Spontaneous spinal epidural haematoma: report of two cases and review of the literature.

The clinical presentation, investigation, management and outcome of two patients with spontaneous spinal epidural haematoma (SSEH) are presented. CT myelogram revealed an extradural compressive lesion in one patient and MRI confirmed extradural haemorrhage in the second. Both the cases were treated surgically. One patient made a complete recovery and the other made no neurological recovery. The clinical presentation, diagnosis, treatment and factors determining the outcome of SSEH are discussed and the literature reviewed.     

Spinal cord changes after the evacuation of a spinal subdural haematoma

Spinal subdural haematoma is a rare entity. Only a few cases have been reported, mainly in patients with coagulopathies or bleeding diathesis, and also in patients undergoing anticoagulant therapy following surgery, trauma, or lumbar puncture. Symptoms of spinal cord compression produced by spinal subdural haematoma may progress rapidly causing complete and irreversible deficits. However, rapid diagnosis and surgical intervention can result in a good functional outcome for the patient. We report on a 41-year-old woman with a normal coagulation profile who developed a spinal subdural haematoma after a minor motor vehicle accident. Although initially asymptomatic, she developed a dense quadriparesis over a 36-h period. A magnetic resonance imaging study demonstrated a subdural mass compressing the spinal cord, and at surgery a spinal subdural haematoma was found. She was discharged to an inpatient rehabilitation facility. Follow-up at 1 year showed significant improvement in motor function, but absence of posterior column function. A follow-up magnetic resonance study demonstrated widening of the spinal cord, advanced myelomalacia and a large, central, multi-loculated syrinx.     

Chronic lumbar extradural haematoma simulating disc syndrome

Two patients presenting with a clinical picture of nerve root compression suggestive of the herniated disc syndrome are reported. In both the diagnosis proved to be chronic encapsulated extradural haematoma. Recognition of this entity at the time of surgical exposure should render the surgical dissection easier. The postoperative results in both were excellent. One of these patients was on chronic anticoagulant therapy and the unusual location and good prognosis of extradural haematoma in the lumbar spinal canal in such patients is emphasized. In the other, the haematoma developed after a minor back injury, which introduces medico-legal implications.     

Low incidence of seizures in patients with chronic subdural haematoma.

A total of 129 patients treated for chronic subdural haematoma were studied retrospectively to evaluate the incidence of seizures. None of 73 patients who were given prophylactic antiepileptic drug treatment developed seizures. Only two of 56 patients not given prophylaxis, developed early postoperative seizures. In these two, surgical technique was thought to be responsible. One patient developed complex partial seizures preoperatively. The incidence of seizures was therefore low, and similar to that previously reported for minor head injury. This study suggests that routine use of antiepileptic prophylaxis is not justified in patients with chronic subdural haematoma caused by minor head injuries, or other causes when there are no additional lesions present on CT scans.     

自发性低颅压综合征31例临床特征和影像学分析

目的 探讨自发性低颅压综合征（SIH）的临床特点和影像学改变.方法 回顾性分析31例SIH患者的临床及影像资料.结果 所有患者均有体位性头痛,可伴有恶心、呕吐、头晕、耳鸣、听力丧失、行走不稳、一过性视物模糊、复视、颈肩部疼痛、颈强直 CSF压力均＜70 mmH2O,蛋白升高12例,WBC增多11例,RBC增多7例 全部患者行头颅CT检查,8例见脑肿胀,脑沟变浅,脑室变窄,临床症状消失后复查均恢复正常 15例行头颅MRI检查,8例行增强检查示硬脑膜弥漫性强化,头颅CT及MRI检查见4例硬膜下积液、2例硬膜下血肿 全部患者采用内科综合疗法,1例行硬膜下血肿清除术,均痊愈.结论 SIH的临床表现多样,体位性头痛是特征性症状,腰穿CSF及头颅MRI检查具有诊断价值 本病预后良好,但少数并发硬膜下血肿.     

Abnormal brain scan with subacute extradural haematomas

Four patients are described with proven subacute extradural haematomas, each with an abnormal cerebral scan of diagnostic assistance. A possible mechanism of production of the subacute extradural haematoma is discussed, and appears to be similar to the mechanism involved in the subacute subdural haematoma. The means by which the abnormal scan results in such cases is also examined, from which it appears that non-specific meningeal membrane inflammatory reaction surrounding the haematoma is significant.     

Spontaneous intracranial hypotension in the absence of magnetic resonance imaging abnormalities

BACKGROUND: Spontaneous intracranial hypotension (SIH) is a neurologic syndrome of unknown etiology, characterized by features of low cerebral spinal fluid (CSF) pressure, postural headache and magnetic resonance imaging (MRI) abnormalities. METHODS: Four symptomatic cases of SIH presented to our institution over a six-month period. Magnetic resonance imaging studies were performed in all four cases. Diagnostic lumbar puncture was done in all except one case. RESULTS: All of the patients on whom lumbar punctures were performed demonstrated low CSF pressure and CSF protein elevation with negative cultures and cytology. Three out of the four patients exhibited MRI findings of diffuse spinal and intracranial pachymeningeal gadolinium enhancement and extradural or subdural fluid collections. One patient had no MRI abnormalities despite prominent postural headache and reduced CSF pressure at lumbar puncture. All patients recovered with intravenous fluids and conservative treatment. CONCLUSIONS: Magnetic resonance imaging abnormalities are found in most, but not all patients, with SIH. Cerebral spinal fluid abnormalities can be detected even in patients with normal MRI studies. It is important to recognize the variability of imaging results in this usually benign disorder.     

Prospective analysis of bedside percutaneous subdural tapping for the treatment of chronic subdural haematoma in adults

OBJECTIVES: Although there is general agreement that surgery is the best treatment for chronic subdural haematoma (CSDH), the extent of the surgical intervention is not well defined. METHODS: The less invasive surgical technique of bedside percutaneous subdural tapping and spontaneous haematoma efflux after twist drill craniostomy under local anaesthesia was prospectively analysed in 118 adult patients, 99 with unilateral and 19 with bilateral CSDH. RESULTS: The mean number of subdural tappings was 3.2. Ninety two of the patients with unilateral CSDH were successfully treated by up to five subdural tappings, 95% of the patients with bilateral CSDH were successfully treated by up to 10 subdural tappings. The mean duration of inpatient treatment was 12 days. In 11 patients (9%) the treatment protocol had to be abandoned because of two acute subdural bleedings, two subdural empyemas, and seven cases of insufficient haematoma efflux and no neurological improvement. The only significant predictor for failure of the described treatment protocol was septation visible on preoperative CT. CONCLUSIONS: The described therapy protocol is-apart from a purely conservative treatment-the least invasive presently available surgical technique for treating chronic subdural haematoma. Its results are comparable with other modern treatment protocols. Thus, it can be recommended in all patients as a first and minimally invasive therapy, especially in patients in a poor general condition. Patients with septation visible on preoperative CT should be excluded from this form of treatment.     

Haematoma of the tentorium cerebelli - new pathology or new prognostic factor in neurotraumatology? A preliminary report

BACKGROUND AND PURPOSE: The aim of the study was to establish the frequency of haematoma of the tentorium cerebelli, to elucidate the possible pathomechanism related to its formation, and to assess its clinical significance. MATERIAL AND METHODS: 84 patients with haematoma of the tentorium cerebelli were selected out of the 1159 patients treated in our Department from 2003 to 2005 due to craniocerebral trauma. All patients had computed tomography (CT) performed on admission. In selected cases, magnetic resonance imaging (MRI) was performed. Additionally, 4 autopsies were performed using a special technique for better recognition of blood location within the region of the tentorium. RESULTS: The study group comprised 61 men (73%) and 23 women (age range: 18-84 years). Fall on the occiput was the main cause of trauma. The clinical status of patients was rather serious (53% of patients scored below 8 pts on the Glasgow Coma Scale on admission), as was the clinical course (39% of patients eventually died). The following co-existing pathologies were found in CT: traumatic subarachnoid haemorrhage and cerebral contusion (60% of patients), subdural haematoma (45%), intracerebral haematoma (31%), pathology in posterior fossa (12%), and epidural haematoma (8%). MRI revealed subdural collection of blood above or below the tentorium or the subarachnoid haemorrhage beneath the occipital lobes and/or over the cerebellar hemisphere. CONCLUSIONS: The progress in neuroimaging, especially in CT scanning, enables haematoma of the tentorium cerebelli to be discerned as a distinct clinical entity.     

Successful conservative treatment of traumatic subacute subdural haematomas in neonates with haemophilia A

PURPOSE: The aim of this report is to enlighten the role of an early diagnosis and treatment of haemophilia A during the management of an intracranial haemorrhage as well as to discuss the efficiency of a subdural transcoronal puncture compared to a craniectomy as surgical treatment of the haematoma. BACKGROUND: Haemophilia A constitutes a well-known risk factor for intracranial bleeding. However, it has been rarely described as a cause of subdural haematoma in neonates. Management of subdural haematomas in haemophilic patients is still debated. MATERIALS AND METHODS: We report two cases of infants with subacute subdural haematoma. The first of them had a familial history of haemophilia A. In the second subject, the diagnosis was obtained during the etiological workup of an intracranial haematoma. Both infants were successfully treated with transcoronal puncture of the subacute component of the haematoma and factor VIII infusion. CONCLUSIONS: Transcranial punctures associated to infusion of factor VIII should be considered an alternative surgical option in the management of subdural haematomas in neonates with haemophilia A.     

Post-surgical thoracic pseudomeningocele causing spinal cord compression

Pseudomeningoceles are extradural cerebrospinal fluid collections categorized into three groups: traumatic, congenital, and iatrogenic. Iatrogenic pseudomeningoceles occur after durotomy, usually after cervical or lumbar spine surgery. Although many remain asymptomatic, pseudomeningoceles can compress or herniate the spinal cord and nerve roots. We present a 57-year-old woman who had a thoracic laminectomy and discectomy. Two weeks after surgery, she presented with lower extremity weakness and gait difficulty. Physical examination revealed hyperreflexia and a T11 sensory level. MRI revealed a pseudomeningocele compressing the thoracic spinal cord. The patient underwent surgical drainage of the cyst. On follow-up, she had complete resolution of her symptoms, and MRI did not show a residual lesion. To our knowledge, this is the second documented post-operative pseudomeningocele causing symptomatic spinal cord compression of the thoracic spine. In this article, a review of the literature is presented, including four reported patients with post-traumatic pseudomeningocele causing myelopathic symptoms and 20 patients with iatrogenic pseudomeningocele that resulted in neurological decline due to herniation or compression of neural tissue. Treatment options for these lesions include conservative management, epidural blood patch, lumbar subarachnoid drainage, and lumbo-peritoneal shunt placement. Surgical repair, usually by primary dural closure, remains the definitive treatment modality for iatrogenic symptomatic pseudomeningoceles.     

Predicting posttraumatic epilepsy with MRI: prospective longitudinal morphologic study in adults

PURPOSE: Evaluation of morphologic risk factors for posttraumatic epilepsy (PTE) by using brain magnetic resonance imaging (MRI) in serial assessments 相似文献   

Lumbar subdural haematoma after temporomesial resection in epilepsy patients--report of two cases and review of the literature

We present two cases of lumbar subdural haematoma, both occurring after an uneventful temporomesial focus resection in patients suffering from medically intractable epilepsy. Initial symptom was back pain and sciatica 4 days and 13 days postoperatively, but no neurological deficits were observed. The diagnosis was confirmed by MRI. No risk factor could be identified. The pain responded well to conservative treatment and the haematomas resolved without neurological sequelae. A review of the literature reveals that the characteristics of spinal subdural haematoma following craniotomy are very similar. Six out of 12 reported cases occurred in temporal epilepsy surgery. All had a benign course and did not require an operative procedure. Back pain after epilepsy surgery may be caused by an intraspinal haematoma and should be investigated by MRI.     

椎管内外肿瘤的微侵袭手术治疗

目的探讨椎管内外肿瘤的微侵袭手术方法。方法回顾性分析164例椎管内外肿瘤病人的临床资料。根据MRI显示的肿瘤部位分为4型:椎间孔硬脊膜下型54例,椎旁椎间孔硬脊膜下型33例,椎旁椎间孔硬脊膜外型61例,广泛巨大型16例。其中经后正中入路131例,经侧方入路29例,经胸腔入路4例;广泛巨大型肿瘤术后均行脊柱内固定。结果肿瘤全切除155例,次全切除9例。病理检查显示:神经鞘瘤153例,神经纤维瘤9例,神经节细胞瘤和脊膜瘤各1例。术后并发轻度感染4例,脑脊液切口漏3例,颈部硬膜外局部积液1例。133例随访3.5个月~7年,平均29个月。恢复良好94例,无明显改善26例,加重13例。复查MRI131例,肿瘤复发6例。结论掌握微创手术技术,根据肿瘤分型,应用后正中入路或侧方入路多可一期全切除部分椎间孔硬脊膜下型、椎旁椎间孔硬脊膜下型或椎旁椎间孔硬脊膜外型肿瘤,且无需行脊柱内固定。     

Clinical experiences with different valve systems in patients with normal-pressure hydrocephalus: evaluation of the Miethke dual-switch valve

OBJECTIVE: In patients with normal-pressure hydrocephalus (NPH) and beginning brain atrophy the conventional differential pressure valve bears the disadvantage of opening abruptly when the patient moves into an upright position. In this way severe suction on the already atrophic brain could be induced. We wished to find whether this disadvantage, and especially the complication of the overdrainage, could be reduced or solved by a hydrostatic valve? METHODS: In 115 patients diagnosed with NPH we implanted 36 Cordis standard valves (CSV), 19 Cordis-Orbis-Sigma valves type I (OSV), and 60 Miethke Dual-Switch valves (M-DSV). The patients were re-evaluated 7 months after surgical treatment. NPH was diagnosed from the clinical symptoms, the results of the CAT scan or MRI scan, the intrathecal infusion test, and the patients' recovery after a CSF tap test. RESULTS: The clinical follow-up showed significantly better results for patients with an implanted M-DSV valve than in patients with a conventional differential pressure valve. We found clear differences in the incidences of overdrainage and subdural hematoma: 2 patients (6%) with a CSV, 3 patients (16%) with an OSV and 1 (2%) with a M-DSV exhibited clinical signs of overdrainage. Three patients (16%) with the OSV later developed subdural hematomas, for which neurosurgical treatment was necessary. One of these 3 patients (5%) died of an intraventricular hemorrhage. One patient with a CSV (3%) and 1 with a M-DSV (2%) had to be operated on a subdural hematoma. CONCLUSION: The clinical course in patients with NPH is influenced by the stage of the disease, the beginning of therapy and the implanted valve type. Although little clinical experience is so far available with the M-DSV, we have to underline the advantages of this valve for patients with NPH.     

Spontaneous regression of an acute spinal subdural hematoma. MR imaging

We report a case of acute spinal subdural hematoma which developed then regressed spontaneously. MR imaging contributed essential information for diagnosis and follow-up after conservative treatment. We made a short review of the literature and discuss the causes, pathogenesis, clinical presentation and usual treatment of acute spinal subdural hematoma. The differential diagnosis with the more frequent and extradural hematoma requiring immediate surgical evacuation is fundamental.     

Relation between brain displacement and local cerebral blood flow in patients with chronic subdural haematoma

OBJECTIVES: To evaluate the relation between brain displacement, clinical signs and symptoms, and local cerebral blood flow (lCBF) in patients with chronic subdural haematoma (CSDH). METHODS: Forty five patients (age range 58-87 years, mean 71.9 (SD 8.4)) with unilateral CSDH were studied. Patients were categorised into three groups: I, headache (n=16); II, paresis (n=14); and III, mental change (n=15). T1 weighted MR images were obtained in all patients preoperatively. Quantitative values of maximum haematoma thickness, midline shift, and brain rotation angle were measured on axial and coronal MR images. In 21 patients, lCBF was measured by Xe enhanced CT. Values for lCBF were obtained in selected regions of interest in the frontal cortex, thalamus, and hemisphere on both the haematoma and contralateral sides. RESULTS: The lCBF reduction in the ipsilateral frontal cortex showed the best linear correlation with haematoma thickness (r=0.57), whereas the reduction in the ipsilateral thalamus had the most significant correlation with pineal shift (r=0.65) and third ventricle incline (r=0.67). In patients with paresis, lCBF decreased significantly on the ipsilateral side of both the frontal cortex and thalamus (p<0.05), whereas patients with mental change showed a significant reduction of lCBF on both sides of the thalamus (p<0.01) and in the ipsilateral frontal cortex (p<0.01). CONCLUSIONS: The lCBF reduction and clinical symptoms correlated well with local brain displacement in patients with CSDH. The lCBF in the central cerebral area including the thalamus was reduced in patients with clinical signs. The mental changes found were thought to derive from mild impairment of consciousness due to upper brain stem displacement.     

Results of surgery in patients with refractory extratemporal epilepsy with normal or nonlocalizing magnetic resonance findings investigated with subdural grids

PURPOSE: To study the efficacy of extensive coverage of the brain surface with subdural grids in defining extratemporal cortical areas amenable for resection in patients with refractory extratemporal epilepy (R-ExTE) and normal or nonlocalizing magnetic resonance imaging (MRI) scans. METHODS: Sixteen patients with R-ExTE were studied. Eleven patients had simple partial, eight had complex partial, and three had supplementary motor area seizures. Seizure frequency ranged from three per month to daily episodes. Interictal EEG showed large focal spiking areas in 11 patients, secondary bilateral synchrony in four, and was normal in one patient. Surface ictal recordings were nonlocalizing in six patients, and in 10, they disclosed large ictal focal spiking areas. MRI was normal in 10 patients, and in six patients, focal nonlocalizing potentially epileptogenic lesions were found. All patients were given an extensive coverage of the cortical convexity with subdural electrodes through large unilateral (n = 13) or bilateral (n = 3) craniotomies. Bipolar cortical stimulation was carried out through the implanted electrodes. RESULTS: Interictal invasive recording findings showed widespread spiking areas in 13 patients and secondary bilateral synchrony in three. Ictal invasive recordings showed focal seizure onset in all patients. There were six frontal, two parietal, one temporooccipital, four rolandic, and three posterior quadrant resections. Thirteen patients had been rendered seizure free after surgery, and three had > or =90% of seizure-frequency reduction. Pathologic findings included gliosis (n = 10), cortical dysplasia (n = 5), or no abnormalities (n = 1). Six patients had transient postoperative neurologic morbidity. CONCLUSIONS: Extensive subdural electrodes coverage seems to be an effective way to investigate patients with R-ExTE and normal or nonlocalizing MRI findings.     

Chronic subdural haematoma complicating spinal anaesthesia

Abstract Cranial subdural haematoma formation following spinal anaesthesia is exceptionally rare. A 38-year-old male developed headache two days after testicular surgery under spinal anaesthesia. The headache progressed in spite of analgesics, and three weeks later cranial CT showed a large chronic subdural haematoma in the left fronto-parietal region. The patient improved after surgical decompression. The pathogenesis of subdural haematoma formation after dural puncture is discussed and the literature briefly reviewed. Prolonged and severe post-dural puncture headache should be viewed with suspicion and investigated promptly to rule out any intracranial complication.     

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.