Modified surgical method of supra-and infratentorial epidural hematoma and the related anatomical study of the squamous part of the occipital bone

BACKGROUND Supra-and infratentorial acute epidural hematoma(SIEDH)is a common posterior cranial fossa epidural hematoma located at the inner surface of the squamous part of the occipital bone(SOB).Traditionally,surgical treatment of the SIEDH requires a combined supra-infratentorial craniotomy.AIM To analyze the morphological characteristics of the SOB and introduce a single supratentorial craniotomy for SIEDH.METHODS Skull computed tomography(CT)scan data from 32 adult patients were collected from January 1,2019 to January 31,2020.On the median sagittal plane of the CT scan,the angle of the SOB(ASOB)was defined by two lines:Line A was defined from the lambdoid suture(LambS)to the external occipital protuberance(EOP),while line B was defined from the EOP to the posterior edge of the foramen magnum(poFM).The operative angle for the SIEDH(OAS)from the supra-to infratentorial epidural space was determined by two lines:The first line passes from the midpoint between the EOP and the LambS to the poFM,while the second line passes from the EOP to the poFM.The ASOB and OAS were measured and analyzed.RESULTS Based on the anatomical study,a single supratentorial craniotomy was performed in 8 patients with SIEDH.The procedure and the results of the modified surgical method were demonstrated in detail.For males,the ASOB was 118.4±4.7 and the OAS was 15.1±1.8;for females,the ASOB was 130.4±5.1 and the OAS was 12.8±2.0.There were significant differences between males and females both in ASOB and OAS.The smaller the ASOB was,the larger the OAS was.The bone flaps in 8 patients were designed above the transverse sinus intraoperatively,and the SIEDH was completely removed without suboccipital craniotomy.The SOB does not present as a single straight plane but bends at an angle around the EOP and the superior nuchal lines.The OAS was negatively correlated with the ASOB.CONCLUSION The single supratentorial craniotomy for SIEDH is reliable and effective.

Multiple different remote epidural hematomas after craniotomy:A case report

BACKGROUND Epidural hematoma is one of the common postoperative complications after craniotomy.However,multiple remote epidural hematomas in different sites,including supratentorial and infratentorial regions,are exceedingly rare.CASE SUMMARY We present a rare case in which three remote epidural hematomas occurred after craniotomy.A 21-year-old woman was admitted with a headache for 1 mo,vomiting,and rapid vision loss for 1 wk.Brian magnetic resonance imaging indicated a right thalamic tumor.The intraoperative diagnosis was a cystic tumor,posterior cerebral artery aneurysm,and vascular malformation.The operation was successful.Unfortunately,the patient developed three extradural hematomas within 48 h.Family members consented to the first two hematoma evacuations but refused the third.CONCLUSION More attention should be paid to this kind of rare complication.Adequate preoperative evaluation is important,especially for acute patients.Monitoring neural function and early computed tomography scanning of the brain after surgery should be highlighted.

Acute spontaneous thoracic epidural hematoma associated with intraspinal lymphangioma: A case report

BACKGROUND Spontaneous spinal epidural hematoma is a rare neurosurgical emergency.CASE SUMMARY A 53-year-old healthy woman suffered from complete paraplegia in both legs and loss of all sensation below the xiphoid process.She was diagnosed as acute spontaneous thoracic epidural hematoma caused by an intraspinal lymphangioma.The primary lab survey showed all within normal limits.Presence of a posteriorly epidural space-occupying lesion at the T4-T8 level of the spinal canal was confirmed on magnetic resonance imaging.A decompressive laminectomy was performed from the T4 to T7 levels at the sixth hour following abrupt onset of complete paraplegia.The lesion was confirmed as lymphangioma.This patient recovered well within one month.CONCLUSION This study reports a case of acute spontaneous thoracic epidural hematoma caused by an intraspinal lymphangioma with well recovery after surgical intervention.

Spinal epidural hematoma after spinal manipulation therapy:Report of three cases and a literature review

BACKGROUND Spinal manipulation therapy(SMT)has been widely used worldwide to treat musculoskeletal diseases,but it can cause serious adverse events.Spinal epidural hematoma(SEH)caused by SMT is a rare emergency that can cause neurological dysfunction.We herein report three cases of SEH after SMT.CASE SUMMARY The first case was a 30-year-old woman who experienced neck pain and numbness in both upper limbs immediately after SMT.Her symptoms persisted after 3 d of conservative treatment,and she was admitted to our hospital.Magnetic resonance imaging(MRI)demonstrated an SEH,extending from C6 to C7.The second case was a 55-year-old man with sudden back pain 1 d after SMT,numbness in both lower limbs,an inability to stand or walk,and difficulty urinating.MRI revealed an SEH,extending from T1 to T3.The third case was a 28-year-old man who suddenly developed symptoms of numbness in both lower limbs 4 h after SMT.He was unable to stand or walk and experienced mild back pain.MRI revealed an SEH,extending from T1 to T2.All three patients underwent surgery after failed conservative treatment.The three cases recovered to ASIA grade E on day 5,1 wk,and day 10 after surgery,respectively.All patients returned to normal after 3 mo of follow-up.CONCLUSION SEH caused by SMT is very rare,and the condition of each patient should be evaluated in full detail before operation.SEH should be diagnosed immediately and actively treated by surgery.

Epidemiological Analysis of Surgically Treated Acute Traumatic Epidural Hematoma

This study is a retrospective analysis of demographic, clinical, radiological and outcome data of surgically treated acute traumatic epidural hematomas. Forty-six consecutive cases of epidural hematomas were operated at the University Hospital Center of Yaoundé, Cameroon, between February 2006 and December 2013. The mean age was 29.56 years and63.04% of patients were between 21 and 30 years. Almost 94% of patients were males. Thirty-five percent of patients were motorcycle riders. Road traffic accident was the cause in 70% of cases. Mean time between head trauma and surgical evacuation was 78 hours. Head trauma was moderate in 52.17%. Initial loss of consciousness was found in 78.26% and lucid interval in 65.23%. Seventy-four percent of patients had signs of intracranial hypertension on admission, 35% had at least one neurologic focal sign and 50% had a scalp wound. Eight patients (17.39%) presented with unilateral or bilateral mydriasis. On computed tomography, the hematoma was on the left side in 60.86% of patients and frontal-parietal location was the most frequent. Computed tomography showed mass effect in 97.82% of patients. The most frequent surgical procedure was craniotomy. Six (13.04%) patients died, but 82.60% recovered fully (GOS 5). In Cameroon, traumatic acute epidural hematoma affects primarily healthy young men in their twenties and thirties. Road traffic accidents are the main etiology. Most patients had moderate head trauma and presented with intracranial hypertension. Early surgery is rarely done. Nevertheless, even with delayed surgery, most patients have good outcome.

Delayed arterial symptomatic epidural hematoma on the 14th day after posterior lumbar interbody fusion:A case report

BACKGROUND Delayed arterial symptomatic epidural hematoma(SEH)on the 14th day after posterior lumbar interbody fusion(PLIF)is rare but it may lead to severe complications if not identified and treated in a timely manner.After diagnosis of the current case,early surgical removal of the hematoma and strict hemostasis treatment was accomplished.This case report highlights the importance of swift diagnosis and treatment in SEH patients.CASE SUMMARY A 41-year-old male patient with a single-segment lumbar disc herniation underwent left-side PLIF.On the 14th post-operative day,the patient complained of lumbar incision pain with sudden onset accompanied by left limb radiation pain and aggravated cauda equina symptoms.Magnetic resonance imaging examination and a puncture blood draw at the incision site confirmed a delayed arterial SEH.Emergency surgical removal of the hematoma and hemostasis was performed.About 70 mL of hematoma was found in the left incision.Continuous bleeding was found in the anterior branch of the transverse process of the 4th lumbar artery in the muscle area about 2 cm below the transverse process of the 4th lumbar vertebra.A blood jet of about 10 cm in height was observed and bipolar electrocoagulation was used to stop the bleeding.Post-operative lumbar incision pain and left lower limb pain were relieved immediately and gradually disappeared.There was no recurrence during the 12-mo follow-up.CONCLUSION For delayed arterial SEH on the 14th day after PLIF,preventive measures including pre-,intra-and post-operative prevention should be implemented.

Spontaneous acute epidural hematoma secondary to skull and dural metastasis of hepatocellular carcinoma: A case report

BACKGROUND The skull and dura are uncommon sites for the metastasis of hepatocellular carcinoma(HCC).Spontaneous acute epidural hematoma(AEDH)is also very rare.We report here a spontaneous AEDH secondary to skull and dural metastasis of HCC.This case is extremely rare.CASE SUMMARY A 48-year-old male patient with a history of HCC developed unconsciousness spontaneously.Head computed tomography showed"a huge AEDH in the left parietal and occipital region with osteolytic destruction of the left parietal bone.Emergent operation was performed to evacuate the hematoma and resect the lesion.Pathological study revealed that the lesion was the metastases from HCC.The patient died of lung infection,anemia,and liver failure 3 wk after operation.CONCLUSION Spontaneous AEDH caused by hepatocellular carcinoma(HCC)dural and skull metastases is extremely rare,the outcome is poor.So,early diagnosis is important.If the level of AFP does not decrease with the shrinkage of intrahepatic lesions after treatment,it is necessary to be alert to the existence of extrahepatic metastases.Since most of the patients had scalp and bone masses,physicians should pay attention to the patient's head palpation.Once a patient with the history of HCC had sudden neurological dysfunction,the possibility of spontaneous AEDH caused by the skull and dura mater metastases should be considered.Since hemorrhage is common in the skull HCC metastases,for patients with spontaneous AEDH accompanied by skull osteolytic lesions,it is also necessary to be alert to the possibility of HCC.For AEDH secondary to HCC metastases,early diagnosis and timely treatment are critical to improve the patients’outcomes.

Spontaneous Cervical Epidural Hematomas in Mild Cervical Spondylotic Myelopathy Patients：An Analysis of 8 Cases

Spontaneous cervical epidural hematoms（SCEH） complicated with mild cervical spondylotic myelopathy（CSM） is a rare but emerging condition.Early diagnosis and treatment are important for good outcomes.This study aimed to investigate the clinical characteristics of this condition and to discuss the optimal treatment.The clinical data from 8 patients with SCEH plus CSM who were divided into two groups by treatment methods were retrospectively analyzed.The neurological function of the patients was assessed by Japanese Orthopedic Association（JOA） score before and after the surgical operations.Other factors were reviewed with medical records.Among them,4 out of the 8 patients underwent emergency surgery,and the rest 3 patients experienced an initial conservative treatment and ultimately received a laminectomy.We found that the Frankel Scale scores in most of the surgical patients were increased after surgery（6/7,85.7%）.However,the JOA scores at the 6th month after onset were even lower than those before onset in 3 of the operative cases,and those in the patients who were given conservative treatment showed no significant change.It was concluded that some patients with SCEH and CSM treated with a timely operation may obtain relief from their previous CSM symptoms.However,the final neurological deficits of these patients were closely related to the progressive interval which refers to the hours between the initial onset and the occurrence of new neurological deficits or mild CSM deterioration,no matter whether they accept the operation.We found the crucial progressive interval may be in 9 h.Early MRI and prompt neurosurgical intervention are also important to improve the neurological deficits.

Retrospective study on progressive epidural hematoma

Objective To study the clinical issues of progressive epidural hematoma ( PEDH ) Methods The incidence,impacts on clinical course and short term outcomes and predictors of PEDH were retrospectively studied. Results PEDH occurred in 20. 3% of the patients. The rates of neurological deterioration and

Spontaneous Thoracic Spinal Epidural HematomaDuring Pregnancy

To editor:Spontaneous spinal epidural hematoma(SSEH)is uncom-mon,especially during pregnancy.However,SSEH is a seriousemergency that must be managed immediately to prevent per-manent neurological deficit of the mother and stillbirth.Theetiology and pathogenesis of SEEH remain unknown,al-though multiple theories and precipitating factors are de-scribed in the literature.In this report,we describe the caseof a pregnant female who developed SSEH.

Early diagnosis and treatment of acute or subacute spinal epidural hematoma

Background Despite low morbidity, acute or subacute spinal epidural hematoma may develop quickly with a high tendency to paralysis. The delay of diagnosis and therapy often leads to serious consequences. In this study we evaluated the effects of a series of methods for the diagnosis and treatment of the hematoma in 11 patients seen in our hospital. Methods Of the 11 patients （8 males and 3 females）, 2 had the hematoma involving cervical segments, 2 cervico-thoracic, 4 thoracic, 1 thoraco-lumbar, and 2 lumbar. Three patients had quadriplegia, including one with central cord syndrome; another had Brown-Sequard＇s syndrome; and the other seven had paraplegia. Five patients were diagnosed at our hospitals within 3-48 hours after appearance of symptoms, and 6 patients were transferred from community hospitals within 21-106 hours after development of symptoms. Key dermal points, key muscles and the rectal sphincter were determined according to the American Spinal Injury Society Impairment Scales as scale A in two patients, B in 5 and C in 4. Emergency MRI in each patient confirmed that the dura mater was compressed in the spinal canal, with equal intensity or hyperintensity on T1 weighted image and mixed hyperintensity on T2 weighted image. Preventive and curative measures were taken preoperatively and emergency operation was performed in all patients. Open laminoplasty was done at the cervical and cervico-thoracic segments, laminectomy at the thoracic segments, laminectomy with pedicle screw fixation at the thoraco-lumbar and lumbar segments involving multiple levels, and double-sided laminectomy with the integrity of articular processes at the lumbar segments involving only a single level. During the operation, special attention was given to hematoma evacuation, hemostasis and drainage tube placement. Results Neither uncontrollable hemorrhage nor postoperative complications occurred. All patients were followed up for 1-6 years. A marked difference was noted between postoperative and preoperative scales （u=-3.66, P〈0.01）. Most patients recovered after therapy, but the recovery of patients treated at our hospitals was superior to that of those transferred from community hospitals （t =2.95, P〈0.05）. Of the patients treated at our hospitals, 4 were cured and 1 was upgraded with scale from A to D, whereas none of those transferred from community hospitals recovered completely, even one remained scale C. Conclusions Physical examination plus MRI is essential to early diagnosis of acute or subacute spinal epidural hematoma. Preventive and curative measures including emergency operation are helpful to the recovery of patients＇ nerve function.

Spontaneous Absorption of a Lumbar Epidural Hematoma after Interlaminar Epidural Steroid Injection in a Patient with Spinal Stenosis： Close Observation as a Treatment Strategy

To the Editor： A lumbar epidural block is used to treat patients with a herniated intervertebral disc, spinal stenosis, or lumbosacral radiculopathy. This approach reduces radicular pain by decreasing inflammation of nerve roots through epidural corticosteroid injection. Patients with moderate-to-severe spinal stenosis who taking various anticoagulant agents have more risk for epidural hematoma.

Delayed neurological dysfunction following posterior laminectomy with lateral mass screw fixation:A case report and review of literature

BACKGROUND While most complications of cervical surgery are reversible,some,such as symptomatic postoperative spinal epidural hematoma(SEH),which generally occurs within 24 h,are associated with increased morbidity and mortality.Delayed neurological dysfunction is diagnosed in cases when symptoms present>3 d postoperatively.Owing to its rarity,the risk factors for delayed neurological dysfunction are unclear.Consequently,this condition can result in irreversible neurological deficits and serious consequences.In this paper,we present a case of postoperative SEH that developed three days after hematoma evacuation.CASE SUMMARY A 68-year-old man with an American Spinal Injury Association(ASIA)grade C injury was admitted to our hospital with neck pain and tetraplegia following a fall.The C3-C7 posterior laminectomy and the lateral mass screw fixation surgery were performed on the tenth day.Postoperatively,the patient showed no changes in muscle strength or ASIA grade.The patient experienced neck pain and subcutaneous swelling on the third day postoperatively,his muscle strength decreased,and his ASIA score was grade A.Magnetic resonance imaging showed hypointense signals on T1 weighted image(T1WI)and T2WI located behind the epidural space,with spinal cord compression.Emergency surgical intervention for the hematoma was performed 12 h after onset.Although hypoproteinemia and pleural effusion did not improve in the perioperative period,the patient recovered to ASIA grade C on day 30 after surgery,and was transferred to a functional rehabilitation exercise unit.CONCLUSION This case shows that amelioration of low blood albumin and pleural effusion is an important aspect of the perioperative management of cervical surgery.Surgery to relieve the pressure on the spinal cord should be performed as soon as possible to decrease neurological disabilities.

Surgical Outcome of Extradural Hematoma Patients in Relation to Preoperative Neurological Status

Introduction: Epidural hematoma (EDH) is characterized by the acute onset of traumatic haemorrhage into potential space between the dura mater and skull following head injury. About 85% of the epidural cases are caused by skull fracture with rupture of the middle meningeal artery or its branches and rest of 1the time ruptured venous sinuses, fractured diploic bone. The BTF recommends that all patients with an EDH volume of greater than 30 cc should undergo surgical evacuation regardless of Glasgow Coma Scale (GCS). Aim of the Study: To assess the surgical outcome of extradural hematoma patients by using Glasgow Outcome Scale (GOS) postoperatively. Material & Methods: This prospective study was conducted in the Department of Neurosurgery, Dhaka Medical College and Hospital (DMCH), during the period of January 2016 to December 2017. A total of 98 patients of both sex and any age with EDH were selected purposively. Statistical analyses were carried out by using the Statistical Package for Social Sciences version 22.0 for Windows (SPSS Inc., IBM and New York, USA). Prior to commencement of this study, the “Research Review Committee” & the “Ethical Committee” of DMCH, Dhaka, approved the research protocol. Results: In this study, 98 patients were included;they were divided into 6 groups. Age range was 04 - 55 years. It was observed that majority, 30 (30.60%) patients were from 21 - 30 years of age. The mean age was found 25.24 ± 12.2 years. Other age related distributions were shown in the table. Male patients were 78 (78.55%) and 22 (22.44%) patients were female. A male predominance was observed. Among admitting GCS 3-8, 56.25% patients had unfavorable outcome and 43.25% had favorable outcome. Admitting GCS 9-13, 2.5% patients had unfavorable outcome and 97.5% had favorable outcome. Admitting GCS 14-15, all patients (100.0%) had favorable outcome. Unfavorable outcome was observed in 9 (9.18%), 1 (1.00%) patients who belong 3-8, 9-13 GCS on admission. Mean GCS on admission was found 6.7 ± 2.44 score in unfavorable outcome group and 13.45 ± 2.30 score in favorable outcome group. Conclusion: This study revealed good surgical outcome in extradural hematoma patients. Preoperative GCS is an important predictor of outcome. Other preoperative neurological statuses like pupillary changes, neurological focal deficit, cranial nerve involvement, plantar reflexes and seizure also influence the surgical outcome.

Neck pain and absence of cranial nerve symptom are clues of cervical myelopathy mimicking stroke:Two case reports

BACKGROUND Cervical myelopathy is a potential stroke imitator,for which intravenous thrombolysis would be catastrophic.CASE SUMMARY We herein present two cases of cervical myelopathy.The first patient presented with acute onset of right hemiparesis and urinary incontinence,and the second patient presented with sudden-onset right leg monoplegia.The initial diagnoses for both of them were ischemic stroke.However,both of them lacked cranial nerve symptom and suffered neck pain at the beginning of onset.Their cervical spinal cord lesions were finally confirmed by cervical computed tomography.A literature review showed that neck pain and absence of cranial nerve symptom are clues of cervical myelopathy.CONCLUSION The current report and the review remind us to pay more attention to these two clues in suspected stroke patients,especially those within the thrombolytic time window.

Traumatic extradural hematoma in the middlecranial fossa base:clinical analysis of 14cases

Toexploreclinicalcharacteristics ,CT manifestationandoperativeindicationsoftraumatic extraduralhematomainthemiddlecranialfossabase (EHMCFB) . Methods: Atotalof 14caseswithtraumatic EHMCFBfromJanuary 1997toMay 2 0 0 0were retrospectivelyanalyzed . Results : Of 14cases ,12cases (85 .7% )maintained formchangeofcisternaambiensforbeingpressed ;11cases whoreceivedoperationswereallcured ;3received conservativetherapy ,ofwhom 2becamebetterand 1died . Conclusions: IntraumaticEHMCFB ,theform changeofcisternaambiensoccurseasily .Therefore ,if thereappearsprogressivelyaggravatedformchangeof cisternaambiensafterthecisternaambiensbeingpressed , anearlyandactiveoperationisnecessaryandcrucial.