Extracerebral Fluid Collections Research Articles

Head circumference alone at birth, is it practical?

Head circumference alone at birth, is it practical?

Benign extracerebral fluid collection in infancy as a risk factor for the development of de novo intracranial arachnoid cysts

Intracranial arachnoid cysts are a relatively common benign intracranial pathology, accounting for as many as 0.75%-1% of nontraumatic CNS lesions. Although it has already been demonstrated that rupture of arachnoid cysts may lead to subdural hematomas/hygromas, no study to date has investigated benign extracerebral collection in infancy as a possible predisposing factor for further development of arachnoid cysts. The authors performed a retrospective imaging and chart review of macrocephalic infants 12 months old or younger who were referred to neurosurgical care at OSF St. Francis Medical Center from 2003 to 2010, and who were diagnosed with benign extracerebral fluid collection in infancy on thin-slice (1-mm) head CT scans. Special attention was given to the investigation of risk factors for further development of de novo arachnoid cysts. Several epidemiological factors in the infants and mothers were analyzed, including gestational age at delivery, mode of delivery, mother's age at delivery, delivery complications, birth weight, age of macrocephaly development, degree of macrocephaly, family history of macrocephaly, prenatal and postnatal history of infection, fontanel status, presence of papilledema, previous history of head trauma, and smoking status. Imaging characteristics of the initial scans, such as location of subdural collection (frontal vs frontoparietal and frontotemporal) and presence of ventriculomegaly, were also evaluated. For those patients in whom arachnoid cysts were identified on subsequent CT scans, the size and location of the cysts were also analyzed. The authors identified 44 children with benign extracerebral fluid collection in infancy. From this group, over a mean follow-up of 13 months (range 6-13 months), 18 children developed intracranial arachnoid cysts (a 40.9% incidence of de novo development of arachnoid cysts), with 27.8% presenting with bilateral cysts. In the multiple logistic regression analysis, infants who presented with an extracerebral collection restricted to the bilateral frontal region were more likely to develop intracranial arachnoid cysts (p = 0.035) than those with collections involving the frontotemporal and frontoparietal regions (odds ratio [OR] = 5.73). Additionally, children with benign extracerebral fluid collections and plagiocephaly were more likely to develop intracranial arachnoid cysts (p = 0.043) than those without plagiocephaly (OR = 4.96). This is the first report in the neurosurgical literature demonstrating that benign extracerebral fluid collections in infancy may constitute a significant risk factor for development of de novo arachnoid cysts. These findings support a 2-hit hypothesis for the development of arachnoid cysts, in which the combination of an embryological defect in arachnoid development followed by a second event leading to impairment of CSF fluid absorption in early childhood could lead to abnormal CSF dynamics and the consequent expansion of fluid collections in the intraarachnoid spaces.

Posttraumatic extracerebral fluid collections

Abstract Objective: Posttraumatic extracerebral fluid collections represent a heterogeneous group of conditions that have different terminologies but the same clinical and imaging features, benefiting from the same therapeutic modalities. Between hygroma/hydroma and serous meningitis there is only a topographic difference that has no influence regarding the therapeutic decision or the patient’s outcome. Posttraumatic extracerebral fluid collections present themselves as a unitary group which benefits from a unitary management, regardless the given terminologies. This 5 years study reviews the experience, treatment and outcome of patients with such conditions. Method: A retrospective analysis of data collected from 46 patients with posttraumatic extracerebral fluid collections is presented. Asymptomatic patients or those with mild symptoms were conservatively treated (n=27). Surgical evacuation was performed in cases of intracranial hypertension or neurological worsening (n=19). Results: Clinical results are presented using the Glasgow Outcome Scale (GOS). Regarding the group of patients treated conservatively, good results were obtained (GOS score 4 or 5) in 81.4 % of the cases. Regarding the surgical treated group of patients, good results were obtained in 73.6% of the cases. The mortality rate was 18.5%, and 26.3% respectively. Conclusions: Although several different names can be found in literature, posttraumatic extracerebral fluid collections present themselves as a unitary group, with good outcome after conservative or surgical treatment. The therapeutic decision is made regarding the neurological status and the clinical evolution, which can be correlated with some imaging features.

Challenges and pitfalls in the forensic assessment of posttraumatic extracerebral fluid collections

The purpose of this article is to analyze the particularities of these collections and to discuss their medical- legal consequences. Different types of collections were presented together as they have similar prognosis and management. � Aretrospectiveanalysisofdatacollectedfrom�46�patientswithposttraumaticextracerebralfluidcollectionsispresented.� Asymptomatic patients or those with mild symptoms were conservatively treated (n=27). Surgical evacuation was performed in cases of intracranial hypertension or neurological worsening (n=19). Clinical results are presented using the Glasgow Outcome Scale (GOS). Regarding the group of patients treated conservatively, good results were obtained (GOS score 4 or 5) in 81.4 % of the cases. Regarding the surgical treated group of patients, good results were obtained in 73.6% of the cases. The mortality ratewas�18.5%,�and�26.3%�respectively.�Conclusions:�posttraumaticextracerebralfluidcollectionsappearmoreofteninelder� patients,�oftensecondarytominortrauma�(likefalls),�butcanleadtodifficultiesinanalyzingthecasefromamedical-legal� pointofview.�ThemajorityofpatientswhoseCT-scansshowextracerebralfluidcollectionsareasymptomaticandthefluid� collections are eventually spontaneously resolved. Mortality is in most cases caused by associated cerebral damage or systemic complications.

Results of the Prospective, Randomized, Multicenter Clinical Trial Evaluating a Biosynthesized Cellulose Graft for Repair of Dural Defects

After intradural cranial surgery, a dural substitute is often required for dural closure. Although preferred, limitations of autograft include local availability and additional surgical site morbidity. Thus, allografts, xenografts, and synthetics are frequently used. To report 6-month results of a randomized, controlled trial of a biosynthesized cellulose (BSC) composed duraplasty device compared with commercially available dural replacements. A total of 99 patients (62 BSC; 37 control) were treated on protocol, using a 2:1 (BSC:control) blocked randomization schedule. Physical examinations were performed pre- and postoperatively within 10 days and at 1, 3, and 6 months. Magnetic resonance imaging was performed preoperatively and at 6 months. The primary study endpoint was the absence of pseudomeningocele and extracerebral fluid collection confirmed radiographically and the absence of cerebrospinal fluid fistula at 6 months. At 6 months, the primary hypothesis, noninferiority of the BSC implant compared with the control group, was confirmed (P = .0206). Overall success was achieved by 96.6% of BSC and 97.1% of control patients. No significant difference was revealed between treatment groups for surgical site infection (P = 1.0000) or wound healing assessment (P ≥ .3685) outcomes, or radiologic endpoints (P ≥ .4061). Device strength and seal quality favored BSC. This randomized, controlled trial establishes BSC as noninferior to commercially available dural replacement devices. BSC offers a hypothetical advantage concerning prion and other infectious agent exposure; superior handling qualities are evident. Longer term data are necessary to identify limitations of BSC and its potential equivalence to the gold standard of pericranium.

Outcome of Infant Extracerebral Fluid Collections

Cases of benign infantile extracerebral fluid collections and nontraumatic chronic subdural hygroma or hematoma were reviewed retrospectively at Nebraska Medical Center, Omaha.

Partial Trisomy 3p and Monosomy 7p Associated with Tetralogy of Fallot and Infantile Seizure

A 7-month-old female infant was referred because of hypothyroidism, seizure, respiratory distress syndrome, and tetralogy of Fallot (TOF) with hypoxic spell. Her father and 24-year-old mother were healthy and nonconsanguineous. There was no family history of congenital malformations. The mother denied any exposure to alcohol, teratogenic agents or infectious diseases during this pregnancy. She received regular prenatal examinations at a local clinic. The infant was born prematurely at 35 weeks of gestation. However, bradycardia, restlessness, cyanosis, gasping respiration, upgaze, and episodes of seizure developed soon after delivery. The infant’s external appearance was grossly normal, and the extremities were freely movable. The body weight was less than third percentile with growth restriction. Serial studies were arranged. Echocardiography revealed an atrial septal defect, a large ventricular septal defect, right ventricular hypertrophy, and severe pulmonary stenosis that were consistent with TOF. Brain sonography revealed moderate dilatation of lateral and third ventricles, in favor of the diagnosis of benign extracerebral fluid collection. Conventional cytogenetic studies performed on the

Benign extracerebral fluid collections in infancy: clinical presentation and long-term follow-up

Benign extracerebral fluid collections are common in infants, but there are unanswered questions regarding presentation and long-term outcome. This study was undertaken to establish head size at birth, head size at presentation, head growth over time, history of presentation, indications for surgery, and long-term results. Cases of benign extracerebral fluid collections in infancy were retrospectively reviewed. Data pertaining to clinical presentation, progress, and long-term follow-up were evaluated. Patients were divided into two groups on the basis of the presence or absence of increased signal intensity of fluid in the extracerebral space on T1-weighted magnetic resonance images. Group 1 consisted of 39 patients who had benign extracerebral fluid collections without any subdural collections. Group 2 consisted of nine patients who had a chronic subdural hematoma or hygroma without a history of trauma and had generous subarachnoid spaces and/or a history of premature birth. Patients were observed for an average of 49 months. Group 1 included 39 patients (ages at presentation 3-12 months); the most common presentation in this group was macrocephaly (28 cases). Of those Group 1 cases in which data regarding gestational age at birth were available, 15 births were either severely or mildly premature and 14 were full term. Of those Group 1 patients with adequate data, 14 had an occipitofrontal circumference (OFC) in the 50th to 98th percentile at birth and two had OFCs greater than the 98th percentile. Measurements obtained at 24 months of age were available for 18 Group 1 patients: OFC was at approximately the 98th percentile in eight (all eight born at full term) and more than 1 cm larger than the 98th percentile in 10. Head growth in Group 1 patients continued to decrease, approaching the 98th percentile after 24 months of age. Only three of the 39 patients in Group 1 required shunt placement. Of the 33 Group 1 patients for whom long-term follow-up was available, 30 were developing normally, and three had mild developmental delays. Group 2 included nine patients (ages at presentation 3-7 months); the most common presentations were large head (three patients) and seizures (three patients). Data concerning gestational age at birth were available in eight Group 2 cases: birth was severely premature in four and gestation was full term in four. Five Group 2 patients were treated surgically-two with subduroperitoneal (SDP) shunt placement, two with subdural punctures, and one with subdural punctures and SDP shunt placement. Adequate follow-up information was available in eight of nine Group 2 cases; all eight patients were found to be developing normally. Group 1 patients usually had a normal head size at birth, they rarely required shunt placement, their head growth eventually leveled off toward the 98th percentile line, and their outcomes were generally good. Although five of nine Group 2 patients required subdural punctures and/or SDP shunt placement, that group of patients also developed well. Infants with nontraumatic subdural hematomas or hygromas, presumably associated with benign extracerebral fluid collections, can often experience significant resolutions of the hematoma or hygroma within several months without surgical treatment.

Prevention of postoperative subdural fluid collections following transcortical transventricular approach

Background Subdural fluid collections appear in about 39% of patients after the removal of intra- and paraventricular tumors. This extracerebral fluid collection requires surgical intervention when progressive fluid accumulation takes place. The authors retrospectively and prospectively studied the efficacy of gelfoam and fibrin adhesive in closing cortical and ependymal defects after intraventricular and/or paraventricular lesion resection to prevent the development of SFCs. Methods From 1999 to 2004, we used gelfoam and fibrin adhesive on the cortical and ependymal defects of 28 patients who underwent the resection of intraventricular and/or paraventricular lesions via the transcortical approach associated with the communicated ventricle. We investigated the percentage of symptomatic and asymptomatic SFC. Results The patients median age was 59.5 years (range, 30-76 years), and the male/female ratio was 16:12. A frontal approach was performed in 18 patients, an occipital approach in 2, a parietal approach in 4, and a temporal approach in 4. The incidence of SFCs was 7% (2 patients). Of the 2 patients with SFCs, 1 required temporary drainage. The other patient was asymptomatic, and the SFCs were spontaneously absorbed 2 months later. Conclusions The use of gelfoam and fibrin adhesive to seal cortical and ependymal defects after a transcortical procedure might be a viable method of preventing the development of SFC.

Abnormalities in Head Size

Abnormalities in Head Size

External hydrocephalus in small children

Confusion exists in literature regarding the entity of external hydrocephalus which has been addressed by different terms like subdural effusion, hygroma, benign infantile hydrocephalus, etc. In this report, the author has tried to define the clinical and radiological criteria for reaching the diagnosis of external hydrocephalus. Five children 9 months to 2 years of age with subdural fluid collection were studied prospectively for a period of 8 years. The radiological and clinical criteria sparsely described in literature were followed to study the profile of suspected cases. Four children presented with craniomegaly; the fifth case had tense, wide, and bulging fontanelle. CT of all five children showed hemispheric extracerebral fluid collection with enlarged subarachnoid spaces. Three children had mild to moderate ventriculomegaly without significant periventricular lucency, while the other two had borderline ventricular enlargement. All were managed conservatively. All five children were asymptomatic at follow-up from 12 weeks to 2 years. The possible conclusions from this study of rare cases are: external hydrocephalus needs differentiation from other conditions of subdural fluid collections. The radiological criteria such as (a) extracerebral fluid collection (relatively more in anterior convexity than posterior convexity), (b) dilatation of subarachnoid spaces, and (c) mild to moderate ventriculomegaly without (or with questionable) periventricular lucency may be helpful in making a radiological diagnosis of external hydrocephalus. Conservative treatment with acetazolamide helped in ameliorating the clinical features of the cases studied.

Diagnostic Value of The Cortical Vein Sign: Unreliable Index of Atrophy on MR Image

Objective: Differentiation of the subdural and the subarachnoid spaces is a matter of debate in the extracerebral fluid collections. Visualization of the cortical veins, so-called cortical vein sign was proposed as an index of the subarachnoid space. W e examined the validity of this sign. Methods: W e reviewed the anatomy of cerebral meninges in the literature. W e also examined the cortical vein sign in some patients with extracerebral fluid collections, evaluated by magnetic resonance imaging and computed tomography. Results: The subarachnoid space is a space below the arachnoid barrier cell layer, above the pia mater, and between arachnoid trabeculae. Since the trabeculae are not elastic, the subarachnoid space cannot be enlarged unless the trabeculae are torn. Before tearing of the trabeculae, dural border cell layer of the dura will be separated. Anatomically, the subarachnoid space cannot expand beyond the limit of t he trabeculae. The cortical veins lie on the surface of i ntima pia anchored by arachnoid trabeculae. As t hey approach the convexity, cortical veins cross the arachnoid and dura, draining into the sinus. Near the sinuses, theses vessels lie between the dura and the arachnoid, and they can be seen even in patients with subdural hygroma. Conclusion: The cortical vein sign is not useful to differentiate subdural hygroma and atrophy.

Positional skull deformities in children: skull deformation without synostosis

Patients with craniosynostosis are readily diagnosed by clinical and neuroimaging findings. Surgical treatment is indicated for preventing neurological deficits and for correcting esthetically unacceptable head deformities. In recent years, we have witnessed a progressive number of neurosurgical consultations for abnormal head shapes unrelated to premature fusion of the cranial sutures, especially of positional plagiocephaly. There have been descriptions of abnormalities in the cerebrospinal fluid (CSF) spaces in children with craniosynostosis. The aim of the present study was to investigate the role of the changes of the CSF spaces in the development of positional skull deformities in children. The authors reviewed demographic, clinical, and neuroimaging data of 23 patients assessed for some form of nonsynostotic skull deformity (group A). The results were compared with those of a simultaneous group of nine infants diagnosed with benign extracerebral collections of fluid (group B). The study group was composed of 11 boys and 12 girls, aged 3 years or younger. Seventeen children had plagiocephaly, four scaphocephaly, and two brachycephaly. Sixteen children (15 with plagiocephaly and 1 with brachycephaly) exhibited enlarged subarachnoid CSF spaces. In group B, the boy/girl ratio was of 7:2. Infants in group A presented at an older age (mean 12.7 months) than group B (mean age at presentation of 7.17 months). Children with benign extracerebral fluid collections were born with a head circumference (HC) greater than infants with positional skull deformities (p=0.005). The percentile of the children's HC at consultation was also larger for children of group B (p=0.03). The form of clinical presentation differed between the two groups. Most infants of group A were seen because of a type of head deformity, and children in group B were studied for macrocephaly. Long-term follow-up assessment showed better outcomes for patients in group B than for children of group A in regard to regression of initial symptoms (p=0.03). Most positional head deformities appear to be related with the children's positioning for sleeping. We have not confirmed macrocephaly as a contributing factor for positional deformities. The distribution of extracerebral CSF and the presence of abnormal collections of fluid in children with positional head deformities do not seem to be related with the findings of pericerebral CSF encountered in children with benign extracerebral collections of fluid. In our view, brain pulsations, transmitted to these accumulations of CSF, play an important part in the development of the infants' skull deformities (p=0.02). The findings of enlarged CSF spaces in children with nonsynostotic skull deformation constituted an age-related event, as these collections tended to disappear as the children grew older (p=0.04).

Chronic Subdural Hematoma in Children

Chronic subdural hematoma (CSH) is generally a disease affecting the elderly and infants. In infants, the process is particularly confusing and frequently misunderstood. In the pediatric population, CSH is just one of a group of sometimes related conditions known as extracerebral fluid collections. In the past, extracerebral fluid collections, in general, and CSHs, in particular, have been inaccurately or incompletely described. Modern neuroimaging techniques, however, have greatly advanced our understanding of these conditions. Surprisingly little literature exists on the subject, and publications before the advent of modern computed tomography and magnetic resonance imaging should be interpreted with caution.

Cerebellar haemorrhage after evacuation of an acute supratentorial subdural haematoma

Recent reports have highlighted the unusual complication of distant cerebellar haemorrhage after supratentorial craniotomy, with only 25 previous cases reported in the literature. Nearly all reported cases occurred after craniotomy for temporal lobectomy or for deep seated intracerebral pathology requiring brain retraction and removal of CSF at surgery. Only one previous case of a cerebellar haemorrhage after evacuation of an extracerebral fluid collection has been reported. We describe the case of a cerebellar haemorrhage complicating the evacuation of an acute/subacute supratentorial subdural haematoma in a 83-year-old woman. The literature is reviewed and possible mechanisms of haemorrhage discussed.

Extra-cerebral intracranial fluid collections in childhood: differentiation between benign subarachnoid space enlargement and subdural effusion using color-coded duplex ultrasound

Extracerebral fluid collections in infancy are a common diagnostic problem, because by noninvasive imaging studies (including cranial ultrasonography, CT and NMR), no definite differentiation between two distinct pathological conditions can be found until today: An enlargement of the subarachnoid spaces in children with macrocephaly is a frequent observation of mostly unknown etiology but is known to be associated with a good prognosis. If surgery is necessary in these patients, ventricular shunting is required. On the other hand subdural effusions are often of traumatic origin and require frequently neurosurgical intervention (subdural shunting). Most reports on extracerebral fluid collections in infancy have not differentiated between both pathological conditions and therefore reveal confusing results. Recent studies using magnetic resonance imaging have shown that vascular flow phenomena in the arachnoid space can be used to a reliable diagnosis, whereas previous noninvasive neuroimaging attempts including high resolution computerized tomography (CT) have been useless. We investigated a cohort of 20 patients aged 4 mths to 30 mths (mean 10.5 +/- 6.6 months) 16 with the history of macrocephaly and normal neurological development and 4 patients after head trauma and symptoms of an elevated intracranial pressure. In all 16 patients with the clinical diagnosis of benign subarachnoid space enlargement colour coded Doppler sonography detected archnoid vessels within the fluid collection, furthermore high resolution ultrasound demonstrated the dural border of of the arachnoidea as an echogenic membrane, an observation useful as a further sign of the subarachnoid location of the fluid collection. In the 4 patients with subdural hematoma the fluid collection showed an increased echogenity, no vascular structures and no surrounding border. Out of these observations we conclude that high resolution ultrasound and colour-Doppler sonography are able to reliably differentiate between a subdural and a subarachnoid fluid collection. An NMR investigation with its higher risks (sedation, anesthesia) focused on this target only seems therefore to be not necessary in these patients.

Extracerebral fluid collections in infancy: role of magnetic resonance imaging in differentiation between subdural effusion and subarachnoid space enlargement.

The pathological process of extracerebral fluid collections in infancy includes subdural effusion and enlargement of the subarachnoid spaces. Both conditions have traditionally been investigated as a single clinical entity, because of difficulty in differentiating between them. The prognosis of subdural effusion is not as benign as that of enlargement of subarachnoid spaces, requiring differential diagnosis between these disorders. The present study was conducted to elucidate whether this differentiation could be made on magnetic resonance (MR) images. The series consisted of 16 infants aged 10 months or younger, including eight with verified subdural effusion and eight in whom a diagnosis of enlargement of the subarachnoid spaces was achieved by neuroimaging studies other than MR imaging. In all eight patients with subdural effusion, the intensity of the fluid was greater than that of cerebrospinal fluid (CSF) in at least one of the sequences using T1-weighted, proton-density, and T2-weighted MR images. The flow-void sign, indicating vessels in the fluid spaces, was not seen in any of these eight patients. On the other hand, in all eight patients with enlargement of the subarachnoid spaces, the fluid was isointense in relation to CSF, and vascular flow-void areas were seen in at least one of the MR imaging sequences. Based on these observations, it is concluded that differentiation between subdural effusion and enlargement of the subarachnoid spaces can be established by focusing on two aspects of MR imaging findings: 1) the intensity of the fluid, which is either iso- or hyperintense relative to CSF, and 2) the presence or absence of vascular flow-void areas in the fluid spaces.

Early and delayed SPECT images of extracerebral fluid collection in infants using 123I-N-isopropyl-p-iodoamphetamine.

Cerebral blood flow in seven infants with extracerebral fluid collections was investigated using single photon emission computed tomography (SPECT) with 123I-N-isopropyl-p-iodoamphetamine. Early and delayed SPECT imaging was carried out. Areas of hypoperfusion were observed in five cases. The watershed zone of the major cerebral arteries or the territory of the anterior cerebral arteries were common areas of low perfusion. The hypoperfusion area was redistributed in two cases with intracranial hypertension. Subduroperitoneal shunts produced improvement of clinical symptoms in these cases. Hypoperfusion without redistribution was observed in three patients. In these areas, permanent tissue damage caused by a primary disease existed. Normal circulation patterns were observed in two patients. They showed normal development and follow-up CT revealed a decrease in the size of the extracerebral fluid collection. Measurement of regional cerebral blood flow may be helpful in considering surgical indications and in following up extracerebral fluid collection in infants.

Reduction Cranioplasty for Craniocerebral Disproportion in Infancy: Indications and Technique

Craniocerebral disproportion is a gross discrepancy between the volume of the brain and the volume of the cranial cavity that persists after initial treatment of the underlying condition, which in most cases is severe congenital hydrocephalus. The goals of treatment are control of intracranial pressure and arrest of the growth of the head. These goals can usually be accomplished by cerebrospinal fluid shunts supplemented as needed by shunting of extracerebral fluid collections. When conventional methods fail, or when in the setting of extreme degrees of craniocerebral disproportion they seem doomed to failure, reduction cranioplasty may simplify management. A surgical technique is described, three cases are presented, and indications are discussed.

Macrocephaly Is Not Always Due to Hydrocephalus

Macrocephaly is a clinical symptom with a heterogeneous cause. Besides enlarged ventricles (hydrocephalus) it can be caused by increased brain volume, expanded extracerebral spaces, intracranial cysts, and dilated vessels. Drawing on the experience of more than 8 years using transfontanellar sonography including Doppler techniques, some typical clinical and sonographic features of several forms of macrocephaly are addressed. Besides isolated familial or sporadic megalencephaly, extracerebral fluid collections are the main explanation of macrocephaly. Subdural effusions with compression of the brain by increased intracranial pressure should be differentiated from craniocerebral disproportion without increased intracranial pressure. Subependymal and subarachnoidal cysts may cause extraodinary displacements and compression of brain structures; nevertheless, the prognosis is rather optimistic, for the brain structure itself is generally not destroyed. In some infants with complex genetic, neurocutaneous, and neurometabolic syndromes, macrocephaly is an early clinical sign. The outcome in these infants is very different and dependent on the dysfunction of the brain by the specific disease (eg, storage of neurotoxic substances, dysplasia, gliosis, vascular disturbances, or brain tumors). In infants with vascular malformations the diagnosis can be established more exactly by using Doppler techniques. I recommend some practical diagnostic procedures in cases of macrocephaly. Nevertheless, in many patients with increased head size an exact statement about the further prognosis cannot be established by one examination; therefore, a developmental evaluation in combination with regular sonographic evaluation is the most valuable method in taking care of all infants with macrocephaly.