Epidural blood patch for spontaneous intracranial hypotension with subdural hematoma: A case report and review of literature

BACKGROUND Cerebrospinal fluid(CSF)leakage at C1/2 in spontaneous intracranial hypotension(SIH)is rare.Subdural hematoma(SDH),a serious complication of SIH,may lead to neurological deficits.This report presents a case of SDH after spontaneous C1/2 CSF leakage,which was treated with a targeted epidural blood patch(EBP).CASE SUMMARY A 60-year-old man with no history of trauma was admitted to our hospital with orthostatic headache,nausea,and vomiting.Brain computed tomography imaging revealed bilateral,subacute to chronic SDH.Brain magnetic resonance imaging(MRI)findings were SDH with dural enhancement in the bilateral cerebral convexity and posterior fossa and mild sagging,suggesting SIH.Although the patient underwent burr hole trephination,the patient’s orthostatic headache was aggravated.MR myelography led to a suspicion of CSF leakage at C1/2.Therefore,we performed a targeted cervical EBP using an epidural catheter under fluoroscopic guidance.At 5 d after EBP,a follow-up MR myelography revealed a decrease in the interval size of the CSF collected.Although his symptoms improved,the patient still complained of headaches;therefore,we repeated the targeted cervical EBP 6 d after the initial EBP.Subsequently,his headache had almost disappeared on the 8th day after the repeated EBP.CONCLUSION Targeted EBP is an effective treatment for SDH in patients with SIH due to CSF leakage at C1/2.

Recurrent Intracranial Hypotension Complicated with Subdural Hematoma—A Case Report and a Case Series Review

Intracranial hypotension has variable clinical manifestations;subdural hematoma is one of the complications of intracranial hypotension with the reported incidence ranging from 16% to 57%. The author would like to share a case of subdural hematoma caused by recurrent intracranial hypotension with different cerebrospinal fluid (CSF) leakage site and to review a case series of intracranial hypotension treated in the author’s hospital (Kaohsiung Veterans General Hospital). A 44-year-old male having the past history of intracranial hypotension was treated in our Neurology division one month previous to this admission, who was sent to our emergency room (ER) due to severe orthostatic headache with nausea and vomiting. Computed tomography (CT) scan of brain at ER showed bilateral subdural hematoma, more on the left side with mass effect. Both surgical removal of the subdural hematoma and epidural blood patch were performed and he had a good outcome. Orthostatic headache is a specific symptom sign of intracranial hypotension. Epidural blood patch is effective to manage intracranial hypotension either the leakage site of CSF is detected or not. In case of non-traumatic subdural hematoma, intracranial hypotension should be kept in mind.

Piezo1 as a potential player in intracranial hemorrhage:From perspectives on biomechanics and hematoma metabolism

Intracranial hemorrhage(ICH)causes numerous neurological deficits and deaths worldwide each year,leaving a significant health burden on the public.The pathophysiology of ICH is complicated and involves both primary and secondary injuries.Hematoma,as the primary pathology of ICH,undergoes metabolism and triggers biochemical and biomechanical alterations in the brain,leading to the secondary injury.Past endeavors mainly aimed at biochemical-initiated mechanisms for causing secondary injury,which have made limited progress in recent years,although ICH itself is also highly biomechanics-related.The discovery of the mechanically-activated cation channel Piezo1 provides a new avenue to further explore the mechanisms underlying the secondary injury.The current article reviews the structure and gating mechanisms of Piezo1,its roles in the physiology/pathophysiology of neurons,astrocytes,microglia,and bone-marrow-derived macrophages,and especially its roles in erythrocytic turnover and iron metabolism,revealing a potential interplay between the biomechanics and biochemistry of hematoma in ICH.Collectively,these advances provide deeper insights into the secondary injury of ICH and lay the foundations for future research.

Acquired factor XIII deficiency presenting with multiple intracranial hemorrhages and right hip hematoma:A case report

BACKGROUND Factor XIII(FXIII)deficiency is a rare yet profound coagulopathy.FXIII plays a pivotal role in hemostasis,and deficiencies in this factor can precipitate unchecked or spontaneous hemorrhaging.Immunological assays for detecting FXIII inhibitors are indispensable for diagnosing acquired FXIII deficiency;however,the availability of suitable testing facilities is limited,resulting in prolonged turnaround times for these assays.CASE SUMMARY In this case study,a 53-year-old male devoid of significant medical history presented with recurrent intracranial hemorrhages and a hematoma in the right hip.Subsequent genetic analysis revealed a homozygous mutation in the ACE gene,confirming the diagnosis of acquired FXIII deficiency.CONCLUSION This case underscores the significance of considering acquired deficiencies in clotting factors when evaluating patients with unexplained bleeding episodes.

A Rare Etiology of a Life-Threatening Subdural Hematoma: Case Report and Literature Review

Background: Life-threatening subdural hematoma is commonly related to trauma and rarely revealed by neoplasm. Observation: We report a case of a 53-year-old suffering from mild headache and without a history of trauma, was admitted unconscious due to a subdural hematoma on radiological investigations. Beside the left subdural hematoma, there was also alytic lesion of the sphenoid wing and the temporal bone on the same side. An emergent removal of the subdural hematoma and an excision of the bone lesion were performed. Pathological examination diagnosed a cavernous hemangioma of the skull. The postoperative period was uneventful with a dramatic recovery of the patient. Conclusion: A quick worsening of a chronic headache, acute impairment of an uncommon headache deserve prompt investigation and emergent surgical management in case of intracranial hematoma. Any bone and dural abnormalities at the vicinity of a subdural hematoma require total excision with clean border and pathological examination.

Chronic Subdural Hematoma Associated with an Arachnoid Cyst in Elderly, an Intraoperative Finding after Re-Bleeding: Case Report

Intracranial arachnoid cysts (AC) are believed to be congenital and chronic subdural hematomas tend to occur in elderly patients with a history of mild head injury. The association between these two entities sporadically occur in relatively young patients but rare in elderly patients. We report a 65-year-old man who presented with headache and dizziness of 2 months’ duration with a history of head injury. Brain computed tomography (CT) a CSDH in right side and a hygroma in left side. After first operation with burr holes in both sides, the patient underwent an early recurrence of acute subdural hematoma in the right side. The evacuation of this hematoma by a craniotomy allowed seeing an AC that we resected partially with complete recovery of the patient. The association CSDH/AC is rare and possible in elderly patients and there is no consensus on treatment.

Left Hemispherical Subdural Hematoma on the Same Side as the Motor Deficit (Kernohan)

Chronic subdural hematoma represents 25% of traumatic subdural collections;common in elderly subjects with a clear male predominance. It occurs over the age of 50 in more than 90% of cases and 50% of patients have no history of head trauma even if the latter remains the main risk factor with others such as coagulopathy, anticoagulant treatment, chronic alcoholic poisoning. Its discovery is rarely fortuitous and has an important clinical polymorphism including an intracranial hypertension syndrome (complete or incomplete). We report a clinical case of a left hemispheric subacute subdural hematoma with post-traumatic falcorial involvement in a 70-year-old patient admitted with a picture of impaired consciousness and weakness of the left hemibody. The objective of this work is to draw the attention of neurosurgeons and neurologists to the paradoxical existence of the neurological deficit on the same side as the causal brain lesion.

Enigmatic rapid organization of subdural hematoma in a patient with epilepsy:A case report

BACKGROUND Determining a subdural hematoma(SDH)to be chronic by definition takes 3 wk,whereas organized chronic SDH(OCSDH)is an unusual condition that is believed to form over a much longer period of time,which generally demands large craniotomy.Therefore,it is a lengthy process from the initial head trauma,if any,to the formation of an OCSDH.Acute SDH(ASDH)with organization-like,membranaceous appearances has never been reported.CASE SUMMARY A 56-year-old woman presented to our hospital with a seizure,and computed tomography(CT)on admission was negative for signs of intracranial hemorrhage.She had clear consciousness and unimpaired motor functions on arrival and remained stable for the following week,during which she underwent necessary examinations.On the morning of day 10 of hospitalization,she accidentally hit her head hard against the wall in the bathroom and promptly lapsed into complete coma within 2 h.Therefore,we performed emergency CT and identified a left supratentorial SDH that was an absolute indication for surgery.However,the intraoperative findings were surprising,with no liquefaction observed.Instead,a solid hematoma covered with a thick membrane was noted that strongly resembled an organized hematoma.Evacuation was successful,but the family stopped treatment the next day due to financial problems,and the patient soon died.CONCLUSION Neurosurgeons should address SDHs,especially ASDHs,with discretion and individualization due to their highly diversified features.

Positioning and design by computed tomography imaging in neuroendoscopic surgery of patients with chronic subdural hematoma

BACKGROUND Neuroendoscopy is a very useful technique to Chronic Subdural Hematoma(CSH).But how to achieve the goal of treatment more minimally invasive?AIM To develop a simple,fast and accurate preoperative planning method in our way for endoscopic surgery of patients with CSH.METHODS From June 2018 to May 2020,forty-two patients with CSH,admitted to our hospital,were performed endoscopic minimally invasive surgery;computed tomography(CT)imaging was employed to locate the intracerebral hematoma and select the appropriate endoscopic approach before the endoscopic surgery.The clinical data and treatment efficacy were analyzed.RESULTS According to the learning of CT scanning images,the surgeon can accurately design the best minimally invasive neuroendoscopic surgical approach and realize the precise positioning and design of the drilling site of the skull and the size of the bone window,so as to provide the most effective operation space with the smallest bone window.In this group,the average operation time was only about 1 h,and the clearance rate of hematoma was about 95%.CONCLUSION Patients with CSH can achieve good therapeutic effect by using our way to positioning and design to assist the operation of CSH according to CT scan and image,and our way is very useful and necessary.

Risk Factors of Reoperation and Outcome of Patients Operated for Chronic Subdural Hematoma in a Teaching Hospital in Rabat

Background: chronic subdural hematoma is a common pathology, especially in the elderly. Although it has a good prognosis, it poses the problem of recurrence after surgical evacuation. Objective: To analyze the risk factors of reoperation in patients surgically treated for chronic subdural hematoma (cSDH) and evaluate the outcome of patients who benefited from a reoperation. Materials and Methods: A retrospective review was conducted in a single University Hospital Center in Rabat (Morocco) on 49 patients operated on from January 2020 to June 2021 for cSDH. Possible risk factors described in the literature were analyzed and the outcome of post-operative course was evaluated. Statistical significance was defined by p-value Results: 49 patients underwent surgical evacuation of cSDH. The sex ratio of male/female was 3.08. The mean age was 70.6 years. Concerning the medical history, 8.2% were diabetics, 10.2% had heart disease, 18.4% had hypertension, 16.3% associated of comorbidities, 2% had pulmonary embolism, and 2% had neoplasm. 18.4% were on anticoagulation therapy, no patients were on new oral anticoagulants. The clinical findings upon admission were motor deficit at 57.1%, signs of intracranial hypertension at 20.4%, altered consciousness at 16.9% and impaired behavior at 6.1%. 28.6% of patients had a past history of head trauma. The pre-operative CT scan showed unilateral cSDH at 81.6%, midline shifts at 77.6%, and false membranes at 34.7%. Blood appeared chronic at 40.8%, subacute at 24.5%, and mixed densities at 34.7%. The post-operative course was uneventful in 73.5%. According to Ibanez grading 8 patients had mild complications (grade I) and 5 moderate complications (grade II) after the first surgery. We recorded 10.2% of patients who needed a second surgery because of the deterioration of neurologic status or motor deficit associated with an abnormal CT scan. According to the GOS, 85.7% of patients had a good recovery while 10.2% died. None of the factors assessed was found to be a risk factor for reoperation. Conclusion: No risk factors of reoperation after an initial burr hole evacuation for cSDH were found. However medical history and male sex was common condition among reoperated patients with their CT scan showing a chronic aspect of blood, midline shift and false membranes. Most patients who underwent revision surgery died on the postoperative course.

Ossified Subdural Chronic Hematoma: Two Cases Report and Literature Review

Ossified subdural chronic hematoma (OSCH) is a rare disease that accounts 0.3% to 2% of subdural chronic hematoma which is common. The surgical management depends on his clinical expression. The aim of this study is to highlight the surgical procedure because the management of this type of lesion has no consensus. The authors reported two cases of OSCH which were successfully excised with good outcomes. Taking care during the procedure of dissection from parenchyma is the key for this surgery.

Individual idea about the micro-invasive aspiration and drainage of intracranial hematoma

AIM： This study aimed to expound the individual idea of micro-invasive surgery from pre-operative preparation, intra-operative processing and post-operative management. METHODS： Pre-operative preparation was improved by analyzing pathological factors and hematoma property, and considering patients＇ age, basic disease, blood pressure control, with persistent haemorrhagia/rehaemorrhagia or not, operative occasion choice, positioning and other procedures. In the surgery, positioner was used. Initial aspiration volume was cautiously controlled. After operation, vital signs of patients were kept stable by cautiously using hematoma liquefacient and combining with free radical scavenger. RESULTS： The core content of individual micro-invasive surgery was mainly to relieve intracranial pressure. Under the condition of sufficient pre-operative preparation known by patients＇ family members, precise positioning was determined and individual therapeutic regimen was made. Meanwhile, caution should be taken in hematoma aspiration. Liquefaction and drainage should be paid more attention, and complications were processed actively. CONCLUSION： During the process of micro-invasive evacuation of intracranial hematoma for treating cerebral hemorrhage, attention should be paid to analyzing cerebral hematoma etiology and pathophysiological mechanism, and individual idea should be considered in surgical treatment aiming at patients＇ concrete disease condition.

Effect of Postoperative Administration of Saireito for Bilateral Chronic Subdural Hematomas

The aim of this retrospective study was to investigate the efficacy of saireito for bilateral chronic subdural hematomas (B-CSDH). Between April 2006 and March 2010, a total of 18 patients undergoing unilateral burr hole drainage for B-CSDH took part in a controlled clinical study. Postoperative status of the nonsurgical side was subsequently evaluated, with (n = 10) and without (n = 8) saireito administration. Two in the saireito-treated group patients and four in the control group patients ultimately required contralateral surgical intervention. The remainder, including eight saireito-treated hematomas, resolved without further surgery, generally within eight weeks of the surgical side procedure. However, two of the four resolving control lesions took longer to regress. The hydragogue and anti-inflammatory/steroid-evoking properties ascribed to saireito may facilitate hematoma resolution. After unilateral surgery for B-CSDH, saireito administration may prevent symptomatic deterioration of a contralateral low-density CSDH, preempting subsequent surgery.

Vertebroplasty and delayed subdural cauda equina hematoma: Review of literature and case report

Vertebroplasy is considered an alternative and effective treatment of painful oncologic spine disease. Major complications are very rare, but with high morbidity and occur in less than 1% of patients who undergo vertebroplasty. Spinal subdural hematoma(SDH) is an extremely rare complication, usual developing within 12 h to 24 h after the procedure. We report the case of a tardive SDH in an oncologic patient who underwent VP for Myxoid Liposarcoma metastasis. Trying to explain the pathogenesis, we support the hypothesis that both venous congestion of the vertebral venous plexus of the vertebral body and venous congestion due to a traumatic injury can provoke SDH. To our best knowledge, only 4 cases of spinal subdural hematoma following a transpedicular vertebroplasty have been previously described in International literature and only one of them occurred two weeks after that surgical procedures. Percutaneous verteboplasty is a wellknown treatment of pain oncologic spine disease, used to provide pain relief and improvement of quality life and is considered a simple surgical procedure, involving a low risk of complications, but related to high morbidity, such as SDH. Therefore it has to be performed by experienced and skilled surgeons, that should also recognize possible risk factors, making SDH more risky.

Efficacy of Single Burr Hole in Management of Chronic Subdural Hematoma

Background: Surgery of chronic subdural hematoma (CSDH) is a common practice of neurosurgeons. CSDH is considered a pathology of the elderly and usually many co-morbidities are present. CSDH carries high risk of mortality if not treated or not treated well. So, the minimal, safe and adequate surgical intervention is the bases to choose specific surgical maneuver. Aim of the Study: The efficacy of a single burr in evacuation and treatment of chronic subdural hematoma. Methods: This study was held in Assiut university hospitals, neurosurgical department. It is a prospective randomized controlled study. 113 patients were enrolled in this study in the period between March 2018 and June 2019. We included all cases of chronic subdural hematoma (CSDH) and subacute subdural hematoma that were evacuated with single burr hole. Hematomas either, unilateral or bilateral were included. Septated hematomas were excluded. Patients’ clinical characteristics as age, sex, clinical presentation, co-morbidities and patients outcome were recorded. Postoperative status as regards improvement of the neurological status, complications and recurrence of hematoma were recorded. Results: We had 113 patients operated via properly situated single burr hole in our study. 113 patients were included in this study, 79 males (69.9%) and 34 females (30.1%). Age of the patients ranges between 27 years old and 90 years old. Postoperative follow up was evaluated according to Glasgow outcome score (GOS). We had 98 patients with good recovery, 4 patients with moderate disability, 6 patients with severe disability and 5 patients died. Complications were in form of 3 patients with residual hematoma, 2 patients with tension pneumocephalus, 7 patients developed postoperative seizure, 5 cases developed cortical/parenchymal hematoma and 9 cases developed hematoma recurrence. Conclusion: Single, properly situated burr hole with previously described characters is an effective treatment option in cases of CSDH. It helps adequate, effective and safe removal of the pathology with limited maneuver.

Recovery of corticospinal tract injury following subdural hematoma removal A diffusion tensor imaging study

Subdural hematoma can cause compression or damage to the neural tracts in the brain;however,very little is known about this injury.We report on a patient with subdural hematoma who was evaluated by diffusion tensor imaging prior to and after trephination and drainage of subdural hematoma.A 58-year-old male patient and ten age-matched normal control subjects were evaluated.The patient showed mild hemiparesis for 3 weeks prior to surgery.His hemiparesis recovered to a nearly normal state at 5 weeks post-surgery when the follow up diffusion tensor image was acquired.Two diffusion tensor image parameters,fractional anisotropy and apparent diffusion coefficient,were measured along the corticospinal tract.Pre-operative diffusion tensor image showed that the corticospinal tract of the affected hemisphere seemed to be injured or compressed.However,the follow up diffusion tensor image showed recovery of this corticospinal tract to a normal state.It would appear that diffusion tensor images are a useful tool for evaluation of the effects of subdural hematomas on neural tracts.

Efficacy evaluation of neuroendoscopy vs burr hole drainage in the treatment of chronic subdural hematoma:An observational study

BACKGROUND Chronic subdural hematoma(CSDH)is a common disease in neurosurgery.The traditional treatment methods include burr hole drainage,bone flap craniectomy and other surgical methods,and there are certain complications such as recurrence,pneumocephalus,infection and so on.With the promotion of neuroendoscopic technology,its treatment effect and advantages need to be further evaluated.AIM To study the clinical effect of endoscopic small-bone approach in CSDH.METHODS A total of 122 patients with CSDH admitted to our hospital from August 2018 to August 2021 were randomly divided into two groups using the digital table method:the neuroendoscopy group(n=61 cases)and the burr hole drainage group(n=61 cases).The clinical treatment effect of the two groups of patients with CSDH was compared.RESULTS At the early postoperative stage(1 d and 3 d),the proportion of 1/2 re-expansion of brain tissue in the hematoma cavity and the proportion of complete reexpansion was higher in the neuroendoscopy group than in the burr hole drainage group,and the difference between the two groups was statistically significant(P<0.05).The recurrence rate of hematoma in the neuroendoscopy group was lower than that in the burr hole drainage group,and the difference between the two groups was statistically significant(P<0.05).No intracranial hematoma,low cranial pressure,tension pneumocephalus or other complications occurred in the neuroendoscopy group.CONCLUSION The neuroendoscopic approach for the treatment of CSDH can clear the hematoma under direct vision and separate the mucosal lace-up.The surgical effect is apparent with few complications and definite curative effect,which is worthy of clinical promotion and application.

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.

Neonatal infratentorial subdural hematoma contributing to obstructive hydrocephalus in the setting of therapeutic cooling: A case report

BACKGROUND Symptomatic neonatal subdural hematomas usually result from head trauma incurred during vaginal delivery,most commonly during instrument assistance.Symptomatic subdural hematomas are rare in C-section deliveries that were not preceded by assisted delivery techniques.Although the literature is inconclusive,another possible cause of subdural hematomas is therapeutic hypothermia.CASE SUMMARY We present a case of a term neonate who underwent therapeutic whole-body cooling for hypoxic ischemic encephalopathy following an emergent C-section delivery for prolonged decelerations.Head ultrasound on day of life 3 demonstrated a rounded mass in the posterior fossa.A follow-up brain magnetic resonance imaging confirmed hypoxic ischemic encephalopathy and clarified the subdural hematomas in the posterior fossa causing mass effect and obstructive hydrocephalus.CONCLUSION The aim of this report is to highlight the rarity and importance of mass-like subdural hematomas causing obstructive hydrocephalus,particularly in the setting of hypoxic ischemic encephalopathy and therapeutic whole-body cooling.

Intervention of Peiyuan Huayu Decoction on the neuron damage in model rats with acute subdural hematoma

Objective:To study the intervention effect of Peiyuan Huayu Decoction on the neuron damage in model rats with acute subdural hematoma (ASDH).Methods: 160 SD rats were randomly divided into four groups, and the ASDH model rats were made by stereotactic autoblood injection, and sham operation group received craniotomy without blood injection. Sham operation group and model group were normally bred after model establishment, and 6 h after model establishment, the treatment group received intragastric administration of Peiyuan Huayu Decoction, and control group received intragastric administration of Piracetam Tablets, 1 time a day. On the 1d, 3d, 5d and 7d after model establishment, the general conditions of rats (activity, food intake and mental state) were observed, blood was collected via auricula dextra, ELISA method was used to determine peripheral plasma NSE and S100β protein contents, routine HE staining was conducted after perfusion fixation, the neurons in blood injection side of brain tissue were counted, and the neuron damage was observed.Results: 26 rats were dead in the experiment. The general conditions of sham operation group were significantly better than those of other groups, treatment group was significantly better than model group and control group on the 5d group (P<0.05), and there was no significant difference on the 1d, 3d and 7d (P>0.05);neuron count of sham operation group was basically stable, treatment group was not different from model group and control group on the 1d (P>0.05), treatment group was better than model group (P<0.05), and not different from control group (P>0.05) on the 3d, and treatment group was better than model group and control group on the 5d and 7d (P<0.05);peripheral plasma S100β protein and NSE contents of sham operation group were at lower levels, treatment group was not significantly different from model group and control group on the 1d (P>0.05), S100β protein and NSE contents decreased significantly on the 3d, and treatment group was significantly different from model group and control group (P<0.05), S100β protein and NSE contents increased on the 5d and 7d, the increase in treatment group was slower than that in model group and control group, and there was significant difference (P<0.05).Conclusion:Peiyuan Huayu Decoction has obvious protective effect on the neurons in ASDH model rats, and this effect may be based on the inhibition of secondary neuron damage.