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PubMed2003

Carbon dioxide insufflation for chronic subdural haematoma: a simple addition to burr-hole irrigation and closed-system drainage.

Burr-hole irrigation with closed-system drainage is a common surgical method used for chronic subdural haematoma. However, the subdural space with air that entered during surgery sometimes remains for a prolonged period after surgery and may hamper uncomplicated healing of the subdural space. We combined a simple procedure, insufflation of carbon dioxide (CO2) into the subdural space through a drainage catheter, with conventional burr-hole irrigation and closed-system drainage. By this additional procedure, both the subdural space and the gas within the space decreased rapidly, and the subdural drain could be removed within 24 h. By promoting obliteration of the subdural space, this simple combined technique may contribute to early recovery and discharge of patients, and to a reduction in the recurrence rate of the disease.

Aged↗
PubMed1997

Arachnoid cyst rupture producing subdural hygroma and intracranial hypertension: case reports.

OBJECTIVE: To analyze the association between arachnoid cysts and subdural hygromas. METHODS: We reviewed five cases of arachnoid cysts that ruptured, producing acute subdural hygromas. The surgical management and diagnostic methods used are assessed. RESULTS: Five male patients ranging in age from 6 to 25 years sustained the rupture of arachnoid cysts, which produced acute subdural hygromas. Four of the patients had incurred blunt head trauma. All patients presented with symptoms referable to intracranial hypertension. The pathognomonic features of a middle fossa arachnoid cyst (MFAC) were noted on the computed tomographic scans and/or magnetic resonance images of each patient. The hygroma exerted mass effect on the ipsilateral hemisphere and was noted to be under significant pressure at the time of surgical intervention in each case. Two of the five cases are unique in the literature. In one, a coexisting quadrigeminal cyst ruptured, producing a subdural hygroma ipsilateral to the MFAC and dilating the basal cisterns. In the other, the MFAC ruptured into the basal cisterns as well as into the subdural space. The MFAC in each of the remaining three patients ruptured into the subdural space alone. All patients were treated with drainage of the subdural space. In the two patients in whom the basal cisterns were involved, both the hygromas and the MFACs failed to change significantly in size. The hygromas resolved completely and the MFACs decreased in size considerably in the three patients without cisternal involvement. CONCLUSION: The rupture of an arachnoid cyst can produce a subdural hygroma and intracranial hypertension. The latter mandates emergent drainage of the subdural space. In patients in whom the basal cisterns are not dilated by cyst rupture, both the MFACs and hygromas resolve after subdural drainage.

Adolescent↗
PubMed2000

Relationship between drainage catheter location and postoperative recurrence of chronic subdural hematoma after burr-hole irrigation and closed-system drainage.

OBJECT: This study was conducted to determine the best position for the subdural drainage catheter to achieve a low recurrence rate after burr-hole irrigation and closed-system drainage of chronic subdural hematoma (CSDH). METHODS: The authors studied 63 patients with CSDH in whom the drainage catheter tip was randomly placed and precisely determined on postoperative computerized tomography (CT) scans and 104 patients with CSDH in whom CT scans were obtained 7 days postsurgery. The location of the subdural drainage catheter, the maximum postoperative width of the subdural space, and the percentage of the ipsilateral subdural space occupied by air postoperatively were determined and compared with the postoperative recurrence and reoperation rates. Patients with parietal or occipital drainage had a higher rate of CSDH recurrence and much more subdural air than those with frontal drainage. In addition, patients with residual subdural air demonstrated on CT scans obtained 7 days postsurgery also had a higher recurrence rate than those without subdural air collections. Furthermore, patients with a subdural space wider than 10 mm on CT scans obtained 7 days postsurgery had a higher recurrence rate than those with a space measuring 10 mm or less. CONCLUSIONS: The incidence of postoperative fluid reaccumulation seems to be reduced by placing the tip of the drainage catheter in the frontal convexity and by removing subdural air during or after surgery.

Adult↗
PubMed1980

Improvements in the radiotherapy of medulloblastoma, 1946-1975.

The prognosis in medulloblastoma has often been reported to be gloomy, and five-year survival rates of approximately 25% are often reported. In recent years, however, some centers have published results that indicate a possible cure rate of 60% or even more. During the years 1946-1975, 50 children received radiotherapy for medulloblastoma at the University Hospital, Lund, Sweden. During this period the target volume had been defined in three different ways, whereas the target-absorbed dose had not differed. When only the demonstrated tumor was treated, the ten-year survival rate was 5%. If the spinal subdural space also was included, it rose to 25%, and when the whole subdural space was treated in addition to the demonstrated tumor, the projected ten-year survival rate was 53%. It is apparent that the target volume in the radiotherapy of medulloblastoma should include not only the demonstrated tumor but also the whole subdural space from the tip of the frontal lobes down to and including the second sacral segment. The size of the target-absorbed dose to be aimed at is not settled, but should consider not only the cure rate but also the performance status of the survivors. It seems from the present series that an absorbed dose of 45 Gy in not more than 30 fractions over six weeks to the demonstrated tumor and 30 Gy in 20 fractions over four weeks to the subdural space resulted in a fair frequency of tumor healing and minimal side effects. The delivery of this complicated treatment demands a high degree of precision in the technique. In this material the performance status of the children was not affected by the radiation treatment.

Adolescent↗
PubMed1996

Subdural hemorrhage of the cauda equina. A rare complication of cerebrospinal fluid shunt. Case report.

We describe the case of a 16-year-old boy with idiopathic hydrocephalus, who developed cranial subdural hygromas and subsequent cranial subdural hemorrhage after a shunting procedure. Sciatica and radicular lumbar pain initially seemed to be unrelated to the proceeding implantation of a ventriculoatrial shunt. CT scan revealed a sharply demarcated hyperdensity in the lumbar subdural space with compression of the cauda equina. Differential diagnosis considerations included vascular malformations, vascular tumors, benign tumors of meninges or nerve sheets, ependymoma, lymphoma, and metastases. MR investigation did, in fact, clearly recognize this hyperintense space-occupying lesion as blood in the subdural space which outlined the cauda equina. We believe that the spinal subdural hematoma in our case represented an extension of intracranial subdural haemorrhage fluid into the spinal subdural space.

Adolescent↗
PubMed1990

[Repeated inadvertent subdural catheterization: a case report].

We had a patient who had repeated inadvertent subdural catheterization. Eighty-two year old woman with post herpetic neuralgia had a continuous epidural anesthesia for the relief of pain. An epidural catheter was inserted at the Th 5-6 interspace using a paramedian approach. Fifteen minutes after 4 ml test dose of 1% lidocaine injection, she developed circulatory depressions and massive sensory block. The exact position of the catheter and the distribution of the local anesthetic agent were confirmed by radiographic contrast material. The catheter was observed in the subdural space. Anesthesia was therefore continued with an injection of 1.5 ml mepivacaine. After one month, epidural catheterization was done in the same patient. The catheter was inserted in subdural space again. The subdural injection has been implicated in a case in whom there has been extensive spread of an epidural block. The diagnosis of subdural block can be made by a subsequent injection of contrast medium, since an unusual clinical course might be seen. Subdural space has a poor blood supply, and injected medium may stay in this space for considerable period of time. Subdural catheterization in epidural anesthesia probably occurs more frequently than previously recognized.

Aged↗
PubMed2000

A theoretical model of benign external hydrocephalus that predicts a predisposition towards extra-axial hemorrhage after minor head trauma.

INTRODUCTION: There is controversy over whether there exists a predisposition towards bleeding into the subdural space in infants with benign external hydrocephalus (BEH) or other enlargement of the extra-axial space (e.g. subdural hygroma). The presumed etiology implicates shear forces in over-stretching the extra-axial blood vessels. We have created a model of the intracranial space that approximates certain aspects of BEH. Using this model, we predict situations where children with BEH will bleed into the extra-axial space when normal infants will not. METHODS: The cranial model consists of two spheres representing the brain and the skull. The distance between them represents the width of the extra-axial space. The spheres are concentric (with interspheric distance equal to N) in the normal condition and nonconcentric in BEH. In BEH, the distance between the two spheres varies from N to Q (0 < N </= Q) over a 906 M </= Q, with the translation orthogonal to the vector of N and parallel to that of M or vice versa), then the final length V(f) of a vein V is V(f) = (N(2) + M)(1/2), and the stretch ratio V(f)/V(i) is: V(f)/V(i) = (N(2) + M(2))(1/2)/N.S(i), with S(i) the slack factor, where i represents either n for normal or b for BEH and M = N in the normal condition. RESULTS: Given an equivalent capacity of veins to resist stretch injury (based on the proportion of change in length), for brain translations after a low-impact head injury, stretch ratios for BEH veins range from 1.677 to 3.436, whereas in the normal condition they range from 1.061 to 1.179. Therefore, for an increase in subarachnoid space from 3 (normal) to 6 mm (BEH), brain translocation in BEH will stretch veins beyond an average breaking point when the translation for the normal condition will not. CONCLUSIONS: Mathematical modeling of the cranial vault produces a relationship between venous stretch and the width of the extra-axial space. These equations predict an increased frequency of venous stretch injury in the situation of widened extra-axial space. Such venous injury is consistent with forces generated by minor trauma. This relationship, as predicted by our model, could underlie a predisposition towards extra-axial bleeding after minor head trauma in infants with BEH.

Biomechanical Phenomena↗
PubMedDate not supplied

CT and MR in infants with pericerebral collections and macrocephaly: benign enlargement of the subarachnoid spaces versus subdural collections.

PURPOSE: To compare CT and MR in the differentiation of benign enlargement of the subarachnoid spaces and subdural collections in infants with macrocephaly. METHODS: MR was performed in 19 infants with macrocephaly, showing bifrontal enlargement of the subarachnoid spaces on CT. RESULTS: In 11 patients, a single fluid layer could be distinguished on MR of the pericerebral collections, suggesting benign enlargement of the subarachnoid spaces. In eight patients, two separate layers were clearly differentiated, an outer layer that was hyperintense on all sequences and an inner layer with the same intensity as the cerebrospinal fluid. This indicated the presence of subdural collections. These collections were mainly frontal in six and extended over the entire hemisphere in two patients. On CT, these separate lesions were seen only in three patients and missed in three others. In two final patients, CT findings were equivocal with evidence of membrane formation within the hypodense collections. In seven patients with a subdural collection, subdural-external drainage was performed. In three patients, the collection was hemorrhagic. The protein content of the fluid showed a mean of 1381.7 +/- 785.6 mg/dL. The MR and surgical findings of a subdural collection correlated with the absence of a family history of macrocrania, an age under 5 months, and acute clinical signs of vomiting, somnolence, and hypotonia. CONCLUSION: MR appears essential in the differential diagnosis between benign enlargement of the subarachnoid spaces and subdural collections in infants.

Brain Diseases↗
PubMed1992

[A pathogenesis of chronic subdural hematoma; it's relationship to subdural membrane].

Our report concerns 112 cases of chronic subdural hematoma (CSH). M:F ratio is 3.5:1. (Fig. 1). The etiology of CSH is as follows; mild head injury (71 pts.), post-craniotomy (3 pts.), post-V-P shunt (1 pt.) and unknown (37 pts.). All patients are diagnosed by CT scan. Twenty patients were followed up after the subdural space was expressed as low density on CT (Fig.2). 14 of these were found to have extremely thin subdural fluid collection without compression of the brain. Cisternography by using radioisotope and/or metrizamide was carried out in seven patients in whom the subdural fluid collection was found on CT, and in five of whom the dye flowing into the subdural space was retained for 24-48 hours (Fig. 3 a). For treatment, burr holes and irrigation of the hematoma was carried out and then a drain was inserted into the subdural space. The inner membrane of the chronic subdural hematoma was looked at in 19 patients during surgery. All but one showed the inner membrane totally covering the brain surface. However, in one patient the inner membrane didn't entirely cover the brain surface, suggesting that this was the condition just before the entire encapsulation of the hematoma (Fig. 4 b). It used to be considered that a blood clot in the subdural space is needed to develop a chronic subdural hematoma. However, since the introduction of CT scan, there have been many reports suggesting that chronic subdural hematoma has developed from subdural fluid collection without apparent evidence of blood clot after head injury. Therefore, it has been controversial whether the blood clot is absolutely essential to develop into the chronic subdural hematoma or not.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1996

Pericerebral fluid collection: differentiation of enlarged subarachnoid spaces from subdural collections with color Doppler US.

PURPOSE: To determine if the cerebral cortical vain sign seen on magnetic resonance (MR) images can be used with color Doppler ultrasound (US) to differentiate enlarged subarachnoid space from subdural collection. MATERIALS AND METHODS: Eighteen infants with pericerebral fluid collection were prospectively examined with color Doppler US and MR imaging. Patients were classified into two groups: group A, with positive cortical vein sign (visualization of color-coded cortical veins that cross fluid collections at cerebral convexities); and group B, without the sign. RESULTS: Positive cortical vein sign was seen at US in 12 patients (group A): nine with benign enlargement of subarachnoid spaces, two with brain atrophy, and one with meningococcal meningitis. The veins were displaced and embedded within the echogenic pia-arachnoid that surrounds the brain or were trapped in the subarachnoid spaces between the neo-membrane and cortical surface (group B, negative cortical vein sign) in four patients with meningitis, two victims of child abuse, and one patient with leukemia. Findings from subsequent MR imaging confirmed the color Doppler US findings. CONCLUSION: Color Doppler US depiction of the cortical vain sign appears to be as effective as MR imaging in differentiating enlargement of the subarachnoid fluid space from subdural effusion.

Brain↗
PubMed1959

The relationship of toxin and antitoxin injection site to tetanus development in the rat.

The pattern of development of symptoms was studied following injection of 3 MLD (minimum lethal dose) of tetanus toxin in each of the following sites in the rat: vein, muscle, endoneurium, epineurium, spinal cord, subarachnoid space, and subdural space. Similar observations were made when 3 MPD (minimum protective dose) of antitoxin were injected into each of the above sites a few minutes after the intramuscular injection of toxin. Local tetanus followed intramuscular, endoneurial, and epineurial injection of the toxin; blood-borne tetanus also appeared in the latter instance. Tetanus dolorosus followed intraspinal injection of toxin. Both dorsal tetanus and blood-borne tetanus developed after subdural administration of toxin. Blood-borne tetanus, alone, appeared following intravenous and subarachnoid injection of toxin. In no case did injection of antitoxin at the various sites listed above prevent local tetanus from developing after intramuscular injection of toxin. Of the various sites injected with antitoxin, the intramuscular, intraspinal, and intravenous were the most effective. It is suggested that the endoneurial tissue spaces serve as a conduit for tetanus toxin from the muscle to the CNS. The perilemma of the peripheral nerve trunk may act as a selectively permeable membrane which permits tetanus toxin to pass from the epineurium to the endoneurium. Outward diffusion of toxin from the endoneurial spaces is apparently markedly reduced. The antitoxin probably is prevented from permeating this barrier in either direction. The importance of absorption of tetanus toxin by the lymphatic and blood circulation is discussed.

Animals↗
PubMed2007

[A case of infected subdural hematoma].

A 87-year old male was admitted to our hospital due to generalized convulsion with loss of consiousness. He was afebrile and his blood sampling was not infectious. Computed tomography scan suspected left chronic subdural hematoma. Burr hole drainage was performed to remove the hematoma, but the abscess was aspirated in the subdural space. Infected subdural hematoma is rare. We discuss the clinical presentation, diagnosis and. treatment, and also briefly review the literature.

Aged, 80 and over↗
PubMed1997

[A case of infected subdural hematoma complicating chronic subdural hematoma in a healthy adult man].

The authors report a case of so-called "infected subdural hematoma" as a complication of chronic subdural hematoma. The patient was a 55-year-old man who had sustained a small laceration of the forehead in a traffic accident on March 29, 1995. No fractures were detected on skull roentgenograms, and general and neurological examinations failed to reveal any abnormal findings. In early August 1995, the patient began to experience headaches, and on August 5 he developed a fever of 38 degrees C. On August 8 he suffered a left motor seizure and was admitted to our hospital. Laboratory studies revealed a peripheral leukocyte count of 10,800/mm3 and a C-reactive protein level of 18.1 mg/dl. Computed tomography scans showed a thick right fronto-parietal subdural low density mass and a thin left frontal subdural low density mass. An emergency operation was performed via a single right fronto-parietal burr hole. A chronic subdural hematoma containing slightly yellowish, bloody, purulent fluid was found beneath an outer membrane. The hematoma was irrigated with physiological saline containing antibiotics, and a drain was inserted into the subdural space. A subdural membrane was also present on the left but it contained no pus. Aggressive antibiotic therapy was performed, and the patient was discharged without any neurological deficit. Histologically the membrane was determined to be the outer membrane of a typical chronic subdural hematoma. Enterococcus faecalis, which has rarely been reported to cause infection of the central nervous system, was detected in a bacterial culture of the pus. Systemic investigation showed no evidence of otorhinologic or other focal infection. The above clinical findings suggested that hematogenous seeding of a chronic subdural hematoma had occurred in this patient. Subdural empyema arising from hematogenous seeding to a pre-existing subdural hematoma by an infection is very rare, but this type of complication must be kept in mind not only in the elderly, infants, and compromised hosts, but in patients without complications as well.

Chronic Disease↗
PubMed1995

Subdural injection of a local anesthetic with steroids: complication of epidural anesthesia.

We describe the unintentional injection of a small amount of local anesthetic with steroids into the subdural space during an attempted lumbar epidural injection for low back pain. When small volumes of local anesthetic are injected into the subdural space, a patchy and unilateral block of greater magnitude than expected will result. When larger volumes of local anesthetic are injected, a massive motor and sensory block can occur due to the small confines of this space. Accidental subdural injection must be recognized early and treated appropriately to avoid serious complications, especially in an outpatient setting.

Aged↗
PubMed1982

Spinal subdural metastasis. A case report.

A case of metastasis to the thoracic spinal subdural space is reported. Metrizamide myelography showed narrowing of the upper thoracic subarachnoid space. A tumor in the spinal subdural space is unusual; only a few cases have been reported. The myelographic appearance is not specific; an epidural metastasis can produce the same myelographic picture.

Carcinoma, Bronchogenic↗
PubMed1999

Treatment of a recurrent subdural hematoma using urokinase.

Previous reports describe the intraventricular, subarachnoid, and intraparenchymal use of thrombolytic agents. However, the use of thrombolytic agents in the management of extraaxial hematomas has not been described. Following the evacuation of a subacute subdural hematoma, this 48-year-old woman experienced declining neurologic function due to the reaccumulation of blood in the subdural space. Urokinase was administered via a subdural drain. The patient experienced rapid clinical improvement and radiographic resolution of the recrudescent subdural hematoma. If repeat surgical evacuation of a subdural hematoma is not possible, urokinase may be instilled into the subdural space to enhance drainage of a subdural hematoma.

Female↗
PubMed1989

Omentum graft for intractable subdural empyema.

A subdural empyema developed in a young man after craniotomy for evacuation of a hematoma in a sylvian fissure arachnoid cyst and the subdural space. Despite prolonged systemic and subdural antibiotic administration and a debridement of the subdural space, infection persisted, as evidenced by persistent fever, an elevated white blood cell count, and an extremely low cerebrospinal fluid glucose level. The infection was cured after a second debridement operation where microsurgically revascularized free omentum was used to obliterate the cyst and to cover the cerebral hemisphere in the craniotomy defect. The use of vascularized free omentum may prove useful in cases of refractory cranial wound infection and cerebrospinal fluid fistulas.

Adolescent↗