Chronic Subdural Hematoma: Observation Of Ultrastructure Features Of The Outer Membrane And Changes In Circulating Endothelial Progenitor Cells, And Analysis On Clinical Characteristics

PART ONE:Observation of ultrastructure features of the outer membrane of chronic subdural hematoma[OBJECTIVE] Observed the ultrastructure of outer membrane of CSDH and explored the pathological and pathophysiological basis of the development and progression of CSDH. [METHODS] A total of 8 outer membranes of CSDH samples were selected. Routine light microscopy and electron microscope were used to observe the tissue ultrastructure. [RESULTS] The outer membrane of the hematoma capsule contained numerous macrocapillaries with a wide vascular lumen. The endothelial cells of those macrocapillary were weak, discontinous or partially dissolved. Scattered red blood cells in the extracellular space were found and this indicated bleeding had occurred within the outer membrane. Esoinophils increased and the granules within the cellular cytoplasm enlarged. Neutrophils and macrophages also presented in some specimens. Fibroblast show a significantly proliferation and activation state. [CONCLUSION] There are abundant newly formed vascular networks in the outer membrane of CSDH, Neomembrane formation, neovascularization and repeated micro-haemorrhages from these fragile new vessels maybe play a key role in the development and progression of CSDH.PART TWO:Changes in circulating endothelial progenitor cells of chronic subdural hematoma[OBJECTIVE] Through the study about circulating endothelial progenitor cells of CSDH patients, explored the the development mechanism of the fragile macrocapillary of the outer membrane of CSDH, and the etiology of CSDH. [METHODS] Collected blood samples of 48 consecutive patients who aditted to General hospital of Tianjin medical university for surgical management of CSDH and 16 health volunteer who older than 60 years. The numbers of circulating EPCs were measured by flow cytometry. Explored the change of EPCs and investigate the relationship between EPCs and etiology, prognosis and postoperative recurrence of CSDH. [RESULTS] The average number of the circulating EPCs were significantly decreased in CSDH patients as compared with control group (59.0±69.5/200,000 mononueletic cells versue 34.0±28.5/200,000 mononueletic cells P<0.05).The average number of the circulating EPCs was significantly lower in recurrent patients than in nonrecurrent patients (18.5±25.25/200,000 mononueletic cells versue 35.5±28.5/200,000 mononueletic cells P<0.05). [CONCLUSION] The decrease of circulating EPCs maybe correlate with the aetiology and postoperative recurrence of CSDH. We herein hypothesize the decrease of circulating EPCs maybe play an important role on the development and progression of CSDH:When some cause, such as minor trauma, dissect the layer of dural border cells and formed virtual subdural space, blood and/or cerebral spinal fluid will accumulated in such space as a foreign material and triggered local inflammatory reaction. The formation of neomenbrane and new vessels may be occurring under such physiological or pathological conditions. The aim is absorbing those foreign materials. Circulating EPCs is a source of cells that can participate in the development of new vessels and dynamic maintenance the integrity of vascular system. The decreased numbers and diminished functional capacity of circulating EPCs will result in the structural and functional defect of newly formed vessels. Perivascular leakage of blood substance ocurred easily and repeatedly on such pathological and pathophysiological basis, then a vicious cycle may develop and this may contribute to the development and enlargement of CSDH.PART THREE:Analysis on clinical characteristics of chronic subdural hematoma[OBJECTIVE] To describe the clinical epidemiologic characteristics of chronic subdural hemotoma (CSDH) and provide the scientific basis for prevention, diagnosis, treatment and prognostic evaluation. [METHODS] Reviewed the traumatic brain injury database of general hospital of Tianjin medical university and a retrospective analysis on the clinical characteristics, causes, surgical results, complication, and the factors related to prognosis and recurrence rate of 150 cases of CSDH was done. [RESULTS] The hematoma volume of the patients with poor outcome is significantly more than with good outcome. Age, sex, single or double side had no significantly influence to outcome. But patients with brain atrophy, cerebral infraction, shift of midline and postoperative complications had a significantly higher rate of poor outcome. Multivariate logistic regression analysis show postoperative complication, midline shift and bilateral CSDH were risk factor of poor outcome. Modified Markwalder scale was related to patient's age, hematoma volume and surgical result. Recurrence of CSDH was significantly associated with bilateral CSDH. Hematoma volume of the patients in the recurrence group was more than that in the non-recurrence group. Age older than 80 years and brain atrophy were was an independent risk factor for the recurrence of CSDH. The density of hematoma on CT correlated with recurrence. The incidence of CSDH recurrence in the high-density groups was significantly higher than those in the low- and iso-density groups. [CONCLUSION] Age, hematoma volume, the density of hematoma on CT were significantly correlated with surgical result and recurrence of CSDH. A detailed clinical and radiological evaluation is very important for the treatment and prognosis of CSDH.