Neurosurgical Treatment of Patients with Posterior Fossa Acute Subdural Hematoma Right after Cardiac Surgery

As posterior fossa acute subdural hematoma (ASDH) right after cardiac surgery is extremely rare, the clinical course and optimal treatment strategy remain undetermined. We performed a retrospective analysis of patients with posterior fossa ASDH right after cardiac surgery requiring neurosurgical treatment at our institution over a 7-year period and, in this study, discussed the neurosurgical strategy and clinical course. Collected data included clinical history, laboratory results, time course, symptoms, neurosurgical treatment, outcome at discharge, and imaging studies. All six patients were women who had no history of head trauma and had received antithrombotic therapy during the perioperative period of cardiac surgery. All patients showed lower platelets count and were diagnosed with ASDH within 3 days (longest time 64 h) right after cardiac surgery. After discontinuation of anticoagulation therapy and administration of reversal agents, they underwent emergency hematoma evacuation craniotomy (n = 5) or burr hole drainage surgery (n = 1), which were performed in the prone (n = 4) or lateral (n = 2) positions. Four of these patients showed favorable outcomes, and two showed poor outcomes. One of the poor-outcome patients received three antithrombotic therapies, and another developed rapidly progressive ASDH. Posterior fossa ASDH associated with antithrombotic therapy right after cardiac surgery is frequently found in women, and emergent neurosurgical treatment with anticoagulation discontinuation and reversal agent administration can be performed safely. Burr hole drainage surgery might be acceptable in nonsevere cases. By contrast, we must pay attention to cases receiving both anticoagulant and antiplatelet drugs and rapid progression cases.     

The Prognostic Importance of the Volume of Traumatic Epidural and Subdural Haematomas Revisited

Summary  The size of a traumatic intracranial haematoma at the moment of diagnosis can be impressive. Haematoma thickness is an inaccurate estimator of haematoma volume, and association with patient outcome is controversial. In this study computerized volumetry of off-line digitized CT scans was used to relate haematoma volume with both patient characteristics on admission and at the six months outcome.  This retrospective study covered the time period 1981/1990. Ninety eight patients operated upon for an epidural haematoma and 91 patients operated upon for an acute subdural haematoma were analyzed. The relative importance of clinical data, CT scan parameters, and calculated haematoma volumes was determined by multivariate analysis.  Volume of the haematoma did not correlate with preoperative neurological condition or the six months outcome in either group, and consequently is not of additional prognostic value.     

Posterior Cranial Fossa Gangliogliomas

Ganglioglioma (GG) is an uncommon primary lesion of the central nervous system that is typically located supratentorially. There are only a few reports of GG arising from the cerebellum. To the best of our knowledge this is the first case of a cerebellar GG with supratentorial extension and a longstanding history before its recognition. In fact, this 29-year-old male presented with an 11-year history of intermittent headaches. A cranial computerized tomography (CT) performed at the onset of his complaints failed to reveal the tumor. After a particularly longstanding cephalalgic episode, the patient underwent a new CT scan that was also negative. However, magnetic resonance (MR) imaging of the brain revealed a space-occupying lesion in the right cerebellar hemisphere with extension to the level of the superior colliculi and pineal recess. The tumor was partially removed through a midline suboccipital craniotomy and supracerebellar approach. Pathological examination of the tumor showed composition of atypical ganglion cells and astrocytes, indicating the diagnosis of cerebellar GG. At last follow-up, 24 months after surgery, the patient reported a marked improvement of his clinical condition with significant reduction of intensity and frequency of the headache. The present report illustrates how cerebellar GG may remain undetectable by CT and may therefore present with a longstanding history and nonspecific signs and symptoms. MR investigation can lead to the proper diagnosis. Even after partial removal the prognosis remains good and remission of the symptoms may be achieved. In this article, we review the literature and summarize the current understanding of infratentorial GGs.     

外伤性颅后窝血肿84例分析

目的 总结８４例外伤性颅后窝血肿病人的临床特点，诊治经验。方法 对８４例外伤笥颅后窝血肿病人进行回顾性总结。结果 手术治疗５８例，治愈４３例，好转８例，死亡７例，非手术治疗２４例，治愈１９例，好转２例，死亡３例。２例在行术前准备时死亡。结论颅后窝血肿早期缺乏特异症状及体征，ＣＴ扫描易忽略而漏诊，对枕部头皮损伤，特别有枕骨骨得应警惕颅后窝血肿，颅后窝应作ＣＴ薄层扫描，及时手术预后等。     

Chronic Subdural Haematomas and Parkinsonian Syndromes

Summary  We describe three men with parkinsonian syndromes caused or aggravated by chronic subdural haematomas. A 63-year-old man developed tremor at rest, rigidity and bradykinesia one week after he fell and hit his head. A 70-year-old patient suffering from tardive dyskinesia and drug-induced parkinsonism experienced deterioration of his bradykinetic symptoms over two weeks. There was no history of trauma. The third patient, a 82-year-old man with idiopathic Parkinson's disease had a marked increase of his leftsided parkinsonian symptoms. Again, there was no history of trauma. In all three patients chronic subdural haematomas were demonstrated by computed tomography. Evacuation of the chronic subdural haematoma resulted in disappearance respectively improvement of the movement disorder. Diagnostic evaluations appear to be delayed and initial misinterpretations are frequent. The findings of our report and review of the literature point out that a favourable outcome after appropriate surgical treatment is achieved in most instances.     

Spinal Subdural and Epidural Haematomas: Diagnostic and Therapeutic Aspects in Acute and Subacute Cases

Summary  Background. The diagnosis of spontaneous spinal haematomas mainly depends on magnetic resonance imaging. This study evaluates the MRI characteristics of spinal epidural and subdural haematomas. The results were correlated with medical history, coagulation abnormalities and therapeutic outcome to provide guidelines for early diagnosis and treatment of spinal epidural and subdural hematomas.  Summary of Background Data. Imaging signs of epidural and subdural haematomas have been reported before, however without special attention to the differential-diagnostic and therapeutic implications of haematoma localisation.  Method. Seven patients (3 women, 4 men, age range 55–86 years) with acute progressive neurological deficits and without a history of severe trauma were studied. In all cases neurological examinations were performed after admission followed by MRI studies with T2 and T1 weighted images, before and after administration of contrast agent. Spinal angiography was performed twice to exclude a vascular malformation. All patients underwent open surgery.  Findings. Acute and subacute hematomas were detected once in the cervical spine, in five cases in the thoracic region and once in the lumbar region. The hematomas had an epidural location in three cases and a subdural in four. In the thoracic region subdural haemorrhage was much more common than epidural hematomas. Subdural blood collections were mainly found ventral to the spinal cord. Epidural haemorrhage was always located dorsal to the spinal cord. The evaluation of the haematoma localisation may be difficult occasionally, but delineation of the dura is frequently possible in good quality MRI. The clue to the diagnosis of ventrally located subdural haemorrhage is the absence of the “curtain sign”, which is typical for epidural tumours.  Interpretation. Spontaneous spinal hematomas are frequently located in the thoracic spine. Subdural spinal haemorrhage is more frequent than epidural. Epidural haemorrhage is frequently located dorsal to the spinal cord because of the tight fixation of the dura to the vertebral bodies.     

Posterior Cranial Fossa Meningiomas

This study evaluated the outcomes, complications, and recurrence rates of posterior cranial fossa meningiomas. We retrospectively reviewed our surgical experience with 64 posterior cranial fossa meningiomas. Mean age was 56 years with a female preponderance (67.2%). Headache was the most common symptom. Retrosigmoid approach was the commonest surgical procedure (23.4%). The incidence of cranial nerve related complications was 28%. Postoperatively facial nerve weakness was observed in 11%. The incidence of cerebrospinal fluid leak was 4.6%. Gross total resection was achieved in 37 patients (58%). Sixteen patients (25%) with residual tumors underwent Gamma knife radiosurgery. Recurrence or tumor progression was observed in 12 patients (18.7%). Operative mortality was 3.1%. At their last follow-up, 93% of the cases achieved Glasgow Outcome Scale scores 4 or 5. Total excision is the ideal goal which can be achieved with meningiomas located in certain location, such as lateral convexity, but for other posterior fossa meningiomas the close proximity of critical structures is a major obstacle in achieving this goal. In practicality, a balance between good functional outcome and extent of resection is important for posterior cranial fossa meningiomas in proximity to critical structures.     

Burr Hole Evacuation of Chronic Subdural Haematomas Followed by Continuous Inflow and Outflow Irrigation

Summary  Chronic subdural haematomas are prone to recollect, increasing the risk of further complications and death. Burr hole evacuation followed by continuous irrigation of a Ringer solution into the remaining subdural cavity, allows remaining blood to be washed out and the brain to re-expand.  This technique was compared with burr hole evacuation either without or with a passive drainage and craniotomy, respectively.  Reformation of haematomas after continuous irrigation occurred in 2,6% (2/77); more than a twelve (32,6%; 15/46) and a nine (23,8%; 5/21) times rate reduction compared to burr hole evacuation without and with passive drainage, respectively. Compared to the craniotomy results, the rate dropped seventeen times (44,4%; 4/9).  Expect from the two rebleedings in 77 haematomas operated on through burr holes followed by irrigation, all patients recovered including nine recurrent haematomas re-operated on by this method.  Recurrent haematomas operated on through burr hole evacuation alone or with insertion of a passive drainage, recollected in 50% (2/4) and 33,3% (2/6). Similar rate after craniotomies was 11,1% (1/9).  Neither infections nor deaths followed burr hole evacuation combined with continuous irrigation, whereas 5,3% (2/38) and 5,9% (1/17) suffered from empyema after burr hole evacuation alone or combined with a passive drainage, respectively. Five (9,1%) of these 55 patients died either from empyemas (three) or rebleedings (two).  Recurrent haematomas evacuated through a craniotomy had no complications from infections.  Compared to other methods, continuous irrigation reduces the need for re-operation significantly by preventing haematoma recurrence and empyema formation. Contrary to other surgical techniques, haematoma recurrence after second time surgery did not occur.     

Traumatic acute subdural haematomas of the posterior fossa: clinicoradiological analysis of 24 patients

Background. We report 24 patients with a traumatic acute subdural haematoma of the posterior fossa managed between 1997 and 1999 at 8 Italian neurosurgical centres. Method. Each centre provided data about patients clinico-radiological findings, management, and outcomes, which were retrospectively reviewed. Findings. A poor result occurred in 14 patients (58.3%). Ten patients (41.7%) had favourable results. Patients were divided into two groups according to their admission Glasgow Coma Scale (GCS) scores. In Group 1 (12/24 cases; GCS score, 8), the outcome was favourable in 75% of cases. In Group 2 (12/12 cases; GCS score, <8), the outcome was poor in 91.6% of cases. Nineteen patients underwent posterior fossa surgery. Factors correlating to outcome were GCS score, status of the basal cisterns and the fourth ventricle, and the presence of supratentorial hydrocephalus. Multivariate analysis showed significant independent prognostic effect only for GCS score (P<0.05). Interpretation. acute posterior fossa subdural haematomas can be divided into two distinct groups: those patients admitted in a comatose state and those with a moderate/mild head injury on admission. Comatose patients present usually with signs of posterior fossa mass effect and have a high percentage of bad outcomes. On the contrary, patients admitted with a GCS of 8 or higher are expected to recover. In these patients the thickness of the haematoma (<1cm) seems to be a guide to indicate surgical evacuation of the haematoma.     

Serum Protein Exudation in Chronic Subdural Haematomas: a Mechanism for Haematoma Enlargement?

Summary A study was conducted to investigate the role of serum protein exudation in the aetiology of chronic subdural haematoma (SDH). Scintigraphy after intravenous injection of 99mTc-labelled human serum albumin (HSA) was performed in three patients with chronic SDH and a patient with subdural effusion. In nother 60 haematomas, the amounts of total protein and albumin as indices of serum exudation were measured, and then compared among low-density, iso-density and high-density haematomas. Accumulation of 99mTc-HSA in the haematoma cavity was seen 6 h after isotope injection and became more evident at 24 h. However, the protein concentrations and albumin ratios in the haematomas exhibited a reciprocal relationship, suggesting that not all the protein in the haematomas was derived from serum exudation. The higher the total protein concentration in the haematoma became, the higher the haematoma density which was observed on CT. The albumin concentration in low-density haematomas was lower than that in iso-density and high-density haematomas, whereas no significant difference was seen between the latter two haematoma types. These results provide morphological evidence for serum protein exudation into the haematoma cavity, and therefore it is possible that serum protein exudation plays a role in the progression of chronic SDH and is related to changes in haematoma density on CT.     

Spontaneous Chronic and Subacute Subdural Haematoma in Young Adults

Summary  Spontaneous subacute and chronic haematoma in young adults is rare. It has not been previously reported in this age group.  We present three cases of chronic and subacute subdural haematoma in young adults, in one of whom the diagnosis was certainly delayed.  All three patients underwent burrhole evacuation and made a full neurological recovery. A cause for the haematoma was never established. The literature on the subject, which is scanty, is reviewed and the condition is briefly discussed. The aetiology remains obscure.     

The CT criteria for conservative treatment — but under close clinical observation — of posterior fossa epidural haematomas

Summary In order to assess whether the indications for conservative treatment of supratentorial epidural haematomas are applicable also to posterior fossa epidural haematomas (PFEDH), the author reviewed the records of 25 patients. With a PFEDH volume of no more than 10 ml, a thickness of no more than 15 mm, a midline shift of no more than 5 mm, and in the absence of a significant intracranial haematoma elsewhere on computed tomography (CT) scans, the patients undergoing conservative treatment achieved the same excellent outcome as those undergoing early surgery. These CT criteria for conservative treatment of PFEDHs are similar to those of supratentorial epidural haematomas except the volume factor, namely, 10 ml in the former against 30 ml in the latter. That means a PFEDH of 10 ml or larger in the small posterior fossa may produce the same degree of midline shift and compression, and be as dangerous as an epidural haematoma of 30 ml or larger in the more capacious supratentorial compartment. But also for epidural haematomas of the posterior fossa, which initially are smaller than 10 ml, the general rule remains valid that they should be under close clinical supervision     

Spontaneous bilateral chronic subdural haematoma of the posterior fossa. Case report and review of the literature

Summary. Summary.   Introduction: Chronic subdural haematomas of the posterior fossa in adults without a history of trauma are very rare. To our knowledge, only 15 cases have so far been reported in the literature, including those with anticoagulation therapy. A case of spontaneous bilateral infratentorial chronic subdural haematoma associated with anticoagulation therapy in an alive adult is presented and the relevant literature is reviewed.   Case Report: A 70 year old female presented with progressive dizziness, vertigo and gait ataxia. She was on anticoagulation therapy for heart disease. Neuro-imaging revealed bilateral infratentorial subdural masses.  The subdural masses were suspects for chronic subdural haematomas by neuroradiological criteria. Because of the progressive symptomatology, the haematomas were emptied through burrhole trepanations. Chocolate-colored fluid, not containing clotted components, gushed out under great pressure. The source of bleeding could not be identified. The patient recovered well from surgery, but died 4 months later shortly after admission to another hospital from heart failure.   Discussion: The chronic subdural haematomas in this patient may have been due to rupture of bridging veins caused by a very mild trauma not noticed by the patient and possibly aggravated by the anticoagulation therapy. Infratentorial chronic subdural haematoma should at least be a part of the differential diagnosis in elderly patients with cerebellar and vestibular symptomatology even without a history of trauma.     

Local Hypercoagulative Activity Precedes Hyperfibrinolytic Activity in the Subdural Space During Development of Chronic Subdural Haematoma from Subdural Effusion

Summary The involvement of coagulation and fibrinolysis in the development of chronic subdural haematoma (CSH) from subdural effusion was investigated. Subdural fluid and venous blood samples were obtained from 34 patients with CSH and 9 patients with subdural effusion, and analyzed using enzyme-linked immunosorbent assays for thrombin-antithrombin III complex (TAT), prothrombin fragment F1+2 (F1+2), tissue factor, tissue factor pathway inhibitor (TFPI) and D-dimer. CSH was classified into the layering type, believed to be active, and other types according to x-ray computed tomography. All markers in the blood of both patient groups were similar to the values of normal subjects. Levels of TAT and F1+2 were much higher in the subdural fluid than in the blood of patients with CSH (P<0.001, P<0.001) and with subdural effusion (P<0.05, P<0.05). The level of D-dimer in the subdural fluid was significantly higher than in the blood (P<60.001) in patients with CSH, but not in patients with subdural effusion. All markers in the subdural fluid of layering type CSH, except TFPI, were significantly higher than in the other types (P<0.05). Local hypercoagulative activity in the subdural space is present in subdural effusion and precedes hyperfibrinolytic activity in CSH. Thrombin generation as indicated by TAT and F1+2 might be involved in the development of CSH. Propagation of CSH may be modulated by the coagulation system including the extrinsic pathway and fibrinolysis.     

Long-term Outcomes of Gamma Knife Surgery for Posterior Fossa Arteriovenous Malformations

The long-term outcomes of gamma knife surgery (GKS) in patients with posterior fossa arteriovenous malformations (AVMs) were retrospectively analyzed in 82 patients followed up for more than 5 years to evaluate the efficacy and safety. The median AVM volume at GKS was 0.95 cm³. The prescribed dose to the AVM margin was median 18 Gy with 1–18 isocenters. The actual complete AVM obliteration rate was 58.5% at 3 years and 78.0% at 5 years. The significant factors for higher complete obliteration rate were younger patient age and smaller maximum/minimum nidus diameter ratio. Two patients experienced hemorrhage caused by residual AVM rupture at 4 and 49 months. Twenty patients developed peri-nidal edema as an adverse radiation-induced reaction at median 13 months. One patient developed radiation-induced necrosis at 6.8 years. Neurological complication was observed in 12 patients and 6 patients remained with neurological dysfunction permanently. Larger nidus volume and location adjacent to an eloquent area significantly increased the risk of neurological complication. Pittsburgh radiosurgery-based AVM grading scale was significantly correlated with the outcome of neurological symptoms after GKS. GKS achieved acceptable and complete obliteration rate for posterior fossa AVM with relatively low risk of morbidity on neuroimaging and neurological symptoms for the long-term period after treatment. We recommend conformable and selective treatment planning to achieve both obliteration of the AVM nidus and preservation of neurological function.     

Regression of Symptomatic Syringomyelia after Resection of Posterior Fossa Tumour

Summary.  Syringomyelia associated with posterior fossa tumours is a very infrequent combination of pathological entities. The few cases which have been reported generally were asymptomatic in respect of the spinal cavitations. The authors report on a 36-year-old woman with a large extradural posterior fossa epidermoid tumour with a concomitant holocord symptomatic syringomyelia. Some of her symptoms were clearly attributed to the intraspinal cavitation. The lesions were both diagnosed by magnetic resonance imaging (MR). The patient did well after surgery of the brain lesion, with an objective improvement in her neurological status and a complete resolution of the syrinx documented by the MR 7 months after tumour removal.  Syringomyelia in this case could be explained by blockage of the cerebrospinal fluid (CSF) circulation at the foramen magnum which in turn resulted in cranio-spinal pressure dissociation. This led to an accumulation of extracellular fluid (ECF) in the central canal, starting cavitation. Consequently, the syrinx was slowly expanded by the long-standing “slosh” effect of the systolic pressure waves. However, also via a distortion mechanism within the posterior fossa a pathologically plugged obex could have contributed to syrinx formation by means of preventing drainage of fluid from the ventricular CSF system.     

Inflammatory Cytokines Locally Elevated in Chronic Subdural Haematoma

Summary The involvement of inflammation in the development and propagation of chronic subdural haematoma (CSH) was investigated by measuring the levels of inflammatory cytokines (tumour necrosis factor [TNF]α, interleukin [IL]-1β, IL-6, and IL-8). Peripheral venous blood and subdural fluid were obtained at the time of burr hole surgery from 34 patients with CSH and from 9 with subdural effusion. The levels of the inflammatory cytokines were analysed by enzyme-linked immunosorbent assay. The blood levels of TNFα, IL-1β, IL-6, and IL-8 in both CSH and subdural effusion groups were almost within the range of normal subjects, and no differences were observed between the two groups. IL-6 and IL-8 in the subdural fluid were much higher than in the blood of both groups, and the levels in CSH patients were significantly higher (10 times) than in subdural effusion patients. Local elevation of inflammatory cytokines in the subdural space of both CSH and subdural effusion without systemic change suggests the presence of local inflammation in the two diseases. The same behavioural patterns of cytokines for these and higher levels of cytokines in the CSH also suggest that inflammatory cytokines may be involved in the continuous development from subdural effusion to CSH and propagation of CSH.