Subdural Membrane Research Articles

Subdural hematoma due to dural metastasis: Case report and review of the literature

A case of chronic subdural hematoma associated with dural metastasis from gastric cancer is reported. It is compatible with the concept that subdural bleeding may result from obstruction of dural vessels by neoplastic cells. Other possible pathogenetic mechanisms of this rare complication are discussed and a literature review is given. For proper diagnosis of this condition histologic investigation of the subdural membrane is mandatory.

Clinical correlates of erythropoiesis in chronic subdural hematoma

Histologic investigation was performed in 38 out of 224 chronic subdural hematomas treated at our institution from 1978 to 1988. Nucleated red blood cells were found in 33% of the chronic subdural membranes examined. Additional sections were examined in 14 of these 38 patients, revealing erythroblasts in 57%. The clinical course and radiographic findings in the patients whose membranes contained erythroblasts were compared with those whose specimens did not. Neither history, presentation, size of hematoma, nor postoperative recovery differed from one group to the other. By comparing histologic and clinical findings, we are able to conclude that the production of erythrocytes by chronic subdural membranes is of no surgical significance.

Prostatic adenocarcinoma metastatic to chronic subdural hematoma membranes

A case of adenocarcinoma of the prostate metastatic to chronic subdural hematoma membranes is presented. The relevant literature is reviewed and the mechanism of transdural invasion by metastatic tumor cells is discussed.

Infantile acute subdural hematoma.

A retrospective analysis of the infantile acute subdural hematoma was made with special reference to its pathogenesis. In 11 of 15 cases, the hematomas were bilateral or a contralateral subdural fluid collection was present. In 7 of 11 patients who underwent operation the collection was bloody fluid and/or clotted blood. In 3 patients, a subdural membrane, as seen in adult chronic subdural hematoma, was found. In only 1 patient with unilateral hematoma was clotted blood present without subdural membrane. The thickest collection of clotted blood was in the parasagittal region. It is postulated that in most cases hemorrhage occurs after minor head injury, from the bridging veins near the superior sagittal sinus, into a pre-existing subdural fluid collection such as chronic subdural hematoma or subdural effusion with cranio-cerebral disproportion, and that infants without intracranial disproportion are unlikely to have acute subdural hematoma caused by minor head injury.

Acute Subdural Hematoma after Irrigation of the Contralateral Chronic Subdural Hematoma in a Hemodialyzed Patient

A case of acute subdural hematoma immediately after surgical intervention for the contralateral chronic subdural hematoma in a regularly hemodialyzed patient is reported. A 59-year-old male was admitted because of progressive right hemiparesis after six years of regular hemodialysis. A computed tomography (CT) scan revealed typical left chronic subdural hematoma. Irrigation and drainage of the hematoma through a single burr hole was performed. The right hemiparesis was improved after surgery and a CT scan two hours after surgery revealed a marked reduction of the hematoma cavity. However, the patient suddenly became comatose eight hours after surgery, and another CT scan showed a contralateral acute subdural hematoma. The patient expired the following morning. Postmortem pathologic examination showed an old left subdural hematoma membrane and a massive subdural hematoma without any membrane in the right fronto-temporal area. Subdural hematoma has a higher mortality rate among hemodialysis patients than in the normal population, and many authors have reported disappointing results of surgical intervention in such cases. This case suggests that the high frequency of subdural hematoma can be attributed to the accompanying coagulopathy and the acute decrease of intracranial pressure. The authors emphasize careful management including peritoneal dialysis before and after the surgical intervention.

The Origin of Chronic Subdural Hematoma considered on the Basis of Hematoma Membrane Findings and Contained Fluid Findings

The authors divided chronic subdural hematoma into 5 stages, from occurrence to disappearance, mainly according to computerized tomography (CT) findings. The origin was determined on the basis of the findings from the hematoma membrane and the contained fluid obtained at the surgery in each stage. The initial stage (about 7-14 days after head injury) was characterized by the presence of communication between the subdural low density area and the subarachnoid space, shown by the CT scan. In this stage, a thin fibroblastic membrane was recognized beneath the dura mater. The contained fluid consisted of cerebrospinal fluid and a minimal amount of blood. The premature stage (about 15-30 days after head injury) was characterized by insufficient communication between the subdural low density area and the subarachnoid space in the CT scan. In this stage, the subdural membrane was thicker and consisted of fibroblastic cells, capillaries, and infiltrating cells. The contained fluid was rich in protein and showed increased plasmin activity. In the mature stage (about 30-60 days after head injury), CT change into iso- or high-density without mass sign was noted. In this stage, the subdural membrane consisted of fibroblastic cells, well-developed capillaries, and many infiltrating cells. Intramembranous bleeding was seen. Moreover, the contained fluid was very similar to fresh blood, and increased in fibrin degradation products. The progressive stage showed the typical chronic subdural hematoma with mass sign. The subdural membrane and the contained fluid were typical, as reported previously by other authors. In the resolving stage, the hematoma was relatively low in CT density and gradually disappearing. Mass sign was not found. In this stage, the subdural membrane became fibrous and consisted of well-developed collagen fibers. From these findings, the authors postulated the following: The hematoma begins as a subdural fluid collection which is a mixture of a minimal amount of blood and cerebrospinal fluid. The fluid collection produces an active fibroblastic membrane beneath the dura mater (initial and premature stages). Immature capillaries in the membrane are made to bleed by physical factors, such as variation of the intracranial pressure. The intramembranous bleeding breaks the membrane to form the subdural hematoma without mass sign yet (mature stage). The subdural hematoma is expanded by repeated bleeding from the membrane (perhaps due to topical fibrinolysis, etc.) to form the typical chronic subdural hematoma (progressive stage). Finally, the membrane becomes fibrous and ceases to bleed (resolving stage).

Computed tomographic findings in metastatic dural carcinomatosis

A case is presented of metastatic dural carcinomatosis associated with a thickened subdural membrane similar to those found in association with posttraumatic chronic subdural hematomas. In this case burr-hole drainage was attempted as a result of findings on computed tomography scanning that suggested a right frontal chronic subdural hematoma. However, no chronic subdural hematoma or effusion was found. The pathology, radiographic findings, and clinical features of this phenomenon are discussed.

Significance of eosinophilic infiltration in chronic subdural hematoma, with special reference to the relationship with estrogens

Remarkable eosinophilic infiltration of the hematoma membrane, observed not infrequently around sinusoidal vessels, has not been well documented. Histological analysis of the membrane obtained from 57 patients was performed and the findings were classified into 5 groups according to histological maturity and clinical stage. Eosinophils were most conspicuous in membrane which had attained a certain thickness and had completed the sinusoidal pattern of the vessels. It was considered that eosinophils were closely related to the membrane's histological maturity, indicating healing. Eosinophilic infiltration was found in 30% of male patients, whereas all of the female patients showed marked eosinophilic infiltration of the membrane. Significantly, the number of female patients was much smaller. In male patients, the degree of eosinophilic infiltration was related to the estrogen level. An experimental work was undertaken to produce hematoma membrane in the subcutaneous tissue of the guinea pig, and eosinophilic infiltration of the membrane was examined in relation to estrogen administration and the animal's sex. The results suggested a significant relationship between the membrane eosinophilia and estrogen level, as well as to the sex. It was postulated that eosinophilic infiltration of the chronic subdural hematoma membrane was a manifestation of healing, as in chronic inflammatory granulation, and that it was closely related to the estrogen level as evidenced by the predominate occurence of chronic subdural hematoma in males.

Demonstration of Subdural Empyema by CT Scanning-Reply

In Reply.— Dr Davidson's comments are true as far as they go. Improved x-ray film detection configurations and more sophisticated computer programs give the later-generation CT scanners improved resolution. Still, we continue to regard our new scanner as invaluable but not infallible. The features common to most of the reported cases of failure to diagnose subdural empyema by CT scan were as follows: (1) all were acute, fulminant infections in persons without previous intracranial lesions; (2) the subdural pus was in a thin layer widely dispersed in the subdural space; and (3) the pus was not confined by any subdural membranes other than normal arachnoid. In our two reported cases, the thickest collections of pus were in the basal subarachnoid space that surrounded the left temporal tip and in the left frontal parasagittal region. These two regions are best seen with coronal reconstructions of the CT, which were not available

Demonstration of Subdural Empyema by CT Scanning

To the Editor.— I would like to comment on the article by Ralph O. Dunker, MD, and Rashida Khakoo, MD, regarding failure of computed tomographic (CT) scanning to demonstrate subdural empyema (1981; 246:1116). It is evident that one of the problems the authors have with the analysis of subdural collections is the lack of distinction of gray and white matter resolution owing to their particular scanner's limitations. Of the images published in their article, none of them show the gray matterwhite matter differentiation well such as third- and fourth-generation CT scanners do on a routine basis now. As pointed out by numerous authors and generally recognized by neuroradiologists and others involved in CT head scanning, any recognized midline shift of structure should prompt further investigation, including delayed scans, to differentiate subdural membranes and even reexamination to the point of angiography to evaluate possible subdural collections. I believe that if they

A note for interns and residents: a new law and advice on its circumvention.

A NOTE FOR INTERNS AND RESIDENTS: A NEW LAW AND ADVICE ON ITS CIRCUMVENTION ROBERTJ. JOYNT* There are a number of immutable laws which have been proposed, dealing with scientific, social, and organizational problems. The most famous of these is Murphy's Law, but hundreds of similar ones have sprung from this. However, there is one important situation (indeed, one's very livelihood may depend on it) which has not been treated. A long experience as a house officer, and a much longer one observing house officers, has allowed me not only to state the law, but to suggest ways to circumvent its consequences. While I claim no particular priority in formulating this patent truism, if future generations wish to credit me with the appropriate eponym I will not demur as, thus far, no sign, disease, or maneuver has been so designated. It is said—for good reason, but perhaps the CAT scan may change this—that every neurologist when he dies is buried in a posterior fossa with a subdural membrane as a shroud. But to die without an eponym and miss the hagiography of neurologic saints would make one feel it had all been for nought. Now for the law: No matter how well you have examined your patients, the attending physician or surgeon will always want to see the one you didn't have time to get around to. I don't need to emphasize the implications of this. If it has not happened to you, it will. Can it be dealt with? Yes, and here are the means, in ascending degrees of duplicity. 1. The early-bird-makes-you-feel-like-a-worm technique. This employs the hoary, but successful, battle plan that the best defense is a good offense. When the attending asks you about that patient he admitted yesterday, the one you haven't seen, you reply that he was all right when you saw him at 5:30 this morning. This immediately gives you an edge over the ?Professor and chairman, Department of Neurology, University of Rochester, Rochester , New York 14642.© 1981 by The University of Chicago. All rights reserved 003 1-5982/82/2501-0243$01 .00 144 I RobertJ.Joynt ¦ NoteforInterns and Residents attending who was in the arms of Morpheus or a similar name at the time. Occasionally, however, you will get a quick attending who will shoot back, "Yes, wasn't the sunrise nice at that time, I wasjust on my fourteenth mile of my usual 15-milejog." If this happens you have to go on to the next ploy. 2.Theflattery-will-get-you-everywhere stratagem. Having failed with No. 1, you immediately shoot back, "I certainly enjoyed your paper on the disease that patient X has." In many instances this will break the attending up completely, and he will be putty in your hands for the rest of rounds. But again, a smart one may reply, "Yes, I know it was the definitive paper on that subject but I wasn't satisfied with it." Immediately you respond with a putdown like, "I guess that's why the New EnglandJournal ofMedicine didn't accept it." This will put you back in the ballgame. Obviously, if the attending hasn't written a paper on that subject this stratagem has to be abandoned and you can go on to No. 3. 3.The I-have-read-about-this-in-a-more-obscure-journal-than-you-have approach . This can lead to an escalating or de-escalating series ofexchanges which can take up several minutes and distract the attending's attention from the unexamined patient. Don't start too obscurely, as you want to test his mettle. For example, lead offwith, "I read about this condition in the FrenchJournal ofRespiratory Disease." He may counter with a Spanish Archives ofRheumatology; you riposte with a Czechosbvakian Bulletinfrom the Ministry ofHealth on Silicosis. In most instances you have defeated him at that point, but an unusually resilient attending will come on with a Bulletin of the Chinese Workers' Health Committee on PsoriasL·. I have seen grown residents cry at this point. Usually, it doesn't go that far, and only once did I witness...

CT scanning after drainage of subdural haematoma: An unusual case

A unique patient with bilateral subdural haematomas with localized subdural membranes on one side is reported. Serial CT scans suggested that the membranes resolved spontaneously after drainage of the haematoma. The pathophysiology of subdural haematoma and the value of CT scanning in postoperative follow-up are discussed, especially in regard to learning more about the optimal treatment in this still somewhat enigmatic problem.

Relapsing juvenile chronic subdural hematoma in adult life.

Two cases of relapsing juvenile chronic subdural hematoma with late relapse in adult life are presented and the literature reviewed. Both patients contracted subdural hematoma early in life; its persistence resulted in characteristic skull deformitites. The patients led an asymptomatic life until a second head trauma caused rebleeding into the old hematoma sac with recurring symptoms and signs. The source of rebleeding is the outer subdural membrane. Radiographic features vary, depending on the location and size of the subdural hematoma. The significance of localized thickening of the cranium is stressed in refining the differential diagnosis.

Dural liposarcoma associated with subdural hematoma. Case report.

On September 1, 1966, a 4-month-old baby girl was admitted to the hospital because of increasing head circumference and intermittent vomiting. No history of birth trauma or head injury could be obtained. First Admission. Head circumference was 18 inches, the fontanel full, and the scalp veins prominent. Radiographs showed marked separation of the sutures. The hemoglobin was 85 %. Fontanel aspiration yielded 40 cc of blood-stained fluid from the subdural cavity of each side, and thereafter 25 cc from each side on four successive days. Operation. On September 5, bitemporal burr holes drained further amounts of subdural hematoma and revealed a thin subdural membrane on the right side; there was no membrane on the left side. A 4F rubber tube placed in the right subdural cavity was removed the following day. The fontanel remained concave until the 10th postoperative day when it became tense; subdural tap released 30 cc of blood-stained fluid from the right side and 5 to 10 cc from the left side. Eleven days after the burr hole operation, unhealthy-looking skin over the right temporal burr hole was excised, and an additional burr hole was made more posteriorly on the right side, through which further subdural hematoma escaped. The right subdural space was drained with a 4F rubber catheter for 3 days. When the baby went home on September 23, 1966, the head circumference was 17.5 inches and the fontanel concave. Second Admission. On December 31, 1968, the child now 2 years 7 months was readmitted to the hospital because of headaches, vomiting, and increasing drowsiness of 4 weeks' duration. She was thin and pale, with slight neck rigidity. There was bilateral papilledema with retinal hemorrhages. The temperature was 36.2~ the head circumference 20 inches, and the fontanel fused. The right posterior burr hole was bulging but not tense. Power in the limbs was normal, reflexes uniformly brisk, and plantar responses both extensor. The hemoglobin was 79%, white blood cell count 84,000 cu mm with predominant polymorphs, and the sedimentation rate 50 mm in the first hour. X-ray films of the skull showed marked separation of sutures. The serum electrolytes were normal and the blood urea 37 mg%. Bilateral carotid angiograms showed a lens-shaped filling defect on the right anteroposterior venogram, and the left lateral venogram showed a filling defect in the posterior parietal region. Operation. On January 1, 1969, a burr hole placed just above and behind the left

Late complications of hemispherectomy: report of a case relieved by surgery.

A case of Sturge-Weber disease treated with left hemispherectomy presented, 11 years later, with complications related to delayed intracranial haemorrhage. A loculation syndrome of the right lateral ventricle was detected and it was corrected by a ventriculoatrial shunt operation. The side of the hemispherectomy was evacuated of all the chronic products of haemorrhage, including the subdural membrane. The patient was relieved of her symptoms. It is considered that complications related to delayed haemorrhage after hemispherectomy are remediable.

Postmeningitic subdural effusions: the syndrome and its management.

LTHOUGH subdural effusions have been recognized since 19502 as a complication of purulent meningitis in infants, the precise role of these fluid collections and associated membranes on the course and sequelae of the meningitis is not clear. Effusions have been implicated as a cause of seizures, persistent fever, focal neurological deficits, a poor or relapsing clinical course, and increased intraeranial pressure. However, in as many as 50% of cases of meningitis without such manifestations, routine subdural taps may reveal fluid accumulations, a,a4 and, conversely, effusions may be absent when clinically suspected. 11 There is a divergence of opinion as to the optimal management of postmeningitic effusions. Since many effusions following meningifts are encapsulated and resemble infantile subdural hematomas, techniques already in vogue for treating the latter have been applied to the former. 4,a Ingraham and his associates e-s have popularized the concept that eraniotomy for stripping of subdural membranes is essential for achieving the best results. However, this notion has not gone unchallenged. Recently, some neurosurgeons, no longer convinced that removal of subdural membranes is necessary for sueeessful treatment, have proposed various operations to shunt subdural fluid to other body cavities. ~,1~ Pediatricians, who have had the most experience in treating and following infants with meningitis and its complications, generally favor nonoperative management of subdural effusions and refer only recalcitrant cases for neurosurgical treatment.a,5,1a This is a study of 30 selected cases of postmeningitic subdural effusions treated by repeated taps which were often followed by burr holes and craniotomy. Our analysis has

Subdural haematoma and effusion in infancy.

Analysis of 116 cases of subdural haematoma and effusion in infancy showed that in 40% trauma was involved and in 5% meningitis was an aetiological factor; in the remainder there was no known antecedent disease. Apart from retinal or subhyaloid haemorrhages there were no clinical features pathognomonic of the condition, though vomiting was the commonest presenting symptom and a tense fontanelle the commonest finding on examination. Treatment by subdural pleural shunt operation, which allows the fluid to drain into the chest, where it is absorbed, was found to be effective, and there is no longer any justification for the older method of removal of the subdural membrane by craniotomy.

RADIOISOTOPIC LOCALIZATION IN SUBDURAL HEMATOMAS. AN EXPERIMENTAL STUDY WITH ARSENIC-74 AND RADIOIODINATED HUMAN SERUM ALBUMIN IN DOGS.

Observations were made of the differential qualitative and quantitative uptakes of As/sup 74/ and I/sup 131/-labeled human serum albumin (RISA) in experimental subdural hematomas and adjacent tissues of dogs to augment results available from human biopsy samples, and to elucidate more fully the nature and magnitude of the uptake of these isotopes in hematomas. Intracranial distribution of the isotopes was studied in 20 dogs with experimental subdural hematomas, 7--41 days old. Radioautography and radioassay of samples were used to determine and compare the uptakes of the two isotopes in these lesions and contiguous tissue. Concentrations of both isotopes were higher in the subdural membranes than in the more inert contents of the hematomas or subjacent cerebral cortex. This contignous cortex in turn contained somewhat higher activities of the isotopes than did cortex from the normal hemispheres. Ratios of the concentrations in the subdural hematomas to underlying brain were greater with RISA than with As/sup 74/, suggesting the preferential use of RISA for clinical scanning. These studies indicate that it is the nature of the subdural membranes that largely determines the extent of the uptake of As/sup 74/ or RISA about subdural hematomas. The similarity of these experimental data to themore » results found in clinical biopsy material indicated that these observations can be applied to man. The higher activity of RISA found in cortex subjacent to the hematoma relative to normal cerebral cortex may aid in the lateralization of these subdural lesions in scanning. The chief disadvantage of the use of RISA in the detection of subdural hematomas as compared to scanning with As/sup 74/ is the tendency of RISA to remain at higher levels in the blood. Thus, normally in the scan the activity is higher over the cranial periphery. Since this experimental study, subdural hematomas also were demonstrated more clearly by photoscanning with Hg/sup 203/ -tagged Neohydrin, and recent experience here with this newer agent in three patients suggests that subdural hematomas may be detected more readily by scanning with it than with either As/sup 74/ or RISA. (BBB)« less

Peritoneal drainage of subdural hematomas in infants

Summary A technique for internal drainage of subdural hematomas in infants is described. The results of subdural peritoneal drainage in 14 patients are summarized. There were 9 bilateral and 5 unilateral subdural hematomas in the group of infants. Good results were obtained in 14 of the 23 sides. Serial biopsy of the subdural membranes showed marked regression in membrane thickness, cellularity, and vascularity provided drainage was adequate. The results suggest that with adequate drainage of subdural hematomas in infants, excision of the membranes is not always indicated.

Subdural membrane with arachnoiditis of the otic chiasm: a clinical and pathological report.

Arachnoiditis involving the optic nerves and chiasm has been reported previously by Heuer and Vail 4 (1931), Craig and Lillie 1 (1931), and Ryan 7 (1943). Except for Davis and Haven's 3 study of the arachnoid membrane (1931), the reported cases were clinical and surgical without microscopic study of the adhesion or cyst. The clinical concept of arachnoiditis does not appear to be clearly defined in previous reports, for Walsh 8 stated that he was skeptical regarding its existence. The recognition of arachnoiditis is of great importance, since it frequently produces a chiasmal syndrome which simulates a suprasellar neoplasm or aneurysm. Further, with lysis of adhesions or release of cystic collections of fluid by surgery, many have obtained improvement of vision. The occurrence of a free subdural membrane with arachnoiditis of the optic nerves and chiasm after spinal anesthesia and meningitis has not been previously noted. The following case is,