Predictive (subtle or overlooked) initial head CT findings in patients who develop delayed chronic subdural hematoma

With the aging population, the incidence of chronic subdural hematoma (CSDH) is expected to rise. Once symptomatic the morbidity from CSDH is not insignificant. We studied patients who had a minor head injury and CT brain scan prior to developing CSDH to determine if there were any predictors on these scans for subsequent development of a CSDH. A retrospective review was performed on all patients operated for CSDH over a 3-year period and a review performed on those who had imaging studies at the time of a preceding minor head injury. Seven of 37 patients had CT scans prior to developing CSDH. All had evidence of small increases in CSF intensity on the side or sides of the subsequent CSDH. In conclusion, in those patients with a history of minor head injury prior to developing a CSDH, CT brain demonstrated small increases in cerebral spinal fluid (CSF) intensity on the side or sides of the subsequent CSDH. Recognizing this finding may be helpful in monitoring these patients or initiating medical therapy.     

Spontaneous disappearance of middle fossa arachnoid cyst after head injury

A case of middle fossa arachnoid cyst is presented, which disappeared after head injury. Five days after the trauma, CT scan revealed subdural fluid collection in addition to an arachnoid cyst in the middle fossa on the same side. As the subdural fluid resorbed, the cyst became smaller and disappeared on the follow-up CT scans without surgical intervention.     

A spontaneous bilateral subdural effusion in an 11-year-old boy with middle cranial fossa arachnoid cyst

An 11-year-old boy gradually developed headache, vomiting and diplopia over a period of 1 month. Repeated examinations of head CT scan revealed an arachnoid cyst in the right middle cranial fossa and bilateral subdural effusion of enlarging size. Papilledema was absent on admission, but it became evident after 1 week, and lumbar puncture disclosed very high pressure (800 mmH2O) of the cerebrospinal fluid. Fenestration of the cyst to the basal cisterms quickly alleviated his symptoms of intracranial hypertension as well as the bilateral subdural effusion on CT. Macroscopically, there was a small tear on the wall of the arachnoid cyst, and it probably served as a communication valve with the subdural space. Since he had no history of head trauma in the past few months, the reason of the tear formation was unclear. Intracranial arachnoid cyst is a relatively common congenital malformation of usually benign and non-pathogenic nature. However, it may occasionally cause non-traumatic subdural effusion and intracranial hypertension.     

蛛网膜囊肿合并慢性硬膜下血肿的治疗及临床分析

目的探讨蛛网膜囊肿合并慢性硬膜下血肿的临床特点及治疗方法。方法采用回顾性病例研究方法,对安徽省立医院神经外科2009年1月至2014年1月所收治的9例确诊为蛛网膜囊肿合并慢性硬膜下血肿患者进行分析,其中男6例,女3例,年龄1.5~60岁,平均23.9岁。临床表现为头痛患者8例;其中6例伴恶心、呕吐,1例伴有肢体无力,1例仅有肢体抽搐;有明确外伤史6例,无明确外伤史3例。结果9例患者中5例行颅骨钻孔硬膜下血肿引流术,5例患者术后均恢复良好,后出院;另2例行开颅硬膜下血肿清除并蛛网膜囊肿切除术,术后痊愈。2例患者行保守治疗,一月后复查头颅CT提示血肿较前缩小,患者无症状,未手术。9例患者分别随访10个月至4年,未再复发硬膜下血肿,生活质量可。结论蛛网膜囊肿合并慢性硬膜下血肿,常见于有头部外伤史的年轻患者。有明显临床症状者需手术治疗,并根据血肿量及是否合并囊内出血等,选择单纯做硬膜下血肿钻孔引流术还是同时开颅清除血肿并处理囊肿。     

Arachnoid Cyst with Spontaneous Intracystic Hemorrhage and Chronic Subdural Hematoma

We report a case of arachnoid cyst in which subdural hematoma and intracystic hemorrhage developed spontaneously. Usually, arachnoid cysts are asymptomatic, but can become symptomatic because of cyst enlargement or hemorrhage, often after mild head trauma. Although they are sometimes combined with subdural hematoma, intracystic hemorrhage has rarely been observed. Our patient had a simultaneous subdural hematoma and intracystic hemorrhage without evidence of head trauma.     

Spontaneous Resolution of a Large Chronic Subdural Hematoma Which Required Surgical Decompression

We report on a case of an 87-year-old woman who showed spontaneous resolution of a large chronic subdural hematoma which required surgical decompression. She had suffered from confused mentality and right side weakness of motor grade II for 10 days. The initial brain CT scan showed a 22 mm thick low density lesion located in the left fronto-temporo-parietal region with midline shift (12 mm) which required emergency decompression. However, because she and her family did not want surgery, she was followed up in the outpatient clinic. Five months later, follow up brain CT showed that the CSDH had disappeared and the patient became neurologically normal. The reasons for spontaneous resolution of CSDH remain unclear. We discuss the possible relation between mechanisms of physio-pathogenesis and spontaneous resolution of a large chronic subdural hematoma (CSH) in an elderly patient.     

Do cranial subdural hematomas migrate to the lumbar spine?

We report a patient with minor head trauma-related bilateral hemispheric subdural hematoma (SDH) and subsequent delayed spinal SDH or presumed migration to the lumbar spine. An acutely confused 88-year-old man presented to the Emergency Department after minor head trauma. Head CT scan revealed a small hemispheric SDH. The patient was admitted for observation. CT scan 6 hours later showed bilateral SDH with extension to the tentorium. Three days later SDH had resolved leaving bilateral subdural hygromas. Local leg weakness localized to the lumbar spine developed on day 6; spinal CT scan and MRI revealed a posterior L5-S1 collection. A pure subacute subdural hematoma compressing the cauda equina was drained after an L5 laminectomy. His lower leg weakness improved. The patient was discharged to rehabilitation two weeks after surgery. Patients with traumatic SDH who develop late-onset neurological deterioration attributable to any region of the spine should be evaluated for spinal SDH.     

133例慢性硬膜下血肿患者的临床特点研究

目的：探究慢性硬膜下血肿（CSDH）病的临床特点。方法：133例CSDH患者,依据血肿的CT表现分为两组：双侧组（47例）和单侧组（86例）。对两组患者的临床表现、致病因素、CT表现、术后并发症及预后进行比较。结果：双侧CSDH组的恶心呕吐、头痛、步态不稳的症状显著多见于单侧CSDH组（P〈0.05）。双侧CSDH组的抗凝及抗血小板药物服用者显著多于单侧CSDH组（P〈0.05）。单侧CSDH组的中线移位（CT）发生率显著高于双侧CSDH组（P〈0.05）。结论：双侧CSDH常见于有抗凝及抗血小板药物服用史患者;双侧CSDH患者较单侧CSDH患者更易出现颅内压增高症状,而CT上较少出现明显的中线移位。     

Subdural hygroma in association with middle fossa arachnoid cyst: acetazolamide therapy

Intracranial arachnoid cysts are cerebrospinal fluid-filled collections between arachnoid layers. While many are silent, arachnoid cysts can become symptomatic if there is sudden expansion, haemorrhage or rupture with the development of subdural hygroma or subdural hematoma. Several studies have demonstrated the association of arachnoid cysts with subdural hygroma and subdural hematoma. We describe a 9-year-old girl with a moderate-sized middle-fossa arachnoid cyst and bilateral frontal subdural hygroma presenting with raised intracranial pressure. She was treated with acetazolamide which resulted in resolution of the subdural hygroma and relief of symptomatology.     

Three Cases of Chronic Subdural Hematoma with Depressive State

Abstract: The authors described 3 cases of chronic subdural hematoma (CSDH) with a depressive state. There were no abnormal findings from general and neurological examinations. Computed tomographic (CT) brain scans revealed sickle-shaped low density areas in the bilateral frontal lobes. Two of the 3 cases had not had episodes of head contusion, and it was not until the CT brain scanning that they were found to have CSDH. Evacuation of the hematomas was not considered suitable and the depressive state of these 2 cases was improved by antidepressants. The remaining case seemed to have become depressive because of failure in business. After the head contusion, his depressive state gradually became more severe. A neurosurgical operation was carried out to evacuate the hematoma. CSDH seemed to aggravate his depressive state. These 3 cases show that CSDH located in the bilateral frontal lobes may cause and/or influence affective disorder.     

Chronic subdural hematoma in capoeira sport

Chronic subdural hematomas in young people is extremely rare and has some provoking factors such as V-P shunts, arachnoid cyst, anticoagulant drug usage, vigorous sports and coagulopathies. A static or dynamic mechanical load is almost always delivered to skull associated with either mild or severe head trauma. A 25-year old-man who was previously healthy has complained of intermittent headache for six months. He had been interested in capoiera (Brazilian exciting sport) for two years and has had no any evidence of head injury. After admission, he was operated immediately because of chronic subdural hematoma. We report a patient who is the first chronic subdural hematoma in the literature due to playing capoeira.     

Three cases of chronic subdural hematoma with depressive state

The authors described 3 cases of chronic subdural hematoma (CSDH) with a depressive state. There were no abnormal findings from general and neurological examinations. Computed tomographic (CT) brain scans revealed sickle-shaped low density areas in the bilateral frontal lobes. Two of the 3 cases had not had episodes of head contusion, and it was not until the CT brain scanning that they were found to have CSDH. Evacuation of the hematomas was not considered suitable and the depressive state of these 2 cases was improved by antidepressants. The remaining case seemed to have become depressive because of failure in business. After the head contusion, his depressive state gradually became more severe. A neurosurgical operation was carried out to evacuate the hematoma. CSDH seemed to aggravate his depressive state. These 3 cases show that CSDH located in the bilateral frontal lobes may cause and/or influence affective disorder.     

Dural metastasis of prostate carcinoma misdiagnosed as a bilateral subdural hematoma: A case report

Dural metastases originating from prostate cancer are exceedingly uncommon and may clinically imitate a subdural hematoma. Additionally, head computed tomography scan findings can be mistaken for meningioma or subdural hematoma. We present a 75-year-old male patient with dural metastasis as a first presenting sign of prostate cancer, misdiagnosed as a bilateral subdural hematoma on initial non-contrast brain CT scan. Also, a review of literature is presented. We found 12 cases of dural metastasis of prostate cancer mimicking subdural hematoma described in the literature, and unlike in our case, prostate cancer was already diagnosed.     

外伤性慢性硬脑膜下血肿发生机理探讨

目的：探讨慢性硬脑膜下血肿（CSDH）的发生机理，方法：对我科1997年至1999年治疗的17例急性硬脑膜下血肿（ASDH），11例CSDH及9例硬脑膜下积液病人进行观察分析，结果：17例ASDH非手术治疗后无1例发展成为CSDH，9例硬脑膜下积液有2例发展成为CSDH，1例发展为张力性硬脑膜下积液。11例CSDH病人中，在第一次外伤后72h内头部CT示6例硬脑膜下积液，4例脑挫伤，1例无特殊显示，无一例为硬膜下血肿，结论：CSDH的发生可能与硬脑膜下积液有密切关系。     

Intracranial arachnoid cyst with subdural hematoma

A case of a middle fossa arachnoid cyst associated with a post-traumatic subdural hematoma is reported, where the inner membrane of the hematoma did not entirely cover the cyst surface. At operation a third cavity was detected between the arachnoid cyst and the hematoma and it is postulated that the subdural hematoma was consequent to the developmental anomaly. We have reviewed 72 cases in the literature and discuss the management of subdural hematoma in the presence of arachnoid cysts.     

Chronic subdural haematoma and arachnoid cyst in autosomal dominant polycystic kidney disease (ADPKD).

We present the unusual association between chronic subdural haematoma (CSDH), intracranial arachnoid cyst and autosomal dominant polycystic kidney disease (ADPKD) in a 27-year-old man. CSDH is a documented complication of intracranial arachnoid cyst, the incidence of which is increased in patients with ADPKD. Awareness of this association may lead to earlier diagnosis of ADPKD and treatment of its systemic complications, including renal insufficiency, systemic hypertension and previously unsuspected intracranial saccular aneurysm. Surgery for CSDH associated with intracranial arachnoid cyst may be complicated by over-drainage of cerebrospinal fluid due to communication between the cyst and the cisternal subarachnoid space, as illustrated in the present case, and the development of epidural haemorrhage.     

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.     

Chronic subdural hematoma presenting visual disturbance: a case report]

The authors reported a rare case of chronic subdural hematoma presenting bilateral visual impairment caused by papilledema. A 49-year-old man was admitted to our department due to left blurred vision. On admission, ophthalmological examination revealed visual acuity disturbance on the left eye, bilateral nasal visual field defect and papilledema. CT scan and MRI demonstrated bilateral subdural hematoma. No remarkable findings were detected on cerebral angiography. After evacuation of bilateral subdural hematomas, his visual symptoms recovered. In this report, we discuss the mechanism of visual impairment caused by chronic subdural hematoma.     

Prediction of postoperative recurrence of chronic subdural hematoma using quantitative volumetric analysis in conjunction with computed tomography texture analysis

Chronic subdural hematoma (CSDH) is a common disease in older individuals with a substantial rate of recurrence. The mechanism of CSDH recurrence remains unclear. This study aimed to detect imaging parameters that could indicate the risk for CSDH recurrence by using quantitative volumetric analysis and computed tomography (CT) texture analysis (CTTA).Clinical and imaging parameters were retrospectively investigated in 147 newly diagnosed CSDH lesions in 114 patients surgically treated at the Keio University Hospital during a 6-year period. For CT images, quantitative volumetric and texture analyses were performed. Hematoma volume, postoperative air volume, hematoma density, and texture parameters including kurtosis, skewness, and entropy were evaluated and compared with CSDH recurrence rate. Data were statistically evaluated, and a difference of p < 0.05 was considered significant.Reoperation for CSDH recurrence was required in 27 sides (18.4%) of 26 patients. Multivariate analysis showed that postoperative hematoma volume and postoperative hematoma density were independent risk factors for symptomatic CSDH recurrence that required reoperation. Postoperative hematoma volume, postoperative significant residual air, and postoperative hematoma density were also identified as independent risk factors for potential CSDH recurrence. Preoperative hematoma entropy was prone to be associated with both symptomatic and potential CSDH recurrence in univariate analysis, but not in multivariate analysis because of confounding factors.Quantitative volumetric analysis and CTTA could aid in distinguishing individuals at risk for CSDH recurrence.     

Chronic subdural hematoma associated with the middle fossa arachnoid cyst: pathogenesis and review of its management

Background

The pathogenesis of chronic subdural hematoma (CSDH) associated with an arachnoid cyst (AC) is still not clear. We propose an origin of initial bleeding of CSDH in patients with AC based on our experience and discuss the management of this disease.

Materials and methods

The total number of operations included in this study was 23. Eleven cases were indicated because of associated CSDH (group 1), and the other cases were due to different reasons (group 2). The relationship of the AC and dura was evaluated in patients who did not have CSDH (group 2) because patients with CSDH would have had structural changes of AC due to hematoma.

Results

In group 1, the age distribution was from 8 to 61 years (mean 23.0). The development of CSDH was not related with Galassi types. The hematomas were located outside of the outer cyst membrane in six patients and both inside and outside in three patients. In two patients, the location could not be reviewed. After suspicion of the outer cyst membrane as the origin of the bleeding site, we found small bridging vessels between the dura and outer cyst membrane in three of five consecutive patients in group 2.

Conclusions

Based on our surgical experience of AC cyst, we found small bridging vessels between the dura and outer membrane of the AC. We suggested that these small vessels are the source of initial bleeding leading to CSDH in AC.