Percutaneous needle trephination for external CSF drainage: experience with 226 punctures

We report on our experience with 226 percutaneous needle trephinations in a total of 192 consecutive patients. Trephination was performed with a hand-driven drill. A special puncture needle was inserted into the anterior horn of the lateral ventricle. The main indication for this procedure was the treatment of occlusive hydrocephalus in an emergency. Duration of drainage ranged from 1 to 34 days and was 7 days on the average. We encountered 14 cases of infection (6.2%) and one case of symptomatic bleeding (0.4%). All these complications eventually resolved without permanent sequelae. In our opinion, ventricle puncture with this device is a simple and effective method and can especially be recommended for external CSF drainage in cases of emergency.     

Acute epidural hematoma developing during twist-drill craniostomy: a complication of percutaneous subdural tapping for the treatment of chronic subdural hematoma

BACKGROUND

This case illustrates that although percutaneous subdural tapping for patients with chronic subdural hematoma (CSDH) is successful and minimally invasive, it can be complicated by acute epidural hematoma.

CASE PRESENTATION

A 62-year-old woman presented with headache two months after minor head trauma. Computed tomography (CT) scanning revealed CSDH with mixed density on the right side. Prior to percutaneous subdural tapping, twist-drill craniostomy was performed at the parietal tuber. When the drill-needle reached the dura mater, the patient began to complain of headache, which was followed by altered consciousness. CT scanning disclosed acute epidural hematoma abutting the CSDH; both hematomas were evacuated by emergency craniotomy. At surgery, no definite bleeding source was identified apart from oozing on the dura mater.

CONCLUSION

Hemorrhagic complications after percutaneous subdural tapping are rare. The formation of acute epidural hematoma during twist-drill craniostomy has not been reported in the literature. This complication can occur when the blunt tip of the drill-needle remains on the dura mater without penetrating into the subdural hematoma cavity.     

Spontaneous Intracranial Hypotension Associated with Subdural Hematoma: Diagnostic Usefulness of Percutaneous Subdural Tapping and Magnetic Resonance Imaging

Summary A 55-year-old woman presented with headache which was characterized by aggravation in the upright position and relief in recumbency. Although intracranial hypotension syndrome was condidered to be the most-likely possible entity, computed tomography (CT) scans demonstrated subdural fluid collections associated with findings reminiscent of transtentorial herniation. Because of these CT features, cerebrospinal fluid pressure measurement by a lumbar puncture was not performed. Instead, as an alternative method, she underwent percutaneous subdural tapping, which failed to obtain spontaneous drainage of liquid haematoma, indicating intracranial hypotension. In addition, gadolinium-enhanced magnetic resonance imaging study performed later supported the diagnosis of spontaneous intracranial hypotension. Thus, the usefulness and safety of percutaneous subdural tapping for the diagnosis of spontaneous intracranial hypotension is stressed.     

神经内窥镜治疗分隔型慢性硬膜下血肿(45例报告)

目的　评估神经内窥镜治疗分隔型慢性硬膜下血肿 (SCSH)的疗效及优点。　方法　通过单一钻孔用内窥镜显微剪分离血肿腔内隔膜并冲洗引流血肿液 ,治疗 4 5例分隔型慢性硬膜下血肿。　结果　所有病例治疗有效 ,原有意识状况、定位体征改善 ,无血肿复发、感染、脑水肿、颅内出血、积气及新的神经功能缺失。　结论　神经内窥镜是治疗分隔型慢性硬膜下血肿安全、有效、便捷的微侵袭技术。     

Lumbosacral subdural hematoma associated with cranial subdural hematoma and craniocerebral surgery: Three cases and a systemic literature review

ObjectiveThe authors aim to focus on lumbosacral subdural hematoma (SDH) associated with cranial subdural hematoma and craniocerebral surgery, which has been rarely reported.Material and MethodsThey present 3 cases of lumbosacral SDH, including 2 associated with cranial chronic SDH and 1 following craniotomy for neck clipping of cerebral aneurysm. Using a PubMed search, they also provide a systemic literature review to summarize pathogenesis, treatment and outcome.ResultsAll cases presented with bilateral radiating leg pain, and recovered completely by conservative managements. Predisposing factors were trauma, anticoagulant therapy and brain atrophy. Literature review revealed 54 such cases, in which 28 cases associated with cranial SDH and 26 cases associated with craniocerebral surgery. In both group, main symptoms were low back and radiating leg pain, and sensorimotor deficits. Regardless of treatments, conservatively or surgically, outcome was favorable. Migration of cranial hematoma is most supported pathogenesis, while intracranial hypotension due to cerebrospinal fluid overdrainage procedures may also be a contributing factor for cases associated with craniocerebral surgery.ConclusionsLumbosacral SDH should be considered in patients present with unexpected low back and radiating leg pains associated with cranial SDH and craniocerebral surgery. Conservative treatment would be reasonable for cases with mild symptoms as the first treatment of choice.     

Conservative Treatment of Chronic Subdural Hematoma with Gorei-san

Most asymptomatic patients with chronic subdural hematoma (CSDH) are followed conservatively but can require surgical treatment if the hematoma expands. We conducted a retrospective evaluation of the effect of Gorei-san on CSDH. This study included patients treated between April 2013 and March 2015. In total, 289 patients were diagnosed with CSDH and 110 patients received conservative management. Finally, 39 patients who met the requirements were registered. We retrospectively examined the age, gender, medical history, hematoma thickness, clarity of sulci below hematomas, and midline shift of the patients. The primary outcome was the median surgery-free interval, and the secondary results were the rate of CSDH shrinkage and surgery avoidance. A comparison of patient characteristics between the Gorei-san (G) and non-Gorei-san (NG) groups found no significant differences in the percentage of men, average ages, past history, thickness of CSDH (15.0 ± 3.1 mm vs. 15.3 ± 2.6 mm, p = 0.801), or midline shift (2.0 ± 2.7 mm vs. 4.0 ± 5.0 mm, p = 0.230). The median surgery-free interval was significantly different between the G and NG groups [n. r. vs. 41 days (95% CI: 5-79), log-rank p = 0.047]. The CSDH avoidance rate was not significantly different between the two groups (70.0% vs. 34.4%, p = 0.071). Additionally, the CSDH shrinkage rate was significantly different between the two groups (60.0% vs. 10.3%, p = 0.004). This retrospective study demonstrated that CSDH treatment with Gorei-san reduces hematoma significantly more than treatment that does not include Gorei-san.     

Effectiveness of adjuvant corticosteroid therapy for chronic subdural hematoma: a retrospective study of 198 cases

BACKGROUND AND PURPOSE: Adjuvant treatments can be proposed in addition to surgery for patients with chronic subdural hematoma (CSDH) in order to improve the postoperative outcome. According to the survey published in 2001 by the Neurosurgery French Society, 38% of French neurosurgeons use adjuvant corticosteroid therapy after surgery. Does this adjuvant corticosteroid therapy have an effect on the postoperative outcome of CSDH? METHODS: A retrospective trial was performed on patients who were surgically treated for CSDH between January 1998 and July 2002 in the Nice Department of Neurosurgery. Corticosteroid therapy was initiated just after surgery and maintained for one month. Part of the patients were not given corticosteroids enabling a comparison of two groups: "corticosteroid therapy" versus "no corticosteroid therapy". RESULTS: One hundred and ninety-eight patients were included in the trial, 142 patients in the "corticosteroid therapy" group and 56 patients in the "no corticosteroid therapy" group. The difference in survival between the two groups was significant in favor of the group give corticosteroids. A multivariate analysis was carried out which confirmed the beneficial effect of the corticosteroid therapy on survival of the operated patients. Their risk of death was threefold less than those not given this treatment (p=0.006). CONCLUSIONS: This study highlighted a protective effect of postoperative corticosteroid therapy on patient survival. This effect persisted at multivariate analysis. However, due to skews inherent in retrospective studies, a multicentric prospective randomized trial is being prepared in our institution to confirm these results.     

Chronic Subdural Hematoma―Evolution of Etiology and Surgical Treatment―

In this paper, I review the historical changes in the etiological concepts and surgical treatments for chronic subdural hematoma (CSDH) across the world and in Japan. I also examine future problems associated with its surgical procedures and medical costs. CSDH was first reported by Wepfer in 1657 as “delayed apoplexy.” In 1857, Virchow described the famous concept of so-called “pachymeningitis hemorrhagica interna.” He considered that the etiology of CSDH involved inflammation. In 1914, Trotter described the origin of CSDH as traumatic. Currently, CSDH is considered to arise with a first leak of blood from dural border cells after mild trauma. Inflammatory cells are then drawn to the border cell layer. At this point, new membranes form from activated inflammation; then, the hematoma enlarges, promoted by angiogenic factors and new capillaries. In 1883, Hulke reported successful trepanning of a patient with CSDH. Burr holes and craniotomy for removal of the hematoma were subsequently reported, and new methods were developed over the course of several decades around the world. In Japan, after the first report by Nakada in 1938, many Japanese pioneering figures of neurological surgery have studied CSDH. After Mandai reported the middle meningeal artery embolization in 2000, this method is now considered useful as an initial or second treatment for CSDH. However, the age of patients is increasing, so more minimally invasive surgeries and useful pharmacotherapies are needed. We must also consider the costs for treating CSDH, because of the increasing numbers of surgical cases.     

Burr-hole Irrigation with Closed-system Drainage for the Treatment of Chronic Subdural Hematoma: A Meta-analysis

There is controversy among neurosurgeons regarding whether irrigation or drainage is necessary for achieving a lower revision rate for the treatment of chronic subdural hematoma (CSDH) using burr-hole craniostomy (BHC). Therefore, we performed a meta-analysis of all available published reports. Multiple electronic health databases were searched to identify all studies published between 1989 and June 2012 that compared irrigation and drainage. Data were processed by using Review Manager 5.1.6. Effect sizes are expressed as pooled odds ratio (OR) estimates. Due to heterogeneity between studies, we used the random effect of the inverse variance weighted method to perform the meta-analysis. Thirteen published reports were selected for this meta-analysis. The comprehensive results indicated that there were no statistically significant differences in mortality or complication rates between drainage and no drainage (P > 0.05). Additionally, there were no differences in recurrence between irrigation and no irrigation (P > 0.05). However, the difference between drainage and no drainage in recurrence rate reached statistical significance (P < 0.01). The results from this meta-analysis suggest that burr-hole surgery with closed-system drainage can reduce the recurrence of CSDH; however, irrigation is not necessary for every patient.     

Effect of Inner Membrane Tearing in the Treatment of Adult Chronic Subdural Hematoma: A Comparative Study

The postoperative results of chronic subdural hematoma (CSDH) procedures using catheterization and tearing of inner membrane (CTIM) technique have not previously been discussed in the literature. This article compares the effects of CTIM technique on brain re-expansion and re-accumulation with cases operated on with a burr-hole craniotomy and outer membrane incision (BCOMI) technique. The study involved operations on 144 patients (Group 1) using the CTIM technique and 108 patients (Group 2) using the BCOMI technique. In the operations using the CTIM technique in Group 1, the mean effusion measured in the subdural space (SDS) was 10.0 ± 0.2 mm, and for Group 2, 14.3 ± 0.6 mm in the postoperative period on the first and third days and this difference was found to be significant (p < 0.05). The means were 6.6 ± 0.2 mm for Group 1 and 10.3 ± 0.5 mm for Group 2 on the seventh day (p < 0.05). Recurrence rate was 8.3% in Group 2 and 0 in Group 1. This difference was statistically significant (p = 0001). The length of hospital stay was 7.0 ± 0.1 days for the Group 1 and 8.8 ± 0.2 days for Group 2 and this difference was significant (p < 0.05). These results indicate that the CTIM technique is preferable because it results in earlier re-expansion, lower recurrence, less subdural effusion and pneumocephalus, and shorter hospital stays.     

Chronic Subdural Hematoma Associated with Spontaneous Intracranial Hypotension: Therapeutic Strategies and Outcomes of 55 Cases

Spontaneous intracranial hypotension (SIH) has increasingly been recognized, and it is well known that SIH is sometimes complicated by chronic subdural hematoma (SDH). In this study, 55 cases of SIH with SDH were retrospectively analyzed, focusing on therapeutic strategies and outcomes. Of 169 SIH cases (75 males, 84 females), 55 (36 males, 19 females) were complicated by SDH. SIH was diagnosed based on clinical symptoms, neuroimaging, and/or low cerebrospinal fluid pressure. Presence of orthostatic headache and diffuse meningeal enhancement on magnetic resonance imaging were regarded as the most important criteria. Among 55 SIH with SDH cases, 13 improved with conservative treatment, 25 initially received an epidural blood patch (EBP), and 17 initially underwent irrigation of the hematomas. Of the 25 initially treated with EBP, 7 (28.0%) needed SDH surgery and 18 (72.0%) recovered fully without surgery. Of 17 SDH cases initially treated with surgery, 6 (35.7%) required no EBP therapy and the other 11 (64.3%) needed EBP and/or additional SDH operations. In the latter group, 2 cases had transient severe complications during and after the procedures. One of these 2 cases developed a hoarse voice complication. Despite this single, non-severe complication, all enrolled in this study achieved good outcomes. The present study suggests that patients initially receiving SDH surgery may need additional treatments and may occasionally have complications. If conservative treatment is insufficient, EBP should be performed prior to hematoma irrigation.     

A Prospective Randomized Study on the Preventive Effect of Japanese Herbal Kampo Medicine Goreisan for Recurrence of Chronic Subdural Hematoma

Although the recurrence of chronic subdural hematoma (CSDH) after surgical treatment significantly affects the patients’ quality of life, the recurrence rate has not improved in decades. Goreisan, a Japanese herbal Kampo medicine, promotes the hydragogue effect and has been empirically used in the treatment of CSDH in Japan. We conducted a prospective randomized study to investigate whether Goreisan treatment decreases the recurrence rate of CSDH. Between March 2013 and December 2018, a total of 224 patients who underwent initial burr hole surgery for CSDH were randomly assigned to receive Goreisan for 3 months (Group G) or no medication (Group N). The primary endpoint was symptomatic recurrence within 3 months postoperatively, and the secondary endpoint was complications, including the adverse effects of Goreisan. Of 224 randomized patients, 208 were included in the final analysis (104 in Group G and 104 in Group N). The overall recurrence rate was 9.1% (19/208). The recurrence rate of Group G was lower than that of Group N (5.8% vs 12.5%, P = 0.09), but the difference was not statistically significant. However, a significant preventive effect of Goreisan was found in 145 patients with high-risk computed tomography (CT) features, namely, homogeneous and separated types (5.6% vs 17.6%, P = 0.04). Although the present study did not prove the beneficial effect of Goreisan treatment, it suggested the importance of selecting patients with an increased risk of recurrence. A subset of patients whose hematoma showed homogeneous and separated patterns on CT image might benefit from Goreisan treatment.     

Unilateral Oculomotor Nerve Palsy as an Initial Presentation of Bilateral Chronic Subdural Hematoma: Case Report

Isolated oculomotor nerve palsy is well known as a symptom of microvascular infarction and intracranial aneurysm, but unilateral oculomotor nerve palsy as an initial manifestation of chronic subdural hematoma (CSDH) is a rare clinical condition. We report a rare case of an 84-year-old woman with bilateral CSDH who presented with unilateral oculomotor nerve palsy as the initial symptom. The patient, who had a medical history of minor head injury 3 weeks prior, presented with left ptosis, diplopia, and vomiting. She had taken an antiplatelet drug for lacunar cerebral infarction. Computed tomography (CT) of the head showed bilateral CSDH with a slight midline shift to the left side. She underwent an urgent evacuation through bilateral frontal burr holes. Magnetic resonance angiography (MRA) after evacuation revealed no intracranial aneurysms, but constructive interference in steady-state (CISS) magnetic resonance imaging (MRI) revealed that the left posterior cerebral artery (PCA) ran much more anteriorly and inferiorly compared with the right PCA and the left oculomotor nerve passed very closely between the left PCA and the left superior cerebellar artery (SCA). There is the possibility that the strong compression to the left uncus, the left PCA, and the left SCA due to the bilateral CSDH resulted in left oculomotor nerve palsy with an initial manifestation without unconsciousness. Unilateral oculomotor nerve palsy as an initial presentation caused by bilateral CSDH without unconsciousness is a rare clinical condition, but this situation is very important as a differential diagnosis of unilateral oculomotor nerve palsy.     

The role of postoperative patient posture in the recurrence of chronic subdural hematoma: a prospective randomized trial

BACKGROUND

Chronic subdural hematoma is known to have a significant recurrence rate. In this report, we evaluate the relationship between the recurrence rate of chronic subdural hematoma and postoperative patient posture.

METHODS

We conducted a prospective randomized study of 46 patients with chronic subdural hematoma treated surgically at the Osaka City General Hospital from January 1997 to December 1999. In Group A, the patients were kept in a supine position for 3 days after the operation. In Group B, the patients assumed a sitting position on the day after the operation.

RESULTS

The recurrence rates in Group A and Group B were not significantly different.

CONCLUSIONS

Assuming an upright posture soon after operation in cases of chronic subdural hematoma is not thought to be a risk factor for recurrence.     

Acute spinal subdural hematoma with hemiplegia after acupuncture: a case report and review of the literature

Background context

Subdural spinal hematoma (SDH) is a very rare entity; however, it can lead to serious complications resulting from injuries to the spinal cord and roots. Although acupuncture has been a popular method for the management of pain control, we encountered the first case of SDH after acupuncture.

Purpose

The purpose of this case report was to present the first case of subdural hematoma after acupuncture and the reasons for the risks of blind cervical acupuncture.

Study design

A case report and review of the previous literature are presented.

Methods

A 69-year-old man complained of progressive weakness in the right upper and lower extremities 2 hours after acupuncture on the cervical spine and back. The diagnosis was delayed because of unilateral weakness, and the symptom was initially misinterpreted as a transient ischemic attack because of no sensory change and pain and normal findings of two brain magnetic resonance imaging (MRI).

Results

Cervical MRI 36 hours after onset revealed acute hematoma from the C3–C5 level; hematoma showed an isointensity on T1-weighted image (WI) with the preservation of epidural fat and a hypointensity on T2WI. A decompressive surgery was scheduled to perform within 2 days after the cervical MRI scan because of a previous anticoagulation therapy, but the patient refused it. Finally, 9 days after the onset, surgical decompression and removal of hematoma were performed. Three months postoperatively, the patient had fully recovered demonstrating fine hand movement and good ability to walk up and down the stairs.

Conclusions

Our study indicates that it is essential to perform cervical MRI when a patient does not show an improvement in the neurologic deficit and has a negative brain MRI after acupuncture. In addition, blind acupuncture if not correctly practiced may be harmful to the cervical structures.     

小孔多方位颅内血肿清除术在高血压脑出血治疗中的价值分析

目的探讨小孔多方位颅内血肿清除术对高血压脑出血的临床疗效。方法选取2013年4月-2014年2月我院收治的120例高血压脑出血患者作为研究对象,将其随机分为治疗组65例和对照组55例。治疗组给予小孔多方位颅内血肿清除术治疗,对照组给予传统开颅血肿清除术。比较两组在总有效率、并发症发生率、病死率中的差异。结果治疗组总有效率为81.54%,并发症发生率为1.54%,病死率为4.62%;对照组总有效率为41.82%,并发症发生率为16.36%,病死率为18.18%。治疗组总有效率明显高于对照组,且并发症发生率及病死率明显低于对照组,均具有统计学差异（P〈0.05）。结论小孔多方位颅内血肿清除术对高血压脑出血有治疗作用,且疗效优于传统开颅血肿清除术。     

表现为慢性脑内血肿的脑血管畸形诊断与治疗

目的：探索CT表现为慢性脑内血肿的脑血管畸形的诊断和外科治疗。方法：回顾性分析10例CT表现为慢性脑内血肿的脑血管畸形，主要症状表现为癫痫，轻瘫和头痛，所有病例均经CT检查，5例经MRI检查，4例经全脑DSA检查，所有病人均经手术治疗，并取得相应资料。结果：术前6例误诊囊性胶质瘤或肿瘤卒中，术后是诊断均为脑血管畸形伴慢性脑内血肿，全组无死亡，除1例轻瘫外均恢复正常；8例临床和影像学随访5月－6年无异常发现。结论：表现慢性脑内血肿的脑血管畸形易误诊为脑胶质瘤，MRI，DSA检查对确诊和治疗有重要意义。     

口服阿托伐他汀钙片联合钻孔引流术治疗慢性硬膜下血肿的疗效分析

目的比较口服阿托伐他汀钙片联合钻孔引流术与单纯钻孔引流术治疗慢性硬膜下血肿(CSDH)的疗效。方法收集中山大学孙逸仙纪念医院与广东同江医院2016年1月至2017年7月期间行钻孔引流术治疗的慢性硬膜下血肿患者资料,以是否辅助口服阿托伐他汀钙片将患者分为观察组36例与对照组32例。观察组行钻孔引流术后辅以口服阿托伐他汀钙片8~12周,对照组单纯行钻孔引流术,然后对比两组间治疗效果,以及术后第8周Karnofsky(KPS)功能状态评分差异。结果观察组总有效率(97.22%)与对照组(84.38%)差异无统计学意义(χ~2=2.062,P=0.151),而观察组治疗效果则优于对照组(Z=-2.413,P=0.016)。观察组复发率(0%)低于对照组(12.5%),差异有统计学意义(χ~2=4.711,P=0.03)。术后第8周KPS评分,观察组平均评分(92.78±9.74)高于对照组(87.19±12.50),差异有统计学意义(Z=-2.093,P=0.036)。结论口服阿托伐他汀钙片联合钻孔引流术治疗慢性硬膜下血肿效果优于单纯钻孔引流术,且血肿复发率低,更有助于患者术后神经功能恢复。     

Percutaneous tracheostomy by forceps dilation: report of 162 cases

A prospective, observational clinical study evaluated the safety of percutaneous single-step dilatational tracheostomy over a 43-month period. One hundred and sixty-two patients were deemed suitable for the procedure. The mean duration of tracheal intubation prior to tracheostomy was 6 days. The mean duration of the procedure was 9.3 min. Intra-operative complications occurred in 27 patients (16.6%), most of which were minor technical difficulties without morbidity. Postoperative complications, some of which were associated with morbidity, occurred in 16 patients. There were two deaths secondary to premature decannulation, one case of severe bleeding and five pneumothoraces. Long-term complications were assessed in 81 patients; there were four tracheal stenoses requiring surgery or laser therapy and seven patients with granulation tissue at the stoma site which did not require treatment. Forceps dilatational percutaneous tracheostomy appeared to be a convenient bedside procedure. However, complications do occur and further studies should address late sequellae, such as tracheal stenosis.     

Percutaneous fixation of the scaphoid through a dorsal approach: an anatomic study

PURPOSE: Percutaneous surgical treatment of nondisplaced scaphoid fractures is becoming more common. Although the surgical anatomy at risk has been well described for the volar approach to the scaphoid, we have not found articles elucidating the dangers with a percutaneous dorsal approach. Additionally, direct placement of the screw is not possible with a percutaneous approach, and there is a risk of not seating the screw below the subchondral bone. The purpose of this study was to delineate the anatomy at risk using a dorsal percutaneous approach to the scaphoid and to determine the accuracy of using fluoroscopy to seat the screw flush with the subchondral surface. METHODS: Cannulated, headless screws were placed into the scaphoids of 12 fresh-frozen cadavers in standard percutaneous fashion through a dorsal approach. Fluoroscopy was used to seat the screw just below the subchondral surface. The wrists were then dissected and the distance from the guide wire to various anatomic structures was measured. The distance that the screw was protruding above or buried below the subchondral bone was also measured. RESULTS: The distances from the guide wire to the posterior interosseous nerve, to extensor digitorum communis to the index, and to extensor indicis proprius were 2.2 mm, 2.2 mm, and 3.1 mm, respectively. These structures were most at risk. The screw was prominent (above the subchondral bone) in 2 of 12 specimens and flush with or buried in the remaining 10 specimens. CONCLUSIONS: The results of this study show that there are anatomic structures at risk of injury with dorsal percutaneous placement of a headless screw into the scaphoid. Despite using live and static fluoroscopy views, we incorrectly placed the screw above the subchondral bone in 2 of the specimens. We support use of a limited incision when internally fixing a scaphoid from the dorsal approach.