Extra-axial Fluid Collections Research Articles

Partial Cranial Reconstruction Using Titanium Mesh after Craniectomy: An Antiadhesive and Protective Barrier with Improved Aesthetic Outcomes

ObjectiveDescribe a new, safe, technique that uses titanium mesh to partially cover skull defects immediately after decompressive craniectomy. MethodsThis study is a retrospective review of eight patients who underwent decompressive craniectomy and placement of a titanium mesh. The mesh partially covered the defect and was placed between the temporalis muscle and the dura graft. The muscle was sutured to the mesh. All patients underwent cranioplasty at a later time. The study recorded and analyzed demographic information, time between surgeries, extra-axial fluid collections, postoperative infections, need for reoperation, cortical hemorrhages, and functional and aesthetic outcomes. ResultsAfter craniectomy, all patients underwent cranioplasty within an average of 112.5 days (30-240 days). One patient reported temporalis muscle atrophy, which was the only complication observed. During the cranioplasties, no adhesions were found between temporalis muscle, titanium mesh, and underlying dura. None of the patients showed complications in the follow-up computerized tomography (CT) scans. All patients had favorable aesthetic and functional results. ConclusionsPlacing a titanium mesh as an extra step during decompressive craniectomy could have anti-adhesive and protective properties, facilitating subsequent cranioplasty by preventing adhesions and providing a clear surgical plane between the temporalis muscle and intracranial tissues. This technique also helps preserve the temporalis muscle and enhances functional and aesthetic outcomes post-cranioplasty. Therefore, it represents a safe alternative to other synthetic anti-adhesive materials. Further studies are necessary to draw definitive conclusions and elucidate long-term outcomes, however, the results obtained hold great promise for the safety and efficacy of this technique.

Factors Associated with Non-Hemorrhagic Extra-Axial Fluid Collection after Cranioplasty

Factors Associated with Non-Hemorrhagic Extra-Axial Fluid Collection after Cranioplasty

Pitfalls in the interpretation of pediatric head CTs: what the emergency radiologist needs to know.

Pediatric radiology studies can be some of the most anxiety-inducing imaging examinations encountered in practice. This can be in part due to the wide range of normal anatomic appearances inherent to the pediatric population that create potential interpretive pitfalls for radiologists. The pediatric head is no exception; for instance, the inherent greater water content within the neonatal brain compared to older patients could easily be mistaken for cerebral edema, and anatomic variant calvarial sutures can be mistaken for skull fractures. This article reviews potential pitfalls emergency radiologists may encounter in practice when interpreting pediatric head CTs, including trauma, extra-axial fluid collections, intra-axial hemorrhage, and ventriculoperitoneal shunt complications.

Successful treatment of an 82-year-old COVID-19 delta variant-infected patient with haemorrhagic stroke and active prostate cancer brain metastasis.

Successful treatment of an 82-year-old COVID-19 delta variant-infected patient with haemorrhagic stroke and active prostate cancer brain metastasis.

Imaging differentiation on extra-axial fluid collections: a clinical Image.

A 3 month – old male patient with a history of seizures presents to the Pediatric neurosurgery department with his parents, on initial evaluation a head circumference of 47.5 cm (> percentile 99 on the WHO chart) was seen. A brain MRI was performed and an extra axial fluid collections (Chronic subdural hematoma and benign external hydrocephalus) was diagnosed. His parents refer a normal delivery without any complication and the medical history and records denied any previous trauma. A neurosurgical evacuation of the subdural hematoma was performed, and a complete improvement of his seizure was seen on 3 months follow up. Benign external hydrocephalus (BEH) has been proposed as a risk factor for the presence of chronic subdural hematoma (SDH) in infants (1). The SDH formation in the presence of BEH has been reported to be a venous rupture either spontaneously or following minor trauma from the bridging veins traversing the subdural/subarachnoid space (Red arrow , image D ) that are stretched with enlarged extra?axial collections (2). Epidemiologically there are striking similarities between these entities (3) that can be differentiated by some MRI findings.The signs that help us in the differentiation are: the subarachnoid layer visible (yellow arrow image B, showing a displaced subarachnoid layer downward by a fluid between it and the dura) the absence of the cortical vein sign and the differential on fluid intensity on T1-T2 weighted images (Images A,B,C,D) (4). Surgery evacuation is necessary for the patients with chronic subdural hematoma associated with BEH and neurological signs of increased intracranial pressure like macrocrania, seizures and altered level of consciousness (Image F , showing the subdural space without hematoma and the subarachnoid layer downward it ) (5).

Extra-Axial Fluid Collections After Decompressive Craniectomy: Management, Outcomes, and Treatment Algorithm

Extra-axial fluid collections (EACs) frequently develop after decompressive craniectomy. Management of EACs remains poorly understood, and information on how to predict their clinical course is inadequate. We aimed to better characterize EACs, understand predictors of their resolution, and delineate the best treatment paradigm for patients. We reviewed patients who developed EACs after undergoing decompressive craniectomy for treatment of refractory intracranial pressure elevations. We excluded patients who had an ischemic stroke, as EACs in these patients have a different clinical course. We performed univariate analysis and multiple linear regression to find variables associated with earlier resolution of EACs and stratified our analyses by EAC phenotype (complicated vs. uncomplicated). We conducted a systematic review to compare our findings with the literature. Of 96 included patients, 73% were male, and median age was 42.5 years. EACs resolved after a median of 60 days. Complicated EACs were common (62.5%) and required multiple drainage methods before cranioplasty. These were not associated with a protracted course or increased risk of death (P > 0.05). Early bone flap restoration with simultaneous drainage was independently associated with earlier resolution of EACs (β= 0.56, P<0.001). Systematic review confirmed lack of standardized direction with respect to EAC management. Our analyses reveal 2 clinically relevant phenotypes of EAC: complicated and uncomplicated. Our proposed treatment algorithm involves replacing the bone flap as soon as it is safe to do so and draining refractory EACs aggressively. Further studies to assess long-term clinical outcomes of EACs are warranted.

Complications Following Decompressive Craniectomy.

Decompressive craniectomy (DC) has become the definitive surgical procedure to manage a medically intractable rise in intracranial pressure. DC is a life-saving procedure resulting in lower mortality but also higher rates of severe disability. Although technically straightforward, DC is accompanied by many complications. It has been reported that complications are associated with worse outcome. We reviewed a series of patients who underwent DC at our department to establish the incidence and types of complications. We retrospectively evaluated the incidence of complications after DC performed in 135 patients during the time period from January 2013 to December 2018. Postoperative complications were evaluated using clinical status and CT during 6 months of follow-up. In addition, the impact of potential risk factors on the incidence of complications and the impact of complications on outcome were assessed. DC was performed in 135 patients, 93 of these for trauma, 22 for subarachnoid hemorrhage, 13 for malignant middle cerebral artery infarction, and 7 for intracerebral hemorrhage. Primary DC was performed in 120 patients and secondary DC in 15 patients. At least 1 complication occurred in each of 100 patients (74%), of which 22 patients (22%) were treated surgically. The following complications were found: edema or hematoma of the temporal muscle (34 times), extracerebral hematoma (33 times), extra-axial fluid collection (31 times), hemorrhagic progression of contusions (19 times), hydrocephalus (12 times), intraoperative malignant brain edema (10 times), temporal muscle atrophy (7 times), significant intraoperative blood loss (6 times), epileptic seizures (5 times), and skin necrosis (4 times). Trauma (p = 0.0006), coagulopathy (p = 0.0099), and primary DC (p = 0.0252) were identified as risk factors for complications. There was no significant impact of complications on outcome. The incidence of complications following DC is high. However, we did not confirm a significant impact of complications on outcome. We emphasize that some phenomena are so frequent that they can be considered a consequence of primary injury or natural sequelae of the DC rather than its direct complication.

Study of factors related to early mortality after primary decompressive craniectomy in patients with severe traumatic brain injury

Background: Traumatic brain injury is considered one of the leading causes of death in paediatrics and adults less than 45 years. Decompressive craniectomy is a common neurosurgical procedure aiming to relieve raised intracranial pressure. In present study we aimed to evaluate factors related to early mortality after primary decompressive craniectomy in patients with severe traumatic brain injury. Material and Methods: Present study was single-centre, prospective, observational study, conducted in patients age &gt; 15 years, with severe traumatic brain injury in whom primary decompressive craniectomies (within 24 hours of trauma) were performed at our centre. Results: During study period total 42 patients satisfying study criteria underwent primary decompressive craniectomy at our centre. Most of patients were male (85.71 %), from age group 31-45 years (50 %), with severe (≤ 8) Glasgow Coma Scale scores on admission (54.76%), common etiology was road traffic accidents. Most of patients were operated within 6-12 hours from trauma (45.24%) and left side was common surgical site (57.14%). At discharge from ICU - Glasgow Outcome score (GOS) outcome was poor in 22 patients (52.38 %) and good outcome noted in 20 patients (47.62 %). Mortality at discharge was noted in 16 patients (38.10%). Conclusion: Advanced age, GCS ≥ 8, timing of surgery (&gt;12 hours), presence of pupillary asymmetry on admission, presence of lung or abdominal injury, hypotension at admission (SBP &lt; 90 mm hg), mean midline shift ( &gt; 7 mm), mean volume of the bleed ( &gt; 70 ml), bone flap ≥130 cm², intraventricular extension of the bleed present and surgery-related complication (hydrocephalus , extra-axial fluid collection, post-operative acute hematoma and skin flap ischemia) were predictors for early mortality patients with severe traumatic brain injury underwent primary decompressive craniectomy.

Management of Extra-Axial Fluid Collections After Decompressive Craniectomy

DiRisio, Aislyn BS; Stopa, Brittany M MPH; Pompeu, Yuri A; Vasudeva, Viren; Khawaja, Ayaz; Izzy, Saef; Gormley, William Author Information

The Brain is Not Flat: Conformal Electrode Arrays Diminish Complications of Subdural Electrode Implantation, A Series of 117 Cases

Intracranial recordings are integral to evaluating patients with pharmacoresistant epilepsy whom noninvasive testing fails to localize seizure focus. Although stereo-electroencephalography is the preferred method of intracranial recordings in most centers, subdural electrode (SDE) implantation is necessary in selected cases. To identify imaging correlates that predict SDE complications (extra-axial fluid collections [EFCs]), and determine if modifications that diminish stiffness of electrode sheets reduce complications. A prospective epilepsy surgery database was used to identify adults undergoing craniotomy for SDE implantation over a 14-year period. EFCs and midline shift were measured via magnetic resonance imaging and computed tomography imaging. Correlation analyses and multivariable logistic regression explored associations between use of conformal arrays, serial order of patients, previous ipsilateral intracranial surgery, midline shift, number of SDEs, and neurologic complications. A total of 111 consecutive patients (59 female) underwent 117 craniotomies (mean, 115 electrode contacts) for SDE implantation. There were 8 surgical complications, 3 in the first 17 (17.7%). and 5 (after electrode modifications) in a subsequent 100 craniotomies (5.0%). We noted an increase in electrode numbers implanted over time (P < 0.001) and decreased midline shift with conformal grids (ρ= - 0.32; P < 0.001). A multivariable regression showed that midline shift correlated with complications (odds ratio, 2.32; 95% confidence interval, 1.12-4.78; P= 0.023). Hemorrhagic complications after SDE implantation are difficult to detect because of artifact from electrodes, but predictable by prominent midline shift (>4 mm). Risks inherent to SDE implantation may be minimized using conformal grids. With symptomatic EFCs, a single electrode cable exit site allows hematoma evacuation without terminating intracranial recordings.

Use of Point-of-care Ultrasound for the Seizing Infant: An Adjunct for Detection of Abusive Head Trauma

Case PresentationAn eight-week-old infant presented to the emergency department in cardiac arrest. Return of spontaneous circulation was obtained and the patient subsequently began seizing. Point-of-care ultrasound of the anterior fontanelle revealed an extra-axial fluid collection consistent with subdural hematoma (SDH).DiscussionAbusive head trauma is still frequently missed on initial presentation. In addition to validated screening clinical prediction rules, point-of-care cranial ultrasound can be used as a noninvasive adjunct for detection of SDH related to abusive head trauma in infants with an open fontanelle.

Incidence and risk factors of early postoperative complications in patients after decompressive craniectomy: a5-year experience.

Decompressive craniectomy is an effective measure to reduce apathologically elevated intracranial pressure. Patients' survival and life quality following this surgery have been asubject of several studies and significantly differ according to the primary diagnosis. Since this operation is often associated with awide spectrum of possibly serious complications, we aimed to describe their incidence and possible associated risk factors. We evaluated 118 patients who underwent decompressive craniectomy at our clinic during years 2013-2017. The indications included traumatic brain injuries, ischaemic or haemorrhagic strokes and postoperative complications of planned neurosurgical procedures. Subsequently, we assessed the incidence of early postoperative complications (occurring during the first 3 postoperative weeks). The results were statistically analysed with relation to awide selection of possible risk factors. At least one early surgical postoperative complication occurred in 87 (73.73%) patients, the most frequent being adevelopment of an extraaxial fluid collection in 41 (34.75%) patients. We were able to identify risk factors linked with extraaxial fluid collections, subcutaneous and extradural haematomas, postoperative seizures and meningitis. An overall need for reoperation was 13.56%. Neither the duration of the surgery nor the qualification of the operating surgeon had any effect on the complications' occurrence. Decompressive craniectomy is associated with numerous early postoperative complications with avarious degree of severity. Most cases of complications can, however, be managed in aconservative way. The risk factors linked with postoperative complications should be taken into account during the indication process in each individual patient.

NIHILISTIC DELUSION IN THE CONTEXT OF MAJOR DEPRESSIVE DISORDER WITH CATATONIC FEATURES IN A GERIATRIC PATIENT: A CASE REPORT AND REVIEW OF LITERATURE

NIHILISTIC DELUSION IN THE CONTEXT OF MAJOR DEPRESSIVE DISORDER WITH CATATONIC FEATURES IN A GERIATRIC PATIENT: A CASE REPORT AND REVIEW OF LITERATURE

Erratum: Impact of extra-axial cerebrospinal fluid collection in frontal morphology after surgical treatment of scaphocephaly.

[This corrects the article on p. 215 in vol. 9, PMID: 30505617.].

Impact of extra-axial cerebrospinal fluid collection in frontal morphology after surgical treatment of scaphocephaly.

Background:Infants with sagittal suture synostosis often present a pathologic dilatation of subarachnoid spaces. The impact of such subarachnoid spaces’ enlargement in the morphology of the skull, especially on the forehead and on the surgical outcome, was analyzed.Methods:Children less than 6 months of age undergoing a surgical correction of the scaphocephaly with Renier's H technique between 2003 and 2008 were included in the study. In these patients, preoperative and postoperative fronto-occipital diameter (FOD), biparietal diameter (BPD), temporal width (TW), and naso-frontal angle (NFA) were measured. Cranial index (CI) and the difference between preoperative and postoperative CI (ΔCI) were calculated. Preoperative cranio-cortical width (CCW) was measured to analyze the subarachnoid spaces’ volumes. The children here considered were then divided into two groups: Group 1 with CCW within normal estimated value corrected for age and Group 2 with CCW larger than estimated normal value.Results:About 159 children were enrolled (72.3% male). CCW was larger than expected in 95 children (59.8%). A positive correlation between CCW and BPD (P ≤ 0.001) and a negative correlation between CCW and NFA (P ≤ 0.001) were found. When comparing the two groups, the mean age at preoperative computed tomography (CT) scan was 121 days in Group 1 and 110 days in Group 2. The mean age at operation was 130 days in Group 1 and 123 in Group 2. The mean age at postoperative examination (RX or CT scan) was 53.4 months in Group 1 and 51.8 months in Group 2. Preoperatively, the mean BPD, TW, and CI were significantly larger in Group 2 (P ≤ 0.01), whereas the NFA was significantly narrower (P = 0.03). Postoperative analysis showed that ΔCI was statistically different between the two groups (Group 1: 10%, Group 2: 7%; P < 0.04). The duration of follow-up period ranged between 19 and 129 months.Conclusion:Two main subtypes of forehead of infants with scaphocephaly may be distinguished. Indeed, the morphology of the forehead differs when a pathologic subarachnoid spaces’ enlargement is present preoperatively and it also affects the postoperative evolution. Such observation highlights the importance of evaluating whether subarachnoid spaces are enlarged when planning a surgical correction in isolated sagittal suture synostosis.

Neonatal cranial sonography: ultrasound findings in neonatal meningitis-a pictorial review.

Neonatal bacterial meningitis is a common manifestation of late onset neonatal sepsis. Cranial sonography (CRS) has a crucial role in assessment of infants with clinical suspicion of bacterial meningitis as well as follows up of its complications. CRS is performed with high frequency transducer through anterior fontanelle in both coronal and sagittal planes. Various sonographic findings range from echogenic and widened sulci, ventriculomegaly, ventriculitis, hydrocephalus, extra-axial fluid collections, cerebritis and brain abscess. Sonography is extremely beneficial in evaluating intraventricular contents, especially debris and intraventricular septations. Linear high frequency probe along with color Doppler interrogation are of utmost importance in evaluating extra-axial fluid collection and helps differentiating it from benign subarachnoid space enlargement. Due to low cost, easy portability, speed of imaging, no need for sedation and above all lack of ionizing radiation make it superior to other cross sectional imaging, like CT and MRI, in evaluation of these sick neonates. Apart from textbooks, there is paucity of recently available literature on cranial sonographic findings in neonatal meningitis. This article is written with an educational intent to review the spectrum of findings in neonatal meningitis, with stress on findings that will be beneficial in the clinical practice.

Dual-Energy CT in Emergency Neuroimaging: Added Value and Novel Applications.

Dual-energy computed tomography (CT) is a powerful diagnostic tool that is becoming more widely clinically available. Dual-energy CT has the potential to aid in the detection or add diagnostic confidence in the evaluation of a variety of emergent neurologic conditions with use of postprocessing techniques that allow one to take advantage of the different x-ray energy-dependent absorption behaviors of different materials. Differentiating iodine from hemorrhage may help in delineating CT angiographic spot signs, which are small foci of intracranial hemorrhage seen on CT angiograms in cases of acute hemorrhage. Bone subtraction can be used to effectively exclude osseous structures surrounding enhancing vessels at imaging for improved vessel visualization and to create images that are similar in appearance to three-dimensional magnetic resonance imaging vessel reconstructions. Bone subtraction may also be helpful for improving the conspicuity of small extra-axial fluid collections and extra-axial masses. Material characterization can be helpful for clarifying whether small foci of intermediate attenuation represent hemorrhage, calcification, or a foreign material, and it may also be useful for quantifying the amount of hemorrhage or iodine in preexisting or incidentally detected lesions. Virtual monochromatic imaging also can be used to problem solve in challenging cases. ©RSNA, 2016.

Case Report: Acute obstructive hydrocephalus associated with infratentorial extra-axial fluid collection following foramen magnum decompression and durotomy for Chiari malformation type I.

Acute obstructive hydrocephalus due to infratentorial extra-axial fluid collection (EAFC) is an extremely rare complication of foramen magnum decompression (FMD) and durotomy for Chiari malformation type I. Presence of infratentorial EAFC invariably causes obstruction at the level of the fourth ventricle or aqueduct of Silvius, thereby indicating its definitive role in hydrocephalus. Pathogenesis of EAFC is said to be a local arachnoid tear as a result of durotomy, as this complication is not described in FMD without durotomy. Controversy exists in management. Usually EAFC is said to resolve with conservative management; so hydrocephalus doesn't require treatment. However, in this case EAFC was progressive and ventriculo-peritoneal shunting (VPS) was needed for managing progressive and symptomatic hydrocephalus.

Neuroendoscopic treatment for hydrocephalus associated to midline arachnoid cysts in a series of nine pediatric patients.

Arachnoid cysts are extra-axial cerebrospinal fluid (CSF) collections surrounded by a membrane. Occasionally, hydrocephalus is associated due to a change in CSF circulatory dynamics. Neuroendoscopic treatment has been recommended for patients who develop symptoms resulting from the cyst location. We retrospectively evaluate the results in our series of 9 patients with hydrocephalus associated to midline arachnoid cysts treated endoscopically. Success was rated on a scale of five degrees of neuroendoscopical success. We performed endoscopic third ventriculostomy (ETV) in three cases; ETV was associated to ventriculocystostomy (VC) in three cases; ETV, VC and septostomy (SPT) were performed in one patient; neuroendoscopic Monro foraminoplasty (NEFPMO) plus SPT were associated in one case; last patient was performed ETV, VC and cystocysternostomy (CC). For first procedures, 6 patients completed permanent Success (grade I). In one case success was transitory (grade II) and required a second procedure (ETV). In one patient VC success and ETV failure implied partial success (grade III). One patient's early failure (grade V) required a second procedure (ETV + NEFPMO). Success in second procedures was grade I in both patients. Follow-up period was over 12 months and altogether success was grade I in 8/9 patients and grade III in 1/9 patients. Shunt independency went over 88%. Endoscopy allows a solution avoiding the implantation of cerebrospinal fluid shunt devices. When possible, we likely approach both, hydrocephalus and arachnoid cyst, with different endoscopic maneuvers in a single procedure. It is important to expand the usage of success classifications for combined procedures.

Case Report: Group B Streptococcus meningitis in an adolescent .

Streptococcus agalactiae (group B Streptococcus, GBS) usually colonizes the gastrointestinal and lower genital tracts of asymptomatic hosts, yet the incidence of invasive disease is on the rise . We describe a case of an 18 year old woman, recently diagnosed with lupus, who reported a spontaneous abortion six weeks prior to her hospitalization. She presented with fever, altered mental status, and meningeal signs, paired with a positive blood culture for GBS. Magnetic resonance imaging of her brain demonstrated an extra-axial fluid collection, and she was diagnosed with meningitis. She received prolonged intravenous antibiotic therapy and aggressive treatment for lupus, leading to clinical recovery. This case illustrates the importance of recognizing GBS as a potential pathogen in all patients presenting with CNS infection .