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PubMed2004

Post-traumatic subdural hygroma: case report.

Subdural Hygroma (SDG) is described in the literature as a common complication of blunt head trauma occurring in a reported 5-20% of all closed head injuries. The Emergency Physician will likely encounter this type of lesion and it is useful to have an understanding of its significance, its relationship to subdural hematoma (SDH), and management strategies. Although surgical intervention is often advocated in the treatment of intracranial fluid collections causing mass effect, there are several reported cases of spontaneous resolution of uncal and central herniation via conservative management alone. The authors report a case of a 90-year-old woman who presented to the Emergency Department 5 days after falling and sustaining a closed head injury with computed tomography (CT) scan evidence of mid-line shift.

Aged↗
PubMed2006

Intracranial hypotension causing headache and neck pain: a case study.

OBJECTIVE: The purpose of this study is to discuss the presentation, examination, diagnosis, and treatment of a case of intracranial hypotension presenting to a chiropractic office as acute severe headache and neck pain. CLINICAL FEATURES: Flexion injury during a weight lift resulted in a severe postural headache and upper cervical spine pain in a 51-year-old man. The patient presented with unusual symptoms, but normal palpatory findings, and a lack of postural distortion. INTERVENTION AND OUTCOME: Based on the history, symptoms, and examination findings, the patient was referred for an emergency medical evaluation. A diagnosis of intracranial hypotension was made, and a dural leak was confirmed by radioisotope cisternography. The patient made a complete recovery. CONCLUSIONS: Intracranial hypotension can cause headache and neck pain that may appear to be musculoskeletal in nature. The key symptom is the orthostatic nature of the headache.

Bed Rest↗
PubMed2003

Management of massive calcified transdural thoracic disk herniation.

Thoracic disk herniation is a not uncommon pathology faced by the spinal surgeon. The management of massive intradural thoracic disk herniation with ventral cord compression is problematic both in terms of obtaining adequate decompression and ensuring no subsequent leakage of cerebrospinal fluid. A 54-year-old woman presented with a 10 year history of back pain and left leg pain. Over the past 6 months she experienced a progressive spastic paraparesis in both legs with recent urinary incontinence. A left anterolateral thoracotomy for excision of T8/9 thoracic disk protrusion was affected. A transdural decompression was performed with resection of the calcified dura and performance of a Gore-Tex duraplasty and pleuroplasty. A free muscle graft was placed in the intervening space and the chest drains were placed on non-suction. A spinal drain was maintained for 5 days. She made an excellent neurological recovery. Avoidance of cerebrospinal leakage is paramount when performing transthoracic approaches as negative intrapleural pressure can lead to persistence of leakage. This report documents a safe and reliable way to deal with massive intradural thoracic disk rupture with avoidance of subsequent spinal fluid leak.

Back Pain↗
PubMed2004

Arachnoid cyst presenting as subdural hygroma.

Arachnoid cysts are developmental lesions which are usually asymptomatic or may present with a variety of clinical features. Subdural hygroma is an extremely unusual complication associated with arachnoid cysts. A case of subdural hygroma that developed after the rupture of an asymptomatic middle cranial fossa cyst, following minor head injury is reported.

Adult↗
PubMed2004

Traumatic acute subdural hygroma mimicking acute subdural hematoma.

Subdural hygroma is a frequent delayed complication of head trauma. Most hygromas are clinically 'silent' and a few cases have shown slow deterioration in the chronic stage. We report a case of subdural hygroma showing unique radiological findings and rapid deterioration. A 74-years-old female presented with a mild headache and consciousness disturbance after head injury. Computed tomography showed a midline shift as a result of two components piling up in the subdural space; the outer components showed low density, the inner components high density. Magnetic resonance imaging demonstrated that these two subdural components were subdural hygroma and subarachnoid hematoma. Simple burr hole irrigation, rather than large craniotomy, was thought to be more appropriate treatment to reduce the mass effect. Simple burr hole irrigation was performed to remove the subdural hygroma and the patient showed an excellent recovery. Careful examination of the radiological findings prevented an unnecessary procedure in this case. A possible mechanism of this phenomenon is discussed.

Acute Disease↗
PubMed2005

Chronic subdural haematoma after riding a roller coaster.

We report a 20-year-old man who developed a chronic subdural haematoma (CSDH) after riding a "giant" roller coaster. The patient had a past history of a subdural hygroma, diagnosed six weeks after a motorcycle accident. Three months after this accident, he rode on a roller coaster, but suffered no direct head trauma during the ride. Three weeks later, he developed a CSDH requiring surgical evacuation. Roller coaster riding, associated with high velocities and extreme acceleration/deceleration forces is a modern cause of CSDH in the young, which may be increasing due to ever-faster rides.

Accidents↗
PubMed2005

Rapid fluctuations in conscious state in a patient with an extensive spinal dural fistula.

A man with a spontaneous spinal dural fistula and significant fluctuations in level of consciousness is discussed. The presentation was that of headache and vomiting followed by an initially enigmatic acute reduction in the level of consciousness. This required urgent evacuation of bilateral chronic subdural haematomas, believed to be causative. Following mobilisation, several episodes of presumed orthostatic intracranial hypotension occurred rendering the patient rapidly unconscious. A large spinal extradural CSF collection extending through the full length of the vertebral canal was later diagnosed however, the precise location of the fistulous leak could not be found radiologically. Non-operative management was successful. To the best of our knowledge, this is the first description of a spontaneous spinal cerebrospinal fluid leak of this magnitude. The case, pathogenesis, investigations and management of this rare entity are considered and the literature reviewed.

Cervical Vertebrae↗
PubMed2006

Determinants of success in endoscopic cerebrospinal fluid leak repair.

OBJECTIVES: To identify factors influencing success in endoscopic repair of CSF leaks of the anterior skull base. METHODS: Through retrospective chart review, 24 endoscopic closures of anterior skull base CSF leaks were analyzed for factors correlating with initial repair outcome. RESULTS: Thirteen patients with either spontaneous leaks or iatrogenic leaks arising from FESS were repaired with significantly lower recurrence rate (8%) than 11 patients with leaks induced by skull base procedures (45%). However, in the latter group, only 14% recurred when the dural defect was directly visualized, whereas leaks always recurred when bony dehiscences were patched in the absence of visible dural defects. Such defects were least frequently localized in patients with craniotomy-induced leaks. A trend toward morbid obesity was also noted among repair failures. CONCLUSIONS: Direct visualization of the dural defect is essential for endoscopic repair of anterior skull base CSF leaks, with craniotomy-induced leaks being the most challenging to localize. Obesity is another likely factor contributing to repair failure.

Adolescent↗
PubMed2004

Organic bipolar disorder occurring together with spontaneous intracranial hypotension.

Spontaneous intracranial hypotension (SIH) is known to cause postural headache, often combined with auditory, and vestibular symptoms, nausea, vomiting, and diplopia. We report a 63-year-old male patient who for the first time developed a depressive episode followed by acute manic symptoms during the course of SIH, both relieved after treatment of the underlying organic disturbance.

Bipolar Disorder↗
PubMed2006

Intracranial hypotension with spinal pathology.

BACKGROUND CONTEXT: Intracranial hypotension (IH) is a syndrome in which volume depletion of the cerebrospinal fluid (CSF) results in various neurological symptoms. Most commonly, a small tear or defect in the spinal dural sac is the underlying lesion that results in a CSF leakage and IH. Causes of IH can be classified as 1) spontaneous (primary), and 2) secondary. Knowledge of IH is essential to spine surgeons, because a small proportion of patients with spontaneous IH require spine surgery, and secondary causes of IH include spine trauma, various spine-related diagnostic/therapeutic procedures (iatrogenic), and degenerative spine disorders. PURPOSE: The purpose of this review is to update knowledge of IH pertinent to spine surgery. STUDY DESIGN/SETTING: Review of the literature. METHODS: A systematic review of the literature was conducted using PUBMED. The literature regarding IH with spinal pathology published from 1966 to 2005 was searched and reviewed comprehensively. RESULTS/CONCLUSIONS: The lower cervical and upper thoracic spine are the predilection sites for a CSF leak in patients with spontaneous IH. Mechanical stress may have a role in the pathogenesis of spontaneous IH, and meningeal diverticula and connective tissue disorders may be important risk factors. Iatrogenic causes of IH include lumbar puncture, spine surgery, and chiropractic manipulation. Rarely, degenerative spine disorders are the secondary cause of IH. Although orthostatic headache is the characteristic symptom of IH, a small proportion of patients present with neck pain or radicular symptoms of the upper extremity. Imaging studies of the spine have contributed significantly to elucidation of the pathophysiology of IH as well as identification of the site of a CSF leak. Typical spinal radiographic findings of IH include extra-arachnoid or extradural fluid collections, meningeal enhancement, engorgement of the epidural venous plexus, and tonsilar descent into the foramen magnum. Most patients with spontaneous IH respond favorably to conservative management, including autologous epidural blood patch. Surgical intervention is reserved for those who fail the conservative management. Although immediate clinical improvement is usually achieved by surgery, the long-term outcomes of surgical patients need to be investigated further. In patients who have a secondary cause of IH, treatment of the underlying lesion or condition may terminate a CSF leak and result in reversal of symptoms.

Humans↗
PubMed2004

Sellar repair with fibrin sealant and collagen fleece after endoscopic endonasal transsphenoidal surgery.

OBJECTIVE: To determine, in patients undergoing sellar repair after endoscopic endonasal transsphenoidal surgery, the clinical efficacy of a combination of fibrin sealant/collagen fleece compared to the use of fibrin sealant or collagen fleece alone, in preventing CSF-related (cerebrospinal fluid) postoperative complications. METHODS: From a retrospective analysis of our series of 242 consecutive endoscopic transsphenoidal procedures, in 56 out of the 90 cases in which the sella had been repaired, fibrin sealant and/or collagen fleece was employed, both in combination with one or multiple layers of other materials. The incidence of postoperative CSF leaks and the need for a postoperative lumbar drainage in the groups of fibrin sealant or collagen fleece treated patients were compared to the group of patients treated with the fibrin sealant/collagen fleece combination. RESULTS: In 2 out of 16 fibrin sealant treated patients a postoperative CSF leak presented, and in 6 out of these 16 subjects a postoperative lumbar drainage was necessary; patients who received a fibrin sealant/collagen fleece combination exhibited no detectable postoperative CSF leak, and no postoperative lumbar drainage was used. CONCLUSIONS: Closure of the sella turcica with fibrin sealant in combination with a collagen fleece is a safe and effective method to prevent CSF fistulas. When used in combination, the collagen fleece enhances the sealing and tissue regeneration properties of the fibrin sealant, thus reducing the incidence of postoperative CSF leaks, obviating the need for a lumbar drain placement.

Collagen↗
PubMed2005

Penetrating orbitocranial gunshot injuries.

BACKGROUND: The aim of this study was to analyze the effect of a surgical management protocol and other important clinical features on the prognosis of patients who had penetrating orbitocranial gunshot injuries. METHODS: Thirty-five patients (30 unilateral, 5 bilateral) who had penetrating orbitocranial gunshot injuries were analyzed. The wounds were mainly caused by shrapnel fragments or bullets. Craniotomy was the standard treatment in all patients. Investigated clinical features included Glasgow Coma Scale (GCS) score on admission, the mode and the extent of brain injury, and the presence of an intracranial retained foreign body. The prognostic importance of complications such as infection, intracranial hemorrhage, cerebrospinal fluid leak, and epileptic seizures was also investigated. The mechanism and the injury characteristics of the patients were evaluated by predicting the visual outcome of the victims according to a newer classification system as well as other variables pertinent to this specific clinical setting of severe eye trauma. Final visual acuities of the patients were also measured. RESULTS: The outcome of 35 penetrating orbitocranial gunshot injured patients was as follows: death in 3 patients, vegetative state in 1, severe disability in 2, moderate disability in 2, and good recovery in 27 cases. Localization and extent of the injury and GCS score on admission were the most important indicator for good neurological outcome. The predictors for good visual outcome were type B, grade 1, zone I, and relative afferent pupillary defect-negative injuries. The predictors for poor outcome were type A, grade 5, zone III, and relative afferent pupillary defect-positive injuries. CONCLUSION: The prognosis of the injury depends on the course of the bullet or shrapnel fragment and the interdisciplinary care. An extensive preoperative evaluation of penetrating orbital trauma and a combined ophthalmic and neurosurgical approach are recommended to minimize the morbidity of the patients. However, complete removal of the foreign material in a deep or ventricular localization is not mandatory because careful debridement and tight closure of dura provides desired outcome. Evaluation of trauma mechanism and injury characteristics according to the Ocular Trauma Classification System seems to predict accurately the visual outcomes in this series.

Adolescent↗
PubMed2005

Costs of postoperative cerebrospinal fluid leakage: 1-year, retrospective analysis of 412 consecutive nontrauma cases.

BACKGROUND: Cerebrospinal fluid (CSF) leaks are widely recognized as commonly occurring postoperative complications of neurosurgical procedures. We will focus on the direct costs associated with CSF leaks in a single center across multiple neurosurgical procedures, based on a retrospective analysis. We will also compare the costs of using a synthetic agent to prevent such leaks with these costs from a more recent study. METHODS: The single-center retrospective study was carried out at the Neurosurgical Center Nijmegen (University Medical Center St Radboud and Canisius Wilhelmina Hospital, Nijmegen, Netherlands) from January 01, 1999, until December 31, 1999. Four hundred twelve consecutive, nontrauma, elective procedures were examined. RESULTS: By applying strict criteria for CSF leakage (including those self-limiting subcutaneous minor CSF collection), we found an overall leak rate of 10.7% with a lower number for supratentorial and transsphenoidal procedures and much higher numbers for infratentorial procedures and extensive skull base procedures (6 [12.8%] of 47 and 18 [34.6%] of 52, respectively). The CSF leak in these 44 patients was associated with high additional costs which accounted for 21.7% of the total costs of all 412 procedures or on average 1508 per patient and procedure. If DuraSeal (Confluent Surgical, Inc, Waltham, MA) were to be used prophylactically for every procedure, and assuming a 4% leak rate postprocedure (which was achieved in a more recent study of 46 patients using DuraSeal), there would be a saving of 550 for every procedure (reduction in additional costs of CSF leak minus the cost of the sealant), or a total saving of 226600 in the series of 412 patients. CONCLUSION: Our analysis establishes that CSF leaks occur with high frequency and incur significant costs across all types of surgical procedures. A direct correlation of this complication (and ensuring costs) is observed with more extensive procedures, and reduction of these significant costs can be achieved by using augmentation of the dural closure with DuraSeal.

Cost Control↗
PubMed2006

Prolonged Jackson-Pratt drainage in the management of lumbar cerebrospinal fluid leaks.

BACKGROUND: Cerebrospinal fluid (CSF) leak is a complication of spinal surgery. Intraoperative or postoperative identification of a CSF leak often results in wound healing complications, lumbar drain placement, and/or reoperation. These complications usually extend a patient's hospital stay, can be painful, and have their own associated risks. The authors describe a technique that may improve on traditional interventions by managing postoperative CSF leaks after lumbar instrumentation without an additional procedure or extended hospitalization. METHODS: A retrospective review of lumbar instrumentation cases performed by 5 attending surgeons from the Division of Neurosurgery, University of California at San Diego, was performed. In all, 184 charts were reviewed, spanning a 3-year period. There were 16 cases in which a dural tear and repair were carried out and subsequently treated with subfascial Jackson-Pratt (JP) drainage. Of those 16 cases, 8 patients were managed with prolonged JP drainage using the intraoperatively placed subfascial drain. Patients were discharged home on oral antibiotics according to the customary criteria with the JP drain in place and were instructed regarding proper drain maintenance. Jackson-Pratt drains were removed in clinic in a delayed fashion, approximately 10 to 17 days postoperatively. Patients were subsequently reevaluated at regular intervals for any persistent CSF leak. RESULTS: In the 8 cases reviewed, all patients were discharged in a time frame comparable to that of patients undergoing similar instrumentation in which no CSF leak was identified, or in whom a CSF leak was identified and repaired intraoperatively. No patients suffered complications arising from prolonged drain presence. No patients suffered from persistent CSF leak after drains were removed. CONCLUSION: Our study suggests that routine intraoperative subfascial JP drain placement aids in the early diagnosis of postoperative lumbar CSF leak. Primary closure of dural tear remains the standard of care. Furthermore, in select cases, prolonged JP drainage in the setting of postoperative CSF leak may be a useful technique for the treatment of these leaks.

Adult↗
PubMed2003

Cranial-base surgery: a reconstructive algorithm.

Skull-base surgery is associated with a high risk of cerebrospinal fluid (CSF) leak, infection, and functional and aesthetic deformity. Appropriate reconstruction of cranial-base defects following surgery helps to prevent these complications. Between March 1998 and May 2000, 28 patients (age: 1-68 years) underwent reconstruction of the anterior and middle cranial fossae. The indications for surgery were tumours, trauma involving the anterior cranial fossa, midline dermoid cysts with intracranial extension, late post-traumatic CSF leak, craniofacial deformity and recurrent frontal mucocoele. We used local anteriorly based pericranial flaps (23 flaps, alone or in combination with other flaps), bipedicled galeal flaps (seven patients) and free flaps (nine patients; radial forearm fascial/fasciocutaneous flaps, rectus abdominis muscle flap and latissimus dorsi muscle flap). Follow-up has been 4-24 months. We had no deaths, no flap failure and no incidence of infection. Complications included two CSF leaks, three intracranial haematomas and one pulsatile enophthalmos. All patients had a very good aesthetic result. We present an algorithm for skull-base reconstruction and comment on the design and vascularity of the bipedicled galeal flap. The monitoring of intracranial flaps and the difficulties of perioperative management of free flaps in neurosurgical patients are also discussed.

Adolescent↗
PubMed1984

Ultrasonic assessment of infectious meningitis.

Real-time ultrasonography was performed, utilising the patent anterior fontanelle, on 82 infants with viral or bacterial meningitis. One third of the cases had normal ultrasonic appearances. The other two thirds demonstrated abnormalities of the subdural space, parenchyma and ventricles. Ventricular dilatation was the commonest abnormality and was present in 57% of the infants; ultrasonic evaluation was used to monitor the progress of treatment of these patients.

Cerebral Ventricles↗