Bilateral Subdural Fluid Collections Research Articles

Clinical Features of Patients With Spontaneous Intracranial Hypotension Complicated With Bilateral Subdural Fluid Collections.

Subdural hygromas are often found bilaterally in spontaneous intracranial hypotension (SIH). They frequently progress to chronic subdural hematomas (CSDHs), and if the hematomas are formed, it is difficult to consider SIH as an underlying cause. Whether SIH is underlying or not among the patients presenting bilateral subdural fluid collections (hygromas or CSDHs) is clinically important because the treatment strategy should be different between them. We designed a retrospective case-control study to figure out differential clinical features of the patients presenting bilateral symptomatic subdural fluid collections owing to SIH. Sixty-two patients with bilateral symptomatic subdural fluid collections were enrolled, and their data on general demographics, clinical courses, radiological findings, treatments, and outcomes were collected. The patients were divided into "SIH" and "Non-SIH" groups, and a simple logistic regression analysis was performed to clarify the differences between the groups. The consequent receiver operating characteristics (ROC) curve analyses were performed with the significant predictors. Eight patients (13%) were diagnosed with SIH. Young age (odds ratio [OR]=0.831, 95% confidence interval [CI]: 0.743-0.929, P=.0012), no underlying disease (OR=0.062, 95% CI: 0.007-0.544, P=.0121), radiological features of brain sagging (OR=10.36, 95% CI: 0.912-93.411, P=.0017), pseudo-subarachnoid hemorrhage (OR=15.6, 95% CI: 2.088-116.52, P=.0074), and small amount of fluid collections (OR=0.719, 95% CI: 0.579-0.893, P=.0029) were significantly associated with SIH group. ROC curve analyses were performed in parameters of age and amount of fluid collection and the cut-off values for each parameter were ≤55 years old and ≤22.08 mm, respectively. Patients diagnosed with SIH underwent epidural blood patches and showed good results, except 1 patient who underwent burr-hole trephinations. Bilateral subdural fluid collections due to underlyingSIH isassociated with young age (≤55 years old), no underlying diseases, smaller amount of fluid collections (≤22.08 mm of depth), and radiologicalfindings of brain sagging or pseudo-subarachnoid hemorrhages.

Subdural hygroma associated with axillary cystic hygroma

We present a case of a 4-month-old girl with a history of a huge axillary cystic hygroma since birth, with elective surgical resection of the lesion and subsequent development of infection at the surgery site. During hospitalization for the infection, she developed seizures, a bulging fontanelle, increased head circumference, and widely separated cranial sutures. Brain imaging demonstrated new, large, bilateral subdural fluid collections with membrane enhancement around the left-sided collection. She was managed by subdural tap, bilateral craniotomy, broad-spectrum antibiotics, and subduroperitoneal shunt insertion. Ultimately, she had complete recovery without complications. This case adds to the spectrum of intracranial conditions that have been associated with cystic hygroma.

Teaching Neuro Images : A dangerous complication of spontaneous intracranial hypotension

A 43-year-old man presented with a nontraumatic orthostatic headache, spatial disorientation, and visual hallucinations ("colored flames"). General and neurologic examination were normal. Turbo spin echo T2-weighted MRI showed bilateral subdural fluid collection and venous sinus engorgement (figure, A), suggesting spontaneous intracranial hypotension (SIH). Two subdural hematomas were also found, the biggest (2.5 cm) with mass effect in the left hemisphere (figure, B). Spine MRI identified a small radicular cyst emerging from the left T1-T2 foramen as the putative cause of CSF leakage (figure, C and D). The patient underwent drainage of the largest hematoma with benefit. Though initially planned, epidural blood patch and surgical treatment of the radicular cyst were not performed because clinical and radiologic findings improved with hematoma drainage, bed rest, and hydration. At a 3-month follow-up, MRI documented complete resolution of the subdural collection and dimensional stability of the radicular cyst. SIH is often considered benign and treated conservatively,(1)but it can rarely manifest with serious complications requiring rapid surgical evaluation.(2).

Stroke and Death Due to Spontaneous Intracranial Hypotension

Spontaneous intracranial hypotension has become a well-recognized cause of headaches and a wide variety of other manifestations have been reported. Recently, several patients with asymptomatic spontaneous intracranial hypotension were reported. I now report two patients with spontaneous intracranial hypotension who developed multiple arterial strokes associated with death in one patient, illustrating the spectrum of disease severity in spontaneous intracranial hypotension. Medical records and radiologic imaging of the two patients were reviewed. Case 1. A 45-year-old man presented with an orthostatic headache. Neurologic examination was normal. MRI showed bilateral subdural fluid collections, brain sagging, and pachymeningeal enhancement. At lumbar puncture, the opening pressure was too low to record. He underwent two epidural blood patches with transient improvement of symptoms. His headaches progressed and a CT-myelogram showed a lower cervical CSF leak. Subsequently, periodic lethargy and confusion was noted and he then rapidly deteriorated. Examination showed coma (GCS: 4 [E1, M2, V1]), a fixed and dilated right pupil, and decerebrate posturing. Bilateral craniotomies were performed for the evacuation of chronic subdural hematomas. Immediate postoperative CT showed bilateral posterior cerebral artery infarcts and a recurrent right subdural hematoma, requiring re-evacuation. Postoperative examination was consistent with brain death and support was withdrawn. Case 2. A 42-year-old man presented with a non-positional headache. Neurologic examination was normal. CT showed bilateral acute on chronic subdural hematomas and effacement of the basilar cisterns. MRI showed brain sagging, bilateral subdural hematomas, and pachymeningeal enhancement. Bilateral craniotomies were performed and subdural hematomas were evacuated. Postoperatively, the patient became progressively lethargic (GCS: 8 [E2, M4, V2]) and variable degrees of pupillary asymmetry and quadriparesis were noted. MRI now also showed multiple areas of restricted diffusion in the pons and midbrain, consistent with multiple infarcts. CT showed worsening subdural fluid collections with midline shift and increased effacement of the basilar cisterns. Repeat bilateral craniotomies were performed for evacuation of the subdural fluid collections. Neurologic examination was then noted to be fluctuating but clearly improved when lying flat (GCS: 10T [E4, M6, VT]). CT-myelography demonstrated an extensive cervico-thoracic CSF leak. An epidural blood patch was performed. The patient made a good, but incomplete, recovery with residual quadriparesis and dysphagia. Arterial cerebral infarcts are rare, but potentially life-threatening complications of spontaneous intracranial hypotension. The strokes are due to downward displacement of the brain and can be precipitated by craniotomy for evacuation of associated subdural hematomas.

External hydrocephalus and subdural bleeding in infancy associated with transplacental anti-Ro antibodies

BackgroundThe isolated finding of an unexplained chronic subdural haematoma in an infant may suggest non-accidental head injury (NAHI). The authors report a previously undescribed cause of multifocal chronic subdural haematoma...

Degos disease: a new simulator of non‐accidental injury

Recent high-profile cases have made paediatricians very aware of the serious implications of either missing or wrongly diagnosing non-accidental injury. Subdural fluid collections in non-mobile infants usually represent haemorrhage caused by non-accidental injury. We report a 6-month-old male who presented to the Accident and Emergency Department of Birmingham Heartlands Hospital with bilateral subdural fluid collections and skin ulcers resembling cigarette burns. Non-accidental injury was considered to be the most likely diagnosis. However, while under observation in hospital, the child's neurological condition deteriorated with progressive cerebral infarctions, and serial photographs of the skin lesions showed failure to heal. The revised diagnosis, confirmed histologically, was Degos disease, an extremely rare and often fatal occlusive vasculopathy. The child was treated palliatively and died 8 weeks after presentation. This report informs doctors of a new simulator of non-accidental injury to be considered in infants with otherwise unexplained subdural fluid collections.

Cortical Laminar Necrosis Caused by Critically Increased Intracranial Pressure in an Infant -Case Report-

A 3-month-old boy presented with critically elevated intracranial pressure (ICP) due to bilateral subdural hematomas, which resulted in diffuse cortical laminar necrosis, manifesting as a 1-week history of appetite loss, fever, and intermittent seizure. Initial computed tomography revealed bilateral subdural fluid collections. Burr hole drainage was carried out to control the ICP. T(1)-weighted magnetic resonance imaging on day 26 revealed diffuse linear hyperintense lesions, which suggested cortical laminar necrosis. This is an extremely unusual case of cortical laminar necrosis caused by elevated ICP due to subdural hematoma in an infant.

A large arachnoid cyst of the lateral ventricle extending from the supracerebellar cistern—case report

Background The pathogenetic mechanism of intraventricular arachnoid cyst development is still controversial, but is believed to originate from the vascular mesenchyme or as an extension of the arachnoid cyst in the subarachnoid space into the ventricle through the choroidal fissure. We report a case supporting the extension hypothesis and suggest differential points between an intraventricular arachnoid cyst that extended from the supracerebellar space and a lateral ventricular diverticulum that extended into the supracerebellar cistern. Case Description A 12-month-old girl presented with macrocephaly and developmental delay. Her magnetic resonance imaging showed an arachnoid cyst that had developed from the supracerebellar space in the posterior fossa, and which extended into the left lateral ventricle resulting in expansion of the left lateral ventricle and displacing the choroids plexus anteriorly and laterally and the midline to the right. We treated an intraventricular arachnoid cyst by endoscopic fenestration resulting in dramatic reduction of the intraventricular arachnoid cyst with large bilateral subdural fluid collection. We performed a subduroperitoneal shunt for subdural fluid collection and subsequent cystoperitoneal shunt for the remnant cyst. Conclusion We suggest that this case supports the extension hypothesis from the subarachnoid space through the choroidal fissure into the lateral ventricle. We also suggest that one of the radiological differential points between an intraventricular arachnoid cyst and a ventricular diverticulum is displacement and compression of the choroid plexus of the lateral ventricle.

Sinking brain syndrome: craniotomy can precipitate brainstem herniation in CSF hypovolemia.

Intracranial hypotension associated with CSF hypovolemia can occur spontaneously from cryptic CSF leaks, after trauma, or from iatrogenic causes, especially lumbar puncture. It is not widely known that it increases the risk of complications from craniotomy. We present two cases in which patients with CSF hypovolemia experienced posture-dependent deteriorations in level of consciousness after craniotomy. ### Patient 1. A 59-year-old woman sought treatment for progressive headache. CT and MRI demonstrated bilateral subdural fluid collections with diffuse pachymeningeal enhancement and a left subdural hematoma with mild left to right shift. She had a craniotomy with evacuation of the hematoma and dural biopsy. This showed only thrombus and normal dura. Headache persisted postoperatively, and she became progressively more obtunded despite head elevation. CT showed bifrontal pneumocephalus and effacement of the suprasellar cistern. By postoperative day 5, she was responsive only to pain and had no voluntary eye movements. Pupils were reactive at 4 mm, but plantar responses were extensor. Neurology was consulted. Further history disclosed the preoperative headaches were orthostatic. Reanalysis of the radiologic …

Neuroimaging features of spontaneous intracranial hypotension.

We reviewed the cranial MRI and radionuclide cisternograms of four adults with postural headache indicating spontaneous intracranial hypotension (SIH). All four underwent clinical and radiological follow-up. MRI showed diffuse, thin meningeal enhancement; bilateral subdural fluid collections; and morphological abnormalities secondary to "sagging" of the brain. Radionuclide cisternography revealed direct or indirect signs of leakage of cerebrospinal fluid (CSF) along the spinal axis, and the symptoms resolved after the leak treated by epidural injection of blood at a level indicated by the cisternogram. The diffuse meningeal enhancement decreased but persisted on follow-up MRI, although the patients were asymptomatic. All morphologic abnormalities resolved during 3-5 months follow-up.