Subdural haematoma: a potentially serious consequence of spontaneous intracranial hypotension

Non-invasive biomarkers for spontaneous intracranial hypotension (SIH) through phase-contrast MRI

BACKGROUND AND OBJECTIVE

Spontaneous intracranial hypotension (SIH) is an underdiagnosed disease. To depict the accurate diagnosis can be demanding; especially the detection of CSF-venous fistulas poses many challenges. Potential dynamic biomarkers have been identified through non-invasive phase-contrast MRI in a limited subset of SIH patients with evidence of spinal longitudinal extradural collection. This study aimed to explore these biomarkers related to spinal cord motion and CSF velocities in a broader SIH cohort.

METHODS

A retrospective, monocentric pooled-data analysis was conducted of patients suspected to suffer from SIH who underwent phase-contrast MRI for spinal cord and CSF velocity measurements at segment C2/C3 referred to a tertiary center between February 2022 and June 2023. Velocity ranges (mm/s), total displacement (mm), and further derivatives were assessed and compared to data from the database of 70 healthy controls.

RESULTS

In 117 patients, a leak was located (54% ventral leak, 20% lateral leak, 20% CSF-venous fistulas, 6% sacral leaks). SIH patients showed larger spinal cord and CSF velocities than healthy controls: e.g., velocity range 7.6 ± 3 mm/s vs. 5.6 ± 1.4 mm/s, 56 ± 21 mm/s vs. 42 ± 10 mm/s, p < 0.001, respectively. Patients with lateral leaks and CSF-venous fistulas exhibited an exceptionally heightened level of spinal cord motion (e.g., velocity range 8.4 ± 3.3 mm/s; 8.2 ± 3.1 mm/s vs. 5.6 ± 1.4 mm/s, p < 0.001, respectively).

CONCLUSION

Phase-contrast MRI might become a valuable tool for SIH diagnosis, especially in patients with CSF-venous fistulas without evidence of spinal extradural fluid collection.

A proposed stratification system to address the heterogeneity of Subdural Hematoma Outcome reporting in the literature

A major challenge within the academic literature on SDHs has been inconsistent outcomes reported across studies. Historically, patients have been categorized by the blood-product age identified on imaging (i.e., acute, subacute, or chronic). However, this schematic has likely played a central role in producing the heterogeneity encountered in the literature. In this investigation, a total of 494 patients that underwent SDH evacuation at a tertiary medical center between November 2013-December 2021 were retrospectively identified. Mechanism of injury was reviewed by the authors and categorized as either positive or negative for a high-velocity impact (HVI) injury. Any head strike injury leading to the formation of a SDH while traveling at a velocity beyond that of normal locomotion or daily activities was categorized as an HVI. Patients were subsequently stratified by those with an acute SDHs after a high-velocity impact (aSDHHVI), those with an acute SDH without a high-velocity impact injury (aSDHWO), and those with any combination of subacute or chronic blood products (mixed-SDH [mSDH]). Nine percent (n = 44) of patients experienced an aSDHHVI, 23% (n = 113) aSDHWO, and 68% (n = 337) mSDH. Between these groups, highly distinct patient populations were identified using several metrics for comparison. Most notably, aSDHHVI had a significantly worse neurological status at discharge (50% vs. 23% aSDHWO vs. 8% mSDH; p < 0.001) and mortality (25% vs. 8% aSDHWO vs. 4% mSDH; p < 0.001). Controlling for gender, midline shift (mm), and anticoagulation use in the acute SDH population, multivariable logistic regression revealed a 6.85x odds ratio (p < 0.001) for poor outcomes in those with a positive history for a high-velocity impact injury. As such, the distribution of patients that suffer an HVI related acute SDH versus those that do not can significantly affect the outcomes reported. Adoption of this stratification system will help address the heterogeneity of SDH reporting in the literature while still closely aligning with conventional reporting.

Brain Sagging Dementia

PURPOSE OF REVIEW

Brain sagging dementia (BSD) is a rare but devastating form of early-onset dementia characterized by intracranial hypotension and behavioral changes resembling behavioral variant frontotemporal dementia. This review aims to provide a comprehensive overview of BSD, highlighting its pathomechanism, diagnostic tools, and available treatment options.

RECENT FINDINGS

BSD exhibits a complex clinical manifestation with insidious onset and gradual progression of behavioral disinhibition, apathy, inertia, and speech alterations. Additionally, patients may exhibit brainstem and cerebellar signs such as hypersomnolence and gait disturbance. Although headaches are common, they may not always demonstrate typical orthostatic features. Recent radiological advances have improved the detection of CSF leaks, enabling targeted treatment and favorable outcomes. Understanding the pathomechanism and available diagnostic tools for BSD is crucial for a systematic approach to timely diagnosis and treatment of this reversible form of early-onset dementia, as patients often endure a complex and lengthy clinical course.

A Subdural Hygroma Necessitating a Subdural-Peritoneal Shunt in a Pediatric Patient Following Total Cranial Vault Remodeling Surgery

Sagittal synostosis is a common non-syndromic synostosis treated with open or endoscopic cranial vault remodeling. Early intervention is recommended to avoid restricted brain growth, increased intracranial pressure, and resultant developmental delay. Common complications such as failure or reconstruction, cerebrospinal fluid leak, blood loss, and stroke are well-reported in the literature. Here, we present a rare case of the development of a subdural hygroma following cranial vault remodeling in a seven-month-old male, necessitating the insertion of a subdural-peritoneal shunt.

Dural and Leptomeningeal Diseases: Anatomy, Causes, and Neuroimaging Findings

Meningeal lesions can be caused by various conditions and pose diagnostic challenges. The authors review the anatomy of the meninges in the brain and spinal cord to provide a better understanding of the localization and extension of these diseases and summarize the clinical and imaging features of various conditions that cause dural and/or leptomeningeal enhancing lesions. These conditions include infectious meningitis (bacterial, tuberculous, viral, and fungal), autoimmune diseases (vasculitis, connective tissue diseases, autoimmune meningoencephalitis, Vogt-Koyanagi-Harada disease, neuro-Behçet syndrome, Susac syndrome, and sarcoidosis), primary and secondary tumors (meningioma, diffuse leptomeningeal glioneuronal tumor, melanocytic tumors, and lymphoma), tumorlike diseases (histiocytosis and immunoglobulin G4-related diseases), medication-induced diseases (immune-related adverse effects and posterior reversible encephalopathy syndrome), and other conditions (spontaneous intracranial hypotension, amyloidosis, and moyamoya disease). Although meningeal lesions may manifest with nonspecific imaging findings, correct diagnosis is important because the treatment strategy varies among these diseases. ©RSNA, 2023 Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. Quiz questions for this article are available through the Online Learning Center.

Postoperative Intracranial Hemorrhage after an Endoscopic L5-S1 Laminectomy and Discectomy: A Case Report and Literature Review

BACKGROUND

Postoperative intracranial hemorrhage (PIH) is a fairly rare but catastrophic perioperative complication following lumbar spine surgery. This is a case report of a 54-year-old male patient who experienced PIH 2 h after an endoscopic L5-S1 laminectomy and discectomy.

CASE PRESENTATION

A 54-year-old male patient presented with right L5-S1 radiculopathy that corresponded with the picture revealed in medical imaging and the signs seen upon physical examination. Subsequently, he underwent endoscopic L5-S1 laminectomy and discectomy. The patient presented with idiopathic unconsciousness and limb twitching 2 h after surgery. An emergency cranial CT scan was obtained which demonstrated intracranial hemorrhage. Following an emergency consultation with the Department of Neurology and Neurosurgery, the patient underwent an emergency interventional thrombectomy as per their orders. The surgery was performed successfully. However, the patient's situation did not improve and he died on the second postoperative day.

CONCLUSION

PIH after spinal endoscopic surgery is a rare but horrible complication. Several factors could lead to PIH. However, in this patient, the cause of PIH might be attributed to the long operation time combined with cerebrospinal fluid (CSF) leakage. Great attention should be attached to the issue of PIH development in spinal endoscopic procedures due to constant irrigation. This study aims to highlight the issue of PIH following endoscopic spinal surgery by presenting a case report of a patient who died despite successful surgery.

MRI Findings after Recent Image-Guided Lumbar Puncture: The Rate of Dural Enhancement and Subdural Collections

BACKGROUND AND PURPOSE

The rate of abnormal intracranial MR imaging findings including subdural collections and dural enhancement after recent lumbar puncture is not known. The purpose of our study was to examine the intracranial MR imaging findings after recent image-guided lumbar puncture.

MATERIALS AND METHODS

Patients who underwent contrast-enhanced MR imaging of the brain within 7 days of a CT-guided lumbar puncture between January 2014 and April 2021 were included. Contrast-enhanced MR images were reviewed for diffuse dural enhancement, morphologic findings of brain sag, dural venous sinus distension, and subdural collections.

RESULTS

Of the 160 patients who met the inclusion criteria, only 6 patients (3.9%) had new diffuse dural enhancement, though none had dural enhancement when the MR imaging was within 2 days of lumbar puncture. All 6 patients with dural enhancement had small, concurrent subdural collections. Two additional patients had subdural collections, for a total of 5.2% of our population.

CONCLUSIONS

Our study is the first to examine intracranial MR imaging after recent lumbar puncture and has 2 key findings: First, 5.2% of patients had small, bilateral subdural collections after recent lumbar puncture, suggesting that asymptomatic subdural collections after recent lumbar puncture are not atypical and do not require further work-up. Additionally, when MR imaging was performed within 2 days of lumbar puncture, none of our patients had diffuse dural enhancement. This argues against the commonly held practice of performing MR imaging before lumbar puncture to avoid findings of dural enhancement, and should not delay diagnostic work-up.

Epidural blood patch for spontaneous intracranial hypotension with subdural hematoma: A case report and review of literature

BACKGROUND

Cerebrospinal fluid (CSF) leakage at C1/2 in spontaneous intracranial hypotension (SIH) is rare. Subdural hematoma (SDH), a serious complication of SIH, may lead to neurological deficits. This report presents a case of SDH after spontaneous C1/2 CSF leakage, which was treated with a targeted epidural blood patch (EBP).

CASE SUMMARY

A 60-year-old man with no history of trauma was admitted to our hospital with orthostatic headache, nausea, and vomiting. Brain computed tomography imaging revealed bilateral, subacute to chronic SDH. Brain magnetic resonance imaging (MRI) findings were SDH with dural enhancement in the bilateral cerebral convexity and posterior fossa and mild sagging, suggesting SIH. Although the patient underwent burr hole trephination, the patient’s orthostatic headache was aggravated. MR myelography led to a suspicion of CSF leakage at C1/2. Therefore, we performed a targeted cervical EBP using an epidural catheter under fluoroscopic guidance. At 5 d after EBP, a follow-up MR myelography revealed a decrease in the interval size of the CSF collected. Although his symptoms improved, the patient still complained of headaches; therefore, we repeated the targeted cervical EBP 6 d after the initial EBP. Subsequently, his headache had almost disappeared on the 8^th day after the repeated EBP.

CONCLUSION

Targeted EBP is an effective treatment for SDH in patients with SIH due to CSF leakage at C1/2.

Spontaneous intracranial hypotension complicated by diffuse cerebral edema and episodes of severely elevated intracranial pressure: illustrative case

BACKGROUND

Spontaneous intracranial hypotension (SIH) is a well-documented condition that typically follows a defined clinical course. Previously published studies describing the pathophysiology of SIH have demonstrated extensive evidence of low intracranial pressure (ICP) driving the clinical features of the condition. Through lumbar puncture and use of intracranial monitoring devices, however, both low and normal cerebrospinal fluid (CSF) pressures have been documented. This report outlined and discussed the unique finding of elevated ICP associated with clinical features of SIH.

OBSERVATIONS

Here, the authors presented a case of a patient with spontaneous spinal CSF leak who developed tonsillar herniation, cerebral edema, and subsequent episodes of elevated ICP. Although more diverse presentations of SIH are being reported, the authors believed the case to be unique because SIH was accompanied by elevated ICP.

LESSONS

This case adds to the growing body of literature surrounding SIH by demonstrating that patients can develop elevated CSF pressures associated with acute encephalopathy.

Middle meningeal artery embolization for chronic subdural hematoma with cerebrospinal fluid hypovolemia: A report of 2 cases

BACKGROUND

Chronic subdural hematoma (CSDH) with cerebrospinal fluid hypovolemia syndrome (CHS) remains refractory to standard treatment with hematoma drainage by burr hole and irrigation and/or epidural blood patch. Previously, we reported the utility of middle meningeal artery (MMA) embolization for intractable CSDH. In this study, we present the usefulness of MMA embolization as a treatment for CSDHs with CHSs.

CASES

We present two cases of CSDHs with CHSs occurring in patients, 1 treated with burr hole craniotomy and irrigation, and the other treated with the epidural blood patch. Both patients exhibited similar-appearing bilateral relatively-thin hematomas, hyperplasia, and enhanced contrast effects in the dura mater, and extradural hygroma in the cervical portion on enhanced magnetic resonance imaging scans. Also, to reviewing prior literature and imaging findings, they had already undergone conventional treatment. We added MMA embolization treatment and they followed a good course.

RESULTS

Despite the known intractable outcomes of patients with CSDHs with CHSs, MMA embolization worked well in the current case series.

CONCLUSION

MMA embolization might be considered as a preferred therapeutic option for CSDHs with CHSs in order to buy time before the epidural blood patch starts working.

Chronic subdural hematoma: A previously unreported life-threatening complication in adult with Sotos syndrome

Macrocephaly, defined as head circumference ≥ 2 SDs, is a cardinal feature of Sotos syndrome (SS) and generally persists in adulthood. Subdural fluid collection, typically associated with macrocephaly, is described in children due to anatomical conformation, and in adulthood due to brain atrophy and ex-vacuo hydrocephalus. On the other hand, a true, symptomatic, chronic subdural hematoma (CSH) is a previously unreported complication of SS in adulthood. Here we describe the first SS patient presenting symptomatic CSH, leading to frequent hospitalizations for surgical evacuations that consistently recurred. Middle meningeal artery (MMA) embolization and epidural blood patch (EBP) allowed to resolve the CSH with complete resolution of clinical signs and symptoms. We hypothesize that appearance and recurrences of CSH may be related to pathological biomechanics of brain, cerebro-spinal fluid and skull, secondary to anatomical features of SS. In this context, surgical evacuation may be less efficient than usual to cure CSH. Alternative treatment to avoid blood extravasation, as MMA embolization, or to cure concurrent causes of the pathology, as EBP, may be considered.

Acute subdural hematoma recurrence during drain removal associated with spontaneous intracranial hypotension - A non-reported complication

BACKGROUND

Spontaneous intracranial hypotension (SIH) is an uncommon, benign, and generally self-limiting condition caused by low cerebrospinal fluid (CSF) volume and pressure usually caused by a CSF leak. Patients with SIH have an increased incidence of subdural hematomas (SDH), which may be bilateral and recurrent.

CASE DESCRIPTION

We report a unique case of a man presenting with SIH and bilateral SDH that were drained with bilateral craniotomies. During drain removal, the patient had an acute neurological deterioration and a CT scan showed SDH recurrence. The patient had two new recurrent SDH afterwards. After the third surgical intervention, the drain was removed in the OR with concomitant subdural saline infusion, there was no recurrence of SDH after that and the patient has had no further complications after a 2-year follow-up.

CONCLUSION

Patients with intracranial hypotension are predisposed to form SDH. In this case, drain removal caused further decrease in intracranial pressure and triggered a new SDH formation, subdural saline irrigation masked atmospheric pressure and prevented this complication from happening again.

Spontaneous intracranial hypotension: key features for a frequently misdiagnosed disorder

Spontaneous intracranial hypotension (SIH) is a rare neurological condition caused by low cerebrospinal fluid (CSF) volume, most commonly due to a CSF leak. The most common presenting symptom is an orthostatic headache, but some patients may present with atypical neurological manifestations such as cranial nerve palsies, an altered mental status, and movement disorders, which complicate the clinical diagnosis. Therefore, the diagnosis is based on the combination of clinical signs and symptoms, neuroimaging, and/or a low cerebrospinal fluid pressure. In this review, we describe the wide variety of neurological manifestations and complications seen in patients with SIH as well as the most common features described on imaging studies, including both subjective and objective measurements, in order to lead the clinician to a correct diagnosis. The prompt and correct management of patients with SIH will help prevent the development of life-threatening complications, such as subdural hematomas, cerebral venous thrombosis, and coma, and avoid unnecessary invasive procedures.

Spontaneous Intracranial Hypotension: Atypical Radiologic Appearances, Imaging Mimickers, and Clinical Look-Alikes

Spontaneous intracranial hypotension is a condition characterized by low CSF volume secondary to leakage through a dural defect with no identifiable cause. Patients classically present with orthostatic headaches, but this symptom is not specific to spontaneous intracranial hypotension, and initial misdiagnosis is common. The most prominent features of spontaneous intracranial hypotension on intracranial MR imaging include "brain sag" and diffuse pachymeningeal enhancement, but these characteristics can be seen in several other conditions. Understanding the clinical and imaging features of spontaneous intracranial hypotension and its mimickers will lead to more prompt and accurate diagnoses. Here we discuss conditions that mimic the radiologic and clinical presentation of spontaneous intracranial hypotension as well as other disorders that CSF leaks can imitate.

Imaging of the Spontaneous Low Cerebrospinal Fluid Pressure Headache: A Review

Spontaneous intracranial hypotension (SIH) is a significant cause of chronic, postural headaches. Spontaneous intracranial hypotension is generally believed to be associated with cerebrospinal fluid (CSF) leaks, and these leaks can be posttraumatic, iatrogenic, or idiopathic in origin. An integral part of the management of patients with this condition consists of localizing and stopping the leaks. Radiologists play a central role in the workup of this condition detecting leaks using computed tomography, magnetic resonance imaging, or nuclear imaging. In this article, we briefly review SIH and the various imaging modalities, which can be used to identify and localize a spontaneous CSF leak.

Spontaneous subdural haematoma in a patient with a total artificial heart on warfarin

We present the unusual case of a middle-aged woman who developed a spontaneous subdural haematoma (SSH) while on oral anticoagulation therapy for a total artificial heart (TAH). Headache was followed by paraesthesia and numbness of the left hand. The diagnosis was made from a CT scan. Symptoms resolved with conservative management and careful control of anticoagulation. In this case report, the risk factors and pathophysiology behind this condition are explored. TAHs in their own entity are a rare phenomenon. Coupled with the highly unusual presentation of an SSH in which only a few cases have been documented, we hope to highlight the management of such a difficult case. After navigating this complication, we were able to successfully bridge this patient to a heart transplant 26 days after the SSH.

Reversible, Position-Dependent Midbrain Compression in a Patient with Spontaneous Intracranial Hypotension

BACKGROUND

Intracranial hypotension is an underrecognized cause of spontaneous subdural hematoma. Failure to identify this entity and treat the underlying etiology can result in profoundly dangerous clinical consequences, prolonged and costly hospitalization, and caregiver fatigue, as seen in the case presented here.

CASE DESCRIPTION

We present a case of intracranial hypotension associated with a spontaneous cerebrospinal fluid (CSF) leak in the cervical spine leading to consistently reproducible herniation syndrome with head of bed elevation, and bilateral subdural hematomas as a result of a pressure gradient favoring downward migration of intracranial contents resulting in traction on bridging veins. This gradient promoted transtentorial herniation with resultant brainstem compression, leading to a prolonged intensive care unit stay, recurrent respiratory failure, and severe deconditioning. An exhaustive diagnostic workup uncovered a cervical root CSF leak with a nuclear medicine CSF flow study, which was successfully treated with nerve root ligation and dural closure. The patient recovered well postprocedurally and was able to return to baseline level of function.

CONCLUSIONS

This case demonstrates the importance of considering intracranial hypotension in cases of positional herniation syndrome and the necessity for early and aggressive attempts at identifying and treating the underlying cause to prevent unnecessary neurologic dysfunction and protracted medical care.

MRI Findings of Spontaneous Intracranial Hypotension: Usefulness of Straight Sinus Distention

OBJECTIVE. Spontaneous intracranial hypotension (SIH) shows various characteristic MRI findings. We evaluated the usefulness of straight sinus distention compared with transverse sinus distention and also evaluated other MRI findings of SIH. MATERIALS AND METHODS. Forty-three consecutive patients (28 female and 15 male patients) treated for SIH and 43 age- and sex-matched control subjects at two institutions from 2012 through 2014 were included in this study. Two reviewers determined whether the transverse sinus distention sign and straight sinus distention sign were present on MRI. Diagnostic performance values and interobserver agreement were calculated. Reviewers also assessed MRI examinations in consensus for the presence of the following findings: pachymeningeal enhancement, subdural effusion or hematoma, enlargement of the pituitary gland, and downward displacement of the brainstem and tonsils. RESULTS. The sensitivity, specificity, and diagnostic accuracy of the transverse sinus distention sign for SIH were 76.7%, 83.7%, and 80.2%, whereas those of the straight sinus distention sign were 79.1%, 95.4%, and 87.2%, respectively. The specificity of the straight sinus distention sign for SIH was significantly higher (p = 0.025) than that of the transverse sinus distention sign. In addition, the straight sinus distention sign showed substantial agreement (κ = 0.79), whereas the transverse sinus distention sign showed moderate agreement (κ = 0.60). The diagnostic accuracy of the presence of either transverse or straight sinus distention (83.7%) was significantly higher than that of pachymeningeal enhancement (80.2%, p = 0.032). CONCLUSION. The straight sinus distention sign could be helpful for the diagnosis of SIH because it has sensitivity comparable to other imaging findings and higher specificity and higher level of interobserver agreement than other imaging findings.

Spontaneous intracranial hypotension and its complications

Spontaneous intracranial hypotension (SIH) is a syndrome that was unknown until the advent of magnetic resonance imaging (MRI). It is a cause of orthostatic headache, which remains underdiagnosed and, rarely, can result in several complications including dural venous sinus thrombosis, subdural hematoma and subarachnoid hemorrhage. Some of these complications are potentially life-threatening and should be recognized promptly, mainly by imaging studies. We reviewed the MRI of nine patients with SIH and describe the complications observed in three of these patients. Two of them had subdural hematoma and one had a dural venous sinus thrombosis detected by computed tomography and MRI. We concluded that MRI findings are of great importance in the diagnosis of SIH and its complications, which often influence the clinical-surgical treatment of the patient.

Coma

Objective

To review our experience with patients with spontaneous intracranial hypotension (SIH) and coma because, although disorders of consciousness may complicate SIH, no comprehensive study of such patients has been reported.

Methods

Using a prospectively maintained registry, we identified all patients with SIH in whom coma developed. Patients or their caregivers/families were contacted for follow-up. Patients were compared to a cohort of patients with SIH without coma.

Results

The mean age of the 12 men and 3 women with SIH was 56.2 years (range 34–72 years) at the time of onset of coma. In one-third of patients, coma developed after craniotomy for subdural hematomas or for an unrelated intracranial pathology. Imaging showed brain sagging, including bilateral temporal lobe herniation, in all 15 patients and brainstem edema in 8 patients (53%). Overall, coma was reversible in 7 of 15 patients treated with epidural blood patches, in 2 of 4 treated with percutaneous glue injections, and in 6 of 6 treated surgically. Only 1 patient had residual neurologic deficit related to coma (Glasgow Outcome Scale score 4 [moderate disability]). Compared to patients with SIH without coma (n = 568), those with coma were older, more often were male, and more often underwent surgery.

Conclusions

Coma in SIH is rare, reversible, and invariably associated with brain sagging. Coma due to SIH may be refractory to the usual percutaneous procedures, and surgical closure of the CSF leak may be required to regain consciousness.

Treatment and outcome of subdural hematoma in patients with spontaneous intracranial hypotension: a report of 35 cases

Spontaneous intracranial hypotension (SIH) is characterized by orthostatic headache, low CSF pressure and diffuse pachymeningeal enhancement on brain MRI. SIH results from spontaneous CSF leakage leading to brain sag. Sometimes, tearing of bridging veins may produce subdural hematomas (SDHs). Patients with SDH were identified retrospectively from 212 consecutive SIH patients. Data were collected on demographics, clinical courses, neuroimaging findings, treatment and outcome of SDH. Thirty-five patients (16%), (6 women, 29 men; aged 33-68; mean, 50 years) with SDH were recruited. They were divided into two groups: initially withSIH diagnosed (n = 29) and undiagnosed (n = 6). After conservative treatment, the first group underwent a lumbar epidural blood patch (EBP) (n = 27) and emergent evacuation of symptomatic SDH (n = 2). After EBP, ten patients had enlarged SDH. Nine of them underwent evacuation of symptomatic SDH with mass effect (ME). In the second group, three patients with clinical worsening from SIH underwent, erroneously, evacuation of mild SDH. They worsened after the evacuation; after SIH diagnosis was made, they underwent one EBP (n = 2) and three EBPs (the patient with coma). The other three cases with symptomatic SDH with ME underwent evacuation with recurrence of SDH (n = 2). All 35 patients enjoyed a good outcome. If conservative treatment is insufficient, EBP should be performed prior to hematoma irrigation. When an emergent evacuation is necessary before EBP, it is preferable to perform, after surgery, one early EBP before the patient gets up to prevent frequent recurrences of SDH by underlying CSF leakage.

Misdiagnosis of Spontaneous Intracranial Hypotension as a Risk Factor for Subdural Hematoma

OBJECTIVE

This study aimed to evaluate the association between misdiagnosis of spontaneous intracranial hypotension (SIH) and subdural hematoma development.

BACKGROUND

Although SIH is more prevalent than expected and causes potentially life-threatening complications including subdural hematoma (SDH), the association between misdiagnosis of SIH and SDH development is not yet evaluated.

METHODS

Retrospective observational study was conducted between January 1, 2005, and December 31, 2014. Adult patients with spontaneous intracranial hypotension (age ≥ 18 years) were enrolled.

RESULTS

Of the 128 patients with SIH, 111 (86.7%) were in no SDH group and 17 (13.3%) were in SDH group. Their clinical presentation did not show significant different between the two groups, except age, the days from symptom onset to correct diagnosis, and the number of misdiagnoses. Age (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.07-1.23) and the number of times SIH was misdiagnosed (OR, 1.82; 95% CI, 1.03-3.21) were independent risk factors for the development of SDH in SIH patients by multivariate logistic analysis. The clinical outcomes, including length of hospital stay and revisit rate, were similar in the two groups.

CONCLUSIONS

The number of times SIH was misdiagnosed was associated with the later development of SDH perhaps because of delay in correct diagnosis of SIH. Clinicians would prevent the later complication of SDH in SIH patients by increasing the awareness and a high index of suspicion of SIH.

Epidural Anesthesia Complicated by Subdural Hygromas and a Subdural Hematoma

Inadvertent dural puncture during epidural anesthesia leads to intracranial hypotension, which if left unnoticed can cause life-threatening subdural hematomas or cerebellar tonsillar herniation. The highly variable presentation of intracranial hypotension hinders timely diagnosis and treatment. We present the case of a young laboring adult female, who developed subdural hygromas and a subdural hematoma following unintentional dural puncture during initiation of epidural anesthesia.

Subdural Haematoma in Patients With Spontaneous Intracranial Hypotension

The incidence and clinical relevance of subdural haematoma (SDH) in patients with spontaneous intracranial hypotension (SIH) remain undetermined. We reviewed 40 consecutive SIH patients (18 female, 22 male) in a tertiary hospital. Eight (20%) of them had SDH and nine (23%), non-haemorrhagic subdural collections. The presence of SDH was associated with higher frequencies of male gender, recurrence of severe headache and neurological deficits. Outcomes were satisfactory after supportive care or epidural blood patches except for one SDH patient, who developed transtentorial herniation resulting in Duret haemorrhage and infarctions of bilateral posterior cerebral artery territories. In conclusion, subdural fluid collections were common in patients with SIH. SDH was associated with headache worsening or neurological deficits. Patients with SDH generally recovered well; however, serious sequela might occur.

Spontaneous chronic subdural hematomas in human immunodeficiency virus-infected patients with normal platelet count and no appreciable brain atrophy: Two case reports and review of literature

Background:

Chronic subdural hematomas (CSDHs) usually occur in elderly patients following minor head trauma. Their occurrence is usually linked to cerebral atrophy secondary to alcohol, old age, or human immunodeficiency virus (HIV) infection. Spontaneous CSDHs have also been documented but are rare. They are usually caused by coagulopathies and various pathologies resulting in intracranial hypotension.

Cases:

We have observed a number of spontaneous CSDHs in HIV patients with normal platelet counts and no appreciable cerebral atrophy possibly caused by platelet dysfunction, hence we report about two such cases. To the best of our knowledge, no such cases have been reported in literature before.

Conclusion:

It is important to include CSDHs in the differential diagnosis of HIV patients presenting with neurological deficits even without a history of trauma.

Spontaneous Subdural Haemorrhage: A Rare Association with Plasmodium Vivax Malaria

Malaria is an endemic disease in tropical countries and disease of universal importance. Central Nervous System (CNS) complications of malaria are severe and associated with significant mortality. Thrombocytopaenia in malaria causing haemorrhagic CNS complications is rare. We report a case of 35-year-old male patient presented with headache, vomiting and was diagnosed to have subdural haemorrhage (SDH). On examination patient was found to be febrile with peripheral smear showing evidence of Plasmodium vivax (P.vivax) infection with severe thrombocytopaenia. In endemic regions with malaria, SDH being rare presentation of malaria should be considered as a differential diagnosis in febrile patients with neurological manifestations. Rarity of spontaneous SDH in malaria and raising awareness amongst treating physicians about the same is the driving factor for reporting this case.

Chronic Subdural Hematoma Associated with Spontaneous Intracranial Hypotension: Therapeutic Strategies and Outcomes of 55 Cases

Spontaneous intracranial hypotension (SIH) has increasingly been recognized, and it is well known that SIH is sometimes complicated by chronic subdural hematoma (SDH). In this study, 55 cases of SIH with SDH were retrospectively analyzed, focusing on therapeutic strategies and outcomes. Of 169 SIH cases (75 males, 84 females), 55 (36 males, 19 females) were complicated by SDH. SIH was diagnosed based on clinical symptoms, neuroimaging, and/or low cerebrospinal fluid pressure. Presence of orthostatic headache and diffuse meningeal enhancement on magnetic resonance imaging were regarded as the most important criteria. Among 55 SIH with SDH cases, 13 improved with conservative treatment, 25 initially received an epidural blood patch (EBP), and 17 initially underwent irrigation of the hematomas. Of the 25 initially treated with EBP, 7 (28.0%) needed SDH surgery and 18 (72.0%) recovered fully without surgery. Of 17 SDH cases initially treated with surgery, 6 (35.7%) required no EBP therapy and the other 11 (64.3%) needed EBP and/or additional SDH operations. In the latter group, 2 cases had transient severe complications during and after the procedures. One of these 2 cases developed a hoarse voice complication. Despite this single, non-severe complication, all enrolled in this study achieved good outcomes. The present study suggests that patients initially receiving SDH surgery may need additional treatments and may occasionally have complications. If conservative treatment is insufficient, EBP should be performed prior to hematoma irrigation.

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.

Treatment and prognosis of subdural hematoma in patients with spontaneous intracranial hypotension

Objective

The objective of this article is to elucidate the outcome, prognostic predictors and timing of surgical intervention for subdural hematoma (SDH) in patients with spontaneous intracranial hypotension (SIH).

Methods

Patients with SDH were identified retrospectively from 227 consecutive SIH patients. Data were collected on demographics, clinical courses, neuroimaging findings, and treatment of SDH, which was later divided into conservative treatment, epidural blood patches (EBP), and surgical intervention. Poor outcome was defined as severe neurological sequelae or death.

Results

Forty-five patients (20%) with SDH (mean maximal thickness 11.9 ± 6.2 mm) were recruited. All 15 patients with SDH <10 mm achieved good outcomes by either conservative treatment or EBP. Of 30 patients with SDH ≥10 mm, patients with uncal herniation ( n = 3) had poor outcomes, even after emergent surgical evacuation ( n = 2), compared to those without ( n = 27) (100% vs. 0%, p < 0.001). Fourteen patients underwent surgical evacuation, resulting in good outcomes in all 12 who received early intervention and poor outcomes in the remaining two who received delayed intervention after Glasgow Coma Scale (GCS) score ≤8 (100% vs. 0%, p = 0.01).

Conclusions

Uncal herniation results in poor outcomes in patients with SIH complicated with SDH. In individuals with SDH ≥10 mm and decreased GCS scores, early surgical evacuation might prevent uncal herniation.

Risk factors for subdural haematoma in patients with spontaneous intracranial hypotension

Subdural haematoma (SDH) is a potentially life-threatening complication in patients with spontaneous intracranial hypotension (SIH). In serious cases, SIH patients who present with SDHs develop neurological deficits, a decreased level of consciousness, or cerebral herniation, and may even require an urgent neurosurgical drainage. Despite numerous publications on SDHs, few report its potential risk factors in patients with SIH. In this study, we retrospectively investigated 93 consecutive SIH patients and divided them into an SDH group (n = 25) and a non-SDH (NSDH) group (n = 68). The clinical and radiographic characteristics of these 93 patients were analyzed, and then univariate analysis and further multiple logistic regression analysis were performed to identify the potential risk factors for the development of SDHs. The univariate analysis showed that advanced age, male gender, longer clinical course, dural enhancement, and the venous distension sign were associated with the development of SDHs. However, multivariate analysis only included the latter three factors. Our study reveals important radiological manifestations for predicting the development of SDHs in patients with SIH.

Low-pressure/spinal fluid leak headache

Low cerebrospinal fluid (CSF) pressure results in neurologic deficits, of which the most common manifestation is headache. Typically, the headache is postural - and specifically, orthostatic - in presentation. There are three hypotheses to explain the occurrence of headache associated with low CSF fluid. The first is traction on pain-sensitive intracranial and meningeal structures; the second is CSF hypovolemia; and the third is spinal loss of CSF resulting in increased compliance at the caudal end of the CSF space. Spontaneous intracranial hypotension (SIH), once believed to be rare, is now more commonly recognized. It is typically associated with orthostatic headache (although initially it may not be) and one or more other symptoms such as alterations in hearing, nausea, vomiting, neck stiffness, diplopia, and visual field cuts. Magnetic resonance imaging (MRI) of the brain with gadolinium is the first study of choice, which typically reveals diffuse pachymeningeal enhancement and, frequently, cerebellar tonsillar descent and posterior fossa crowding. Epidural blood patch (EBP) is the treatment of choice. Surgery and epidural fibrin glue injection are options for those who fail conservative therapy and/or EBP.

Chronic Subdural Hematomas: Comparison between Unilateral and Bilateral Involvement

Objective

Chronic subdural hematoma (CSDH) is a common intracranial hemorrhage, encountered in neurosurgical practice. Most CSDHs are unilateral, but some show bilateral involvement. However, the clinical characteristics of bilateral CSDH remain unclear. In this study, we investigated the clinical differences between bilateral and unilateral CSDH.

Methods

A retrospective study was performed on 120 patients with CSDH surgically treated at our institute from January 2008 to December 2012. Patients were divided into two groups: the bilateral CSDH and the unilateral CSDH groups. Clinical presentations, precipitating factors, computed tomography (CT) findings, postoperative complications, and outcomes of patients were analyzed.

Results

Bilateral CSDH was identified in 11 of 120 (10.9%) patients with CSDH. Patients with bilateral CSDH tended to have a lower rate of head injury compared to patients with unilateral CSDH (36.4% vs. 59.6%), but it had no statistical significance (p=0.201). The frequency of marked midline shift on CT scans was significantly greater in unilateral CSDH than in bilateral CSDH (p=0.010). Presenting symptoms, coexisting systemic diseases, postoperative complications, and clinical outcomes were not significantly different between the two groups.

Conclusion

Bilateral CSDH has comparatively similar clinical features and precipitating factors as unilateral CSDH. Patients with bilateral CSDH have significantly lower incidences of midline shift on CT scans, and most patients with either bilateral or unilateral CSDH have good postoperative outcomes.

Intracranial hypotension after trauma

INTRODUCTION

Intracranial hypotension (IH) occurs typically spontaneous and is a potentially life-threatening condition characterized by symptoms varying from postural headache to coma, with classical magnetic resonance imaging (MRI) findings.

CASE DESCRIPTION

We report two cases of clinically relevant trauma-related IH and review of the literature. One patient with a cerebral trauma presented unilateral mydriasis and coma resolved by the Trendelenburg position (-20°) as urgency intervention. In the second patient, IH was caused by a lesion of the brachial plexus after a motor vehicle accident.

DISCUSSION AND CONCLUSION

A history of mild or moderate trauma in association with prolonged postural or permanent headache may indicate IH. Posttraumatic IH is rare, nevertheless life-threatening in case of misdiagnosis. Intracranial hypotension in a trauma context is rarely described and difficult to diagnose. The change from tipical supine 30° to Trendelenburg position (0-20°) can be a life-saving manoeuver in these patients.