Bilateral Subdural Collections Research Articles

Radiological insights into rheumatoid meningitis - a rare central nervous system manifestation of rheumatoid arthritis: a retrospective review of six cases.

The objective is to analyze and review the clinical, laboratory, and neuroimaging characteristics of rheumatoid meningitis (RM) in six patients with known rheumatoid arthritis (RA). We performed a retrospective review of patients diagnosed with RM from August 2012 to June 2023. To identify the cases, we used medical term search engines and the hospital´s radiology case database. Clinical information and laboratory findings were gathered from the medical records. A neuroradiologist with five years of experience reviewed and analyzed the RM to determine the characteristics findings of RM. Six patients with RM are included. Seizures along with headaches were among the clinical signs that were documented. All the patients had high levels of rheumatoid factor (RF) and anti-cyclic citrullinated peptides (ACPA) in the peripheral blood. Biopsy in two cases confirmed typical rheumatoid nodules. Leptomeningeal enhancement was found bilaterally in all cases and was predominantly found in the frontoparietal region. "Mismatch DWI/FLAIR" was found in five patients. Bilateral subdural collections could be found in two patients. Brain PET scan revealed increased metabolism in two cases. Rheumatoid meningitis is a rare complication of rheumatoid arthritis (RA) with challenging clinical diagnosis due to non-specific symptoms. This study highlights the importance of MR in detecting characteristic neuroimaging patterns, including "mismatch DWI/FLAIR", to aid in early diagnosis. Increased awareness of this condition may facilitate timely intervention and improve prognosis. These results still need to be verified by large studies.

Cervical epidural blood patch for spontaneous intracranial hypotension with bilateral subdural collection - A case study.

Cervical epidural blood patch for spontaneous intracranial hypotension with bilateral subdural collection - A case study.

Salmonella Infantis Meningitis in a Pediatric Patient After in-Utero Exposure to Ustekinumab

Abstract Introduction/Objective Salmonella meningitis is associated with a significant neurological sequelae, subdural effusions, cerebral infarction, encephalitis, cerebral abscess, and high mortality. It is a rare complication of Salmonella sepsis and occurs almost exclusively during early infancy. Salmonella is identified as pathogen in less than 1% of confirmed cases of bacterial meningitis in infants. Immunocompromised individuals have higher risk of having invasive salmonellosis. Methods/Case Report We present a case of 4-month-old male with no significant past medical history who was presented to emergency department with five days history of fever, cough and decreased oral intake. At the time of admission, complete blood count was obtained and showed a platelet count of 702 x 10(3)/mcL, hematocrit of 25% and WBC of 17.0 x 10(3)/mcL with differential showing absolute neutrophilia and absolute monocytosis. Head ultrasound was concerning for meningoencephalitis with bilateral parenchymal echogenicity and bilateral subdural collections. Lumbar puncture showed WBC cell count of 229 (36 % PMNs, 52% lymphocytes, 12% monocytes), red blood cells of 0, glucose of 13 mg/dL, protein of 151 mg/dL. Meningitis multiplex PCR panel of the CSF was negative. MRI of the brain showed findings suggestive of meningitis with associated subdural empyema and ventriculitis without hydrocephalus. CSF culture identified Salmonella species that is susceptible to ampicillin and ceftriaxone which later identified as Salmonella infantis by the State laboratory. Immunodeficiency workup including next generation sequencing immunodeficiency panel did not reveal any known causes. Of note, mother has psoriasis and was treated with ustekinumab; an antibody against a cytokine subunit shared by IL12 and IL23, during pregnancy. The patient responded to antibiotic treatment and was discharged in a stable condition. Results (if a Case Study enter NA) N/A. Conclusion This case report highlights Salmonella infantis meningitis in a pediatric patient who was exposed to ustekinumab in utero which could cause drug induced immunodeficiency state as IL-12 is known to activate macrophages and macrophages are critical for Salmonella clearance. Although ustekinumab level was undetected in the patient right prior to discharge, the long half-life and mechanism of action of this medication could have caused an immunodeficiency state which allowed rare Salmonella infantis meningitis.

MRI Findings after Recent Image-Guided Lumbar Puncture: The Rate of Dural Enhancement and Subdural Collections.

The rate of abnormal intracranial MR imaging findings including subdural collections and dural enhancement after recent lumbar puncture is not known. The purpose of our study was to examine the intracranial MR imaging findings after recent image-guided lumbar puncture. Patients who underwent contrast-enhanced MR imaging of the brain within 7 days of a CT-guided lumbar puncture between January 2014 and April 2021 were included. Contrast-enhanced MR images were reviewed for diffuse dural enhancement, morphologic findings of brain sag, dural venous sinus distension, and subdural collections. Of the 160 patients who met the inclusion criteria, only 6 patients (3.9%) had new diffuse dural enhancement, though none had dural enhancement when the MR imaging was within 2 days of lumbar puncture. All 6 patients with dural enhancement had small, concurrent subdural collections. Two additional patients had subdural collections, for a total of 5.2% of our population. Our study is the first to examine intracranial MR imaging after recent lumbar puncture and has 2 key findings: First, 5.2% of patients had small, bilateral subdural collections after recent lumbar puncture, suggesting that asymptomatic subdural collections after recent lumbar puncture are not atypical and do not require further work-up. Additionally, when MR imaging was performed within 2 days of lumbar puncture, none of our patients had diffuse dural enhancement. This argues against the commonly held practice of performing MR imaging before lumbar puncture to avoid findings of dural enhancement, and should not delay diagnostic work-up.

Infantile Macrocephaly: Complicated Familial Benign Enlargement of Subarachnoid Space in Twins of Suspected Nonaccidental Injury

A 3-month-old first of dizygotic male twins, born at 34+ 5 weeks gestational age, presented with a 4-week history of increasing head circumference and vomiting. He had a tense anterior fontanelle and a head circumference above the 97th percentile. Magnetic resonance imaging showed large bilateral subdural collection with hemosiderin deposits suggestive of hemorrhage. Nine days of bilateral subdural drainage reduced the collection size and blood load. On postoperative day 16, magnetic resonance imaging confirmed persistent but smaller subdural collections, unmasking the underlying subarachnoid space enlargement. On day 18, a right subdural-peritoneal valveless shunt was inserted as definitive treatment. As part of a nonaccidental injury investigation, Twin 2 was also found to have macrocephaly secondary to benign enlargement of subarachnoid space, which was managed conservatively. Benign enlargement of subarachnoid space has an assumed autosomal/multifactorial inheritance and predisposes to subdural hemorrhage. Ultimately, no safeguarding issues were raised. Both twins continued to be neurologically stable at 2-year follow-up with head circumferences between the 98th and 99th percentiles.

¿Crisis convulsiva o maltrato infantil?

More child abuse cases are reported in Peru every year; however, there is no official report that describes the actual incidence, especially of the most vulnerable population such as infants. Signs of physical abuse generally involve brain injury and constitute shaken baby syndrome or pediatric abusive head trauma, which is a challenging diagnostic challenge. A 3-month-old infant is admitted to the emergency room for 30-minute generalized tonic-clonic seizures. On physical examination, the presence of a bony callus on the right clavicle was striking. A brain tomography and magnetic resonance imaging were performed, showing hyperintense lesions in the white matter, non-contrast enhancers, limited diffusion, and a bilateral subdural collection. Together, a bone survey was taken, which revealed multiple fractures in different areas of the body and suspecting the case of child abuse, so the relevant authorities (medical and judicial) were notified. Currently, the infant is in the custody of the Child Protection Unit, pending the definition of her final custody.

Macrocephaly and subdural collections.

Enlarged subarachnoid spaces are a common finding in infants and young children imaged for macrocephaly or an enlarging head circumference, and benign enlargement of the subarachnoid spaces is often diagnosed. Infrequently, presumed "spontaneous" subdural hemorrhages or subdural collections might complicate these enlarged subarachnoid spaces. Children with large bilateral subdural collections might also present for imaging with macrocephaly. Each scenario potentially raises concerns for prior injury because subdural hemorrhage is a frequent finding in children with abusive head trauma.

Unusual Clinical and Imaging Presentation of Chronic Subdural Hematoma

AbstractVarious clinical and radiologic presentations of chronic subdural hematoma (SDH) are reported in the literature. Therefore, sometimes the presentation of a patient with chronic SDH often creates confusion regarding decision making. Here, the authors present three cases of chronic SDH, in which the clinical presentation, radiology, and operative findings were unusual. In the first case, the patient presented with acute extradural hematoma like clinical as well as radiologic presentation but intraoperatively found to have chronic calcified SDH, whereas another case with history of bilateral ventriculoperitoneal (VP) shunting at childhood presented with large head with discharging sinus at the forehead. Radiologic and operative findings were very much unusual. Intraoperatively, the bilateral subdural collection was found to have fungus-like projections with subdural space communicating with the forehead sinus. In another case, a 10-year-old girl with history of VP shunting at age of 6 months presented with left hemiparesis of subacute onset. Computed tomographic (CT) scan revealed biconvex lesion at the right parietal region intraoperatively. The authors found the shell-like lesion with inner and outer membrane calcified, within which the subdural collection was present. In these three cases, they observed the very unusual mode of presentation of chronic SDH, and in the literature such mode of presentation and operative findings of such type are very rare.

Giant Cell Arteritis Presenting with Bilateral Subdural Haematomas of Arterial Origin.

Giant cell arteritis or temporal arteritis is an inflammatory condition affecting medium to large sized vessels, particularly the cranial arteries. A 76-year-old man with no significant past medical history presented to the emergency department with a 3-week history of diffuse headaches associated with fever, loss of appetite, weight loss and general malaise. A CT scan of the brain showed bilateral shallow chronic low density subdural haematomas. A complete laboratory panel was unremarkable except for a raised erythrocyte sedimentation rate and elevated C-reactive protein. A transthoracic echocardiogram and CT scan of the body were unremarkable. MRI of the brain confirmed bilateral old subdural collections and showed marked vessel wall enhancement in the frontal branches of the left superficial temporal artery. A left temporal artery biopsy confirmed giant cell temporal arteritis. We speculate that a vasculitic process in the small subdural arteries may have contributed to our patient’s spontaneous subdural haematomas.LEARNING POINTSA contrast-enhanced T1 axial fat-suppressed MRI of the brain is a non-invasive modality of diagnostic value in giant cell arteritis (GCA); increased access to high resolution MRI technology may reduce the requirement for invasive temporal artery biopsy in the future.Subdural hematomas may be of arterial origin; GCA has been reported in association with subdural hematomas but causation is not proven.GCA must be suspected in patients presenting with headaches and raised inflammatory markers even in the absence of classic features or dual pathology as failure to recognize and treat promptly could lead to permanent visual loss.

Validation of a clinical prediction rule for pediatric abusive head trauma.

To reduce missed cases of pediatric abusive head trauma (AHT), Pediatric Brain Injury Research Network investigators derived a 4-variable AHT clinical prediction rule (CPR) with sensitivity of .96. Our objective was to validate the screening performance of this AHT CPR in a new, equivalent patient population. We conducted a prospective, multicenter, observational, cross-sectional study. Applying the same inclusion criteria, definitional criteria for AHT, and methods used in the completed derivation study, Pediatric Brain Injury Research Network investigators captured complete clinical, historical, and radiologic data on 291 acutely head-injured children <3 years of age admitted to PICUs at 14 participating sites, sorted them into comparison groups of abusive and nonabusive head trauma, and measured the screening performance of the AHT CPR. In this new patient population, the 4-variable AHT CPR demonstrated sensitivity of .96, specificity of .46, positive predictive value of .55, negative predictive value of .93, positive likelihood ratio of 1.67, and negative likelihood ratio of 0.09. Secondary analysis revealed that the AHT CPR identified 98% of study patients who were ultimately diagnosed with AHT. Four readily available variables (acute respiratory compromise before admission; bruising of the torso, ears, or neck; bilateral or interhemispheric subdural hemorrhages or collections; and any skull fractures other than an isolated, unilateral, nondiastatic, linear, parietal fracture) identify AHT with high sensitivity in young, acutely head-injured children admitted to the PICU.

Subdural hygroma accompanied by parenchymal and subarachnoid haemorrhage after epidural analgesia in an obstetric patient

Anaesthetists need to know the different causes of persistent headache or a change in level of consciousness following epidural analgesia for labour. Failure to recognise these neurological complications can lead to delayed diagnoses, with subsequent serious implications. We present a patient who was re-admitted for postural headache resulting from an unrecognised dural puncture during an epidural for pain relief while in labour. During the interview, the patient confirmed drug use (cocaine), so she was evaluated by a psychiatrist with possible post-partum psychosis or drug withdrawal syndrome. Afterwards, the patient deteriorated neurologically, showing impaired consciousness and seizures. The cranial computed tomography showed bilateral frontoparietal subdural collections with intraparenchymal and subarachnoid haemorrhaging. She improved by burr hole drainage of subdural hygroma and a blood patch. Neurological signs should alert the clinician to the possibility of subdural collection and other possible complications such as sinking of the brain in order not to delay the request for imaging tests for diagnoses and effective treatments.

Cranial Neuropathy Due to Intradural Disc Herniation

Herniated intervertebral disc fragments rarely penetrate the thecal sac, and intracranial hypotension attributable to such penetrating fragments is even more unusual. We describe the first reported case of a cranial neuropathy due to intradural herniation of a disc fragment, in which intracranial hypotension from a resulting cerebrospinal fluid leak caused bilateral abducens palsies. A 45-year-old man presented with a positional headache after having experienced a "popping" sensation in his back while lifting a heavy object. He also reported blurred vision and was noted to have lateral gaze palsies bilaterally. Magnetic resonance imaging (MRI) of the brain revealed bilateral subdural collections, abnormal pachymeningeal enhancement, and cerebellar tonsillar herniation, suggesting intracranial hypotension. T2-weighted MRI of the spine revealed extrusion of the T12-L1 disc and suggested the presence of a disc fragment in the intradural space, displacing the caudal nerve roots. A myelogram demonstrated a filling defect extending into the subarachnoid space adjacent to the disc herniation, consistent with a free disc fragment in the intradural space. A diagnosis of intracranial hypotension due to a cerebrospinal fluid leak resulting from an intradural herniated disc was made. The diagnosis was confirmed intraoperatively. Surgical removal of the herniated disc fragment and repair of the dural defect resulted in complete resolution of the cranial neuropathy. This rare etiology of a cranial neuropathy, arising from pathology in the thoracolumbar spine, illustrates the clinical teaching that the sixth cranial nerve is highly sensitive to deformation induced by intracranial hypotension.

Rapid resolution of a spontaneous large chronic subdural haematoma in the posterior fossa under conservative treatment with platelet administration to aplastic anaemia

Infratentorial chronic subdural hematomas are rare. Simultaneous supra- and infratentorial chronic subdural hematoma is extremely rare. Commonly caused by head trauma in a predisposed brain; coagulopathy, cerebral atrophy secondary to alcohol, old age, or human immunodeficiency virus infection. Only a few cases have been reported, and this is the first report from our setup.50 years old human immunodeficiency virus-positive woman presented to our hospital with headache, decreased mentation and left side body weakness of two days. Brain magnetic resonant imaging showed bilateral supra-and infratentorial chronic subdural collection. Under local anesthesia and light sedation, bilateral burr hole and evacuation of supratentorial hematoma were done and the infratentorial hematoma was managed conservatively as it is thought asymptomatic. Postoperatively consciousness and weakness improved but the patient complained of severe global headache and computed tomography scan showed significant residual right side supratentorial chronic subdural hematoma. Thus under local anesthesia and light sedation right parietal burr hole was done and the hematoma was removed. Postoperatively patient was conscious, the headache disappeared.This experience demonstrates conservative management of asymptomatic infratentorial chronic subdural hematoma is a viable treatment option in patients presenting with both supra- and infratentorial chronic subdural hematoma. We suggest burr hole evacuation, irrigation and placement of closed drainage system should be considered as a first choice surgical treatment for symptomatic infratentorial chronic subdural hematoma.

574 Varicella Zoster Infection Complicated by Meningeococcalmeningits, Seosis and Subdural Empyema in an Infant, a Case Report

AimsTo highlight possible and may be fatal complications of Varicella Zoster virus (VZV) infection.MethodWe report a case of an infant with VZV infection who developed meningeococcal sepsi, meningeococcal meningitis, VZV...

An interesting case of headache

A 35-year-old businessman with a history of migraine with aura developed new neck pain while lying on a sofa in his home. He was given neck massage and physical therapy for a day, and subsequently after two days developed severe generalized headache when sitting or standing. He was hospitalized in his hometown. Investigations revealed venous sinus thrombosis and bilateral thin subdural collections for which he was anticoagulated. Headache improved and then worsened and became severe in all positions. He was then admitted under our care. MRI scan of the brain at our hospital showed left subdural hematoma with midline shift. It required urgent evacuation. His previous first brain MRI was re-evaluated. It showed characteristic features of spontaneous intracranial hypotension (SIH). If not recognized early, SIH results in various complications, some of which require immediate intervention. Any change in the pattern of headache in SIH one must alert the clinician due to the possibility of one of its complications.

Síndrome de hipotensión intracraneal: revisión de hallazgos en resonancia magnética

Intracranial hypotension syndrome (IHS) is a syndrome with a variable aetiology and clinical presentation that is, in most cases, caused by leakage of cerebrospinal fluid (CSF) through the thecal sac. Orthostatic headache associated to the typical magnetic resonance imaging (MRI) findings, secondary to depletion of CSF, is the key to a correct diagnosis. To show the imaging findings that, within a suitable clinical context, allow this condition to be identified and diagnosed. Decreased CSF volume plays an important role in IHS, which leads to an increase in the compensatory volume of blood, essentially dependent on the venous system. MRI is a sensitive technique in the diagnosis of IHS. Yet, separate findings are unspecific. The MRI findings include diffuse and homogeneous dural enhancement, the presence of small bilateral subdural collections, caudal displacement of the encephalic structures (pseudo-Chiari), dilatation of the cortical and medullar veins, and the recent sign of venous distension. This last sign is a highly sensitive finding of IHS, which tends to disappear following the patient's clinical improvement even before the disappearance of the pachy-meningeal enhancement, and could be used as a marker for response to treatment. IHS is a condition that is difficult to diagnose clinically for which several typical MRI findings have been reported; both neurologists and radiologists must be familiar with these findings.

Intracranial hypotension secondary to spinal arachnoid cyst rupture presenting with acute severe headache: a case report.

IntroductionHeadache is a common presenting complaint and has a wide differential diagnosis. Clinicians need to be alert to clues that may suggest an underlying secondary aetiology. We describe a novel case of headache secondary to intracranial hypotension which was precipitated by the rupture of a spinal arachnoid cyst.Case reportA 51-year-old Indian female presented with sudden onset severe headache suggestive of a subarachnoid haemorrage. Investigations including a computed tomography brain scan, cerebrospinal fluid examination and a magnetic resonance angiogram were normal. The headache persisted and magnetic resonance imaging revealed bilateral thin subdural collections, a spinal subarachnoid cyst and a right-sided pleural effusion. This was consistent with a diagnosis of headache secondary to intracranial hypotension resulting from spinal arachnoid cyst rupture.ConclusionsSpinal arachnoid cyst rupture is a rare cause of spontaneous intracranial hypotension. Spontaneous intracranial hypotension is a common yet under-diagnosed heterogeneous condition. It should feature significantly in the differential diagnosis of patients with new-onset daily persistent headache.

Invasive pneumococcal disease following treatment for choroid plexus carcinoma

A 13-month-old child was treated for choroid plexus carcinoma with partial embolisation, complete surgical excision and chemotherapy. The patient's course was complicated by the presence of chronic bilateral subdural collections. Four months from completing treatment, the child presented with an empyema in the subdural space caused by Streptococcus pneumoniae subtype 6A. The case highlights a number of questions about pneumococcal immunisation after standard chemotherapy. Evidence-based guidelines are required urgently to direct best practice.

Headaches, delusions, and catharsis

In November, 2008, a 37-year-old previously healthy man presented to us with a 6-week history of headache and neck pain occurring while sitting or standing, but not when lying down. CT of the head and cervical spine and one as an outpatient 12 days earlier had been normal. He had no history of trauma, operation, spinal infi ltration, or lumbar puncture. Physical examination was unremarkable. Postural headache caused by intracranial hypotension was diagnosed. He was managed conservatively with bed rest, oral rehydration, and theophylline; he quickly improved and was discharged 3 days later. 1 week later he returned with more severe orthostatic headache and onset of delusional ideas. He believed his illness was a form of “catharsis” of his sins. He exhibited some paranoid ideas, believing that his friend had “polished” his thoughts. Again, physical examination was normal. Laboratory test results and electroencephalography were unremarkable. MRI of the brain (fi gure A) showed bilateral small subdural collections of cerebrospinal fl uid (CSF), also known as subdural hygroma. Contrast images showed diff use, supratentorial and infratentorial enhancement of the dura mater and indicated possible leakage of CSF at the upper cervical spine. The leak was confi rmed by radionuclide cisternography and postmyelography CT (fi gure B and C). Lumbar puncture showed low pressure, normal cell count, and high concentration of protein (1·23 g/L). Conservative therapy was initiated. Psychiatric consultation confi rmed a psychosis, and antipsychotic therapy with quetiapine was started. 14 days later there was no improvement in our patient’s clinical status; he had worsening delusional ideas and had subsequently became stuporous. An epidural blood patch was considered, but MRI showed progression of the subdural hygroma with new subdural haemorrhage; he was transferred to the neurosurgical team and underwent emergency evacuation of the subdural haematoma. 5 days later a laminoforaminotomy was done; a very small CSF leak at the level of the left third cervical pedicle was found and sealed. Postoperatively, our patient fully recovered with no residual headache. He had no recollection of his admission to hospital. Further psychiatric consultation was unremarkable and he had no further delusional ideas. At his fi nal follow-up in May, 2009, he remained well and had resumed work. Postural headache most often arises after lumbar puncture; it rarely occurs as a result of spontaneous intracranial hypotension. Spontaneous intracranial hypotension headache is caused by spontaneous CSF leaks and is an important—but underdiagnosed—cause of headaches of new onset in young and middle-aged patients. Typical MRI fi ndings consist of subdural hygromas and enhanced dura mater; myelography can identify the spinal CSF leak. Therapy includes bed rest, epidural blood patch, and surgical leak repair, although no randomised trials have assessed the outcome of the diff erent strategies. A variety of symptoms can occur, although typically comprise headache, nausea, tinnitus, hypoacusia, or photophobia worsening after sitting and standing. Psychiatric symptoms rarely manifest, and cases of reversible frontotemporal dementia and bipolar disorder have been described. An organic psychosis, as in our case, is possibly caused by diencephalic compression. In our patient, the co-occurrence of a fi rst episode of an underlying primary psychotic disorder cannot be excluded, but is unlikely because the psychotic symptoms developed in parallel to the hygromas, resolved immediately after operation, and have not reappeared.

Rapidly resolving acute subdural hematoma. A case report

Rapidly resolving acute subdural hematoma is a rare condition reported infrequently in the literature. A 52 year old man presented with head injury following a road traffic accident. He was drowsy arousable with a GCS score of 13/15. His initial CT brain showed a 0.7mm thick right frontoparietal acute SDH which was managed conservatively. A repeat CT done after an interval of 48 hours showed complete resolution of the Acute SDH with bilateral subdural hypodense collections. He also had associated facial bone and ACF base fractures along with CSF rhinorrhea. Brief review of the literature and possible mechanisms of resolution are discussed.