Effective coil embolization of intracavernous carotid artery pseudoaneurysm with parental artery preservation following severe head trauma in a pediatric patient

Background

Intracranial traumatic pseudoaneurysms are rare in children. If left untreated, mortality rate can be as high as 50 % due to delayed rupture and disastrous bleeding. Endovascular embolization is considered the preferred treatment option because of its minimal invasiveness and negligible mortality. However, exclusion of the pseudoaneurysm with preservation of the parental vessel is not always possible. In comparison with peripheral aneurysms, intracavernous internal carotid artery lesions are technically more challenging with both open surgery and endovascular techniques.

Case report

We report the case of a successful two-stage coil embolization of a traumatic intracavernous carotid artery pseudoaneurysm with preservation of parental vessel in a 6-year-old boy.

Conclusion

Endovascular embolization with parental vessel preservation should be considered the first treatment option for traumatic intracavernous internal carotid artery pseudoaneurysms in children. Although treatment of pseudoaneurysms in this location may be technically difficult, it is feasible in experienced hands.     

Sphenoid and Subdural Hemorrhage as a Presenting Sign of Ruptured Clinoid Aneurysm

Background

Aneurysm rupture presenting as an isolated or pure subdural hematoma (SDH) without subarachnoid hemorrhage is an extremely rare radiographic presentation. We present a case of a ruptured internal carotid artery aneurysm with a pure SDH and concurrent sphenoid sinus hemorrhage.

Methods

Case report and review of the literature.

Results

We describe a case of a 48-year-old right-handed woman found comatose brought by emergency medical services to an outside hospital. A non-contrast head CT scan demonstrated bilateral acute SDHs without evidence of intraparenchymal or subarachnoid hemorrhage. A CT angiogram of the head showed a focal hyperdensity in the distal left internal carotid artery (ICA) and was confirmed by conventional cerebral angiography to be a 7-mm left supraclinoid ICA aneurysm. On repeat CT scan a new hemorrhage was seen in the sphenoid sinus indicating a re-bleeding. The aneurysm was treated with coil embolization and complete occlusion was confirmed with subsequent angiograms. The patient had an eventful hospital course complicated by a Takotsubo cardiomyopathy and pulmonary edema. She was medically treated with successful recovery of her cardiopulmonary function. She remained markedly disabled and was transferred to an inpatient rehabilitation center for continued convalescence.

Conclusions

Acute subdural hematoma may be due to a ruptured clinoid carotid aneurysm. Acute hemorrhage into the sphenoid sinus can be an important clue.     

Intracranial Supraclinoid ICA Dissection Causing Cerebral Infarction and Subsequent Subarachnoid Hemorrhage

Background

Intracranial arterial dissection usually leads to cerebral infarction or subarachnoid hemorrhage (SAH). It is rare to see both complications in one clinical scenario.

Methods

Case report and review of the literature.

Results

A 48-year-old woman suffered a left middle cerebral infarct from a dissection of the left supraclinoid ICA. As she was recovering from the ischemic stroke 5 days later she suffered a SAH. The SAH was caused by rupture of a dissecting pseudoaneurysm, which only became evident on repeat catheter angiography. The dissecting pseudoaneurysm was treated with coil occlusion.

Conclusion

Intracranial ICA dissections are typically associated with either ischemic or hemorrhagic presentation. We report an unusual case of a patient who suffered a SAH a few days after an ischemic stroke from the dissection. This case contradicts the long-held dogma that intracranial dissection can have either an ischemic or a hemorrhagic presentation, but not both.     

Traumatic carotid-cavernous fistula at the anterior ascending segment of the internal carotid artery in a pediatric patient

Introduction

Traumatic carotid-cavernous fistula (CCF) in children is a rare condition. Early diagnosis and treatment is still a challenge, and it is associated with good neurological recovery.

Case summary

We present a rare case of a 10-year-old boy with mild head trauma, who developed a CCF at the anterior segment of the ascending internal carotid artery. The patient was treated with endovascular coil embolization and evolved with a favorable outcome.

Discussion

Most of reports in the literature address the traumatic CCF in adult patients, in which early treatment may prevent poor recovery or fatal outcomes. The diagnosis and management of this condition are discussed based on a literature review.

Conclusion

It is important to keep a high degree of suspicion for CCF, especially in traumatic head injury associated with skull base fracture, since the early diagnosis and treatment may prevent potentially permanent neurological deficits.     

Iatrogenic intracranial aneurysms in childhood: case-based update

Purpose

Iatrogenic aneurysms are very rare in children. Characteristic clinical manifestations are variable and asymptomatic course is possible especially for fusiform dilatation of internal carotid artery. Even though radiological diagnosis is easy, the management of iatrogenic intracranial aneurysm is still a subject for discussion.

Methods

Fusiform dilatations of internal carotid artery were diagnosed on three pediatric patients during follow-up imaging after primary surgery for suprasellar–parasellar tumor. All patients were asymptomatic. Conservative treatment was proposed because the lesion did not show any progression in subsequent examinations. Patients are stable under conservative treatment.

Conclusions

Iatrogenic aneurysm may have an unusual presentation and their therapy still remains unclear. Fusiform dilatation of internal carotid artery rarely causes symptoms and there is no published paper of subarachnoid bleeding. Treatment would be difficult, since the main arterial branches arise from the dilated carotid segment. Conservative treatment is a choice only if aneurysm has no progression or in case of spontaneous healing. Intervention should be performed only in case of progression or if the aneurysm becomes symptomatic.     

Neurovascular stents in pediatric population

Purpose

The purpose of the study is to analyze the results obtained using stents for the treatment of neurovascular diseases in pediatric patients.

Methods

A retrospective study of 6-year period was undertaken evaluating clinical charts and imaging studies of patients treated with stents because of neurovascular diseases.

Results

Nine patients were managed with 10 stents. Seven children were females. The median age was 11 years. There were four cases of broad neck cerebral aneurysms, a pseudoaneurysm of the cervical internal carotid artery, a vertebro-jugular fistula, two patients with internal carotid artery (ICA) stenosis affecting the cervical and supraclinoid segment, and a vertebral artery dissection. The only complication was a silent posterior communicating artery (PCoA) thrombosis in a PCoA aneurysm treated with two stents. Dual antiplatelet therapy was given after the procedure to avoid in stent thrombosis.

Conclusion

Stents are safe and effective for treatment of neurovascular diseases in children, but studies are needed in order to protocolize the use of antiplatelet drugs in children.

     

Diagnosing Brain Death by CT Perfusion and Multislice CT Angiography

Introduction

Although the diagnosis of brain death (BD) is usually based on clinical criteria, in sedated patients, ancillary techniques are needed. This study was designed to assess the accuracy of cerebral multislice computed tomographic angiography (CTA) and CT perfusion (CTP) in diagnosing BD.

Methods

Prospective observational study in 27 BD patients.

Results

All patients were diagnosed as BD based on clinical and electroencephalogram findings. After BD diagnosis, CTP was performed followed by 64-detector multislice CTA from the aortic arch to the vertex. Images were reconstructed from 0.5 mm sections. In 24 patients, a lack of cerebral blood flow (CBF) was detected by CTP, and CTA revealed luminal narrowing of the internal carotid artery in the neck and absence of anterior and posterior intracranial circulation (sensitivity 89%). CTA detected CBF exclusively in extracranial portions of the internal carotid and vertebral arteries. Two patients with anoxic brain injury and decompressive craniectomy showed CBF in the CTA such that the CTP results were considered false negatives, given BD had been confirmed by clinical and EEG findings, along with evoked potentials. In one clinically BD patient, in whom an alpha rhythm was detected in the electroencephalogram, CBF was only observed in the intracranial internal carotid with no posterior circulation noted. This patient was therefore considered exclusively brain stem dead.

Conclusions

The radiological protocol used shows a high sensitivity and excellent specificity for detecting the cerebral circulatory arrest that accompanies BD. As a rapid, non-invasive, and widely available technique it is a promising alternative to conventional 4-vessel angiography.     

A successful treatment of arterial ischemic stroke with stent insertion in a child with congenital heart disease

Introduction

Diagnosis of arterial ischemic stroke in pediatric patients is often delayed due to the uncertainty and variability of clinical symptoms. Early diagnosis of arterial ischemic stroke can bring a favorable prognosis with prompt thrombolytic therapy or stent insertion, via transfemoral cerebral arteriogram. Acute thrombolytic therapy is rarely attempted in children because of the delayed diagnosis.

Patient and method

We report a case of a 4-year-old girl with complex heart disease who was presented with arterial ischemic stroke at the right distal internal carotid artery and successfully treated by stent insertion in which repeated thrombolysis or ballooning had failed.

Result

Left hemiparesis was nearly recovered 6 days after the stent insertion. The mean flow velocity of the right middle cerebral artery has slightly improved compared to that of the initial study. She has been followed-up for 6 months in the outpatient clinic without neurologic sequelae.

Conclusion

This case suggests that intracranial stent insertion may be a safe and an effective modality in young children, when the thrombolytic therapy or ballooning is inapplicable. Additionally, transcranial Doppler ultrasonography is useful to monitor the cerebral blood flow after stent insertion in children.     

Efficacy of clip-wrapping in treatment of complex pediatric aneurysms

Purpose

Pediatric aneurysms (PAs) are distinct from their adult counterparts with respect to typical location, aneurysm type, and known predisposing risk factors. Many strategies have been employed to treat PAs, but although it has been used frequently in adults, clip wrapping in pediatric patients has only been reported once. We present a series of pediatric patients that underwent clip wrapping and discuss this strategy as an effective means of treating unclippable PAs.

Methods

Pediatric patients with clip-wrapped aneurysms over a 5-year period were retrospectively identified. Clinical presentation, surgical management, and clinical and radiological outcome of the patients were evaluated.

Results

Five pediatric patients with aneurysms were treated with clip wrapping during the specified period. Three had traumatic pseudoaneurysms, with two subarachnoid hemorrhages from aneurysm rupture. One patient presented with mycotic pseudoaneurysm rupture causing a large intraparenchymal and subarachnoid hemorrhage. Another patient had a dissecting complex saccular lenticulostriate aneurysm with four perforating vessels arising from the dome. Four patients had good clinical results, with Glasgow Outcome Scale (GOS) scores of 5 after at least 1-year follow-up (mean 24.2); one patient had a GOS score of 5 at discharge, but no additional follow-up. Postoperative neuroimaging demonstrated vessel patency after clip wrapping with no recurrent hemorrhages or increase in aneurysm size; however, one had progressive occlusion of the artery in a delayed fashion and had a small clinical ischemic event from which she fully recovered.

Conclusions

Clip wrapping appears to be an effective underutilized technique for treatment of pediatric complex aneurysms that cannot be treated with conventional methods.     

Multiple encephalogaleoperiosteal synangiosis for bilateral carotid artery stenosis in a 13-year-old girl: a case report

Introduction

Encephalogaleoperiosteal synangiosis (EGS) has been widely used to treat children with moyamoya disease (MMD). We present the first case of successful multiple EGS in a patient with brain ischemic disease who presented with different cerebrovascular findings from MMD.

Methods

A 13-year-old girl had an increased frequency of transient ischemic attacks that affected her right extremities. Digital subtraction angiography showed tapering of the internal carotid artery (ICA). The anterior cerebral artery (ACA) and middle cerebral artery (MCA) were visible on vertebral angiogram, but not on carotid angiogram. The intact circle of Willis and lack of hypervascularity of the lenticulostriate arteries were observed. Decreased regional cerebral blood flow (CBF) in the bilateral ACA and MCA territories quantified by ¹²³I-N-isopropyl-p-iodoamphetamine-single photon emission computed tomography indicated the need for extracranial-intracranial bypass surgery. Multiple EGS procedures were performed instead of direct anastomosis, which is the standard procedure for intracranial ICA stenosis, because the space for the craniotomy was limited by transdural anastomosis.

Results

Despite the fact that the diagnosis of MMD was questionable, the hemispheres were well vascularized, and the neurology and CBF improved postoperatively.

Conclusion

The preserved circle of Willis and lack of moyamoya vessels were inconsistent with the features of MMD. However, childhood onset, bilateralness, chronic intracranial ICA stenosis, and transdural anastomosis indicated the same underling pathogenicity as MMD. It is hypothesized that ICA stenosis occurred immediately proximal to the posterior communicating artery in this case. This would have produced the atypical finding of the remaining circle of Willis without growth of the basal moyamoya vessels.

     

Asymptomatic Carotid Stenosis: Intervention or Best Medical Therapy?

Purpose of Review

Provide a current overview regarding the optimal strategy for managing patients with asymptomatic carotid artery stenosis.

Recent Findings

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) reduce long-term stroke risk in asymptomatic patients. However, CAS is associated with a higher risk of peri-procedural stroke. Improvements in best medical therapy (BMT) have renewed uncertainty regarding the extent to which results from older randomised controlled trials (RCTs) comparing outcomes following carotid intervention can be generalised to modern medical practise.

Summary

‘Average surgical risk’ patients with an asymptomatic carotid artery stenosis of 60–99% and increased risk of late stroke should be considered for either CEA or CAS. In patients deemed ‘high risk’ for surgery, CAS is indicated. Use of an anti-platelet, anti-hypertensive and statin, with strict glycaemic control, is recommended. Results from ongoing large, multicentre RCTs comparing CEA, CAS and BMT will provide clarity regarding the optimal management of patients with asymptomatic carotid artery stenosis.

     

Thalamic arteriovenous malformation fed by the artery of Percheron originating from the contralateral posterior cerebral artery in a child

Purpose

Artery of Percheron (AOP) is a rare variant of thalamoperforating artery with a single common trunk feeding both thalami and with or without contribution to the rostral midbrain. We report the first case of thalamic arteriovenous malformation (AVM) fed by AOP with hemorrhagic onset.

Methods

A 12-month-old girl suddenly weakened and developed coma. Left thalamic hemorrhage was detected with the third and both lateral ventricles' hematoma. Thalamic AVM was discovered to be fed by an AOP originating from the contralateral posterior cerebral artery.

Results

Endovascular embolization of AVM was impossible due to a risk of bilateral thalamic infarction and anatomical inaccessibility. Thalamic AVM was removed by high superior parietal approach without new neurological symptoms.

Conclusion

The first case of thalamic AVM fed by AOP originating from the contralateral posterior cerebral artery is reported. Surgical removal of AVM would be at the heart of treatment in order to avoid bilateral thalamic infarction.     

Mucor Thrombus

Background

To describe a rare presentation of ischemic stroke secondary to angioinvasive mucormycosis and endovascular retrieval of mycotic thrombus with stenting of the compressed vessel.

Summary of Case

We report a case of angioinvasive mucormycosis that externally compressed and invaded the internal carotid artery causing ischemic cerebral infarction. A sample of the thrombus was obtained using a stent retriever. Subsequent pathological analysis was shown to be consistent with the diagnosis of angioinvasive mucormycosis. The thrombosed and compressed segment was recanalized with the deployment of a stent.

Conclusions

The endovascular placement of an expandable stent in the setting of angioinvasive mucormycosis restored good cerebral blood flow in a proximal internal carotid artery occlusion. The patient’s aphasia resolved following this intervention. Artifacts of CT angiography may result in the overestimation of acute arterial occlusions. Endovascular carotid stenting may be a palliative measure in the setting of angioinvasive rhino-cerebro-orbital mucormycosis.

     

The merci retrieval system for acute stroke

Introduction

The Merci Retrieval System^® was cleared for use in patients with stroke in August 2004. However, there are few published results of “real world experience” with the device.

Methods

We captured single-center data on 25 consecutive patients with acute ischemic stroke treated with the Merci Retrieval System according to the MERCI trial except that we treated some patients with tandem proximal carotid and intracranial lesions with carotid angioplasty and stenting and some patients were treated within the 3-hour window.

Results

Median patient age was 63 years and median initial National Institute of Health Stroke Scale (NIHSS) score was 18. Isolated M₁ or M₂ middle cerebral artery lesions occurred in 52% “carotid T” lesions in 8%, and vertebrobasilar lesions in 8% Tandem lesions involving proximal carotid and proximal intracranial vessel occurred in 32%, necessitating emergent multilevel treatment including carotid stenting. Median duration from symptom onset to Merci device utilization was 5.2 hours. Successful reperfusion (≥thrombolysis in myocardial infarction [TIMI] 2 flow) in the target vessel was obtained in 56% of cases. Statistical analysis revealed a strong correlation between ability to achieve greater than or equal to TIMI 2 flow a good clinical outcome as measured by 3-month NIHSS score, modified Rankin Scale (mRS), and mortality (nine out of the 12 without successful reperfusion died compared to none of the 13 with ≥TIMI 2 flow, p<0.001). Younger age and lower NIHSS score on presentation were also predictors of good clinical outcome at 3 months.

Conclusion

These “real world data” demonstrate that the results of the previous MERCI trial can be “independently replicated” at a regional stroke center. Although the results of placebo-controlled trials are still pending, mechanical revascularization has become a critical component of our acute stroke protocol, particularly for severe strokes. Issues still remain regarding recalcitrant lesions and operator experience, which necessitate further clinical testing and device optimization.     

Transcerebellar biopsy of diffuse pontine gliomas in children: a technical note

Introduction

The need for a surgical biopsy for diffuse pontine glioma (DPG) is increasing, and a safer and less invasive procedure is required.

Methods

We describe a transcerebellar stereotactic biopsy procedure that can be safely performed in young children. Four pediatric patients with DPG underwent transcerebellar stereotactic biopsies.

Results

All of the patients were diagnosed with gliomas, and one patient had a transient numbness of the lip margin after the procedure.

Discussion

Transcerebellar stereotactic biopsy is a relatively safe way to obtain a tissue diagnosis for children with DPG.     

Kognitive Leistungsfähigkeit nach Operation und stentgeschützter Angioplastie einer Karotisstenose

Background

This prospective, controlled, randomised study evaluates differences concerning cognitive functions between carotid endarterectomy (CEA) and stent-protected angioplasty (CAS) as a treatment for symptomatic carotid stenosis. Both techniques include risks whose effect on neuropsychological abilities remains yet unknown.

Methods

Twenty-seven patients suffering from high-grade symptomatic carotid stenosis underwent neuropsychological testing before, 1 month, and 6 months after treatment. After the first testing patients were randomly assigned for CEA (n=10) or CAS (n=17) as treatment. The patients’ cognitive functions were compared to those of 13 healthy controls.

Results

Whether patients underwent CEA or CAS made no difference in the neuropsychological outcome 4 weeks and 6 months after treatment. Patients always performed worse than the healthy controls.

Conclusion

Both techniques seem to have no different effect on cognitive functions.     

Carotid Artery Stenosis: Medical Therapy,Surgery, and Stenting

Purpose of Review

The purpose of the study was to update the recent information pertaining to carotid artery stenosis risk stratification and treatment.

Recent Findings

Current decision-making related to carotid artery stenosis is based on clinical trials that are outdated. Medical therapy has improved considerably in the past two decades, and this has reduced the stroke rate for both symptomatic and asymptomatic carotid stenoses. In recent community-based studies, the stroke risk with asymptomatic stenosis has been < 1% per year. For asymptomatic carotid stenosis, new trials such as CREST 2 and ECST 2 will determine whether revascularization has any benefit beyond aggressive medical management. For symptomatic patients, carotid endarterectomy is associated with a lower periprocedural stroke rate compared to carotid stenting. Age greater than 70 years is also associated with an increased risk for carotid stenting patients.

Summary

Clinicians should consider a variety of clinical and radiologic variables in reaching treatment decisions for patients with carotid stenosis. Both symptomatic and asymptomatic patients should receive optimal medical therapy.

     

Imaging of vertebral artery stenosis: a systematic review

Background and purpose

Posterior circulation stroke accounts for 20% of ischaemic strokes. Recent data suggest that the early stroke recurrence risk is high and comparable with carotid artery disease. Vertebral artery stenosis accounts for approximately 20% of posterior circulation stroke, and with endovascular treatment available accurate diagnostic imaging is important. We performed a systematic literature review to validate the accuracy of the non‐invasive imaging techniques Duplex ultrasound (DUS), magnetic resonance angiography (MRA) and computed tomographic angiography (CTA) in detecting severe vertebral artery stenosis, with intra‐arterial angiography (IAA) as the reference standard.

Methods

We identified studies that used non‐invasive imaging and IAA as the reference standard to determine vertebral artery stenosis and provided adequate data to calculate sensitivity and specificity. We analysed the quality of these studies, looked for evidence of heterogeneity and performed subgroup analysis for different degrees of stenosis.

Results

11 studies categorised stenosis into 50–99%. The sensitivity of CTA (single study) and pooled sensitivities of contrast enhanced MRA (CE‐MRA) and colour duplex were 100% (95% CI 15.8 to 100), 93.9% (79.8 to 99.3) and 70.2% (54.2 to 83.3), respectively. The specificities for CTA, CE‐MRA and colour duplex were 95.2% (83.8 to 99.4), 94.8% (91.1 to 97.3) and 97.7% (95.2 to 99.1). However, specificities for CE‐MRA and colour duplex demonstrated significant heterogeneity (p = 0.003 and p = 0.002, respectively).

Conclusions

CE‐MRA and possibly CTA may be more sensitive in diagnosing vertebral artery stenosis than DUS. However, data are limited and further high quality studies comparing DUS, MRA and CTA with IAA are required.Posterior circulation stroke accounts for a fifth of strokes,^1,2 and 20–25% of these are believed to be due to stenosis of a vertebral artery, with artery to artery embolism being the likely mechanism.³ Despite its apparent aetiological importance, optimal management of vertebral artery stenosis remains uncertain. This is in marked contrast with carotid stenosis for which the role of revascularisation with carotid endarterectomy has been established in large randomised controlled trials.^4,5 Surgical revascularisation for vertebral artery stenosis is more complex because of the more difficult surgical access. Angioplasty and stenting are technically feasible, and no more difficult than carotid stenting, although their role in preventing recurrent posterior circulation stroke is uncertain.⁶ Progress in managing vertebral artery stenosis has been hampered by the traditional perception that vertebrobasilar strokes and transient ischaemic attacks (TIAs) have a benign prognosis compared with carotid territory ischaemic events. This has tended to make clinicians reluctant to investigate for vertebral stenosis, particularly when the role of revascularisation is uncertain. However, recent data demonstrate that the prognosis is far from benign and a systematic literature review has demonstrated that the risk of subsequent stroke is significantly higher in the acute phase of vertebrobasilar ischaemic events than carotid territory events.⁷Non‐invasive imaging of vertebral stenosis is technically more complex compared with carotid stenosis. On Duplex ultrasound (DUS), most carotid stenoses can be clearly imaged, while only limited visualisation of the vertebral artery is possible. Until recently, the only alternative was intra‐arterial angiography (IAA) which remains the gold standard but carries a risk of iatrogenic stroke of approximately 1–2%.⁸ Non‐contrast magnetic resonance angiography (MRA) allows improved visualisation of the vertebral arteries, and more recently, contrast enhanced MRA (CE‐MRA) and contrast enhanced computed tomographic angiography (CTA) have been proposed as alternatives to the gold standard of IAA (fig 1​1).). Many studies have compared these different imaging modalities for carotid artery stenosis. A recent meta‐analysis of carotid artery stenosis suggested CE‐MRA is more sensitive and specific than ultrasound, non‐contrast MRA and CTA.⁹ Fewer studies have compared these imaging modalities in vertebral artery stenosis. Furthermore, to extrapolate conclusions drawn for the carotid artery to the vertebral artery might be inappropriate, as the vertebral artery differs significantly anatomically from the internal carotid artery.Open in a separate windowFigure 1 Intra‐arterial angiography (IAA), extracranial contrast enhanced magnetic resonance angiography (CE‐MRA) and computed tomographic angiography (CTA), demonstrating right vertebral artery stenosis in a 64‐year‐old patient who presented with a posterior circulation stroke. (A) IAA with right subclavian artery injection; (B) extracranial CE‐MRA maximum intensity projection image; (C) extracranial CTA sagittal reformatted image.The vertebral artery is structurally divided into four sections (fig 2​2):): V₁–V₃ form the extracranial vertebral artery and V₄ forms the intracranial vertebral artery. The vertebral artery is much smaller (3–5 mm) than the internal carotid artery. It arises at right angles to its feeding vessel whereas the carotid artery arises directly from the common carotid artery. It is asymmetrical, with up to 15% of the population having one vertebral artery which is atretic. Approximately 50% have a dominant left vertebral, 25% a dominant right vertebral and 25% have both vertebral arteries of similar calibre.¹⁰Open in a separate windowFigure 2 Schematic diagram illustrating the four segments of the vertebral arteryWe conducted a systematic review of the literature to determine the diagnostic accuracy of DUS, both contrast and non‐contrast enhanced MRA, and CTA, in diagnosing vertebral artery stenosis or occlusion. Previous systematic analyses of carotid artery imaging have highlighted important methodological criteria by which such studies should be assessed.^11,12 We used these criteria in assessing the quality of the vertebral artery imaging studies.     

Spontaneous Subdural Fluid Collection Following Aneurysmal Subarachnoid Hemorrhage: Subdural Hygroma or External Hydrocephalus?

Background

Subdural fluid collections (hygromas and effusions) in adults are usually seen following head trauma or overdrainage of cerebrospinal fluid (CSF) after CSF diversion procedures. We report an unusual case of subdural fluid collection that developed spontaneously 5 days after an aneurysmal subarachnoid hemorrhage (SAH). This patient neither had permanent CSF diversion procedure nor history of significant head trauma during her clinical course.

Methods

This study is a Case report of the patient suffering from an SAH.

Results

A 71-year-old woman suffered an SAH from a ruptured right-sided posterior communicating artery aneurysm. Computed tomography (CT) demonstrated diffuse SAH and signs of early hydrocephalus that did not require treatment. The aneurysm was treated with endovascular coil occlusion without any complications. Throughout her hospital course, she remained alert without neurological deficits. A large subdural fluid collection was discovered incidentally during a routine CT scan of the brain 5 days after the SAH. The patient remained asymptomatic; therefore, the collection was treated conservatively. It resolved spontaneously at five days after the initial diagnosis.

Conclusion

Subdural fluid collections following SAH can occur as a result of head trauma, external hydrocephalus, or as a treatment complication of CSF shunting and craniotomies. It is critical to differentiate simple hygromas from external hydrocephalus since their response to CSF diversion is entirely different.