Unilateral chronic subdural hematoma due to spontaneous intracranial hypotension: a report of four cases

Endoscopic Membranectomy's Role in the Treatment of Nonhomogeneous Chronic Subdural Hematoma (EMiT-CSDH): Prospective Single-arm Interventional Pilot Study

BACKGROUND

Chronic subdural hematoma (CSDH) is a prevalent neurosurgical condition characterized by blood accumulation within the border cell layer. Despite various treatment options-medical, endovascular, and surgical-recurrence rates remain high. Our pilot study investigates the safety and efficacy of endoscopic membranectomy (EM) in reducing recurrence in nonhomogenous CSDH.

METHODS

This was a prospective single-arm interventional pilot study from March to June 2023. It included patients of all ages who presented with symptomatic nonhomogenous CSDH requiring surgical intervention.

RESULTS

A total of 19 patients were enrolled in this study. The average age was 60.4 ± 10.4 years. The male:female ratio was 5.3:1. In this group, 73.7% (n = 14) of patients had a history of trauma. All patients presented with a history of altered sensorium and contralateral limb weakness. The most common type of CSDH was trabecular (42.1%), followed by gradient (21%), separated (15.8%), and laminar (15.8%). The average duration of surgery was 43.42 ± 10 minutes. CSDH may be thin or thick based on its tractability and has significance in EM technique. All patients started recovering within 24 hours. All patients were asymptomatic, without any neurologic deficit, at 2 weeks, and remained so at the 6-month review. In 17 patients, the 6-month follow-up computed tomography did not show any bleeding/recurrence. There were no postoperative seizures, wound-healing issues, or infections.

CONCLUSIONS

There are multiple treatment options for CSDH at present. EM is a potentially safe and effective treatment for CSDH, with lower recurrence and faster recovery. Large-scale controlled studies on EM are required.

Duret Brainstem Hemorrhage After Transtentorial Descending Brain Herniation: A Systematic Review and Meta-Analysis

BACKGROUND

Historically, the occurrence of hemorrhage in the brainstem after an episode of supratentorial intracranial hypertension was described by Henri Duret in 1878. Nevertheless, to date the eponym Duret brainstem hemorrhage (DBH) lacks systematic evidence regarding its epidemiology, pathophysiology, clinical and radiologic presentation, and outcome.

METHODS

We conducted a systematic literature review and meta-analysis using the Medline database from inception to 2022 looking for English-language articles concerning DBH, in accordance with the PRISMA guidelines.

RESULTS

The research yielded 28 articles for 32 patients (mean age, 50 years; male/female ratio, 3:1). Of patients, 41% had head trauma causing 63% of subdural hematoma, responsible for coma in 78% and mydriasis in 69%. DBH appeared on the emergency imaging in 41% and on delayed imaging in 56%. DBH was located in the midbrain in 41% of the patients, and in the upper middle pons in 56%. DBH was caused by sudden downward displacement of the upper brainstem secondary to supratentorial intracranial hypertension (91%), intracranial hypotension (6%), or mechanical traction (3%). Such downward displacement caused the rupture of basilar artery perforators. Brainstem focal symptoms (P = 0.003) and decompressive craniectomy (P = 0.164) were potential favorable prognostic factors, whereas an age >50 years showed a trend toward a poor prognosis (P = 0.0731).

CONCLUSIONS

Unlike its historical description, DBH appears as a focal hematoma in the upper brainstem caused by the rupture of anteromedial basilar artery perforators after sudden downward displacement of the brainstem, regardless of its cause.

Acute supratentorial subdural hematoma after craniocervical junction arachnolysis in a patient with posttraumatic syringomyelia; case report and literature review

In patients with SAA rapid CSF drainage while performing durotomy must be avoided by utilizing cotton pads and lowering the head level to avoid catastrophic complications.

Comparison of clinical characteristics with spontaneous intracranial hypotension complicated with subdural hematoma between surgical treatment and non-surgical treatment

OBJECTIVES

The aim of this current study was to analyze the possible surgical predictive factors about spontaneous intracranial hypotension (SIH) complicated with subdural hematoma (SDH).

METHODS

178 patients diagnosed with both SIH and SDH were retrospectively reviewed. All the participants were divided into as EBP group (BPG) and surgical treatment group (STG). The demographic, clinical manifestations, radiographic and treatment data of the two groups were collected and compared by the electrical medical history system.

RESULTS

The male patients accounted for the majority in the STG (77.88 %), which was significantly larger than those in the BPG(p = 0.004). Patients who regularly smoked and drunk alcohol in the STG group were significantly greater than those in the BPG group (p_(smoking)= 0.049, p_(drinking)= 0.014). The headache occurring in the temporal position in the STG accounted for 44.44 % which was significantly greater than those in the BPG (25.17 %, p = 0.040). The durations days of symptoms were 54.85 ± 34.78 and 33.72 ± 34.97 in the STG and BPG respectively (p = 0.005). The midline shift degree in the STG was also significantly greater than that in the BPG (p = 0.001). The largest hematoma depth in the STG was significantly greater than that in the BPG (p = 0.000). The frequency of blood patch in the STG was significantly greater than that in the BPG(p = 0022).

CONCLUSION

Male, unhealthy living habits, temporal headache, duration of headache, midline shift, hematoma depth and blood patch frequency were possible related factors with the poor outcome of blood patch and surgical treatment.

Spontaneous and recurrent subdural haematoma in a patient with May-Hegglin anomaly

Both acute and chronic subdural haematomas typically occur following trauma. Non-traumatic causes are less common, but aetiologies include arteriovenous malformation, intracranial aneurysm rupture, tumour-associated haemorrhage and coagulopathies. May-Hegglin anomaly is an example of a coagulopathy, which is caused by a mutation in the gene encoding non-muscle myosin heavy chain 9 (MYH9) and therefore falls into a group of diseases referred to as MYH9-related diseases (MYH9-RD). The symptomology of MYH9-RD is often mild, and patients tend to experience epistaxis, gingival bleeding and bruising. Life-threatening haemorrhage rarely occurs. In this short report, we describe a patient with known May-Hegglin anomaly who presented with a potentially life-threatening, spontaneous subdural haematoma requiring surgery on two occasions. This is only the second such report in the literature, and the first of spontaneous and recurrent haemorrhage in association with May-Hegglin anomaly.

Brain Herniation and Intracranial Hypertension

This article introduces the basic concepts of intracranial physiology and pressure dynamics. It also includes discussion of signs and symptoms and examination and radiographic findings of patients with acute cerebral herniation as a result of increased as well as decreased intracranial pressure. Current best practices regarding medical and surgical treatments and approaches to management of intracranial hypertension as well as future directions are reviewed. Lastly, there is discussion of some of the implications of critical medical illness (sepsis, liver failure, and renal failure) and treatments thereof on causation or worsening of cerebral edema, intracranial hypertension, and cerebral herniation.

Misdiagnosis of Spontaneous Intracranial Hypotension Presenting as Acute Mental Deterioration Caused by Unilateral Acute Subdural Hematoma: Case Report

Spontaneous intracranial hypotension (SIH) is usually a benign disease which mostly present as orthostatic headache and resolves by conservative treatment or epidural blood patch. However, in severe cases large subdural hematoma or brain caudal herniation can progress to brain herniation and neurologic complications. We introduce a rare case of SIH which presented as acute mental deterioration with unilateral acute subdural hematoma. A 60 years old female visited to emergency room for stuporous mental change and unilateral acute subdural hematoma. Decompressive craniectomy and hematoma removal was performed to release brain herniation and increased intracranial pressure. There was temporary improvement of consciousness, but sustained leakage of cerebrospinal fluid (CSF) and caudal brain herniation worsened patient's condition. After recognizing that CSF leakage and hypovolemia was the underlying disease, emergent epidural blood patch and early cranioplasty was performed. After treatment CSF volume was normalized and patient recovered completely without neurologic deficits. Acute mental deterioration with unilateral subdural hematoma is a rare presentation for SIH. Treatment strategy for subdural hematoma with concomitant SIH patients, should be planned carefully with concerns to CSF hypovolemia and intracranial pressure.