Epidural, Inadvertent Subdural, and Combined Epidural-Subdural Anesthesia in Lumbar Spine Surgery: A Retrospective Analysis.

This study aimed to categorize contrast media images associated with epidural, subdural, and combined epidural-subdural anesthesia in patients who had undergone fluoroscopy-guided epidural anesthesia using contrast media combined with monitored anesthesia care (MAC) targeted at deep sedation, incorporating capnography over 5 years. Additionally, a correlation was established between the anesthetic effects and radiographic findings according to the categorized imaging appearances. This study included 628 patients who underwent endoscopic, open, or fusion surgery under epidural anesthesia at Nanoori Hospital in Gangnam between March 2018 and September 2023. Fluoroscopy-guided epidural anesthesia using contrast media combined with MAC and capnography was used. The dataset included detailed radiographic imaging, nursing, and anesthesia records. Distinct patterns of anesthesia administration were observed, with 49%, 19.6%, and 31% of patients receiving epidural, subdural, and combined epidural-subdural anesthesia, respectively. The incidence and duration of motor block were significantly different among the three groups. Additionally, subdural anesthesia displayed a higher incidence of motor block and a prolonged motor deficit duration than epidural anesthesia. Fluoroscopic guidance using a contrast medium for epidural and subdural anesthesia ensures precise space identification and prevents serious anesthetic complications. Our findings suggest the potential to achieve stable anesthesia, particularly using subdural and combined epidural-subdural anesthesia.

Middle meningeal artery embolization for treatment of chronic subdural hematoma.

BACKGROUND: Chronic subdural hematoma (cSDH) is caused by rupture of bridging intracranial veins located in the subdural space. Predominantly, cSDH is a disease of older adults and other predisposing risk factors include minor head trauma, cerebral atrophy, antiplatelet and anticoagulation therapies, arterial hypertension, cerebrovascular atherosclerosis, diabetes mellitus, cerebrospinal fluid loss, and excessive alcohol consumption. The incidence of cSDH is rising worldwide due to an aging population and the increased use of anticoagulant or antiplatelet medications. Clinical manifestations are varied, with altered mental status and focal neurologic deficits among the most common. METHODOLOGICAL INNOVATIONS: Treatment strategies depend on the symptomatology and extent of hematoma. In general, conservative treatment is sought for patients who are asymptomatic or have only mild symptoms, whereas symptomatic patients are often treated surgically. However, the recurrence rate of cSDH may be as high as 30%. In recent years, middle meningeal artery embolization has emerged as a complementary option to surgery aimed at decreasing the recurrence rate after excision as well as an alternative therapeutic approach to surgical therapy in certain circumstances. CONCLUSION: Embolization of the middle meningeal artery appears to be a promising treatment for patients with cSDH, both before and after surgical excision.

Puerto Rico Recurrence Scale: Predicting chronic subdural hematoma recurrence risk after initial surgical drainage.

Background: Chronic subdural hematoma (CSDH) commonly affects older individuals and is associated with a relatively high rate of recurrence after surgery. Many studies have created grading systems to identify patients at high risk of CSDH recurrence after the initial surgery. However, no system has been adopted widely. The authors present the first CSDH grading system created from a population-based single-center data set. Methods: A single-center Puerto Rican population-based retrospective analysis was performed on consecutive patients treated for a CSDH at a designated institution from July 1, 2017 to December 31, 2019. Univariate and multivariate analyses were used to create a CSDH recurrence grading scale. Retrospective validation was conducted on this sample population. Results: The study included 428 patients. Preoperative midline shift, postoperative midline shift, and size of postoperative subdural space differed between the recurrence and nonrecurrence groups (P = 0.03, 0.002, and 0.002, respectively). A multivariate analysis was used to create a 10-point grading scale comprising four independent variables. Recurrence rates progressively increased from the low-risk (0-3 points) to high-risk (8-10 points) groups (2.9% vs. 20.3%; P < 0.001). Conclusion: A 10-point grading scale for CSDH recurrence was developed with four components: preoperative midline shift (≤1 and >1 cm), laterality (bilateral, unilateral-right, and unilateral-left), size of postoperative subdural space (≤1.6 and >1.6 cm), and pneumocephalus (present or absent). Patients who scored higher on the scale had a higher risk of recurrence. This CSDH grading scale has implications for Puerto Rico and the general population as the elderly population increases worldwide.

Steroid in Chronic Subdural Hematoma: An Updated Systematic Review and Meta-Analysis Post DEX-CSDH Trial.

BACKGROUND: Chronic subdural hematoma (CSDH) is a neurologic condition characterized as a hematoma in the subdural space with a period >3 weeks that primarily affects the elderly. Glucocorticoid, especially dexamethasone, either alone or combined with surgery, has been used to manage CSDH. We aimed to perform an updated systematic review and meta-analysis of the literature regarding the role of steroids in CSDH. METHODS: We searched the electronic databases PubMed, PubMed Central, Scopus, and Embase for relevant articles until December 2020. Study characteristics, quality, and end points were extracted, and analysis was performed by RevMan 5.4. RESULTS: The odds for subdural hematoma recurrence were decreased by 61% in the steroid group (odds ratio [OR], 0.39; confidence interval [CI], 0.19-0.79) compared with the control group. There was no significant difference in mortality during the study period (OR, 0.66; CI, 0.20-2.18), modified Rankin Scale score 0-3 (OR, 0.87; CI, 0.31-2.40), and modified Rankin Scale score 4-6 (OR, 1.15; CI, 0.42-3.18) between the 2 groups. However, pooling data from 3 studies showed 2.7 times higher odds of occurring adverse effects in steroid groups using the fixed-effect model (OR, 2.70; CI, 1.71-4.28). The treatment success was similar between the steroid and control groups (OR, 2.39; CI, 0.94-6.04). CONCLUSIONS: Treatment with steroids was associated with a lesser recurrence of CSDH. However, there was no benefit of steroid treatment in CSDH compared with nonsteroid treatment in terms of mortality and treatment success and some but significantly increased risk of adverse events.

Bloqueo subdural como complicación de la anestesia epidural / Subdural block as a complication of epidural anesthesia

El bloqueo subdural involuntario es una rara pero conocida complicación. Describimos el caso de un bloqueo subdural ocurrido al intentar realizar una analgesia epidural para el parto. (AU)

Unintentional subdural block is a rare but known complication. We describe the case of unintentional subdural block while attempting to perform an epidural block for delivery. (AU)

Subdural Air Increases Postoperative Recurrence of Chronic Subdural Hematoma After Initial Burr-hole Surgery Only in the Very Elderly: A Pilot Study.

OBJECTIVE: Numerous randomized controlled trials have identified risk factors increasing the postoperative recurrence of chronic subdural hematoma (CSDH). Postoperative subdural air is frequently seen on computed tomography imaging. The aim of this study was to test the hypothesis that the presence of significant subdural air postoperatively is related to recurrence of CSDH after burr-hole surgery. METHODS: A single-center, retrospective pilot study analyzed patients 20 years and older who underwent initial burr-hole surgery for CSDH. Data from 452 consecutive patients were included. Significant subdural air was considered to be present when the subdural air area was >4 cm2 in 1 axial CT slice. Correlation of the recurrence and the number of slices that included significant subdural air at postoperative day (POD) 1 was evaluated. Other classic predictive factors were also investigated. RESULTS: The recurrence rate was 13.0% in these 452 cases. After univariate analyses of all the variables, multivariate analysis for age, sex, cerebral infarction, number of slices containing significant subdural air, and maximum depth of the subdural space confirmed that older age and male sex were independent risk factors for recurrence (P = 0.032 and 0.047, respectively). After subdividing cases into older (≥75 years of age)/younger and male/female subgroups, the presence of significant subdural air at POD 1 was identified as an independent risk factor for recurrence in older adults (P = 0.025, OR = 1.12). CONCLUSIONS: Although this is a pilot study, it is suggested that significant postoperative subdural air increases recurrence after initial burr-hole surgery for CSDH in adults ≥75 years of age.

Juvenile xanthogranuloma of the subdural spaces mimicking chronic hematoma with positive FDG uptake on PET: case report.

The authors report an unusual presentation of juvenile xanthogranuloma (JXG), a non-Langerhans cell histiocytosis of infancy and early childhood. This entity typically presents as a cutaneous head or neck nodule but can manifest with more systemic involvement including in the central nervous system. However, currently there is limited information regarding specific imaging features differentiating JXG from other neuropathological entities, with diagnosis typically made only after tissue sampling. The authors reviewed the initial images of a young patient with shunt-treated hydrocephalus and enlarging, chronic, extraaxial processes presumed to reflect subdural collections from overshunting, and they examine the operative discovery of a mass lesion that was pathologically proven to be JXG. Their results incorporate the important associated histological and advanced imaging features, including previously unreported metabolic activity on FDG PET. Ultimately, the case underscores the need to consider JXG in differential diagnoses of pediatric intracranial masses and highlights the potential role of PET in the initial diagnosis and response to treatment.

Tumoral Mimics of Subdural Hematomas: Case Report and Review of Diagnostic and Management Strategies in Primary B-Cell Lymphoma of the Subdural Space.

BACKGROUND: Subdural lymphomas are a rare subtype of primary central nervous system lymphomas that can radiographically mimic epidural blood and pose a diagnostic challenge. They can complicate treatment if not preemptively identified. METHODS: We present a case report of a subdural lymphoma that mimicked a compressive subdural hematoma, and we review the PubMed database for similar cases. RESULTS: A 77-year-old woman presented with a transient left facial droop and what appeared to be a subdural hematoma on computed tomography scan. The patient underwent surgery, during which grossly abnormal solid epicortical adherent tissue was noted instead of the expected appearance of a subdural hematoma. An intraoperative biopsy was suggestive of lymphoma, and the surgery was converted to a craniectomy. Pathology confirmed the diagnosis of extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue. The patient underwent radiotherapy with no complications or recurrence. Magnetic resonance imaging demonstrated complete resolution of the mass at 3 months after treatment, at which time the patient underwent a synthetic cranioplasty. Seven case reports of primary dural lymphomas mimicking subdural blood were found, with variable pathologic subclassifications. CONCLUSIONS: Although rare, a primary dural lymphoma can be mistaken for a subdural hematoma on computed tomography scan. The most common subtype is low-grade extranodal marginal zone lymphomas. It is important to keep these diseases in the differential diagnosis, especially when there is incongruence between imaging and the clinical picture, as earlier detection correlates to a stronger therapeutic response.

Informe de caso: Anestesia subdural en la paciente obstétrica / Case report: Subdural anesthesia in the obstetric patient

Introduction: Subdural anesthesia is a relatively frequent complication though seldom recognized. It has a broad spectrum of presentations ranging from an unexpectedly high sensory block with limited motor block, to substantial hemodynamic and respiratory involvement. Case presentation: A 22-year old woman undergoing cesarean section under epidural anesthesia with evidence of long-lasting higher than expected sensory block and respiratory distress. Conclusion: Neuraxial anesthesia comprises a number of versatile and safe techniques, though not exempt from complications including subdural anesthesia. We should be aware of this possibility in our clinical practice, know the risk factors and the diagnostic criteria.

Introducción: La anestesia subdural es una complicación de la anestesia neuroaxial relativamente frecuente pero poco reconocida, tiene un espectro de presentación bastante amplio que va desde un bloqueo sensitivo inesperadamente alto con poco bloqueo motor, hasta compromiso hemodinámico y respiratorio importante. Presentación del caso: Mujer de 22 años que es llevada a cesárea con anestesia epidural, con evidencia de bloqueo sensitivo más alto de lo esperado, de larga duración y dificultad respiratoria. Conclusión: La anestesia neuroaxial es un conjunto de técnicas versátiles y seguras, aunque no exentas de complicaciones como lo es la anestesia subdural. En la práctica clínica debemos estar atentos a esta posibilidad, conocer los factores de riesgo y los criterios diagnósticos.

Comparision between Brain Atrophy and Subdural Volume to Predict Chronic Subdural Hematoma: Volumetric CT Imaging Analysis.

OBJECTIVE: Brain atrophy and subdural hygroma were well known factors that enlarge the subdural space, which induced formation of chronic subdural hematoma (CSDH). Thus, we identified the subdural volume that could be used to predict the rate of future CSDH after head trauma using a computed tomography (CT) volumetric analysis. METHODS: A single institution case-control study was conducted involving 1,186 patients who visited our hospital after head trauma from January 1, 2010 to December 31, 2014. Fifty-one patients with delayed CSDH were identified, and 50 patients with age and sex matched for control. Intracranial volume (ICV), the brain parenchyme, and the subdural space were segmented using CT image-based software. To adjust for variations in head size, volume ratios were assessed as a percentage of ICV [brain volume index (BVI), subdural volume index (SVI)]. The maximum depth of the subdural space on both sides was used to estimate the SVI. RESULTS: Before adjusting for cranium size, brain volume tended to be smaller, and subdural space volume was significantly larger in the CSDH group (p=0.138, p=0.021, respectively). The BVI and SVI were significantly different (p=0.003, p=0.001, respectively). SVI [area under the curve (AUC), 77.3%; p=0.008] was a more reliable technique for predicting CSDH than BVI (AUC, 68.1%; p=0.001). Bilateral subdural depth (sum of subdural depth on both sides) increased linearly with SVI (p<0.0001). CONCLUSION: Subdural space volume was significantly larger in CSDH groups. SVI was a more reliable technique for predicting CSDH. Bilateral subdural depth was useful to measure SVI.

Comparision between Brain Atrophy and Subdural Volume to Predict Chronic Subdural Hematoma: Volumetric CT Imaging Analysis / 대한신경손상학회지

OBJECTIVE: Brain atrophy and subdural hygroma were well known factors that enlarge the subdural space, which induced formation of chronic subdural hematoma (CSDH). Thus, we identified the subdural volume that could be used to predict the rate of future CSDH after head trauma using a computed tomography (CT) volumetric analysis. METHODS: A single institution case-control study was conducted involving 1,186 patients who visited our hospital after head trauma from January 1, 2010 to December 31, 2014. Fifty-one patients with delayed CSDH were identified, and 50 patients with age and sex matched for control. Intracranial volume (ICV), the brain parenchyme, and the subdural space were segmented using CT image-based software. To adjust for variations in head size, volume ratios were assessed as a percentage of ICV [brain volume index (BVI), subdural volume index (SVI)]. The maximum depth of the subdural space on both sides was used to estimate the SVI. RESULTS: Before adjusting for cranium size, brain volume tended to be smaller, and subdural space volume was significantly larger in the CSDH group (p=0.138, p=0.021, respectively). The BVI and SVI were significantly different (p=0.003, p=0.001, respectively). SVI [area under the curve (AUC), 77.3%; p=0.008] was a more reliable technique for predicting CSDH than BVI (AUC, 68.1%; p=0.001). Bilateral subdural depth (sum of subdural depth on both sides) increased linearly with SVI (p<0.0001). CONCLUSION: Subdural space volume was significantly larger in CSDH groups. SVI was a more reliable technique for predicting CSDH. Bilateral subdural depth was useful to measure SVI.

Spinal subdural hematoma following cranial subdural hematoma : a case report with a literature review.

Coexistence of cranial and spinal subdural hematomas is rare and only a few cases have been reported in the literature. Herein, we report a case of cranial and spinal subdural hematomas after previous head trauma. As the pathogenesis of simultaneous intracranial and spinal subdural hematoma yet remains unclear, we developed an alternative theory to those proposed in the literature for their coexistence, the migration of blood through the subdural space.

Spinal Subdural Hematoma Following Cranial Subdural Hematoma : A Case Report with a Literature Review

Coexistence of cranial and spinal subdural hematomas is rare and only a few cases have been reported in the literature. Herein, we report a case of cranial and spinal subdural hematomas after previous head trauma. As the pathogenesis of simultaneous intracranial and spinal subdural hematoma yet remains unclear, we developed an alternative theory to those proposed in the literature for their coexistence, the migration of blood through the subdural space.

The subdural space of the spine: A lymphatic sink? Myodil's last message.

Following the radiological study of a large number of myelograms, starting over 50 years ago when the only clinical contrast medium available to show the contents of the spinal canal was an iodized oil, the author has collected a number of examples where the oil was inadvertently injected into the subdural area, rather than the intended subarachnoid space. By taking follow-up films at various intervals following the inadvertent injection, it has been possible to study the extent to which the subdural space could become visualized from a lumbar injection, the contrast medium sometimes passing to the top of the cervical region and the lower part of the sacrum. Also, the contrast passed outward along the peri-neural lymphatic sheaths or spaces of the issuing spinal nerves, where it might remain for months, and under the influence of gravity it could extend for a considerable way. It also passed into abdominal and thoracic lymph vessels and nodes. Considering the morphology, predictability, and ease with which the demonstrated subdural space fills, the author concludes that the subdural region is a true and functionally significant "space," and an important conduit or functional part of the body's lymphatic system. He also considers that it has implications for the spread or dissemination of various organisms, substances or pathological conditions, as well as being part of the normal conduit for reabsorption of CSF with implications for hydrocephalus, and with potential for misplacement of spinal anaesthetic agents.

Clinical value of monitoring subdural intracraniai pressure in post-operative patients with severe brain injury / 中华创伤杂志

Objective To investigate the value of subdural intracranial pressure (ICP) monito-ring in post-operative patients with severe brain injury. Methods A total of 100 patients with severe brain injury treated with craniotomy were randomly divided into ICP monitoring group (n=50) and rou-tine treatment group (n = 50). In ICP monitoring group, the treatment methods were adjusted according to the changes of ICP, whereas the patients in routine treatment group underwent general treatment ac-cording to standard neurosurgical protocol. Results Patients in ICP monitoring group received mannitol for eight days, with the average dosage of 950 g. Marmitol was administered to patients in routine treat-ment group for 12 days, with average dosage of 1 450 g. There was statistical difference in aspects of time duration and mannitol dosage between two groups (P <0.01). Of all patients in ICP monitoring group, four were found with electrolyte disturbance (8%), seven with acute renal failure (14%), four with stress ulcer (8%) and eight with pulmonary infection (16%). The corresponding numbers of patients in routine treatment group were nine (18%), 14 (28%), five (10%) and nine (18%), respectively. The occurrence of electrolyte disturbance and acute renal failure between two groups showed significant statistical difference (P < 0.05), while the occurrence of stress ulcer and pulmonary infection were be-yond of statistical difference between two groups (P > 0.05). The post-operative initial ICP level was positively correlated with mortality rate (P <0.01). All patients were followed up for three months post-operatively. In ICP monitoring group, 27 patients (26%) obtained good prognosis without any disability (54%), 13 were under mild disability, two (4%) under severe disability, three (6%) under vegeta-tive state and five (10%) died . In the routine treatment group, 17 patients (34%) were with good prognosis without any disability , six (12%) with mild disability , six (12%) with severe disability, eight (16%) under vegetative state and 13 (26%) died. The ICP monitoring group had better prognosis than the routine treatment group(P < 0.05). Conclusion Continuous ICP monitoring postoperatively in severe brain injury patients is valuable in reducing mortality, complication and improving the prognosis.

Subdural Tension Pneumocephalus following Burr - hole Irrigation of Traumatic Chronic Subdural Hematoma / 中华创伤杂志

We report 3 cases of subdural tension pneumocephalus following burr - hole irrigation of traumatic chronic subdural hematoma. All of them were cured. Main factors leading to the pneumocephalus may be the damage to the hematoma capsule during operation, unidirection vaives formed from dural leceration and delayed re - expansion of the compressed brain. The clinical feature, CT finding, management and preventive measure of such a complication are also discussed.