Subdural Collection Research Articles

Temporal development of subdural collections in infants with confessed abusive head trauma: a forensic neuroimaging study.

Estimating the age of injury in pediatric abusive head trauma (AHT) is a challenging task but potentially valuable for the identification of perpetrators. The aims of the study are (1) to describe the temporal development of different imaging features of subdural collections (SDCs), and (2) to provide novel age-diagnostic reference data for forensic-radiological expert reports. Using a multi-center approach and a 10-year study period, serial neuroimaging studies of 13 comprehensively investigated AHT cases (8 CT and 26 MRI scans) were analyzed regarding several subdural imaging parameters (SDC appearances, entities, components, and associated findings). Due to confessions by perpetrators, the time points of the trauma were presumed unique and known in all cases facilitating correlation of imaging findings with time. Hyperdense SDCs in CT were found up to 9 d post-injury (p.i.), CSF-like SDCs in CT or MRI as early as from the 3rd hour p.i., and subdural membrane formation as late as from day 283. The heterogeneous variant of the subdural hematohygroma was observed to be the dominant SDC entity between 3 h and 22 d p.i. The tadpole sign was detected in MRI between 3 h and 46 d p.i. Certain subdural imaging findings may be helpful for estimating the age of injury in AHT. Subdural membrane formation is demonstrated to be a late finding and the tadpole sign is an early phenomenon p.i. The data corroborated that the sediment but not the supernatant has the potential for being valuable for age-diagnostic aspects. Question Reliable evidence-based data on the development of SDCs is sparse but required for expert opinions on pediatric AHT. Findings Reference data on the evolution of the imaging appearance of SDCs and associated phenomena in confirmed cases of AHT are provided. Clinical relevance As there is a great need for estimating the age of injury in criminal and civil proceedings, many clinical radiologists are confronted with the diagnostic and forensic aspects of AHT that are addressed in the present study.

A Symptomatic Calcified Chronic Subdural Hematoma in an Elderly Patient: A Case Report

Calcified chronic subdural hematomas are rare forms of chronic subdural hematoma, accounting for 0.3-2.7%. Surgery is adequate for most chronic subdural hematomas, but its effectiveness is uncertain for calcified chronic subdural hematomas. In this case report, we illustrate a case of a 70-year-old male presenting with a motor function deficit in his left limbs over two months and neurological deterioration. A substantial calcified subdural collection was seen on computed tomography in the right parietal hemisphere. This was surgically removed with success and completeness. A chronic subdural hematoma has minimal possibility of becoming calcified. Because of the patient's condition's severity, surgery was the only remaining choice. J Shaheed Suhrawardy Med Coll 2023; 15(1): 83-86

Gluteric aciduria ( type-I) Presenting as Bilateral Subdural Hygroma- A Case Report with Literature Review

Glutaric aciduria type 1 (GA-1) is an autosomal recessive rare neurometabolic disorder caused by absent or deficient activity of glutaryl- CoA dehydrogenase. Patient with gluteric aciduria are more likely to develop collection in the subdural space secondary to cerebral atrophy and expansion of CSF spaces. A 1 year and 10 months toddler presented with increased head circumference since birth and generalized seizure for last few days. Neuroimaging showed bilateral subdural collection of CSF intensity. Bilateral subdural peritoneal shunt was inserted. With early diagnosis and adequate treatment , the majority of children with gluteric aciduria type-I are able to live normal. However treatment for gluteric aciduria type-I must be continued for life to avoid lifethreatening complications Bang. J Neurosurgery 2024; 13(2): 162-164

Subdural fluid accumulation with two meningiomas in a cat.

A case of two separate meningiomas with concurrent subdural fluid accumulation is presented. A 13-year-old, male neutered domestic shorthair cat presented with behavior change and progressive neurologic signs localizing to the forebrain. Two extra-axial masses were seen along with a large subdural fluid collection on advanced imaging of the brain. Histology of the lesions was consistent with multiple meningiomas, while analysis of the subdural fluid was consistent with cerebrospinal fluid. A case of multiple feline meningiomas with peritumoral subdural fluid accumulation has not previously been reported.

Optimal Timeline and Hematoma Size Parameters for Middle Meningeal Artery Embolization in Acute-On-Chronic Subdural Hematomas.

Chronic subdural hematomas (cSDH) are subdural collection of blood for which the current treatment option remains as surgical evacuation due to recurring focal inflammation and angiogenesis. An adjunctive therapeutic intervention is endovascular embolization of the middle meningeal artery (MMA) to cease the prolific cycle of angiogenesis. Few investigations have been made into the indications of this treatment modality regarding the intervention timeline and hematoma size for non-surgical candidates with acute-on-chronic subdural hematomas. We examined the clinical outcomes of 19 patients with 31 acute-on-chronic SDHs undergone MMA embolization and highlighted preliminary trends in radiological and morbidity outcomes. Primary outcomes identified a 57.6% success rate for MMA embolization of acute-on-chronic SDHs defined as significantly reduced hematoma size (i.e. >50%) without recurring bleeds, peri-procedural complications, post-procedural neurological deficits, and need for post-procedural surgical evacuation. Subgroup analysis demonstrated a success rate of 90.9% in patients undergone embolization after a minimum 3-week delay from initial CT head study compared to 33.3% with early intervention as well as a success rate of 75% in patients presenting with a large (i.e. >10mm) SDH compared to 30% for small SDH. Our preliminary data in this retrospective cohort study demonstrates significantly improved outcomes of MMA embolization in patients presenting with large (>10mm) acute-on-chronic SDHs and in patients undergone embolization after >3 weeks from initial CT head and symptomatic presentation.

Middle fossa arachnoid cyst fenestration for ruptured cysts associated with subdural collections: paediatric neurosurgery tertiary unit experience.

Arachnoid cysts are commonly encountered benign cystic structures and often come to attention as incidental findings following cranial imaging. Surgical intervention rates vary in different studies; however, rupture of cyst and subdural collection with mass effect are some of the indications for surgical intervention. In this study, we aimed to evaluate our operated cohort of middle fossa arachnoid cysts to determine the rate of traumatic subdural collection in this cohort and further assess outcomes. A retrospective review of all consecutive operated middle cranial fossa arachnoid cysts was carried out for the period 2010 to 2024. Demographics including age, sex, Galassi type, surgical technique for fenestration, preceding history of trauma, presence of papilloedema, and complications following surgery were extracted. Indication for surgery included papilloedema and headaches or increasing head circumference or rupture and subdural collections. Arachnoid cysts managed with CSF diversion as primary surgery were excluded. Over the study period, 21 fenestrations of the arachnoid cysts were carried out in 19 patients with mean age of 7years and M:F ratio of 2.2:1 (laterality: 9 right-sided and 10 left-sided). These included seven Galassi 2 and twelve Galassi 3 arachnoid cysts. At presentation, 10 had papilloedema, 5 with no papilloedema, and 4 with no available ophthalmological assessment. Fenestration of cyst included 12 microscopic, 6 endoscopic, and 3 combined approaches. Of the operated cohort, 8 were due to rupture of arachnoid cyst and subdural collections causing mass effect. Of 8 cases of ruptured arachnoid cyst with subdural collections, 75% had clear history of preceding head injury in the context of accidental or sports-related injuries. Two patients required redo-fenestration (10.5%), 1 patient required temporary lumbar drain (5.2%), and 2 patients required cysto-peritoneal shunts (10.5%). Rupture of arachnoid cysts and subdural collections although rare can be associated with head injury in majority of cases. All operated cases belonged to grade 2 and 3 Galassi.

The hidden threat: subdural empyema strikes a healthy teen

BackgroundThe incidence estimates for intracranial subdural empyema are 0.1 per 100,000 individuals, making it a rare clinical condition. It is a highly morbid and fatal illness that is most commonly the result of a primary infection somewhere else.Case presentationThe authors present a young male patient 15 years presented with 1 week history of headache, fever, confusion and seizure attack with initial negative CT head and nearly negative CSF analysis. With few days he developed left sided weakness. MRI brain showed right temporoparietal subdural fluid collection with midline shift. Urgent neurosurgical evacuation was made and revealed subdural empyema. The boy received combination therapy of vancomycin, ceftriaxone, and metronidazole. The culture of the pus was negative but 16S rRNA gene sequencing (bacterial) revealed streptococcus intermedius. He made a good recovery with no recollection or neurological deficit on follow up.ConclusionThis case highlights the possibility of occurrence of this rare infection in otherwise healthy individuals without obvious precipitating factor. It also indicates the superiority of MRI brain over CT head in detection of subdural collection. The rapid diagnosis and intervention improve the outcome of the patient.

Epidural Blood Patch in Subdural Hematoma Due to Spontaneous Intracranial Hypotention: A Case Report and Literature Review

Spontaneous intracranial hypotension (SIH) is an orthostatic headache syndrome with variable symptoms and complications which is often misdiagnosed at initial manifestations. SIH results from spontaneous CSF leakage leading to brain sag. The typical findings on cranial MR imaging consist of subdural fluid collections, enhancement of the pachymeninges, engorgement of venous structures, pituitary hyperemia, and sagging of the brain. Subdural hematoma may occur as a result of tearing of bridging veins and usually develop into chronic subdural hematoma. The majority of patients with SDH due to SIH have chronic DSH and, therefore, rarely present with neurological deficits. Evacuation of SDH may be performed for large SDH with ME (mass effects), or when dilated or asymmetric pupil is present. However in most cases, evacuation of the hematoma is not necessary and may result in worsened outcomes. The epidural blood patch (EBP) is a treatment of choice. Fortunately, most of these subdural hematomas can be handled with treatment directed at the underlying spinal CSF leak without the need for surgery. We report the case of 42-year-old man with the chief complaint of orthostatic headache. He was admitted to neurology ward and after imaging studies, it was found that he has bilateral subdural hematoma. Due to the lack of history of trauma, underlying disease, and coagulation disorder, and considering the imaging findings, the patient was referred to the pain department to perform an epidural blood patch. After performing the epidural blood patch, the patient's pain was relieved immediately, and during a three-month follow-up period, the epidural hematoma was completely absorbed. Spontaneous intracranial hypotension (SIH) is a highly misdiagnosed and underdiagnosed disorder and requires a high index of suspicion for diagnosis. During the last decades, a much larger number of spontaneous cases are identified. Literature is a bit confusing, with some authors recommending evacuation of subdural fluid in cases of deteriorating consciousness and few others recommending EBP first even in patients with comatose state but epidural patch is often an important part of treatment.

Acute-to-chronic subdural hematoma: radiographic and clinical progression from acute subdural hematoma

Introduction: The pathogenesis of chronic subdural hematoma (CSDH) has not been completely understood. However, different mechanisms can result in space-occupying subdural fluid collections, one pathway can be the transformation of an original trauma-induced acute subdural hematoma (ASDH) into a CSDH. Materials and Methods: All patients with unilateral CSDH, requiring burr hole trephination between 2018 and 2023 were included. The population was distributed into an acute-to-chronic group (group A, n = 41) and into a conventional group (group B, n = 282). Clinical and radiographic parameters were analyzed. In analysis A, changes of parameters after trauma within group A are compared. In analysis B, parameters between the two groups before surgery were correlated. Results: In group A, volume and midline shift increased significantly during the progression from acute-to-chronic (p < 0.001, resp.). Clinical performance (modified Rankin scale, Glasgow Coma Scale) dropped significantly (p = 0.035, p < 0.001, resp.). Median time between trauma with ASDH and surgery for CSDH was 12 days. Patients treated up to the 12th day presented with larger volume of ASDH (p = 0.012). Before burr hole trephination, patients in group A presented with disturbance of consciousness (DOC) more often (p = 0.002), however less commonly with a new motor deficit (p = 0.014). Despite similar midline shift between the groups (p = 0.8), the maximal hematoma width was greater in group B (p < 0.001). Conclusion: If ASDH transforms to CSDH, treatment may become mandatory early due to increase in volume and midline shift. Close monitoring of these patients is crucial since DOC and rapid deterioration is common in this type of SDH.

Chronic Pediatric Headache as a Manifestation of Shunt Over-Drainage and Slit Ventricle Syndrome in Patients Harboring a Cerebrospinal Fluid Diversion System: A Narrative Literature Review.

The main subject of the current review is a specific subtype of headache, which is related to shunt over-drainage and slit ventricle syndrome, in pediatric patients harboring an implanted shunt device for the management of hydrocephalus. This clinical entity, along with its impairment regarding the quality of life of the affected individuals, is generally underestimated. This is partly due to the absence of universally agreed-upon diagnostic criteria, as well as due to a misunderstanding of the interactions among the implicated pathophysiological mechanisms. A lot of attempts have been performed to propose an integrative model, aiming at the determination of all the offending mechanisms of the shunt over-drainage syndrome, as well as the determination of all the clinical characteristics and related symptomatology that accompany these secondary headaches. This subcategory of headache, named postural dependent headache, can be associated with nausea, vomiting, and/or radiological signs of slim ventricles and/or subdural collections. The ultimate goal of our review is to draw clinicians' attention, especially that of those that are managing pediatric patients with permanent, long-standing, ventriculoperitoneal, or, less commonly, ventriculoatrial shunts. We attempted to elucidate all clinical and neurological characteristics that are inherently related to this type of headache, as well as to highlight the current management options. This specific subgroup of patients may eventually suffer from severe, intractable headaches, which may negatively impair their quality of daily living. In the absence of any other clinical condition that could be incriminated as the cause of the headache, shunt over-drainage should not be overlooked. On the contrary, it should be seriously taken into consideration, and its management should be added to the therapeutic armamentarium of such cases, which are difficult to be handled.

Radiological insights into rheumatoid meningitis - a rare central nervous system manifestation of rheumatoid arthritis: a retrospective review of six cases.

The objective is to analyze and review the clinical, laboratory, and neuroimaging characteristics of rheumatoid meningitis (RM) in six patients with known rheumatoid arthritis (RA). We performed a retrospective review of patients diagnosed with RM from August 2012 to June 2023. To identify the cases, we used medical term search engines and the hospital´s radiology case database. Clinical information and laboratory findings were gathered from the medical records. A neuroradiologist with five years of experience reviewed and analyzed the RM to determine the characteristics findings of RM. Six patients with RM are included. Seizures along with headaches were among the clinical signs that were documented. All the patients had high levels of rheumatoid factor (RF) and anti-cyclic citrullinated peptides (ACPA) in the peripheral blood. Biopsy in two cases confirmed typical rheumatoid nodules. Leptomeningeal enhancement was found bilaterally in all cases and was predominantly found in the frontoparietal region. "Mismatch DWI/FLAIR" was found in five patients. Bilateral subdural collections could be found in two patients. Brain PET scan revealed increased metabolism in two cases. Rheumatoid meningitis is a rare complication of rheumatoid arthritis (RA) with challenging clinical diagnosis due to non-specific symptoms. This study highlights the importance of MR in detecting characteristic neuroimaging patterns, including "mismatch DWI/FLAIR", to aid in early diagnosis. Increased awareness of this condition may facilitate timely intervention and improve prognosis. These results still need to be verified by large studies.

Prospective measurement of the width of cerebrospinal fluid spaces by cranial ultrasound in neurologically healthy children aged 0–19 months

BackgroundUltrasound (US) is often the first method used to look for brain or cerebrospinal fluid (CSF) space pathologies. Knowledge of normal CSF width values is essential. Most of the available US normative values were established over 20 years ago, were obtained with older equipment, and cover only part of the age spectrum that can be examined by cranial US. This prospective study aimed to determine the normative values of the widths of the subarachnoid and internal CSF spaces (craniocortical, minimal and maximal interhemispheric, interventricular, and frontal horn) for high-resolution linear US probes in neurologically healthy infants and children aged 0–19 months and assess whether subdural fluid collections can be delineated.MethodsTwo radiologists measured the width of the CSF spaces with a conventional linear probe and an ultralight hockey-stick probe in neurologically healthy children not referred for cranial or spinal US.ResultsThis study included 359 neurologically healthy children (nboys = 178, 49.6%; ngirls = 181, 50.4%) with a median age of 46.0 days and a range of 1–599 days. We constructed prediction plots, including the 5th, 50th, and 95th percentiles, and an interactive spreadsheet to calculate normative values for individual patients. The measurements of the two probes and the left and right sides did not differ, eliminating the need for separate normative values. No subdural fluid collection was detected.ConclusionNormative values for the widths of the subarachnoid space and the internal CSF spaces are useful for evaluating intracranial pathology, especially when determining whether an increase in the subarachnoid space width is abnormal.

An Interdisciplinary Protocol for Ventriculoperitoneal Shunt Patient Selection in Normal Pressure Hydrocephalus

BackgroundNormal pressure hydrocephalus (NPH) can be treated with ventriculoperitoneal shunt (VPS) placement, but no broadly implemented indication for VPS exists. MethodsOur protocol consists of physical therapy and occupational therapy practitioners administering validated tests of gait, balance, and cognition before and after lumbar drain (LD) placement. Specific tests include: Timed “Up & Go”, Tinetti Gait and Balance Assessment, Berg Balance Scale, Mini Mental Status Exam, Trail Making Test Part B, and the Rey Auditory and Visual Learning Test. Minimal clinically important difference values for each test were determined from literature review. A retrospective review of patients treated under this protocol was performed. The primary outcomes were candidacy for VPS based on the protocol and patient-reported symptomatic improvement after VPS placement. Results48/75 (64%) patients received VPS. 43/48 (89.6%) of those shunted reported improved symptoms at 6 week follow up. However, 10/22 (45.5%) reported worsening symptoms at 1 year follow up. The mean Tinetti score significantly increased after LD in patients who improved with VPS compared to the no shunt group (4.27 vs -0.48, p<0.001). 6/33 (18%) patients with post-op imaging had a subdural fluid collection identified and 3/49 (6%) had other complications, including 1 seizure, 1 intracerebral hemorrhage, and 1 stroke. ConclusionsStandardized assessment of gait, balance, and cognition before and after temporary CSF diversion identifies patients with NPH likely to benefit from VPS placement with a low complication rate. One year after VPS, approximately half of patients had symptoms recur.

Spontaneous intracranial hypotension: Exploring the viability of non-contrast FLAIR as a substitute for contrast-enhanced T1WI in assessing pachymeningeal thickening.

To avoid contrast administration in spontaneous intracranial hypotension (SIH), some studies suggest accepting diffuse pachymeningeal hyperintensity (DPMH) on non-contrast fluid-attenuated inversion recovery (FLAIR) as an equivalent sign to diffuse pachymeningeal enhancement (DPME) on contrast-enhanced T1WI (T1ce), despite lacking thoroughperformance metrics. This study aimed to comprehensively explore its feasibility. In this single-center retrospective study, between April 2021 and November 2023, brain MRI examinations of 43 patients clinically diagnosed with SIH were assessed using 1.5 and 3.0 Tesla MRI scanners. Two radiologists independentlyassessed the presence or absence of DPMH on FLAIR and DPME on T1ce, with T1ce serving as a gold-standard for pachymeningeal thickening. The contribution of the subdural fluid collections to DPMH was investigated with quantitative measurements. Using Cohen's kappa statistics, interobserver agreement was assessed. In 39 out of 43 patients (90.7%), pachymeningeal thickening was observed on T1ce. FLAIR sequence produced an accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 72.1%, 71.8%, 75.0%, 96.6%, and 21.4% respectively, for determining pachymeningeal thickening. FLAIR identified pachymeningeal thickening in 28 cases; however, among these, 21 cases (75%) revealed that the pachymeningeal hyperintense signal was influenced by subdural fluid collections. False-negative rate for FLAIR was 28.2% (11/39). The lack of complete correlation between FLAIR and T1ce in identifying pachymeningeal thickening highlights the need for caution in removing contrast agent administration from the MRI protocol of SIH patients, as it reveals a major criterion (i.e., pachymeningeal enhancement) of Bern score.

Ventriculoperitoneal Shunt Placement Safety in Idiopathic Normal Pressure Hydrocephalus: Anticoagulated Versus Non–Anticoagulated Patients

Many patients with idiopathic normal pressure hydrocephalus (iNPH) have medical comorbidities requiring anticoagulation that could negatively impact outcomes. This study evaluated the safety of ventriculoperitoneal shunt (VPS) placement in iNPH patients on systemic anticoagulation versus those not on anticoagulation. Patients > 60 years of age with iNPH who underwent shunting between 2018 and 2022 were retrospectively reviewed. Baseline demographics, comorbidities (quantified by modified Frailty Index (mFI) and Charlson Comorbidity Index (CCI)), anticoagulant/antiplatelet agent use (other than aspirin), operative details, and complications were collected. Outcomes of interest were the occurrence of postoperative hemorrhage and overdrainage. A total of 234 patients were included in the study (mean age 75.22 ± 6.04 years; 66.7% male); 36 were on anticoagulation/antiplatelet therapy (excluding aspirin). This included 6 on Warfarin, 19 on direct Xa inhibitors, 10 on Clopidogrel, and one on both Clopidogrel and Warfarin. Notably, 70% of patients (164/234) used aspirin alone or combined with anticoagulation or clopidogrel. Baseline mFI was similar between groups, but those on anticoagulant/antiplatelet therapy had a higher mean CCI (2.67±1.87 vs. 1.75±1.84; p=0.001). Patients on anticoagulants were more likely to experience tract hemorrhage (11.1 vs. 2.5%; p=0.03), with no significant difference in the rates of intraventricular hemorrhage or overdrainage related subdural fluid collection. Anticoagulant and antiplatelet agents are common in the iNPH population, and patients on these agents experienced higher rates of tract hemorrhage following VPS placement; however, overall hemorrhagic complication rates were similar.

Incidence of surgically treated chronic subdural hematoma after head injury with normal initial computed tomography

PurposeThe objective was to determine the incidence of surgically treated chronic subdural hematoma (cSDH) within six months after head trauma in a consecutive series of head injury patients with a normal initial computed tomography (CT).MethodsA total of 1941 adult patients with head injuries who underwent head CT within 48 h after injury and were treated at the Tampere University Hospital’s emergency department were retrospectively evaluated from medical records (median age = 59 years, IQR = 39–79 years, males = 58%, patients using antithrombotic medication = 26%). Patients with no signs of acute traumatic intracranial pathology or any type of subdural collection on initial head CT were regarded as CT negative (n = 1573, 81%).ResultsTwo (n = 2) of the 1573 CT negative patients received surgical treatment for cSDH. Consequently, the incidence of surgically treated cSDH after a normal initial head CT during a six-month follow-up was 0.13%. Both patients sustained mild traumatic brain injuries initially. One of the two patients was on antithrombotic medication (warfarin) at the time of trauma, hence incidence of surgically treated cSDH among patients with antithrombotic medication in CT negative patients (n = 376, 23.9%) was 0.27%. Additionally, within CT negative patients, one subdural hygroma was operated shortly after trauma.ConclusionThe extremely low incidence of surgically treated cSDH after a normal initial head CT, even in patients on antithrombotic medication, supports the notion that routine follow-up imaging after an initial normal head CT is not indicated to exclude the development of cSDH. Additionally, our findings support the concept of cSDH not being a purely head trauma-related disease.

Infantile Acute Subdural Hematohygroma: A Clinical and Neuroimaging Analysis of 18 Cases

&amp;lt;i&amp;gt;Objective&amp;lt;/i&amp;gt;: Even after the advent of magnetic resonance imaging (MRI), few studies have focused on the clinical profiles and neuroimaging characteristics of acute subdural hematohygroma (ASDHy) in infants. The present study attempted to elucidate the pathogenesis of ASDHy by analyzing the clinical and neuroimaging findings of ASDHy. &amp;lt;i&amp;gt;Materials &amp; Methods&amp;lt;/i&amp;gt;: The subjects were 18 patients (eight males and ten females) younger than 2 years with ASDHy. Their median age at diagnosis was 3.8 months (range: 2-10 months), and 15 (83%) were younger than 4 months. Imaging studies found no evidence of any primary brain injury. &amp;lt;i&amp;gt;Results&amp;lt;/i&amp;gt;: Five patients experienced a fall, and 13 (72%) had no history of head trauma. The presenting symptoms and signs were the acute onset of generalized convulsive seizures and or repeated vomiting. Retinal hemorrhage occurred in 14 patients (78%). The imaging studies revealed a large amount of bilateral, subdural fluid collection with an intensity higher than that of cerebrospinal fluid on MRI. Benign enlargement of the subarachnoid space (BESS) was found in 14 patients (78%), an enlarged sylvian fissure (LSF) was found in all the patients (100%), and greater, left-sided enlargement was evident in 16 patients (89%). Two patients underwent subdural drainage, and 16 patients (89%) were conservatively managed. All the patients had a favorable outcome. &amp;lt;i&amp;gt;Conclusions&amp;lt;/i&amp;gt;: ASDHy is a self-limiting disorder associated with retinal hemorrhage and a benign clinical course. Most cases develop in early infancy. LSF presumably loosens the tight fixation of the temporal lobes at the middle cranial fossa, thereby increasing the rotational force of the brain even during mild or unnoticeable impacts. Increased cranio-cerebral disproportion, including BESS and LSF, is a structural vulnerability which can lead to ASDHy in early infancy.

17 years of experience with shunt systems in normal pressure hydrocephalus - From differential pressure to gravitational valves

ObjectiveComplication rate of shunting for normal pressure hydrocephalus (NPH) has significantly improved over the last decades. Especially the use of overdrainage protection has reduced the incidence of subdural hematoma and collections. However, gravitational valves were associated with other complications of shunt dysfunction. We present our 17 years of experience with patients with normal pressure hydrocephalus who changed from a differential pressure valve to a gravitational valve system. MethodsWe retrospectively identified all patients with the diagnosis of normal pressure hydrocephalus, in whom primary shunt implantation was performed between 2004 and 2020. Shunt implantation was performed as per our internal standard. Review of imaging, charts and patient reports was performed. ResultsIn total, 409 patients were included in the analysis. Mean age was 73.0 ± 7.1years. Between 2004 and 2010, predominantly Hakim valves (n = 100, 24.4%) were implanted, whilst from 2009 until 2020, proGAV valves (n = 296, 72.4%) were used. Mean follow-up was 8.9 ± 4.5 years. Initial subjective improvement of symptoms was reported in 69.9%, whilst this number decreased at the last follow-up to 29.8%. No significant differences were observed between the valves in the frequency of surgery for subdural hematoma. Shunt assistant implantation was performed in 17% of patients with Hakim valve, in 9.5% of patients with proGAV, a shunt assistant was added. Shunt obstruction was significantly higher in proGAV valves (p < 0.001). ConclusionsOur findings confirm the observation of frequent overdrainage in shunts without anti-siphon/gravitational component. Gravitational valves on the other hand may be associated with more obstruction.

Brain MRI features of postdural puncture headache

BackgroundPostdural puncture headache (PDPH) is a relatively common acute complication that occurs following regional anesthesia and is among the clinical features of secondary intracranial hypotension syndrome (IHS).The aim of this...

Management of Spontaneous Spinal CSF Leaks Using Noninvasive Dynamic MR Neurography: A Case Series

AbstractSpontaneous spinal cerebrospinal fluid (CSF) leak presents with orthostatic headache and may lead to formation of subdural collection. Invasive magnetic resonance imaging or computed tomography myelography is routinely used to detect these leaks. Noninvasive dynamic magnetic resonance neurography can also detect these leaks and confirm its resolution post treatment. It includes three-dimensional NerveView, a high-resolution short-tau inversion recovery sequence for better visualization of spinal nerves and leak sites. This article showcases the diagnostic and therapeutic journey of three patients with spontaneous spinal CSF leak all of whom were diagnosed with dynamic magnetic resonance neurography and treated successfully with autologous targeted epidural blood patch. In one case, epidural blood patch was repeated after 2 months for recurrence of the leak.