Acute-on-chronic subdural cranial hematoma in a dog: case report / Hematoma craniano subdural crônico-agudizado em um cão: relato de caso

A ten-month-old male Yorkshire terrier dog was evaluated via CT four months after traumatic brain injury. The head CT scan showed dilated ventricles associated with a peripheral crescent-shaped collection of blood near the right parietal bone with a mineralized area. The visceral layer of the hematoma was hyperattenuating on the native scan and showed moderate contrast enhancement after administration of intravenous iodinated contrast medium. No fractures were identified in the calvarium. These findings were compatible with acute-on-chronic calcified subdural hematoma, which have been described with more detail in humans. This is the first report to include the description of the imaging findings related to this condition using computed tomography in a dog.(AU)

Um cão Yorkshire Terrier, de 10 meses de idade, foi avaliado por tomografia computadorizada, quatro meses após lesão encefálica de origem traumática. A tomografia da cabeça demonstrou dilatação dos ventrículos associada com coleção de sangue periférico, em formato crescente, próxima ao osso parietal direito, com uma área mineralizada interna. A camada visceral do hematoma era hiperatenuante no exame pré-contraste e demonstrou moderado aumento de atenuação radiográfica após a administração de contraste iodado intravenoso. Fraturas no calvário não foram identificadas. Esses achados foram compatíveis com agudização de hematoma subdural crônico calcificado, condição que tem sido descrita com mais detalhes em humanos. Este é o primeiro relato que descreve os achados de imagem, por tomografia computadorizada, em um cão, relacionados a essa condição.(AU)

Cost-effectiveness analysis of hernioplasties before and after the implementation of the ACERTO project / Análise da custo-efetividade em hernioplastias antes e após a implementação do projeto ACERTO

ABSTRACT Objective: to compare hospital costs and clinical outcomes in inguinal and incisional hernioplasty before and after implementation of the ACERTO project in a university hospital. Methods: retrospective study of 492 patients undergoing either inguinal hernioplasty (n=315) or incisional hernioplasty (n=177). The investigation involved two phases: between January 2002 and December 2005, encompassing cases admitted before the implementation of the ACERTO protocol (PRE-ACERTO period), and the other phase, with cases operated between January 2006 and December 2011, after the implementation of the protocol (ACERTO period). The main outcome variable was the comparison of the mean hospital costs between the two periods. As secondary endpoints, we analyzed the length of stay, the surgical site infection rate and mortality. We used the cost method suggested by Public Sector Cost Information System. Results: surgical site infection was higher (p = 0.039) in the first phase of the study for both inguinal hernia operations (2 (1.6%) versus 0 (0%) cases) and incisional hernioplasty (5 (7.6%) versus 3 (2.7%) cases). The length of stay decreased one day after the implementation of the ACERTO protocol (p=0.005). There was a reduction in costs per patient from R$ 4,328.58 per patient in the first phase to R$ 2,885.72 in the second phase (66.7% reduction). Conclusion: there was a reduction in infectious morbidity, length of stay and hospital costs in hernioplasty after the implementation of the ACERTO protocol.

RESUMO Objetivo: comparar custos hospitalares e desfechos clínicos em hernioplastias inguinal e incisional antes e após a implementação do projeto ACERTO, em hospital universitário. Métodos: estudo retrospectivo com 492 pacientes submetidos à hernioplastias inguinais (n=315) ou incisionais (n=177). A investigação envolveu duas fases: entre janeiro de 2002 e dezembro de 2005, englobando casos internados antes da implantação do protocolo ACERTO (período PRÉ-ACERTO), e outra, com casos operados entre janeiro de 2006 e dezembro de 2011, após a implantação (período ACERTO). A variável de desfecho principal foi o custo médio de internação comparando-se os dois períodos estudados. Como desfecho secundário, analisou-se tempo de internação, infecção de sítio cirúrgico e mortalidade. Foi utilizado o método de custeio do Sistema de Informação de Custos do Setor Público. Resultados: a ocorrência de infecção de sítio cirúrgico foi maior (p=0,039) na primeira fase do estudo tanto para hernioplastias inguinais (2 (1,6%) versus 0 (0%) casos) quanto para incisionais (5 (7,6%) versus 3 (2,7%) casos). O tempo de internação diminuiu em um dia após a implementação do protocolo ACERTO (p=0,005). Houve redução no custo por paciente indo de R$ 4.328,58 por paciente na 1ª fase para R$ 2.885,72 na 2ª fase (redução de 66,7%). Conclusão: o conjunto de dados mostrou que houve redução da morbidade infecciosa, tempo de internação e custos hospitalares em hernioplastias após a implementação do protocolo ACERTO.

Trauma quality indicators: a way to identify attention points in the treatment of elderly trauma patients / Filtros de qualidade: uma maneira de identificar pontos de atenção no atendimento ao idoso traumatizado

ABSTRACT Purpose: to trauma quality indicators as a tool to identify opportunities of improvement in elderly trauma patient's' treatment. Methods: prospective analysis of data collected between 2014-2015, and stored in the iTreg software (by Ecossistemas). Trauma victims, aged older than 60 years and trauma quality indicators were assessed, based on those supported by SBAIT in 2013: (F1) Acute subdural hematoma drainage after 4 hours from admission, in patients with GCS<9; (F2) emergency room transference without definitive airway and GCS <9; (F3) Re-intubation within 48 hours from extubation; (F4) Admission-laparotomy time greater than 60 min. in hemodynamically uinstable patients with abdominal bleeding; (F5) Unprogrammed reoperation; (F6) Laparotomy after 4 hours from admission; (F7) Unfixed femur diaphyseal fracture; (F8) Non-operative treatment for abdominal gunshot; (F9) Admission-tibial exposure fracture treatment time greater than 6 hours; (F10) Surgery after 24 from admission. The indicators, treatments, adverse effects and deaths were analyzed, using the SPSS software, and the chi-squared and Fisher tests were used to calculate the statistical relevance. Results: from the 92 cases, 36 (39,1%) had complications and 15 (16,3%) died. The adequate use of quality indicator's were substantially different among those who survived (was of 12%) compared to those who died (55,6%). The incidence of complications was of 77,8% (7/9) in patients with compromised indicators and 34,9% (28/83) in those without (p=0.017). Conclusions: trauma quality indicators are directly related with the occurrence of complications and deaths, in elderly trauma patients.

RESUMO Objetivo: analisar a utilidade de "filtros de qualidade" pré-estabelecidos para a identificação de oportunidades de melhora no atendimento ao idoso traumatizado. Método: análise prospectiva dos dados coletados entre 2014-2015 e armazenados em software iTreg (Ecossistemas). Foram revisados vítimas de trauma maiores de 60 anos e filtros de qualidade propostos, baseados naqueles idealizados pela SBAIT em 2013: (F1) Drenagem de hematoma subdural agudo após 4 horas da admissão em pacientes com ECG<9; (F2) transferência da sala de emergência sem via aérea definitiva e ECG<9; (F3) Reintubação em até 48 horas da extubação; (F4) Tempo admissão-laparotomia exploradora maior que 60 min. em pacientes instáveis com foco abdominal; (F5) Reoperação não programada; (F6) Laparotomia após 4 horas da admissão; (F7) Fratura de diáfise de fémur não fixada; (F8) Tratamento não operatório de ferimento abdominal por PAF; (F9) Tempo admissão-tratamento de fraturas expostas de tíbia superior a 6 horas; (F10) Operação após 24 horas da admissão. Foi analisada relação dos filtros com tratamentos, complicações e óbitos, pelo software SPSS, utilizando-se o teste qui-quadrado e Fisher para calcular a relevância estatística. Resultados: dos 92 casos, 36 (39,1%) tiveram complicações e 15 (16,3%) morreram. A frequência da quebra dos filtros foi de 12% em pacientes que sobreviveram e 55,6% nos entre os que faleceram (p=0,005). A incidência de complicações foi de 77,8% (7/9) nos doentes com FQ comprometido, contra 34,9% (28/83) nos não comprometidos (p=0,017). Conclusões: o comprometimento dos filtros de qualidade se relaciona diretamente com a ocorrência de complicações e óbitos em idosos traumatizados.

Arachnoid Cyst with a Non-traumatic Acute Subdural Hematoma in an Eleven-year-old Patient

A non-traumatic intra-cystic hemorrhage in an arachnoid cyst is a rare event, with few cases reported in the literature. We present a case of an eleven-year-old boy patient, which presented a spontaneous acute subdural hematoma and intra-cystic hemorrhage after a strong headache episode. The results were evidenced by a computed tomography (CT) scan and surgical findings. We perform a brief literature review on the arachnoid cyst and its suggested treatments. In our case, the patient underwent a surgical treatment with a complete resolution of the case.

Sabe-se que uma hemorragia intracística não traumática em um cisto aracnoide é um acontecimento raro, com poucos casos relatados na literatura. Nós apresentamos o caso de um menino de onze anos de idade, o qual apresentou espontaneamente um hematoma subdural agudo acompanhado de hemorragia intracística após um forte episódio de dor de cabeça. Os resultados foram evidenciados através de uma tomografia computadorizada e dos achados cirúrgicos. Foi feita uma breve revisão da literatura sobre cisto aracnoide e seus respectivos tratamentos sugeridos.

Hematomas subdurales subagudos: ¿solo dos trépanos? / Subacute subdural hematomas: only two drills?

Objetivo: Comparar la evolución postoperatoria de los hematomas subdurales subagudos (HSDSA) y hematomas subdurales crónicos (HSDC) intervenidos con técnica de 2 trépanos, desde junio 2013 a junio 2015. Material y métodos: Se realizó un análisis prospectivo comparando 2 grupos de pacientes: HSDSA y HSDC. Ambos fueron tratados con la misma técnica quirúrgica: dos orificios de trepano, lavado y drenajes subdurales. Se analizaron y compararon: tiempo de cirugía, resolución de los síntomas, necesidad de re-intervención y días de internación. Las variables se presentan como media y DS y mediana y RI, las comparaciones se realizaron con test o Chi2 según su naturaleza, una p <0.05 se considero significativa. Resultados: Fueron evaluados 66 pacientes, 30 HSDSA y 36 HSDC. La edad fue 75 ±11 años (HSDA 76± 11 y HSDC 74 ±12, p 0.5), masculinos 66% (HSDSA 50% y HSDC 85%, p 0.006). El tiempo medio de cirugía para HSDSA fue 59±12 y HSDC 59±17 minutos, p 0.9. Resolvieron la sintomatología en HSDSA 28 (93,3%) y HSDC 34 (94,4%), p 0.8; y requirieron una segunda cirugía por recidiva HSDSA 2 (6,7%) y HSDC 2 (5,6%), p 0.6. La mediana del tiempo de internación fue HSDSA 10 [9- 12] días y HSDC 7,5 [6-10] días, p 0.01. La sobrevida fue del 100%. Conclusiones: La trepanación es una técnica ampliamente aceptada para el tratamiento de HSDC. En hematomas subdurales agudos no existe discusión sobre la necesidad de realizar un abordaje mayor (craneotomía o craniectomía). En el caso de HSDSA la evidencia publicada no es tan concluyente tendiendo en muchos centros a tratarlos en forma similar a los hematomas subdurales agudos generalmente por considerar que la técnica de trepanación y drenaje podría ser insuficiente. Basado en los resultados obtenidos en el presente trabajo podemos concluir que esta técnica es igualmente efectiva para el tratamiento de HSDC y HSDSA y recomendamos su utilización sistemática.

Objective: To compare the postoperative course of subacute subdural hematomas (SSDH) and chronic subdural hematoma (CSDH) operated upon using two burr holes from June 2013 to June 2015. Methods: A prospective analysis was performed comparing patients with SSDH versus CSDH. Both were treated with the same surgical technique —two burr holes— followed by lavage and subdural drainage. Variables compared were surgery time, resolution of symptoms, the need for re-intervention, and number of inpatient days. Variables are presented as means with SD, medians and range, with statistical comparisons performed via Pearson χ2 analysis or XXXXXXXX, as appropriate, with p <0.05 considered significant. Results: A total of 66 patients were analyzed, 30 with SSDH and 36 with CSDH. Mean overall age was 75 ± 11 years with no difference between the two groups (76 ± 11 versus 74 ± 12, respectively; p=0.5). Overall, 66% were male, including 50% with SSDH and 85% with CSDH (p = 0.006). The average lengths of surgery were 59 ± 12 versus 59 ± 17 minutes, respectively (p = 0.9). No intergroup differences were noted in the rate of symptom resolution (93.3% versus 94.4%; p = 0.8) or need for a second surgery for disease recurrence (6.7% vs. 5.6%, p = 0.6). The median length of stay was somewhat shorter in SSDH patients (10 [9-12] vs. 7.5 [6-10] days; p = 0.01). Overall survival was 100%. Conclusions: Trepanation is a widely-accepted technique for the treatment of CSDH. For acute subdural hematomas, there is no discussion regarding the need for a more aggressive approach (e.g., craniotomy or craniectomy). For SSDH, however, published evidence is not as conclusive; yet many centers treat such patients similarly to those with acute subdural hematomas, usually in the belief that trepanation and drainage would be insufficient. Based upon the results obtained in our series, we conclude that this technique is equally effective for the treatment of CSDH and SSDH, and recommend its routine use.

Life-threatening acute subdural haematoma after combined spinal-epidural anaesthesia in labour / Hematoma subdural agudo potencialmente fatal após anestesia combinada raqui-peridural em parto

ABSTRACTBACKGROUND AND OBJECTIVES: Only few reports in literature have pointed out to the possibility of a cranial subdural haematoma formation associated with dural puncture during spinal or epidural analgesia. We herein describe such a rare case who was diagnosed to have acute subdural haematoma after combined spinal-epidural anaesthesia used in labour.CASE REPORT: A 34-year-old, primigravid women with a gestation of 38 weeks underwent caesarean section under combined spinal-epidural anaesthesia and gave birth to a healthy boy. Thirty-two hours after delivery, her moderate headache progressed to a severe headache associated with nausea and vomiting and later was more complicated with a generalized tonic-clonic seizure and ensuing lethargy. Computed tomography of the brain demonstrated a right-sided fronto-temporo-parietal acute subdural haematoma with diffuse cerebral oedema. She underwent urgent FTP craniotomy and evacuation of the haematoma. Early postoperative cranial computed tomography showed a clean operative site. Eight days after subdural haematoma surgery, she became lethargic again, and this time cranial computed tomography disclosed an extradural haematoma under the bone flap for which she had to undergo surgery again. Two days later, she was discharged home with Karnofsky performance score of 90/100. At follow-up exam, she was neurologically intact and her cranial computed tomography and magnetic resonance were normal.CONCLUSIONS: As conclusion, with the use of this combined spinal-epidural anaesthesia, it should be kept in mind that headache does not always mean low pressure headache associated with spinal anaesthesia and that a catastrophic complication of subdural haematoma may also occur.

RESUMOJUSTIFICATIVA E OBJETIVOS: Apenas alguns relatos na literatura mencionaram a possibilidade de formação de hematoma subdural craniano associada à punção durante a raquianestesia ou anestesia epidural. O presente relato descreve um caso tão raro que foi diagnosticado como hematoma subdural agudo após anestesia combinada raqui-peridural usada em parto.RELATO DE CASO: Paciente primípara, 34 anos, com 38 semanas de gestação, submetida à cesariana sob anestesia combinada raqui-peridural, deu à luz um menino saudável. Após 32 horas do parto, a dor de cabeça moderada da paciente progrediu para dor de cabeça intensa associada a náusea e vômito e se complicou subsequentemente com crise convulsiva generalizada tônico-clônica e consequente letargia. Tomografia computadorizada do cérebro revelou hematoma subdural agudo do lado direito em região frontotemporoparietal (FTP) com edema cerebral difuso. A paciente foi submetida à craniotomia FTP de urgência e evacuação do hematoma. Tomografia computadorizada do crânio no pós-operatório precoce mostrou um sítio operatório limpo. Oito dias após a cirurgia do hematoma subdural, a paciente voltou a ficar letárgica e, dessa vez, a tomografia computadorizada revelou um hematoma extradural sob o retalho ósseo que exigiu outra cirurgia. Dois dias depois, a paciente recebeu alta hospitalar com classificação de desempenho Karnofsky de 90/100. Ao exame de acompanhamento, a paciente apresentou-se neurologicamente intacta e sua tomografia computadorizada e ressonância magnética estavam normais.CONCLUSÃO: Ao usar a anestesia combinada raqui-peridural deve-se ter em mente que dor de cabeça nem sempre significa dor de cabeça hipotensiva associada à raquianestesia e que uma complicação catastrófica de hematoma subdural também pode ocorrer.

Conocimiento de los profesionales de enfermería sobre la prevención de complicaciones en pacientes postoperados de hematoma subdural agudo en la Unidad de Neurocirugía del Hospital Nacional Dos de Mayo - 2015 / Knowledge of the nursing professionals on the prevention of complications in post-operated patients of acute subdural hematoma in the Neurosurgery Unit at the National Hospital Dos de Mayo - 2015

El objetivo fue determinar los conocimientos de los profesionales de enfermería sobre la prevención de complicaciones en pacientes postoperados de hematoma subdural agudo en la Unidad de Neurocirugía del Hospital Nacional Dos de Mayo-2015. Material y Método: El estudio fue de tipo cuantitativo y método descriptivo simple. La población estuvo conformada por 30 profesionales de enfermería. La técnica fue la encuesta y el instrumento una lista de chequeo. Resultados: Del 100 por ciento (30), 60 por ciento (18) conoce y 40 por ciento (12) no conoce sobre la prevención de complicaciones en pacientes postoperados de hematoma subdural agudo; en la dimensión prevención de complicaciones pulmonares, 66.7 por ciento (20) conoce y 33.3 por ciento (10) no conoce; en la dimensión prevención de complicaciones gástricas, 53.3 por ciento (16) no conoce y 46.7 por ciento (14) conoce; en la dimensión prevención de complicaciones vasculares, 53.3 por ciento (16) conoce y 46.7 por ciento (14) no conoce; en la dimensión prevención de complicaciones cutáneas y osteomusculares, 60 por ciento (18) conoce y 40 por ciento (12) no conoce. Conclusiones: los profesionales de enfermería conocen sobre la prevención de complicaciones en pacientes postoperados de hematoma subdural agudo en la Unidad de Neurocirugía del Hospital Nacional Dos de Mayo; el mayor porcentaje de enfermeras(os) conoce la prevención de complicaciones pulmonares, vasculares, cutáneas y osteomusculares; y un porcentaje considerable no conocen sobre la prevención de complicaciones gástricas...

The objective was to determine the knowledge of nursing professionals on the prevention of complications in patients after acute subdural hematoma in the Neurosurgery Unit of the National Hospital Dos de Mayo - 2015. Material and Methods: The study was quantitative and descriptive method simple. The population consisted of 30 nursing professionals. The technique was the survey instrument and a checklist. Results: Of 100 per cent (30), 60 per cent (18) know and 40 per cent (12) does not know about the prevention of complications in patients after acute subdural hematoma; in the prevention of pulmonary complications dimension, 66.7 per cent (20) known and 33.3 per cent (10) not known; in preventing gastric complications dimension, 53.3 per cent (16) does not know and 46.7 per cent (14) know; prevention of vascular complications dimension, 53.3 per cent (16) known and 46.7 per cent (14) not known; in preventing skin and musculoskeletal complications dimension, 60 per cent (18) knows and 40 per cent (12) unknown. Conclusions: Nurses know about preventing complications in patients after acute subdural hematoma in the Neurosurgery Unit of the National Hospital Dos de Mayo; the highest percentage of nurses (you) knows the prevention of pulmonary, vascular, skin and musculoskeletal complications; and a large percentage do not know about the prevention of gastric complications...

Hematoma Subcapsular Hepático: Rara Complicación De Colecistectomía Laparoscópica. Presentación De Caso Y Revisión De La Literatura / Hepatic Subcapsular Hematoma: Rare Complication Of Laparoscopic Cholecystectomy. Presentation Of Case And Review Of Literature

El Hematoma subcapsular hepático es una raracomplicación de la colecistectomía por videolaparoscopia la cual se presenta en mujeres, en la bibliografíase describe una asociación con el uso deketorolac.La cápsula de Glisson, es una cápsula fibrosaexterna, que envuelve firmemente al hígado y limita alhematoma subcapsular hepático (HSH),Suele manifestarse con síntomas similares a otrascomplicaciones hemorrágicasEl manejo del HSH se basa en el diagnosticoprecoz y tratamiento del sangrado o infección.Hasta tener más información se recomienda noutilizar ketorolac en el postquirúrgico.Presentamos un caso de una paciente de 68 añosque tras una colecistectomía por video presento un granhematoma que requirió internación y se realizo tratamientoconservador...

The liver has an outer fibrous capsule calledGlisson capsule , enveloping firmly . Which limits theintrahepatic subcapsular hematoma (ISH). ISH is a rarecomplication of cholecystectomy videolaparoscopy. We present a case of a patient of 68 years after acholecystectomy video present a large hematoma whichrequired hospitalization and conservative treatment waspossible. It occurs in women, There is an associationwith the use of ketorolac and usually presents with similarsymptoms to other bleeding complications andmanagement of ISH is based on early diagnosis andtreatment of bleeding or infection.To have more information it is recommended notto use in the postoperative ketorolac...

Hematoma subdural agudo espontâneo e hemorragia intracerebral em paciente com microangiopatia trombótica gestacional / Spontaneous acute subdural hematoma and intracerebral hemorrhage in a patient with thrombotic microangiopathy during pregnancy

Pré-eclâmpsia, síndrome HELLP (hemólise, elevação de enzimas hepáticas e plaquetopenia) e fígado gorduroso agudo da gestação são as principais causas de microangiopatia trombótica e disfunção hepática grave durante a gestação, representando um spectrum do mesmo processo patológico. Relatou-se aqui o caso de uma gestante com 35 semanas internada em unidade de terapia intensiva no pós-operatório imediato de cesariana por morte fetal, com náuseas, vômitos e icterícia. Diagnosticaram-se pré-eclâmpsia pós-parto e fígado gorduroso agudo da gestação. Houve evolução tardia com hematoma subdural agudo e hemorragia intracerebral, sendo realizado tratamento neurocirúrgico. A paciente foi a óbito por anemia hemolítica refratária, com sangramento espontâneo em múltiplos órgãos. Pré-eclâmpsia, síndrome HELLP e fígado gorduroso agudo da gestação são processos patológicos que podem se sobrepor e se associar a complicações potencialmente fatais, como a hemorragia intracraniana aqui descrita. Sua detecção e diagnóstico precoces são fundamentais para a instituição de manejo adequado e sucesso do tratamento.

Preeclampsia, HELLP syndrome (hemolysis, elevated liver enzymes, and low-platelet count), and acute fatty liver of pregnancy are the main causes of thrombotic microangiopathy and evere liver dysfunction during pregnancy and represent different manifestations of the same pathological continuum. The case of a 35-week pregnant woman who was admitted to an intensive care unit immediately after a Cesarean section due to fetal death and the presence of nausea, vomiting, and jaundice is reported. Postpartum preeclampsia and acute fatty liver of pregnancy were diagnosed. The patient developed an acute subdural hematoma and an intracerebral hemorrhage, which were subjected to neurosurgical treatment. The patient died from refractory hemolytic anemia and spontaneous bleeding of multiple organs. Preeclampsia HELLP syndrome, and acute fatty liver of pregnancy might overlap and be associated with potentially fatal complications, including intracranial hemorrhage, as in the present case. Early detection and diagnosis are crucial to ensure management and treatment success.

Hematoma subdural agudo infratentorial: relato de caso / Posterior fossa acute subdural hematoma: case report

Os autores relatam o caso de um paciente adulto vítima de traumatismo cranioencefálico e que apresentou uma lesão considerada rara na literatura, o hematoma subdural agudo da fossa posterior. O paciente foi submetido à craniectomia suboccipital com drenagem do hematoma e recebeu alta com escore de 3 pontos na Glasgow Outcome Scale; um bom resultado, pois essa lesão atinge 71% de mortalidade em algumas séries.

The authors report a case of acute subdural hematoma of posterior fossa in an adult male patient secondary to a head trauma. This is considered a rare pathology in literature. The patient was operated and discharged with a score 3 in GOS. This can be considered a good result since some series show a mortality of 71% for this pathology.

Intracranial meningioma causing acute spontaneous subdural hematoma / Meningioma intracraneal causante de hematoma subdural agudo espontáneo

The spontaneous intracranial hemorrhage associated with cerebral tumors constitutes a rare event. The isolated spontaneous subdural hematoma related to a cerebral tumor represents an even more striking condition. Some hypotheses have been formulated to attempt to explain the occurrence of the spontaneous hemorrhages associated with intracranial meningiomas, but there is no consensus on its formation. We report on a case of a male patient presenting intense headache, without traumatic brain injury history, in which investigation showed an intracranial meningioma associated to a spontaneous subdural hematoma. He was submitted to a cranial surgery, presenting good recovery. We also perform a brief review on the theme.

La hemorragia intracraneal espontánea asociado con tumores cerebrales constituye un evento raro. El hematoma subdural espontáneo aislado relacionada con un tumor cerebral representa una condición aún más sorprendente. Algunas hipótesis han sido formuladas para intentar explicar la aparición de las hemorragias espontáneas asociadas con meningiomas intracraneales, pero no hay consenso sobre su formación. Se presenta un caso de un paciente de sexo masculino que presentó dolor de cabeza intenso, sin historia de lesión cerebral traumática, en el que la investigación mostró un meningioma intracraneal asociado a un hematoma subdural espontáneo. Se le sometió a una neurocirugía, presentando una buena recuperación. También realizamos una breve revisión sobre el tema.

Fenómeno de Kernohan-Woltman: Un caso de hematoma subdural agudo / Kernohan-Woltman phenomenon: A case of acute subdural hematoma

Introducción: Kernohan y Woltman describieron en 1929 la compresión del pedúnculo cerebral contra lateral contra la incisura tentorial por un tumor primario. Clínicamente se traduce por un foco del mismo lado de la lesión, y en apariencia incongruente a la lesión original. Este fenómeno es observado en pacientes con tumoración cerebral en estadios avanzados o en traumatismo cerebral severo. Caso clínico: Paciente varón de 63 años, con hemiparesia derecha, la tomografía cerebral demostró hematoma subdural agudo derecho y desviación de la línea media hacia la izquierda. Por el compromiso del nivel de conciencia se realizó una craneotomía descompresiva y evacuación de hematoma por emergencia, mejoró el nivel de conciencia pero persistió el déficit motor derecho. Conclusión: El fenómeno de Kernohan, es poco frecuente, motivo por el cual es importante la anamnesis, examen físico y la correlación clínica con las imágenes. La tomografía no es suficiente para evaluar en la totalidad el espectro de la lesión, se recomienda el uso de la resonancia magnética para detección de lesiones traumáticas cuando existen condiciones aparentemente inexplicables.

Introduction: Kernohan and Woltman demonstrated in 1928 the compression of the cerebral peduncle against the edge of the tentorium caused by a contralateral supratentorial mass, originally by a primary tumor. Clinically it produces ipsilateral hemiplegia or hemiparesia apparently not in accordance with the lesion. This phenomenon is observed in patients with an advanced-stage brain tumor or severe head injury. Clinical case: We reported the case of a 63-year-old man, with right hemiparesia, due to an acute subdural ipsilateral hematoma, an initial CT scan showed a subdural hematoma and midline shift from right to left. By the level of consciousness, an emergent craniotomy was performed to evacuate the subdural hematoma. His cognition gradually improved, but the physical examinations demonstrated persistent motor ipsilateral deficit. Conclusion: The Kernohan´s phenomenon is a very rare clinical entity. In which the anamnesis, physical examination and correlation with images are very important. The CT scan is not enough to determine the spectrum of the lesions. The MRI should always be performed in cases in which neurological signs are not clearly explained.

Hematoma subdural lumbar agudo espontáneo asociado a hematoma subdural subagudo craneal: reporte de un caso / Acute spontaneous lumbar subdural hematoma associated with subacute cranial subdural hematoma: case report

BACKGROUND: Acute spontaneous spinal subdural hematoma associated with subacute cranial subdural hematoma is a rare entity. There is no precise age of presentation, and there is a slight female predominance. Origin is primary or secondary to hematologic factors or vascular and iatrogenic procedures. The main symptom is motor deficit in 57% of the cases. Surgical treatment is warranted only with neurological deficits. CLINICAL CASE: We present the case of a 44-year-old male with severe headache and diagnosis of subacute frontoparietotemporal subdural hematoma and signs of lumbar radiculopathy. Prognosis is proportional to the initial neurologic deficit. CONCLUSIONS: Patients with cranial subdural hematoma who develop neurological symptoms in the lower extremities should have magnetic resonance imaging study to rule out spinal subdural hematoma.

Hematoma subdural subagudo y cronico: tratamiento quirurgico en 176 pacientes. Nuestra experiencia / Subacute and chronic subdural hematomas: surgical treatment in 176 patients. Our experience

Objective: to describe our surgical experience in suvacute and chronic subdural hematomas. Method: 176 patients with subacute or chronic subdural hematomas were operated between June 1998 and May 2003. Hospital records were used to ascertain data. We did a comparative analysis of the different types of surgical procedures performed. Results: the surgical procedure commonly performed was a burrhole craniostomy with subdural closed - system drainage (66 por ciento). This procedure was associated with a low rate of complications and reoperations, in comparison with the burr hole craniostomy or the craniostomy without subdural closed-system drainge. Global recurrence rate was 13 por ciento and 20,4 por ciento of the cases required reoperation. Clinical improvement rate was 72,3 por ciento. Conclusion: In our cases, burr hole craniostomy with closed-system drainge was the method of choice for the initial treatment in subacute and chronic subdural hematomas. Craniotomy should be reserved for those cases of recurrence or residual hematoma

Acute subdural hematoma and diffuse axonal injury in fatal road traffic accident victims: a clinico-pathological study of 15 patients

OBJECTIVE: Although acute subdural hematoma (ASDH) and diffuse axonal injury (DAI) are commonly associated in victims of head injury due to road traffic accidents, there are only two clinico-pathological studies of this association. We report a clinical and pathological study of 15 patients with ASDH associated with DAI. METHOD: The patients were victims of road traffic accidents and were randomly chosen. The state of consciousness on hospital admission was evaluated by the Glasgow coma scale. For the identification of axons the histological sections of the brain were stained with anti-neurofilament proteins. RESULTS: Twelve of the 15 patients were admitted to hospital in a state of coma; in three patients, the level of consciousness was not evaluated, as they died before hospital admission. CONCLUSION: The poorer prognosis in patients with ASDH who lapse into coma immediately after sustaining a head injury, as described by several authors, can be explained by the almost constant association between ASDH and DAI in victims of fatal road traffic accidents

Actualidades en hematoma subdural / Present times in subdural hematoma

Esta patología constituye la forma más frecuente de hemorragia intracraneal post-traumática; este trabajo tiene como finalidad realizar una revisión detallada de la patogenia del hematoma subdural agudo, el subagudo y el crónico. Las manifestaciones clínicas más comunes que se producen en dichas patologías son: trastornos de la conciencia, cefalea, déficit neurológicos, muerte súbita, etc. El diagnóstico depende principalmente de la clínica del paciente, sus antecedentes y por estudios paraclínicos que se realicen; en especial los de imágenes en los cuales la tomografía axial computarizada, la resonancia magnética y arteriografía son los métodos más usados para el diagnóstico. El tratamiento depende del grado de la lesión y en la mayoría de los casos es quirúrgico