| disease | Multiple Intracranial Hematomas |
| alias | Multiple Intracranial Hematomas |
When two or more hematomas of different locations or types form simultaneously in the intracranial space after a craniocerebral injury, it is referred to as multiple hematomas. Such hematomas are often associated with severe cerebral contusions and lacerations, with an incidence rate of approximately 14.4% to 21.4% of intracranial hematomas. Among these, about 60% are located in different areas, while around 40% are in the same location but of different types.
bubble_chart Clinical Manifestations
Multiple hematomas do not have unique clinical signs. Although a preliminary estimation can be made based on the mechanism of injury and the manifestation of neurological impairment, the symptoms and signs among various multiple hematomas are often confusing, making it difficult to confirm the diagnosis. It usually requires imaging studies or surgical exploration for confirmation. Generally, they are divided into three situations:
Multiple hematomas of different types at the same location, often resulting from contrecoup cerebral contusion and laceration accompanied by acute subdural hematoma and intracerebral hematoma; or epidural hematoma at the site of impact accompanied by local subdural and/or intracerebral hematoma.
Multiple hematomas of the same type at different locations, often bilateral subdural hematomas, especially in children and elderly patients, caused by deceleration injuries to the frontal or occipital regions. When the injuring force is strong and cerebral contusion and laceration are severe, it is often an acute subdural hematoma, usually located in the bilateral frontotemporal regions. If the primary cerebral injury is mild, resulting from tearing of bridging veins on the brain surface, it is mostly a chronic or subacute bilateral convexity subdural hematoma. Occasionally, bilateral temporal bone fractures due to crush injuries may also cause bilateral epidural hematomas, but this is relatively rare.
Multiple hematomas of different types at different locations, seen in epidural hematoma and/or intracerebral hematoma at the site of impact accompanied by subdural and intracerebral hematoma at the contrecoup site. Sometimes, deceleration injuries to the occipital region causing occipital bone fractures can lead to posterior fossa epidural hematoma accompanied by subdural and/or intracerebral hematoma at the contrecoup site.The clinical manifestations of such hematomas are often severe, with patients frequently experiencing persistent unconsciousness or rapid changes in consciousness after injury, and are prone to early tentorial herniation and bilateral pyramidal tract damage.
When multiple hematomas are suspected, early auxiliary examinations such as CT, MRI, or cerebral angiography should be performed to confirm the diagnosis at an early stage. Skull X-rays can indicate the presence of fracture lines crossing venous sinuses or vascular impressions. If cerebral ultrasound detection shows no shift or only a slight shift of the midline wave that does not match the clinical signs, the possibility of multiple hematomas should be considered. If cerebral angiography shows an avascular area, and the anterior cerebral artery pulse does not shift to the opposite side, or the shift is less than half the original thickness of the hematoma, or the hematoma is very small but the midline shift is excessive, the possibility of multiple hematomas should be considered. During emergency rescue, for surgical patients whose multiple hematomas were not confirmed preoperatively, attention should be paid to changes in intracranial pressure after hematoma removal. If there is no significant relief in intracranial pressure, or if there is a temporary improvement to grade I followed by a rise again, or if blood pressure is normal but cerebral tissue pulsation is poor, or even if there is still cerebral herniation, a thorough exploration of possible sites of multiple hematomas should be conducted to avoid missing fistula disease.
For multiple hematomas with clear preoperative imaging and localization diagnosis, the surgical approach, method, and sequence can be reasonably designed; however, for cases where multiple hematomas are suspected during surgery, careful analysis should be conducted based on the injury mechanism, impact point, and skull fracture, followed by exploration or intraoperative B-ultrasound detection.
Removal of different types of hematomas in the same location: The most common scenario is contrecoup contusion in the frontal and temporal regions, accompanied by acute subdural and intracerebral hematomas, which are mixed hematomas in the same location and often interconnected. Therefore, they can be removed together within the same surgical field, occasionally requiring brain puncture for detection. Another scenario is epidural hematoma accompanied by subdural or local intracerebral hematoma. When suspected, the dura must be incised to explore the subdural space or perform brain puncture, and the hematoma should be removed upon confirmation.
Removal of the same type of hematoma in different locations: More commonly seen are bilateral subdural hematomas, often occurring in the frontal, anterior temporal regions, or frontal and parietal convexities. Less common are bilateral temporal epidural hematomas. During surgical exploration and removal of such bilateral hematomas, the patient's head should be elevated in a supine position, and the disinfection and draping should accommodate the requirements for bilateral surgery. Generally, for acute bilateral hematomas, the side with brain herniation or the larger hematoma should be addressed first by performing a craniotomy to remove the hematoma, while the other side can be treated with drilling and drainage or expanded drilling to create an appropriate bone window for hematoma removal. For subacute bilateral hematomas, a single surgery with bilateral bone flap craniotomy can be performed, or the hematomas can be removed in stages based on their size. For chronic subdural hematomas, bilateral drilling and drainage are mostly used.
