1 case of hematoma under the epidural after surgery of the skull bile lioma.

!----, or epidermal cyst, is found in the corner region of the bridge cerebellum and rarely originated in the skull;Changshu City Second People's Hospital recently admitted a case of right frontal cranial biliary lipidoma patients. Aftersurgery to remove the tumor, the epidural was complete and hematoma under the epidural was performed;the clinical data of patients are summarized and analyzed, and the relevant literature is reviewed to explore the clinical characteristics and possible pathogenesis of hematoma and possible pathogenesis after the surgery of cranial biliary lioma.1. Clinical data patients, male, 55 years old.was admitted to hospital in December 2017 for "two months of right tinnitus."patients from two months before admission, there is no obvious cause of right tinnitus.body: the skull is normal in shape, nervous system examination did not see abnormal.head CT examination: low density occupaposition on the right front (Figure 1A).the skull MRI examination shows that the right side of the forehead is occupied, for bone source, T2WI is a high signal, T1WI is a low signal, mixed bar rope-like high signal, DWI dispersion is limited;preoperative diagnosis: right frontal bone tumor.a craniofacial tumor removal.Figure 1 Patient preoperative imaging examination.A: Skull CT; B: Skull MRIT2WI; C:MRIT1WI; D:MRI enhancement scan at full mahjong, right forehead vent spout, bone valve.the outer plate of the skull in the right forehead is thin, the inner plate is damaged by erosion (Figure 2A); the tumor tissue is white viscous tofu slag-like, with thin layers of sac wall, most of which is clearly bound to the epidural, less or herding with the epidural; and the tumor tissue has no blood supply except the sac wall (Figure 2B).the tumor tissue, together with the envelope, all removed, the epidural intact, bone valve grinding after the erosion part to reset;the 2d drain tube after surgery, no obvious drainage, to be removed. The post-pathology examination of tumor tissue was cranial biliary lioma (Figure 3).figure 2 seen during the operation.A: the invaded skull outer plate thinned, inner plate erosion damage; B: tumor tissue is white viscous tofu slag sample, there is thin layer sac wall map 3 tumor pathology examination (HE staining, x 200) after the 3d patients appear consciousness disorders;is the line skull drilling under-dura hematoma removal, the operation sees sub-dura hematoma for non-solidified dark red blood and brown-yellow water samples, there is false envelope formation, gray-white gel-like, the inner layer is covered on the surface of the brain, the outer layer is located in the epidural inner plane, a small amount of bleeding.hematoma culture is bacteria-free.the patient's consciousness disorder after hematoma removal gradually returned to normal; after 1 week, the CT was examined, the hematoma under the epidural of the right forehead was significantly reduced; and hematoma was discharged from the hospital.half a month after discharge, the patient reviewed CT show hematoma fully absorbed, the state of consciousness is normal.Figure 4 After tumor removal, the 3d skull CT review shows the hematoma under the epidural of the right frontal temporal cortex 2. The discussion of cranial biliary lipidoma is formed by the tissue of the outer embryo layer to the skull during embryonic development.primary skull biliary lioma is rare, the tumor is mostly located in the front and forehead of the front of the tibia, mostly originated in the plate barrier. the tissue structure of thetumor consists of a thin layer of sac wall and sac content, the sac wall is composed of a complex scaly epithelial and thin layer connective tissue, the contents of which are angular peeling epithelial, cheese-like substances, cholesterol crystallization.before early skull damage, patients generally have no clinical symptoms, tumors such as inward growth can appear brain tissue compression symptoms, seizures, etc. , outward growth, can appear skull swelling, defects, infected sinus, etc.CT examination showed that the tumor was low-density, even lower than cerebrospinal fluid; the inner and outer plate of the skull expanded thinning, the adjacent skull was trumpet-like, the boundary was clear, the edges could harden; and the tumor was not enhanced.MRI examination, tumor in T2WI for significantly high signal, T1WI signal variability, mainly related to content composition, cholesterol crystallization on CT is uniform low density, in T1WI is uniform low signal, keratatand and high protein components on CT slightly higher, equal, slightly lower mixed density, in T1WI for high signal shadow.the diagnosis of cranial bilioma according to the characteristics of the components of the sac and the characteristics of the skull, but with eosinophily granoma, skull cytomegalooma, dermal cysts, hemangiomas and metastatic tumors.eosinophilic granuloma is often more frequent, the size of the skull map-like defects, defects in the area has "button-like" dead bone signs.cranial cytomegaloblastoma is good at the tibia and butterfly bones, occasionally seen in the top bone and forehead bone, CT performance is mostly expansionary growth; skin-like cyst contains Vaseline-like lipid substances, the density on CT is lower, MRI is short T1, wall thickness can appear calcification. the osteoblastoma damage area of hemangioma, MRI-enhanced scan scans were significantly enhanced, and the blood vessels in the large intracranial can be seen to enter the tumor area. the cranial osteoblastoma, combined with the medical history of diagnosis is not difficult. the patients in this case do not meet the diagnostic criteria for chronic subdural hematoma in the onset time, but according to the CT performance before and after surgery, the recovery after surgery, are in line with the pathological changes and return of chronic subdural hematoma. the vast majority of chronic subdural hematoma is related to minor head trauma, non-injury chronic subdural hematoma is relatively rare, may be related to cerebrovascular lesions, inflammation to produce a variety of inflammatory factors, the exact mechanism is not completely clear. in the pathological manifestations, chronic sub-epidural hematoma has two walls inside and outside, the inner layer is collagen, no blood vessels, the outer layer is also collagen substance, containing incomplete walls of capillary blood vessel seismology, prone to blood cell leakage; is currently considered to be an inflammatory disease, in which inflammatory factors, chemogenesis factors and angiogenesis factors and other inflammatory factors, may be the key factor swelled by the formation of chronic subdural hematoma. studies found that the levels of inflammatory factor sylocutonin (IL-6, IL-8, IL-10) in hematoma fluid were significantly higher than peripheral blood, and the expression of vascular endotheliotherin growth factor (VEGF) in the outer membrane of the hematoma cavity also increased significantly; also found that the hematoma in the venom of angiogenesis-related factors placental growth factor (PIGF), VEGF, fibroblast growth factor (bFGF), matrix metalloproteinase (MMP) expression levels significantly increased, hematoma epidural serotones (angiogenin, Ang) 1, Ang-2m RNA increased, indicating an increase in new angiogenesis. expression of cCL2, CXCL8, CXCL9 and CXCL10, which regulate sedative response and vascular generation in hematoma fluid, also increased. a multi-center double-blind control trial showed that the anti-inflammatory drug dexamethasone can effectively reduce the recurrence of chronic subdural hematoma after surgery. in addition, , hematoma coagulation dysfunction, such as hematoma fluid and tissue-type lysozyme activators, fibrin degradation products and thrombosis-regulating protein levels increased significantly, while coagulation factors II, V.VIII, and levels decreased. the diagnosis of cranial biliary lioma was clearly determined in the patient's diagnosis based on preoperative CT and MRI examination and post-combined pathology. the integrity of the epidural, a short time after surgery appeared sub-epidural hematoma under the bone valve; studies have found that biliary glioma tumor cells can express and produce a variety of inflammatory-related substances, participating in the inflammatory response. the pathogenesis of patients in this case may be, after surgery, epidural tumor envelope rupture, content leakage, leakage of the substance has an inflammatory factor, contact with the epidural, stimulate the epidural sterile inflammation, the emergence of septic sterile inflammation, oozing, and the formation of inflammatory pseudovascular envelope; , therefore, the craniofacial bilioma excision should try to maintain the integrity of the tumor envelope, the implementation of the outer membrane complete removal, and reduce the membrane residue; , after surgery, the normal dynamic examination of the skull CT, vigilance after surgery and post-duranhema. once the occurrence of hematoma under the epidural, if necessary, should be timely cranial bone drilling hematoma removal surgery; .