summary and Conclusions