Surgical indications for infantile subdural effusion

Thirty-four cases of infantile subdural effusion (ISE) were reviewed in relation to surgical treatment and its prognosis during an average of 4 years of extended follow-up. The surgical indications were determined mainly by the size of the ISE on computed tomography (CT) scan and by metrizamide CT cisternography (MCTC). Consequently, 18 cases were categorized as type A according to MCTC, including 11 cases (61.1%) of ISE CT grade 1. All type A cases were closely observed. This nontreatment regimen yielded excellent results in 15 cases (83.3%). For 10 cases categorized as type B according to MCTC, including 5 cases (50%) of ISE CT grade 3, surgical treatment was indicated and excellent results were obtained in 8 cases (80%). For 6 cases categorized as type C according to MCTC and as ISE CT grade 3, surgery yielded excellent results in 4 cases (66.7%). Antiepileptic drugs have been given to three (27.3%) of the 11 patients who had convulsive attacks. In conclusion, the surgical indications for ISE were based mainly on MCTC in addition to the clinical course, and it is emphasized that, in the early stages, surgery on ISE cases categorized as MCTC types B and C is necessary.

[Post-traumatic subdural hygroma: diagnostic conditions and therapeutic attitude in Gabon]

An excessive collection of cerebrospinal fluid in the subdural space is known as subdural hygroma, or hydroma. By far, the most common cause is severe cranial trauma. The diagnosis can be made by angiography or computer tomography and, with certainly, only by trephine or burr hole evacuation. 11 cases of post-traumatic subdural hygromas, mainly diagnosed during operative interventions, from April 1981 to September 1988, are reported. Most patients had acute forms of hygroma requiring acute surgical intervention. The acuteness could broken down as: coma (medium Glasgow coma scale: 6), lateralizing neurologic signs (4 cases) and temporal lobe herniation signs (7 cases). There were difficulties in obtaining angiographic studies. 10 patients underwent burr hole evacuation. Craniectomy was performed in one case. Time between cranial trauma and surgical intervention varied from 24 hours (6 cases) to 34 days. It appears that the prognosis is related to the extent of primary brain damage and not to the pressure exerted by the (usually) small mass lesion. The authors propose a clinical management of this lesion and hope for improvement in the diagnostic technics available.

Subdural effusion in the acute stage of Kawasaki disease (Mucocutaneous lymph node syndrome)

A 6-month-old girl with complications of subdural effusions at the acute stage of Kawasaki disease is reported. Based on the pathology of Kawasaki disease and considering the possibility of systemic vasculitis, the subdural effusions were assumed to be attributable to vasculitis involving the dura mater.

Computer tomographic long-time results after surgical removal of subdural fluid collections in infancy and childhood

61 infants and children underwent surgery of acute hygroma, acute subdural hematoma, chronic subdural hygroma, chronic subdural hematoma, and subdural empyema. Long time-follow up including computerized tomography could be performed in 20 of these cases. Only 3 CT-scans had been without pathological finding. The most common finding had been an enlargement of the inner and outer CSF spaces suggesting cerebral atrophy. No correlation had been found to kind of surgical treatment and clinical status.

Hypotension during surgery for subdural hematoma and effusion in infants

A retrospective study of subdural hematoma was conducted in 36 patients ranging in age from 2 months to 9 years. Hypotension occurred in 41% of the children during the evacuation of the subdural hematoma. This study suggests that hypovolemia was caused, in part, by the blood loss into the subdural hematoma. In patients with hematoma larger than 8% of the intravascular volume, the frequency of the hypotension was high (88%). Infants, in particular, had larger hematomas, ranging in size from 8-27% of intravascular blood volume and, therefore, were at high risk to develop hypotension. These larger hematomas may be due to the infants' higher ratio of subdural space to the body weight. The study also suggests that the preoperative infusion of adequate fluid and blood is a significant factor in preventing hypotension during the hematoma evacuation.

Traumatic subdural hygroma in adults

The authors review 25 cases of post-traumatic subdural hygroma in adults and report the findings of computer tomography in 4 cases. There was marked diversity in the severity of injury and in chronicity. The site of the lesion was consistently delineated by angiography, but preoperative differentiation from subdural hematoma was possible only with computed tomography. The mortality was 28%. Good recovery occurred in 48%. The prognosis was best among younger patients with subacute or chronic lesions.

[Contribution to the surgical treatment of haematoma and hygroma in adults (author's transl)]

Among thirty cases of chronic subdural hematoma and hygroma in patients between 16 and 78 years of age, nine were found on the left side, ten on the right side and eleven were bilateral. The diagnosis was made in all cases by computer assisted tomography. Surgical treatment consisted in evacuating the subdural collection of fluid through two or three enlarged burr-holes, resection of the membranes were accessible through the burr-hole, irrigation of the subdural space and its subsequent drainage. The drain was left in postoperatively until the draining fluid became clear or the subdural space was dry. In one case there was a superficial intracerebral hematoma which obsorbed spontaneously. One patient with a subdural empyema required craniotomy. Only four out of ten patients who were comatose pre-operatively survived. Out of the 30 patients, 24 had a satisfactory postoperative outcome.

[Traumatic subdural hygromas (author's transl)]

Out of a group of 97 patients with intracranial haematomas, 12 were found to have a traumatic subdural hygroma. In four patients a small fluid effusion was demonstrated by CT scan just after the head injury. In the majority of cases the CT scan demonstrated a significant increase of volume and pressure of the subdural effusion during the second to third week. Half the patients simultaneously developed a moderate ventricular dilatation. The development of a subdural effusion was hard to recognize from the clinical course. Nevertheless the patients mostly had a good post-operative recovery. The hygromas disappeared by subdural peritoneal shunting. In two patients a ventriculoatrial shunt was necessary on account of the hydrocephalus. Based upon clinical and CT scan characteristics a multifactorial hypothetical model of the development of the traumatic subdural effusion is proposed.

Developmental process of chronic subdural collections of fluid based on CT scan findings

One hundred twenty-four follow-up scans were performed on 24 patients who had had posttraumatic subdural collections of low density. Of the 24 patients, 6 developed chronic subdural hematomas. Six other subdural collections showed a temporary increase in attenuation but eventually resolved. The remaining 12 subdural collections resolved without apparent increase in density. Illustrative cases are presented with computed tomographic scans. The identity of these posttraumatic subdural lesions of low density is discussed. They seem to be posttraumatic subdural hygromas.

Circumferential cranio-reduction

A simple procedure for reduction of the skull capacity is presented. This operation is indicated in cases where a hygroma had produced a marked disproportion between brain volume and skull capacity. A 'double drain' should be applied for 10-14 days in order to obliterate the intermembranous space optimally.

Subdural hygroma: results of treatment by ventriculo-abdominal shunt

Subdural hygromas, which differ from acute and chronic subdural haematomas in clinical features and pathogenetic mechanism, can occur as isolated lesions or in association with ventricular dilatation and/or subarachnoid cysts which are mistaken for atrophy. On the basis of the postulate that these fluid accumulations might be related to a disturbance in CSF circulation, we treated them by ventriculoperitoneal CSF drainage. This was regarded as indicated only for children with symptoms of retardation and a distended ventricular system. Disappearance of the hygroma or the cortical cysts and ventricular dilatation was demonstrated in 9 of 14 children treated by ventriculo-abdominal shunt and in 4 of 7 less seriously affected untreated children. Clinical improvement came later than neuroradiological improvement, and was incomplete in a number of children. Although there are anamnestic factors with an unfavourable effect on development, the hygromas per se can cause cerebral dysfunction which is associated with their bifrontal localization. The principal symptoms are those of retardation in the development of verbal expression, leg motor function and manipulation.

Subdural effusion: results after treatment with subdural-pleural shunts

In an unselected material of 22 consecutive patients subdural effusion, which did not respond to repeated taps, was treated with subdural-pleural shunt operation using nonvalve silicone catheters. After a mean follow-up time of 3 years 4 months, 17 patients (77%) were mentally and 15 patients (69%) neurologically normal. The results are certainly not worse than results achieved with craniotomies and membranectomies. A shunt operation is more simple and less hazardous than membranectomy and we agree with the opinion that the latter is an obsolete procedure in the treatment of persistent subdural effusions.

Angiographic characteristics of certain subdural collections of fluid

The presence of abnormal amounts of fluid in the subdural space has been referred to as subdural hematoma, subdural effusion and subdural hygroma. These are supposed to be differentiated by the appearance of the fluid and the presence of membranes in the dubdural space. Although both hygroma and chronic subdural hematoma are liquid, space-occupying lesions which cause pressure in the underlying brain, we have found that there are definite angiographic, clinical and prognostic differences between them. These differences are described.

Simultaneous subdural effusion and hydrocephalus in infancy

Hydrocephalus and subdural hematoma or effusion of infancy rarely present simultaneously, where both are active contributors to acutely increased intracranial pressure. In three cases, clinical findings characteristic of both were present. Decompression of one can facilitate expansion of the other. Rapid progression of unsuspected hydrocephalus could be responsible for some of the poor results reported after treatment of subdural effusion alone. This possibility should be considered whenever progress is unsatisfactory during treatment of subdural effusion.

Treatment of hydrocephalus and bilateral subdural effusions in a patient with closed sutures. Case report

For management of bilateral subdural hematomas in a hydrocephalic child with fused sutures, a simple technique is described that involves minimal cranial procedures for modification of an already installed ventriculoperitoneal shunt system.

Surgical treatment of subdural effusions in infants

We puropose a simplified method for external drainage of subdural effusions in infants, not calling for a second operation to remove the catheters. This method allows the daily control of evacuated fluid, guarantees smooth and uninterrupted drainage, and permits analysis of the subdural collection. This operation which we would like to call external controlled drainage, does not call for parenteral feeding, but demands paediatric and neurosurgical collaboration. The method has no pretensions other than being simple, easy, and safe.

[Clinical further development of children after surgery for subdural effusions (author's tranls)]

Follow-up examinations of 82 children after surgery for subdjral effusions show a varied degree of retardation of motor- and speech-development. This corresponds to neurologic signs of varying severity. Preoperative EEG findings are improved both in pre-school- and school children. Disturbance of motor and intellectual development as a rule corresponds to severe EEG changes. Among pre-school children 35% had an IQ below 69%, among school-children 36%. But their occupational chances cannot yet be finally assessed. Children with large effusions (over 50 ml) and extensive capsules show a higher percentage of retardation. Present results do not establish relations between site of effusion, frequency of recurrence and mental development.

Aspirating subdural effusions, so called brain stem shock

A shift of blood into the head during negative pressure aspiration of subdural haematomas in an infant has been demonstrated, and also that aspiration may restart bleeding. An estimate of the elasticity of a 47 cm circumference skull has been obtained. It is suggested that the observed changes in distribution of blood are sufficient to explain the occasional deaths of infants after aspiration of subdural haematomas and that so-called "brain stem shock" need not be invoked.

[Traumatic aneurysm of the frontopolar artery developing after evacuation of the subdural effusion in a 6-month-old girl (author's transl)]

A 6-month-old girl developed bilateal subdural effusion after head injury. She gradually improved after the partial stripping of the membrane of the subdural effusion although postoperative tappings of the subdural fluid were necessary. Thirty nine days after the injury, she suddenly suffered from a massive intraventricular hemorrhage. A cerebral angiography showed an aneurysm arising from the proximal part of the right frontopolar artery, which had not been revealed in the previous angiograms. It was obscure whether the congenital anomaly of the arterial wall had been existed or not, but this aneurysm might be mentioned as a traumatic aneurysm and definitely developed after the treatment for the traumatic sequence. The mechanism of this aneurysmal formation was supposed that the arterial wall was initially injured by the abnormal traumatic movement of the brain underneath the falx cerebri, and teared arterial wall was further injured by the fluctuating movements of the brain caused by repeated tappings of the effused fluid. Relation of delayed posttraumatic apoplexy and ruptured posttraumatic aneurysms was also discussed, and analysis of the reported cases of the traumatic aneurysm, as well as aneurysm in the infant, was made.