Parche de sangre cervical para tratamiento de síndrome de hipotensión/ hipovolumen de líquido cefalorraquídeo espontáneo. Reporte de un caso / Cervical blood patch for the treatment of spontaneous cerebrospinal fluid hypotension/hypovolume syndrome. A case report

Presentamos el tratamiento eficaz de una filtración espontánea de líquido cefalorraquídeo (LCR) asociada a un síndrome de hipoten-sión/hipovolumen de LCR a nivel cervical alto, caracterizado por delirio y hematomas subdurales secundarios, refractarios al drenaje quirúrgico, que se resolvió con dos parches de sangre epidurales cervicales consecutivos.

We present the case of a cerebrospinal fluid (CSF) hypotension/hypovolume syndrome due to a spontaneous CSF fistula at the upper cervical level characterized by loss of consciousness and bilateral subdural hematomas refractory to two drainage surgeries that resolved with two consecutive blood patches on the leak site.

A 44-year-old male Filipino with Spontaneous Acute Subdural Hematoma and Subarachnoid Hemorrhage caused by a Dural Arteriovenous Fistula of the Occipital Lobe: A case report

Introduction@#Spontaneous acute subdural hematoma (ASDH) is rare and comprises 2.6% of all ASDH. In one recent study, only 178 spontaneous ASDH were documented. However, only 1 case was attributed to dural arteriovenous fistula (dAVF). Vascular malformations cause less than 10% of subarachnoid hemorrhage (SAH). Spontaneous ASDH and SAH occurring together are extremely rare. Literature is scarce on cases with dAVF of the occipital lobe as a cause of simultaneous spontaneous ASDH and SAH. @*Objective@#This paper aims to present a case of a spontaneous acute subdural hematoma and subarachnoid hemorrhage caused by a dural arteriovenous fistula of the occipital lobe, along with its clinical presentation, diagnosis, and treatment. @*Case Summary@#A 44-year-old Filipino male with no history of trauma presented with severe headache, vomiting, and decreasing sensorium – CT scan revealed acute parenchymal bleed in the left occipital lobe with subarachnoid extension and subdural hematoma in the left fronto-parieto-temporal convexity along the tentorium cerebelli and posterior interhemispheric falx. Due to the location of the lesion seen on the CT scan and the gender distribution, Arteriovenous malformation (AVM) was initially considered, thus proceeded to computed tomography angiogram (CTA) to establish the diagnosis of vascular anomaly, however, revealed dAVF instead. Four-vessel angiogram was done to assess the tributaries of the dAVF and confirmed the diagnosis. Complete obliteration of dAVF of the occipital lobe was done with Onyx Embolization in one session. @*Conclusion@#This is the first case of Borden type II, Cognard type IIa+IIb dAVF, as reported in this institution. Although extremely rare as a cause of SAH and ASDH, dAVF should be considered a differential diagnosis in patients with no identifiable common cause of the new onset of severe headache and poor neurologic status.

Delayed Operation of Acute Subdural Hematoma in Subacute Stage by Trephine Drainage using Urokinase / 대한신경손상학회지

OBJECTIVE: The principle operation of acute subdural hematoma (ASDH) is a craniotomy with hematoma removal, but a trephination with hematoma evacuation may be another method in selected cases. Trephine drainage was performed for ASDH patients in subacute stage using urokinase (UK) instillation, and its results were evaluated. METHODS: Between January 2016 and December 2018, the trephine evacuation using UK was performed in 9 patients. The interval between injury and operation was from 1 to 2 weeks. We underwent a burr hole trephination with drainage initially, and waited until the flow of liquefied hematoma stopped, then instilled UK for the purpose of clot liquefaction. RESULTS: The mean age of patients was 71.6 years (range, 38–90 years). The cause of ASDH was trauma in 8 cases, and supposed a complication of anticoagulant medication in 1 case. Four out of 8 patients took antiplatelet medications and one of them was a chronic alcoholism. The range of the Glasgow Coma Scale score before surgery was from 13 to 15. Most of patients, main symptom was headache at admission. The Glasgow Outcome Scale score was 5 in 8 cases and 3 in 1 case. CONCLUSION: It is thought to be a useful operation method in selected patients with ASDH that the subdural drainage in subacute stage with UK instillation. This method might be another useful option for the patients with good mental state regardless of age and the patients with a risk of bleeding due to antithrombotic medications.

Burr Hole Drainage with Urokinase Irrigation for the Treatment of Acute Subdural Hematoma: A Case Report / 대한신경손상학회지

We describe the case of a patient with an acute subdural hematoma (SDH) that was removed using urokinase irrigation after burr hole trephination in a limited situation where craniotomy was not possible. A 90-year-old woman was admitted to our hospital with a stuporous mental status. Computed tomography (CT) scans revealed a chronic SDH, and a burr hole procedure was performed. The patient's postoperative progression was good until the third day after surgery when we found that the acute SDH had increased on CT scans. The patient's guardian refused further surgery, and thus we drained the blood from the hematoma by injecting urokinase through a drainage catheter. We used urokinase for two days, and removed the catheter after confirming via CT scans that the hematoma was almost alleviated. The patient recovered gradually; she was discharged with few neurological deficits.

Development of Delayed Acute Subdural Hematoma after Mild Traumatic Brain Injury: A Case Report / 대한신경손상학회지

We report a case involving the development of a delayed acute subdural hematoma (ASDH) after trauma, with the absence of any abnormal radiological and clinical findings at initial examination. A 54-year-old male visited the emergency department after a minor trauma. The patient only complained of mild headache after head injury. He presented no abnormal findings on neurological examination, and brain computed tomography (CT) did not show any intracranial lesion or skull fractures. However, he developed seizure with disorientation eight hours after trauma, and ASDH with midline shift was found during a follow-up CT. He recovered without neurological deficits after immediate primary care and admission to the neurosurgery department. On serial follow-up CT images, a gradually increasing mass effect of hematoma was detected, and removed by craniotomy. The patient recovered without neurologic deficits.

Arachnoid Cyst with a Non-traumatic Acute Subdural Hematoma in an Eleven-year-old Patient

A non-traumatic intra-cystic hemorrhage in an arachnoid cyst is a rare event, with few cases reported in the literature. We present a case of an eleven-year-old boy patient, which presented a spontaneous acute subdural hematoma and intra-cystic hemorrhage after a strong headache episode. The results were evidenced by a computed tomography (CT) scan and surgical findings. We perform a brief literature review on the arachnoid cyst and its suggested treatments. In our case, the patient underwent a surgical treatment with a complete resolution of the case.

Sabe-se que uma hemorragia intracística não traumática em um cisto aracnoide é um acontecimento raro, com poucos casos relatados na literatura. Nós apresentamos o caso de um menino de onze anos de idade, o qual apresentou espontaneamente um hematoma subdural agudo acompanhado de hemorragia intracística após um forte episódio de dor de cabeça. Os resultados foram evidenciados através de uma tomografia computadorizada e dos achados cirúrgicos. Foi feita uma breve revisão da literatura sobre cisto aracnoide e seus respectivos tratamentos sugeridos.

Decompressive Craniectomy (DC) - Comparative Study of 30-Day Mortality in Surgeries of Severe Brain Trauma with Subdural Hematoma, with and without DC

Objective Compare 30 days mortality of patients harboring acute subdural hematomas in two series, one treated only by wide aspiration of hematoma and other with aspiration followed by decompressive craniectomy. Methods Comparing retrospectively two series of ASD with and without DC. Involved 81 TBI patients with acute subdural hematoma and GCS 8 (Jan 2000 to Nov 2014) arranged into two groups. Group 1 - 58 cases underwent to DC. Group 2 - 23 patients underwent only hematoma aspiration. Results Group 1 showed 44.8% mortality directly due to brain lesion within 30 days. The most frequent associated lesion were contusion in 37.2%. Group 2 the mortality within 30 days was 47.8%. The majority of deaths (82%) resulted from uncontrollable brain swelling, midline shift was present in 94.7% of patients. Conclusion High admission GCS and age less than 50 remain better outcome predictor in 30 days survival for patients undergoing surgery of traumatic ASDH.

Objetivo Comparar a mortalidade em 30 dias de pacientes que sofreram hematoma subdural agudo em duas séries, uma tratada por aspiração do hematoma e outro por aspiração seguida de craniectomia descompressiva. Métodos Comparar retrospectivamente duas séries de HSD com e sem CD. Envolveu 81 pacientes com TCE com hematoma subdural agudo e GCS 8 (Jan 2000 a Nov 2014) em dois grupos. Grupo 1­58 casos tratados submetidos a CD. Grupo 2­23 pacientes submetidos a drenagem do hematoma somente. Resultados Grupo 1 apresentou 44,8% de mortalidade diretamente devido a lesão cerebral dentro de 30 dias. A mais comum lesão associada era contusão em 37,2%. Grupo 2 a mortalidade dentro de 30 dias foi 47,8%. A maioria dos óbitos (82) resultou de edema cerebral incontrolável, desvio de linha média estava presente em 94,7% dos pacientes. Conclusão Alto GCS de admissão e idade menor que 50 anos permanecem melhores preditores de desfecho na mortalidade em 30 dias para paciente submetidas a cirurgia de hematoma subdural agudo.

Early Decompression of Acute Subdural Hematoma for Postoperative Neurological Improvement: A Single Center Retrospective Review of 10 Years / 대한신경손상학회지

OBJECTIVE: This study was conducted to investigate survival related factors, as well as to evaluate the effects of early decompression on acute subdural hematoma (ASDH). METHODS: We retrospectively reviewed cases of decompressive craniectomy (DC) for decade. In total, 198 cases of DC involved ASDH were available for review, and 65 cases were excluded due to missing data on onset time and a delayed operation after closed observation with medical care. Finally, 133 cases of DC with ASDH were included in this study, and various factors including the time interval between trauma onset and operation were evaluated. RESULTS: In the present study, survival rate after DC in patients with ASDH was shown to be related to patient age (50 years old, p=0.012), brain compression ratio (p=0.042) and brain stem compression (p=0.020). Sex, preoperative mental status, and time interval between trauma onset and operation were not related with survival rate. Among those that survived (n=78), improvements in Glasgow Coma Scale (GCS) score of more than three points, compared to preoperative measurement, were more frequently observed among the early (less than 3 hours between trauma onset and operation) decompressed cases (p=0.013). However, improvements of more than 4 or 5 points on the GCS were not affected by early decompression. CONCLUSION: Early decompression of ASDH was not correlated with survival rate, but was related with neurological improvement (more than three points on the GCS). Accordingly, early decompression in ASDH, if indicated, may be of particular benefit.

Stability of acute subdural hematoma in rats developed by subdural injection of different volumes of autologous blood / 中国比较医学杂志

ObjectiveToexplorethestabilityofratmodelsofsubduralhematomapreparedbysubduralinjection of different volumes of autologous blood .Methods The rats were randomly divided into sham group (36), 300μL blood group, 500 μL blood group, and 700 μL blood group (each group 60 rats).The rats of model groups received subdural injection of 300 μL, 500 μL, or 700 μL autologous blood, respectively.At the postoperative 2nd, 4th, 6th, 8th, 10th, 14th days, blood samples were taken from the abnormal aorta , and the brains were taken out for gross examination and taking photographs , six rats were used for each time .Enzyme linked immunosorbent assay ( ELISA ) was performed to determine the content of serum NSE and S100B proteins in the rats in each group.Results Compared with the sham operation group, the serum NSE in the 300μL group was significantly increased at the 2nd and 4th days (P0.05).In the 500 μL and 700 μL blood groups, the NSE contents at 2nd, 6th, 8th, 10th and 14th days were significantly increased ( P 0.05 ).The content of S100B protein in the 300 μL blood group was significantly higher at the fourth day (P0.05 for all ) , indicating that the hematoma disappeared gradually, and the damages repaired .The S100B protein content of the 500 μL and 700 μL blood groups was constantly kept at a higher level ( P<0.05 ) .Conclusions Compared with the 300 μL ad 700 μL blood groups , the rat model of subdural hematoma developed by subdural injection of 500 μL autologous blood is the best , and can be used for studies of rat subdural hematoma .

Acute Spontaneous Subdural Hematoma due to Rupture of a Tiny Cortical Arteriovenous Malformation

Acute subdural hematoma (SDH) of arterial origin is rare, especially SDH associated with an arteriovenous malformation (AVM) is extremely rare. The authors report a case of acute spontaneous SDH due to rupture of a tiny cortical AVM. A 51-year-old male presented with sudden onset headache and mentality deterioration without a history of trauma. Brain CT revealed a large volume acute SDH compressing the right cerebral hemisphere with subfalcine and tentorial herniation. Emergency decompressive craniectomy was performed to remove the hematoma and during surgery a small (5 mm sized) conglomerated aciniform mass with two surrounding enlarged vessels was identified on the parietal cortex. After warm saline irrigation of the mass, active bleeding developed from a one of the vessel. The bleeding was stopped by coagulation and the vessels were removed. Histopathological examination confirmed the lesion as an AVM. We concluded that a small cortical AVM existed at this area, and that the cortical AVM had caused the acute SDH. Follow up conventional angiography confirmed the absence of remnant AVM or any other vascular abnormality. This report demonstrates rupture of a cortical AVM is worth considering when a patient presents with non-traumatic SDH without intracerebral hemorrhage or subarachnoid hemorrhage.

Selection of Treatment for Large Non-Traumatic Subdural Hematoma Developed during Hemodialysis / 대한구급학회지

A 49-year-old man with end-stage renal disease was admitted to the hospital with a severe headache and vomiting. On neurological examination the Glasgow Coma Scale (GCS) score was 15 and his brain CT showed acute subdural hematoma over the right cerebral convexity with approximately 11-mm thickness and 9-mm midline shift. We chose a conservative treatment of scheduled neurological examination, anticonvulsant medication, serial brain CT scanning, and scheduled hemodialysis (three times per week) without using heparin. Ten days after admission, he complained of severe headache and a brain CT showed an increased amount of hemorrhage and midline shift. Emergency burr hole trephination and removal of the hematoma were performed, after which symptoms improved. However, nine days after the operation a sudden onset of general tonic-clonic seizure developed and a brain CT demonstrated an increased amount of subdural hematoma. Under the impression of persistent increased intracranial pressure, the patient was transferred to the intensive care unit (ICU) in order to control intracranial pressure. Management at the ICU consisted of regular intravenous mannitol infusion assisted with continuous renal replacement therapy. He stayed in the ICU for four days. Twenty days after the operation he was discharged without specific neurological deficits.

Hematoma subdural agudo espontâneo e hemorragia intracerebral em paciente com microangiopatia trombótica gestacional / Spontaneous acute subdural hematoma and intracerebral hemorrhage in a patient with thrombotic microangiopathy during pregnancy

Pré-eclâmpsia, síndrome HELLP (hemólise, elevação de enzimas hepáticas e plaquetopenia) e fígado gorduroso agudo da gestação são as principais causas de microangiopatia trombótica e disfunção hepática grave durante a gestação, representando um spectrum do mesmo processo patológico. Relatou-se aqui o caso de uma gestante com 35 semanas internada em unidade de terapia intensiva no pós-operatório imediato de cesariana por morte fetal, com náuseas, vômitos e icterícia. Diagnosticaram-se pré-eclâmpsia pós-parto e fígado gorduroso agudo da gestação. Houve evolução tardia com hematoma subdural agudo e hemorragia intracerebral, sendo realizado tratamento neurocirúrgico. A paciente foi a óbito por anemia hemolítica refratária, com sangramento espontâneo em múltiplos órgãos. Pré-eclâmpsia, síndrome HELLP e fígado gorduroso agudo da gestação são processos patológicos que podem se sobrepor e se associar a complicações potencialmente fatais, como a hemorragia intracraniana aqui descrita. Sua detecção e diagnóstico precoces são fundamentais para a instituição de manejo adequado e sucesso do tratamento.

Preeclampsia, HELLP syndrome (hemolysis, elevated liver enzymes, and low-platelet count), and acute fatty liver of pregnancy are the main causes of thrombotic microangiopathy and evere liver dysfunction during pregnancy and represent different manifestations of the same pathological continuum. The case of a 35-week pregnant woman who was admitted to an intensive care unit immediately after a Cesarean section due to fetal death and the presence of nausea, vomiting, and jaundice is reported. Postpartum preeclampsia and acute fatty liver of pregnancy were diagnosed. The patient developed an acute subdural hematoma and an intracerebral hemorrhage, which were subjected to neurosurgical treatment. The patient died from refractory hemolytic anemia and spontaneous bleeding of multiple organs. Preeclampsia HELLP syndrome, and acute fatty liver of pregnancy might overlap and be associated with potentially fatal complications, including intracranial hemorrhage, as in the present case. Early detection and diagnosis are crucial to ensure management and treatment success.

Natural Course of Initially Non-Operated Cases of Acute Subdural Hematoma : The Risk Factors of Hematoma Progression

OBJECTIVE: The objectives of the present study were to characterize the natural course of initially non-operated traumatic acute subdural hematoma (ASDH) and to identify the risk factors of hematoma progression. METHODS: Retrospective analysis was performed using sequential computed tomography (CT) images maintained in a prospective observational database containing 177 ASDH cases treated from 2005 to 2011. Patients were allocated to four groups as followings; 136 (76.8%) patients to the spontaneous resolution group, 12 (6.8%) who underwent operation between 4 hours and 7 days to the rapid worsening group (RWG), 24 (13.6%) who experienced an increase of hematoma and that underwent operation between 7 and 28 days to the subacute worsening group (SWG), and 5 (2.8%) who developed delayed aggravation requiring surgery from one month after onset to the delayed worsening group (DWG). Groups were compared with respect to various factors. RESULTS: No significant intergroup difference was found with respect to age, mechanism of injury, or initial Glasgow Coma Scale. The presence of combined cerebral contusion or subarachnoid hemorrhage was found to be a significant prognostic factor. Regarding CT findings, mixed density was common in the RWG and the SWG. Midline shifting, hematoma thickness, and numbers of CT slices containing hematoma were significant prognostic factors of the RWG and the SWG. Brain atrophy was more severe in the SWG and the DWG. CONCLUSION: A large proportion of initially non-operated ASDHs worsen in the acute or subacute phase. Patients with risk factors should be monitored carefully for progression by repeat CT imaging.

A Study of the Progression from Acute Subdural Hematoma to Chronic Stage Requiring Surgical Treatment / 대한신경손상학회지

OBJECTIVE: The conscious patients with a small amount of acute subdural hematoma had no neurological deterioration are managed conservatively. Most of them are resolved spontaneously in several weeks without surgery. In our experience, however, some progressed to chronic stage requiring surgical treatment in a few days, unlike chronic subdural hematoma derived from acute hematoma following several weeks or months after head trauma. We aimed to analyse this phenomenon and associated the risk factor comparing with the chronic subdural hematomas. METHODS: Retrospective analysis of 175 alert patients with unilateral acute subdural hematoma identified among 661 patients diagnosed the acute subdural hematoma from October 2009 to September 2012 was performed. Univariate and multivariate analyses were performed to describe the relationships between progression to chronic stage requiring surgery from small amount of acute subdural hematoma and clinical characteristics and radiologic features. RESULTS: Eighteen patients (10.3%) showed neurological deterioration due to progression to chronic stage of acute subdural hematoma and underwent a surgical treatment. The mean time interval between the head trauma and development of neurological symptoms was 12.7 days. Univariate and multivariate analyses found that depth of hematoma and degree of brain swelling were a risk factor for progression to chronic stage requiring surgery from the acute subdural hematoma. CONCLUSION: In spite of the conscious patients with acute subdural hematoma not requiring surgical decompression, the more amount of hematoma and the severer brain swelling, there is higher probability of neurological deterioration caused by the progression to chronic stage in a few days.

Clinical Outcomes of Patients with Good Neurological Scores in Spite of Significant Amounts of Acute Subdural Hematoma / 대한신경손상학회지

OBJECTIVE: Acute subdural hematoma (ASDH) with good initial Glasgow Coma Scale (GCS) score 13-15 is generally regarded as a mild head injury. However, the risk increases when significant amount of hematoma with midline shift exists. This study is to evaluate the clinical outcomes of patients with good neurological scores in spite of significant amounts of ASDH, and to compare the outcomes according to the treatment modalities. METHODS: Sixty patients with initial GCS score 13-15 in spite of significant amounts of ASDH and midline shifts were enrolled. They were divided into groups according to age, sex, side of location, initial GCS score, midline shift, and hematoma thickness. According to the therapeutic modalities, early craniotomy and initially conserved groups were identified, and initially conserved group was further classified into persistently conserved and delayed operation groups. The outcomes were measured by Glasgow Outcome Scale. RESULTS: Initial GCS score was a significant factor that influenced the final outcome (p=0.001). The outcomes were good in both early craniotomy and initially conserved groups without significant differences (p=0.268). Fifteen of initially conserved 49 patients underwent delayed operations from neurological deteriorations, but the outcomes were good without significant differences from persistently conserved group (p=0.481). CONCLUSION: Initial GCS score is an important factor that influences the clinical outcome. These patients can be conserved under close observations without early preventive craniotomies if no deteriorations are seen in the acute stage. Only those with delayed deteriorations may require simple operations such as burr hole trephinations which still guarantee good outcomes.

Hematoma subdural agudo infratentorial: relato de caso / Posterior fossa acute subdural hematoma: case report

Os autores relatam o caso de um paciente adulto vítima de traumatismo cranioencefálico e que apresentou uma lesão considerada rara na literatura, o hematoma subdural agudo da fossa posterior. O paciente foi submetido à craniectomia suboccipital com drenagem do hematoma e recebeu alta com escore de 3 pontos na Glasgow Outcome Scale; um bom resultado, pois essa lesão atinge 71% de mortalidade em algumas séries.

The authors report a case of acute subdural hematoma of posterior fossa in an adult male patient secondary to a head trauma. This is considered a rare pathology in literature. The patient was operated and discharged with a score 3 in GOS. This can be considered a good result since some series show a mortality of 71% for this pathology.

Acute Spontaneous Subdural Hematoma of Arterial Origin

Acute spontaneous subdural hematoma (SDH) of arterial origin is very rare. We report a case of acute spontaneous SDH that showed contrast media extravasation from cortical artery on angiograms. A 58-year-old male patient developed sudden onset headache and right hemiparesis. Brain CT scan demonstrated acute SDH at left convexity. The patient was drowsy mentality on admission. He had no history of head trauma. Cerebral angiography was performed and revealed a localized extravasation of the contrast media from distal cortical MCA branch. After angiography, the patient deteriorated to comatose mentality. Decompressive craniectomy for removal of SDH was performed. We verified the arterial origin of the bleeding and coagulated the bleeding focus. The histological diagnosis was aneurysmal artery. He recovered after surgery with mild disability. In a case of acute spontaneous SDH, the possibility of a cortical artery origin should be considered.

Inhospital Spontaneous Acute Subdural Hematoma (SADH) Patient with Antiplatelet Therapy due to Acute Cerebral Ischemia: A Case Report / 대한구급학회지

A case of "spontaneous" acute subdural hematoma caused by aspirin and plavix therapy has not been described previously. As an isolated cerebrovascular event related to aspirin and plavix therapy, this is the first report described in the literature. It also represents a new differential diagnosis for nontraumatic acute subdural hematomas.

Diagnosis and Treatment of acute subdural hematoma / 中国基层医药

Objective To investigate the clinical characteristics and therapeutic strategy of acute subdural hematoma. Methods A restrospective study was carried out with a total of 94 consecutive ASDH patients who were confirmed through computed tomographic scan and obtained the clinical characteristics by experienced neurosurgeons.15 cases werepure acute subdural hematoma and the other 79 cases were acute compound subdural hematoma according to CT scan. Results In accordance with the GOS,36 cases had good recovery,19 cases had moderate disability,17 cases had severe disability and 22 cases dead. Conclusion The most important treatment for pure acute subdural hematom was to diagnose the source of bleeding, and acute compound subdural hematoma had poor prognosis than pure acute subdural hematoma since the traumatic severity. Early decraniuim by large bone flap to treat acute compound subdural hematoma could improve survival rate,reduce the fatality rate and decrease postoperative complications.