Subacute Hematoma Research Articles

Simultaneous Cranial and Spinal Subdural Hematoma-Case Report-

A 59-year-old male presented with spinal subdural hematoma (SDH) with concomitant cranial chronic SDH manifesting as mild paraparesis and numbness in both lower extremities. Magnetic resonance (MR) imaging showed simultaneous occurrence of cranial and spinal SDHs. The patient was treated conservatively because of poor medical condition and mild neurological symptoms, and recovered well within 1 month. Serial follow-up MR imaging revealed spontaneous resolution of both lesions, with signal intensity changes suggesting the degenerative process of subacute hematoma. The spinal hematoma may have migrated from the cranial lesion. Spinal SDH is a potential sequela of chronic SDH in the cranium.

Open aortic surgical repair for left hemi-arch stent-graft failure

A surgical technique of endovascular graft explant through an open aortic approach for left hemi-arch stent-graft failure is described. Between January and April 2003, we surgically treated 3 patients previously submitted for stent grafts for isthmic aortic diseases. Two patients had atherosclerotic aneurysm and 1 had a false lumen reperfusion of subacute intramural hematoma. At 6 to 8 months computed tomographic scan follow-ups on all patients showed a rapid enlargement of aortic diameters due to type I endoleaks. The presence of an uncovered proximal stent in the parasubclavian aorta did not allow a simple aortic cross clamping; therefore we performed an open aortic procedure through a left posterolateral thoracotomy, using femoro-femoral bypass and mild hypothermic circulatory arrest. Selective antegrade cerebral perfusion was started within 3 to 5 minutes from aortotomy and graft removal. Left hemi-arch and descending thoracic aortic replacement was then performed with continuous cerebral perfusion. No surgical mortality was observed. Postoperative course was uneventful for neurologic, cardiac, respiratory, and renal complications. The 3-month follow-ups were event free. This approach, associated with rapid stent-graft explant and selective cerebral antegrade perfusion, appears to be a safe and effective surgical strategy for treating this new aortic pathology.

Imaging features of unusual adrenal masses.

The widespread use of cross-sectional imaging techniques has resulted in increased detection of adrenal masses. The imaging characteristics of common adrenal masses such as adenoma, phaeochromocytoma and metastasis are well established. In this pictorial essay, the imaging features of unusual adrenal masses including cyst, lymphoma, adrenal carcinoma, myelolipoma, haemangioma, smooth muscle tumour, haematoma, and infection (acute tuberculous adrenitis and histoplasmosis) are presented. Computed tomography permits a diagnosis of cyst, acute or subacute haematoma and myelolipoma. Although the imaging features of other lesions are non-specific, imaging has an important role in the detection of these unusual adrenal masses, and in aiding their diagnosis and management.

Clozapine-Induced Neuroleptic Malignant Syndrome and Subdural Hematoma

Clozapine-Induced Neuroleptic Malignant Syndrome and Subdural Hematoma

Percutaneous drainage of spontaneous subcapsular haematoma of the spleen complicating chronic pancreatitis

Subcapsular haematoma of the spleen is a rare complication of chronic pancreatitis. In the literature only a handful of cases have been documented. The exact aetiology and natural history of this complication remains speculative and its management controversial. A case of spontaneous subacute haematoma of the spleen in a patient with chronic relapsing alcohol-related pancreatitis was reported. A percutaneous drainage was performed with good outcome. A review of the literature has demonstrated only one previous similar report.

A modified technique to treat chronic and subacute subdural hematoma: technical note

Background We present a patient on warfarin in whom a drainage port system was attached to the skull, successfully draining a subacute subdural hematoma. Case description An elderly male presented to our institution with right hemiparesis a week following a motor vehicle accident. He was on warfarin for recurrent pulmonary emboli and suffered from severe coronary artery disease. Physical examination demonstrated a grade 3/5 hemiparesis and a computerized tomography (CT) scan confirmed the diagnosis of subacute subdural hematoma. He underwent twist drill craniostomy and attachment of the subdural evacuating port system. Recovery in this patient was dramatic. Conclusion The subdural evacuating port system (SEPS) permits the neurosurgeon to drain subacute or chronic hematomas by a method that is minimally invasive, simple, and safe. The SEPS appears to promote brain expansion without the potential biohazards of other standard techniques.

Experimental acute intracerebral hemorrhage. Value of MR sequences for a safe diagnosis at 1.5 and 0.5 T.

To determine the detectability of intracerebral hematomas with MR imaging at 1.5 T and 0.5 T with fluid attenuated inversion recovery turbo spinecho (FLAIR) and gradient-echo sequences. Twenty-seven intracerebral hematomas were created in 25 piglets by injection of venous blood into the brain through a burr hole. All were imaged with T2*-weighted gradient echo sequences (fast field echo, FFE), T2-weighted fluid attenuated inversion recovery turbo spin-echo sequences (FLAIR), T2-weighted turbo spin-echo (TSE) and T1-weighted spinecho sequences. Follow-up was performed on the 2nd, 4th and 10th postoperative days. Ten animals were additionally investigated with similar sequences at 0.5 T. Histologic correlation was obtained in all cases. T2* FFE sequences detected all acute intracerebral hematomas and demonstrated the size correctly at 1.5 T and 0.5 T. The conspicuity was better at 1.5 T. FLAIR sequences were unreliable in the hyperacute phase at 1.5 T: However. subarachnoid and intraventricular extension was best appreciated with FLAIR images. T2 TSE images were incapable of detecting paraventricular and subarachnoid hemorrhages, but clearly demonstrated intracerebral blood in other locations. TI-weighted images were insensitive to hemorrhage in the acute state but very useful in subacute and chronic hematomas. The safe and reliable diagnosis of intracerebral hemorrhage is probably possible with MR imaging at 1.5 T and 0.5 T even of hematomas less than 90 min old, but requires the application of at least FLAIR, T2* FFE and T1 sequences and is therefore time consuming.

Spinal subdural and epidural haematomas: diagnostic and therapeutic aspects in acute and subacute cases.

The diagnosis of spontaneous spinal haematomas mainly depends on magnetic resonance imaging. This study evaluates the MRI characteristics of spinal epidural and subdural haematomas. The results were correlated with medical history, coagulation abnormalities and therapeutic outcome to provide guidelines for early diagnosis and treatment of spinal epidural and subdural hematomas. Imaging signs of epidural and subdural haematomas have been reported before, however without special attention to the differential-diagnostic and therapeutic implications of haematoma localisation. Seven patients (3 women, 4 men, age range 55-86 years) with acute progressive neurological deficits and without a history of severe trauma were studied. In all cases neurological examinations were performed after admission followed by MRI studies with T2 and T1 weighted images, before and after administration of contrast agent. Spinal angiography was performed twice to exclude a vascular malformation. All patients underwent open surgery. Acute and subacute hematomas were detected once in the cervical spine, in five cases in the thoracic region and once in the lumbar region. The hematomas had an epidural location in three cases and a subdural in four. In the thoracic region subdural haemorrhage was much more common than epidural hematomas. Subdural blood collections were mainly found ventral to the spinal cord. Epidural haemorrhage was always located dorsal to the spinal cord. The evaluation of the haematoma localisation may be difficult occasionally, but delineation of the dura is frequently possible in good quality MRI. The clue to the diagnosis of ventrally located subdural haemorrhage is the absence of the "curtain sign", which is typical for epidural tumours. Spontaneous spinal hematomas are frequently located in the thoracic spine. Subdural spinal haemorrhage is more frequent than epidural. Epidural haemorrhage is frequently located dorsal to the spinal cord because of the tight fixation of the dura to the vertebral bodies.

MRI findings in 32 consecutive lipomas using conventional and advanced sequences.

Intracranial lipomas are histologically benign and usually incidental magnetic resonance imaging findings that must be differentiated from ominous lesions. The authors describe 32 lipomas in 30 patients using conventional spin-echo (CSE) T1-weighted images (T1WI), CSE proton density (PDWI), CSE T2-weighted images (T2WI), fast spin-echo (FSE) T2WI, and FSE fluid-attenuated inversion recovery (FLAIR). Lipomas occurred most commonly in the trigonal choroid plexus, cerebral convexity, pericallosal, and quadrigeminal cistern regions. Lipomas were hyperintense on CSE T1WI and of variable appearance on CSE PDWI and CSE T2WI. Lipomas were isointense to hyperintense on FSE T2WI and hyperintense on FLAIR. Chemical shift artifact (CSA) usually was present on either CSE PDWI or CSE T2WI but was not seen on FSE images. One patient had intracranial hypotension associated with a large convexity lipoma. The authors conclude that lipomas appear different on CSE T2WI than on FSE T2WI. CSE PDWI and CSE T2WI are complementary in detecting CSA. The lack of CSA being detected in lipomas on FSE images most likely relates to inherent bandwidth differences compared with those of CSE. The hyperintense appearance of lipomas on FSE FLAIR and FSE T2WI may be confused with subacute hematomas. The authors recommend that if CSE technique by itself is used to exclude lipomas (in centers that are not using FSE), then T1WI, PDWI, and T2WI usually are sufficient. For centers using FSE routinely, fat saturation or CSE sequences also may be needed to exclude lipomas. Finally, the authors' series suggests that intracranial lipomas may occur in lateral locations more frequently than reported previously.

Sural nerve entrapment after injury to the gastrocnemius: A case report

A 43-year-old man developed progressive calf pain and paresthesias after a strain of the right gastrocnemius muscle. Physical examination revealed sensory loss in the distribution of the sural nerve with a positive Tinel's sign in the posterior calf in the region of his previous injury. Electrodiagnostic studies revealed prolongation of the sural distal latency with reduction of the sensory nerve action potential amplitude. Magnetic resonance imaging of the lower right leg demonstrated abnormal signal in the right medial gastrocnemius consistent with a subacute hematoma. Surgical exploration revealed entrapment of the sural nerve in scar tissue beneath the deep fascia of the gastrocnemius. Surgical release of the nerve resulted in complete resolution of symptoms and full return of sensation by the 3-month follow-up point. A brief review of the literature is presented.

Dynamic T1-weighted spin-echo MR imaging: the role of digital subtraction in the demonstration of enhancing brain lesions.

We compared subtracted and non-subtracted images obtained from a contrast-enhanced dynamic T1-weighted spin echo (SE) magnetic resonance (MR) technique for the demonstration of enhancing brain lesions with and without associated hemorrhage. Thirty-four patients with enhancing brain lesions or subacute parenchymal hematomas were imaged using a contrast-enhanced dynamic T1-weighted SE MR technique modified by a keyhole scheme. On-line digital subtraction was performed. Non-subtracted and subtracted dynamic scans were compared for conspicuity and contrast-to-noise ratios (CNRs) of enhancing brain lesions. The presence and pattern of enhancement in the subacute parenchymal hematomas were evaluated on the subtracted images. In all, 47 enhancing brain lesions were detected on both the non-subtracted and the subtracted images. The enhancing brain lesions were more conspicuous on the subtracted images (P < 0.05). There was an increase in CNRs of the enhancing lesions on the subtracted images compared with the non-subtracted ones (P < 0.001). Seventeen subacute parenchymal hematomas were detected on the non-subtracted images. The subtracted images demonstrated enhancement in 15 hematomas (8 rim enhancement only/7 both nodular and rim enhancement). Digital subtraction in contrast-enhanced dynamic T1-weighted SE MR imaging is helpful in demonstrating enhancing brain lesions with and without associated hemorrhage.

MRI appearance of the pelvis in the post cesarean-section patient

Fever in the post-cesarean section patient may indicate the presence of a potentially life-threatening complication, including abscess, ovarian vein thrombosis, and uterine dehiscence. Imaging findings are often utilized to ascertain the presence or absence of such complications. Familiarity with the normal findings in the post-operative period is essential in making this determination. The purpose of this investigation is to describe the MRI appearance of the post-cesarean section pelvis. Over a 67-month period, 50 patients with persistent low-grade fevers following c-section were referred for MR imaging. Imaging was performed 3–10 days post-operatively. Axial T 1-weighted and T 2-weighted images were acquired in addition to sagittal T 2-weighted images. Coronal images were obtained in some cases. Clinical correlation was obtained through the patients charts, confirming discharge of the patients in stable condition. The uterine incision site usually demonstrated findings consistent with subacute hematoma. The anterior uterine myometrium demonstrated enlargement relative to the posterior uterine wall. Bladder flap hematomas were seen in 64% of cases. Three cases (6%) demonstrated parametrial edema and none of these patients demonstrated ovarian vein thrombosis. Two cases of pelvic hematoma were noted. The normal post-c-section incision site may demonstrate increased or decreased signal intensity on T 2-weighted images and intact endometrial and serosal layers mitigate against the diagnosis of incisional dehiscence. Bladder flap hematomas occurred in slightly more than half the cases. Parametrial edema and pelvic hematoma can be seen as post-surgical changes.

術前診断が困難であった腰椎脊柱管内血腫の１例

A case of lumbar epidural hematoma is reported. The patient was a fifty-seven years old woman. Her complaint started with lumbago. After three weeks from the onset, thigh pain and numbness appeared.An epidural mass was detected at L4/5 by MR imaging, myelogram and CTM. In MRI imaging, the mass showed low intensity in T1, high intensity in T2 and ringed enhancement effect with Gadolinium.The mass was considered as a synovial cyst or a ganglion by MRI, but histological diagnosis was organizing hematoma.The mass was a subacute hematoma. The intensity of hematoma in MRI is said to be changing with time, thus it is difficult to diagnose epidural hematoma.

Spectrum of CT findings in nonmalignant disease of the adrenal gland.

Computed tomography (CT) plays a leading role in the evaluation of nonmalignant disease of the adrenal gland. CT is highly accurate in the localization of adrenal masses in patients with diseases associated with hyperfunctioning adrenal glands such as Cushing syndrome and Cushing disease, Conn syndrome, adrenal tumors leading to virilization or feminization, and pheochromocytomas. CT permits a specific diagnosis of acute or subacute adrenal hematoma and myelolipoma. Hematomas are round to oval and have increased attenuation (50-90 HU) that decreases on follow-up CT scans. Myelolipomas typically manifest as a well-defined suprarenal mass with an attenuation of-30 to -115 HU. Adrenal cysts are usually round to oval and manifest as a hypoattenuating mass with a smooth, thin wall. CT is useful in the evaluation of patients with Addison disease, particularly the subacute form secondary to tuberculosis or disseminated histoplasmosis. Findings typically include bilateral adrenal enlargement with a central necrotic area of hypoattenuation and peripheral enhancement. Thin-section unenhanced CT permits accurate measurement of attenuation and can be used to differentiate adrenal adenoma from metastasis in a cancer patient with an indeterminate mass: Attenuation of 10 HU or less usually indicates adenoma rather than cancer. If the mass is found incidentally at contrast material-enhanced CT, delayed scans obtained as early as 5-15 minutes after intravenous administration of contrast material appear to have comparable accuracy.

Cerebral venous angiomas associated with hemorrhagic lesions their MRI manifestations

Using two 1.5-T magnetic resonance (MR) scanners, 82 venous angiomas (VAs) were imaged. There were 13 (16%) VAs associated with hemorrhagic lesions. Ten of the 13 hemorrhagic lesions were considered hematomas in the subacute or chronic stage, caused by VAs or coexisting cavernous hemangiomas. Two of the 13 were subacute intracerebral hematomas; the remaining one was a sequela of a hemorrhagic venous infarct. After analysis of our data, it was concluded that infratentorial VAs and deeply draining supratentorial VAs in relatively young adults, especially females, are relatively frequently associated with intracerebral hemorrhagic lesions. MR imaging proved useful for diagnosing VAs and associated hemorrhagic lesions.

Epidural Hematoma After Epidural Anesthesia in a Patient with Hepatic Cirrhosis

Epidural Hematoma After Epidural Anesthesia in a Patient with Hepatic Cirrhosis

Noninvasive Investigation of Pericarotid Syndrome: Role of MR Angiography in the Diagnosis of Internal Carotid Dissection

A 52-year-old man presented with unilateral left periorbital and frontotemporal pain associated with a partial ipsilateral Horner's syndrome of the postganglionic type and representing a pericarotid syndrome. MRI demonstrated a perivascular subacute hematoma at the level of the cervical portion of the left internal carotid artery with a markedly reduced flow-void signal. MR angiography confirmed the narrowed lumen of the dissected cervical internal carotid artery. There was also a right-sided precavernous carotid aneurysm. Three months later the left-sided pain had subsided, with complete resolution of the hematoma and incomplete restoration of the left carotid lumen seen on MR angiography. Dissection of the carotid wall may cause the oculosympathetic paralysis by producing a lesion of the superior cervical ganglion, the internal carotid nerve, or the perivascular sympathetic plexus. Whereas in pericarotid syndrome the most common cause is cervical carotid dissection, Raeder's syndrome additionally involving parasellar cranial nerves, may be caused by any paracavernous/cavernous lesion, including neoplasms and intracranial carotid aneurysms. The clinical distinction is useful to determine the appropriate diagnostic investigation, in view of the different pathoanatomical localization and different disease spectrum. As demonstrated in the present case, the combination of MRI and MR angiography is a reliable noninvasive tool to investigate the differential diagnosis of pericarotid syndrome, accurately depicting occlusive, stenotic or aneurysmal lesions of the carotid artery. We suggest that intraarterial angiography is no longer necessary.

破裂および未破裂脳動脈瘤のMRA診断

Most previous reports have explored the efficacy of magnetic resonance angiography (MRA) as a noninvasive screening method for the detection of unruptured intracranial aneurysms and occlusive vascular disease. The purpose of this study was to assess the accuracy of three-dimensional (3D) time-of-flight (TOF) MRA in the identification of ruptured aneurysms presenting subarachnoid hemorrhage (SAH) as well as unruptured aneurysms. Sixty-two consecutive patients with 36 ruptured and 32 unruptured aneurysms were examined. MR angiograms and conventional contrast angiograms were retrospectively reviewed with regard to the relation between the detectability on MRA and size of aneurysm, location, and influence of subarachnoid hematoma. The size of ruptured aneurysms was significantly larger than that of unruptured aneurysms. Twenty-seven of 29 ruptured aneurysms in acute stage (93%) was detected on MRA, whereas 29 of 36 unruptured aneurysms (81%) and none of 4 ruptured aneurysms in subacute stage (0%) were detectable. Individual vessel visualization and image quality of MRA in patients with acute SAH were satisfactory, although in patients with subacute SAH, MRA showed poor visualization of vessels due to T1-shortening of subacute surrounding hematoma and presence of delayed vasospasm. Main causes of failure to detect aneurysms on MRA included limitation of spatial resolution, limited projections obtainable with maximum-intensity-projection (MIP) techniques and subacute hematoma simulating flow signal on MIP reconstructions. Improvement of present limitation of MRA requires higher spatial resolution, higher contrast resolution and a more adequate reconstruction method. MRA was considered to be a safe and useful examination for intracranial aneurysms especially in patients with acute SAH.

The pelvis after cesarean section and vaginal delivery: normal MR findings.

In postpartum women, pain and fever can indicate serious complications, such as phlegmon or abscess of the parametrium or bladder flap, ovarian vein thrombosis, or uterine dehiscence. The purpose of this study was to ascertain the MR appearance of the normal pelvis after uncomplicated cesarean section and vaginal delivery. Twenty-two patients (14 who had cesarean sections and eight who had vaginal deliveries) were imaged with a superconducting 0.35-T MR system 1-5 days after delivery. Sagittal and axial T1-weighted, proton density-weighted, and T2-weighted spin-echo images were acquired. Phase reconstruction of the axial T1-weighted sagittal images was performed to confirm flow in the ovarian veins. The ovarian veins, parametrium, bladder flap, endometrium, and uterine incision were analyzed on all images. The uterine incision was well seen in all 14 patients who had cesarean section. The signal characteristics of the incision suggested subacute hematoma within the myometrium, and no myometrial defects were seen. In all 13 patients with a low transverse incision, a hematoma of the bladder flap was seen. Patency was confirmed in the majority of ovarian veins (39/44). No evidence of parametrial edema or mass, which can be seen in abscess or phlegmon, was found in any of the 22 patients. The ovarian perivenous fat did not show edema, which can indicate acute ovarian vein thrombosis. Increased signal in the endometrial cavity was seen in all patients; the signal characteristics were similar to those of subacute hematoma, consistent with clinical findings. Normal findings of the postpartum pelvis on MR imaging are subacute hematoma in the uterine incision, bladder flap, and endometrial cavity. Patent ovarian veins are demonstrated in most (89%) cases.

Multivariate analysis of magnetic resonance imaging of focal hepatic lesions.

A total of 124 lesions from 1 to 6cm in diameter, including 31 cavernous hemangiomas, 32 metastases and 61 hepatocellular carcinomas (HCC) were analyzed to study the usefulness of magnetic resonance imaging (MRI) at 0.5 Tesla to differentiate focal hepatic lesions on the basis of qualitative criteria. Each focal hepatic lesion was assessed for shape, internal architecture and signal intensity relative to normal liver parenchyma. While all cavernous hemangiomas and metastases except one lesion could be detected, detection rate of HCC was significantly inferior to that of the other two diseases. A tumor capsule and a hyperintense focus on T1-weighted images were demonstrated in only HCC lesions in strong contrast with the other two diseases; however, metastases with slow-growing characteristics or subacute hematoma may appear as similar images. Cavernous hemangiomas appeared markedly hyperintense on T2-weighted images in 23 of 31 lesions, but one metastasis and one HCC had similar images. A multivariate analysis of several MRI resulted in the following mean discriminant scores: cavernous hemangioma, -1.2652; metastasis, 0.1830; and HCC, 0.7138. It appeared to be possible to differentiate the three diseases with 84.4 percent accuracy.