Bilateral Subdural Hematoma Research Articles

Intracranial hemorrhage (ICH) in acute leukemia (AL): A single-center study from a general hospital with two cases managed with middle meningeal artery (MMA) embolization.

e19033 Background: ICH is a devastating and potentially fatal complication in patients with AL. Contributing factors for ICH include thrombocytopenia, hyperleukocytosis, and coagulopathy. Acute promyelocytic leukemia (APL) has a higher risk of disseminated intravascular coagulation (DIC) and fatal ICH, contributing to early deaths from the disease. At our institution, we have incorporated MMA embolization into traditional methods of observation and surgery for the management of ICH in AL patients. Methods: We performed a single-center retrospective study of adult AL patients with ICH at Memorial Hermann Hospital Texas Medical Center from January 1, 2013, to December 31, 2022. Data collected included: age at diagnosis, type of AL, white blood cell count (WBC), platelet count, coagulation profile, Glasgow Coma Scale score at presentation, response to platelet transfusion, need for surgical, minimally invasive intervention, and mortality rates at 72 hours and 30 days. Descriptive statistics were used to analyze the data. Results: Among 160 consecutive AL patients, we identified 22 (13.75%) with ICH at presentation (APL = 11, AML = 6, B-ALL = 3, Burkitt leukemia = 1, myeloid sarcoma = 1). All were newly diagnosed except for one (an intracranial relapse of AML). Median age was 54 (range, 20–82) years; 60% were women. Subject races included white (n = 10), Asian (n = 5), Hispanic (n = 2), African American (n = 2), and others (n = 3). Median WBC count at admission was 23 (range, 0.2–400) × 109/L. Thrombocytopenia (platelet levels < 50,000/μL) was present in 16 patients (72%), and 3 had platelet counts < 10,000/μL. Twelve patients (54%) had evidence of DIC. Sites of ICH included intraparenchymal (n = 8), subarachnoid (n = 3), subdural (n = 10), cerebellum (n = 1). In 3 patients, ICH extended into the ventricles. Three patients had ≥2 types of ICH. Three patients had middle cerebral artery ischemic stroke in addition to ICH. One patient with myelofibrosis and myeloid sarcoma had bilateral subdural hematomas (SDHs) on admission and developed a fatal basal ganglia ICH during induction chemotherapy. All APL patients were promptly started on all-trans retinoic acid. Two patients had refractory thrombocytopenia. Five patients required craniotomy, with 2 deaths from recurrent ICH. Two patients with SDH underwent MMA embolization with favorable outcomes. Four patients (18%) died within 72 hours of admission (APL = 3, AML = 1). The 30-day mortality rate among patients presenting with ICH was 31% (n = 7). Conclusions: ICH in AL continues to be a major cause of mortality and morbidity. Early diagnosis, transfusion support, correction of coagulopathy, and neurosurgical expertise are critical in improving outcomes in AL-associated ICH. MMA embolization is a new, minimally invasive strategy for the management of SDH in these critically ill patients.

Rectal dural metastasis masquerading as chronic subdural hematoma: illustrative case.

Intracranial dural metastasis causing subdural hematoma formation is a rare clinical entity associated with significant morbidity and mortality. A 61-year-old female patient known to have rectal signet ring cell carcinoma presented with cranial computed tomography scan findings of bilateral subdural hematoma. She underwent evacuation of the hematoma with dural biopsy, which showed tumor emboli consistent with colorectal origin. There was an early recurrence of the subdural collection, and an emergency subdural-peritoneal shunt insertion was done; however, there was no sustained clinical improvement. This work reports the first case of rectal dural metastasis presenting as chronic subdural hematoma and discusses the clinical course and current literature. The cases described in these studies are consistent with the clinical course of our patient; that is, evacuation of the subdural hematoma provided temporary clinical improvement and re-accumulation occurred within 3 days. The authors recommend maintaining a high index of suspicion in this select group of patients, including prompt discussion about treatment plans with the patient's family.

Bilateral Subdural Hematoma, The Cause or Consequence (P1-4.005)

<h3>Objective:</h3> Not applicable <h3>Background:</h3> Spontaneous Intracranial hypotension (SIH) currently preferred to be described as spontaneous spinal CSF leak is a disorder which is associated with orthostatic headaches, neck stiffness, tinnitus, but rarely can present with a coma. 50 yr. old woman with no history of alcoholism and taking no anti-thrombotic medications presents with sub-acute onset of headaches and found to have non traumatic acute on chronic bilateral subdural hematomas (SDH). She improved clinically after craniotomy and then worsened with sudden onset of right upper extremity weakness, coma and decerebrate posturing. EEG did not reveal seizures. Repeat CT head showed stable subdural hematomas. Due to the comatose presentation and increased white count, CSF studies were performed which resulted as normal. We noticed that patient was not on any anesthesia or sedating medication which can contribute to the coma. Clinical findings of cranial nerve palsies present during sitting posture improved with supine positioning. She had positive response to noxious stimulus in supine posture only. MRI Brain revealed diffuse dural, reticular system and pituitary enhancement, in addition to sagging brain stem with trans-tentorial herniation concerning for intracranial hypotension. <h3>Design/Methods:</h3> Not applicable <h3>Results:</h3> MRI of the spine identified CSF leak and patient eventually improved with a blood patch <h3>Conclusions:</h3> SIH is a rare entity but can progress to devastating neurological complications and death. Identifying the source of CSF leak and treatment with epidural blood patch is noted to be highly beneficial. Patient’s clinical picture including cranial nerve palsies and coma improved 24–48 hours after the blood patch. The current case of bilateral SDH is in turn a complication of intracranial hypotension that resulted in comatose state. This signifies the potential severity of SIH and urgency of corrective intervention which aided in the resolution of symptoms and returning to her baseline. <b>Disclosure:</b> Dr. Mannem has nothing to disclose. Dr. Yelverton has nothing to disclose.

Effect of postoperative tranexamic acid on recurrence rate and complications in chronic subdural hematomas patients: preliminary results of a randomized controlled clinical trial.

Chronic subdural hematoma (CSDH) is a frequent neurosurgical disease which mainly affects elderly patients. Tranexamic acid (TXA) has been hypothesized as an oral agent to avoid CSDH progression and/or recurrence. We performed an evaluation to determine whether the postoperative use of TXA reduces recurrence rate. A prospective, randomized, and controlled trial. Patients with unilateral or bilateral chronic subdural hematoma undergoing surgical treatment by burr-hole were randomized as to whether or not to use TXA in the postoperative period. We evaluated image and clinical recurrence of CSDH at follow up of 6months and potential clinical and/or surgical complications impact of TXA. Twenty-six patients were randomized to the control group (52%) and twenty-four patients to the TXA group (48%). Follow-up ranged from 3 to 16months. There were no significant difference between baseline data in groups regarding to age, gender, use of antiplatelet or anticoagulants, smoking, alcoholism, systemic arterial hypertension, diabetes mellitus, hematoma laterality, hematoma thickness, and drain use. Clinical and radiological recurrence occurred in three patients (6%), being two cases in TXA group (8.3%) and 1 in control group (3.8%). Postoperative complications occurred in two patients during follow-up (4%), being both cases in TXA group (8.3%), and none in the control group. Although TXA group had a higher recurrence rate (8.3%), there was no statistically significant difference between the two groups. Moreover, TXA group had two complications while control group had no complications. Although limited by experimental nature of study and small sample, our current data suggest that TXA should not be used as a potential agent to avoid recurrences of CSDH and might increase complication odds.

Headache, vision changes and cranial nerve palsy after head trauma.

A 43-year-old female was brought to the hospital after a ground level fall and her Glasgow Coma Scale was 15. Non-contrast head computed tomography (CT) scan showed small bilateral subdural hematomas, left traumatic subarachnoid hemorrhage, left occipital bone and left longitudinal temporal bone fractures. She was managed conservatively. Interval repeat non-contrast head CT scans showed resolution of the hemorrhage. Two and a half months later she presented to the hospital with headaches, intermittent diplopia, blurry vision and a right lateral gaze palsy. Non-contrast head CT scan showed mild hyperattenuation in the cavernous sinus. Subsequently, a CT angiogram of the head was obtained that showed opacification of the bilateral cavernous sinus and distention of the orbital veins (Figure 1A,B). Evaluation with diagnostic cerebral angiogram showed direct bilateral carotid-cavernous fistulas (CCFs) (Figures 2 and 3). She underwent staged embolization of the CCFs. Direct CCF is the abnormal connection between the internal carotid artery and the cavernous sinus.1, 2 CCFs can present with the classic triad of chemosis, pulsatile proptosis and ocular bruit.3, 4 Other symptoms include orbital pain, abducens nerve palsy, deterioration of visual acuity and ophthalmoplegia.4, 5 Causes of CCF formation are traumatic, iatrogenic, connective tissue disorders and spontaneous.2, 6-9 Traumatic CCFs formation occurs in up to 1.25% of patients with traumatic brain injury or facial and skull base fractures.10, 11 Bilateral CCF formation is rare after trauma and symptoms develop in a delayed fashion.10-15 Treatment options include conservative management, open surgery, endovascular procedures and radiosurgery.16-18

High-speed drill craniostomy as a minimally invasive method of chronic subdural hematoma management. Preliminary results of a pilot study

Objectives: The objective of this study was to assess the safety and efficiency of minimally invasive high-speed drill craniostomy in the treatment of chronic subduralhematomas.Study design: The study was designed as a retrospective case series study.Patients and Methods: The patients with compressive chronic subdural hematomas were treated by minimally invasive high-speed craniostomy performed underlocal anesthesia or conscious sedation. A minimal skin incision was followed by a single high-speed drill hole placement in the frontal or parietal region, over the area of maximal hematoma thickness. After hematoma aspiration, a 1.9 mm silicone catheter was placed in subdural space and connected to gravity-assisteddrainage. Patients were ambulatory immediately after surgery. Data on clinical course and outcome were recorded and analyzed.Results: There were 23 patients (5 female, 21.7%) included in the study. The median patient age was 77.5 years (interquartile range 67 - 83). Six (26.1%) of the patients had bilateral subdural hematomas. Septated/multiloculated hematomas were observed in 6 (26.1%) patients. Heterodense hematomas denoting more recent bleeding were recorded in 16 (69.5%) patients. The median duration of subdural drainage was 4 days (interquartile range 3 to 5). The median length of hospital stay was 9.5 days (interquartile range 6 - 16). One patient died of sepsis following a nosocomial respiratory infection. One patient developed a wound infection with subdural empyema, requiring subsequent craniotomy. One patient had deep venous thrombosis and pulmonary embolism. In all patients, postoperative CT scans showed a significant reduction of hematoma volume and midline shifting. No postoperative seizures were observed.Conclusion: High-speed drill craniostomy is a safe, simple, straightforward, and effective treatment for the management of chronic subdural hematomas, including multiloculated and heterodense lesions. Elderly patients could most benefit from such a procedure, avoiding general anesthesia, prolonged intracranial procedures, and lengthy hospital stays.

Anterior Thoracic Discectomy and Fusion for Symptomatic Ventral Bone Spur Associated Type I Cerebrospinal Fluid Leak: A Technical Report and Operative Video.

Technical Report. Cerebrospinal fluid (CSF) leak secondary to anterior osteophytes at the cervico-thoracic junction is a rare cause of intracranial hypotension. In this article we describe a technique for anterior repair of spontaneous ventral cerebrospinal fluid leaks in the upper thoracic spine. In this technical report and operative video, we describe a 23-year-old male who presented with positional headaches and bilateral subdural hematoma. Dynamic CT myelography demonstrated a high flow ventral cerebrospinal fluid leak associated with a ventral osteophyte at the level of the T1-T2 disc space. Targeted blood patch provided only temporary improvement in symptoms. An anterior approach was chosen to remove the offending spur and micro-surgically repair the dural defect. The patient had complete resolution of his preoperative symptoms after primary repair. In select cases, an anterior approach to the upper thoracic spine is effective to repair Type 1 cerebrospinal fluid leaks.

Discovering spontaneous intracranial hypotension after failed middle meningeal artery embolization for subdural hematomas: illustrative cases.

Spontaneous intracranial hypotension (SIH) is a relatively rare and underdiagnosed disease. SIH can lead to subdural hematomas (SDHs) and other complications. SDHs secondary to SIH are difficult to manage, with no consensus in management, and SDHs commonly recur if underlying SIH is not treated. A 46-year-old male with vague sensory and orientation symptoms presented with bilateral SDHs, which were treated with middle meningeal artery (MMA) embolization and burr hole evacuation. The patient improved initially but had recurrent encephalopathy and SDHs. The patient received 3 epidural blood patches (EBPs) over 8 days with continued improvement. A 78-year-old female presented with headaches, and imaging revealed a left chronic SDH. She underwent MMA embolization and mini-craniotomy for SDH evacuation. Her symptoms returned and imaging revealed a recurrent SDH. Pan spine computed tomography myelography showed a high thoracic cerebrospinal fluid (CSF) leak. She underwent 3 EBPs over 8 days with neurological improvement and stabilization of her SDH. The authors show that, if SDH recurs after initial treatment with MMA embolization, then SIH should be strongly considered and treated with EBPs. Further investigation is required to determine the role of targeted or blind EBPs and the use of imaging to find the source of occult CSF leaks causing SIH.

Emergency Medicine Images: Headache After a Lumbar Puncture

A 34-year-old man presented to the emergency department for a persistent, positional headache 3 weeks after a routine lumbar puncture (LP) for the workup of multiple sclerosis. The headache started gradually approximately 1 week after the uneventful LP and consistently improved with lying flat and worsened when upright. At a previous ED visit for this headache, an epidural blood patch was considered for postdural puncture headache (PDPH); however, the anesthesia service did not think a blood patch would be better than conservative treatment, given the usual benign course and the expectation for near-term resolution of symptoms with PDPH. With the patient experiencing persistent symptoms affecting his daily activities despite home analgesics, the ED clinician ordered a noncontrast head computed tomography scan (CT) (Figures 1 and 2). Figure 2Coronal noncontrast head computed tomographyt. There are bilateral convexity subdural hematomas (arrows) and subdural hematoma along the interhemispheric fissure (chevrons). The lateral ventricles partially effaced. View Large Image Figure Viewer Download Hi-res image Brian J. Ahern is a Physician Assistant at the Department of Emergency Medicine, William Beaumont Army Medical Center, Fort Bliss, TX. ORCID identifier: http://orcid.org/0000-0002-5701-3561. Lisa M. Jin is a Physician Assistant at the Department of Emergency Medicine, William Beaumont Army Medical Center, Fort Bliss, TX. Sean M. Sylvia is a Physician Assistant at the Department of Emergency Medicine, William Beaumont Army Medical Center, Fort Bliss, TX.

Retracted: Surgical Treatment of Bilateral Chronic Subdural Hematoma.

[This retracts the article DOI: 10.1155/2022/2823314.].

BILATERAL CHRONIC SUBDURAL HEMATOMA – CLINICAL PRESENTATION, RISK FACTORS, MANAGEMENT AND OUTCOME: A SINGLE CENTRE EXPERIENCE FROM NORTH-EASTERN INDIA

Study design: Background: Retrospective hospital-based study. Annual incidence of bilateral Chronic Subdural Hematoma (CSDH) is increasing due to an increase in the aging population, associated medical comorbidities such as hemodialysis, anticoagulant and/or antiplatelet therapy. 1. To study the clinical spectrum of Bilateral Chronic Subdural Hematoma Objectives: patients. 2. To study the treatment modalities used and outcome of the patients. A retrospective hospital-based study was carried Method: out on 50 conrmed patients of bilateral CSDH. Information of patients such as socio-demographic prole, clinical presentation, and laboratory investigations, along with treatment and outcome were recorded and analyzed. Among 50 patients, male and female were 80% and 20% res Results: pectively. The mean age of patients was 62.08 years. A history of head injury was reported by 40% of patients. The mean Glasgow coma scale (GCS) was 12.24. Common presenting symptoms were headache (76%), hemiparesis (40%), aphasia (28%), complete loss of consciousness (20%). Clinical improvement was observed in 80% while 10% had no change, 04% showed clinical deterioration and 06% of patients died during treatment. Bilateral CSDH is common Conclusion: in the elderly and prognosis is poor with increasing age. Bilateral hematoma has a higher risk of acute deterioration of clinical symptoms because of downward herniation, resulting in a poor clinical outcome. Timely interventions can improve the outcome in bilateral CSDH patients.

Bilateral Sub-acute Subdural Hematoma of the Posterior Fossa As a Complication of Anti-coagulation Therapy: A Case Report and Literature Review

Background: Subdural hematomas are one of the commonest neurosurgical pathologies faced in practice and it is rarely located in the posterior fossa. Posterior fossa subdural hematomas are challenging because of the difficulty in their diagnosis and management.&#x0D; Case Presentation: A case of bilateral sub-acute subdural hematoma of the posterior fossa in a 65-year-old female presented with a complaint of headache and vomiting for three weeks followed by a decreased level of consciousness two days prior to admission. The patient is a known cardiac patient on long-term anti-coagulant, her condition was intensively investigated and the diagnosis of posterior fossa subacute hematoma was reached, following which the patient was treated surgically and improved in the postoperative period.&#x0D; Conclusion: Subdural hematomas located in posterior fossa are considered very rare. Most of the reported cases are due to anti-coagulant use, with minor number of cases due to trauma. Literature denoted difficulty reaching diagnosis using only computed tomography and advice to be aided by magnetic resonance imaging as in our case. In most occasions, surgical management is the best choice for the management of such a case, regardless of surgical technique, and will result in excellent outcome.

Bilateral chronic subdural hematoma in postpartum period: Case report and review of literature

Introduction: Postpartum chronic subdural hematoma (PCSDH) of non-traumatic origin is a rare but potentially life-threatening complication in the obstetric population which usually presents with severe headache. Case Report: We describe timely diagnosis and surgical management of a 27-year-old female patient with bilateral chronic subdural hematoma of non-traumatic origin in the post-postpartum period for which surgical management was employed following irresponsive conservative management. Conclusion: The suspicion of chronic subdural hematoma should be considered in any patient complaining of severe persistent headache following spinal anesthesia in the postpartum period and requires prompt neuroimaging for timely identification. Surgical management following irresponsive conservative management in selected patients can be achieved with satisfactory outcomes.

Surgical Treatment of Bilateral Chronic Subdural Hematoma.

Background Chronic subdural hematoma (CSDH) is one of the common clinical intracranial hemorrhagic disorders, accounting for 16%–20% of bilateral CSDH. At present, the surgical treatment of bilateral CSDH mainly includes drilling drainage and neuroendoscopic assistance. The main objective of this paper was to compare the effects of two surgical methods on CSDH. Methods 153 patients who were diagnosed with CSDH were included in this study. 79 patients were treated with bilateral drilling drainage, and the other 74 patients were treated with neuroendoscope-assisted drainage. The clinical data of the two groups were compared, and the surgical indexes, neurological function, cure rate, and recurrence rate of the two groups were compared. The operation indexes of patients include operation time, postoperative hematoma volume, hospital stay, extubation time, misplacement of drainage tube, recurrence, and hematoma clearance rate. Results All patients underwent CT examination one day after operation. The CT imaging detection of the two groups was generally good. The cranial CT was reexamined before discharge. The bilateral hematoma disappeared in 114 patients, the unilateral hematoma disappeared in 29 patients, a small amount of compensatory crescent very low-density shadow subdural effusion was observed on the other side, and a small amount of compensatory crescent very low-density shadow subdural effusion was observed on both sides in 10 patients. There was no space occupying effect and intracranial gas disappeared. Compared with neuroendoscopic assisted drainage, the operation time of drilling drainage patients was significantly shorter. The extubation time, drainage tube dislocation, recurrence rate, postoperative hematoma volume, and hematoma clearance rate of patients receiving neuroendoscopic assisted drainage were significantly better than those receiving drilling drainage. The Markwalder score and hospital stay between the two groups were not significant. Conclusions Drilling drainage and neuroendoscopic assisted surgery have good therapeutic effects on bilateral CSDH. The operation time of drilling drainage is shorter. Neuroendoscopic assisted surgery has more advantages in extubation time, misplacement of drainage tube, recurrence, postoperative hematoma volume, and hematoma clearance rate.

Practical concepts in the identification of bilateral chronic subdural hematoma

Bilateral chronic subdural hematoma is a neurosurgical pathology whose incidence in older adults has been increasing, as a consequence of the ageing of the population, added to the factors that are linked to it. Neurosurgical diseases with chronic evolution generate a high burden of disease due to morbidity, disability, mortality and health costs associated with reinterventions and rehabilitation. For this reason, the interest in this disease has been increasing, also justified by the little information there is about it, unlike unilateral chronic subdural hematomas, although it has been described that both may have pathophysiological similarities that help to understand them.

Iatrogenic pseudoaneurysm of the middle meningeal artery during embolization of bilateral chronic subdural hematomas.

Summary/AbstractMiddle meningeal artery embolization has become an important treatment option for chronic subdural hematomas. While the treatment is safe, we present a unique case of development of an iatrogenic middle meningeal artery pseudoaneurysm during endovascular embolization with use of a dual-lumen balloon catheter used for injection of a liquid embolic agent. A 62-year-old man on Coumadin for portal vein thrombosis presented to the hospital with headache and supratherapeutic INR. Imaging revealed bilateral acute on chronic subdural hematomas. Given his medical comorbidities he underwent endovascular middle meningeal artery embolization. During the embolization, angiography revealed a pseudoaneurysm of the middle meningeal artery related to use of a dual-lumen balloon catheter. This pseudoaneurysm was successfully treated with ethylene vinyl alcohol embolization. Intracranial pseudoaneurysm related to balloon catheter use is a rare cause of iatrogenic pseudoaneurysm and could lead to life-threatening intracranial bleeding. Therefore, recognition and timely treatment are important.

P.131 Acute subdural hematoma in obstetric patients following epidural anesthesia

Background: Post-dural puncture headache is a known complication of neuraxial anesthesia and acute subdural hematoma has been associated with unintentional dural puncture. Notably, a significant number of unintentional dural punctures remain unidentified. We present two contrasting cases of subdural hematoma (SDH) following labour epidural anesthesia with no sign of dural puncture at time of anesthesia. Patient 1 presented with headache post-partum day (PPD) six, SDH was identified PPD23, and blood-patch treatment performed PPD35. Patient 2 presented with headache immediately, had SDH identified PPD3, and placement of blood-patch PPD4. Methods: The cases are presented and the literature was reviewed for prior cases. Results: Patient 1 developed significant bilateral SDH with severe headache and right abducens palsy. Headache resolved post blood patch however surgical evacuation was required and the abducens palsy persisted. Patient 2 experienced resolution of symptoms two days post blood patch, the small unilateral SDH was managed conservatively, and had no neurological deficits. Conclusions: Headache is common in the postpartum period. The majority are primary etiology and benign. SDH is a rare but serious complication of neuraxial anesthesia, and the consequences may be devastating. Rapid identification and early treatment are essential to avoid severe neurological sequelae.

Bilateral chronic subdural hematoma: clinical presentation, outcome and review literature.

Study design: Prospective hospital-based study. Background: Annual incidence of bilateral chronic subdural hematoma (CSDH) is increasing due to an increase in the ageing population, associated medical comorbidities such as haemodialysis, anticoagulant and/or antiplatelet therapy. Objectives: 1. To determine the socio-demographic and clinical profile of bilateral CSDH patients. 2. To determine treatment outcome and its association with the socio-demographic profile. Method: A prospective hospital-based study was carried out on 100 confirmed patients of bilateral CSDH. Information of patients such as socio-demographic profile, clinical presentation and laboratory investigation, along with treatment and outcome were recorded and analysed. Results: Among 100 patients, male and female were 74% and 26%. The mean age of patients was 63.03±13.57 years. A history of head injury was reported by 49% of patients. The mean Glasgow coma scale (GCS) was 12.14±2.38. Common presenting symptoms were hemiparesis (69%), headache (58%), aphasia (18%) and complete loss of consciousness (16%). Clinical improvement was observed in 81% while 09% had no change, 06% shows clinical deterioration and 04% of patients die during treatment. Conclusion: Bilateral CSDH is common in the elderly and prognosis is poor with increasing age however gender has no association with poor outcomes. More than 80% of patients recover with timely interventions. Key message: Surgery leads to achieving good outcomes in cases of bilateral chronic SDH, but not all such patients will recover completely. Similarly, good functional outcomes can also be achieved in those presented early after symptom onset when managed promptly.

Corrigendum to the paper 'Re-evaluation of medical findings in alleged shaken baby syndrome and abusive head trauma in Norwegian courts fails to support abuse diagnoses'.

We recently carried out a retrospective evaluation of 17 child abuse cases in the Norwegian courts and concluded that 16 of those failed to support the evidence provided by expert witnesses of shaken baby syndrome.1 Our paper focussed on the possible mechanisms behind the children's intracranial injuries and unfortunately a couple of findings were missing or incompletely described. In case number 2, we described rib fractures with callus formation. This was true for some, but not all, of the fractures. We did not mention the term ‘flail chest’, which we have now found in the discharge record. This was not mentioned elsewhere on the medical chart, as a finding or medical condition. The same is true for the bilateral rather than unilateral retinal haemorrhages, which again only were described in the discharge records. In case number 6, we described clavicle and rib fractures, but unfortunately, we did not report that there was also a scapula fracture. Stray-Pedersen et al.2 have claimed that we made other errors. We can explain these by stating, as is also described in the article, that we did not have access to all the data at the time of the retrospective analysis. For example, we made a deliberate decision not to view any legal documents, in order to avoid introducing bias. These discrepancies included the fact that we did not mention the bilateral optic nerve sheath haematomas or metaphyseal fractures in case 4 because the medical charts did not contain this information. Furthermore, Stray-Pedersen et al. have stated that there was a rib fracture in case 4. This was suspected during the autopsy but could not be verified by microscopical examination. With regard to case 6, Stray-Pedersen et al stated that ‘the defendant confessed to having repeatedly shaken the child back and forth’. This information was not given in the article, as it was only mentioned in the legal documents and not in the medical records. However, following a reconstruction in the court, two medical experts, including Stray-Pedersen, concluded that the shaking that was demonstrated had insufficient power to cause intracranial findings. In addition, Stray-Pedersen et al. have disagreed with us on a few other cases, where we stand by our interpretations. For example, in case two, they claim that we have overlooked fresh haemorrhagic components in the subdural effusions. We have simply called these chronic subdural hematomas/hygromas, which we believe is reasonable since small rebledings in chronic SDHs are a common finding. Further, in case 4, which involved a one-month-old infant, Stray-Pedersen et al. claim that there was an acute subdural hematoma. We were unable to detect this on the images, it was not described in the medical charts, and we still find it hard to detect this finding. Our assessment of the low-quality computed tomography images for case 6 was that no definite acute, bilateral subdural haematoma was present, contrary to the view expressed by Stray-Pedersen et al. They also claim that the fractures described in case 6 were new. We felt that this was not the case, because callus was observed after another 11 days. In conclusion, we regret any inadvertent errors in our paper. The aim of our study was to analyse the intracranial findings presented by the court experts involved in these 17 cases and to evaluate if they showed evidence of traumatic origin per se. However, while it is important to present data as accurately and objectively as possible, it is also important to acknowledge the difficulties that arise in retrospective studies. We must stress that we are fully aware of the fact that child abuse exists, and of the importance of protecting abused infants. It is further not our conclusion that abuse can be excluded in all cases in this cohort. In the evaluation of these cases, it is self-evident that extracranial injuries such as bruises and different fractures must be taken into consideration. A comprehensive assessment of these was however beyond the scope of this article. That being said, we believe that the findings of our study still hold and that many of the intracranial findings in this cohort of possibly abused infants could be attributed to non-traumatic causes. One important example quoted in our paper was the group with benign external hydrocephalus. While Stray-Pedersen et al have made some valid points about our paper, it is interesting to note that they did not question our main intracranial findings.

Early–stage epidural blood patch for spontaneous intracranial hypotension with bilateral chronic subdural hematoma: Two cases

Early–stage epidural blood patch for spontaneous intracranial hypotension with bilateral chronic subdural hematoma: Two cases