Clinical study of cerebral blood flow in unilateral chronic subdural hematoma measured by 99mTc-HMPAO SPECT]

Cerebral blood flow (CBF) measured by 99mTc-HMPAO SPECT before operation was studied in 60 patients with unilateral chronic subdural hematoma. The regional CBF was measured in 26 regions of the fronto-occipital 10 cortices, putamen, thalamus and cerebellar hemisphere on both sides. Sixty cases with unilateral chronic subdural hematoma were classified into four groups on the basis of clinical symptoms: 17 cases with headache (headache group), 34 cases with hemiparesis (hemiparesis group) and 9 cases with consciousness disturbance or dementia (consciousness disturbance group), and into three groups on the basis of the degree of midline brain shift on MRI: 7 cases of mild shift group, 24 cases of moderate shift group and 29 cases of severe shift group. The average CBF in 60 patients in each region indicated that the regional CBF was reduced in frontal, occipital cortices and cerebellum on the non-hematoma side, and in putamen and thalamus on the hematoma side. In the headache group, the regional CBF reduction on the non-hematoma side was found in only frontal and occipital cortices compared with the corresponding regions on the hematoma side. In the hemiparesis group, the regional CBF was reduced in frontal and occipital cortices on the non-hematoma side and in putamen and thalamus on the hematoma side. The part of CBF reduction in both hemispheres was also noted in the hemiparesis group. In the consciousness disturbance group, the CBF reduction was markedly noted in whole brain. The CBF reductions in frontal and occipital cortices on the non-hematoma side and in putamen, thalamus and cerebellum on the hematoma side was not mutually related with the degree of midline brain shift. We concluded that the disturbance of CBF in chronic subdural hematoma was started from frontal and occipital cortices on the non-hematoma side observed in the headache group, and which was extended to putamen and thalamus on the hematoma side and a part of both hemispheres observed in the hemiparesis group. And such disturbance was finally observed as the CBF reductions in whole brain in the consciousness disturbance group.     

A case of interhemispheric subdural empyema with sinusitis diagnosed by diffusion-weighted MRI]

The patient was a 29-year-old man with sinusitis. He was admitted with high grade fever, headache, vomiting and disturbance of consciousness. Neurological examination revealed nuchal rigidity, aphasia, right hemiparesis, right sensory disturbance and bilateral Babinski signs. A nonenhanced CT on admission showed a low density area in the interhemispheric fissure. Gadolinium-enhanced MRI and DWI showed an interhemispheric subdural empyema and sinusitis. Neurological deficits gradually improved, after he underwent urgent surgical drainage of sinusitis followed by antibiotics therapy. About three weeks later, he developed right hemiparesis and disturbance of consciousness, and MRI demonstrated the expansion of interhemispheric subdural empyema. Therefore, he underwent surgical drainage of interhemispheric subdural empyema. He was discharged from our hospital without neurologic deficit. We suggest that MRI, in particular DWI, is a useful additional imaging modality for the diagnosis of interhemispheric subdural empyema.     

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.     

Traumatic posterior fossa hematoma

The traumatic posterior fossa hematoma was regarded as relatively rare thing, but recently, as the result of the prevalence of CT scanners, the number of reported cases is increasing. We report nine cases of traumatic posterior fossa hematoma. We divided into two categories: one was the acute epidural hematoma, the other was the acute subdural hematoma with cerebellar contusion. Five were cases of the acute epidural hematoma, three were cases of the acute subdural hematoma with cerebellar contusion and a case had both an epidural and a subdural hematoma. All the cases had struck the occipital region and had the occipital bone fracture. The prognosis of the five cases of the acute epidural hematoma was excellent, but that of the four cases of the acute subdural hematoma with cerebellar contusion was poor and they all died inspite of the removal of the hematoma executed in three cases. We estimated that the hitting forth was extremely strong in cases of the subdural hematoma with cerebellar contusion, and that the momentary deformity of the occipital bone might injure the cerebellum directly. Once a hematoma was produced in the posterior fossa, it oppresses the brainstem and causes the acute hydrocephalus, so the state of consciousness and respiration deteriorate suddenly. In cases of the acute epidural hematoma, appropriate surgical intervention could save the patients and resulted in good outcome. But in some cases of the fulminant type acute epidural hematoma of the posterior fossa caused by tearing the sinuses, though we have not experienced, patients die before the diagnosis and treatment.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Relation between brain displacement and local cerebral blood flow in patients with chronic subdural haematoma

OBJECTIVES: To evaluate the relation between brain displacement, clinical signs and symptoms, and local cerebral blood flow (lCBF) in patients with chronic subdural haematoma (CSDH). METHODS: Forty five patients (age range 58-87 years, mean 71.9 (SD 8.4)) with unilateral CSDH were studied. Patients were categorised into three groups: I, headache (n=16); II, paresis (n=14); and III, mental change (n=15). T1 weighted MR images were obtained in all patients preoperatively. Quantitative values of maximum haematoma thickness, midline shift, and brain rotation angle were measured on axial and coronal MR images. In 21 patients, lCBF was measured by Xe enhanced CT. Values for lCBF were obtained in selected regions of interest in the frontal cortex, thalamus, and hemisphere on both the haematoma and contralateral sides. RESULTS: The lCBF reduction in the ipsilateral frontal cortex showed the best linear correlation with haematoma thickness (r=0.57), whereas the reduction in the ipsilateral thalamus had the most significant correlation with pineal shift (r=0.65) and third ventricle incline (r=0.67). In patients with paresis, lCBF decreased significantly on the ipsilateral side of both the frontal cortex and thalamus (p<0.05), whereas patients with mental change showed a significant reduction of lCBF on both sides of the thalamus (p<0.01) and in the ipsilateral frontal cortex (p<0.01). CONCLUSIONS: The lCBF reduction and clinical symptoms correlated well with local brain displacement in patients with CSDH. The lCBF in the central cerebral area including the thalamus was reduced in patients with clinical signs. The mental changes found were thought to derive from mild impairment of consciousness due to upper brain stem displacement.     

A case of duret hemorrhage demonstrated by computed tomography]

Brainstem hemorrhage in descending transtentorial herniation is well known as Duret hemorrhage. However, CT or MRI rarely reveals Duret hemorrhage. The authors report a case of brainstem hemorrhage after craniotomy of spontaneous acute subdural hematoma. A 47-year-old man suffered sudden onset of severe headache and progressive consciousness disturbance. Initial CT scan demonstrated a right acute subdural hematoma and a marked shift of the midline structures to the left. Emergency craniotomy was performed but he remained comatose. CT scan after 8 days showed multiple petechial hemorrhages in the brainstem. We reported a rare case of Duret hemorrhage diagnosed by CT scan. Duret hemorrhage is almost fatal.     

Impaired cerebral circulation and the effect of glycerol infusion in the acute stage of hypertensive intracerebral hematoma

The purpose of the present study was to clarify the mechanism of reduction in cerebral blood flow (CBF) in the acute stage of hypertensive intracerebral hematoma and the effect of glycerol infusion on the reduced CBF. We examined 55 cases. Thirty-eight cases showed putaminal hematoma and 17 presented thalamic hematoma. The range of consciousness was from alert to stupor. CBF was measured by single photon emission CT with Xe-133 inhalation within five days after the onset of the hemorrhage. A CBF map was obtained at a slice 5 cm above the OM-line and mean CBF of the affected and non-affected hemispheres was calculated. In 20 of 55 cases, 500 ml of glycerol was intravenously infused for 60 minutes and thereafter CBF was measured again. Epidural pressure was also recorded at the affected frontal area during glycerol infusion in three of the 20 cases. CBF reduced more profoundly in the area around the hematoma on the CBF map. Mean CBF of the affected hemisphere was negatively correlated with the volume of hematoma by a quadratic regression. After glycerol infusion, 13 of 20 cases showed a significant increase in mean CBF of the affected hemisphere, while the other seven cases showed no increase. Mean CBF increased with a higher percentage in cases with ventricular hemorrhage than without ventricular hemorrhage. In three cases where epidural pressure was measured during glycerol infusion, mean CBF increased and epidural pressure decreased. The increase in mean CBF was proportional to a rise in perfusion pressure calculated as pressure difference between mean systemic arterial pressure and mean epidural pressure, indicating impaired autoregulation in these cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

A case of cerebral putaminal hemorrhage complicating a brain abscess proved by craniotomy]

A 40-year-old man was admitted to our hospital because of consciousness disturbance, dysarthria and numbness in his right hand. Computed tomography of the head showed a cerebral hemorrhage of the left putamen. The patient was judged to have an indication of operation, and frontal craniotomy to evacuate hematoma was performed. During the operation, massive whitish pus flowed out at the time of surgery. Therefore, hemorrhage into a brain abscess was diagnosed. We reported this unique and interesting case whose brain abscess could not be differentiated from an ordinary hypertensive putaminal hemorrhage based on clinical findings and CT image. This diagnosis was not made until the patient was operated on through a craniotomy.     

Cerebral blood flow patterns in Binswanger's disease: a SPECT study using three-dimensional stereotactic surface projections

We investigated regional cerebral blood flow (rCBF) patterns in Binswanger's disease (BD) patients using single photon emission computed tomography (SPECT). SPECT data on 22 patients with BD were analyzed using three-dimensional stereotactic surface projections (3D-SSP) and were compared with those of 22 patients with Alzheimer's disease (AD). rCBF patterns in patients with BD were different from those with AD. The BD group had greater CBF reduction in the frontal and anterior cingulate cortices, while the AD group had greater CBF reduction in the temporoparietal and posterior cingulate cortices. However, the rCBF pattern of each patient was more variable, and could be divided into three patterns: anterior cerebral hypoperfusion, posterior cerebral hypoperfusion, and diffuse cerebral hypoperfusion patterns. A distinct CBF reduction in the temporoparietal and/or posterior cingulate cortices, indistinguishable from the CBF pattern observed in AD, was demonstrated in 8 of 22 (36%) patients with BD, in particular there was bilateral hemispheric involvement with a diffuse hypoperfusion pattern. Although no pathological confirmation could be performed, some of the BD patients with CBF reduction in the posterior cerebral cortices may represent additional changes in the brain due to AD. In the future, a longitudinal study including pathology will be needed to determine whether these patients have coexisting AD pathology.     

Magnetic resonance imaging findings of Kernohan-Woltman notch in acute subdural hematoma.

OBJECTIVE AND IMPORTANCE: We report the case of a 73-year-old patient who presented a right motor deficit caused by an ipsilateral acute subdural hematoma. A magnetic resonance imaging (MRI) demonstration of Kernohan-Woltman notch phenomenon was obtained. CLINICAL PRESENTATION: The woman sustained a major head injury at home, followed by loss of consciousness. On admission to the emergency room, she was comatose, anisochoric (left > right), and showed a reaction to pain with decerebrating movements of left limbs (Glasgow Coma Scale (GCS) 4/15). A right severe hemiparesis was observed. Cerebral computed tomography scan showed a large right hemispheric subdural hematoma. INTERVENTION AND POST-OPERATIVE COURSE: A wide right craniotomy was performed and the subdural hematoma evacuated. During the post-operative period, the level of consciousness gradually improved. A MRI performed about 2 weeks after operation showed a small area of abnormal signal intensity in the left cerebral peduncle. On discharge, the woman was able to communicate with others, but her right hemiparesis was still severe.     

Traumatic acute subdural hygroma mimicking acute subdural hematoma.

Subdural hygroma is a frequent delayed complication of head trauma. Most hygromas are clinically 'silent' and a few cases have shown slow deterioration in the chronic stage. We report a case of subdural hygroma showing unique radiological findings and rapid deterioration. A 74-years-old female presented with a mild headache and consciousness disturbance after head injury. Computed tomography showed a midline shift as a result of two components piling up in the subdural space; the outer components showed low density, the inner components high density. Magnetic resonance imaging demonstrated that these two subdural components were subdural hygroma and subarachnoid hematoma. Simple burr hole irrigation, rather than large craniotomy, was thought to be more appropriate treatment to reduce the mass effect. Simple burr hole irrigation was performed to remove the subdural hygroma and the patient showed an excellent recovery. Careful examination of the radiological findings prevented an unnecessary procedure in this case. A possible mechanism of this phenomenon is discussed.     

老年性大脑纵裂硬膜下血肿

目的 加强对大脑纵裂硬膜下血肿的认识。方法 对3例大脑纵裂硬膜下血肿患者临床资料进行回顾性分析。结果 3例均为男性，年龄分别为78岁、70岁、74岁；1例为自发性，2例为外伤性；发病后临床表现为头晕、头痛、恶心、呕吐、行走不稳、大脑镰综合征(对侧单瘫或以下肢为重的偏瘫)、或短暂意识障碍等，并有延迟出现的特点；2例经复查头部CT确诊，1例经复查头部CT及MRI确诊，均经保守治疗后康复出院。结论 本病头部CT、MRI具有特征性表现，且头部MRI更具敏感性，结合大脑镰综合征可以确诊，治疗及预后取决于病情严重程度。     

对冲性额叶脑挫裂伤合并枕骨骨折的临床特点及治疗（附198例报告）

目的探讨对冲性额叶脑挫裂伤合并枕骨骨折的临床特点和治疗方法。方法回顾性分析198例对冲性额叶脑挫裂伤合并枕骨骨折患者的临床资料,其中急诊手术治疗28例,保守治疗170例（因病情变化,在保守治疗过程中改行手术治疗34例）。结果出院后随访6月～12年,按GOS评分评定预后,恢复良好156例,中残13例,重残17例,死亡12例。结论对冲性额叶脑挫裂伤合并枕骨骨折的患者入院后如果病情危重,危及生命,应急诊手术治疗;如意识障碍较轻,可保守治疗,尽可能延期手术,减少迟发性硬膜外血肿的发生。     

硬脑膜下血肿清除前后皮质脊髓束的状态：弥散张量成像证据

Abstract Subdural hematoma can cause compression or damage to the neural tracts in the brain; however, very little is known about this injury. We report on a patient with subdural hematoma who was evaluated by diffusion tensor imaging prior to and after trephination and drainage of subdural hematoma. A 58-year-old male patient and ten age-matched normal control subjects were evaluated. The patient showed mild hemiparesis for 3 weeks prior to surgery. His hemiparesis recovered to a nearly normal state at 5 weeks post-surgery when the follow up diffusion tensor image was acquired. Two diffusion tensor image parameters, fractional anisotropy and apparent diffusion coefficient, were measured along the corticospinal tract. Pre-operative diffusion tensor image showed that the corticospinal tract of the affected hemisphere seemed to be injured or compressed. However, the follow up diffusion tensor image showed recovery of this corticospinal tract to a normal state. It would appear that diffusion tensor images are a useful tool for evaluation of the effects of subdural hematomas on neural tracts. Key Words: subdural hematoma; diffusion tensor imaging; hemiparesis; corticospinal tract     

A case of intracerebral and subarachnoid hemorrhage of unknown origin with preceding headache]

We report a case of a 31-year-old female with multiple intracerebral hemorrhage and subarachnoid hemorrhage. She presented with headache one week before hemorrhage, and a CT scan performed at that time showed no abnormal findings. Neurological examination on admission revealed mild disturbance of consciousness, papilledema, and mild left hemiparesis. CT scans demonstrated intracerebral hemorrhage in the right caudate head and left frontal subcortex, and diffuse subarachnoid hemorrhage. Cerebral angiogram and laboratory examination revealed no abnormal findings. Erythrocyte sedimentation rate, C reactive protein and antiphospholipid antibody were within normal ranges. The patient underwent removal of hematoma by craniotomy. One week after the operation, a subcutaneous hematoma in the area of the craniotomy was found. Cerebral angiography demonstrated an aneurysm of the right superficial temporal artery, which was remote from the craniotomy. This aneurysm was surgically removed and examined. Histopathological examination revealed the presence of a pseudoaneurysm but no inflammation. Although primary angitis of the central nervous system was suspected to be the cause of this disease, a definite diagnosis could not be obtained.     

Cerebral blood flow and cerebral oxygen metabolism in patients with dementia of frontal lobe type

This study was designed to investigate the differences in cerebral blood flow (CBF) and cerebral metabolic rate of oxygen (CMRO2) between patients with dementia of frontal lobe type and patients with Alzheimer's disease. Positron emission tomography (PET) using 15O steady state inhalation technique was carried out in 5 patients with a clinical diagnosis of dementia of frontal lobe type and 7 patients with a clinical diagnosis of Alzheimer's disease. CBF and CMRO2 were significantly decreased in the frontal cortex except for precentral region in patients with dementia of frontal lobe type in comparison to those values in patients with Alzheimer's disease. However, in patients with dementia of frontal lobe type CBF and CMRO2 in the parietal cortex and the occipital cortex were relatively preserved when compared with patients with Alzheimer's disease. In comparison with values for CBF and CMRO2 in the posterior part of brain [frontal or temporal/(parietal + occipital)/2 ratio], both values in the frontal cortex were markedly decreased in all 5 patients with dementia of frontal lobe type, but there was no marked reduction in the frontal cortex in patients with Alzheimer's disease. In addition, in 2 patients with dementia of frontal lobe type whose duration of the disease was more than 7 years, CBF and CMRO2 in the temporal cortex were markedly reduced in comparison with values in the posterior part of brain. These results suggested that PET findings of marked reduction in CBF and CMRO2 in the frontal cortex are useful to distinguish dementia of frontal lobe type from Alzheimer's disease.     

Chronic Subdural Hematoma after Eccentric Exercise Using a Vibrating Belt Machine

We report a case of bilateral chronic subdural hematoma (CSDH) in a 75-year-old man after exercise using a vibrating belt machine on the head. He suffered from headache and intermittent left side numbness for ten days. He denied any head injuries except eccentric exercise using a vibrating belt on his own head for 20 days. An MRI revealed bilateral CSDH. The hematoma was isodense on the CT scan. We made burr-holes on the both sides under local anesthesia. We identified the neomembrane and dark red subdural fluid on both sides. In the postoperative CT scan, we found an arachnoid cyst on the left temporal pole. Although the arachnoid cyst itself is asymptomatic, trivial injury such as vibrating the head may cause a CSDH.     

Spontaneous subdural spinal haematoma presenting as occipital headache: a case report

Spinal subdural hematoma (SSDH) with no underlying pathology is a very rare condition and has been rarely reported. Our patient presented with severe occipital headache as isolated symptom during the first 4 days. SSDH slowly enlarges with time, and first determines tension of the pain-sensitive dural membrane, resulting in cervicogenic-like headache. Therefore, spontaneous SSDH should be considered in the differential diagnosis of recent occipital headache.     

Interhemispheric subdural empyema in a patient with allergic rhinitis, pansinusitis and acute excerbation of frontal sinusitis

We reported a 10-year-old boy with an interhemispheric subdural empyema caused by acute excerbation of frontal sinusitis. He has suffered from allergic rhinitis and pansinusitis for years. He had fever and a generalized tonic-conic seizure, followed by prolonged consciousness disturbance and right hemiparesis. CT and MRI were useful to diagnose an interhemispheric subdural empyema, which showed a characteristic double-layer fluid collection pattern. Prompt diagnosis and treatment with craniotomy resulted in recovery without any neurological sequelae. His basic disorders, allergic rhinitis and pansinusitis, were successfully treated with macrolides and antiallergic drugs: pranlukast hydrate and sodium cromoglicate, administered per os and by inhalation, respectively.