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.

Resolution of epidural hematoma related to osteoporotic fracture after percutaneous vertebroplasty

We are the first to report a case that showed spontaneous resolution of epidural hematoma which was related to a steroid-induced osteoporotic compression fracture.The patient had a painful fracture with an intravertebral cleft at L1 accompanying an epidural hematoma posteriorly.Immediate pain relief was achieved after percutaneous vertebroplasty.Complete resolution of hematoma was noted three months after procedure.We theorized that intravertebral stability after treatment might have played a role in this patient.

Acute Epidural Hematoma Compressing the Dominant Sigmoid Sinus as an Unusual Cause of Intracranial Hypertension: Case Report and Review of Literature

Post traumatic dural sinus vein stenosis has been rarely described in pediatric population. We present a case of a 9-year-old child that had sustained a head injury after a fall from height causing an acute epidural hematoma compressing the dominant sigmoid sinus. The patient had developed sub acutely signs and symptoms of increased intracranial pressure. Prophylactic treatment with anticoagulants was initiated despite the presence of an intracranial bleeding. Clinical and radiological improvements were achieved. We had also reviewed the literature regarding this uncommon entity and discussed other existing diagnostic and therapeutic alternatives. Further gathering of information is essential in order to form a therapeutic protocol.

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.

Epidural Hematoma after the Use of Subcutaneous Unfractionated Heparin and History of Epidural Tumor

The patient was a 66-year-old male with a history of renal cell carcinoma with metastasis to the L2, L3, and L4 vertebral bodies scheduled for a radical nephrectomy and adrenalectomy. Prior to surgery the patient had undergone 10 radiation treatments for the vertebral metastasis. Patient medications included colace, prednisone, ibuprofen (taken 4 days prior to procedure), sunitinib, hydrocodone, benazepril, nexium, rosuvastatin, allopurinol, and azor. Physical exam prior to surgery was normal with no focal findings. Laboratory values were within normal limits with a platelet count of 286. General anesthesia was planned with a pre-operative thoracic epidural for postoperative analgesia. The epidural was placed at the T9-T10 level without complication. Adequate pain control was present post operatively and the epidural was discontinued on post-operative day 3. At that time the patient was noted to have numbness over the bilateral lower extremities and decreased strength. Heparin 5000 units subcutaneous had been given 12 hours prior to discontinuation of the epidural. The patient was afebrile, hemoglobin was 7, white blood cell count was 9.7, and platelets were 166 at time of epidural removal. Subcutaneous heparin was restarted 6 hours after catheter removal. The anesthesia acute pain service was contacted by the primary service 25 hours after discontinuation of the epidural catheter regarding complaints of persistentbilateral lower extremity weakness and sensory loss. An magnetic resonance image (MRI) revealeda focus posterior to the spinal cord at the T10/T11 interspace likely representing a hematoma. A high intensity T2 signal within the central spinal cord at T10/T11 was also observed;likely a vascular infarct. The patient was immediately scheduled for a T9-T10 laminectomy and evacuation of the epidural hematoma. No significant abnormalities were noted in coagulation studies prior to surgery. The patient was discharged on post-operative day 20 with no neurologic deficits.An epidural hematoma is rare with an estimated occurrence of <1 in 150,000[1]. Issues related to anticoagulation therapy are involved in 25% - 30% of cases. The utilization of three times daily dosed (TID) heparin could have played a role in the development of this complication in the present case. Other contributing factors may have been chemotherapy and radiation therapy. These treatments are quite damaging to bone marrow and may cause severe marrow suppression thereby suppressing the function and number of platelets. Cancer cells are also capable of producing local cell signals which can initiate new blood vessel growth and proliferation[2]. This can also lead to blood vessels that are defective and leaky at the level of the endothelium. Increasing the number of fragile blood vessels may easily predispose this patient to laceration and shearing of blood vessels during epidural placement.

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.

Intrathecal hematoma and sacral radiculitis following repeat epidural blood patch

Postdural puncture headache(PDPH)is an incapacitating complication that can occur following spinal anesthesia and with inadvertent dural puncture during epidural anesthesia.We present a case of a 32-year-old G2 P1 female who was admitted for induction of labor and received epidural catheter placement for analgesia.After an inadvertent dural puncture and development of a PDPH,the patient was offered conservative measures for the first 48 hours without improvement.An epidural blood patch(EBP)was placed achieving only moderate relief.Two days later,a second EBP was performed and the patient developed severe back pain which radiated bilaterally to her buttocks.Magnetic resonance imaging(MRI)demonstrated the presence of blood in the intrathecal space.This could be the cause of sacral radiculitis,an uncommon complication of an EBP.This suggests that EBPs could potentially cause neurologic symptoms which may be more common than people previously thought.As complicated outcomes have followed both conservative and aggressive management,MRI can be an early diagnostic tool in such cases and a multidisciplinary approach should be taken.

Subdural Hematoma and Postdural Puncture Headache from Intrathecal Pump Placement Resolved with Lumbar Epidural Blood Patch

Intrathecal drug delivery systems are commonly used in the management of chronic pain, cancer pain and neuromuscular disorders with muscle spasticity. The complications associated with in-trathecal pump placement include persistent cerebrospinal fluid (CSF) leak, hygroma, meningitis, and granuloma formation. A severe persistent CSF leak may cause postdural puncture headache along with acute intracranial subdural hematoma, which can be potentially life threatening. Surgical exploration with dural repair is required to treat this severe complication when conservative treatments fail. We present a case report of severe persistent CSF leak after intrathecal pump revision that resulted in a subdural hematoma and postdural puncture headache. In this case, an epidural blood patch was performed using epidural catheter under fluoroscopic guidance to target the site of CSF leak and to avoid damaging the intrathecal catheter. This patient’s headache was resolved and intrathecal catheter remained intact after this blood patch.

Early Diagnosis of Spontaneous Spinal Epidural Hematoma with Echo-Planar Gradient-Echo T2*-Weighted MR Imaging

Spontaneous spinal epidural hematoma (SSEH) is a rare idiopathic condition that leads to the acute onset of neurological deficits, which can have catastrophic consequences if not recognized early. It is important to make an early precise diagnosis. Spinal epidural hematoma has been increasingly recognized since the advent of magnetic resonance imaging (MRI). However, T1- and T2-weighted gradient-echo sequences are relatively less sensitive to the magnetic susceptibility effects of hemorrhage. Echo-planar gradient-echo T2*-weighted MR imaging (T2* MRI) is sensitive to these magnetic susceptibility effects and is commonly used for the detection of hemorrhage. We reported that the case of a 76-year-old man who presented with tetra paresis had an early diagnosis of spontaneous spinal epidural hematoma early diagnosed by T2* MRI.

Spontaneous Spinal Epidural Hematoma Causing Paraplegia: A Case Report

A spontaneous spinal epidural hematoma without any identified etiology is a very rare entity. We report here a 44 years old woman admitted within our department for 04 days of severe back pain complicated rapidly of bilateral lower-limbs weakness and urinary retention. Neurological examination found a complete paraplegia (0/5 stergh), with incomplete sensory deficit below the T-10 level, bowel and bladder dysfunction, decreased deep and superficial reflex. MRI with different sequences showed a large epidural mass lesion with slightly high signal intensity on T1-weighted images and heterogeneous low signal intensity on T2-weighted images from T11 to L1 suggesting an epidural hematoma. She underwent an urgent total laminectomy from T11 to L1 following by a complete removal of a large dark and compact epidural hematoma compressing the spinal cord. Operatively, there’s no sign suggesting an AVM. Postoperative course was uneventful and she was discharged ten days after surgery with complete recovery.

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 Hematoma Mimicking Stroke: A New Perspective on Diagnosis and Treatment

Objective: The authors report an extremely rare case of stroke-mimicking, spontaneous cervical epidural hematoma treated with tissue plasminogen activator (TPA). Case Report: We report the case of a 69-year-old female presenting with left-sided hemiparesis of the arm and leg. She was administered by TPA because she was thought to have an ischemic stroke and intracranial CT showed no hemorrhage. However, her neurological condition continued to decline, and MRI of her cervical spine revealed a large spontaneous epidural hematoma. Subsequently, the patient underwent emergency surgery. Conclusions: TPA administration to spinal epidural hematoma (SEH) patients is dangerous. Because cervical epidural hematomas can mimic stroke, the attending medical staff needs to exercise vigilance in diagnosis. In addition to the head, the spine should also be scanned prior to TPA administration.

Why do thoracic epidurals fail?A literature review on thoracic epidural failure and catheter confirmation

Thoracic epidural anesthesia(TEA)has been the gold standard of perioperative analgesia in various abdominal and thoracic surgeries.However,misplaced or displaced catheters,along with other factors such as technical challenges,equipment failure,and anatomic variation,lead to a high incidence of unsatisfactory analgesia.This article aims to assess the different sources of TEA failure and strategies to validate the location of thoracic epidural catheters.A literature search of PubMed,Medline,Science Direct,and Google Scholar was done.The search results were limited to randomized controlled trials.Literature suggests techniques such as electrophysiological stimulation,epidural waveform monitoring,and x-ray epidurography for identifying thoracic epidural placement,but there is no one particular superior confirmation method;clinicians are advised to select techniques that are practical and suitable for their patients and practice environment to maximize success.

Role of N-formyl peptide receptor 2 in germinal matrix hemorrhage:an intrinsic review of a hematoma resolving pathway

Germinal matrix hemorrhage is one of the leading causes of morbidity,mortality,and acquired infantile hydrocephalus in preterm infants in the United States,with little progress made in its clinical management.Blood clots have been shown to elicit secondary brain injury after germinal matrix hemorrhage,by disrupting normal cerebrospinal fluid circulation and absorption after germinal matrix hemorrhage causing post-hemorrhagic hydrocephalus development.Current evidence suggests that rapid hematoma resolution is necessary to improve neurological outcomes after hemorrhagic stroke.Various articles have demonstrated the beneficial effects of stimulating the polarization of microglia cells into the M2 phenotype,as it has been suggested that they play an essential role in the rapid phagocytosis of the blood clot after hemorrhagic models of stroke.N-formyl peptide receptor 2(FPR2),a G-protein-coupled receptor,has been shown to be neuroprotective after stroke.FPR2 activation has been associated with the upregulation of phagocytic macrophage clearance,yet its mechanism has not been fully explored.Recent literature suggests that FPR2 may play a role in the stimulation of scavenger receptor CD36.Scavenger receptor CD36 plays a vital role in microglia phagocytic blood clot clearance after germinal matrix hemorrhage.FPR2 has been shown to phosphorylate extracellular-signal-regulated kinase 1/2(ERK1/2),which then promotes the transcription of the dual-specificity protein phosphatase 1(DUSP1)gene.In this review,we present an intrinsic outline of the main components involved in FPR2 stimulation and hematoma resolution after germinal matrix hemorrhage.

Safety and effectiveness of butorphanol in epidural labor analgesia:A protocol for a systematic review and meta-analysis

BACKGROUND Epidural analgesia is the most effective analgesic method during labor.Butorphanol administered epidurally has been shown to be a successful analgesic method during labor.However,no comprehensive study has examined the safety and efficacy of using butorphanol as an epidural analgesic during labor.AIM To assess butorphanol's safety and efficacy for epidural labor analgesia.METHODS The PubMed,Cochrane Library,EMBASE,Web of Science,China National Knowledge Infrastructure,and Google Scholar databases will be searched from inception.Other types of literature,such as conference abstracts and references to pertinent reviews,will also be reviewed.We will include randomized controlled trials comparing butorphanol with other opioids combined with local anesthetics for epidural analgesia during labor.There will be no language restrictions.The primary outcomes will include the visual analog scale score for the first stage of labor,fetal effects,and Apgar score.Two independent reviewers will evaluate the full texts,extract data,and assess the risk of bias.Publication bias will be evaluated using Egger's or Begg's tests as well as visual analysis of a funnel plot,and heterogeneity will be evaluated using the Cochran Q test,P values,and I2 values.Meta-analysis,subgroup analysis,and sensitivity analysis will be performed using RevMan software version 5.4.This protocol was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA)Protocols statement,and the PRISMA statement will be used for the systematic review.RESULTS This study provides reliable information regarding the safety and efficacy of using butorphanol as an epidural analgesic during labor.CONCLUSION To support clinical practice and development,this study provides evidence-based findings regarding the safety and efficacy of using butorphanol as an epidural analgesic during labor.

A Structured Method of Teaching Epidural Block reduces the incidence of accidental dural puncture in inexperienced trainees.

Background: The rate of accidental dural puncture is particularly high during the period of training, especially in novices. The structured epidural teaching model (SETM) includes three standardized video lessons, the construction of a 3D epidural module by trainees and practical training by using an epidural simulator with and without the CompuFlo™ Epidural instrument. In this study we report the retrospective analysis of the accidental dural puncture rate of inexperienced trainees during their 6 months clinical practice rotation in obstetrics before and after the introduction of the SETM in our Institution. Method: We evaluated the incidence of accidental dural puncture before the introduction of the SETM methodology and afterwards by analyzing our departmental database from February 2019 to January 2023. All epidural blocks were executed by trainees who had never previously performed an epidural block and were about to begin their obstetrics rotation. Results: We analyzed 7415 epidurals: 3703 were performed before the introduction of the SETM methodology (control group) and 3712 afterwards (study group). The incidence of accidental dural puncture was 0.37% for the control group and 0.13% for the study group (p<.05). The probability of making an accidental dural puncture was 64% (OR: 0.36) lower for trainees who had the training than for those who did not. Conclusions: After the introduction of the structured teaching method, we observed a significant reduction of accidental dural puncture during the training period. We hope that our observation will encourage a constructive discussion among experts about the need to use standardized and validated tools as a valuable aid in teaching epidural anesthesia.

Unique method for removal of knotted lumbar epidural catheter: A case report

BACKGROUND Combined spinal-epidural(CSE)anesthesia is the preferred anesthesia method for cesarean delivery.The use of an epidural catheter is essential for administering additional drugs intraoperatively and managing postoperative pain.However,the insertion of epidural catheters is associated with various complications,such as total spinal anesthesia,symptoms indicative of spinal nerve root irritation,and challenges in epidural catheter removal.CASE SUMMARY We present a case report of a challenging epidural catheter removal due to knotting.The lumbar computed tomography scan results revealed that the catheter formed a tight knot in the epidural space.We used a novel extubation method and successfully removed the catheter.CONCLUSION The operator can use opposite forces to"spiral"apart the spinal joints by positioning the patient's body in a specific position.The findings indicate that,when combined with imaging examination results,this method is effective for the removal of epidural catheters.

Management of a Retained Epidural Catheter in a Pregnant Patient: A Case Report and Review of Literature

Background: Epidural anesthesia is an effective intervention to treat labor pain and provide analgesia for orthopedic procedures. A rare complication of this technique is epidural catheter retention. Case Presentation: In this case report, we present an otherwise healthy 21-year-old G2P0010 woman at 39 weeks and 3 days gestation whose anesthetic management was complicated by a symptomatic retained epidural catheter fragment. Computed tomography (CT) imaging of her spine showed the fractured catheter within her paraspinal muscles and neurosurgery recommended no surgical intervention at that time. The patient reported resolution of back pain while in the postpartum unit which she continues to endorse two weeks after discharge. Conclusion: Retained epidural catheter is a medical emergency that requires immediate imaging and neurological evaluation. While magnetic resonance imaging is typically regarded as the standard imaging modality for this complication, in epidural sets that contain metallic components, we suggest using CT to avoid the risk of thermal nerve damage. In cases where the patient does not report any acute complaints, nonsurgical management may be appropriate but close follow-up is required to monitor for catheter migration.

ATAT1 deficiency enhances microglia/macrophage-mediated erythrophagocytosis and hematoma absorption following intracerebral hemorrhage

MIcroglia/macrophage-mediated erythrophagocytosis plays a crucial role in hematoma clearance after intracerebral hemorrhage.Dynamic cytoskeletal changes accompany phagocytosis.However,whether and how these changes are associated with microglia/macrophage-mediated erythrophagocytosis remain unclear.In this study,we investigated the function of acetylatedα-tubulin,a stabilized microtubule form,in microglia/macrophage erythrophagocytosis after intracerebral hemorrhage both in vitro and in vivo.We first assessed the function of acetylatedα-tubulin in erythrophagocytosis using primary DiO GFP-labeled red blood cells co-cultured with the BV2 microglia or RAW264.7 macrophage cell lines.Acetylatedα-tubulin expression was significantly decreased in BV2 and RAW264.7 cells during erythrophagocytosis.Moreover,silencingα-tubulin acetyltransferase 1(ATAT1),a newly discoveredα-tubulin acetyltransferase,decreased Ac-α-tub levels and enhanced the erythrophagocytosis by BV2 and RAW264.7 cells.Consistent with these findings,in ATAT1-/-mice,we observed increased ionized calcium binding adapter molecule 1(Iba1)and Perls-positive microglia/macrophage phagocytes of red blood cells in peri-hematoma and reduced hematoma volume in mice with intracerebral hemorrhage.Additionally,knocking out ATAT1 alleviated neuronal apoptosis and pro-inflammatory cytokines and increased anti-inflammatory cytokines around the hematoma,ultimately improving neurological recovery of mice after intracerebral hemorrhage.These findings suggest that ATAT1 deficiency accelerates erythrophagocytosis by microglia/macrophages and hematoma absorption after intracerebral hemorrhage.These results provide novel insights into the mechanisms of hematoma clearance and suggest ATAT1 as a potential target for the treatment of intracerebral hemorrhage.