Minicraniotomy with a subgaleal pocket for the treatment of subdural fluid collections in infants

Pediatric Cerebral Venous Sinus Thrombosis: A Case Report

Cerebral venous sinus thrombosis (CVST) in infants is a rare vascular disorder that presents with nonspecific symptoms leading to a delay in diagnosis and treatment. Thrombus formation in the cerebral sinuses prevents blood from draining out of the brain leading to local and systemic complications. Here, we present an 11-week-old patient who presented to the emergency department (ED) with three days of lethargy, multiple episodes of projectile emesis, increased fussiness, and downward gaze. A CT scan demonstrated intraventricular hemorrhage (IVH) with acute hydrocephalus. A CT venogram of the cranial vault with contrast showed a large intraluminal thrombus occupying the right transverse sinus and torcula with proximal extension into the left transverse sinus confirming the diagnosis of CVST.

Subdural Hematomas in Adults and Children

Subdural hematoma is a common entity encountered by the neurosurgeon. The disease has acute, subacute, and chronic forms. Management of the disease changes according to the etiology of the lesion, yet the main goals are, as with most neurosurgical interventions, decompression of neural tissue and restoration of perfusion. Due to various forms and causes of the disease such as trauma, anticoagulant/antiaggregant use, arterial rupture, oncologic hemorrhages, intracranial hypotension, and idiopathic hemorrhages, several approaches for management have been documented in the literature. Herewith, we present various up-to-date management options for the disease.

Middle meningeal artery embolization in pediatric patient

PURPOSE

There is paucity of data in management of recurrent and expanding subdural hematomas (SDH) within the pediatric population, who are otherwise not surgical candidates. Middle meningeal artery (MMA) embolization has been utilized minimally in this population and here, we explore the utility of this procedure in a 15-month-old-child, along with review of the literature.

METHODS

A case report of a 15-month-old child who underwent MMA embolization for recurrent and expanding SDH in the setting of anticoagulation for cardiac condition. A literature review of MMA embolization in pediatric patients was conducted.

RESULTS

Initially stabilization of SDH was noted on serial imaging; however, recurrent hemorrhages were noted with subsequent boluses of antiplatelet and anticoagulating agents. There are only 5 total reported cases, included ours, of MMA embolization in pediatrics with an overall success rate of 80%.

CONCLUSION

Treatment of chronic or recurrent subdural hematoma by MMA embolization in the pediatric population is understudied. Our case notes limitation of this procedure and impact on long-term success, specifically in patients with systemic illness and ongoing anticoagulation.

Paediatric chronic subdural haematoma: what are the predisposing factors and outcomes in management of these cases?

INTRODUCTION

Chronic subdural hematoma (cSDH) is a disease of the elderly population. Incidence in paediatric population is relatively uncommon. Child abuse, birth trauma, coagulopathy and shunt surgeries represent major causes. Major impact of the disease on life of patient due to recurrence and repeat surgical procedure is significant, not to mention the burden on health care system.

MATERIAL AND METHODS

We retrospectively reviewed our institute data for chronic sub-dural cases for the past 10 years (2008-2018) and collected data on the demography, clinical features, metabolic workup, mode of treatment, recurrence rates, predisposing factors, laterality, hematoma characteristics and factors associated with recurrence in all cases with less than or equal to 18 years of age.

RESULTS

A total of 30 such cases were found in a period of 10 years (2008-2018). The mean patient age was 7.3 years (range 2 months-17 years), with 20 males (66.67%) and 10 females (33.33%). Raised intracranial pressure (n = 9) was the commonest presenting symptom in 30% of cases followed by seizures in 26.67% (n = 8). The previous shunt was the commonest predisposing factor seen in 43.33% (n = 13). cSDHs were unilateral in 56.67% cases (n = 17) and bilateral in 43.33% (n = 13). Burr hole craniostomy was done in 27 cases (90%), and conservative management was done in three cases (10%). Follow up was available for 27 cases (90%) with a mean follow up duration of 24 months. Recurrence rate was 30% (n = 9). Shunt surgery contributed to 77% of bilateral disease (p = 0.009). Child abuse was not reported in our series.

CONCLUSION

Presence of paediatric cSDH is alarming, and the physician should be alerted to look for underlying cause and rule out child abuse. Detailed metabolic, skeletal workup is required. Treatment of primary pathology should be the goal as CSF diversion is not the solution to all problems, but can definitely be the cause of all the problems.

Examining perinatal subdural haematoma as an aetiology of extra-axial hygroma and chronic subdural haematoma

AIM

Benign external hydrocephalus (BEH), hygroma and chronic subdural haematoma are extra-axial fluid collections in infants. MRI studies have shown that almost half of all new-borns have perinatal subdural blood, generally referred to as subdural haematoma (SDH) or perinatal SDH. Epidemiologically there are striking similarities between chronic SDH and BEH in infants.

METHODS

Discussion of pathophysiological mechanisms for BEH and chronic SDH, based on existing literature.

RESULTS

Perinatal SDH is common, and we hypothesise that this condition in some infants develop into extra-axial fluid collections, known as hygroma, BEH or chronic subdural haematoma. The mechanism seems to be an intradural bleeding that creates an obstructive layer preventing normal CSF absorption. The site where the bleeding originates from and those areas enveloped in blood from the primary damaged area are prone to later rebleeds, seen as 'acute on chronic' haematomas. With steady production of CSF and the blockage, increased intracranial pressure drives the accelerated skull growth seen in many of these children.

CONCLUSION

Perinatal SDH hampers CSF absorption, possibly leading to BEH and chronic SDH, with a high risk of false accusations of abuse. Close monitoring of head circumference could prove vital in detecting children with this condition.