Subdural Hygroma Research Articles

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

Outcomes and complications of vertical parasagittal hemispherotomy in children: a nationwide population-based study.

The goal of this study was to assess the complications associated with vertical parasagittal hemispherotomy (VPH), the impact of incomplete disconnection on long-term seizure freedom, and how VPH impacts cognitive development. A retrospective evaluation was performed in all patients who had undergone VPH during 1991-2022 at the authors' institution. Two-year follow-up data were available for 45 patients, and there were 6-month data for 3 more. All available postoperative MRI studies (31/48, 64.6%) were reviewed. Before 2010, postoperative MRI was only performed if seizures recurred. Primary VPH led to Engel class I in 73% of patients. Acquired etiologies had a higher rate of Engel I compared to developmental and progressive etiologies (96% vs 46% and 44%, p < 0.001). Nearly half of patients (45%) showed improved cognitive trajectories as opposed to their preoperative ones, whereas in 45% trajectories remained unchanged. Additionally, 5 patients (10%) exhibited new major deficits or accelerated cognitive deterioration after VPH. Surgical complications occurred in 14 patients (29%) after the first VPH; 4 cases were classified as transient, resolving during follow-up without surgical intervention. Nontransient complications included 8 cases of hydrocephalus requiring surgical treatment, 1 shunted subdural hygroma, and 1 case of CSF leakage from the wound. Diabetes insipidus occurred in 6 patients, with all resolving spontaneously. Residual connections were present in 16 patients, primarily in the temporomesial region. Seven patients remained seizure free despite visible residual connections. VPH is a highly effective treatment for drug-resistant hemispheric epilepsy, resulting in durable seizure freedom and often favorable cognitive outcomes. Diabetes insipidus in addition to hydrocephalus is a common complication after VPH. Incomplete disconnection does not necessarily preclude seizure freedom.

Rediscovering extra-axial collections on medical imaging: subdural lymphatic hygroma.

Rediscovering extra-axial collections on medical imaging: subdural lymphatic hygroma.

Resolution of subdural hygroma with Homoeopathy: A case report

Resolution of subdural hygroma with Homoeopathy: A case report

Pathogenesis and epidemiology of chronic subdural hematoma

Background: Chronic subdural hematoma (SDH) is a common condition encountered in neurosurgical practice; however, its pathogenesis remains controversial.Current Concepts: SDH refers to blood accumulation inside the dura and is classified into acute, subacute, and chronic types. Histopathologically, acute SDH shows no neomembrane formation and the hematoma is a clot, in contrast to chronic SDH characterized by a neomembrane surrounding the liquefied hematoma. SDH is usually categorized into acute and chronic types, with subacute SDH being more similar to chronic SDH. Posttraumatic subdural lesions include acute and chronic SDH, subdural hygroma (SDG), or effusion. SDG is a blood-tinged fluid accompanied by neomembrane formation in some cases. These lesions are pathologically different from each other but may change depending on the situation.Discussion and Conclusion: Chronic SDH mainly originates from an SDG and acute SDH. SDG is usually triggered by trauma but only occurs in patients in whom sufficient potential space is available and may occur spontaneously in such cases. Therefore, SDG frequently occurs in children and in elderly patients, in men with a larger skull size, and on the left side of the body, which usually shows a wider hemisphere. Separation of the dural border cell layer causes inflammation, indicated by fibroblast proliferation and neovascularization. Conversion of an SDG into a chronic SDH or enlargement of a chronic SDH is attributable to formation of neomembranes, neovascularization, and repeated microhemorrhages from fragile capillaries. Chronic SDH is treated with removal of the hematoma to relieve the mass effect and embolization of the feeding artery for the bleeder. Outcomes of chronic SDH depend on the absorptive-expansion capacity dynamics.

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.

Perioperative risk factors for major complications after bone replacement in decompressive craniectomy

IntroductionBone flap replacement after a decompressive craniectomy is a low complexity procedure, but with complications that can negatively impact the patient's outcome. A better knowledge of the risk factors for these complications could reduce their incidence. Patients and methodsA retrospective review of a series of 50 patients who underwent bone replacement after decompressive craniectomy at a tertiary center over a 10-year period was performed. Those clinical variables related to complications after replacement were recorded and their risk factors were analyzed. ResultsA total of 18 patients (36%) presented complications after bone flap replacement, of which 10 (55.5%) required a new surgery for their treatment. Most of the replacements (95%) were performed in the first 90 days after the craniectomy, with a tendency to present more complications compared to the subsequent period (37.8% vs 20%, p > 0.05). The most frequent complication was subdural hygroma, which appeared later than infection, the second most frequent complication. The need for ventricular drainage or tracheostomy and the mean time on mechanical ventilation, ICU admission, or waiting until bone replacement were greater in patients who presented post-replacement complications. Previous infections outside the nervous system or the surgical wound was the only risk factor for post-bone flap replacement complications (p = 0.031). ConclusionsPostoperative complications were recorded in more than a third of the patients who underwent cranial bone flap replacement, and at least half of them required a new surgery. A specific protocol aimed at controlling previous infections could reduce the risk of complications and help establish the optimal time for cranial bone flap replacement.

Subdural hygromas After Decompressive Craniotomies

Subdural hygromas occur after various brain interventions, are often asymptomatic but sometimes may require surgical treatment. They can develop in the immediate postoperative period, but they are more common a few weeks or even months after surgery. Subdural hygromas are particularly common after decompressive craniotomy in patients with traumatic brain injury or massive stroke. The pathogenesis is explained by the fact that a large bone defect causes a pressure difference in the skull, and a concomitant displacement of the ventricular system disrupts the normal cerebrospinal fluid circulation, contributing to the redistribution of cerebrospinal fluid flow into the subdural space.We review data from contemporary studies on subdural hygromas after decompressive craniotomy, their risk factors, and management strategies. We also present our case of recurrent subdural hygroma in a patient operated on for a ruptured aneurysm of the middle cerebral artery.

Risk factors for postoperative ventriculoperitoneal shunt requirement in pediatric patients with brain tumors invading or adjacent to CSF circulation pathways.

Hydrocephalus is a common comorbidity of brain tumors in children that may persist following brain tumor resection. This study aimed to explore perioperative risk factors associated with postoperative ventriculoperitoneal shunt (VPS) placement for tumors located at or adjacent to the CSF circulation pathway. Patients aged 0-18 years with tumors invading or adjacent to the CSF circulation pathways who underwent brain tumor resection between October 2015 and September 2021 were included in this study. The outcome metric was whether patients underwent VPS placement within 6 months of tumor resection. Patients were followed up every 3-6 months after surgery. Demographic and perioperative imaging characteristics, clinical variables, and long-term treatments, including radiotherapy or chemotherapy, were included in the analysis. Two hundred sixty-five children were included in this study. Of these patients, 38 (14.34%) underwent VPS placement within 6 months of tumor resection. One hundred thirty-two patients (49.81%) presented with preoperative hydrocephalus. Results from the multivariate analysis showed that medulloblastoma (OR 4.15, 95% CI 1.74-9.91, p = 0.001), lateral/third ventricle tumors (OR 4.07, 95% CI 1.33-12.30, p = 0.014), postoperative intraventricular hematoma (OR 3.36, 95% CI 1.53-7.38, p = 0.003), and presence of subdural hygroma in the nonoperated area within 48 hours after tumor resection (OR 2.78, 95% CI 1.15-6.74, p = 0.024) were independent risk factors for postoperative VPS placement. Postoperative lateral/third ventricle hematoma and subdural hygroma in the nonoperated area, anatomical location, and tumor histology may be potential risk factors for a postoperative VPS after brain tumor resection.

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

Enhanced recovery programs may be especially useful in patients with chronic subdural hematoma or hygroma (cSDH), who frequently exhibit frailty and multimorbidity. We aim to evaluate the real-world safety and effectiveness of an enhanced recovery protocol in this population. From a prospective registry, burr hole evacuations for cSDH carried out under the protocol (including early thromboprophylaxis, no flat bed rest, early mobilization without drain clamping, and early resumption of antithrombotic medication) were extracted, along with those procedures carried out within the past year before protocol change. Propensity score-based matching was carried out. A range of clinical and imaging outcomes were analyzed, including modified Rankin Scale as effectiveness and Clavien-Dindo adverse event grading as safety primary end points. Per group, 91 procedures were analyzed. At discharge, there was no significant difference in the modified Rankin Scale among the standard and enhanced recovery groups (1 [1; 2] vs 1 [1; 3], P = .552), or in Clavien-Dindo adverse event grading classifications of adverse events (P = .282) or occurrence of any adverse events (15.4% vs 20.9%, P = .442). There were no significant differences in time to drain removal (2.00 [2.00; 2.00] vs 2.00 [1.25; 2.00] days, P = .058), time from procedure to discharge (4.0 [3.0; 6.0] vs 4.0 [3.0; 6.0] days, P = .201), or total hospital length of stay (6.0 [5.0; 9.0] vs 5.0 [4.0; 8.0] days, P = .113). All-cause mortality was similar in both groups (8.8% vs 4.4%, P = .289), as was discharge disposition (P = .192). Other clinical and imaging outcomes were similar too (all P > .05). In a matched cohort study comparing perioperative standard of care with a novel enhanced recovery protocol focusing on evidence-based drainage, mobilization, and thromboprophylaxis regimens as well as changes to the standardized reuptake of oral anticoagulants and antiaggregants, no differences in safety or effectiveness were observed after burr hole evacuation of cSDH.

Left Sixth Nerve Palsy and Subdural Hygroma Following Intrathecal Morphine Pump Placement: A Case Report

BACKGROUND: An intrathecal (IT) pump is an effective drug delivery system that assists patients with chronic pain management. However, due to the invasive nature of the procedure, a complication that could arise is cerebrospinal overdrainage or leak, which could lead to adverse effects. CASE REPORT: The patient underwent an IT morphine pump implant for treatment of his chronic, intractable low back pain. Following the procedure, he developed persistent headaches and diplopia and was found to have left lateral rectus palsy. Imaging studies showed the development of bilateral subdural hygromas. His condition was resolved with surgical intervention and time. CONCLUSIONS: After an extensive literature search and review, to our knowledge, this is the first reported case of sixth nerve palsy and subdural hygromas following the implant of a drug delivery system. KEY WORDS: Abducens palsy, IT pump, subdural hydrgomas, intrathecal drug delivery system, lateral rectus palsy

Nomogram for preoperative estimation of symptomatic subdural hygroma risk in pediatric intracranial arachnoid cysts.

The occurrence and predictors of symptomatic subdural hygroma (SSH) subsequent to the fenestration of pediatric intracranial arachnoid cysts (IACs) are unclear. In this study, the authors aimed to investigate the likelihood of an SSH following IAC fenestration and the impact on operative efficacy with the ultimate goal of constructing a nomogram. The medical records of 1782 consecutive patients who underwent surgical treatment at the Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine were reviewed. Among these patients, a training cohort (n = 1214) underwent surgery during an earlier period and was used for the development of a nomogram. The remaining patients formed the validation cohort (n = 568) and were used to confirm the performance of the developed model. The development of the nomogram involved the use of potential predictors, while internal validation was conducted using a bootstrap-resampling approach. SSH was detected in 13.2% (160 of 1214) of patients in the training cohort and in 11.1% (63 of 568) of patients in the validation cohort. Through multivariate analysis, several factors including Galassi type, IAC distance to the basal cisterns, temporal bulge, midline shift, IAC shape in the coronal view, area of the stoma, and artery location near the stoma were identified as independent predictors of SSH. These 7 predictors were used to construct a nomogram, which exhibited a concordance statistic (C-statistic) of 0.826 and demonstrated good calibration. Following internal validation, the nomogram maintained good calibration and discrimination with a C-statistic of 0.799 (95% CI 0.665-0.841). Patients who had nomogram scores < 30 or ≥ 30 were considered to be at low and high risk of SSH occurrence, respectively. The predictive model and derived nomogram achieved satisfactory preoperative prediction of SSH. Using this nomogram, the risk for an individual patient can be estimated, and the appropriate surgery can be performed in high-risk patients.

An arachnoid cyst rupture complicated with subdural hygroma in a middle-aged woman: a case report and review of the literature

BackgroundArachnoid cysts (ACs) account for about 1% of all intracranial mass lesions. The Sylvian fissure is the most common site of ACs which are usually asymptomatic. Traumatic rupture of arachnoid cysts complicated with subdural hygroma is a relatively rare entity in adults especially in females. There is no consensus on their management and each case could add to previous experiences leading to more uniform therapeutic measurements. This case encompasses a combination of watchful strategy, limited surgery and ultimately successful cyst fenestration which highlights a good outcome without complications by adopting a stepwise procedure.Case presentationHere, the case of a 51-year-old Persian woman being presented with a 2-month history of a localized headache which had begun 4 days after a minor head trauma. Early brain computed tomography (CT) obtained in another center at 4th day of post-injury which misinterpreted as an old infarct. Repeated CT in our center revealed a large AC of Sylvian fissure complicated with subdural hygroma. Initially a conservative management pursued but due to worsening of the symptoms, a burr-hole craniotomy performed for hygroma evacuation that subsequently followed by cyst fenestration about 1-month later.ConclusionPrevious awareness about radiographic characteristics of ACs as well as employing appropriate imaging modality are necessary for correct and timely diagnosis of symptomatic patients after minor head trauma because incidentally found ACs might be the underpinning causes of symptoms. Also, following a multistage therapeutic process along with the involvement of patients in decision-making are of paramount importance.

Subdural Hygroma After Management of Ruptured Intracranial Aneurysms: Incidence, Associated Factors, Clinical Course, and Management Options

To evaluate the incidence, associated factors, clinical course, and management options of subdural hygroma in patients treated for aneurysmal subarachnoid hemorrhage (aSAH). From January 2013 until June 2022, 336 consecutive patients with aSAH underwent treatment in our center. No one patient was excluded from the study cohort. Computed tomography (CT) examinations were performed at admission, immediately after surgery and on the first postoperative day, and subsequently in case of any neurologic deterioration or, at least, once per week until discharge from the hospital. Thereafter, CT examinations were at the discretion of specialists in the rehabilitation facility, referring physicians, or neurosurgeons at the outpatient clinic. The length of radiologic follow-up starting from CT at admission ranged from 1 to 3286 days (mean, 673 ± 895 days; median, 150 days). Subdural hygromas developed in 84 patients (25%). An average interval until this imaging finding from the initial CT examination was 25 ± 55 days (median, 8 days; range, 0-362 days). Evaluation in the multivariate model showed that patient age ≥72 years (P < 0.0001), cerebrospinal fluid (CSF) shunting (P < 0.0001), and microsurgical clipping of ruptured intracranial aneurysm (RIA; P < 0.0001) are independently associated with the development of subdural hygroma. In 54 of 84 cases (64%), subdural hygromas required observation only. Increase of the lesion size with (5 cases) or without (10 cases) appearance of midline shift was associated with patient age <72 years (P= 0.0398), decompressive craniotomy (P= 0.0192), and CSF shunting (P= 0.0009), whereas evaluation of these factors in the multivariate model confirmed independent association of only CSF shunting (P= 0.0003). Active management of subdural hygromas included adjustment of the shunt programmable valve opening pressure, cranioplasty, external subdural drainage, or their combination. Overall, during follow-up (mean, 531 ± 824 days; median,119 days; range, 2-3285 days) after the start of observation or applied treatment, subdural hygromas showed either decrease (50 cases) or stabilization (34 cases) of their sizes, and no one lesion showed progression again. The clinical course of subdural hygromas in patients treated for aSAH is generally favorable, but occasionally these lesions show progressive enlargement with or without the appearance of midline shift, which requires active management.

Salmonella meningitis with hydrocephalus as complication in children: A case series

Background: Bacterial meningitis by salmonella serotype is a rare infection among neonates and young children. The treatment of salmonella meningitis requires bactericidal agents that are capable of penetrating into cerebrospinal fluid (CSF). Acute complications of bacterial meningitis mainly include hydrocephalus, subdural collection, cerebral infarction, ventriculitis, empyema, intracranial abscess and cranial nerve palsy. Two Cases Presentation: First case, 1 months-old boy brought to the general hospital with chief complaint of fever. Patient had decreased of consciousness and bulging of anterior fontanella. Analysis of cerebrospinal fluid (CSF) showed Pandy test (+4) and None test (+4), high protein 369 mg/dl (mononuclear 44%, polymorphonuclear 56%), liquor glucose 2 mg/dl, CSF culture and blood culture resulted salmonella. Electrolyte and blood sugar was normal, complete blood count showed leukocytes 13.96x 103/µL and mild normochromic normocytic anemia. Head CT scan revealed communicating hydrocephalus. Second case, 6 months-old boy brought to general hospital with seizure as chief complaint. Cerebrospinal fluid (CSF) analysis showed Pandy test (+4) and None test (+4), high protein 569 mg/dL, liquor glucose 26 mg/dL, CSF culture and blood culture results found salmonella sp. Head CT scan revealed subdural hygroma at frontoparietal. Patient was treated by 3rd generation of cephalosporins (ceftriaxone) for 4 weeks. Patient discharge from hospital. Summary: Management of salmonella meningitis include administration of empiric antibiotic, supportive treatment and management of complication. High dose of antibiotic is given empirically without waiting for the results of culture. Learning Points: Clinical manifestations and outcome of meningitis salmonella

Staged Neuroendoscopic Management of a Dandy Walker Malformation Case Presenting with Complex Hydrocephalus

Backgroud: Dandy-Walker malformation is a rare congenital condition characterized by alteration of posterior fossa anatomy. Hydrocephalus is a common finding in these patients. VP-shunt placement remains the treatment of choice. Endoscopic Third Ventriculostomy (ETV) is an acceptable alternative for older children. Other techniques have also been proposed. Case presentation: A full-term infant presented with signs of hydrocephalus. An endoscopic foraminoplasty of the posterior fossa cyst was conducted as a first stage. The cyst’s volume was reduced, without any changes of the supratentorial ventricular dimensions. A month post-surgery signs of hydrocephalus reoccurred. An ETV was performed alongside a fenestration of the tentorium. The toddler was discharged in good condition with amelioration of her symptoms. One month later she presented with recurrent hydrocephalus and subdural hygromas. A shunt was placed in the posterior fossa under endoscopic guidance, and an additional one was introduced in the subdural space. The patient was followed-up for 18 months without any further need for treatment. VP-shunt placement is the treatment of choice. Discussion: Lushka and Magendie foraminoplasty seems to be ineffective. ETV should be reserved for older children. The ventriculoscope can be employed for positioning the VP-shunt in a specific anatomical region. Subdural hygromas may present after neuroendoscopic treatment. A staged approach may be mandatory for complex hydrocephalus treatment.

Endoscopic Treatment of Chronic Subdural Hematoma Combined with Inner Subdural Hygroma.

A chronic subdural hematoma (CSDH) is a collection of bloody fluid located in the subdural space and encapsulated by neo-membranes. An inner subdural hygroma (ISH) is observed between the inner membrane of a CSDH and the brain surface. We present 6 cases of CSDH combined with ISH treated via endoscopy. Between 2011 and 2022, among the 107 patients diagnosed with CSDH in our institute, 6 patients were identified as presenting with CSDH combined with ISH and were included in this study. Preoperative CT and MRI were performed simultaneously, and endoscopic surgery for aspiration of the hematoma was performed in all cases of CSDH combined with ISH. The mean age of patients was 71 years (range, 66 to 79 years). The patients were all male. In two cases, the ISH was not identified on CT, but was clearly seen on MRI in all patients. The inner membrane of the CSDH was tensive and bulging after draining of the CSDH in endoscopic view due to the high pressure of the ISH. After fenestration of the inner membrane of the CSDH and aspiration of the ISH, the membrane was sunken down due to the decreasing pressure of the ISH. There was one recurrence in post-operative 2-month follow up. The symptoms improved in all patients after surgery, and there were no surgery-related complications. CSDH combined with ISH can be diagnosed on imaging, and endoscopic surgery facilitates safe and effective treatment.

Gauging the pressure: The clinical dilemma with Chiari! (P11-4.004)

<h3>Objective:</h3> N/A <h3>Background:</h3> Differentiating between Chiari Malformation I (CMI) and acquired tonsillar herniation due to spontaneous or iatrogenic intracranial hypotension (IH) can be challenging. We describe a case of IH misdiagnosed as CM1 to emphasize several distinct clinical signs that can prevent misdiagnosis. <h3>Design/Methods:</h3> <h3>Case Description:</h3> A 36-year-old multigravida female with history of multiple epidural analgesia during vaginal deliveries presented with 6 months of constant, poorly localized headaches. Fundoscopic exam revealed bilateral mild inferior disc edema without vessel obscuration. Contrasted magnetic resonance imaging (MRI) showed diffuse pachymeningeal enhancement with a 7mm downward herniation of the cerebellar tonsils but no syrinx in the upper cervical cord. The patient was thought to have CM1, and she was treated with supportive care. After 2 years, the patient again presented with severe intractable headaches and vomiting 7 weeks following epidural for vaginal delivery. Repeat MRI brain showed a 23 mm downward herniation of the cerebellar tonsils associated with severe effacement of the basilar and prepontine cisterns and diffuse sulcal effacement. MRI cervical spine showed a large cervical syrinx at this time. MRI thoracic and lumbar spine showed an epidural cerebrospinal fluid (CSF) collection extending from T1 to L3 levels with diffuse cord edema, confirming CSF leak. Given high risk of complications, blood patch was not attempted, and the patient ultimately underwent suboccipital decompressive craniotomy. <h3>Results:</h3> N/A <h3>Conclusions:</h3> This case highlights the importance of considering acquired causes of cerebellar tonsillar herniation in symptomatic adults. Headache description, chronicity, and presence/absence of syrinx cannot differentiate CMI from IH. Pachymeningeal enhancement, subdural hygromas, pituitary enlargement, distention of cerebral venous sinuses, and effacement of subarachnoid spaces along with flattening of pons are more indicative of IH. Evidence of an extradural CSF collection in the spinal cord or a CSF leak on computerized tomography myelogram are diagnostic of IH. <b>Disclosure:</b> Miss Phillips has nothing to disclose. Dr. Mannyam has nothing to disclose. Dr. Sharma has nothing to disclose.

Abstract Number ‐ 89: Left M1 occlusion rescued by the Recurrent artery of Huebner: a spectrum of MCA collaterals

Introduction Proximal MCA occlusion has variable presentation and clinical course, ranging from MCA syndrome with completed infarct at presentation to asymptomatic, discovered incidentally on imaging. This variability is likely dictated by variable collateral circulation that ultimately fails on variable time courses. For discussion we can divide these into (1) rapid progressors, (2) standard, (3) slow progressors, (4) situationally symptomatic, and (5) asymptomatic. There is clear evidence for the role of endovascular therapy for those who are significantly symptomatic and progress along an acute timeline when combined with imaging criteria (1 and 2), but there is no clear guidance for those patients who progress slowly or are minimally symptomatic (3‐5). Methods We present selected cases of patients with left MCA occlusion from groups 3–5 along with their presentation and collateral flow as assessed by non‐invasive imaging and DSA. Results Case 1. Slow Progressor. A 63‐year‐old woman with past occipital lobe strokes presented with progressive aphasia of insidious onset that began at some point the previous day. NIHSS 4 for aphasia and LOC questions. Initial CTA revealed a left M1 occlusion with ASPECTS 9. Despite low NIHSS and extended time to LKW, she was brought to the angiography suite. Initial angiogram confirmed M1 occlusion with extensive collateralization via the left ACA and anterior temporal artery, but no reconstitution of the MCA proper. Thrombectomy was completed with TICI2B recanalization. Followup MRI revealed minimal infarct in the left insula. The patient was discharged with an NIHSS of 1 for a baseline hemianopia not appreciated on initial exam. Case 2. Situationally Symptomatic. A 55‐year‐old man with symptomatic epilepsy from bilateral subdural hygromas was admitted for video EEG monitoring of episodic dizziness and word‐finding difficulty. Initial exam revealed only orthostatic light‐headedness. Further history revealed these events often happed at night upon standing. No epileptiform events were captured. MRA revealed a complete occlusion of the proximal M1 with reconstitution at the M2 bifurcation in the sylvian fissure. Given lack of persistent clinical deficit and absence of infarct on MRI, DSA was deferred. The patient is followed outpatient without further symptom progression. Case 3. Asymptomatic. A 38 year‐old‐man with TBI presented to the emergency department with thunderclap headache. Initial exam was without deficits. CTA and MRA revealed complete occlusion of the left MCA. We proceeded to the angiography suite where DSA revealed complete left M1 occlusion with distal reconstitution at the M2 bifurcation primarily via the Recurrent Artery of Huebner in addition to ACA collaterals. Lumbar puncture was benign and his headache responded completely to typical migraine treatment. The patient was discharged to outpatient follow up without further sequalae. Conclusions We present a series of illustrative cases of patients with MCA occlusion of variable collateral supply and clinical course, none of whom met conventional criteria for endovascular intervention. More research is needed to establish clinical and imaging criteria to separate patients who would benefit from endovascular intervention from those who are best managed medically in these scenarios.

Cerebral Microbleeds-Long-Term Outcome After Cerebrospinal Fluid Shunting in Idiopathic Normal Pressure Hydrocephalus.

Cerebral microbleeds (CMBs) are common in idiopathic normal pressure hydrocephalus (INPH) and have been suggested as radiological markers of a brain prone to bleeding. The presence of CMBs might be relevant when selecting patients for shunt surgery. To evaluate whether CMBs increases long-term risk of hemorrhagic complications and mortality or affects outcomes after cerebrospinal fluid shunt surgery in a cohort of patients with INPH. One hundred and forty nine shunted patients with INPH (mean age, 73 years) were investigated with MRI (T2* or susceptibility-weighted imaging sequences) preoperatively. CMBs were scored with the Microbleed Anatomic Rating Scale. Patients were observed for a mean of 6.5 years (range 2 weeks to 13 years) after surgery. Hemorrhagic events and death were noted. Improvement in gait was evaluated 3 to 6 months after surgery. At baseline, 74 patients (50%) had CMBs. During follow-up, 7 patients (5%) suffered a hemorrhagic stroke and 43 (29%) suffered a subdural hematoma/hygroma with a median time from surgery of 30.2 months (IQR 50). Overall, having CMBs was not associated with suffering a subdural hematoma/hygroma or hemorrhagic stroke during follow-up with 1 exception that an extensive degree of CMBs (≥50 CMB) was more common in patients suffering a hemorrhagic stroke ( P = .03). CMBs were associated with increased mortality ( P = .02, Kaplan-Meier, log-rank test). The presence of CMBs did not affect gait outcome ( P = .28). CMBs were associated with hemorrhagic stroke and mortality. CMBs do not seem to reduce the possibility of gait improvement after shunt surgery or contribute to the risk of hemorrhagic complications regarding subdural hematoma or hygroma.