Postoperative hyperperfusion syndrome in elderly patients with chronic subdural hematoma

Development and internal validation of a nomogram to predict temporary acute agitated delirium after surgery for chronic subdural hematoma in elderly patients: an analysis of the clinical database

Background

This study aimed to develop a nomogram for predicting temporary acute agitated delirium after surgery in patients with chronic subdural hematoma (CSH) without neurological compromise and hospitalized in the neurosurgery.

Methods

We included 289 patients with chronic subdural hematoma (CSH) from the medical information system of Yuebei People's Hospital of Shaoguan City, Guangdong Province, and collected 16 clinical indicators within 24 h of admission. We used the least absolute shrinkage and selection operator (LASSO) regression to identify risk factors. We established a multivariate logistic regression model and constructed a nomogram. We performed internal validation by 1,000 bootstrap samples; we plotted a receiver operating curve (ROC) and calculated the area under the curve (AUC), sensitivity, and specificity. We also evaluated the calibration of our model by the calibration curve and the Hosmer-Lemeshow goodness-of-fit test (HL test). We performed a decision curve analysis (DCA) and a clinical impact curve (CIC) to assess the net clinical benefit of our model.

Results

The nomogram included alcoholism history, hepatic insufficiency, verbal rating scale for postoperative pain (VRS), pre-hospital modified Rankin Scale (mRS), and preoperative hematoma thickness as predictors. Our model showed satisfactory diagnostic performance with an AUC value of 0.8474 in the validation set. The calibration curve and the HL test showed good agreement between predicted and observed outcomes (p = 0.9288). The DCA and CIC showed that our model had a high predictive ability for the occurrence of postoperative delirium in patients with CSDH.

Conclusion

We identified alcoholism, liver dysfunction, pre-hospital mRS, preoperative hematoma thickness, and postoperative VRS pain as predictors of postoperative delirium in chronic subdural hematoma patients. We developed and validated a multivariate logistic regression model and a nomogram.

Underwater versus Closed Drainage System for Surgical Treatment of Chronic Subdural Hematoma

OBJECTIVES

Chronic subdural hematoma (CDH) is a prevalent condition in neurosurgery. Standard care includes surgical evacuation with drainage of residual subdural cavity. We hypothesized that effective and timely drainage of subdural space may improve clinical and radiological outcomes. This study was conducted to compare the effectiveness of standard closed drainage and underwater drainage.

METHODS

Medical data of 300 surgically treated chronic subdural hematoma CDH patients were retrospectively collected and analyzed. The patients were divided into two 2 groups: Group I with underwater drainage, and Group II with closed drainage. Groups were compared in terms of gender, age, complication rates, recurrence rates, seizure rates, and length of hospital stay.

RESULTS

Underwater drainage was found superior to closed system by all clinical and radiographic parameters. The recurrence rate was significantly lower in Group I (2%) compared to with Group II (10%). Subdural empyema was observed in 10 patients in Group II and none in Group I. The seizure rate was higher in Group II (18%) compared to with Group I (5%). Postoperative pneumocephalus rates was were 20% in Group I and 54% in Group II. The length of hospital stay was 6±2.6 days in Group I and 8.9±6.1 days in Group II. The length of intensive care unit (ICU) stay was 0.6±1.12 days in Group I and 2.7±5 days in Group II. A minority (5%) of the patients in Group II required reoperation due to recurrence.

CONCLUSIONS

The use of underwater system significantly the reduces the rates of pneumocephalus, seizures, infection, and recurrence. Additional benefits are shorter intensive care unit ICU and total hospital stays.

Risk stratification and predictive modeling of postoperative delirium in chronic subdural hematoma

Background- Postoperative delirium is a common complication associated with the elderly, causing increased morbidity and prolonged hospital stay. However, its risk factors in chronic subdural hematoma patients have not been well studied. Methods- A total of 202 consecutive patients with chronic subdural hematoma at Peking University Third Hospital between January 2018 and January 2023 were enrolled. Various clinical indicators were analyzed to identify independent risk factors for postoperative delirium using univariate and multivariate regression analyses. Delirium risk prediction models were developed as a nomogram and a Markov chain. Results- Out of the 202 patients (age, 71 (IQR, 18); female-to-male ratio, 1:2.7) studied, 63 (31.2%) experienced postoperative delirium. Univariate analysis identified age (p < 0.001), gender (p = 0.014), restraint belt use (p < 0.001), electrolyte imbalance (p < 0.001), visual analog scale score (p < 0.001), hematoma thickness (p < 0.001), midline shift (p < 0.001), hematoma side (p = 0.013), hematoma location (p = 0.018), and urinal catheterization (p = 0.028) as significant factors. Multivariate regression analysis confirmed the significance of restraint belt use (B = 7.657, p < 0.001), electrolyte imbalance (B = -3.993, p = 0.001), visual analog scale score (B = 2.331, p = 0.016), and midline shift (B = 0.335, p = 0.007). Hematoma thickness and age had no significant impact. Conclusion- Increased midline shift and visual analog scale scores, alongside restraint belt use and electrolyte imbalance elevate delirium risk in chronic subdural hematoma surgery. Our prediction models may offer reference value in this context.

Bilateral post-traumatic hygromas in patient with frontotemporal dementia

Background

Frontotemporal dementia (FTD) is a highly disabling neurologic disorder characterized by behavioral alterations and movement disorders, involving patients with a mean age of 58 years. We present a unique case of a patient suffering from FTD who developed post traumatic bilateral hygromas.

Case Description

A 52-year-old male patient, with an history of head trauma 3 months before, was admitted to our department for recurrent motor seizures. Anamnesis was positive for FTD with severe frontal syndrome. Brain computed tomography and magnetic resonance imaging (MRI) showed the typical "knife-blade" appearance of the cortical atrophy associated to bilateral hemispheric hygromas exerting mild mass effect. Brain MRI showed the signs of the cortical and "anti-cortical" vein. The two subdural collections were evacuated through two bilateral burr holes and controlled drainage. Despite anti-epileptic drugs therapy, in the early postoperative period, the patient presented further tonic-clonic seizures. The patient showed progressive recovery and was transferred to the neurorehabilitation center. After 6-month follow-up, he completely recovered.

Conclusion

In FTD, severe cortical atrophy leads to space increase between arachnoid and pia mater that could affect the anatomical integrity especially after trauma, with possible development of hygromas. The coexistence of radiological findings of the cortical vein and sign of the "anti-cortical" vein can make difficult an exact differential diagnosis between a primitive hygroma and a Virchow hygroma from resorption of previous blood collection. Surgical treatment may be indicated in selected patients, but it is burdened by higher postoperative risks compared to the general population.

Functional Outcome in Patients with Chronic Subdural Hematoma: Postoperative Delirium and Operative Procedure

Chronic subdural hematoma (CSDH) is a common neurosurgical condition and neurological condition improves after treatment in most patients. Recently more patients have poor prognosis because of aging of the population and presence of multiple comorbidities. The risk factors for poor prognosis, including postoperative delirium, were retrospectively evaluated to assess appropriate operative procedures. This study included 108 patients who underwent primary surgery from 2016 to 2017 at a single center. Operative procedures were drainage with or without irrigation. Functional outcome at discharge assessed the effect of various factors including postoperative delirium and operative procedure. Twenty-nine of 108 patients (27%) had worsened modified Rankin Scale (mRS) score at discharge, most with mobility disturbance or deteriorated cognitive function. Multivariate analysis found higher age (odds ratio [OR] = 5.13; 95% confidence interval [CI] = 1.0-1.14), poor pre-hospital mRS score (OR = 1.57; 95% CI = 1.0-2.46), and preoperative consciousness disturbance caused by CSDH (OR = 5.13; 95% CI = 1.27-20) were significant predictors of poor outcome. Operative procedure was not significantly related to functional outcome or recurrence, but irrigation was significantly related to postoperative delirium (OR = 4.83; 95% CI = 1.09-21.7). Patients with postoperative delirium were likely to require longer hospitalization stays (P = 0.028). Higher age, poor pre-hospital mRS, and preoperative consciousness disturbance caused by CSDH are the risk factors for poor recovery after CSDH. Irrigation is significantly likely to cause postoperative delirium and longer hospital stay.

Endoscopically Treated Subacute Subdural Hematoma Presenting Postoperative Cerebral Hyperperfusion Syndrome: Chronological Changes of Cerebral Blood Flow on Arterial Spin Labeling and Subcortical Low Intensity on Fluid-attenuated Inversion Recovery Images

Subacute subdural hematoma (SASDH) is a neurotraumatic entity. There are few reports of chronological changes of cerebral blood flow (CBF) on arterial spin labeling (ASL) and subcortical low intensity (SCLI) on fluid-attenuated inversion recovery (FLAIR) images of magnetic resonance imaging (MRI) observations from the injury onset, deterioration, to post-surgery. We reported a SASDH patient presenting postoperative cerebral hyperperfusion (CHP) syndrome with chronological changes of those findings. An 85-year-old woman fell and presented right ASDH. She was treated conservatively due to no neurological deficits. On day 3, ASL image revealed increased CBF against brain compression. On day 7, the CBF was normalized on ASL image, but SCLI was confirmed. On day 14, SCLI was strengthened. Then she developed left hemiparesis due to brain compression by SASDH. Considering age and comorbidities, we performed endoscopic hematoma removal under local anesthesia, and her neurological deficits improved after the surgery. On postoperative day 1, she newly presented left upper limb paresis. MRI revealed increased CBF and enhanced SCLI. We diagnosed CHP syndrome, and antihypertensive treatment improved the symptoms gradually. However, SCLI had been consistently observed, and CBF easily changed depending on the blood pressure, suggesting dysfunction of the CBF autoregulation. We showed the endoscopically treated SASDH patient with CBF’s chronological changes on ASL images and SCLI on FLAIR images. Long-time brain compression would lead to dysfunction of the CBF autoregulation, and we should be careful about CHP syndrome after the endoscopic surgery for SASDH.

Cerebral Hyperperfusion and Delayed Coma Recovery after Subdural Hematoma Evacuation

Acute subdural hematoma is a devastating neurological injury with significant morbidity and mortality. In patients with large subdural hematoma resulting in compression of the underlying brain and lateral brain shift, severe neurological deficits and coma can occur. Emergent neurosurgical decompression is a life-saving intervention which improves mortality and neurological function. Persistent coma despite subdural hematoma evacuation is often the result of persistent midline shift, cerebral infarctions related to initial elevated intracranial pressure and herniation, nonconvulsive seizures, and other metabolic and infectious causes; however, a subset of patients remains comatose without a discernable etiology. In this report, we describe an elderly patient who remained comatose without a known cause for several weeks after subdural hematoma evacuation and was found to have delayed cerebral hyperperfusion on brain imaging. After several days, there was marked recovery of consciousness which occurred in a timeframe that matched improvement in brain imaging findings. Cerebral hyperperfusion following subdural hematoma evacuation requires further investigation, and should be considered as a cause of persistent but potentially recoverable coma.

Surgical Management of Chronic Subdural Hematoma in Older Adults: A Systematic Review

BACKGROUND

Chronic subdural hematoma (cSDH) is a form of intracranial hemorrhage common in older adults. Optimal treatment remains controversial. We conducted a systematic review to identify surgical thresholds, characterize outcomes, and delineate critical considerations in the surgical management of older adults in order to summarize the evidence supporting the best contemporary management of cSDH.

METHODS

A systematic review exploring surgical management of cSDH among individuals aged 65 years and older was conducting by searching the PubMed, Embase, and Scopus databases for articles in English. Abstracts from articles were read and selected for full-text review according to a priori criteria. Relevant full-text articles were analyzed for bibliographic data, aim, study design, population, interventions, and outcomes.

RESULTS

Of 1473 resultant articles, 21 were included. Surgery rationale was case-by-case for symptomatic patients with cSDH. Surgery was superior to conservative management and promoted equivalent neurologic outcomes and rates of complications. Recurrence and reoperation rates in older adults were similar to younger individuals. Some studies reported higher mortality rates for older adults, while others reported no difference. Anticoagulation or antiplatelet agent use did not seem to be associated with poorer outcomes in older adults.

CONCLUSIONS

Surgery for cSDH in older adults leads to favorable neurologic outcomes without increased risk of overall complications, recurrence, or reoperation compared to younger patients. However, older adults may be at increased risk for mortality after surgery. It is important to determine use of anticoagulant or antiplatelet agents in older adults to optimally manage patients with cSDH.

Intraparenchymal Hemorrhage After Evacuation of Chronic Subdural Hematoma: A Case Series and Literature Review

BACKGROUND

Intraparenchymal hemorrhage (IPH), possibly due to reperfusion, after evacuation of a cranial chronic subdural hematoma (cSDH) is a known phenomenon. However, it is sparingly reported and not well understood.

METHODS

An illustrative case series is presented. A literature review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to identify all previously reported cases.

RESULTS

A total of 48 cases were analyzed. Males were 85.4% of the population, and the mean age was 67.5 years. Pre-existing head trauma and hypertension were the most common comorbidities. Headache was a presenting symptom in 60.4% of cases. Midline shift was explicitly stated in 54.2% of cases. Initial burr hole alone was performed 75.0% of the time, whereas craniotomy alone was performed in 16.7% of cases. Any initial craniotomy patients were associated with a modified Rankin Scale score of 5 (P = 0.03). The IPH was located in the cerebral hemisphere in 62.5% of cases and more likely to occur ipsilateral to a unilateral cSDH (P = 0.02). The IPH occurred a mean 1.9 days after surgery, and 50.0% occurred within 24 hours of initial intervention. The median modified Rankin Scale at discharge was 2. The mortality rate was 25%. Lastly, a multifactorial reperfusion pathophysiology was proposed.

CONCLUSION

IPH after cSDH evacuation is associated with significant morbidity and mortality. Prompt recognition, regulating blood pressure, controlling the amount and rate of extra-axial fluid drained, and a meticulous surgical technique are critical to optimize the care of patients with cSDH and reduce the rate of postoperative IPH.

Delirium in neurosurgery: a systematic review and meta-analysis

Delirium is a frequent occurring complication in surgical patients. Nevertheless, a scientific work-up of the clinical relevance of delirium after intracranial surgery is lacking. We conducted a systematic review (CRD42020166656) to evaluate the current diagnostic work-up, incidence, risk factors and health outcomes of delirium in this population. Five databases (Embase, Medline, Web of Science, PsycINFO, Cochrane Central) were searched from inception through March 31st, 2021. Twenty-four studies (5589 patients) were included for qualitative analysis and twenty-one studies for quantitative analysis (5083 patients). Validated delirium screening tools were used in 70% of the studies, consisting of the Confusion Assessment Method (intensive care unit) (45%), Delirium Observation Screening Scale (5%), Intensive Care Delirium Screening Checklist (10%), Neelon and Champagne Confusion Scale (5%) and Nursing Delirium Screening Scale (5%). Incidence of post-operative delirium after intracranial surgery was 19%, ranging from 12 to 26% caused by variation in clinical features and delirium assessment methods. Meta-regression for age and gender did not show a correlation with delirium. We present an overview of risk factors and health outcomes associated with the onset of delirium. Our review highlights the need of future research on delirium in neurosurgery, which should focus on optimizing diagnosis and assessing prognostic significance and management.

Hyperperfusion and intracranial hemorrhage after burr hole surgery of chronic subdural hematoma

Background:

Chronic subdural hematomas (CSDHs) mainly occur in elderly people and usually develop after minor head injuries. CSDH can be cured by a relatively simple burr hole surgery. Rarely reported, hemorrhagic postsurgical complications include subarachnoid, intracerebral, intraventricular, and remote cerebellar hemorrhages. The causes of such uncommon complications are difficult to explain and remain poorly understood.

Case Description:

We report the case study of an 89-year-old man with CSDH who presented with the right hemiparesis. He underwent burr hole surgery with a closed-drainage system. A computed tomography (CT) scan conducted the following day demonstrated an acute intraventricular hemorrhage and hyperperfusion of the ipsilateral hemisphere.

Conclusion:

This is a rare case of an acute hematoma in the ventricle following drainage of a CSDH. The likely mechanism of this intraventricular hemorrhage could be that the drainage of the hematoma produced a movement of the ventricle and hemisphere accompanied by hyperperfusion.

Bilateral Oculomotor Palsy After Surgical Evacuation of Chronic Subdural Hematoma

BACKGROUND

Chronic subdural hematoma is a common neurosurgical disease and the most benign form of intracranial hematoma. Most patients are successfully treated with simple burr hole evacuation and external drainage with good outcome and low rate of complications. Brainstem hemorrhage is a rare cause of severe disability in these patients, and cannot be ignored.

CASE DESCRIPTION

We report the first case of bilateral oculomotor palsy due to a midbrain hemorrhage after evacuation of a unilateral chronic subdural hematoma. The relevant literature is also reviewed to better understand the causes of this rare but disabling occurrence and how it can be prevented during and after surgery.

CONCLUSIONS

Neurosurgeons must have awareness of remote intracerebral hemorrhage after burr hole evacuation of chronic subdural hematoma, and take measures to avoid it during surgery. Our experience and the review of the relevant literature demonstrate that preoperative computed tomography can provide information to identify the patients at major risk.

Cerebral Hyperperfusion Syndrome After a Burr Hole Drainage Surgery for Chronic Subdural Hematoma

BACKGROUND

Although chronic subdural hematoma (CSDH) has a good prognosis after classical minimally-invasive drainage surgery, severe complications still occur at a substantial rate. Cerebral hyperperfusion syndrome (CHS), which is a common severe complication after carotid endarterectomy or carotid artery stenting for cervical carotid artery stenosis, is rare after drainage surgery for a CSDH.

CASE DESCRIPTION

We describe the case of an 82-year-old woman who presented with ipsilesional symptoms including contralateral hemiparesis and dysarthria, progressively worsening consciousness, and status epilepticus after a burr hole drainage surgery for CSDH. Magnetic resonance fluid-attenuated inversion recovery imaging showed diffuse subcortical low intensity in the ipsilesional hemisphere almost simultaneously with the appearance of the symptoms. Arterial spin labeling magnetic resonance perfusion imaging showed the abnormal increase of cerebral blood flow in the hemisphere. Continuous propofol administration and blood pressure management improved the symptoms.

CONCLUSIONS

CHS can cause severe postoperative complications after drainage surgery for CSDH. Subcortical low-intensity fluid-attenuated inversion recovery imaging is a useful investigation for early detection of CHS in CSDH, and arterial spin labeling imaging is an effective minimally-invasive modality for confirming the diagnosis.

Postoperative Subarachnoid Hemorrhage and Multipunctate Intracerebral Hemorrhages Following Evacuation of Bilateral Chronic Subdural Hematomas

Chronic subdural hematoma (CSDH) can be easily treated by burr hole surgery. However, several complications including intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and acute subdural hematoma are rare after evacuation of a CSDH. A 77-year-old man was admitted with right hemiparesis and dysarthria. A brain computed tomography (CT) scan revealed a bilateral CSDH with midline shifting toward the right side. The patient got the burr hole trephination with the catheters insertion in the both sides of parietal area under the local anesthesia. After burr hole surgery immediately, he developed left side weakness and decreased level of consciousness. Repeat CT scans detected a diffuse SAH and multiple small ICHs. He was treated conservatively and fully recovered at discharge after 1 month. To avoid these complications, slow and gradual drainage of the CSDH is needed. The authors report a rare case of SAH and multipunctate ICHs in both cerebral hemispheres after evacuation of a bilateral CSDH.

Remote Hemorrhage after Burr Hole Drainage of Chronic Subdural Hematoma

Chronic subdural hematoma (CSDH) and symptomatic subdural hygroma are common diseases that require neurosurgical management. Burr hole trephination is the most popular surgical treatment for CSDH and subdural hygroma because of a low recurrence rate and low morbidity compared with craniotomy with membranectomy, and twist-drill craniotomy. Many reports suggest that placing a catheter in the subdural space for drainage can further reduce the rate of recurrence; however, complications associated with this type of drainage include acute subdural hematoma, cortical injury, and infection. Remote hemorrhage due to overdrainage of cerebrospinal fluid (CSF) is another possible complication of burr hole trephination with catheter drainage that has rarely been reported. Here, we present 2 cases of remote hemorrhages following burr hole trephination with catheter drainage for the treatment of CSDH and symptomatic subdural hygroma. One patient developed intracerebral hemorrhage and subarachnoid hemorrhage in the contralateral hemisphere, while another patient developed remote hemorrhage 3 days after the procedure due to the sudden drainage of a large amount of subdural fluid over a 24-hour period. These findings suggest that catheter drainage should be carefully monitored to avoid overdrainage of CSF after burr hole trephination.

Prolonged Cerebral Hyperperfusion and Subcortical Low Intensity on Fluid-Attenuated Inversion Recovery Images: Unusual Manifestation After Removal of Organized Chronic Subdural Hematoma

BACKGROUND

Cerebral hyperperfusion sometimes occurs after removal of chronic subdural hematoma (CSH) and usually resolves within a few days without any symptoms. Subcortical low intensity (SCLI) on fluid-attenuated inversion recovery (FLAIR) magnetic resonance images is rare and has been reported in some diseases other than CSH. A case of organized CSH who suffered prolonged neurologic deterioration, SCLI, and cerebral hyperperfusion postoperatively is described.

CASE DESCRIPTION

An 81-year-old man, presenting with left hemiparesis, underwent craniotomy for right organized CSH after 2 burr-hole surgeries. After the craniotomy, the symptoms improved, but on postoperative day 2, left hemiparesis, hemispatial neglect, and hemiasomatognosia developed. Magnetic resonance imaging revealed SCLI on FLAIR images, and single-photon emission computed tomography with N-isopropyl-p-[¹²³I]-iodoamphetamine revealed cerebral hyperperfusion in the right hemispheric cortex. Antihypertensive treatment improved the symptoms gradually, which resolved completely 1 month postsurgery.

CONCLUSIONS

A case of organized CSH, which showed postoperative neurologic deterioration associated with prolonged cerebral hyperperfusion and SCLI on FLAIR images, is reported. Prolonged cerebral hyperperfusion could be a cause of postoperative neurologic deterioration in organized CSH.

Amlodipine and the Successful Management of Post-Electroconvulsive Therapy Agitation

Electroconvulsive therapy (ECT) is a highly effective nonpharmacologic treatment for the management of depression and some other psychiatric disorders. Post-ECT agitation occurs in up to 12% of ECT treatments and is characterized by motor restlessness, irritability, disorientation, and panic-like behaviors. The severity of post-ECT agitation ranges from mild and self-limited to serious and severe forms requiring prompt medical intervention to protect the patient and the medical staff. In severe agitation medical management may be necessary which consists of using sedative agents, either benzodiazepines or propofol. The side-effects of these sedative agents, especially in the elderly population, necessitate finding ways that could help the prevention of the occurrence of agitation after ECT treatments. We report a 68-year-old female with major depression who was referred for ECT. She experienced severe post-ECT agitation requiring medical intervention after all ECT treatments. Administering of oral amlodipine (5 mg) one hour before ECT treatment successfully prevented the occurrence of post-ECT agitation in this patient. We briefly discuss the possible underlying mechanisms and pathophysiology of amlodipine in the prevention of post-ECT agitation.

Gradual and controlled decompression for brain swelling due to severe head injury

Patients suffering from uncontrollable intracranial hypertension due to posttraumatic brain swelling (BS) generally either die or survive in an extremely disabled state. Decompressive craniectomy (DC) with dural augmentation may be the best method to assist these patients. However, the efficacy of DC on functional outcomes remains controversial. One of the factors contributing to poor outcomes could be intraoperative brain extrusion, which is an acute potential complication of DC. The authors have adopted a new surgical technique for traumatic BS that can prevent and control massive intraoperative BS (IOS). In the past 3 years, the authors have used a unique technique, called "gradual and controlled decompression", in the treatment of posttraumatic BS. This procedure consists of creating numerous small dural openings and removing clots; enlarging fenestration in the frontal and temporal basal regions to detect and treat brain contusion; making U-shaped, discontinuous, small dural incisions around the circumference of the craniotomy; and performing an augmentation duraplasty through the discontinuous small opening with dural prosthetic substances. This technique has been employed in 23 patients suffering from posttraumatic BS. In all cases, IOS was prevented and controlled through gradual stepwise decompression, and expanded duraplasty was performed successfully. This new surgical approach for posttraumatic BS can prevent severe extrusion of the brain through the craniotomy defect and allows the gradual and gentle release of the subdural space. Further clinical studies should be conducted to estimate the impact of this new technique on morbidity and mortality rates.

Infrequent Hemorrhagic Complications Following Surgical Drainage of Chronic Subdural Hematomas

Chronic subdural hematomas mainly occur amongst elderly people and usually develop after minor head injuries. In younger patients, subdural collections may be related to hypertension, coagulopathies, vascular abnormalities, and substance abuse. Different techniques can be used for the surgical treatment of symptomatic chronic subdural hematomas : single or double burr-hole evacuation, with or without subdural drainage, twist-drill craniostomies and classical craniotomies. Failure of the brain to re-expand, pneumocephalus, incomplete evacuation, and recurrence of the fluid collection are common complications following these procedures. Acute subdural hematomas may also occur. Rarely reported hemorrhagic complications include subarachnoid, intracerebral, intraventricular, and remote cerebellar hemorrhages. The causes of such uncommon complications are difficult to explain and remain poorly understood. Overdrainage and intracranial hypotension, rapid brain decompression and shift of the intracranial contents, cerebrospinal fluid loss, vascular dysregulation and impairment of venous outflow are the main mechanisms discussed in the literature. In this article we report three cases of different post-operative intracranial bleeding and review the related literature.

Transient focal spinal cord hyperemia after resection of spinal meningioma: case report

OBJECTIVE

Transient postoperative focal hyperemia in the spinal cord is rare. We report 2 patients with transient focal hyperemia after the resection of a spinal meningioma that led to temporal neurological deterioration followed by complete recovery.

CLINICAL PRESENTATION

Two patients presented with cervical meningiomas at the C7 and C1-C2 levels. Preoperatively, both patients experienced gradual exacerbation of spastic tetraparesis. Magnetic resonance imaging revealed isointensity on T1-weighted images and high intensity on T2-weighted images with homogeneous enhancement.

INTERVENTION

Both patients underwent complete tumor removal. A histopathological examination revealed a meningothelial meningioma in both patients. Postoperative magnetic resonance imaging revealed transient focal hyperemia of the cervical cord.

CONCLUSION

Both patients manifested transient focal hyperemia of the spinal cord after acute decompression by resection of a spinal meningioma.

Planning for early emergence in neurosurgical patients: a randomized prospective trial of low-dose anesthetics

BACKGROUND

For early detection of a cerebral complication, rapid awakening from anesthesia is essential after craniotomy. Systemic hypertension is a major drawback associated with fast tracking, which may predispose to formation of intracranial hematoma. Although various drugs have been widely evaluated, there are limited data with regards to use of anesthetics to blunt emergence hypertension. We hypothesized that use of low-dose anesthetics during craniotomy closure facilitates early emergence with a decrease in hemodynamic consequences.

METHODS

Three emergent techniques were evaluated in 150 normotensive adult patients operated for supratentorial tumors under standard isoflurane anesthesia. At the time of dural closure, the patients were randomized to receive low-dose propofol (3 mg.kg(-1).h(-1)), fentanyl (1.5 microg.kg(-1).h(-1)) or isoflurane (end-tidal concentration of 0.2%) until the beginning of skin closure. Nitrous oxide was discontinued after head dressing.

RESULTS

Median time to emergence was 6 min with propofol, 4 min with fentanyl, and 5 min with isoflurane (P=0.008). More patients had hypertension in the pre-extubation compared with extubation or postextubation phase (P=0.009). Comparing the three groups, fewer patients required esmolol with fentanyl use overall, and in the pre-extubation phase (P=0.01). Significant midline shift in the preoperative cerebral imaging scans was found to be an independent risk factor for emergence hypertension.

CONCLUSIONS

Pain during surgical closure may be an important cause of sympathetic stimulation leading to emergence hypertension. The use of low-doses of fentanyl during craniotomy closure is more advantageous than propofol or isoflurane for early emergence in neurosurgical patients and is the most effective technique for preventing early postoperative hypertension.

Awakening management after neurosurgery for intracranial tumours

PURPOSE OF REVIEW

Major complications after intracranial surgery occur in 13-27% of patients. These complications may have multiple causes, but a body of arguments suggests that the haemodynamic and metabolic changes of anaesthesia recovery may be responsible for intracranial complications. The aim of this review is to explain the rationale of this hypothesis and analyse the recent studies relevant to neuroanaesthesia recovery.

RECENT FINDINGS

Rapid recovery and extubation after intracranial tumour surgery is desirable in order to make an early diagnosis of intracranial complications. Since light pharmacological sedation may worsen a neurological deficit, short-acting anaesthetics are preferable intraoperatively. Extubation in the operating room, however, may be associated with agitation, increased oxygen consumption, catecholamine secretion, hypercapnia and systemic hypertension. This may exacerbate cerebral hyperaemia observed even during an uneventful recovery, leading to cerebral oedema or haemorrhage.

SUMMARY

Pain, hypothermia, hypercapnia, hypoxia, hypoosmolality, hypertension, and anaemia should be avoided during emergence. Early emergence is associated with minimal haemodynamic and metabolic changes. If there is any doubt as to whether the patient should be extubated in the operating room, a gradual emergence in the intensive care unit makes it possible to decide whether or not extubation can be performed safely.

The role of neuroimaging in elucidating delirium pathophysiology

Understanding of delirium pathogenesis remains limited despite improved diagnosis, and elucidation of risk factors and prognosis. Major advances in neuroimaging offer the possibility of probing the mechanisms and networks involved in delirium and hence improving understanding of this often devastating syndrome. This review describes the current literature of imaging studies in delirium and related conditions, introduces some of the newer capabilities of neuroimaging with magnetic resonance imaging, positron emission tomography, and single photon emission computed tomography, and discusses how these techniques may be applied to the study of delirium. Despite considerable challenges in patient recruitment, study design, intersubject variability, and scanner and contrast agent availability, imaging offers great potential for the identification and clarification of pathogenic mechanisms of delirium and its long-term sequelae.

Neurosurgery in the elderly: brain tumors and subdural hematomas

Primary malignant brain tumors present a formidable challenge to surgeons, patients, and families. Although the prognosis in elderly patients approaches only 6 months, aggressive resection and adjuvant treatment may be indicated in a select group of patients who have preserved functional status. Subdural hematomas in the geriatric population usually are chronic. Patients often benefit from evacuation but their advanced age and significant comorbidities often increase perioperative morbidity and mortality. Minimally invasive evacuation, possibly under local anesthesia, often is indicated as an initial treatment.

Subfalcine herniation in the absence of a high pressure collection or mass: 'brain-slump'?

Subfalcine brain herniation is well documented in the presence of raised intracranial pressure. However, we report a case of herniation occurring after decompression of bilateral chronic subdural haematomas, which did not appear to be related to high pressure. We suggest that after rapid decompression of a collection, the unsupported brain can herniate under the falx with serious consequences: 'brain-slump'.

Modifications hémodynamiques cérébrales et systémiques au moment du réveil en neurochirurgie

Major complications after intracranial surgery occur in 13-27% of patients. Among multiple causes, haemodynamic and metabolic changes of anaesthesia recovery may be responsible for intracranial complications. Recovery from neurosurgical anaesthesia is followed by an increase in body oxygen consumption and catecholamines concentrations. However, in normothermic patients, theses changes are usually mild and not prevented by a 2-h recovery delay. Systemic hypertension is common after neurosurgery and a link between perioperative hypertension and intracranial haemorrhage has been established. The cerebral consequences of recovery associate cerebral hyperaemia and increased ICP in patients with a tight brain at the end of surgery. Cerebral hyperaemia may promote or exacerbate cerebral haemorrhage or oedema. This has been demonstrated in patients operated for subdural haematoma removal or undergoing carotid surgery. Prevention of hypothermia and pain are key factors to prevent metabolic changes. Beta-blockers seem to be suitable agents to obtain haemodynamic control in neurosurgical patients.

Chronic subdural haematoma treated by craniotomy, durectomy, outer membranectomy and subgaleal suction drainage. Personal experience in 39 patients

According to the CT and MRI appearances, 39 chronic subdural haematoma (CSDH) patients were suspected of having solid clots and/or a high likelihood of loculation. Craniotomy was planned from the start. Beside the better exposure, excision of the dura and outer membrane, assumed to be the source of haematoma fluid, this is an additional step to minimize the incidence of significant recollection. There were no additional operative or postoperative cranial and/or systemic complications when compared with other minor procedures. Two patients (5%) required once percutaneous tapping and aspiration. Accordingly, if a case is considered to be better managed with craniotomy, durectomy and outer membranectomy this is an easy and safe technique with minimal incidence of recollection, morbidity and mortality.