Abstract
Subdural fluid collections are frequently encountered in young children after non-accidental injury. In a subset of patients, these collections progress in size and ultimately require permanent drainage, which is commonly achieved with subdural-peritoneal shunts. However, excessive protein and cellular contents in the fluid are potential risk factors for shunt failure. Here, we describe the adaptation of an endoscopic lavage technique established for ventricular endoscopy with the aim of improving fluid condition prior to shunting. We present a case of subdural fluid collections secondary to non-accidental injury, where permanent shunting was required but could not be performed due to excessive protein and cellular levels in the subdural fluid despite conventional burr hole drainage. A two-month-old male infant presented with a bulging and tense fontanel, a reduced level of consciousness, bradycardia, and significant macrocephaly. Computed tomography (CT) demonstrated massive bilateral, low attenuation subdural fluid collections, reaching a diameter of 4.5 cm. Emergency burr hole washout and insertion of subdural drains was performed. Despite prolonged drainage over 10 days, the protein level remained at 544 mg/dl and the mean erythrocyte count at 6,493/µl. Continuous drainage was required to avoid clinical deterioration due to raised intracranial pressure; however, the fluid condition was still considered incompatible with permanent subdural-peritoneal shunting. We, therefore, performed an endoscopic subdural lavage with a careful evacuation of residual blood deposits. No complications were encountered. Postoperatively, mean protein level was 292 mg/dl and mean erythrocyte count was 101/µl. Endoscopic lavage could be safely performed in a case of extensive subdural low attenuation fluid collections, where conventional burr hole drainage failed to improve protein and cellular contents as a prerequisite for successful permanent shunting. We conclude that adaptation of this technique can be helpful in selected cases as an alternative procedure.
Highlights
Subdural fluid collections are frequent findings in children after non-accidental traumatic head injury, including acute subdural hematoma, chronic subdural hematoma, low attenuation subdural collections, and intermediate or overlapping stages suggestive of repeated significant head injuries [1,2]
While moderately elevated cerebrospinal fluid (CSF) protein and red blood cells (RBC) counts do not appear to increase the risk of shunt failure, excessively high levels or presence of particles and clotted blood presumably pose a risk of catheter or valve occlusion [5]
We describe the adaptation of neuroendoscopic lavage for the treatment of a progressive hemorrhagic subdural fluid collection in an infant with a non-accidental head injury
Summary
Subdural fluid collections are frequent findings in children after non-accidental traumatic head injury, including acute subdural hematoma, chronic subdural hematoma, low attenuation subdural collections, and intermediate or overlapping stages suggestive of repeated significant head injuries [1,2]. Among several approaches to reduce the proportion of shunt-dependent children and positively influence the risk of shunt failure, neuroendoscopic intraventricular lavage appears to be a promising neurosurgical approach [7]. This technique allows for direct visualization of hematoma removal and irrigation, as well as for active hemostasis of active bleedings. Computed tomography demonstrated massive bilateral low attenuation subdural fluid collections, reaching a diameter of 4.5 cm, with focal hyperdense areas corresponding to subacute blood clots (Figure 1). Preoperative cranial computed tomography scans demonstrating excessive bilateral subdural low attenuation fluid collections (arrows) in the axial (A) and coronal (B) planes, as well as a three dimensional reconstruction (C) showing macrocephaly with split cranial sutures (arrow). Endoscopic views obtained with a 0° rigid endoscope inserted through a right coronal burr hole: (A) Both cerebral hemispheres (L/R), the falx (*), and a stretched bridging vein (**) are visualized; (B) close-up image of a stretched bridging vein (*), revealing thrombosis; (C) once the endoscope is passed between the falx (*) and the left hemisphere (L), the contralateral middle cranial fossa (***) can be accessed
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