Subdural Hematoma Research Articles

A Case of Growing Chronic Subdural Hematoma with Niveau Formation Showing an Enhanced Subdural Hyperintense Band on Magnetic Resonance Diffusion-weighted Imaging Over Time.

This case report describes an 84-year-old female patient with a growing chronic subdural hematoma (CSDH) that showed an enhanced subdural hyperintense band (SHB) on magnetic resonance (MR) diffusion-weighted imaging over time, indicating that it reflects fresh bleeding from the outer membrane covering the hematoma. The presence of SHB on MR diffusion-weighted imaging of CSDH, possibly reflecting hemorrhagic diathesis of the outer membrane, might be a predictor of enlargement of CSDH.

Letter: Safety and Effectiveness of an Enhanced Recovery Protocol in Patients Undergoing Burr Hole Evacuation for Chronic Subdural Hematoma.

Letter: Safety and Effectiveness of an Enhanced Recovery Protocol in Patients Undergoing Burr Hole Evacuation for Chronic Subdural Hematoma.

The impact of renin-angiotensin-aldosterone system inhibitors on the recurrence of chronic subdural hematoma: a systematic review and meta-analysis.

This meta-analysis seeks to investigate the effects of renin-angiotensin-aldosterone system (RAAS) inhibitors on the recurrence of chronic subdural hematoma (cSDH). Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, this study conducted a comprehensive online search across various databases, including PubMed, EMBASE, CINAHL, Web of Science, and Cochrane, without time restrictions. Two reviewers independently screened titles, abstracts, and full texts based on predetermined criteria, resolving any discrepancies through discussion or consultation with a third reviewer. The quality and risk of bias of the included studies were assessed using the Methodological Index for Non-Randomized Studies (MINORS) and Cochrane's tool for evaluating risk of bias in randomized controlled trials. Six studies aligned with the study objectives were included after a systematic search across 6 databases. The RAAS inhibitors group comprised 404 participants, while the control or placebo group included 1828 participants. Analysis for publication bias using the Egger test indicated no bias in the studies (P = 0.151). The odds ratio for cSDH recurrence with RAAS inhibitor use compared to non-use was reported as OR = 1.06; confidence interval 0.6-1.893, p-value = 0.818, showing no significant association between RAAS inhibitor use and cSDH recurrence. The results suggest no significant link between RAAS inhibitor use and cSDH recurrence. However, due to the limited number and design of studies, as well as the lack of clinical trials, further research is needed to determine the effectiveness of this treatment.

In Reply: Safety and Effectiveness of an Enhanced Recovery Protocol in Patients Undergoing Burr-Hole Evacuation for Chronic Subdural Hematoma.

In Reply: Safety and Effectiveness of an Enhanced Recovery Protocol in Patients Undergoing Burr-Hole Evacuation for Chronic Subdural Hematoma.

Factors Influencing Surgical Outcome of Patients with Traumatic Acute Subdural Hematoma

Background: Traumatic acute subdural hematoma (ASDH) is a catastrophic devastating component of brain injury in neurosurgical arena. Due to its significant mortality rate, potential for functional disability and disastrous consequence of complications, it is considered as a challenge for neurosurgeons worldwide. Consequently, precise recognition of predictive outcome factors is crucial for appropriate neurosurgical management and prognostication for patients with traumatic ASDH. Aims: The study aimed to determine the demographic, clinical, radiological and therapeutic factors associated with the surgical outcomes in patients with traumatic acute subdural hematoma (ASDH) who managed surgically in the Neurosurgery Department at a tertiary level hospital in Bangladesh. Materials and Methods: This prospective observational study included 40 radiologically diagnosed cases of traumatic ASDH age more than 18 years who were admitted and operated in the Department of Neurosurgery of Chittagong Medical College Hospital from May 2022 to April 2023. Data regarding demographic, clinical, radiographic, surgical procedure and findings were recorded. Three months mortality rate with clinical outcome was assessed by Glasgow Outcome Scale (GOS) score and analyzed. The outcome was divided into favorable outcomes (GOS score >3) and unfavorable outcomes (GOS score d”3). Results: The median age of the patients was 45 years (range: 19-82 years), and there was a male predominance (82.5%) with a male to female ratio of 4.7:1. Road traffic accident (RTA) was the most common cause of trauma (65%), followed by fall from height (15%), and physical assault (12.5%). Craniotomy was done in 16 (40%) patients and other 24 (60%) patients had decompressive craniectomy. Overall, 21 (52.5%) patients had good outcome and other 19 (47.5%) had poor outcome, and three months mortality rate was 42.5%. Regression analysis revealed that, increasing age [Odds ratio (OR): 1.12, 95% Confidence interval CI: 1.02-1.22. p=0.014], preoperative GCS of d”8 (OR: 13.98, 95% CI:1.22-160.00, p=0.034), and presence of Anisocoria with non-reacting pupil (OR; 17.99, 95% CI: 1.32-244.08, p=0.030) were independently associated with poor outcome. Conclusions: This study identified higher age, preoperative low GCS score and pupillary abnormality as the independent predictors for 3-months poor outcome in patients who underwent surgical treatment for traumatic ASDH Bang. J Neurosurgery 2024; 13(2): 140-148

Prognostic Factors of Outcome in Patients Undergoing Surgical Intervention following Traumatic Intracerebral Haemorrhage

Background: Intracerebral hemorrhage is a common complication after traumatic brain injury. While it is accepted practice to remove extra-axial (extradural and subdural) haematoma following traumatic brain injury, but surgical practice in the treatment of traumatic intracerebral hemorrhage (TICH) differs widely, and prognostic factors associated with outcome following surgery have not yet been well established. Aims: The study aimed to determine the prognostic factors of outcome in patients undergoing surgical intervention following traumatic intracerebral hemorrhage in a tertiary care hospital in southeastern part of Bangladesh. Materials and Methods: This prospective interventional study included 45 patients requiring craniotomies for decompression and evacuation of an intracranial hemorrhage following traumatic intracerebral hemorrhage in the Neurosurgery Department of Chittagong Medical College Hospital between December 2021 to June 2023. Demographic features, perioperative clinical and radiological characteristics of these patients were examined in relation to favorable/good outcome, defined as Glasgow Outcome Scale (GOS) score >3 at 3months follow-up, and unfavorable/poor outcome, defined as 3months mortality or GOS score d”3 at 3months after surgery. Results: The median age was 45 (range 8-75) years, 82.2% were male, and road traffic accident was the commonest cause (73.3%). Initial loss of consciousness was found in 75.7% of patients and the median GCS on admission was 9 (Interquartile range 8-10). Craniotomy and evacuation was done in 23(51.1%) of the cases, followed by craniectomy and evacuation in 22 (48.9%)patients. In-hospital and 3 months mortality rate was 28.9%. At three months post surgery, all of the survived patients(32) had good outcomes; 29 (92.3%) had GOS scores of 5, while the remaining 3 had GOS scores of 4. In bivariate analysis, age, history of comorbidity and loss of consciousness, GCS on admission, hematoma volume, and injury to surgery interval was found to have significant association with poor outcome (p<0.05). Age (OR: 1.211, 95% CI: 1.012-1.241, p=0.009) and GCS score on admission (OR: 0.301, 95% CI: 0.086-0.827, p=0.004) were independent predictors of 3-months poor outcome or mortality in multivariate logistic regression analysis. Conclusions: This study presented that older age(60 years) and lower GCS(7-10) on admission were the independent predictors of poor outcome after 3 months of surgery. Multicenter studies are needed to provide accurate data on traumatic intracerebral hemorrhage in Bangladesh. Bang. J Neurosurgery 2024; 13(2): 104-111

Night-time versus daytime surgical outcomes in chronic subdural hematomas: a post hoc analysis of the FINISH randomized trial

ObjectiveThe optimal timing of surgical intervention for chronic subdural hematomas (CSDH), specifically night-time versus daytime, remains a subject of debate, with concerns about the potential impact of circadian timing on surgical outcomes. This study evaluated the association between the timing of burr-hole drainage for CSDH and postoperative outcomes, comparing night-time and daytime surgeries.MethodsIn a post-hoc analysis of the FINISH trial, we included adult patients with symptomatic unilateral or bilateral CSDH who underwent burr-hole drainage between January 2020 and August 2022. Night-time surgery was defined as procedures starting between 23:00 and 06:00, with daytime surgeries occurring between 06:01 and 22:59. The primary outcome was functional outcome at six months post-surgery, assessed using the modified Rankin Scale (mRS), with favorable outcomes defined as an mRS of 0–3. Secondary outcomes included mortality, reoperation rates, and adverse events within six months.ResultsOur analysis of 589 patients (83% daytime surgery, 17% night-time surgery) revealed no significant differences in baseline characteristics. The unadjusted analysis suggested a higher rate of favorable functional outcomes in the night-time surgery group than in the daytime group (94% vs. 86%, p = 0.037). Mortality, adverse events, and reoperation rates were similar in the groups. Adjusted logistic regression analyses, accounting for potential confounders, indicated that night-time surgery was not associated with a higher risk of unfavorable functional outcomes compared to daytime surgery.ConclusionsOur findings suggest that night-time surgery versus daytime surgery is not associated with worse postoperative outcomes. These findings challenges the traditional preference for daytime CSDH surgery and emphasizes the potential for flexibility in surgical scheduling to optimize patient care in CSDH management.

Diagnosis of Menopause in a Captive Sumatran Orangutan (Pongo abelii).

Humans were long thought to be the only mammal to experience menopause, the permanent cessation of reproduction followed by a long post-reproductive lifespan. More recently, evidence has been found for the existence of menopause in other long-lived mammals, including chimpanzees and gorillas. However, orangutans, which have the longest interbirth interval of any primate, have rarely been studied in this period of their lives. In this paper, we describe clinical, ultrasound, endocrine, and histological evidence consistent with a natural menopause in a captive, previously fertile, Sumatran orangutan (Pongo abelii), aged approximately 50. Consecutive serum samples showed low levels of estradiol and high levels of follicle-stimulating hormone. Transvaginal ultrasound revealed an atrophic uterus with an antero-posterior diameter of 2.36 cm, an endometrial thickness of 2 mm, and inactive ovaries. Following this female's death from a subdural hematoma, histological examination of the ovaries showed a dense stroma with corpora albicantia, in comparison to the numerous primordial follicles seen in the ovaries of a stillborn infant female orangutan. These multiple lines of evidence suggest that Sumatran orangutans can now be added to the list of mammals which undergo a true menopause, which may ensure that females' final offspring can be reared to independence.

Prognostic factors of chronic subdural hematomas in two reference university teaching hospitals in the city of Yaounde

ObjectivesDespite the good prognosis of surgical treatment of chronic subdural hematomas, there are some early deaths, recurrences and post-operative complications. The objective of this study is to analyze the prognostic factors of chronic subdural hematomas in two reference university teaching hospitals in the city of Yaounde. MethodThree hundred and ten cases of chronic subdural hematomas were diagnosed on 3788 patients hospitalized in the neurosurgery departments of two reference university teaching hospitals in the city of Yaounde from January 1st, 2015 to December 31st, 2021 (7 years). The authors collected data from patients in whom surgical treatment was performed and assessed their prognosis with regard to the rate of early and late recurrence, mortality rate and postoperative complications and associated factors. ResultsData from 284 patients were analyzed. The mortality rate was 6.7 % and the recurrence rate was 3.2 % in early postoperative period and 4.5 % after a follow-up of 3–24 months. Prognostic factors for death were age greater than or equal to 80 years (p value = 0.034) and presence of cortico-subcortical atrophy (p value = 0.003). The main recurrence factors were age greater than or equal to 70 years and compartmentalization of the hematoma. ConclusionChronic subdural hematomas are generally of good prognosis when the Glasgow coma score on admission is good and adequate management is carried out as soon as possible. Advanced age, lesions such as cortico-subcortical atrophy and compartmentalization of the hematoma are all factors that predispose to recurrence or early mortality. Those groups of patients should therefore benefit from a closer follow-up in post-operative period.

Subdural Hematoma Following Spinal Anesthesia.

Subdural Hematoma Following Spinal Anesthesia.

Spatial attention-based CSR-Unet framework for subdural and epidural hemorrhage segmentation and classification using CT images

BackgroundAutomatic diagnosis and brain hemorrhage segmentation in Computed Tomography (CT) may be helpful in assisting the neurosurgeon in developing treatment plans that improve the patient’s chances of survival. Because medical segmentation of images is important and performing operations manually is challenging, many automated algorithms have been developed for this purpose, primarily focusing on certain image modalities. Whenever a blood vessel bursts, a dangerous medical condition known as intracranial hemorrhage (ICH) occurs. For best results, quick action is required. That being said, identifying subdural (SDH) and epidural haemorrhages (EDH) is a difficult task in this field and calls for a new, more precise detection method.MethodsThis work uses a head CT scan to detect cerebral bleeding and distinguish between two types of dural hemorrhages using deep learning techniques. This paper proposes a rich segmentation approach to segment both SDH and EDH by enhancing segmentation efficiency with a better feature extraction procedure. This method incorporates Spatial attention- based CSR (convolution-SE-residual) Unet, for rich segmentation and precise feature extraction.ResultsAccording to the study’s findings, the CSR based Spatial network performs better than the other models, exhibiting impressive metrics for all assessed parameters with a mean dice coefficient of 0.970 and mean IoU of 0.718, while EDH and SDH dice scores are 0.983 and 0.969 respectively.ConclusionsThe CSR Spatial network experiment results show that it can perform well regarding dice coefficient. Furthermore, Spatial Unet based on CSR may effectively model the complicated in segmentations and rich feature extraction and improve the representation learning compared to alternative deep learning techniques, of illness and medical treatment, to enhance the meticulousness in predicting the fatality.

Neovascularization in Outer Membrane of Chronic Subdural Hematoma : A Rationale for Middle Meningeal Artery Embolization.

Neovascularization in Outer Membrane of Chronic Subdural Hematoma : A Rationale for Middle Meningeal Artery Embolization.

Development and Validation of a Clinical Score to Predict Epilepsy After Cerebral Venous Thrombosis

One of 10 patients develop epilepsy in the late phase after cerebral venous thrombosis (CVT) diagnosis but predicting the individual risk is difficult. To develop and externally validate a prognostic score to estimate the individual risk of post-CVT epilepsy. This observational cohort study included both retrospective and prospective patients enrolled from 1994 through 2022. For development of the DIAS3 score, data from the International CVT Consortium (n = 1128), a large international hospital-based multicenter CVT cohort, were used. For validation, data from 2 independent multicenter cohorts, the ACTION-CVT (n = 543) and the Israel CVT study (n = 556), were used. Of 2937 eligible, consecutively enrolled adult patients with radiologically verified CVT, 710 patients with a history of epilepsy prior to CVT, follow-up less than 8 days, and missing late seizure status were excluded. The prediction score (DIAS3) was developed based on available literature and clinical plausibility and consisted of 6 readily available clinical variables collected during the acute phase: decompressive hemicraniectomy, intracerebral hemorrhage at presentation, age, seizure(s) in the acute phase (excluding status epilepticus), status epilepticus in the acute phase, and subdural hematoma at presentation. Time to a first late seizure, defined as occurring more than 7 days after diagnosis of CVT. Of 1128 patients included in the derivation cohort (median age, 41 [IQR, 30-53] years; 805 women [71%]), 128 (11%) developed post-CVT epilepsy during a median follow-up of 12 (IQR, 3-26) months. According to the DIAS3 score, the predicted 1-year and 3-year risk of epilepsy in individual patients ranged from 7% to 68% and 10% to 83%, respectively. Internal and external validation showed adequate discrimination in the derivation cohort (1 year and 3 years: C statistic, 0.74; 95% CI, 0.70-0.79) and the 2 independent validation cohorts, (ACTION-CVT) 1 year: C statistic, 0.76; 95% CI, 0.67-0.84; 3 years: C statistic, 0.77; 95% CI, 0.66-0.84; and Israel CVT study 1 year: C statistic, 0.80; 95% CI, 0.75-0.86. Calibration plots indicated adequate agreement between predicted and observed risks. The DIAS3 score (freely available online) is a simple tool that can help predict the risk of post-CVT epilepsy in individual patients. The model can improve opportunities for personalized medicine and may aid in decision-making regarding antiseizure medication, patient counseling, and facilitation of research on epileptogenesis in CVT.

Delayed Diagnosis of a Ruptured Distal Posterior Inferior Cerebellar Artery (PICA) Dissecting Aneurysm Presenting as Craniocervical Junction and Spinal Subdural Hematoma

Delayed Diagnosis of a Ruptured Distal Posterior Inferior Cerebellar Artery (PICA) Dissecting Aneurysm Presenting as Craniocervical Junction and Spinal Subdural Hematoma

Internal hematoma architecture predicts subdural hematoma responsiveness to standalone middle meningeal artery embolization.

Subdural hematoma (SDH) is quickly becoming the most common neurosurgical pathology due to the aging population. Middle meningeal artery embolization (MMAE) has recently emerged as an effective adjunct to surgical SDH evacuation by decreasing recurrence risk. MMAE has also shown promise as a standalone SDH intervention, but clinical and radiographic predictors of successful MMAE remain ill-defined. Retrospective chart review from 2020 to 2023 at a single center identified all MMAE cases performed as primary SDH treatment. Cases were classified by hematoma internal architecture as homogeneous, separated, laminar, or trabecular. SDH maximal thickness was assessed on all follow-up imaging and any recurrences or expansions requiring surgery were denoted as treatment failures. 164 standalone MMAE cases were reviewed. Most cases were in male patients (75.0%) with a mean age of 73.2 years. The overall MMAE treatment failure rate was 6.7% with a 4.9% periprocedural complication rate. The cases with trabecular and laminar collections were slightly larger than those with homogeneous and separated collections (16.2mm vs. 14.2mm, p = 0.008*), but other baseline characteristics were similar. The MMAE failure rate was significantly lower in the laminar and trabecular subgroup (1.2%) compared to the homogeneous and separated subgroup (12.4%) (p = 0.005*). Homogeneous and separated internal hematoma architecture was the only predictor of MMAE failure in multivariate analysis (OR 10.5, p = 0.027*) and was also associated with delayed SDH resorption (ANOVA: F = 4.8, p = 0.0025*). Standalone MMAE is an effective, safe, and durable treatment for non-acute SDHs, and is especially effective for SDHs with more membranous internal architecture.

Atypical Presentation of a Ruptured Anterior Communicating Artery Aneurysm With Subdural, Intraparenchymal, and Subarachnoid Hemorrhage

Atypical Presentation of a Ruptured Anterior Communicating Artery Aneurysm With Subdural, Intraparenchymal, and Subarachnoid Hemorrhage

Subdural Electroencephalogram Monitoring for Early Seizure Detection in Patients With Subdural Hematoma: Considering It in the Real World.

Subdural Electroencephalogram Monitoring for Early Seizure Detection in Patients With Subdural Hematoma: Considering It in the Real World.

A Tale of Two Cases: Acquired Hemophilia A and/or Lupus Anticoagulant?

Abstract Distinguishing between acquired hemophilia A (AHA) and lupus anticoagulant (LA) is essential for effective clinical management. This can be challenging due to similarities in laboratory tests and potential interference between their diagnostic tests. Here we present two complex cases. Case 1 is a 69-year-old female with PNH presenting with a subdural hematoma. Prolonged aPTT with no correction on mixing raised clinical suspicion of AHA. Factor VIII activity was low (2%) across three dilutions in the factor assay. A Bethesda assay revealed a low factor VIII inhibitor (1%). LA was negative by DRVVT. Antiphospholipid antibodies (Cardiolipin and Beta-2-Glycoprotein 1) were also negative. Treatment with prednisone and intravenous immunoglobulin was initiated with presumptive diagnosis of AHA. Subsequent samples to check other factor levels uncovered low Factor IX as well. Higher dilutions in factor assays exhibited non-parallelism in Factor IX and VIII, suggesting a non-specific inhibitor. Chromogenic Factor VIII was within the normal range. Another LA test, Staclot-LA was positive. Overall, this case was consistent with LA rather than AHA. The initial ‘positive’ Bethesda assay was attributed to interference by LA. Case 2 is a 20-year-old female with no significant medical history who was admitted elsewhere for a complicated C-section with intraabdominal hemorrhage. She had prolonged aPTT and positive LA by platelet neutralization test there. Upon transfer, the initial assessment confirmed prolonged aPTT and a time-dependent inhibitor pattern in mixing studies. Factor studies revealed significantly diminished factor VIII activity (<1%) using both one-stage clotting and chromogenic assays. A strong factor VIII inhibitor was identified through chromogenic Bethesda assay (126 BU). Non-parallelism was observed in other factors (Factor IX, XI, XII). LA was negative by DRVVT but positive by Staclot-LA. Cardiolipin and beta2-glycoprotein-1 antibodies were negative. The diagnosis of AHA was evident. But is there concurrent LA present? Both Staclot-LA and platelet neutralization tests are PTT-based and susceptible to interference from factor VIII inhibitor. The patient underwent treatment, and factor VIII inhibitor disappeared in 3 months. Staclot-LA also turned negative, suggesting that the initially ‘positive’ LA test was likely a result of interference. In both cases, adopting a holistic approach to differentiate between AHA and LA is beneficial. Relying solely on individual tests may lead to false interpretations, as LA can inhibit FVIII activity assays and produce false positives in the Bethesda assay. It is advisable to include higher dilutions in factor assays and/or chromogenic assays to mitigate interference. The presence of factor VIII inhibitor can also result in false-positive LA results such as Staclot-LA assay. For more reliable results, DRVVT and antibody tests are preferable. If the aPTT-based assay is the sole positive LA test, the presence of LA is suggested when it occurs before and/or after the presence of a factor inhibitor.

The prevalence of subdural blood products in extremely premature infants with no history of abusive head trauma, studied by magnetic resonance imaging around term-equivalent age.

Prematurity and enlarged subarachnoid spaces are both hypothesised to represent an increased risk of subdural haemorrhages (SDHs) in infancy, both with and without a history of abuse. To examine the prevalence of a previous haemorrhage, particularly SDHs, in infants born extremely prematurely around term-equivalent age; to examine intra- and inter-observer agreement for identification of haemorrhages; and to examine the width of the subarachnoid spaces. A total of 121 extremely premature infants had cerebral magnetic resonance imaging (MRI) performed around term-equivalent age (mean chronological age 14.7weeks, range 10.3-24.0weeks). There were no infants investigated for abuse in our cohort. Intracranial haemorrhages were classified as isolated germinal matrix-haemorrhages, parenchymal haemorrhages (cerebellar- and cerebral haemorrhages), or extra-axial haemorrhages (subarachnoid haemorrhages, SDHs, or epidural haemorrhages). Sinocortical width and interhemispheric distance were measured. No appreciable SDH was detected with the performed sequences. Haemorrhage/blood products related to prematurity were seen in 60 (49.5%) of the neonates. Agreement was good to very good for identification of haemorrhage. The mean sinocortical width was 3.5mm with a standard deviation (SD) of 1.4mm on the right side and 3.3mm (SD 1.2mm) on the left side. The mean interhemispheric distance was 3.1mm (SD 1.1mm). 61.1% of the infants had a sinocortical width > 3mm on one or both sides. Our study does not support the hypothesis that premature infants are more prone to SDH unrelated to abusive head trauma during the first 3-4months of life. A large percentage of the ex-premature infants had prominent subarachnoid spaces.

Steroid response in a rare case of vertebrae butterfly with spinal cord compression caused by chronic subdural hematoma

IntroductionSpinal subdural hematoma (SSH) is a rare entity. Clinical symptoms include motor, sensory and/or autonomic dysfunction due to compression of the spinal cord. There is no standard consensus in the management of SSH. Here, we report a rare case of SSH of sudden onset following trauma, successfully treated with conservative therapy.AimThis case highlights butterfly vertebrae as an incidental imaging finding before SSH diagnosis.Case studyA 30-year-old female presented with weakness in the lower extremities after trauma, accompanied by paresthesia, urinary retention, and impaired defecating function. The thermoregulatory sweat exam revealed sudomotor dysfunction. Multiple slice computed tomography (MSCT) examination of the whole spine revealed wedge deformity of vertebral corpus (VC) L4 on the right lateral side, and VC L5 butterfly vertebrae. Spine magnetic resonance imaging (MRI) revealed an extramedullary intradural lesion at the T7 to T10 level suggestive of subdural hematoma.Results and discussionThe administration of methylprednisolone pulse therapy, combined with physical rehabilitation, led to a rapid and significant improvement in the patient's motor function. The absence of the spinal pain possibly indicated that there was no more extension of the hematoma; motor recovery, even if slight, should be a predictor of successful conservative therapy, and physical rehabilitation.ConclusionsSSH is an uncommon condition, with varying clinical presentation, and progression. This case report highlights significant improvement following conservative steroid treatment of a SSH. It also highlights a unique incidental finding of butterfly vertebra in a patient with paraparesis following trauma.