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PubMed2003

Lumbar myofascial flap for pseudomeningocele repair.

OBJECT: Initial management for lumbar pseudomeningoceles entails the closed external drainage of cerebrospinal fluid (CSF) with or without blood patch application. The presence of longstanding pseudomeningoceles and those associated with nonmicroscopic dural tears can be more problematic. Additionally the failure of nonoperative measures may necessitate surgery. Ideally the procedure should involve repairing the dural defect, removing the encapsulated cavity of the pseudomeningocele, and obliterating the extraspinal dead space to minimize the recurrence of the problem. METHODS: The authors describe a technique performed in 12 patients with large (> 5-cm-diameter) pseudomeningoceles referred for management following the failure of less aggressive measures. Diagnosis was based on symptoms of lumbar wound swelling, postural headaches, back and leg pain, and was confirmed by imaging studies. In all patients subarachnoid CSF drainage and initial operative attempts to obliterate the pseudomeningocele had failed. They were treated between July 1990 and July 1998. The cause of the pseudomeningoceles was lumbar discectomy (four patients), lumbar decompression (one patient), lumbar decompression and placement of instrumentation (five patients), and intradural procedures (two patients). Their mean age was 47.9 years (range 20-67 years), and they presented at a mean of 5.5 months postoperatively (range 3 weeks-37 months). In all cases there was a satisfactory repair of the pseudomeningocele, dead space obliteration, and long-term symptomatic resolution. CONCLUSIONS: Lumbar myofascial advancement for this problem is a useful technique in cases of symptomatic pseudomeningoceles. This technique requires the medial advancement of the musculofascial units of the paravertebral muscles for a layered closure over the exposed spinal canal with obliteration of the pseudomeningocele.

Adult↗
PubMed2003

Spinal pseudomeningoceles and cerebrospinal fluid fistulas.

Spinal pseudomeningoceles and cerebrospinal fluid (CSF) fistulas are rare extradural collections of CSF that result following a breach in the dural-arachnoid layer. They may occur due to an incidental durotomy, during intradural surgery, or from trauma or congenital abnormality. The majority are iatrogenic and occur in the posterior lumbar region following surgery. Although they are often asymptomatic, they may cause low-back pain, headaches, and even nerve root entrapment. Leakage of CSF from the wound may cause a fistulous tract, which is a conduit for infection and should be repaired immediately. Diagnosis can be confirmed on clinical examination or imaging studies including magnetic resonance imaging, computerized tomography myelography, and radionuclide myelography. Treatment must be specific to each patient because the timing, size, symptoms, and location of the dural breach all affect the choice of therapy. Nonsurgical methods may be used, but more frequently operative repair is required. In this article, the authors review the diagnosis and treatment of spinal pseudomeningoceles and CSF fistulas.

Blood Patch, Epidural↗
PubMed1976

Physiopathogenesis of subdural hematomas. Part 1: Histological and biochemical comparisons of subcutaneous hematoma in rats with subdural hematoma in man.

The dorsal subcutaneous injection in rats of 12 ml or more of autologous hemolyzed whole blood clotted in situ induced the formation of sterile, hemispheric lesions, 47% of which showed an initial decrease in volume followed by a progressive enlargement. The behavior, histology, and biochemical characteristics of the liquid contents of these lesions were found to be remarkably similar to those of subdural hematomas in man. To evaluate the role of the various blood components that may have influenced the formation and growth of these lesions, more than 150 clots composed of human platelet-free plasma, autologous hemolyzed blood, or autologous whole blood were implanted subcutaneously in rats by either surgical or injection techniques. The in vitro behavior of the different clots used was also assessed. This systematic approach led to the following conclusions: 1) the composition and volumes of the clots are critical variables; 2) plasma-fibrin provides the matrix shape of the lesions; 3) the breakdown products derived from erythrocytes, hemoglobin, leukocytes, and other solid blood elements induce neomembrane formation and contribute to the lesion's subsequent growth; and 4) inflammation mechanisms appear to be essential, while cerebrospinal fluid plays no discernable role in this process.

Animals↗
PubMed1980

Oncotic pressure of subdural fluids.

The oncotic pressure of fluid from subdural hematomas and subdural hygromas was compared to that of simultaneously drawn venous blood in 20 patients. There was no significant difference in the oncotic pressure of fluid from subdural hematomas and venous blood; however, the oncotic pressure of fluid from subdural hygromas was significantly less than that of blood. This finding fails to support the Zollinger and Gross modification of Gardner's that chronic subdural hematomas grow and produce symptoms after a latent interval because they attract fluid from the blood via dural vessels.

Hematoma, Subdural↗
PubMed1981

The course of chronic subdural hematomas after burr-hole craniostomy and closed-system drainage.

A consecutive series of 32 adult patients with chronic subdural hematoma was studied in respect to postoperative cerebral reexpansion (reduction in diameter of the subdural space) after burr-hole craniostomy and closed-system drainage. Patients with high subdural pressure showed the most rapid brain expansion and clinical improvement during the first 2 days. Nevertheless, a computerized tomography (CT) scan performed on the 10th day after surgery demonstrated persisting subdural fluid in 78% of cases. After 40 days, the CT scan was normal in 27 of the 32 patients. There was no mortality and no significant morbidity. Our study suggests that well developed subdural neomembranes are the crucial factors for cerebral reexpansion, a phenomenon that takes at least 10 to 20 days. However, blood vessel dysfunction and impairment of cerebral blood flow may participate in delay of brain reexpansion. It may be argued that additional surgical procedures, such as repeated tapping of the subdural fluid, craniotomy, and membranectomy or even craniectomy, should not be evaluated earlier than 20 days after the initial surgical procedure unless the patient has deteriorated markedly.

Adult↗
PubMed1998

External hydrocephalus after aneurysm surgery: paradoxical response to ventricular shunting.

OBJECT: The authors sought to investigate the mechanisms and pathophysiological effects of subdural fluid collection after surgery for aneurysmal subarachnoid hemorrhage (SAH). METHODS: The authors retrospectively analyzed the medical records of 76 patients who had undergone craniotomy. The patients included 55 with aneurysmal SAH (SAH group) and 21 with unruptured aneurysms (non-SAH group) who were used as controls. Subdural fluid collection was more common in the SAH than in the non-SAH group (38% compared with 14%, p < 0.05). Although older patients appeared to be at greater risk for subdural fluid collection in both groups (p < 0.05), this condition developed even in relatively young patients with SAH. In the SAH group most subdural fluid collection was associated with ventricular dilation (81%), and a significant correlation was seen between fluid collection and the need for subsequent shunt placement (48% compared with 21%, p < 0.05). These results point to an association between hydrodynamic dysfunction and subdural fluid collection. The course of patients with subdural fluid collection varied from spontaneous resolution to normal-pressure hydrocephalus. Seven patients with persistent subdural collections underwent shunt placement (ventriculoperitoneal [VP] shunt in six and lumboperitoneal in one), which resulted in resolution of fluid collection in all seven. CONCLUSIONS: The results indicate that for most patients in the SAH group, subdural fluid collection represented "external hydrocephalus" rather than simple "subdural hygroma." Decreased absorption of cerebrospinal fluid because of SAH and surgically created tears in the arachnoid membrane communicating with the subdural space were factors in the development of external hydrocephalus. The authors believe that differentiating external hydrocephalus from subdural hygroma is extremely important, because VP shunt placement can be used to treat the former but could worsen the latter.

Absorption↗
PubMed1998

Papillomas and carcinomas of the choroid plexus in children.

OBJECT: Choroid plexus tumors are rare intraventricular tumors (1% of all intracranial tumors) that occur mainly in children. The pathophysiological characteristics of associated hydrocephalus, surgical management, and oncological issues related to these tumors remain a matter of debate. To understand more about these tumors, the authors have reviewed their experience with the management of 38 children with choroid plexus tumors. METHODS: There were 25 cases of papilloma and 13 of carcinoma. The mean age of the patients at presentation was 22.5 months, and one-half of the patients were younger than 2 years of age. Hydrocephalus was present in 33 patients and poorly correlated with the size, site, and pathological characteristics of the tumor. In nine children, a ventriculoperitoneal shunt was required after tumor excision, calling into question the notion that cerebrospinal fluid oversecretion is the only cause of hydrocephalus. Complete excision was achieved in 96% of the cases of papilloma and 61.5% of the cases of carcinoma. These surgical procedures were complicated by the risks of intraoperative hemorrhage, which proved to be fatal in two cases, and postoperative brain collapse, which led to subdural fluid collections requiring subdural shunt placement in six patients. Preoperative embolization was partially successful in four cases and significantly assisted surgery. Preoperative controlled drainage of excessively dilated ventricles and intraoperative gluing of the cortical incision have been used to address the problem of postoperative brain collapse. Patients with carcinomas were treated postoperatively by chemotherapy alone (seven cases), radiotherapy (one case), or chemotherapy plus radiotherapy (one case). The overall 5-year survival rate was 100% for patients with papillomas and 40% for those with carcinomas. CONCLUSIONS: Total surgical excision is curative in cases of papillomas. For carcinomas, the most effective treatment remains total surgical excision; however, adjuvant treatment in the form of chemotherapy in patients younger than age 3 years, supplemented by radiation therapy in older children, can moderately reduce the risk of recurrence.

Adolescent↗
PubMed1998

Spinal dural enhancement on magnetic resonance imaging associated with spontaneous intracranial hypotension. Report of three cases and review of the literature.

This report offers a description of typical changes seen on gadolinium-enhanced magnetic resonance (MR) imaging of the entire spine that indicate spontaneous intracranial hypotension (SIH). To the authors' knowledge, this is the first report of its kind. They describe three cases of SIH that were accompanied by dural enhancement throughout the neuraxis on imaging, with the evolution of associated subdural and epidural fluid collections in the spine. Recognition of this disorder is important to be able to distinguish it from an infectious or neoplastic process in which surgical intervention might be warranted. Evaluation using gadolinium-enhanced cranial and spinal MR imaging in patients with postural headaches and an (111)In-labeled cerebrospinal fluid leak study are discussed. Treatment with an epidural blood patch is shown to be particularly effective, with resolution of the radiological and clinical findings.

Adult↗
PubMed1999

Ventricular pressure monitoring during bilateral decompression with dural expansion.

OBJECT: The management of massive brain swelling remains an unsolved problem in neurosurgery. Despite newly developed medical and pharmacological therapy, the rates of mortality and morbidity caused by massive brain swelling remain high. According to many recent reports, surgical decompression with dural expansion is superior to medical management in patients with massive brain swelling. To show the quantitative effect of decompressive surgery on intracranial pressure (ICP), the authors performed a ventricular puncture and measured the ventricular ICP continuously during decompressive surgery and the postoperative period. METHODS: Twenty patients with massive brain swelling who underwent bilateral decompressive craniectomy with dural expansion were included in this study. In all patients, ventricular puncture was performed at Kocher's point on the side opposite the massive brain swelling. The ventricular puncture tube was connected to the continuous monitor via a transducer device. The ventricular pressure was monitored continuously, during the bilateral decompressive procedures and postoperative period. The initial ventricular ICP was variable, ranging from 16 to 65.8 mm Hg. Immediately after the bilateral craniectomy, the mean ventricular ICP decreased to 50.2+/-16.6% of the initial ICP (range 5-51.5 mm Hg). Additional opening of the dura decreased the mean ICP by an additional 34.5% and reduced the ventricular pressure to 15.7+/-10.7% of the initial pressure (range 0-15 mm Hg). Ventricular pressure measured postoperatively in the neurosurgical intensive care unit was lowered to 15.1+/-16.5% of the initial ICP. The ventricular ICP trend in the first 24 hours after decompressive surgery was an important prognostic factor; if it was greater than 35 mm Hg, the mortality rate was 100%. CONCLUSIONS: Bilateral decompression with dural expansion is an effective therapeutic modality in the control of ICP. To obtain favorable clinical outcomes in patients with massive brain swelling, early decision making and proper patient selection are very important.

Adolescent↗
PubMed2000

Prevention of subdural fluid collections following transcortical intraventricular and/or paraventricular procedures by using fibrin adhesive.

OBJECT: Subdural fluid collections following transcortical intraventricular and/or paraventricular neurosurgical procedures for tumors are common and can be difficult to treat. The authors prospectively studied the efficacy of a fibrin adhesive (Tisseel) in closing cortical and ependymal defects following intraventricular and/or paraventricular lesion resection and in preventing the development of subdural fluid collections. METHODS: Twenty-five patients who underwent 29 transcortical approaches for the resection of intraventricular and/or paraventricular lesions were studied. No patient developed a symptomatic subdural fluid collection and no new seizure or progression of a preexisting seizure disorder was encountered during a median follow-up time of 29 months (range 1-57 months). The incidence of preoperative hydrocephalus was 72% and four (22%) of these patients required postoperative shunt placement. CONCLUSIONS: The use of a fibrin adhesive to seal cortical and ependymal defects after transcortical procedures appears to prevent the development of subdural fluid collections.

Adolescent↗
PubMed2000

Diagnosis of spontaneous intracranial hypotension by using magnetic resonance myelography. Case report.

The authors describe a case of spontaneous intracranial hypotension in which the leakage site was determined by using magnetic resonance (MR) myelography. This technique demonstrated the route of cerebrospinal fluid (CSF) leakage, whereas other methods failed to show direct evidence of leakage. Magnetic resonance myelography is a noninvasive method that is highly sensitive in detecting CSF leakage. This is the first report in which a site of CSF leakage was detected using MR myelography.

Adult↗
PubMed2001

Analysis of hearing loss after shunt placement in patients with normal-pressure hydrocephalus.

OBJECT: Following shunt placement for treatment of normal-pressure hydrocephalus (NPH), several patients suffered hearing loss. The authors undertook a study to analyze this outcome. METHODS: Sixteen patients in whom NPH was diagnosed were treated by placement of a ventriculoperitoneal shunt. Their hearing was assessed pre- and postoperatively by using pure tone audiometry. Two thirds of the ears tested showed a postoperative hearing loss of more than 10 dB. Recovery of the hearing loss occurred 6 to 12 weeks after shunt placement in 75% of the ears examined. CONCLUSIONS: Although shunt insertion for treatment of NPH results in a decrease in hearing, most of the loss can be recovered.

Aged↗
PubMed2002

Spontaneous spinal cerebrospinal fluid leaks and minor skeletal features of Marfan syndrome: a microfibrillopathy.

OBJECT: Spontaneous spinal cerebrospinal fluid (CSF) leaks are increasingly recognized as a cause of postural headaches. The authors examined a group of patients suffering from spontaneous spinal CSF leaks who also had minor skeletal features of Marfan syndrome for abnormalities of fibrillin-containing microfibrils. METHODS: Patients with spontaneous CSF leaks were evaluated for the clinical characteristics of connective tissue disorders. Skin biopsies were obtained in three patients with skeletal manifestations that constitute part of the Marfan syndrome phenotype. Cultured fibroblasts were studied for fibrillin-1 synthesis and incorporation into the extracellular matrix (ECM) by performing quantitative metabolic labeling and immunohistochemical analysis. Among 20 consecutive patients found to have spinal CSF leaks, four (20%) exhibited minor skeletal features of Marfan syndrome, but lacked any ocular or cardiovascular abnormalities. The mean age of these patients (30 years) was lower than that of the 16 patients without skeletal abnormalities (44 years; p = 0.01). Abnormalities in fibrillin-1 metabolism and immunostaining were detected in all three patients with the skeletal abnormalities who underwent examination, but not in a control patient without these skeletal manifestations. CONCLUSIONS: Twenty percent of patients who experience spontaneous spinal CSF leaks have minor skeletal features of Marfan syndrome. The authors demonstrated abnormalities in fibrillin-1 protein deposition in all patients examined, but only one person was found to have a fibrillin-1 abnormality typically found in classic Marfan syndrome. The results indicate that there is a heterogeneous involvement of other components of ECM microfibrils at the basis of this cerebrospinal manifestation. In addition, the authors identified a connective-tissue etiological factor in a group of disorders not previously classified as such.

Adult↗
PubMed2002

Age-related changes in the proportion of intracranial cerebrospinal fluid space measured using volumetric computerized tomography scanning.

OBJECT: The purpose of this study was to establish a standard curve to demonstrate normal age-related changes in the proportion of intracranial cerebrospinal fluid (CSF) space in intracranial volume (ICV) during each decade of life. METHODS: Using volumetric computerized tomography (CT) scanning and computer-guided volume measurement software, ICV and cerebral parenchymal volume (CPV) for each decade of life were measured and the intracranial CSF ratio was calculated by the following formula: percentage of CSF = (ICV - CPV)/ICV x 100%. The standard curve for age-related changes in normal percentages of intracranial CSF was obtained. CONCLUSIONS: Based on this standard curve, the percentage of intracranial CSF rapidly increased after the sixth decade, seeming to reflect the brain atrophy that accompanies increased age.

Adolescent↗
PubMed2003

Third ventriculostomy for internal hydrocephalus complicated by unrecognized subdural hygroma and hematoma: a case report of a patient treated by Dr. Walter Dandy.

The authors review the case of a patient treated by Dr. Walter Dandy. When the patient was a young child he underwent two right transtemporal third ventriculostomies during which he sustained an unrecognized contralateral subdural hygroma and a chronic subdural hematoma with a mild infantile hemiparesis. He was able to complete high school, albeit at a slower pace than usual. As an adult he held several limited employment positions, lived at home for several decades, and was later cared for at a nursing home for a short time. The patient died when he was 66 years of age.

Brain↗