Otomastoiditis crónica supurada complicada con absceso extradural y colecciónsupurada subcutánea (Absceso de Bezold), asociada a hematoma subdural crónico / Chronic suppurative otomastoiditis complicated with extradural abscess and subcutaneous suppurative collection (Bezold's abscess), associated with chronic subdural hematoma

Introducción: Las complicaciones intracraneanas de la otomastoiditis crónica supurada (OMCS) se ven cada vez con menor frecuencia gracias al diagnóstico precoz, acceso a imagenología y uso de antibióticos. La asociación de una OMCS con empiema extradural y hematoma subdural crónico es extremadamente infrecuente y y reportar un caso clinico es el objetivo de este reporte. Caso clínico: Paciente de 28 años, con historia de trauma craneano dos meses antes del ingreso. Consultó por otorrea fétida derecha de 45 días de evolución. Un mes previo a la consulta instala tumoración fluctuante en planos superficiales de región temporoparietal derecha que aumenta de tamaño y se hace dolorosa. Examen neurológico normal. Se realiza tomografía de cráneo que evidencia colección extradural y subdural, asociada a otomastoiditis. Se intervino en conjunto con ORL para evacuación del proceso supurado intracraneano y mastoidectomía, encontrándose en el intraoperatorio que la colección subdural no era infecciosa (empiema), sino que era un hematoma subdural crónico. La evolución fue buena siendo dado de alta asintomático. Reportamos esta asociación lesional muy poco frecuente, cuyo diagnóstico preoperatorio hubiera hecho variar la táctica neuroquirúrgica. Se discuten los hechos clínicos e imagenológicos que podrían haber llevado al diagnóstico correcto.

Introduction: Intracranial complications of chronic suppurative otomastoiditis (OMCS) are seen less and less frequently seen thanks to early diagnosis, access to imaging and access to antibiotics. The association of an OMCS with extradural empyema and chronic subdural hematoma is extremely infrequent. We report a clincal case of OMCS associated with a chronic subdural haematoma. Clinical case: A 28-year-old patient with a history of cranial trauma two months before admission, who consulted for a 46-day history of fetid otorrhea. One month prior to the consultation, he detected a fluctuating tumor in superficial planes of the right temporoparietal region that increased and became painful. He has a normal neurological examination. We performed a cranial CT and we detected an extradural and subdural collection, associated with otomastoiditis. A surgical intervention with a combined team was performed (Othologist and neurosurgeons). The aim of the surgery to evacuate the intracranial process and mastoidectomy. In the intraoperative period, we discovered that the subdural collection was not infectious but a chronic subdural hematoma. The evolution was good being discharged asymptomatic. We report a very rare association (OMCS with chronic subdural haematoma), whose preoperative diagnosis would have changed the neurosurgical tactic. Clinical and imaging facts that could have led to the correct diagnosis are discussed.

Acute subdural haematoma and its various aspects; A Clinical study

Acute subdural hematoma is one of the most common types of intra cranial hematoma caused by trauma accounting for more than 20% severe head injuries and resulting in highest mortality. Various studies have been made to understand the consequences and surgical outcomes of SDH patients. Therefore, the present study was designed to evaluate the clinical spectrum and assess the outcome of surgery in SDH patients. Methods: Present study included 50 patients of both sexes from 1 to 70 years age group with head injury, diagnosed to have traumatic subdural haemorrhage. Clinical examination included pupillary anisocoria, hemodynamic status, extent of hematoma either focal or diffuse, midline shift, GCS, status of basal cisterns, blood pressure. All the patients included in the study underwent surgical procedure for the removal of haematoma. Results: There was 100% mortality rate in patients with bilaterally dilated pupils. Whereas, there was 24.13% and 5.5% mortality rate respectively in unilateral dilated and normal pupil patients. Most of the patient had GCS <8 (40%), followed by GCS 9-12 (34%) and GCS 13-15 (26%) at the time of admission in the hospital. Further, GCS <8, GCS 9-12and GCS 13-15 were found in 32%, 40% and 28% correspondingly in patients after resuscitation. Conclusion: Findings of present study showed that there was an inverse relation between interval between injury and surgery with prognosis, Greater the interval poor will be outcome of surgery. Basal cistern obliteration is a reliable marker of increased intra cranial pressure which is responsible for poor outcome. Further, hypotension is also one of the important factors affecting the outcome of surgery in SDH patients.

Gauze Packing for the Massive Venous Sinus Bleeding in a Patient with Acute Subdural Hematoma of Posterior Fossa / 대한신경손상학회지

A 57-year-old male had cardiac arrest during an operation of traumatic acute subdural haematoma (ASDH) and intraparenchymal haemorrhage in the infratentorium due to a great amount of bleeding from the pre-injured venous sinus. After effective bleeding control using a gauze, the patient recovered without additional neurological sequelae. The operation of traumatic ASDH in the infratentorium always poses a risk of excessive bleeding from the injured venous sinus that could be life-threatening to the patient. This risk could be avoided with the effective first method that can immediately control the bleeding.

Comparison of frontoparietal drill versus parietal drill in burring hole and drainage for chronic subdural hematoma / 局解手术学杂志

Objective To investigate the efficacy of frontoparietal drill versus parietal drill in the burring hole and drainage for chronic subdural hematoma(CSDH),and provide an evidence for clinical application.Methods A total of 82 patients with CSDH from January 2013 to January 2016 in our hospital were randomly divided into observation group and control group.The observation group chose frontoparietal drill which located at the front 1/4 point at the axial view with the thickest hematoma.Control group chose parietal drill which nearby the parietal tuberodties at the axial view with the thickest hematoma.The postoperative residual hematoma volume,intracranial gas volume,recurrence rate,neurologic function and mental state between two groups were compared.Results The postoperative residual hematoma volume,intracranial gas volume,the recurrence rate and CSS were lower compared with the control group,the differences were significant(P<0.05).The MMSE score of observation group were higher that of the control group,the difference was significant(P<0.05).Conclusion The frontoparietal drill has a better effect to remove the hematoma and promotes neural functional recovery.

Curative efficacy of atorvastatin adjuvant therapy in chronic subdural haematoma undergoing trepanation and drainage and its effect on serum NSE / 中国生化药物杂志

Objective To investigate the curative efficacy of adjuvant therapy of atorvastatin in chronic subdural haematoma ( CSDH ) patients treated with trepanation and drainage and its effects on level of serum neuron specific enolase ( NSE ) .Methods 98 patients of CSDH who received therapy in our hospital from January 2014 to April 2016 were selected as research objects.Retrospectively analyzing their clinic materials,those patients were divided into the control group(n=46)and the observation group(n=52)according to therapeutic schemes.The control group were given therapy of trepanation and drainage.Besides that,the observation group were given atorvastatin additionally.2 months later,curative efficacy,China stroke scale (CSS)score and ability of daily life(ADL)score were compared between the two groups.And level of serum NSE between the two groups before treatment and after 7 days were compared.Results The total therapeutic efficacy ratio of CSDH in the observation group was 88.5%,which was statistically higher than that of 71.7% in the control group(P<0.05).2 months after the treatment,in comparison with the control group,the observation group has lower CSS score(15.89 ±3.24 points vs.19.21 ±4.17 points)and higher ADL score(95.24 ±11.36 points vs.89.05 ±10.12 points)with both statistical differences( P<0.05 ) .7 days after the treatment, level of serum NSE in the observation group was statistically lower than that in the control group (10.38 ±2.35 U/mL vs.14.06 ±2.68 U/mL,P <0.05).Conclusion Adjuvant therapy of atorvastatin is effective for CSDH patients treated with trepanation and drainage,and it could improve neurologic function,ability of daily life and reduce level of serum NSE.

Life-threatening acute subdural haematoma after combined spinal-epidural anaesthesia in labour / Hematoma subdural agudo potencialmente fatal após anestesia combinada raqui-peridural em parto

ABSTRACTBACKGROUND AND OBJECTIVES: Only few reports in literature have pointed out to the possibility of a cranial subdural haematoma formation associated with dural puncture during spinal or epidural analgesia. We herein describe such a rare case who was diagnosed to have acute subdural haematoma after combined spinal-epidural anaesthesia used in labour.CASE REPORT: A 34-year-old, primigravid women with a gestation of 38 weeks underwent caesarean section under combined spinal-epidural anaesthesia and gave birth to a healthy boy. Thirty-two hours after delivery, her moderate headache progressed to a severe headache associated with nausea and vomiting and later was more complicated with a generalized tonic-clonic seizure and ensuing lethargy. Computed tomography of the brain demonstrated a right-sided fronto-temporo-parietal acute subdural haematoma with diffuse cerebral oedema. She underwent urgent FTP craniotomy and evacuation of the haematoma. Early postoperative cranial computed tomography showed a clean operative site. Eight days after subdural haematoma surgery, she became lethargic again, and this time cranial computed tomography disclosed an extradural haematoma under the bone flap for which she had to undergo surgery again. Two days later, she was discharged home with Karnofsky performance score of 90/100. At follow-up exam, she was neurologically intact and her cranial computed tomography and magnetic resonance were normal.CONCLUSIONS: As conclusion, with the use of this combined spinal-epidural anaesthesia, it should be kept in mind that headache does not always mean low pressure headache associated with spinal anaesthesia and that a catastrophic complication of subdural haematoma may also occur.

RESUMOJUSTIFICATIVA E OBJETIVOS: Apenas alguns relatos na literatura mencionaram a possibilidade de formação de hematoma subdural craniano associada à punção durante a raquianestesia ou anestesia epidural. O presente relato descreve um caso tão raro que foi diagnosticado como hematoma subdural agudo após anestesia combinada raqui-peridural usada em parto.RELATO DE CASO: Paciente primípara, 34 anos, com 38 semanas de gestação, submetida à cesariana sob anestesia combinada raqui-peridural, deu à luz um menino saudável. Após 32 horas do parto, a dor de cabeça moderada da paciente progrediu para dor de cabeça intensa associada a náusea e vômito e se complicou subsequentemente com crise convulsiva generalizada tônico-clônica e consequente letargia. Tomografia computadorizada do cérebro revelou hematoma subdural agudo do lado direito em região frontotemporoparietal (FTP) com edema cerebral difuso. A paciente foi submetida à craniotomia FTP de urgência e evacuação do hematoma. Tomografia computadorizada do crânio no pós-operatório precoce mostrou um sítio operatório limpo. Oito dias após a cirurgia do hematoma subdural, a paciente voltou a ficar letárgica e, dessa vez, a tomografia computadorizada revelou um hematoma extradural sob o retalho ósseo que exigiu outra cirurgia. Dois dias depois, a paciente recebeu alta hospitalar com classificação de desempenho Karnofsky de 90/100. Ao exame de acompanhamento, a paciente apresentou-se neurologicamente intacta e sua tomografia computadorizada e ressonância magnética estavam normais.CONCLUSÃO: Ao usar a anestesia combinada raqui-peridural deve-se ter em mente que dor de cabeça nem sempre significa dor de cabeça hipotensiva associada à raquianestesia e que uma complicação catastrófica de hematoma subdural também pode ocorrer.

Síndrome del niño sacudido / Shaken baby syndrome

El síndrome del niño sacudido (SNS) es una forma de abuso físico caracterizada por ciertos hallazgos clínicos entre los que se encuentran presencia de hematoma subdural o subaracnoideo, edema cerebral difuso, y hemorragias retinianas, en ausencia de otras muestras físicas de lesión traumática, los cuales se producen al sacudir fuertemente al niño tomado del tórax o las extremidades. La aceleración-desaceleracion producida por dicho movimiento constituye el mecanismo de lesión. El cuadro clínico se puede manifestar con hallazgos inespecíficos como vómitos, somnolencia, irritabilidad hasta signos como los mencionados anteriormente, estos niños suelen presentar secuelas a corto y largo plazo. En Costa Rica la legislación ampara al menor contra los maltratos y da al sistema de salud la labor de salvaguardar la integridad y vida del mismo.

The shaken baby syndrome (SBS) is a form of physical abuse characterized for some clinical findings including the presence of a subdural or subarachnoid haematoma, diffuse cerebral edema and retinal haemorrhages and absence of other physical signs of traumatic injury which are produced when the victim is held by the torso or the extremities and violently shaken. The acceleration - deceleration produced by the movement is thought to be the production mechanism of the injury. The clinical findings could be as unspecific as vomits, sleepiness, irritability or signs like the ones listed above, this children often presents short and long term complications. In Costa Rica the legislation protects the children against abuses and give the health system the responsibility of taking care of children’s integrity and life.

Therapeutic efficacy of modified drain-pipe enhancing the effect of drainage in chronic subdural hematoma / 实用医学杂志

Objective To study the effect of different draining way in the surgical treatment of chronic subdural haematoma (CSDH). Methods 126 patients with CSDH diagnosed by CT scanning or MRI were enrolled. The burr-hole was made at the site of the maximal hematoma thickness. A drainage tube was placed towards either the occipital (group A) or frontal ( group B) region as far as possible respectively, and for the latter, a lateral aperture was made about 2 cm far from the burr-hole on the side of the tube. The surgical complication (such as pneumocephalus, brain injury and recurrent hematoma et al.) and therapeutic efficacy of the two treatments were compared and analyzed to evaluate an optimal surgical technique. Results After treatment, complication rate in group A is 30%, the occurrence of complications in group B rate is 2% (P <0.05); operation time and hospitalization time in group B was significantly shorter than that in group A (P <0.05). Conclusion In the surgical treatment of CSDH, improved drainage pathway is safe and effective, which could improve the treatment efficacy and is worthy of clinical promotion.

Chronic subdural haematoma presenting as late onset psychosis

This case report highlights a case of late onset psychosis which was an uncommon occurrence to psychiatric services in developing countries. Medical causes of late onset psychosis, though known, are often missed. Chronic subdural haematoma (CSDH) is predominantly a disease of the elderly. A history of direct trauma to the head is usually absent. Methods: A previously healthy 80-year-old male presented with 4 months duration of late onset psychosis. Result: Neurological examination was normal. Routine investigations were within normal limits and MRI brain revealed a chronic subdural haematoma. Owing to his age and small size of the haematoma, patient was not operated on and showed improvement with the pharmacologic treatment for psychosis. Conclusion: Detailed longitudinal history, clinical examination, investigations along with high index of suspicion is necessary to effectively manage this condition. As CSDH is known as a great imitator and is usually a disease of the elderly, it should be kept in mind while dealing with cases of late onset psychosis.

Simultaneous Bilateral Proximal Humeri Anterior Fracture Dislocations in a Patient with 1st Onset Seizure. A Case Report and Review of the Literature

Bilateral anterior fracture-dislocations of humeral neck in a patient with seizure are extremely rare. We describe a rare case of a 33 -year-old Chinese gentleman who presented post seizure secondary to subdural gliosis, sequelae from a previous subdural haematoma. Following physical examination and radiographic assessment, including a Computed Tomography scan (CT scan), Rarely fracturedislocation of bilateral proximal humeri were diagnosed; similar fracture patterns were noted. Open reduction and internal fixation with PHILOS proximal humeral locking plate allowed early shoulder rehabilitation.

Hematoma subdural crónico: modalidades de tratamiento: revisión del tema: propuestas de manejo / Chronic subdural hematomas: treatment modalities: review of the literature

El hematoma subdural crónico constituye una entidad nosológica frecuente en la práctica neuroquirúrgica, existiendo múltiples modalidades de tratamiento propuestas con resultados muy diversos. Se hizo una revisión de varios de los aspectos del tratamiento de estos pacientes para intentar formular recomendaciones generales de manejo de acuerdo a los trabajos científicos publicados y a la experiencia de los autores. Se plantea un tratamiento basado en la fisiopatología del hematoma subdural crónico y su correspondiente traducción imagenológica.

Chronic Subdural Haematoma is a frequent neurosurgical condition,with multple treatment modalities and diverse results. The authors have made a review of various aspects of treatmentin these patients aiming to establish general recommendations, based on the scientific publications and their own experience. The proposed treatment is based on the physiopatology of theChronic Subdural Haematoma and the images pattern.

Síndrome de la niña y el niño sacudidos: hallazgos anatomoclínicos / Shaken baby syndrome: anatomoclinic features

El síndrome del niño sacudido es una de las formas más severas de maltrato infantil que ocurre principalmente en niños menores de un año. Por la vulnerabilidad de las víctimas y por las secuelas que puede producir, incluyendo la muerte, es necesario, en el abordaje clínico, tener presente la sospecha diagnóstica ante lesiones de explicación insatisfactoria por parte de los encargados del menor. Asimismo si se trata de un abordaje médico legal deben tenerse las consideraciones necesarias para documentar las lesiones, tanto en el paciente vivo, como en los casos de homicidio, para colaborar con la administración de justicia. Para ello se debe tratar de implementar una metodología homogénea para la realización de dichas pericias, tanto en la parte clínica como patológico forense. En este artículo se describe la forma habitual de presentación clínica del síndrome del niño sacudido y se expone una guía básica para la realización de autopsias medico legales en casos de muertes por esta causa.

The shaken baby syndrome is one of the most severe presentations of child abuse that is seen in children especially under the first year of age. The great vulnerability of this group of patients and the serious consequences that they may encounter in the future, including death, are enough reason to inquire, during the clinical approach, about the possibility that the patient being attended may be a victim of physical abuse. From a medico-legal evaluation, it is pertinent to document and describe thoroughly the physical lesions in the living patient and in cases of homicide, in order to contribute scientifically in the administration of justice. For that reason it is essential to follow a uniform methodology in the management of both the clinical and the forensic assessment. This article reviews the usual clinical presentation of the shaken baby syndrome and proposes a basic guide to evaluate the autopsies in cases of deaths originated by this cause.

Diagnosis and results of surgery for 39 patients with chronic post-traumatic subdural haematoma treated at the 103 Hospital

Review 39 patients with chronic post-traumatic subdural haematoma, who were treated at the 103 Hospital between January 2000 and July 2003. CT scan is a good method of diagnosis and select surgery. The methods of surgery concluded: Burr-hole cranniostomy for haematoma evacuation and irrigation and closed-system drainge are safe and effective method for treatment. Results: 92.3% patients with good outcome, recurrence occurred in 2 cases, airway injection in 2 cases, there wasn't death.

The life threatening bilateral subdural haematoma: A case report.

Chronic subdural haematona (CSH) is one of the great mimicker in neurology and usually leading to misdiagnosis, because the symptoms and sign are variable. Most patients usually had no previous history of head injury. Bilateral subdural haematoma is even more different to diagnosis and it is one of the most life threatening condition, but fortunately it is a very rare event. We report a 52 year old man who had suffered from severe headache for 1 mouth and later developed confusion. CT scan and lumbar puncture were done at the other hospital. But the diagnosis was dubious and paracetamol was prescribed. He was referred to Siriraj Hospital by himself. Repeated lumber puncture was done and the result was still normal then he was consulted but his previous neuroimagine revealed bilateral isodensity subdural haematoma. Haemolytic clot from subdural haematoma was removed bilaterally in the same day which resulted in complete resolution of confusion and headache.

Chronic subdural haematoma in adults: A clinical analysis of 120 cases.

Clinical analysis of 120 adult patients with chronic subdural haematoma admitted into the Department of Surgery Siriraj Hospital showed that the majority of them (75%) were male with the highest incidence during 51ข90 year of age 70% of cases) followed by age range 21ข50 (30% of cases). The ratio of male to female was 3: 1. Ninety four patients gave history of minor head trauma without loss of consciousness. A rather insidious onset of progressive headache plus focal neurological deficits was the main symptoms and signs which led to medical intention. Computerized tomography of the brain was the brain was the investigation of choice. All 120 cases were operated upon for removal of lesions by Burr holes and drainage. The result of operative treatment was excellent and there was no operative death in this series.