A suggestion for diminishing the amount of gas introduced into the subdural space during lumbar pneumoencephalography.
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The long-term administration of nitrous oxide anesthesia during craniotomy as well as following closure of the parietal craniotomy flap (under no tension) leads to significant expansion of the residual air bubble trapped under the dura. A case is presented in which an extracerebral avascular space, filled only with gas, caused a marked shift of the intracranial structures and uncal herniation secondary to nitrous oxide anesthesia during craniotomy and postcraniotomy angiography.
Quite a number of cases of upward shunt migration have already been reported in the literature. The authors report the case of a newborn boy who presented a sequential alternate change of pressure gradients based, according to their opinion, on fields of pressures exerted by fluids in different compartments of the patient's body. The authors propose a physicoanatomical explanation on the basis of the surgical findings.
The author describes a conical sub-dural space above the vermis limited in front by Galien's ampulla, behind by the right venous sinuses and, below by the superior cerebellar vein. This space, which is not filled with air injected by the cisternal route, is only shown in lateral views thanks to its venous outlines. In cases of raised intracranial pressure, the superior cerebellar vermis may occupy this space so that a sort of impaction occurs at this level, which the author proposes calling smaller than superior vermial impaction greater than. Among forms of cerebral herniation, vermial impaction may not occur when the CSF obstruction occurs at another level.
Post-traumatic or spontaneous rupture of an arachnoid cyst resulting in a subdural haematoma is rare. Much more rarely, a ruptured arachnoid cyst may be present with a subdural CSF collection without evidence of haemorrhage. These are most commonly seen in the middle cranial fossa, where arachnoid cysts occur most frequently. In this paper, five teenage patients (four male, one female) are reported with post-traumatic or spontaneous arachnoid cyst ruptures, resulting in subdural haematomas in four patients and a subdural CSF collection without haemorrhage in one patient. Possible pathogenesis of the condition is discussed.
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A 75-year-old man on anticoagulant therapy suddenly experienced an excruciating back pain and subsequently developed a paraplegia. At operation a subarachnoid and a subdural haematoma were found, extending between the levels of the vertebrae T3 and L2. This extremely rare combination of haematomas may have been caused either by rupture of a small vessel in the arachnoid membrane or by rupture of the arachnoid membrane itself, secondary to a massive haemorrhage in the subarachnoid space.
Electron microscopic data on human bridging veins show thin walls of variable thickness, circumferential arrangement of collagen fibres and a lack of outer reinforcement by arachnoid trabecules, all contributory to the subdural portion of the vein being more fragile than its subarachnoid portion. These features explain the laceration of veins and the subdural location of resultant haematomas.
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