Significance of a Subdural Hematoma in a Child with External Hydrocephalus
Significance of a Subdural Hematoma in a Child with External Hydrocephalus
复制标题
外部脑积水儿童硬膜下血肿的意义
DOI：
10.1159/000071315
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发表时间：
2003
影响因子：
0.7
通讯作者：
T. Pittman
中科院分区：
文献类型：
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作者：
T. Pittman
大多数医生把没有外伤史的儿童出现硬膜下血肿作为虐待的假定证据。这一假设基于我们对硬膜下出血的病理生理学的理解;硬膜下血肿是由颅内桥静脉撕裂引起的，需要相当大的力量才能使静脉破裂并引起出血。所需的力量被认为是超过可以在短期内下降或典型的家庭事故产生。此外，硬膜下血肿最常与其他损伤一起发生，如视网膜损伤和长骨骨折，这表明严重创伤。然而，有一些情况被认为即使是轻微损伤也容易使儿童发生硬膜下血肿：其中包括凝血病、谷氨酸尿症、大蛛网膜囊肿和成骨不全[1-5]。有人认为，外部脑积水（即家族性巨头畸形、婴儿期良性硬膜下积液）的存在也会使儿童处于风险中[6-8]。理论和临床证据都支持这一观点。理论证据来自Papasian和Frim [9]，他们创建了一个数学模型，专门用于检查导致外部脑积水儿童硬膜下血肿所需的力。他们用两个同心的空心球体来代表大脑和头骨。桥接静脉被建模为在两个球体之间正交延伸。使用目前公认的静脉长度和抗拉强度信息，作者计算了各种力引起的静脉应变，然后定义了静脉在给定情况下失效的可能性。他们发现，同样的力量会使有额外轴向集合的儿童的静脉比没有轴向集合的儿童的静脉更成比例地伸展。他们计算出与低冲击损伤相关的力足以导致外部脑积水儿童的静脉破裂。这一发现适用于各种血管长度和直径的模拟。其他研究也得出了类似的结论[10]。作为一个实际的问题，似乎有不成比例的外部脑积水儿童发展硬膜下血肿。几个团体对这种关系发表了评论。Laubscher等人[11]描述了22例患有巨脑畸形和蛛网膜下腔扩大的儿童。22例患者中有3例有硬膜下血肿：所有患者均表现良好，无明显外伤。Mori等人[12]、Azais和Echenne [13]以及后来的Piatt [14]报告了类似的结果。临床协会.
Most physicians take the presence of a subdural hema-toma in a child without a history of trauma as presump-tive evidence of abuse. This assumption rests on our understanding of the pathophysiology of subdural hemorrhage ; subdural hematomas are caused by tearing intra-cranial bridging veins and it requires substantial force to rupture the veins and cause bleeding. The force required is thought to be more than can be generated in a short fall or by typical household accidents. Moreover, subdural hematomas most frequently occur in conjunction with other injuries, such as retinal hemorrhages and long bone fractures, which are indicative of severe trauma. There are some conditions, however, that are recognized to pre-dispose a child to develop a subdural hematoma after even minor injury: among them are coagulopathies, glu-taric aciduria, large arachnoid cysts and osteogenesis im-perfecta [1–5]. There have been suggestions that the presence of external hydrocephalus (i.e. familial macrocepha-ly, benign subdural effusions of infancy) also puts a child at risk [6–8]. Both theoretical and clinical evidence supports this position. Theoretical evidence comes from Papasian and Frim [9], who have created a mathematical model specifically to examine the forces required to cause a subdural hema-toma in a child with external hydrocephalus. They used two concentric hollow spheres to represent the brain and skull. Bridging veins were modeled to run orthogonally between the two spheres. Using currently accepted information about venous length and tensile strength, the authors calculated the strain on the veins caused by various forces and then defined the likelihood that the veins would fail in a given situation. They found that the same force caused veins to stretch proportionately more in children with extra axial collections than in those without. They calculated that the forces associated with low impact injuries were sufficient to cause venous rupture in children with external hydrocephalus. This finding held true for simulations with a variety of vessel lengths and diameters. Other groups have come to similar conclusions [10]. As a practical issue, it does appear that a disproportionate number of children with external hydrocephalus develop subdural hemorrhages. Several groups have commented on the relationship. Laubscher et al. [11] described 22 children with megalencephaly and enlarged subarachnoid spaces. Three of the 22 had subdural hema-tomas: all apparently did well and none had recognized trauma. Similar results were reported by Mori et al. [12], Azais and Echenne [13] and, later, by Piatt [14]. The clinical association …