Cerebro-venous hypertension: a frequent cause of so-called "external hydrocephalus" in infants.

INTRODUCTION: External hydrocephalus (eHC) is commonly defined as a subtype of infant "hydrocephalus" consisting of macrocepahly associated with enlarged subarachnoid space and no or mild ventriculomegaly. This status is thought to be related to impaired CSF absorption because of arachnoid villi immaturity. However, other factors like the venous system might be involved in the development of the clinical picture. METHODS: All patients diagnosed with eHC received prospectively contrast-enhanced 3D MR phlebography. Venous sis abnormalities were graded depending on the number of affected sinus segments and type. External CSF space volume was quantified planimetrically. RESULTS: Seventeen patients with the typical clinical feature of eHC were included. In 15, venous sinus abnormalities were found. There was a significant correlation between the volume of the widened cortical subarachnoid space (CSAS) and the number of venous sinus segments affected. Conversely, ventricular volume was not correlated. CONCLUSION: These results support the hypothesis that impaired venous outflow plays a major role in external hydrocephalus development. Raised venous pressure increases intracranial pressure accelerating head growth, resulting in an enlargement of the cortical subarachnoid space. Increased venous pressure increases the capillary bed pressure and brain turgor preventing ventricular space to enlarge forcing displacement of ventricular CSF to the subarachnoid space. As a result, ventriculomegaly is rarely found. The descriptive term "external hydrocephalus" implying a primary etiology within the CSF system is misleading and this work supports the notion that venous hypertension is the leading cause of the clinical picture.

Venous or arterial blood components trigger more brain swelling, tissue death after acute subdural hematoma compared to elderly atrophic brain with subdural effusion (SDE) model rats.

Acute subdural hematoma (ASDH) is a frequent complication of severe head injury, whose secondary ischemic lesions are often responsible for the severity of the disease. We focused on the differences of secondary ischemic lesions caused by the components, 0.4ml venous- or arterial-blood, or saline, infused in the subdural space, evaluating the differences in vivo model, using rats. The saline infused rats are made for elderly atrophic brain with subdural effusion (SDE) model. Our data showed that subdural blood, both venous- and arterial-blood, aggravate brain edema and lesion development more than SDE. This study is the first study, in which different fluids in rats' subdural space, ASDH or SDE are compared with the extension of early and delayed brain damage by measuring brain edema and histological lesion volume. Blood constituents started to affect the degree of ischemia underneath the subdural hemorrhage, leading to more pronounced breakdown of the blood-brain barrier and brain damage. This indicates that further strategies to treat blood-dependent effects more efficiently are in view for patients with ASDH.

Hematoma subdural crónico calcificado: cerebro blindado / Chronic calcified subdural haematoma: armoured brain

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Update on intracranial hypertension and hypotension.

PURPOSE OF REVIEW: The aim of this article is to review recent findings on the pathophysiology of idiopathic changes in intracranial pressure. The review will focus on idiopathic intracranial hypertension (IIH) and spontaneous intracranial hypotension (SIH). RECENT FINDINGS: Substantial evidence indicates that IIH is associated with delayed absorption of cerebrospinal fluid (CSF). Stenoses of the transverse sinus are common in IIH, but their clinical significance has not been entirely clarified. Despite the observed efficacy of endovascular treatment in some IIH patients, a correlation between the extent of observed stenoses and the clinical course of the disease could not be demonstrated. The underlying cause of SIH is a spontaneous CSF leakage into the epidural space. Conservative treatment and the epidural blood patch remain the treatment of choice for this rare syndrome. SUMMARY: Recent clinical evidence indicates that IIH is probably a result of CSF outflow abnormality rather than of CSF production. Further research is needed to elucidate the causes of elevated intracranial pressure and the mechanism leading to visual loss. Prospective randomized clinical trials are needed to clarify a possible therapeutic potential of endovascular treatment. Research efforts on SIH should focus further on associated connective tissue disorders predisposing to CSF leaks.

Pathophysiology and management of spontaneous intracranial hypotension--a review.

Spontaneous Intracranial Hypotension is a syndrome involving reduced intracranial pressure secondary to a dural tear which occurs mostly due to connective tissue disorders such as Marfans Syndrome, and Ehler Danlos Syndrome. Patients with dural ectasias leading to CSF leakage into the subdural or epidural space classically present with orthostatic headaches and cranial nerve deficits mostly seen in cranial nerves V-VIII. Diagnosis of SIH is confirmed with the aid of neuroimaging modalities of which Cranial MR imaging is most widely used. SIH can be treated conservatively or with epidural blood patches which are now widely being used to repair dural tears, and their effectiveness is being recognized. Recently epidural injection of fibrin glue has also been used which has been found to be effective in certain patients.

Postoperative extra-axial cerebrospinal fluid collection--its pathophysiology and clinical management.

OBJECTIVE: External hydrocephalus, introduced by Dandy and Blackfan in 1914 [Am J Dis Child 1914;8:406-482], is used to describe the clinical condition of cerebrospinal fluid (CSF) accumulation in the subarachnoid space with its space expansion and increased intracranial pressure in pediatric patients. Benign subdural effusion, subdural hygroma and pseudohydrocephalus are some terms used to describe some conditions, not clearly defined at the moment as separate pathological entities. We report 3 pediatric cases which had CSF collections after craniotomy. Neuroimaging investigations revealed CSF collection after surgery. All 3 cases had a poor clinical course with resolution after shunting. This report analyzes the mechanisms and pathophysiology of postoperative extra-axial CSF collections (PECC), indicating that CSF accumulations in the extra-axial spaces (inside or outside the arachnoid) after surgery have a common pathophysiology. Therefore, the treatment protocol can be specific. PATIENTS: Three pediatric cases, aged from 11 months to 6 years, had large tumors located from their suprasellar region to the hypothalamus and third ventricle. The tumors were excised surgically through either an anterior interhemispheric translamina-terminalis or a transsylvian translamina-terminalis approach or both. The surgery conducted created a wide opening of the anterior interhemispheric or the sylvian fissures, dissecting the lamina terminalis and Liliequist's membrane resulting in a new artificial CSF tract from the basal cisterns to the subdural space. Clinical symptoms such as deterioration of consciousness level developed within a few weeks after surgery, and a follow-up computed tomography image confirmed subdural CSF collection. Symptoms improved after ventriculoperitoneal (V-P) shunting. DISCUSSION: External hydrocephalus, subdural effusion and the other entities mentioned above are frequently observed in children, and little is known about their pathophysiology. To differentiate from the whole entity of CSF accumulation within the subdural and subarachnoid space, we use the term PECC to specify the main pathophysiological condition resulting from a wide dissection and opening of the arachnoid membrane and communication with the basal cisterns. CONCLUSION: We present the occurrence of CSF collections in the extra-axial space after surgery as the specific condition of PECC. Broadly dissecting the arachnoid membrane, with a communication remaining with the ventricles, is the main factor contributing to PECC, and patients have shown that V-P shunting is an effective procedure preventing progression and effectively treating PECC.

Subdural hygroma-related heterotopic ossification in a patient with a stroke: a case report.

BACKGROUND: This study presents a patient with a stroke who had total paralysis of his left-side limbs after intracranial haemorrhaging, who later experienced partial weakness of the right-side limbs after a subdural hygroma. Both conditions occurred without major trauma. He received two separate operations, a craniotomy and placement of a ventriculoperitoneal shunt, before the appearance of the subdural hygroma. CASE STUDY: According to the literature, heterotopic ossification is often reported with major trauma-associated diseases, but is less frequently found in patients with non-traumatic conditions, from which this patient suffered. Although the patient had experienced no major trauma, he had multiple heterotopic ossifications on the side of the subdural hygroma-affected limbs, which exhibited better motor control and were less spastic than those of the opposite side. These heterotopic ossifications were around joints of the hip, knee and shoulder on his right side, as proven by plain radiography and a triple-phase bone scan and resulted in marked limitations of joint motions. This patient thus had major disabilities of his limbs bilaterally. CONCLUSIONS: The occurrence of heterotopic ossifications in the less-paretic limbs might have worsened this patient's functional outcome.

Multiple supra- and infratentorial intraparenchymal hemorrhages presenting with seizure after massive sacral cerebrospinal fluid drainage.

STUDY DESIGN: Case report and review of the literature. OBJECTIVE: To describe a case of multiple supra- and infratentorial hemorrhages after spinal surgery presenting with seizure. SUMMARY OF BACKGROUND DATA: Cerebrospinal fluid overdrainage is a well-documented factor associated with remote cerebellar hemorrhage, but supratentorial hemorrhages after spinal surgery have been reported rarely. METHODS: A 64-year-old woman underwent a sacral laminectomy for recurrent chordoma. A negative pressure wound drain was left in after surgery and drained 1300 mL in the first 48 hours. On the fourth postoperative day, the patient presented with tonic-clonic seizures. RESULTS: Diagnostic imaging showed multiple supra- and infratentorial intraparenchymal hemorrhages and a massive sacral cerebrospinal fluid leak. The patient underwent emergent surgery for a primary repair of the presumed dural defect. CONCLUSION: Patients who present with severe positional headache, altered mental status, or tonic-clonic seizures after undergoing intradural spinal procedures involving massive cerebrospinal fluid loss may be suffering from multiple supra- and infratentorial intracranial hemorrhages.

Middle cranial fossa arachnoid cyst presenting with subdural effusion and endoscopic detection of tear of the cyst--case report.

A 15-year-old boy presented with a case of middle cranial fossa arachnoid cyst associated with subdural effusion and manifesting as headache and vomiting after minor head injury. Computed tomography disclosed a cystic lesion in the left middle cranial fossa and ipsilateral subdural effusion. Fundoscopic examination revealed papilledema. A small tear of the cyst wall was confirmed endoscopically. Fenestration of the cyst was performed under the operating microscope. Postoperative course was uneventful. The tear in the outer wall of an arachnoid cyst may suggest the mechanism of occurrence of subdural effusion associated with middle cranial fossa arachnoid cyst.

Endonasal laser tissue welding: first human experience.

BACKGROUND: Adequate repair of cerebrospinal fluid leak remains a significant challenge in endoscopic skull base surgery. Laser tissue welding (LTW) is a method of creating an instant watertight wound closure using a chromophore doped biological solder, which may be used for cranial base reconstruction. The objective of this study is to assess the safety and technical feasibility of endoscopic LTW in human sinonasal mucosa. METHODS: A prospective, Institutional Review Board-approved study was performed of 10 patients undergoing endoscopic LTW using an albumin and hyaluronic acid-based solder for repair of mucosal injuries. Data were collected on patient demographics, total lasing time, and volume of solder used. Wounds were prospectively followed by endoscopic exam and scored on a scale of zero to two by three blinded observers (B.S.B., J.N.P., and A.G.C.) for inflammation, thermal injury, and edema. Results were compared with control wounds using the Mann-Whitney U test. RESULTS: Ten patients (seven men and three women; average age 50 years; range, 33-71 years) underwent endoscopic LTW. Total lasing time was 11 +/- 11 minutes requiring 0.96 +/- 0.83 mL of solder per patient. Patients were followed for an average of 72 days (range, 12-138 days) and no complications were noted. Solder persisted for up to 26 days and there was no significant difference between the lased and control wounds with regard to inflammation (0.87 +/- 0.72 versus 1.31 +/- 0.87), thermal injury (0.06 +/- 0.25 versus 0.12 +/- 0.34), or edema scores (1.13 +/- 0.81 versus 1.44 +/- 0.73). CONCLUSION: Endoscopic LTW is a technically feasible and rapid method of wound closure in sinonasal mucosa that does not result in any significant thermal or inflammatory sequelae.

Atypical spontaneous intracranial hypotension with a head-shaking headache.

Spontaneous intracranial hypotension (SIH) is typically characterized by orthostatic headache; however, various atypical manifestations of SIH have been reported recently. We report here the case of a 46-year-old man with headache secondary to SIH, which was nonorthostatic, triggered only when the patient shook his head. We suggest that SIH should be suspected in patients with headache induced by head-shaking, even without orthostatic features, especially when the headache is accompanied by other symptoms commonly associated with SIH.

Coma from worsening spontaneous intracranial hypotension after subdural hematoma evacuation.

BACKGROUND: Low cerebrospinal fluid volume is typically diagnosed in patients presenting with positional headaches. However, severe intracranial hypotension and brain sagging may cause orthostatic coma. We present a case that illustrates this uncommon presentation. METHOD: Case report. RESULTS: A 50-year-old man presented with orthostatic headaches and then developed bilateral subdural hematomas. Following unilateral subdural hematoma evacuation, the patient became gradually drowsier and more confused. Upon transfer to our hospital, he would become comatose each time he was placed in the upright position. Successful epidural patch at the level of a spontaneous cerebrospinal fluid leak documented by myelography resulted in complete resolution of his orthostatic symptoms despite reaccumulation of the subdural fluid collection. CONCLUSIONS: Evacuation of subdural fluid collections may be detrimental in patients with low CSF volume by exacerbating the intracranial hypotension. Extreme brain sagging may lead to anatomical distortion of the diencephalon and brainstem resulting in coma.

Rupture of middle fossa arachnoid cyst simulating new-onset migraine with aura.

Arachnoid cysts represent a common, innocent, finding in routine neuroimaging of headache patients. We present the first report of symptomatic migraine with aura caused by the spontaneous rupture of a middle fossa arachnoid cyst into the subdural space. Brain imaging enabled an accurate diagnosis and, subsequently, adequate surgical management.