Spontaneous Bilateral Supratentorial Subdural and Retroclival Extradural Hematomas in Association with Cervical Epidural Venous Engorgement

We describe a case of 36-year-old man who presented with a subacute headache preceded by a 1-month history of posterior neck pain without trauma history. Head and neck magnetic resonance imaging (MRI) studies disclosed bilateral supratentorial subdural and retroclival extradural hematomas associated with marked cervical epidural venous engorgement. Cerebral and spinal angiography disclosed no abnormalities except dilated cervical epidural veins. We performed serial follow-up MRI studied to monitor his condition. Patient''s symptoms improved gradually. Serial radiologic studies revealed gradual resolution of pathologic findings. A 3-month follow-up MRI study of the brain and cervical spine revealed complete resolution of the retroclival extradural hematoma, disappearance of the cervical epidural venous engorgement, and partial resolution of the bilateral supratentorial subdural hematoma. Complete resolution of the bilateral supratentorial subdural hematoma was confirmed on a 5-month follow-up brain MRI. The diagnosis and possible mechanisms of this rare association are discussed.     

Calcified chronic subdural hematoma mimicking calvarial mass: a case report

Head trauma is a frequent cause of mortality and morbidity in the pediatric population. Chronic subdural hematoma is the most common traumatic lesion in head injury. Chronic subdural hematomas are rare in children older than 2 years old; they are more frequent during adolescence. Calcified or ossified chronic subdural hematoma is a rare entity that usually presents as a space-occupying lesion over the cerebral convexity. Chronic calcified subdural hematomas are reported less than chronic subdural hematomas. In this article, we report a successfully treated patient with surgical removal case of calcified chronic subdural hematoma mimicking calvarial mass.     

Dural metastasis in patients with malignant neoplasm and chronic subdural hematoma

OBJECTIVES: Dural metastasis associated with chronic subdural hematoma (CSH) is rare in patients with malignant neoplasm. In this study, biopsy of the dura and cytological examination of the subdural hematoma was performed for patients with malignant neoplasm and chronic subdural hematoma to investigate the association of dural metastasis and CSH. MATERIALS AND METHODS: Four patients with malignant neoplasm (one breast, one lung, and one colon cancers, and one lymphoma) were diagnosed with CSH. Biopsy of the dura and cytological examination of the subdural fluid were performed for each of these patients. RESULTS: Pathological examination of the dura revealed metastasis for two patients (one lymphoma and one breast cancer), with no specific change except neomembrane formation revealed for the dura of the other two patients. The cytology study was negative for all four patients. All these four patients died within 10 days of the operation; one from recurrent subdural hematoma, and three from infection. CONCLUSION: The results suggest that dural metastasis should be considered in patients with malignant neoplasm and CSH. Further, the prognosis for patients with malignant neoplasm and CSH may be poor because of systemic metastasis and the side-effects of chemotherapy.     

Superimposed Propionibacterium Acnes Subdural Empyema in a Patient with Chronic Subdural Hematoma

The authors present a case of subdural empyema in a macrocephalic patient. A 23-year-old male was admitted due to headache and fever. One month ago, he had mild head injury by his coworkers. Physical examination showed a macrocephaly and laboratory findings suggested purulent meningitis. Neuroimaging studies revealed a huge size of epidural space-occupying lesion. Under the impression of epidural abscess, operation was performed. Eventually, the lesion was located at subdural space and was proven to be subdural empyema. Later, histological examination of the specimen obtained by surgery demonstrated finings consistent with the capsule of the chronic subdural hematoma. Two weeks after operation, Propionibacterium acnes was isolated. The intravenous antibiotics were used for total of eight weeks under monitoring of the serum level of the C-reactive protein. Follow-up brain computed tomography (CT) scan showed the presence of significant amount of remaining subdural lesion. However, he has complained of minimal discomfort. It is suggested that the subdural empyema occurred with preexisting chronic subdural hematoma after head injury about one month prior to admission and it took a long time to treat Propionibacterium acnes subdural empyema with systemic antibiotics, at least over eight weeks.     

A case of organized chronic subdural hematoma presented with transient neurologic deficits]

A 59-year-old diabetic male presented with transient motor aphasia and monoparesis of the right upper limb. Brain CT scan showed a low density area in the left subdural space with a mild midline shift. Magnetic resonance (MR) T2-weighted and fluid-attenuated inversion recovery (FLAIR) imagings revealed homogenous hyperintensity with a hypointense web-like structure in the subdural hematoma. Cervical MR angiography showed no abnormal lesion at the bifurcation of the bilateral common carotid arteries. Conventional cerebral angiography showed an avascular, crescent, space-occupying mass over the left hemisphere without an etiologic lesion of cerebral ischemia. CT perfusion imagings indicated reduced cerebral blood flow (CBF) and prolonged mean transit time (MTT) in the left middle cerebral artery territory underneath the subdural hematoma. No epileptic discharge was found in electroencephalogram. Operative findings indicated that the hematoma was encapsulated with thickened outer and inner membranes including paste-like materials, and the brain surface was intact. Postoperative CT perfusion imagings revealed normal CBF and MTT. The pathophysiological mechanism which the chronic subdural hematoma produces the transient neurological deficit is still uncertain. The mechanical pressure of the hematoma on the neighboring cerebral vessels may cause impairment of blood flow leading to cerebral ischemia and paralysis of function. Our case indicated the transient neurological deficits attributed to a decreased CBF around the subdural hematoma and a change in pressure exerted by the hematoma during changes of head position and increased blood viscosity.     

Spontaneous chronic spinal subdural hematoma associated with spinal arachnoiditis and syringomyelia

Spontaneous chronic spinal subdural hematoma is rare. We describe a case of spontaneous chronic spinal subdural hematoma associated with arachnoiditis and syringomyelia in a 76-year old woman who presented with a 14-year history of progressive myelopathy. MRI scan revealed a thoraco-lumbar subdural cystic lesion and a thoracic syrinx. The patient underwent thoracic laminectomy and decompression of the lesion, which was a subdural hematoma. A myelotomy was performed to drain the syrinx. Pathological examination revealed features consistent with chronic subdural membrane. This report attempts to elucidate the pathogenesis of chronic spinal subdural hematoma. We discuss possible etiological factors in light of the current literature and pathogenesis of both spinal subdural hematoma and syrinx formation.     

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.     

Idiopathic Hypertrophic Cranial Pachymeningitis Misdiagnosed as Acute Subtentorial Hematoma

A case of idiopathic hypertrophic cranial pachymeningitis (IHCP) misdiagnosed as an acute subdural hematoma is reported. A 37-year-old male patient presented with headache following head trauma 2 weeks earlier. Computerized tomography showed a diffuse high-density lesion along the left tentorium and falx cerebri. Initial chest X-rays revealed a small mass in the right upper lobe with right lower pleural thickening, which suggested lung cancer, such as an adenoma or mediastinal metastasis. During conservative treatment under the diagnosis of a subdural hematoma, left cranial nerve palsies were developed (3rd and 6th), followed by scleritis and uveitis involving both eyes. Magnetic resonance imaging (MRI) revealed an unusual tentorium-falx enhancement on gadolinium-enhanced T1-weighted images. Non-specific chronic inflammation of the pachymeninges was noticed on histopathologic examination following an open biopsy. Systemic steroid treatment was initiated, resulting in dramatic improvement of symptoms. A follow-up brain MRI showed total resolution of the lesion 2 months after steroid treatment. IHCP should be included in the differential diagnosis of subtentorial-enhancing lesions.     

Acute Cervical Spinal Subdural Hematoma Not Related to Head Injury

We report an extremely rare case of traumatic cervical spinal subdural hematoma not related to intracranial injury. There has been no report on traumatic cervical spinal subdrual hematoma not related to intracranial injury. A 27-year-old female patient was admitted to our emergency room due to severe neck pain and right arm motor weakness after car collision. On admission, she presented with complete monoplegia and hypoesthesia of right arm. Magnetic resonance imaging (MRI) revealed subdural hematoma compressing spinal cord. Lumbar cerebrospinal fluid (CSF) analysis revealed 210,000 red blood cells/mm³. She was managed conservatively by administrations of steroid pulse therapy and CSF drainage. Her muscle power of right arm improved to a Grade III 16 days after admission. Follow-up MRI taken 16th days after admission revealed almost complete resolution of the hematoma. Here, the authors report a traumatic cervical spinal SDH not associated with intracranial injury.     

Uncommon findings in idiopathic hypertrophic cranial pachymeningitis

Abstract.Background: Idiopathic hypertrophic cranial pachymeningitis (IHCP) is a rare, poorly understood, inflammatory disease, usually involving the dura mater of skull base, tentorium, and falx, and presenting with headache, progressive cranial nerve palsies, and cerebellar dysfunction.Patients and Methods: In four patients, the diagnosis of IHCP has been made on the basis of extensive clinical, and radiological investigation, and confirmed by dural biopsy in three patients. The clinical follow-up ranges from 24 to 120 months.Results : At diagnosis, all the patients complained of severe, progressively increasing headache, two had simple or complex partial seizures, but none had cranial nerve palsies. Two patients had electrophysiological evidence of axonal peripheral neuropathy, biopsy-proved in one of them. In all the patients, MRI showed linear or focal thickening of the dura mater of the tentorium and/or of the convexity, sparing the skull base. In one patient, MRI findings resembled chronic subdural hematoma. Dural biopsy demonstrated fibrosis and prominent CD4+ T-cells inflammatory infiltrate. Pachymeningitis was highly responsive to steroid therapy, as was the peripheral neuropathy. In three patients, temporary steroids withdrawal led to dramatic clinical worsening including status epilepticus in one.Conclusions : In the patients here reported, absence of cranial nerve impairment, seizures, MRI findings resembling chronic subdural hematoma, and association with polineuropathy were unusual findings of IHCP. Moreover, the type of inflammatory infiltrate, lacking in previous reported cases, suggests a probable pathogenetic role for cell-mediated immunity of unknown origin.     

Kernohan's notch phenomenon in chronic subdural hematoma: MRI findings.

We report two cases of Kernohan's notch phenomenon secondary to chronic subdural hematoma detected by MRI. In the first case, the patient was drowsy with an oculomotor palsy and a hemiparesis ipsilateral to the chronic subdural hematoma. MRI in the post-operative period showed no abnormal signal or deformity of the crus cerebri. The neurological signs immediately resolved after trephination. In the second case, the patient was admitted with progressive decrease in their level of consciousness and ipsilateral hemiparesis with the chronic subdural hematoma. MRI on admission revealed an abnormal signal in the contralateral crus cerebri against the chronic subdural hematoma. After surgery, the mental state gradually recovered to normal with some degree of residual hemiparesis. In patients with chronic subdural hematoma, a compressive deformity of the crus cerebri, without abnormal signal on MRI, may predict a better neurological recovery in patients with Kernohan's notch phenomenon.     

Serial MRI findings in patient with chronic cryptococcus meningo-encephalitis

Abstract

We describe the serial changes of magnetic resonance imaging (MRI) in a patient with chronic cryptococcus meningo-encephalitis. In the subacute phase, MRI revealed a focal lesion with hyperintensity on T2-weighted image (WI) in the left thalamus. At 11 months after the onset, MRI showed a focal lesion with hyperintensity on T2-WI in the right pons that was enhanced with gadolinium (Gd). At 13 months after the onset, the lesion in the left thalamus became rim enhanced with Gd. After antifungal therapy (amphotericin B and 5-flucytosine), the rim enhancement in the left thalamus and the high signal intensity area in the right pons decreased. Cryptococcoma should be in the differential from other ring enhancing lesions. [Neurol Res 2001; 23: 810-812]     

Infected subdural hematoma

A case is presented in which Escherichia coli seeded a pre-existing chronic subdural hematoma. A 77-year-old woman was admitted to our hospital because of lethargy, left hemiparesis and fever. Drainage through a burr hole was performed with the diagnosis of bilateral chronic subdural hematoma. Operative findings revealed the infected subdural hematoma on the right side and non-infected subdural hematoma on the left side. Cultures of the subdural hematoma grew Escherichia coli. In view of the pyuria, the etiology of the infected subdural hematoma was postulated to be a urinary tract infection. In the majority of 14 reported cases, the causative organisms were Escherichia coli, Salmonella, and the systemic sources of infection included the urinary tract, gastrointestinal disease, or were unknown. The possibility of infected subdural hematoma should be considered when computed tomography findings suggestive of chronic subdural hematoma exist in a patient with signs of infection.     

Comparisons of 2/3Sh estimation technique to computer-assisted planimetric analysis in epidural,subdural and intracerebral hematomas

Abstract

Objective: The formula 1/2abc was suitable for the estimation of the epidural, acute subdural, most intracerebral and even some chronic subdural hematoma volume, but its accuracy was prone to be affected by some particular shapes of hematomas. In this study, we aimed to validate a more accurate method for the estimation of the epidural, subdural and intracerebral hematoma volume.

Methods: In the present study, hematomas were categorized into the epidural, subdural and intracerebral groups, and every hematoma in three subgroups was respectively estimated with the following methods, including the computer-assisted planimetric analysis (gold standard), 2/3Sh, 1/2abc, 1/3abc and Tada's formula. Moreover, the percentage deviation of the estimated hematoma volume by every method in comparison with gold standard was assessed respectively.

Results: Compared with gold standard (39.59±24.47 ml), the formula 2/3Sh (40.55±26.58 ml, P>0.05) overestimated the epidural hematoma volume by nearly 1% (0.01±0.09, P>0.05); similarly, the formula 2/3Sh (70.56±49.06 ml, P>0.05) in comparison with gold standard (69.98±45.99 ml) overestimated the subdural hematoma volume by nearly <1% (?0.00±0.13, P>0.05). In addition, the intracerebral hematoma volume assessed by the formula 2/3Sh in contrast with gold standard (33.33±33.19 ml) was 33.88±34.39 ml (P>0.05) with an only 2% (?0.02±0.15, P>0.05) underestimation.

Discussion: The formula 2/3Sh in contrast with other methods was a precise, simple, convenient estimation method, which was suitable for the epidural, subdural and intracerebral hematoma volume.     

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.     

Chronic subdural hematoma after endoscopic third ventriculostomy: case report

Endoscopic third ventriculostomy (ETV) is an effective and rather safe treatment for noncommunicating hydrocephalus secondary to aqueductal stenosis and other obstructive pathologies. It has become a popular alternative to ventricular shunts for noncommunicating hydrocephalus. Although it is a safe procedure, several complications related to this procedure have been reported in the literature. We report a rare case of a large chronic subdural hematoma (ChSDH) after ETV in a patient with aqueductal stenosis. A 42-year-old female patient presented with acute symptoms of obstructive hydrocephalus, headaches and blurring of consciousness. A computerized tomogram (CT) of the patient's brain revealed marked triventricular supratentorial hydrocephalus and an external ventricular drainage (EVD) was performed first. After this procedure, magnetic resonance imaging (MRI) demonstrated hydrocephalus secondary to aqueductal stenosis. ETV was performed and the EVD removed uneventfully. The patient was discharged home after a few days without any complications. She then presented with headaches 4 weeks following ETV. A CT demonstrated chronic subdural hematoma on the contralateral side. This was treated with burr-hole evacuation. Postoperatively, her headaches improved. During the follow-up period, she remains symptom-free and has radiographic evidence of a patent ventriculostomy. This case confirms chronic subdural hematoma formation is a possible complication following endoscopic third ventriculostomy.     

Traumatic induced total myelomalacia of the cervical spinal cord associated with a space-occupying subdural hematoma

We report the case of a 20-year-old male driver who suffered from a trauma to the cervical vertebral column in a head-on collision with a tree. The injuries included subluxation of the 2nd and 3rd cervical vertebrae and fracture of the odontoid process of the axis with ventrally directed displacement of the proximal fragment and dorsally directed displacement of the distal fragment. Already at admission to hospital a space-occupying spinal subdural hematoma was diagnosed. Clinically, paraplegia was diagnosed with progressive loss of consciousness. Pneumonia led to death 40 days after the accident. Autopsy disclosed a total myelomalacia of the cervical spinal cord obviously resulting from an ischemia caused by a traumatic lesion of the dorsal truncus arteriosus spinalis as well as a compression by the spinal subdural hematoma.     

Chronic subdural hematoma: Reliability of radioisotope imaging versus computed tomography

25 surgically verified cases of chronic subdural hematoma (CSH) were examined retrospectively. All the patients had been investigated both with computed tomography (CT) and with radioisotope imaging (RI). RI supplied a correct diagnosis in all cases whilst CT yielded a doubtful diagnosis (generic signs of spaceoccupying lesion) in 5 cases and normal findings (false negative) in one. The clinical use of the two investigations is discussed. The study shows the reliability of RI in the diagnosis of CSH especially when CT determines the site but not the nature of the lesion (hematoma in the isodense phase).

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Sommario Sono stati esaminati retrospettivamente 25 casi di ESC (Ematoma Subdurale Cronico) verificati chirurgicamente. Tutti i pazienti erano stati sottoposti sia a TC (Tomografia Computerizzata) che ad ER (Esame Radioisotopico). L'ER ha permesso diformulare la diagnosi esatta in tutti i casi mentre la TC ha fornito in 5 casi una diagnosi dubbia (segni generici di processo espansivo) ed in un caso è risultato normale (falso negativo). Viene discusso l'uso clinico dei due esami. Lo studio dimostra la affidabilità dell'ER nella diagnosi di ESC in particolare quando la TC permette solo una diagnosi di presenza ma non di natura della lesione (ematoma in fase di isodensità).

     

Parkinsonism secondary to chronic subdural hematoma. A case report]

We described a case of secondary parkinsonism due to chronic subdural hematoma (CSH). An 83-year-old man developed memory impairment and gait disturbance gradually since one year ago, and these symptoms subacutely deteriorated after he fell down and hit his head. On admission he had moderate cognitive impairment, gait disturbance (wide-based, small steps and initial freezing), postual instability, akinesia and right-sided rigidity. He did not have resting tremor. A CT scan showed a right-sided CSH with marked compression on the left hemisphere, and remarkable decrease of the blood flow in the left cerebral hemisphere was revealed by single photon emission computed tomography. His neurological condition improved gradually through the decrease of the CSH, which suggested the diagnosis of secondary parkinsonism due to CSH. We thought that the CSH in the right hemisphere caused right-sided parkinsonism through mechanical compression to the left hemisphere, which was shown in the SPECT image, in this case. Elderly people suffering from subacute progressive parkinsonism, should undergo CT studies be to differentiate the parkinsonism secondary to CSH.     

Chronic subdural haematoma associated with nontraumatic CSF rhinorrhea: a management challenge.

We report an unusual case of chronic subdural haematoma (CSH) associated with cerebrospinal fluid (CSF) rhinorrhoea emphasizing the importance of managing both conditions simultaneously. A 59- year-old man presented with watery discharge from the right nostril, of 2 months duration. MRI of the brain showed a CSH in the left fronto-parietal region with significant mass effect. There was an arachnoidocoele with a defect in the planum sphenoidale. He first underwent a burr hole evacuation of the CSH following which the CSF rhinorrhea did not subside, even with bed rest. Transnasal endoscopic closure of the CSF dural fistula was done. On the first post-operative day, he was disoriented and a CT scan showed a recollection of the subdural haematoma that required repeat evacuation. The patient was asymptomatic at discharge. To our knowledge this is the first reported case of CSF rhinorrhoea associated with CSH. Simultaneous closure of the CSF dural fistula at the time of evacuation of a coexisting CSH would be the optimal management.