[On the diagnosis and judgment of course of subdural effusions in infancy and preschool age. II. Electroencephalographic studies].
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Birth Injuries↗
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Diagnostic method for differentiating external hydrocephalus from simple subdural hygroma.
OBJECT: The various terms used to describe subdural fluid collection--"external hydrocephalus", "subdural hygroma", "subdural effusion", "benign subdural collection", and "extraventricular obstructive hydrocephalus"-reflect the confusion surrounding the diagnoses of these diseases. Differentiating external hydrocephalus from simple subdural hygroma may be difficult, but the former appears to be a distinct clinical entity separate from the latter. In this report, the authors present a diagnostic method for differentiating external hydrocephalus from simple subdural hygroma, based on their clinical experience in treating subdural fluid collection after mild head trauma. METHODS: Twenty patients with subdural fluid collection after mild head trauma were included in this study. Ventricle size was measured using a modified frontal horn index (mFHI); that is, the largest width of the frontal horns divided by the bicortical distance in the same plane, instead of the inner table distance. Bur hole trephination was performed on the appearance of a subdural fluid collection thicker than 15 mm on computed tomography (CT), persistent (longer than 4 weeks) or increasing in size, and accompanied by neurological symptoms (confusion or memory impairment). During the procedure, subdural pressure was measured using a manometer before opening the dura mater. Subdural pressure varied among the patients, ranging from 3 to 27.5 cm H2O. Four patients with a subdural pressure greater than 15 cm H2O had hydrocephalus after surgery (p < 0.05). Hydrocephalus developed in a pediatric patient (2 years old) with a subdural pressure of 12 cm H2O. All of the patients in whom hydrocephalus developed after bur hole trephination had had enlarged ventricles (mFHI > 33%) on preoperative CT scans. CONCLUSIONS: Monitoring subdural pressure may be a valuable tool for differentiating subdural hygroma from external hydrocephalus in patients with mild head trauma. Additionally, the mFHI reflects the nature of the subdural collection more accurately than the standard frontal horn index.
Adolescent↗
[Shunting operation with the medos programmable valve shunt system].
We reviewed 13 patients with hydrocephalus of varied etiology and two patients with arachnoid cyst who underwent shunting operations using Medos programmable valve shunt system. This shunt system allows 18 pressure settings, ranging from 30 to 200mmH2O in 10mmH2O differentials, percutaneously. Following the shunting operation, the size of the ventricle or arachnoid cyst was reduced in all cases and the clinical symptoms improved in 14 cases. The valve pressure was reset during the postoperative course in all cases. In five cases, resetting was performed because of management of complications. In the others, it was performed to find the most appropriate valve pressure for each patient. Complications were subdural effusion (2 cases), chronic subdural hematoma (2 cases) and slit ventricle syndrome (1 case). Subdural effusion and slit ventricle syndrome were improved easily by resetting the valve pressure, but both cases of chronic subdural hematoma finally required surgical treatment. Artifacts in MR imaging and movement of the valve pressure by MR imaging were small and created no clinical problem. In cases 1 and 2, clinical symptoms and CT finding were improved by a change of 30mmH2O. In case 2, hydrocephalus with slight subdural effusion followed a good course with frequent change of the valve pressure. Accordingly, we consider the Medos system to be useful for a more thorough treatment of hydrocephalus and arachnoid cyst after shunting operations.
Adolescent↗
Subdural fat effusion complicating parenteral nutrition.
A preterm infant fed parenterally through a central venous catheter developed a subdural effusion containing fat emulsion. Subsequent postmortem examination failed to demonstrate any vascular abnormality that might have explained this rarely reported complication. Although retrograde flow of feeding solutions into cerebral veins seems a likely explanation, the exact mechanism remains uncertain.
Catheterization, Central Venous↗
Angiographic characteristics of certain subdural collections of fluid.
The presence of abnormal amounts of fluid in the subdural space has been referred to as subdural hematoma, subdural effusion and subdural hygroma. These are supposed to be differentiated by the appearance of the fluid and the presence of membranes in the dubdural space. Although both hygroma and chronic subdural hematoma are liquid, space-occupying lesions which cause pressure in the underlying brain, we have found that there are definite angiographic, clinical and prognostic differences between them. These differences are described.
Cerebral Angiography↗
Subdural haematoma (effusion) and internal hydrocephalus.
It is unusual to encounter a case where subdural haematoma (effusion and internal hydrocephalus coexist and are progressive. Often, when the two diseases are concomitantly present, the pathology of one complicated the other. The pathology of subdural haematoma (effusion), complicated by internal hydrocephalus, and problems involved in the diagnosis and treatment of such cases are described, with particular reference to three such cases treated by the authors, and a review of the literature. When cerebral angiography is used as a follow-up study for postoperative subdural haematoma (effusion), it is necessary to direct attention not only to the disappearance of the subdural clear space but also to the possibility of the occurrence of hydrocephalus. If the intracranial pressure is increased and convulsive seizures appear after a shunting operation for hydrocephalus, it is necessary to consider not only shunt dysfunction but also post-shunt subdural haematoma (effusion).
Cerebral Angiography↗
Rate constant of gadolinium (Gd)-DTPA transfer into chronic subdural hematomas.
Gadolinium (Gd) DTPA concentrations in subdural fluid and arterial blood were measured following intravenous Gd-DTPA injection by ion coupled plasma emission spectrometry in 31 chronic subdural hematomas and 12 with subdural effusions. Dynamic biological modeling analysis was used to calculate the unidirectional transfer rate constant (K) for Gd-DTPA influx into the subdural fluid. The Gd concentrations in subdural hematomas and subdural effusions were 36.3 +/- 3.7 nmol ml(-1) and 80.0 +/- 14.0 nmol ml(-1), respectively. The transfer rate constants (K) for subdural hematomas and subdural effusions were 12.4 +/- 1.5 (x10(-4)) min(-1) and 19.7 +/- 2.2(x10(-4)) min(-1), respectively. The Gd concentration and transfer rate constant for subdural effusions were significantly (p<0.05) higher than for subdural hematoma. The Gd transfer rate constant was significantly correlated with the interval from head injury to operation. The present study shows that the immature outer membrane has a high transfer rate constant, allowing extravasation of plasma components into the subdural space and increasing the volume of the subdural effusion; the rate constant decreases with aging of the subdural hematoma.
Adolescent↗
Inflammatory cytokines locally elevated in chronic subdural haematoma.
The involvement of inflammation in the development and propagation of chronic subdural haematoma (CSH) was investigated by measuring the levels of inflammatory cytokines (tumour necrosis factor [TNF] alpha, interleukin [IL]-1 beta, IL-6, and IL-8). Peripheral venous blood and subdural fluid were obtained at the time of burr hole surgery from 34 patients with CSH and from 9 with subdural effusion. The levels of the inflammatory cytokines were analysed by enzyme-linked immunosorbent assay. The blood levels of TNF alpha, IL-1 beta, IL-6, and IL-8 in both CSH and subdural effusion groups were almost within the range of normal subjects, and no differences were observed between the two groups. IL-6 and IL-8 in the subdural fluid were much higher than in the blood of both groups, and the levels in CSH patients were significantly higher (10 times) than in subdural effusion patients. Local elevation of inflammatory cytokines in the subdural space of both CSH and subdural effusion without systemic change suggests the presence of local inflammation in the two diseases. The same behavioural patterns of cytokines for these and higher levels of cytokines in the CSH also suggest that inflammatory cytokines may be involved in the continuous development from subdural effusion to CSH and propagation of CSH.
Adult↗
[Subdural abscess in infant and child (author's transl].
Two cases of subdural abscess in infant and child treated with irrigation via burr holes were reported. The first case was a 1.4-year-old boy with right hemiparesis and mental retardation since severe head trauma at 9 months old. The patient with manifested with an acute onset of high fever followed by disturbance of consciousness and convulsive seizures 2.5 months prior to admission to our department. During admission in the other hospital, the diagnosis of septicemia caused by E. coli was made by blood cultures when CT scan demonstrated a huge lentiform low density area over the right hemisphere and contralateral crescent low density area. The low density area on the right side was well circumscribed by high density rim which was enhanced by contrast medium. Under the diagnosis of bilateral subdural abscess secondary to septicemia caused by E. coli, irrigation of the purulent cavity was carried out. The contralateral low density area was found to be chronic subdural effusion. The second case of 3-month-old infant who complained of high fever, neck stiffness, unconsciousness and right hemiconvulsions 8 days prior to admission. CT scan showed bilateral crescent low density areas indicating subdural effusion. Subdural punctures performed via the fontanelle revealed pus in the left subdural space and xanthocromic fluid in the right side. The low density area on CT scan was changed to the lentiform high density area circumscribed smooth high density rim during the course of the patient. The subdural abscess was treated with irrigation via burr holes. In this report, the etiology of the subdural abscess and route of infection in addition to follow up study of CT findings were presented with the literature.
Brain Abscess↗
Computed tomography in child abuse head trauma.
Forty-five head trauma cases from 177 child-abuse patients are reported. Intracranial injuries include acute epidural and subdural hematomas, subdural effusion, cerebral contusion, and atrophy (subdural effusion and cerebral contusion being most frequently seen). Incidence of skull fracture among the 45 patients is about 38%. Sixty-five percent of the 17 skull fracture patients also had intracranial injury, and 78% of the 28 patients with normal skulls had intracranial injury. CT should be the primary tool for evaluating child-abuse head trauma.
Brain Concussion↗
Neuroradiologic evaluation of the subdural pathogenesis in infants with small heads.
A marginal low density area is often revealed by CT scan in infants with microcephalia. However, it is difficult to assess precisely the main pathologic state of the marginal low density area and also whether such a lesion exists in the subdural-epiarachnoid space or in the subarachnoid space. A carotid angiographic evaluation of cortical vessels in the marginal avascular area was made and suggestive results were obtained. When there is acute subdural effusion or subdural hematoma, cortical arteries in the marginal avascular area will have a straightened and attenuated figure. But when such a pathologic state persists for a long period, it induces secondary cortical atrophy and the subarachnoid space becomes enlarged. The cortical artery appears as if it is flying in the enlarged subarachnoid space because it is detached from the gyrus and the sulcus following the cortical atrophy. This is why we named it the 'flying artery.' Angiographic findings allow more precise interpretation of the marginal low density area in the CT scan.
Age Factors↗
C-reactive Protein Follow-up of Children With Acute Bacterial Meningitis.
Twenty-two children with bacterial meningitis were prospectively studied to follow C-reactive protein (CRP) in serum at admission, 2nd, 5th and 7th days of treatment, and in the cerebrospinal fluid (CSF) at admission, to investigate if there is any relationship of its levels with the clinical evolution. CRP was measured by latex agglutination and/or ELISA techniques with detection limits of 0.15mg/L and 0.9mg/L, respectively. Patients were classified according to clinical evolution in two groups: uneventful recovery (n=12) and complicated evolution (n=10). Clinical complications observed were: relapse of fever (8), persistent fever (4), arthritis (4), ventricle enlargement (2), subdural effusion (1), subdural empyema (1), ataxia (1), cervical hypotonia (1), deafness (1), endophthalmitis (1), acute otitis media (1), secondary skin infection (1) and treatment change due to poor clinical response (1). A significant fall in CRP serum levels was observed among the uneventful recovery group after admission. Distinctly, in the group with a complicated evolution CRP levels showed either secondary elevation or remained high continuously. Mean serum CRP levels were significantly lower in the uneventful recovery group than in the complicated evolution group on 5th day and on 7th day. CRP levels below 20mg/L on 5th and 7th days were associated with an uneventful recovery, and CRP levels higher than 20mg/L on those same days were associated with a complicated clinical evolution (p=0.01* and p=0.0015*, respectively). We conclude that serum CRP levels monitoring in children with bacterial meningitis represents a useful and objective information about the clinical evolution. This procedure is inexpensive and suitable for use in endemic areas lacking sophisticated laboratories.
Journal Article↗
[The sites of pericerebral effusion in infants].
Clinical observation and chemical analysis led us to consider several anatomical varieties of pericerebral effusions in the infant: pure subdural effusions, subarachnoid effusion as part of ventriculo-subarachnoid hydrocephalus, and at the same time, subdural and subarachnoid effusions resulting from the rupture of a ventriculo-subarachnoid hydrocephalus either in a preexisting subdural effusion or between the dura and the external arachnoid leaf. Amongst these effusions from various aetiologies, the particular cases of the so-called infantile subdural haematomas and postmeningitic effusions are considered. Changes in the pathology and progress in the diagnostic field might explain why the classically described thick membranes are, actually, only exceptionally found.
Cerebral Hemorrhage↗
Computerized tomography in chronic subdural hematomas (effusions) of infancy.
During the past 2 years six infants were seen at University of Wisconsin Hospitals (UWH) with subdural hematomas (effusions). This communication describes the abnormalities found on computerized tomographic (CT) evaluation of the six infants.
Age Factors↗
[Brain abscess and ventriculitis associated with entrapment of the lateral ventricle appearing more like remarkable brain edema than ventricular dilatation--a case report].
We present a case with brain abscess associated with entrapment of the lateral ventricle appearing more like remarkable brain edema in the temporo-occipital lobe than ventricular dilatation. A 72-year-old man suffering from headache and vomiting visited our clinic. CT and MRI showed brain abscess in the right parieto-occipital lobe, associated with ventriculitis. Lumbar puncture also revealed purulent meningitis. Both symptoms and CSF findings improved after administration of antibiotics. The improved condition continued for two months after admission, but disturbed consciousness and left hemiparesis than appeared. MRI and CT showed entrapment of the lateral ventricle and brain edema of the right temporo-occipital region without ventricular dilatation. Because brain edema was thought to be caused by transudate of the CSF through the ventricular wall, lobectomy of the right temporal lobe and opening of the temporal horn were carried out. Although left hemiparesis and disturbed consciousness and brain edema disappeared after the operation, subdural effusion appeared. Using a subdural-peritoneal shunt, the subdural effusion was prevented and disappeared. In this case, we thought Hounsfield Unit (HU) of the brain edema caused by transudate of CSF through the ventricular wall (12.6) was markedly lower than that of so-called vasogenic edema (25.1) due to active inflammation. Measurement of the HU seemed to be a useful means to differentiate the types of brain edema in this situation from that of vasogenic edema caused by brain abscess, and thus a means for selection of the appropriate treatment.
Aged↗
Subdural fat effusion complicating parenteral nutrition.
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Catheterization, Central Venous↗
Effect of arachnoid plasty using fibrin glue membrane after clipping of ruptured aneurysm on the occurrence of complications and outcome in the elderly patients.
BACKGROUND: In elderly patients with aneurysmal subarachnoid hemorrhage (SAH), complications including vasosopasm, subdural effusion, and late hydrocephalus, are liable to occur even after aneurysmal surgery. We examined prospectively the efficacy of arachnoid plasty using fibrin glue membrane during surgery of ruptured aneurysms in the elderly patients for preventing complications. The effects on the modified Rankin scale (mRS) and the Glasgow outcome scale (GOS) 3 months after SAH were noted. METHODS: Total of 31 patients aged more than 70 years selected from a consecutive series of patients with aneurysmal SAH, were divided into two groups alternately, a group with arachnoid plasty (n = 16) and a control group without arachnoid plasty (n = 15). Statistical analyses were performed to assess relationships among various clinical and neuroradiological variables, especially between arachnoid plasty and occurrence of symptomatic vasospasm, subdural effusion, late hydrocephalus, or outcome such as mRS and GOS 3 months after onset. FINDINGS: Statistical analyses revealed that arachnoid plasty were associated with late hydrocephalus and subdural effusion negatively, but with better mRS at 3 months after SAH. A tendency to be associated with less frequent symptomatic vasospasm was also noted. CONCLUSION: Arachnoid plasty using fibrin glue is suggested to be effective in preventing complications associated with SAH and aneurysmal surgery. A better outcome in the elderly patients can be achieved.
Age Factors↗
Fever during treatment for bacterial meningitis.
The records of 476 infants and children with bacterial meningitis treated between 1979 and 1982 were reviewed. By the sixth hospital day 90% or more of children with pneumococcal or meningococcal infection compared with 72% of children with Haemophilus infection (P less than 0.001) were afebrile. The rates of prolonged fever for 10 days or more, persistent fever for 5 to 9 days and secondary fever were 13, 13 and 16%, respectively. The conditions associated with prolonged fever for 10 days or more were subdural effusion (27%), drug fever (23%) and concomitant arthritis or pneumonia (20%); 15% were of indeterminable cause. The principal conditions associated with persistent fever for 5 to 9 days were other foci of disease (17%), nosocomial infections (16%) and subdural effusion (14%); in 42% the cause was unknown. The conditions associated with secondary fever were nosocomial infections (27%) and subdural effusion (23%); 39% were of indeterminable cause. Neither the duration nor the patterns of fever correlated with neurologic abnormalities at discharge, including hearing deficit.
Child↗