A calvarial acute subdural hematoma migrating into the spinal canal in a young male

It is not common for an acute subdural hematoma (SDH) in the supratentorial region to show rapid resolution or migration during the clinical course. In this report, we present a rare case where the SDH in the supratentorial region was observed to rapidly migrate into the lumbar spinal canal, leading to severe radiculopathy. A 20-year-old male patient was admitted to the emergency department with severe headache after head trauma. The patient's overall condition was good, whereas his Glasgow Coma Scale score was 15 and blood pressure was normal. He had vomited 3 times after the onset of pain. No stiff neck was found, and the computed tomography showed an ASDH over the outer layer of the right hemisphere, causing a 7- to 8-mm shift. During the follow-up, the headache regressed and eventually resolved after 12 hours; however, another severe pain occurred in the lumbar region and in both legs. The pain worsened over time, progressing to sciatica in both legs. Acute SDH associated with a minor head trauma may migrate from the supratentorial compartment into the spinal canal by the help of elastic cerebral tissues in young adults and children.

Pathophysiology and management of spontaneous intracranial hypotension--a review

Spontaneous Intracranial Hypotension is a syndrome involving reduced intracranial pressure secondary to a dural tear which occurs mostly due to connective tissue disorders such as Marfans Syndrome, and Ehler Danlos Syndrome. Patients with dural ectasias leading to CSF leakage into the subdural or epidural space classically present with orthostatic headaches and cranial nerve deficits mostly seen in cranial nerves V-VIII. Diagnosis of SIH is confirmed with the aid of neuroimaging modalities of which Cranial MR imaging is most widely used. SIH can be treated conservatively or with epidural blood patches which are now widely being used to repair dural tears, and their effectiveness is being recognized. Recently epidural injection of fibrin glue has also been used which has been found to be effective in certain patients.

Serious head injury in young children: birth trauma versus non-accidental head injury

Birth injury of the skull and central nervous system can be a complication of a difficult delivery, especially following forceps or vacuum-assisted delivery. Birth trauma of the head can also mimic the appearance of a non-accidental head injury and is therefore an important differential diagnosis. We report on two young infants with serious head injuries. The difficult differential diagnosis birth trauma versus non-accidental head injury is discussed and the necessity for cooperation between clinicians, forensic doctors and specialized neuroradiologists is emphasized.

[Dilation of subarachnoid space around the optic nerve in a patient with subdural effusion: a case report]

A fifty-year-old man who had a history of minor head injury a month previously presented with headache, visual disturbance and papilloedema. Brain MR imaging showed bilateral subdural effusion and fat saturated orbital MR imaging demonstrated dilated subarachnoid space around the optic nerve. The diameter of the subarachnoid space behind the globe was 7.0 mm and that of the optic nerve was 3.5 mm. Bilateral simple drainage was performed to prevent deterioration of the visual disturbance. Light bloody fluid with a subdural pressure of 10.5 cmH2O was drained from the burr hole at the left side, and colorless fluid was drained from the right. Orbital MR imaging during continuous drainage revealed shrinkage of the subarachnoid space around the optic nerve. However, follow-up MR imaging 5 months after drainage showed disappearance of the subdural effusion and the reappearance of the subarachnoid space around the optic nerve, even though the size was smaller than before surgery. These findings suggest that the diameter of the optic subarachnoid space co-relates with the intracranial pressure, and may be an indication for increased intracranial pressure.

Traumatic subdural effusions in children following minor head injury

AIM

There is considerable disparity in literature as regards to the presentation of subdural fluid collections in children. In this report, the authors have tried to establish the clinical and radiographic criteria to define the subdural effusions (SDEs) in children following minor head injury.

METHODS

Twenty cases of traumatic SDEs following minor head injury were studied prospectively. The age of these children ranged from 1 month to 2 years with an average of 9 months. The duration from the onset of first symptom to presentation in our outpatient department varied from 1 month to 13 months with a mean of 4.2 months. The duration of follow-up was 6 months to 2 years with an average of 10 months.

RESULTS

Fourteen out of 20 (70%) children presented with subtle findings. Six out of 20 (30%) children presented with overt neurological signs and symptoms. Seizures were the most common mode of presentation in this group. Bilaterality and ventriculomegaly were more common in the subtle group, each with an incidence of 43%. Seven out of 20 (35%) cases required operative management of traumatic SDEs. Recurrence was seen in two of 20 (10%) cases who had been conservatively managed previously. Only one child showed conversion of traumatic subdural hygroma to chronic subdural hematoma on conservative management.

CONCLUSION

Traumatic SDEs in children following minor head injury need to be differentiated from other causes of subdural fluid collections in children. The clinical and radiological criteria proposed by us helps to identify this subset of cases in most of the children.

[Differential diagnosis of subdural liquor accumulation in recurrent craniocerebral injury]

Criteria are proposed for the diagnosis of the origin and time- lapse of subdural accumulations of liquor in patients with repeated craniocerebral injury. The set of this criteria includes specific features of association and relative position of subdural liquor accumulations, their volume, and intracranial manifestations of primary and repeated craniocerebral injuries. Algorithms and nomograms have been developed in the course of the study allowing for accurate differentiation between subdural liquor accumulations as consequences of primary and repeated craniocerebral injuries. The results of the study have implications for practical forensic medical evaluation of repeated craniocerebral injuries with subdural liquor accumulation.

Safety of Low-Dose Intrathecal Fluorescein in Endoscopic Cranial Base Surgery

Objective:

Intraoperative identification of cerebrospinal fluid (CSF) leakage is critical in successful closure after endoscopic cranial base surgery. Intrathecal injection of fluorescein is quite useful in identifying CSF leaks. However, complications have been reported with various doses and the technique has fallen out of favor. We explored the safety of low-dose intrathecal fluorescein administered to patients undergoing endoscopic cranial base surgery.

Methods:

A retrospective chart review and postoperative patient survey were performed. The nature and incidence of complications and subjective complaints were recorded in 54 patients who underwent endoscopic, endonasal approaches to the anterior cranial base and received intrathecal fluorescein after premedication with dexamethasone and diphenhydramine.

Results:

Intraoperative CSF leak was identified with fluorescein in 46.3% of the patients and helped determine the reconstruction technique. Postoperative CSF leak occurred in 9.3% of the patients and resolved with lumbar drainage. There were no seizures. Most side effects were nonspecific, transient, and likely not caused by fluorescein including malaise (57.4%), headache (51.9%), dizziness (31.5%), or nausea/vomiting (24.1%). Three patients (5.6%) experienced persistent subjective lower extremity weakness (n = 2) and numbness (n = 2) postoperatively; however, two of them had undergone lumbar drainage.

Conclusion:

Low-dose injection of intrathecal fluorescein after premedication with steroid and antihistamine agents is generally safe. Most symptoms are nonspecific and transient, likely caused by the surgery or lumbar drainage. However, fluorescein should be administered with some caution because it may be responsible for occasional lower extremity weakness and numbness.

External hydrocephalus in small children

OBJECTIVE

Confusion exists in literature regarding the entity of external hydrocephalus which has been addressed by different terms like subdural effusion, hygroma, benign infantile hydrocephalus, etc. In this report, the author has tried to define the clinical and radiological criteria for reaching the diagnosis of external hydrocephalus.

METHODS

Five children 9 months to 2 years of age with subdural fluid collection were studied prospectively for a period of 8 years. The radiological and clinical criteria sparsely described in literature were followed to study the profile of suspected cases.

RESULTS

Four children presented with craniomegaly; the fifth case had tense, wide, and bulging fontanelle. CT of all five children showed hemispheric extracerebral fluid collection with enlarged subarachnoid spaces. Three children had mild to moderate ventriculomegaly without significant periventricular lucency, while the other two had borderline ventricular enlargement. All were managed conservatively. All five children were asymptomatic at follow-up from 12 weeks to 2 years.

CONCLUSION

The possible conclusions from this study of rare cases are: external hydrocephalus needs differentiation from other conditions of subdural fluid collections. The radiological criteria such as (a) extracerebral fluid collection (relatively more in anterior convexity than posterior convexity), (b) dilatation of subarachnoid spaces, and (c) mild to moderate ventriculomegaly without (or with questionable) periventricular lucency may be helpful in making a radiological diagnosis of external hydrocephalus. Conservative treatment with acetazolamide helped in ameliorating the clinical features of the cases studied.

Facial nerve palsy-an unusual complication after evacuation of a subdural haematoma or hygroma in children

OBJECTIVE

This paper reports and discusses on the possible etiology of postoperative contralateral facial nerve palsy after uneventful evacuation of a subdural haematoma or hygroma after mild head trauma in two children with pre-existing middle cranial fossa subarachnoid cysts.

RESULTS

Two 14- and 15-year-old boys had prolonged headaches after mild head injuries. CT showed a right-sided middle cranial fossa arachnoid cyst in each patient. In one patient, an ipsilateral subdural haematoma was identified, and in the other, bilateral hygromas were identified. Exacerbation of symptoms required emergency evacuation of the subdural haematoma in the first child, and bilateral external drainage of the hygroma in the other child. In both children the late postoperative period was complicated by peripheral facial nerve palsies contralateral to the arachnoid cyst.

CONCLUSION

Facial nerve palsy may be a complication of hygroma or haematoma drainage. The etiology is not clear; traction of the facial nerve due to displacement of the brainstem may be the most likely explanation.

Unilateral traumatic posterior fossa subdural effusion in an infant

Supratentorial subdural effusion is common after infection and trauma, but rarely occurs in the posterior fossa, and is even less commonly unilateral. The authors report a rare case of unilateral traumatic posterior fossa subdural effusion with secondary hydrocephalus. A 6-month-old female infant presented with lethargy, poor appetite, and persistent vomiting after head trauma 2 weeks previously. A non-enhanced brain CT scan revealed a right posterior fossa subdural fluid collection that displaced the fourth ventricle and brainstem and dilated lateral ventricles. While monitoring the intracranial pressure, the baby was treated with temporary external subdural drainage, followed by a permanent subdural peritoneal shunt. The treatment and likely physiopathology of this unique case are discussed.

Neuroradiological aspects of subdural haemorrhages

AIMS

To review the neuroimaging of a series of infants and young children admitted to hospital with subdural haemorrhage (SDH).

METHODS

Neuroradiological investigations of 74 children under 2 years of age, from South Wales and southwest England, in whom an SDH or subdural effusion had been diagnosed between 1992 and 2001, were reviewed. Two paediatric neuroradiologists blinded to the original radiological report reviewed all the relevant images.

RESULTS

Neuroradiological review of images identified radiological features which were highly suggestive of non-accidental head injury (NAHI). Interhemispheric haemorrhages and SDHs in multiple sites or of different densities were almost exclusively seen in NAHI. MRI was more sensitive in identifying SDHs of different signal characteristics, posterior and middle cranial fossa bleeds, and parenchymal changes in the brain. CT scans, if performed with suboptimal protocols, were likely to miss small subdural bleeds.

CONCLUSIONS

Guidelines for neuroimaging in suspected NAHI are recommended. A radiologist with experience in NAHI should report or review these scans. The initial investigation should be CT, but MRI will also be necessary in most cases. Head CT should be an integral part of the skeletal survey in all infants less than 6 months of age referred for child protection investigation, and in children less than 2 years where child abuse is suspected and there are neurological signs, retinal haemorrhages, or fractures.

Rapid fluctuations in conscious state in a patient with an extensive spinal dural fistula

A man with a spontaneous spinal dural fistula and significant fluctuations in level of consciousness is discussed. The presentation was that of headache and vomiting followed by an initially enigmatic acute reduction in the level of consciousness. This required urgent evacuation of bilateral chronic subdural haematomas, believed to be causative. Following mobilisation, several episodes of presumed orthostatic intracranial hypotension occurred rendering the patient rapidly unconscious. A large spinal extradural CSF collection extending through the full length of the vertebral canal was later diagnosed however, the precise location of the fistulous leak could not be found radiologically. Non-operative management was successful. To the best of our knowledge, this is the first description of a spontaneous spinal cerebrospinal fluid leak of this magnitude. The case, pathogenesis, investigations and management of this rare entity are considered and the literature reviewed.

Contralateral subdural effusion after aneurysm surgery and decompressive craniectomy: case report and review of the literature

We report a complication of decompressive craniectomy in the treatment of aneurismal subarachnoid hemorrhage (SAH) and accompanying middle cerebral artery (MCA) infarction. A 56-year-old man presented with subarachnoid hemorrhage and right sylvian hematoma. He was diagnosed with high-grade SAH and medical therapy was employed. He showed rapid clinical deterioration on day 9 of his admission. Computed tomographic scans showed right MCA infarction and prominent midline shift. Because of the patient's rapidly worsening condition, further evaluation to find origin of SAH could not be obtained, and decompressive right hemicraniectomy was performed. During sylvian dissection, right middle cerebral and posterior communicant artery aneurysms were detected and clipped. One week after operation, a contralateral frontoparietal subdural effusion and left to right midline shift was detected and drained through a burr-hole. Through successive percutaneous aspirations, effusion recurred and complete resolution was achieved after cranioplasty and subduroperitoneal shunt procedures. Decompressive craniectomy is generally accepted as a technically simple operation with a low incidence of complications. In the light of this current case, we hypothesize that a large craniectomy may facilitate the accumulation of recurrent effusion on contralateral side creating a resistance gradient between two hemispheres. This point may be especially true for subarachnoid hemorrhage cases requiring aneurysm surgery. We conclusively suggest that subdural effusions may be resistant to simple drainage techniques if a large contralateral craniectomy does exist, and early cranioplasty may be required for treatment in addition to drainage procedures.

Cerebrospinal fluid leakage complicating skull base fractures: analysis of 81 cases

The aim of this study was to evaluate the results of conservative and surgical management options for traumatic cerebrospinal fluid (CSF) leakage complicating skull base fractures. The subjects were 81 patients who were treated between 1996 and 2003 for CSF leaks that had persisted for 24 h or longer after head injury. For each case the medical records were reviewed, and the data collected were as follows: demographic features, clinical and radiological findings, management options, complications and outcome scores. Analysis was done with patients grouped according to Glasgow coma scale (GCS) score at admission (<or=8 vs >8), and findings for three treatment methods (conservative, CSF drainage, surgery) were evaluated. In 32 cases (39.5%), the CSF leakage resolved spontaneously, and the mean hospital stay for these patients was 14+/-11 days. Twenty-four patients (29.6%) were treated by CSF drainage, and seven of these individuals ultimately required surgery to close the leak. Hospital stay was 17+/-7 days. Twenty-five patients (30.9%) underwent surgery as the initial treatment step, and the mean hospital stay for these individuals was 15+/-9 days. The large majority (74.2%) of patients with admission GCS scores <or=8 had poor outcomes. Compared with this group, a greater proportion of the CSF leaks in the patients with admission GCS scores >8 resolved spontaneously. The factors that had a critical influence on outcome in this series were level of consciousness on admission and presence of additional intracranial pathology associated with CSF leakage within cases of traumatic CSF fistulae due to skull base fractures. Treatment decisions should be dictated by the severity of neurological decline during the emergency period and the presence/absence of associated intracranial lesions. The timing for surgery and CSF drainage procedures must be decided with great care and with a clear strategy. The authors offer a treatment algorithm.

Removal of subdural-peritoneal shunts in infants

INTRODUCTION

A common method of treating subdural collections is the insertion of a unilateral subdural-peritoneal shunt. In most cases, the shunt can be removed a few months later, but there is the anxiety that removal could cause complications and some surgeons elect to leave the shunts permanently implanted, on the understanding that they are not causing problems. A retrospective review was performed of patients who had their subdural shunts removed after CT evidence of resolution of the collections, with the intention of assessing the possible risks and benefits.

MATERIALS AND METHODS

Of the 19 patients who had insertion of a subdural shunt for infantile subdural collections by a single surgeon between 1999 and 2003, 14 were eligible for removal of the shunt and 13 had the shunt removed, while in 1 patient the parents refused the option of removal. Mean age at shunt insertion was 9.1 months (range 1.5-25.4 months). The mean shunt implantation time was 5 months (range 0.5-11 months). The mean follow-up period was 30.3 months (range 1-59 months).

RESULTS

All shunts were removed successfully without complications. There was difficulty in removing the shunt in one case (implantation time 10 months) because of migration of the shunt, requiring extension of the incision and a small craniectomy. None of the patients required re-insertion of the shunt.

CONCLUSION

Subdural shunts can be removed safely, but it is advisable to perform such an operation during the first 6 months after insertion to avoid undue operative difficulties.

Chronic subdural haematoma after riding a roller coaster

We report a 20-year-old man who developed a chronic subdural haematoma (CSDH) after riding a "giant" roller coaster. The patient had a past history of a subdural hygroma, diagnosed six weeks after a motorcycle accident. Three months after this accident, he rode on a roller coaster, but suffered no direct head trauma during the ride. Three weeks later, he developed a CSDH requiring surgical evacuation. Roller coaster riding, associated with high velocities and extreme acceleration/deceleration forces is a modern cause of CSDH in the young, which may be increasing due to ever-faster rides.

Cerebral venous sinus thrombosis manifesting as bilateral subdural effusion

Three patients with bilateral subdural effusion, an exclusive manifestation of cerebral venous sinus thrombosis (CVST), are presented. A possible explanation of this rare occurrence is provided, and the differential therapeutic strategies are discussed. We propose to consider CVST in cases of subdural effusions of obscure origin. Appropriate imaging studies should not be delayed if there is suspicion of sinus thrombosis to enable adequate therapy to be started as soon as possible.

Serial positron emission tomography findings in a patient with hydrocephalic dementia and Alzheimer's disease

Comorbidity of normal pressure hydrocephalus (NPH) and Alzheimer's disease (AD) is not uncommon. However, few studies have reported the clinical courses of these patients in depth. A 73-year-old woman was confirmed to have AD by a biopsy performed during a shunt operation for NPH after a head trauma. She was followed for 4 years using serial neuropsychological tests and positron emission tomography (PET). Her clinical symptoms remained improved for 2.5 years and then declined. The 1-year minus the presurgical PET scan highlighted the bilateral frontal area, basal ganglia, and thalamus, which may reflect brain regions associated with the improvement of hydrocephalic dementia. On the other hand, the 1-year minus the 4-year scan highlighted the bilateral temporoparietal area and the posterior cingulate gyrus, which may reflect brain regions associated with the aggravation of AD. This subtraction method may be useful for monitoring the clinical course in patients with NPH and AD.

Toward optimal tissue sealants for neurosurgery: use of a novel hydrogel sealant in a canine durotomy repair model

OBJECTIVE

Watertight dural repairs are difficult to achieve, and cerebrospinal fluid leakage causes complications and extends hospital stays. Therefore, a novel synthetic hydrogel film was evaluated as an adjunct to dural closure in a canine model.

METHODS

The self-polymerizing, absorbable, and biocompatible hydrogel was sprayed onto tissue and formed a flexible, adherent sealant. A 2-cm incision of cranial dura and arachnoid was created in 26 adult dogs and loosely repaired. Hydrogel was applied over the 2-mm dural gap in 13 dogs; 13 control dogs received no hydrogel application.

RESULTS

All dogs remained neurologically intact. Valsalva tests conducted at 1, 4, 7, and 56 days were associated with mean leakage pressures (+/- standard error of the mean) of 5 +/- 0, 5 +/- 0, 7 +/- 2, and 13 +/- 8 cm H(2)O in the controls and of 53 +/- 2, 37 +/- 11, 42 +/- 6, and 48 +/- 4 in the treated animals (P = 0.001, 0.053, 0.010, 0.035, respectively, at each time point; one-tailed t test). Histopathological analysis revealed minimal changes.

CONCLUSION

The hydrogel-treated animals exhibited normal progression of dural healing, no dural adhesions, and no underlying effects on the brain. Although dural healing progressed normally, the control animals displayed marked peridural adhesions. The results of this in vivo study suggest that hydrogels, such as that used here, may significantly decrease cerebrospinal fluid leakage, thereby increasing the safety and effectiveness of dural closure in patients and facilitating surgical reexploration.

Malassezia furfur meningitis associated with total parenteral nutrition subdural effusion

We present a case of Malassezia furfur meningitis arising in a very low birth weight infant with chronic lung disease, necrotizing enterocolitis, and intraventricular hemorrhage. M. furfur meningitis was probably acquired late following successful treatment for earlier systemic central line-associated M. furfur infection. M. furfur meningitis has only once been previously reported. Unlike the previous case where meningitis was secondary to widespread blood-borne dissemination, infection was limited to the leptomeninges and arose in association with extravasation of total parenteral nutrition (TPN) and intralipid fluid into subarachnoid space via peripheral scalp catheter.

Subdural hygroma: an unwanted result of Sylvian arachnoid cyst marsupialization

INTRODUCTION

Subdural hygroma is a known complication of Sylvian fissure arachnoid cysts (SACs). However, most of the data in the literature refer to spontaneous or posttraumatic occurrence of subdural hygromas, regarded as either a favorable or an unfavorable event. Little is known about this phenomenon as a consequence of the surgical management of SACs. The present study was carried out to evaluate the significance of postoperative subdural hygromas in children with temporal arachnoid cysts, who have been treated with craniotomy and wide marsupialization of the cystic membrane.

CLINICAL MATERIAL AND RESULTS

Between 1980 and March 2002, 104 children were operated on for a SAC at the Pediatric Neurosurgical Unit of the Catholic University Medical School in Rome. Six patients (5.8%; boys/girls=4/2; mean age 3.28 years) developed a subdural hygroma postoperatively, which required further treatment. According to Galassi's classification 4 children had a Type III cyst and 2 children a Type II cyst. All the patients had previously been submitted to open marsupialization of their arachnoid cyst and extensive removal of the cyst wall. In 5 patients (Type III cyst: 4 patients; Type II cyst: 1 patient), acute or subacute symptoms and signs of increased intracranial pressure (ICP) developed at a temporal distance, varying from 5 days to 1 month (mean interval: 14.3 days). All these children needed surgical treatment for the hygroma. A subduro-peritoneal (SDP) shunt was implanted as the first step in 3 patients (Type III cyst: 2 patients; Type II cyst: 1 patient). In the remaining 2 patients of this group (Type III cysts) medical therapy was initially attempted (acetazolamide: 24 mg/kg) without any improvement in clinical manifestations; on these grounds an external spinal subarachnoid drainage was implanted, but led only to the transient clearance of symptoms. The direct drainage of the subdural collection (SDP shunt in 1 patient and temporary external subdural drainage in the other), was followed by complete clinical recovery in both cases. The last patient in this series showed a pathologic increase in head circumference during the 1st month after surgery for his arachnoid cyst, followed by a subsequent stabilization. A CT scan documented a subdural hygroma, which first of all increased in size, but stabilized 2 months after surgery. No surgical treatment was performed in this case. At a mean follow-up of 2.38 years (minimum: 1 month; maximum: 5 years) all the patients are in excellent clinical conditions. Complete neuroradiological resolution of the hygroma was observed in 2 of the 4 shunted patients, who have both been submitted to shunt removal (2 and 3 years after the implant respectively).

CONCLUSIONS

It is our opinion that a wide opening of the external membrane of SACs may predispose the CSF fluid to accumulate within the subdural space, where its absorption is insufficient. A ball mechanism created by CSF pulsation may further increase the subdural fluid accumulation. Secondary distortion and occlusion at the level of the basal cisterns may also contribute to the persistence of the subdural fluid collection. Clinical manifestations may be transient, but frequently have a progressive course and the drainage of the subdural collection is, though transient, required in most cases. On these grounds we suggest the selective opening of the basal cisterns associated with a limited resection of the outer cyst walls in order to limit CSF access to the subdural space.

Subdural hygroma as a complication of endoscopic neurosurgery--two case reports

Two cases of subdural hygroma occurred in a series of 77 neuroendoscopic procedures. An 8-year-old boy underwent neuroendoscopic cysto-cisternostomy of a left temporal arachnoid cyst. Routine postoperative magnetic resonance imaging 7 days later showed a large left-sided subdural hygroma without clinical symptoms. During the following 3 months, the subdural hygroma did not resolve spontaneously, so it was drained through a burr hole. A 3-month-old boy with aqueductal stenosis developed bilateral subdural hygromas after third ventriculostomy. Several punctures through the open anterior fontanelle relieved the hygromas but increasing head circumference required ventriculoperitoneal shunting 12 months later. Complications of neuroendoscopic procedures are increasingly reported, including various kinds of bleeding, infections, or damage of neuronal tissue. Only three previous cases of subdural hygroma or hematoma after neuroendoscopic interventions have been reported. The possible etiologies and clinical consequences of this rare complication have to be considered before selecting neuroendoscopy treatment.

Age-related changes in the proportion of intracranial cerebrospinal fluid space measured using volumetric computerized tomography scanning

OBJECT

The purpose of this study was to establish a standard curve to demonstrate normal age-related changes in the proportion of intracranial cerebrospinal fluid (CSF) space in intracranial volume (ICV) during each decade of life.

METHODS

Using volumetric computerized tomography (CT) scanning and computer-guided volume measurement software, ICV and cerebral parenchymal volume (CPV) for each decade of life were measured and the intracranial CSF ratio was calculated by the following formula: percentage of CSF = (ICV - CPV)/ICV x 100%. The standard curve for age-related changes in normal percentages of intracranial CSF was obtained.

CONCLUSIONS

Based on this standard curve, the percentage of intracranial CSF rapidly increased after the sixth decade, seeming to reflect the brain atrophy that accompanies increased age.

Discrepant time course of cranial and spinal subdural collections in a case of SIH treated by EBP

The MR monitoring of a patient with acute spontaneous intracranial hypotension successfully treated by epidural blood patch revealed strikingly different time course of the initially concomitant cranial and spinal subdural fluid collections. This undescribed feature suggested different pathophysiological mechanisms for the disorder in the two locations and should be kept in mind when imaging patients with the condition.

A case of schizencephaly with subdural fluid collection in a neonate

CASE REPORT

A neonate who had schizencephaly associated with ipsilateral chronic subdural fluid collection in the neonatal period is described. A boy was born to a healthy Japanese woman. After birth, the boy presented with rapid expansion of head circumference. Computed tomography (CT) and magnetic resonance images (MRI) of the head demonstrated left schizencephaly combined with a midline shift attributable to hydrocephalus. Thereafter, the patient gradually presented other symptoms caused by increased intracranial pressure. Ultrasonography and MRI of the head showed the presence of a subdural fluid collection overlaid on the schizencephaly. We identified the outer membrane by burr-hole craniotomy.

CONCLUSION

This was a rare case of schizencephaly associated with hydrocephalus and the formation of ipsilateral chronic subdural fluid collection.

Surgical treatment of chronic subdural hygromas in infants and children

BACKGROUND

Extra-axial chronic fluid collections are pathological conditions occurring more frequently in the paediatric age, particularly in children less than two-year-old. Although recognised for many years and repeatedly reported in the literature, some aspects of their treatment are still under debate. This review of the management of chronic subdural collections is based on our experience of 72 cases treated between January 1984 and December 2000.

METHOD

Patients were divided into four groups according to aetiology. Thirty-four cases (47%) occurred following various surgical procedures; 14 cases (20%) occurred as complications of leptomeningeal infections; 13 cases (18%) were post-traumatic, whereas no obvious aetiology could be detected in the last 11 cases (15%). The collections were unilateral in 34 patients (47%) and bilateral in the other 38 (53%).

FINDINGS

Thirty-five patients (48%) were treated by means of a temporary subdural external drainage (SED) (for a total of 38 SED procedures), which was maintained for a mean of 5.8 (+/-3.4) days; it was effective in 26 cases, whereas in the other 9 it was necessary to perform a subdural-peritoneostomy (SPS). Three of these 38 SEDs were complicated by infection. In one more child the external drainage was complicated by a chronic subdural haematoma. A SPS was performed in 44 cases (61%), 9 being failed external drainages. Only in 16 (38%) of these 44 patients the SPS was removed after an average of 27.0 (+/-16.6) months. Three patients (4%) were treated by craniotomy and resection of the neomembranes lining the subdural fluid collection. Obstruction of the SPS occurred in 6 children, infection in 4. Good results were obtained with either external or internal drainage. In fact post-operative neuroradiological investigation disclosed in all the cases complete or almost complete cerebral re-expansion; also the clinical outcome was generally very good, although largely dependent upon the basic clinical condition. Unilateral subdural-peritoneal and/or external drainage was effective also in case of bilateral collections. Only 2 patients required temporary bilateral external drainage.

Spontaneous spinal cerebrospinal fluid leaks and minor skeletal features of Marfan syndrome: a microfibrillopathy

OBJECT

Spontaneous spinal cerebrospinal fluid (CSF) leaks are increasingly recognized as a cause of postural headaches. The authors examined a group of patients suffering from spontaneous spinal CSF leaks who also had minor skeletal features of Marfan syndrome for abnormalities of fibrillin-containing microfibrils.

METHODS

Patients with spontaneous CSF leaks were evaluated for the clinical characteristics of connective tissue disorders. Skin biopsies were obtained in three patients with skeletal manifestations that constitute part of the Marfan syndrome phenotype. Cultured fibroblasts were studied for fibrillin-1 synthesis and incorporation into the extracellular matrix (ECM) by performing quantitative metabolic labeling and immunohistochemical analysis. Among 20 consecutive patients found to have spinal CSF leaks, four (20%) exhibited minor skeletal features of Marfan syndrome, but lacked any ocular or cardiovascular abnormalities. The mean age of these patients (30 years) was lower than that of the 16 patients without skeletal abnormalities (44 years; p = 0.01). Abnormalities in fibrillin-1 metabolism and immunostaining were detected in all three patients with the skeletal abnormalities who underwent examination, but not in a control patient without these skeletal manifestations.

CONCLUSIONS

Twenty percent of patients who experience spontaneous spinal CSF leaks have minor skeletal features of Marfan syndrome. The authors demonstrated abnormalities in fibrillin-1 protein deposition in all patients examined, but only one person was found to have a fibrillin-1 abnormality typically found in classic Marfan syndrome. The results indicate that there is a heterogeneous involvement of other components of ECM microfibrils at the basis of this cerebrospinal manifestation. In addition, the authors identified a connective-tissue etiological factor in a group of disorders not previously classified as such.

[Magnetic resonance in dural post-puncture headache in patient with cerebrospinal fluid hypotension]

Magnetic resonance imaging (MRI) has allowed us to establish a set of radiologic signs associated with intracranial hypotension syndrome. Findings are partly influenced by cerebral displacement. Intracranial hypotension syndrome is characterized by a decrease in cerebrospinal fluid (CSF) pressure to less than 60 mm H2O associated with occipital headache radiating to the frontal and temporal zones. For diagnostic purposes, the most common cause is anesthetic or therapeutic dural puncture, although spontaneous CSF leakage can occur. CSF protein and lymphocyte counts may be high, while the cranial meninges biopsy is normal. MRI images may show a descended brain, taking the start of the sylvian aqueduct and the location of the cerebellar amygdalae as points of reference; diminished size of the subarachnoidal cisterns and occasionally of the cerebral ventricles; meningeal enhancement from increased uptake of the contrast solution; subdural hygromas and hematomas; and pituitary enlargement. Paraspinal fluid and dilated epidural veins may be observed. Radiologic images and clinical signs are related. When CSF pressure is very low, there is greater meningeal enhancement, subdural collection and cerebral displacement. Findings gradually disappear as symptoms diminish. The signs and symptoms that might develop during intracranial hypotension syndrome vary according to the brain structure that might be affected during descent, repositioning and the traction of anchoring structures. MRI allows the degree of cerebral and spinal involvement to be ascertained, to predict whether resolution of the clinical picture will be early or late and to visualize the effect of approaches to reducing CSF leakage.

Meningitis in a girl with recurrent otitis media caused by Streptococcus pyogenes--otitis media has to be treated appropriately

Streptococcus pyogenes rarely causes meningitis. A recent increase in the incidence and severity of diseases due to S. pyogenes has been observed worldwide, without an apparent increase in the incidence of S. pyogenes meningitis. However, more recently severe and fulminant cases of S. pyogenes meningitis have been reported in the literature. This case report emphasizes the fact that S. pyogenes can cause meningitis with severe clinical sequelae such as hygromas and right-sided third cranial nerve palsy. Most importantly, it is concluded that recurrent otitis media has to be treated carefully following appropriate identification of the causing organism in order to prevent severe clinical courses of streptococcal infections.

Spontaneous intracranial hypotension

Spontaneous intracranial hypotension (SIH) is typically manifested by orthostatic headaches that may be associated with one or more of several other symptoms, including pain or stiffness of the neck, nausea, emesis, horizontal diplopia, dizziness, change in hearing, visual blurring or visual field cuts, photophobia, interscapular pain, and occasionally face numbness or weakness or radicular upper-limb symptoms. Cerebrospinal fluid (CSF) pressures, by definition, are quite low. SIH almost invariably results from a spontaneous CSF leak. Only very infrequently is this leak at the skull base (cribriform plate). In the overwhelming majority of patients, the leak is at the level of the spine, particularly the thoracic spine and cervicothoracic junction. Sometimes, documented leaks and typical clinical and imaging findings of SIH are associated with CSF pressures that are consistently within limits of normal. Magnetic resonance imaging of the head typically shows diffuse pachymeningeal gadolinium enhancement, often with imaging evidence of sinking of the brain, and less frequently with subdural fluid collections, engorged cerebral venous sinuses, enlarged pituitary gland, or decreased size of the ventricles. Radioisotope cisternography typically shows absence of activity over the cerebral convexities, even at 24 or 48 hours, and early appearance of activity in the kidneys and urinary bladder, and may sometimes reveal the level of the leak. Although various treatment modalities have been implemented, epidural blood patch is probably the treatment of choice in patients who have failed an initial trial of conservative management. When adequate trials of epidural blood patches fail, surgery can offer encouraging results in selected cases in which the site of the leak has been identified. Some of the spontaneous CSF leaks are related to weakness of the meningeal sac, likely in connection with a connective tissue abnormality.

Syndrome of cerebral spinal fluid hypovolemia: clinical and imaging features and outcome

OBJECTIVE

To investigate clinical, MRI, and radioisotope findings and therapeutic outcome of the syndrome of CSF hypovolemia.

METHODS

Retrospective review was performed of 30 consecutive patients (10 men, 20 women; mean age 37 years) with the syndrome of CSF hypovolemia.

RESULTS

All patients had an orthostatic headache, which was alleviated to a variable extent on recumbency. Additional clinical symptoms included nausea, dizziness, neck stiffness, blurring of vision, tinnitus, plugged ear, hearing difficulties and radicular pain of the arm. Eighty-two percent of the patients had CSF opening pressure less than 60 mm H2O, 59% had CSF pleocytosis, and 95% had increased CSF protein. Brain MRI showed diffuse pachymeningeal gadolinium enhancement on T1-weighted image in 83%, which was seen as hyperintense signals on T2-weighted imaging. Other features included subdural hematoma/hygroma in 17% and descent of the brain in 48% of the patients. Radioisotope cisternographic results identified CSF leakage sites in 52%, most often at the lumbar region. Also observed were limited ascent of the tracer to the cerebral convexity (91%), early appearance of radioisotope in the bladder (65%), and early soft tissue uptake of radioisotope (43%). Epidural blood patches were performed in 23 patients, which produced complete resolution of headaches in 70%. Two patients underwent drainage of subdural hematoma. None died or were disabled during hospitalization.

CONCLUSIONS

Patients with CSF hypovolemia frequently have distinct MRI and radioisotope cisternographic abnormalities and often respond favorably to an epidural blood patch.

The fate of traumatic subdural hygroma in serial computed tomographic scans

We reviewed serial computed tomographic (CT) scans of 58 patients with traumatic subdural hygroma (SDG) to investigate its natural history. All were re-evaluated with a special reference to the size and density of SDG. Thirty-four patients (58.6%) were managed conservatively and 24 patients (41.4%) underwent surgery. The lesion was described as remained, reduced, resolved, enlarged and changed. Means of interval from injury to diagnosis and any changes in CT were calculated. SDGs were resolved in 12 (20.7%), reduced in 15 (25.9%), remained in 10 (17.2%), enlarged in 2 (3.4%), and changed into chronic subdural hematoma (CSDH) in 19 patients (32.8%). SDG was diagnosed at 11.6 days after the injury. It was enlarged at 25.5 days, remained at 46.0 days, reduced at 59.3 days, resolved at 107.5 days, and changed into CSDH at 101.5 days in average. SDGs were developed as delayed lesions, and changed sequentially. They enlarged for a while, then reduced in size. The final path of a SDG was either resolution or CSDH formation. Nearly half of SDGs was resolved or reduced within three months, however, 61.3% of unresolved or unreduced SDG became iso- or hyperdense CSDH. These results suggest that the unresolved SDG is the precursor of CSDH.

Location of the traumatic subdural hygroma: role of gravity and cranial morphology

Traumatic subdural hygroma (TSH) is frequently bilateral and locates on the top of the head in a supine position. It suggests that the gravity and cranial posture act a certain role. The authors tried to test this hypothesis. The computed tomographic (CT) scans or magnetic resonance (MR) images of 86 consecutive patients with TSH were re-evaluated. The symmetry of the cranium, the posture of the head during the radiological examinations, and the location of the lesion were all checked. The cranium was symmetrical in 47 patients and asymmetrical in 39 patients. TSH was more commonly bilateral in patients with symmetrical cranium than those with asymmetrical cranium (77% vs 62%). The asymmetrical cranium tended to turn to the flat side. It was more frequently oblique in MR images, which has a long scanning time, than in CT (29% vs 18%). In 39 asymmetric craniums, TSH was bilateral and it was symmetrical in 14 cases. In the remaining 25 cases, TSH located opposite to the flat side in 18 cases. In seven patients with the same side TSHs, four patients had it on the side of atrophy, two on the opposite side of a mass lesion. The gravity and cranial posture can predict the location of TSH. TSH usually occurs at the least pressure in the cranium as a lesion of ex vacuo.

Infected subdural effusion associated with resolving subdural hematoma--case report

A 70-year-old male presented with rapid neurological deterioration and fever 3 months after suffering a closed head trauma. He underwent craniotomy for possible subdural empyema based on computed tomography and clinical findings. Dural incision revealed an outer membrane typical of chronic subdural hematoma which covered a clear, yellowish fluid containing Campylobacter fetus. Histological examination confirmed the capsule of the hematoma, with a necrotic focus infiltrated by neutrophils. Administration of intravenous imipenem and topical tobramycin and cefalothin achieved total resolution of his neurological deficits. Development of the infected subdural effusion was probably secondary to bacterial infection in the pre-existing chronic subdural hematoma in the resolving stage. The presence of the hematoma capsule always carries the risk of development of an infectious focus.

Spontaneous intracranial hypotension: clinical and magnetic resonance imaging characteristics

The syndrome of spontaneous intracranial hypotension (SIH) is an uncommon cause of postural headache. We describe three patients with classical low pressure headache associated with low CSF pressure, one of whom presented with sudden deafness and another with a unilateral VIth nerve palsy. Initial magnetic resonance imaging (MRI) scans revealed bilateral diffuse subdural fluid collections in all three cases. Follow up MRI scans performed on two patients at 6 months demonstrated partial resolution of the subdural collections but persistent striking meningeal enhancement despite clinical recovery. These findings differ from previous reported cases wherein clinical resolution of postural symptoms was preceded or closely followed by resolution of the MRI changes.

Subarachnoid fluid collection in infants complicated by subdural hematoma

In the natural history of infantile extracerebral fluid collections, subarachnoid fluid collection itself is regarded as a benign lesion, and surgical treatment is not indicated. As this condition is age-related and self-limiting, spontaneous resolution can be expected in most cases by 2-3 years of age. However, out of 20 cases of infantile subarachnoid fluid collection in an 8-year period, 3 infants developed subdural hematoma. Infantile subarachnoid fluid collection seems to be prone to complicate subdural hematoma. Surgical treatment should be considered when subarachnoid fluid collection is complicated by subdural hematoma due to arachnoid ruptures or tearing of the bridging veins. Therefore, all patients should be observed closely and measures should be taken to prevent head trauma since it may precipitate subdural hematoma.

Subdural effusions in children under two years--clinical and computer-tomographical data

We investigated 161 children under 24 months of age by CT of the skull and reviewed the anamnestic and clinical history. 87 children showed subdural effusions, and 74 did not. There were 33 patients with other pathological findings in CT, and 41 had normal scans. Age and sex distribution as well as localization of the subdural effusions were consistent with the literature. The 87 children with subdural effusions represented 1.7% in a sample of about 5.000 CT scans. CT was the most reliable method for diagnosis of subdural effusions, compared to other techniques. There was a preponderance of small subdural effusions from 1 to 7 mm thickness (51%). Other CT abnormalities accompanying subdural effusions were found. Most frequently the interhemispheric sulcus was dilated and an internal hydrocephalus was present. Also in our group there were 7 anamnestical and 6 clinical symptoms highly diagnostic of subdural effusions.

Malignant subdural effusion. A case report

A case of subdural effusion caused by carcinomatous metastatic dural deposits is presented. An attempt is made to explain the possible underlying pathophysiological mechanism of malignant subdural haemorrhagic effusion. Whenever malignant subdural effusion is suspected, biopsy of the membrane and cytological examination of the fluid is imperative for a definite diagnosis.