Spinal cord changes after the evacuation of a spinal subdural haematoma

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

Twist drill craniostomy with closed drainage for chronic subdural haematoma in the elderly: an effective method

OBJECTIVE: Chronic subdural haematoma is a disease of the elderly and surgery in these patients carries a much higher risk. The common surgical procedures for chronic subdural haematoma include twist drill craniostomy, burr hole evacuation or craniotomy. The aim of this study was to analyse the results of twist drill craniostomy with drainage in elderly patients with chronic subdural haematoma. METHODS: Forty-two elderly patients (>65 years) with radiologically proven chronic subdural haematoma were analysed. All the patients underwent twist drill craniostomy and continuous drainage of the haematoma under local anaesthesia and total intravenous anaesthesia (TIVA). RESULTS: There were 24 males and 18 females. Headache and cognitive decline was seen in 50% and weakness of limbs in 60% of patients. CT scan was done in all cases. All patients underwent twist drill 2-3cm in front of the parietal eminence under local anaesthesia. The drain was left for 24-72h depending on the drainage. At 1 week, 88% of patients had a good outcome. CONCLUSION: Twist drill craniostomy with drainage under local anaesthesia is a safe and effective procedure for chronic subdural haematoma in the elderly and could be used as the first and only option in these people.     

Subdural hematoma after lumbar puncture: two case reports and review of the literature.

Two cases of intracranial subdural hematoma following lumbar puncture are presented. A review of all previously reported cases shows that subdural hematoma after lumbar puncture is a rare but serious complication. The pathogenesis of subdural hematoma after lumbar puncture is probably related to that of post lumbar puncture headache. Application of an epidural blood patch may therefore be a safe way not only to treat typical post lumbar puncture headache but also to prevent subdural hematoma after lumbar puncture.     

CSF hypotension: A review of its manifestations,investigation and management

Intracranial cerebrospinal fluid (CSF) hypotension usually arises in the context of known or suspected leak of CSF. This can be spontaneous, or due to central nervous system trauma or dural defects created during lumbar puncture or epidural anaesthesia. Spontaneous intracranial hypotension (SIH) is increasingly being recognised as a cause for orthostatic headache or spontaneous subdural haematoma where no other obvious cause is found. We review CSF physiology, the mechanism of symptom generation in CSF hypotension and the investigation and management of the syndrome. Whilst commonly mild and self-limiting, CSF hypotension may result in life threatening complications and is most often treatable. When the syndrome is severe, prolonged or complicated, epidural blood patching (EBP) is the mainstay of treatment.     

Postpuncture headache

The present study recorded prospectively subjective complaints after lumbar puncture as diagnostic procedure (n = 59), spinal - (n = 41) and peridural anaesthesia (n = 45) over a time interval of 28 days. Posture dependent headaches were never observed following peridural anaesthesis. This result disproves the hypothesis of a purely psychogenic origin of postpunctional headache. The frequency of occurrence of the postpunctional syndrome was 39% after lumbar puncture, but only 4.9% after spinal anaesthesis. The observed difference is due to the fact that needles with a smaller diameter are applied in spinal anaesthesia.     

Successful treatment of acute subdural haematoma associated with severe bleeding disorder

Summary A 76-year-old man suffering from myelofibrosis with thrombocytopenia sustained an acute subdural haematoma with severe neurological deficit. He was treated initially by bedrest and dexamethasone. Craniotomy was contraindicated because his bleeding time exceeded 20 min in spite of multiple infusions of platelet concentrate. After 3 weeks his condition deteriorated with increase of the fluid collection shown by CT. Partial drainage of the haematoma by subdural puncture with a 22-gauge spinal needle resulted in complete recovery from the neurological deficit and complete resorption of the effusion. The case shows that it is possible to avoid craniotomy in the acute phase of a subdural haematoma in patients with bleeding disorders and that it may be advantageous to use needle evacuation instead of burr-hole drainage in the chronic phase.     

Post-dural puncture related complications after diagnostic lumbar puncture, myelography and spinal anaesthesia

Objectives – This study was conducted to investigate complications after dural puncture. Material and methods – A 15 months' prospective observation study of routine clinical practice with dural puncture at a university hospital was conducted. Quincke spinal needles 0.90 to 1.0 mm O.D. (20–19 g) were used for diagnostic lumbar puncture, 0.70 mm O.D. (22 g) for myelography and 0.40 to 0.50 mm O.D. (27–25 g) for spinal anaesthesia. A questionnaire about post-puncture discomfort was given to the patients, to be returned after 1 week. Results – Of 679 questionnaires 537 (79.1%) were returned. Discomfort was experienced by 53.8% of the patients, most often after diagnostic lumbar puncture and myelography. The difference in incidence of headache after diagnostic lumbar puncture and myelography compared with spinal anaesthesia were 27.9% (95% CI: 18.6 to 37.2) and 18.3% (95% CI: 9.1 to 27.5). Conclusion – Small diameter and atraumatic spinal needles will reduce patients' discomfort after dural puncture.     

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

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

Subdural haematoma: a potentially serious consequence of spontaneous intracranial hypotension

BACKGROUND: Spontaneous intracranial hypotension (SIH) is characterised by postural headache and low opening pressure at lumbar puncture without obvious cause. Cranial magnetic resonance imaging often shows small subdural collections without mass effect, dural enhancement, venous sinus dilatation, or downward displacement of the brain. The condition is thought to be benign. OBJECTIVES: To evaluate the incidence of subdural haematoma as a serious complication of SIH. METHODS: A prospective survey of all cases of SIH presenting to a large neuroscience unit over a two year period. RESULTS: Nine cases of SIH were seen. Four of these were complicated by acute clinical deterioration with reduced conscious level because of large subdural haematomas requiring urgent neurosurgical drainage. CONCLUSIONS: SIH should not be considered a benign condition. Acute deterioration of patients' clinical status may occur secondary to large subdural haematomas, requiring urgent neurosurgical intervention.     

Arteriovenous malformation presenting as acute subdural haematoma

Abstract

A case of acute subdural haematoma caused by ruptured arteriovenous malformation is reported. At surgery, there was no association with intracerebral haematoma or definite subarachnoid haemorrhage. The mechanism of acute subdural haematoma in the present case was considered to be rupture of an arteriolized bridging vein drained by arteriovenous malformation. [Neurol Res 1993; 15: 353-355]     

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

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

Spinal subdural abscess--report of a case and a review of the literature of 43 cases

Spinal subdural abscess is rare, compared with spinal epidural abscess. The first case was reported by Sittig in 1927. Only 43 cases have been reported throughout the literature. We experienced an atypical fulminant case of spinal subdural abscess, following the operation for intracranial aneurysms. The patient was a 48-year-old male, admitted to our hospital on April 9, 1987 with complaining of sudden headache and vomiting. A lumbar puncture proved subarachnoid hemorrhage (S.A.H.), CT scan revealed saccular aneurysms in left middle cerebral artery and left internal carotid-ophthalmic artery. Radical surgical treatment for those aneurysms was undergone successfully. Neither cerebral ventricular nor cisternal drainage was established. His postoperative course was uneventful until the 9th postoperative day. He suddenly complained of pain in his legs and back, followed by paraplegia, respiratory, and cardiac arrests with clinical course of several hours. Antibiotics had been used for eight days after surgery, and there was no clinical evidence of inflammation sign. For his abrupt aggravation, a spinal infarction was suspected. However, the autopsy demonstrated that the dorsal side of the entire spinal cord was covered with masses of pus, and central necrosis and hemorrhage of the spinal cord mainly occupied the central gray matter; so-called Pencilsharped softening. In this case, the cause of spinal subdural abscess was unclear. But the lumbar puncture performed on the day of admission, was most responsible. Also, the reasons why the clinical course of our case was rapid and fulminant were discussed with preference of spinal abscess to primary spinal circular disorder. 44 cases in the literature, including the presented report, was reviewed. Those symptomatology, predisposing factors, pathogenesis, the extent of spinal subdural abscess, clinical diagnosis, treatment, and prognosis were discussed. Among previous cases, this case was one of the most extensive subdural abscess and fulminant clinical course.     

Acute Cervical Subdural Hematoma with Quadriparesis after Cervical Transforaminal Epidural Block

Cervical epidural steroid injection is frequently used in the conservative management of neck pain and cervical radiculopathy. Epidural cervical transforaminal injections are usually well-tolerated with mild side effects such as transient decreased sensory and motor function, or headache due to dural puncture. Although there are a few case reports about adverse effects of cervical epidural injection in the literature, it can cause severe complications such as large hematoma, infarction by spinal vascular injury. Subdural hematoma has been occurred much less common rather than epidural hematoma in the spinal cord. We report a rare catastrophic case of cervical spinal subdural hematoma with quadriparesis after cervical transforaminal epidural block.     

Streptococcus salivarius meningitis: a case report and literature review

Twelve hours after spinal anaesthesia, a 61-year-old patient developed meningitis with fever, somnolence, headache and stiffness of the neck. The cerebrospinal fluid was found to contain 5.279/mm³ cells (95 granulocytes), 12.800 mg/l protein and 14.0 mmol/l lactate. Streptococcus salivarius was detected in the culture. The patient was treated with antibiotics (initially cefotaxime, fosfomycin and gentamycin, later piperacillin and sulbactam). Restitutio ad integrum took place after 7 days. Thirteen cases of Streptococcus salivarius meningitis over the past 40 years are described in the literature, nine of which occurred following spinal puncture. Streptococcus salivarius was probably communicated by the medical personnel from the oral cavity when working without masks. The outcome in each case was good. In our opinion suitable masks must be worn during spinal puncture. Although iatrogenic infection is uncommon, it cannot be ruled out.     

Dural puncture and corticotherapy as risks factors for cerebral venous sinus thrombosis

Dural puncture with corticosteroid could be a predisposing factor for cerebral venous thrombosis (CVT). A 35-year-old woman using oral contraception was treated with corticosteroid epidural infiltration for L5 radiculalgia. The following day a postural headache developed and accidental dural puncture was suspected. Four days later, she presented with fever and consciousness impairment requiring mechanical ventilation. Magnetic resonance angiography (MRA) confirmed thrombosis of the superior sagittal sinus. Recanalization was observed three weeks later and the patient fully recovered. Blood tests for thrombophilia showed a moderate decrease in the C protein level (chronometric activity 44%, N = 65-130). CVT has been reported after spinal anaesthesia or peridural anaesthesia with accidental puncture. After dural puncture the decrease of cerebrospinal fluid pressure induces a rostrocaudal sagging effect with traumatic damage to the fragile venous endothelial wall, and may trigger a venous vasodilatation with resultant stasis. CVT has also been described in patients after lumbar puncture and oral corticoid treatment for multiple sclerosis and after corticosteroid intrathecal infiltration. Therefore, corticosteroids can be considered as a potential additional procoagulant stimuli.     

Spectrophotometry of cerebrospinal fluid in subacute and chronic subdural haematomas

Spectrophotometric examinations were performed on cerebrospinal and subdural fluids in subacute (five patients) and chronic (20 patients) subdural haematomas, with special reference to the diagnostic aid of CSF spectrophotometry. Spectrophotometric xanthochromia of haemorrhagic origin was found in all CSFs examined, while definite visible xanthochromia was observed in only 28% and the CSF was judged as colourless in 52% of those cases. Characteristic bleeding patterns were found spectrophotometrically in all the 20 CSFs examined within 24 hours after lumbar puncture, haematoma patterns being detected in 90-95% of the cases. In many cases the electrophoretically separated protein fractions of CSF and subdural fluids were spectrophotometrically examined. In conclusion, CSF spectrophotometry is a simple, fast, and extremely sensitive method, which in our opinion should be used routinely in the diagnosis of suspected subdural haematomas, if lumbar puncture is not contraindicated.     

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

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

Posterior fossa subdural haematoma associated with anticoagulant therapy

This is a report of spontaneous posterioir fossa subdural haematoma associated with anticoagulation therapy. The possibility of posterior fossa lesions related to spontaneous haemorrhage is suggested by the combination of severe headache and increasing disturbance of consciousness associated with signs of brain-stem decompensation. A thorough neurological evaluation including appropriate contrast studies will help rule out a supratentorial lesion. This is a neurological emergency which can be successfully treated by early detection and prompt surgical decompression. This is the second reported case of spontaneous subdural haematoma of the posterior fossa occurring during anticoagulant therapy.     

Life-threatening intracranial hypotension after diagnostic lumbar puncture

Intracranial hypotension syndrome as a complication of diagnostic lumbar puncture is a rarely observed entity. Intracranial hypotension syndrome is characterized by postural headache, neck pain/stiffness, blurred vision, nausea, vomiting, clouding of consciousness, dizziness and vertigo. The majority of cases resolve spontaneously with conservative treatment. Rarely, epidural blood patch is required. We report a 41-year-old man with multiple sclerosis, who developed intracranial hypotension syndrome after diagnostic lumbar puncture and who did not respond to conservative treatment. A subdural hematoma was subsequently found, when the patient showed considerable worsening of clinical conditions with life-threatening symptoms. Surgical evacuation of the subdural hematoma was not sufficient to improve significantly the patient's conditions, while complete symptoms remission was achieved 12 hours after epidural blood patch. We stress the need for epidural blood patch in any case of post-diagnostic lumbar puncture postural headache which does not resolve with conservative therapy. Received: 30 April 2001 / Accepted in revised form: 28 September 2001     

双针穿刺治疗老年患者慢性硬膜下血肿

目的 总结30例经皮双针穿刺引流治疗老年患慢性硬膜下血肿效果，探讨慢性硬膜下血肿治疗方法。方法 本组30例慢性硬膜下血肿均经CT检查确诊，都行经皮双针穿刺引流术。结果 所有病例术后l～3d复查CT，血肿腔缩小90％以上，除10例有颅内积气外，未见颅内血肿、颅内感染、肺部感染和其它并发症。术后3～7d拔针，穿刺点一期愈合，痊愈出院，随访6-24月未见复发。结论 经皮双针穿刺引流治疗慢性硬膜下血肿是一种微创、简单、高效和并发症少的方法，但穿刺针需要作改进。