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PubMed2003

Spinal subdural hematoma: a sequela of a ruptured intracranial aneurysm?

BACKGROUND: A case of spinal subdural hematoma (SSDH) following subarachnoid hemorrhage (SAH) because of a ruptured internal carotid aneurysm is described. Such a case has never been reported. CASE DESCRIPTION: A 52-year-old woman underwent a craniotomy for a ruptured internal carotid aneurysm. A computed tomography scan showed that SAH existed predominantly in the posterior fossa and subdural hematoma beneath the cerebellar tentorium. Intrathecal administration of urokinase, IV administration of fasudil hydrochloride, and continuous cerebrospinal fluid (CSF) evacuation via cisternal drainage were performed as prophylactic treatments for vasospasm. On the sixth postoperative day, the patient complained of severe lower back and buttock pain. Magnetic resonance imaging showed a subdural hematoma in the lumbosacral region. Although the mass effect was extensive, the patient showed no neurologic symptoms other than the sciatica. She was treated conservatively. The hematoma dissolved gradually and had diminished completely 15 weeks later. Her pain gradually subsided, and she was discharged 7 weeks later without any neurologic deficit. CONCLUSION: Although the exact mechanism of SSDH in this case is unclear, we speculate that this SSDH was a hematoma that migrated from the intracranial subdural space. Low CSF pressure because of continuous drainage and intrathecal thrombolytic therapy may have played an important role in the migration of the hematoma through the spinal canal. It is important to recognize the SSDH as a possible complication of the SAH accompanied with intracranial subdural hematoma.

Aneurysm, Ruptured↗
PubMed1989

Plasmin-alpha 2-plasmin inhibitor complex and alpha 2-plasmin inhibitor in chronic subdural hematoma.

Levels of the plasmin-alpha 2-plasmin inhibitor complex (PLN-A2PI complex) and alpha 2-plasmin inhibitor (A2PI) were determined by enzyme-linked immunosorbent assay (ELISA) with monoclonal antibodies in 59 patients with 66 chronic subdural hematomas (SDH's). Normal concentrations of the PLN-A2PI complex and A2PI in plasma are below 0.8 microgram/ml and 60.5 +/- 16.1 micrograms/ml, respectively (mean +/- 2 standard deviations). The hematoma fluid contained high concentrations of the PLN-A2PI complex (4.58 +/- 2.60 micrograms/ml) and low concentrations of A2PI (10.32 +/- 4.81 micrograms/ml), while both values in the plasma of 12 patients with chronic SDH's were within the normal range. This represents local hyperfibrinolytic activity in the hematoma. Stuporous or comatose patients had higher PLN-A2PI complex levels than did the alert and the drowsy or disoriented patients. The layering type of hematoma as seen on computerized tomography scans showed the highest PLN-A2PI complex levels among five types of hematoma. In the fluid drained postoperatively from the subdural cavities of chronic SDH's, both the PLN-A2PI complex and A2PI levels decreased gradually in healing cases. In two patients with hematoma reaccumulation after surgery, both levels increased. The postoperative increase of the PLN-A2PI complex represents the recurrence of intermittent cycles of fibrinolysis, bleeding, coagulation, and hemostasis in the subdural space.

Adolescent↗
PubMed1981

[A case of acute subdural hematoma in one-day-old baby--with special reference to its CT findings (author's transl)].

The authors describe and discuss a case of acute subdural hematoma originating from the lacerated tentorium of 22 hour-old newborn. CT scan revealed crescent high density area in the subdural space between the left frontal area and the occipital area. Another high density area was seen in the left occipital area which was suspected as intracerebral hematoma preoperatively because of its rather intramedullar location. Large craniotomy was performed 22 hours after delivery, evacuating 70 gm subdural hematoma. Bleeding point was determined as lacerated tentarium about 1 cm length. No intracerebral hematoma was found. Postoperative course was uneventful and he is showing normal development. It is now concluded that supratentorial subdural hematoma originating from tentorial laceration at delivery could be misdiagnosed as intracerebral hematoma on CT scan. Anatomical structure should be always compared when CT scan study is performed.

Acute Disease↗
PubMed1982

Meningeal relations of the rat hypothalamo-hypophyseal system. Extravascular fluid spaces in and around the median eminence.

Meningeal relations of the rat pituitary and basal hypothalamus including the pituitary stalk and median eminence, were studied by both light and electron microscopy, and by ink perfusion techniques. The dura mater encapsulates the pituitary gland. The arachnoid covers the basal surface of the hypothalamus except the caudal two-thirds of the median eminence and the pituitary stalk. No arachnoidea, i.e. no subarachnoideal space, was found in the sella. Pia mater covers the entire basal surface of the hypothalamus, including the median eminence and the pituitary stalk, but encapsulates only the posterior lobe of the pituitary. The superficial portal vessels (primary plexus and portal veins) are located in the subdural space, covered by the pia mater. The deep vessels in the median eminence are surrounded by the perivascular space, which is bordered by the vascular and neuropil basement membranes, and separated from the external fluid space around the median eminence only by the pia mater. This special topography suggests that molecules present in the portal vessels or in the cerebrospinal fluid, or in and around the pituitary gland, readily move from one liquid space to another.

Animals↗
PubMedDate not supplied

Cranial epidural empyema with osteomyelitis caused by actinomyces, CT, and MRI appearance.

Actinomycosis is an uncommon cause of intracranial infection. Epidural empyema represents about 6% of CNS actinomycotic lesions. A case of an epidural empyema with parietal bone osteomyelitis caused by Actinomyces israelii is presented. Relevant neuroimaging features were bone erosions and a multiloculated collection with annular contrast enhancing on CT. Postoperative MRI revealed extensive involvement of the neighbor dura, falx, and subdural space. MRI was crucial to follow-up the response to antibiotic treatment.

Actinomycosis↗
PubMed1975

[Experimental study on the lymphatic and cerebrocervical drainage and changes therein caused by ultrasound (author's transl)].

After indian ink or ferritin are introduced into the cerebral hemispheres or subdural space these substances can be found in the deep cervical lymph nodes. The transport of these substances can be enhanced and accelerated by the treatment of deep cervical lymph nodes by ultrasound. Treatment of the paravertebral region with ultrasound after the introduction of ferritin or indian ink subdurally is followed by the appearance of these substances in the suprarenal gland, the testis, epididymis and the prostate gland where they are conveyed by the lymphatic pathways. Thirty minutes after the injection of ferritin into an afferent lymphatic channel of a deep cervical lymphatic node pretreated with ultrasound, ferritin can be found in the pia and arachnoid membranes of the cerebral hemispheres. Ultrasound treatment of the cervical lymph nodes not only seems to enhance the drainage of this substance from the brain but if the dose of ultrasound is high the direction of the lymphatic flow may be reversed.

Animals↗
PubMed1981

Posterior fossa hemorrhages in the newborn.

Of 700 neonates examined by computed tomography (CT) in a 4 years period, 17 were found to have a posterior fossa hemorrhage. Eleven were born at term, and six were premature. Delivery was traumatic in 12 babies. The hematoma was in the subdural space in nine and within the cerebellum in eight. The CT diagnosis of extravasated blood in the posterior fossa is easy both in full-term neonates and prematures. The localization of the hematoma, however, may be difficult. While in the full-term neonates differentiation between subdural and intracerebellar location is relatively easy, in the premature the cerebellar hematoma frequently has a crescentic shape that resembles a subdural collection. Four patients with a subdural hematoma and four with a cerebellar hematoma were operated on. The general prognosis is poor: seven patients died; of the survivors, only three are normal at follow-up.

Cerebral Hemorrhage↗
PubMed2003

[A spontaneous bilateral subdural effusion in an 11-year-old boy with middle cranial fossa arachnoid cyst].

An 11-year-old boy gradually developed headache, vomiting and diplopia over a period of 1 month. Repeated examinations of head CT scan revealed an arachnoid cyst in the right middle cranial fossa and bilateral subdural effusion of enlarging size. Papilledema was absent on admission, but it became evident after 1 week, and lumbar puncture disclosed very high pressure (800 mmH2O) of the cerebrospinal fluid. Fenestration of the cyst to the basal cisterms quickly alleviated his symptoms of intracranial hypertension as well as the bilateral subdural effusion on CT. Macroscopically, there was a small tear on the wall of the arachnoid cyst, and it probably served as a communication valve with the subdural space. Since he had no history of head trauma in the past few months, the reason of the tear formation was unclear. Intracranial arachnoid cyst is a relatively common congenital malformation of usually benign and non-pathogenic nature. However, it may occasionally cause non-traumatic subdural effusion and intracranial hypertension.

Arachnoid Cysts↗
PubMed1983

Congenital hydrocephalus revealed in the inbred rat, LEW/Jms.

We studied the development of congenital hydrocephalus found in a colony of an inbred strain of Wistar-Lewis rats (LEW/Jms) at various intervals after birth. The disorder was transmitted as a simple recessive mendelian character. Hydrocephalic neonates were recognized 2 days after birth by stretching of the skin over the head. Death usually occurred between 10 and 20 days of age. The findings suggested the possibility of a disturbance of cerebrospinal fluid circulation resulting from primary occlusion of the 3rd or lateral ventricles during embryological development. In later phases, the hydrocephalus was aggravated by obliteration of the subarachnoid space and by stenosis of the aqueduct occurring secondary to compression of these structures from increased pressure within the brain. In some animals, external hydrocephalus occurred as a result of rupture of the occipital pole and the establishment of a direct communication between the lateral ventricles and the subdural space. We looked for antibodies against viruses that have been known to produce hydrocephalus in experimental animals and obtained entirely negative results.

Animals↗
PubMed2000

Juxtapositioning of the temporalis muscle for intractable subdural empyema in infants.

We present a case of refractory infantile subdural empyema secondary to pneumococcal meningitis. Initial treatment was with antibiotics and multiple burr hole drainage of the subdural space. As there was no significant improvement with this standard procedure, craniectomy, and juxtapositioning of the temporalis muscle was conducted and the patient recovered promptly.

Brain↗
PubMed2001

Surgical treatment of chronic subdural hematoma in 500 consecutive cases: clinical characteristics, surgical outcome, complications, and recurrence rate.

Chronic subdural hematoma (CSDH) is one of the most common clinical entities in daily neurosurgical practice. The diagnosis and treatment are well established, but recurrence, complications, and factors related to these problems, especially in the elderly, are not completely understood. This study evaluated the clinical features, radiological findings, and surgical results in a large series of the patients treated at the same institution. 500 consecutive patients (359 men and 141 women) with CSDH were treated by burr hole craniostomy with closed system drainage from January 1987 through February 1999. Causes, clinical and computed tomographic findings, surgical results, re-expansion of brain after surgery, and hematoma recurrence were statistically analyzed to elucidate the potential risks of CSDH. Most patients (89.4%) had good recovery, 8.4% showed no change, and 2.2% worsened. Six patients (1.2%) died, three due to disseminated intravascular coagulation. Recurrence of hematoma was recognized in 49 patients (9.8%), at 1 to 8 weeks (3.5 +/- 1.9 weeks) after the first operation. The brain re-expansion rate at one week after operation was 45.0 +/- 21.4% in patients with hematoma recurrence and significantly lower than 55.3 +/- 19.1% in patients without recurrence (p < 0.001). Old age, pre-existing cerebral infarction, and persistence of subdural air after surgery were significantly correlated with poor brain re-expansion (p < 0.001). Twenty-seven patients (5.4%) suffered postoperative complications, of which 13 cases were acute subdural hematoma caused by incomplete hemostasis of the scalp wound and four cases were tension pneumocephalus. Careful hemostasis and complete replacement of subdural hematoma by normal saline to prevent influx of air into the subdural space will further improve the surgical outcome for patients with CSDH.

Adolescent↗
PubMed1997

Chronic subdural hematoma: surgical treatment and outcome in 104 patients.

BACKGROUND: The common occurrence of chronic subdural hematoma (CSDH) in older patients raises some diagnostic and therapeutic difficulties. Despite general agreement about the indication of operation, the extent of surgery is still discussed controversially. We have, therefore, reviewed operative findings and outcome in 104 patients with CSDH. METHODS: Retrospective analysis was performed by differentiating age < or = 60 years (n = 28) versus age > 60 years (n = 76) and burr hole craniostomy with a size range from 12-30 mm (n = 94) versus larger craniotomy (n = 10). All patients received closed-system drainage of the subdural space for 2-4 days. RESULTS: Four patients older than 60 years died within 30 days after surgery, two in each operative group. Excluding these postoperative deaths, 17 out of 92 patients (18.5%) after burr hole trepanation and one out of eight patients (12.5%) after craniotomy required reoperation due to rebleeding (n = 6), residual subdural fluid (n = 4), and residual thick hematoma membranes (n = 8). Eight patients, who had been initially treated by burr hole craniostomy despite preoperative detection of neomembranes by contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI), recovered without further intervention. Clinical outcome was good in both operative groups. The percentage of patients without or with only mild neurologic deficits at the time of discharge from the hospital was 72.3% in the burr hole and 70.0% in the craniotomy group, respectively. CONCLUSIONS: The clinical data of the present study suggest that burr hole craniostomy with closed-system drainage should be the method of choice for the initial treatment of CSDH, even in cases with preoperative detection of neomembranes. Craniotomy should be carried out only in patients with reaccumulating hematoma or residual hematoma membranes, which prevent reexpansion of the brain.

Adult↗
PubMed2001

Interhemispheric subdural empyema--case report.

We report a case of interhemispheric subdural empyema following a meningoencephalitis. Ten days after the beginning of his illness a CT scan showed a left interhemispheric subdural empyema with a low density collection, a faintly enhancing rim, multiple very small cortical abscesses and brain edema. The empyema was successfully treated by the direct introduction of a catheter into the left interhemispheric subdural space via a single posterior frontal parasagittal burr hole, irrigation with saline, aspiration of the empyema, and removal of the catheter at the end of operation.

Brain Abscess↗
PubMed1988

Posttraumatic cerebral atrophy as a risk factor for delayed acute subdural hemorrhage.

It has long been appreciated that chronic alcoholics and the elderly with generalized cerebral atrophy are at increased risk for the development of acute subdural hematomas. The reported incidence of cerebral atrophy after severe head injury is significant. However, the incidence of late morbidity and mortality from acute subdural hematoma is not well documented. Acute subdural hemorrhage is attributed to rupture of bridging cerebral veins. In the presence of cerebral atrophy, the bridging veins are stretched and traverse a greater distance in the subdural space. They are therefore more susceptible to tearing with minor trauma. In addition, there is a delayed tamponade effect since the atrophied brain is shrunken away from the inner table of the skull. A case report is presented which suggests that survivors of severe head injury may be at increased risk for the development of acute subdural hematomas from relatively minor injuries months or even years after their initial trauma.

Adult↗
PubMed1995

[CT-epidurography. A comparison of conventional and CT-epidurography with contrast medium injection through a thoracic peridural catheter].

Epidurography with contrast medium is used to verify the correct position of an epidural catheter and to detect malpositioning. There is great variability in the distribution of contrast medium according to the individual morphology of the epidural space and the way it is injected. Results of investigations of the anatomy of the spinal canal and epidural space performed with anatomic specimens, epiduroscopy, and conventional and computed tomographic (CT) epidurography are sometimes contradictory. We have performed CT epidurography in approximately 30 patients to date. Insights regarding the distribution of contrast medium in the epidural space can help to interpret conventional epidurographies and to explain special features, such as the "rail-road-track phenomenon" or the plica mediana dorsalis. METHODS. Patients scheduled for major abdominal operations were studied. Catheters were introduced into the thoracic epidural space on the day before the operation. Conventional epidurographies were performed routinely after insertion of the catheters with a mobile X-ray apparatus, usually in the recovery room, using 5 ml iopamidol (Solutrast 250 M). Selected patients (good mental state and stable psychic condition), after written consent and with approval of the local ethical committee, were investigated with CT epidurography using the same contrast medium (partly diluted). From among the CT scans performed until now, five characteristic images are presented and compared to conventional epidurographies. RESULTS. When small volumes (5 ml) of iopamidol were injected slowly, we regularly observed a railroad-track phenomenon in the AP images of conventional epidurographies. After rapid injection of larger volumes (10-15 ml), the spread was more homogeneous and sometimes outline a lighter zone of contrast distribution in the midline. CT epidurography in these cases (5 out of 30 patients) revealed a plica mediana dorsalis. In the majority of the CT scans of the thoracic epidural space its anterior (ventral) compartment was unfilled by contrast medium. According to the findings of several investigators, dura mater and ligamentum longitudinal posterius have grown together, so that an epidural space does not exist in ventral thoracic segments of the spinal canal. In lower thoracic and lumbar segments both structures are separate, and a wide anterior epidural space was present and filled with contrast medium. In other cases the dorsal and dorsolateral epidural space was completely filled, but the contrast medium stopped behind the spinal nerves and surrounding dural sheaths, as if these structures, together with the connective tissue strands between them, formed a membrane that spread in a frontal plane. A railroad-track phenomenon is interpreted in the literature as the X-ray correlate of contrast medium spread in the subdural space, indicating an incorrect catheter position. According to conventional epidurographies and confirmed by CT scans, this feature is also seen regularly in cases with correct catheter position. Small volumes of iopamidol spread preferentially into the wider parts of the epidural space between the gaps of the vertebral arcs, whereas the dura mater and periosteal layers touch at the inner side of the pedicules and laminae, allowing the existence of only a potential epidural space. This rhythmic widening and narrowing of the epidural space is the explanation of the "railroad track" in AP contrast epidurographies. CONCLUSIONS. CT epidurography is a valuable tool to provide better insight into the morphology of the epidural space when filled with fluid (contrast medium, local anaesthetics), complementing findings using epiduroscopy and anatomic specimens. It stands to reason that this time- and cost-expensive method can never replace conventional epidurographies, but can help to interpret them properly.

Adult↗
PubMed1986

Ruptured intracranial aneurysms as a cause of subdural haematoma. Potential diagnostic pitfalls and the surgical management of the acute patient.

Seven cases of aneurysms that ruptured into the subdural space and were treated surgically are reviewed. Six out of the seven presented with signs of uncal herniation, three of them for at least for four hours or more. They all died in spite of urgent decompression and drainage. Three others suffered from uncal herniation for less than four hours and they all did well. The seventh patient had a small subdural haematoma with no signs of compression of the underlying neural structures. This last patient also had a good outcome. The authors point out that the aneurysm causing the haematoma might be overlooked should one utilize CT (computerized tomography) scan alone without contrast. However, in most instances the history gives the aneurysm diagnosis despite the CT scan of haematoma only. Intravenous contrast CT scan may occasionally demonstrate the aneurysm, provided modern CT equipment is adequately utilised. Severe neurological deficit and uncal herniation might still be reversible provided decompression can be carried out in less than four hours. If accessible the aneurysm should also be clipped at the same time.

Adult↗
PubMed2002

Fulminant subdural empyema treated with a wide decompressive craniectomy and continuous irrigation--case report.

A 56-year-old male presented with fulminant subdural empyema manifesting as rhinorrhea, periorbital cellulitis, fever, convulsions, and consciousness disturbance. Neuroimaging showed pansinusitis with skull destruction and extensive subdural empyema. Decompressive craniectomy, irrigation of the empyema, and subdural drainage were performed. Endoscopic sinus surgery was performed to remove the source of infection at the same time. Streptococcus milleri was cultured from the pus. Continuous irrigation of the subdural space with saline containing gentamicin for 7 days resulted in prompt elimination of pus and debris. The patient was discharged with only a slight neurological deficit.

Craniotomy↗
PubMed2001

[Extraaxial primary malignant lymphoma associated with calcified chronic subdural hematoma: a case report].

The authors report the case of a 54-year-old male with extraaxial primary malignant lymphoma associated with calcified chronic subdural hematoma. He slowly developed progressive headache accompanied by a bulge in the left forehead. Skull radiogram showed a large biconvex calcification in the left frontoparietal region, with concave change in the overlying bone. Computed tomograms and magnetic resonance images revealed a left frontoparietal chronic subdural hematoma surrounded by a calcified rim, with marginal enhancement in the frontal portion extending upward to the subcutaneous tissue through the underlying bone. The lesion was suspected to be an infectious calcified hematoma. The patient underwent a craniotomy for the removal of the hematoma. It was observed that the tumor was located mainly in the epidural and subdural space. The extent of the tumor corresponded with the enhanced area of the lesion in the preoperative neuroimages. The histological diagnosis was malignant lymphoma of B cell origin. General examination, which included bone marrow study and Ga scintigraphy, failed to prove systemic lymphoma. Extraaxial primary malignant lymphoma is extremely rare, and this is the first report of a lymphoma associated with calcified chronic subdural hematoma. The authors review the literature and discuss the clinical features and the pathogenesis of the lesion.

Brain Neoplasms↗