Subdural haematoma in neonates following forceps-assisted delivery: case series and review of the literature.

PURPOSE: Subdural haematoma (SDH) is a recognised complication of forceps-assisted delivery (FAD). There are no guidelines regarding its management. This study aims to provide a better insight into the management and outcomes of neonatal SDH post-FAD. METHODS: Retrospective review of our neonatal database and systematic review of the literature for neonatal cases that presented with SDH after FAD. Retrospective neurosurgical database search for cases of neonatal SDH post-FAD managed in our unit between January 2007 and January 2017. Systematic review of the literature was performed using PRISMA guidelines. The inclusion criteria are as follows: (1) neonates; (2) forceps-assisted delivery; (3) evidence of SDH on imaging, with or without other traumatic lesions. RESULTS: A literature search yielded nine studies with 30 patients meeting our inclusion criteria. In addition, four cases were identified from our institutional database. Forty-two percent (n = 14) had their SDH managed surgically, with subsequent full neurological recovery in 57%. In comparison, 95% (n = 18) of the conservatively managed patients made a full recovery. Hydrocephalus was present in 1/19 and 11/14 of the conservatively managed and surgically managed patients respectively. CONCLUSIONS: Conservative management can lead to a full neurological recovery in SDH following FAD in neonates. However, a significant minority may still need neurosurgical intervention for the SDH or subsequent hydrocephalus; therefore, we advocate early transfer to a specialist neuroscience centre.

Acute Intracranial and Spinal Subdural Hematoma Associated with Vardenafil.

A 28-year-old healthy man was admitted to our hospital because of right-sided headache, vomiting, and lower back pain after the administration of vardenafil. Computed tomography and magnetic resonance imaging of the brain showed a small, right-sided, subdural hematoma. A lumbar magnetic resonance imaging showed a longitudinally extended subdural hematoma. He had no history of trauma. We speculated that vardenafil might have had an association with the bleeding. Several reports have suggested a relationship between phosphodiesterase-5 inhibitors and intracerebral or subarachnoid hemorrhage. Our case suggested that there may also be risks of bleeding into the subdural space. Although headache and nausea are common side effects of vardenafil, hemorrhagic diseases should also be considered when symptoms are severe or prolonged.

Withdrawal of Life-Sustaining Therapy in Patients With Intracranial Hemorrhage: Self-Fulfilling Prophecy or Accurate Prediction of Outcome?

OBJECTIVES: Withdrawal of life-sustaining therapy may lead to premature limitations of life-saving treatments among patients with intracranial hemorrhage, representing a self-fulfilling prophecy. We aimed to determine whether our algorithm for the withdrawal of life-sustaining therapy decision would accurately identify patients with a high probability of poor outcome, despite aggressive treatment. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Tertiary-care Neuro-ICU. PATIENTS: Intraparenchymal, subdural, and subarachnoid hemorrhage patients. INTERVENTIONS: Baseline demographics, clinical status, and hospital course were assessed to determine the predictors of in-hospital mortality and 12-month death/severe disability among patients receiving maximal therapy. Multivariable logistic regression models developed on maximal therapy patients were applied to patients who underwent withdrawal of life-sustaining therapy to predict their probable outcome had they continued maximal treatment. A validation cohort of propensity score-matched patients was identified from the maximal therapy cohort, and their predicted and actual outcomes compared. MEASUREMENTS AND MAIN RESULTS: Of 383 patients enrolled, there were 128 subarachnoid hemorrhage (33.4%), 134 subdural hematoma (35.0%), and 121 intraparenchymal hemorrhage (31.6%). Twenty-six patients (6.8%) underwent withdrawal of life-sustaining therapy and died, 41 (10.7%) continued maximal therapy and died in hospital, and 316 (82.5%) continued maximal therapy and survived to discharge. The median predicted probability of in-hospital death among withdrawal of life-sustaining therapy patients was 35% had they continued maximal therapy, whereas the median predicted probability of 12-month death/severe disability was 98%. In the propensity-matched validation cohort, 16 of 20 patients had greater than or equal to 80% predicted probability of death/severe disability at 12 months, matching the observed outcomes and supporting the strength and validity of our prediction models. CONCLUSIONS: The withdrawal of life-sustaining therapy decision may contribute to premature in-hospital death in some patients who may otherwise have been expected to survive to discharge. However, based on probability models, nearly all of the patients who underwent withdrawal of life-sustaining therapy would have died or remained severely disabled at 12 months had maximal therapy been continued. Withdrawal of life-sustaining therapy may not represent a self-fulfilling prophecy.

Spontaneous spinal subdural hematoma of intracranial origin presenting as back pain.

BACKGROUND: Spinal subdural hematoma (SDH) is an uncommon condition mainly associated with bleeding dyscrasias, use of anticoagulants, trauma, iatrogenic procedures, and vascular malformations. Prompt diagnosis and treatment are recommended to prevent progressive neurologic compromise. Spinal SDH concomitant with intracranial SDH is an even rarer entity, with few cases reported in the English literature. Here we present a case of spontaneous spinal SDH with intracranial SDH presenting as sacral back pain in a 70-year-old man. We also describe the potential mechanism, treatment, and prognosis of concomitant spinal and intracranial SDH. CASE REPORT: We report an unusual case of spontaneous spinal SDH concomitant with intracranial SDH and discuss the epidemiology, clinical presentation, potential etiology, treatment, and prognosis of this disease. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Awareness of the association between spinal SDH and intracranial SDH can expedite appropriate imaging of both brain and spine, which can lead to a more complete diagnosis and require changes in patient management in the emergency setting.

Bilateral subdural hematoma after inadvertent dural puncture during epidural analgesia.

BACKGROUND: Post-dural puncture headache (PDPH) is typically a benign complication of dural puncture that is clinically diagnosed. It commonly presents as a throbbing and positional headache that occurs 24-48 h after dural puncture. Subdural hematomas, if unrecognized, may occur as a rare and life-threatening complication of dural puncture. OBJECTIVES: We aim to describe the clinical features and sequelae of a rare complication that may result as a consequence of inadvertent dural puncture that, if unrecognized, has the potential to become a life-threatening complication from a common procedure. CASE REPORT: We report the case of a previously healthy 17-year-old primigravida female who initially presented 4 days postpartum with clinical features and imaging studies consistent with PDPH. The patient's symptoms were unremitting, and within 4 weeks, she developed bilateral subdural hematoma. With prompt recognition and diagnosis, she was treated with conservative medical management and subsequently improved on follow-up. CONCLUSION: Patients with unremitting PDPH should prompt the clinician to suspect the development of subdural hematoma as a potential life-threatening complication of an otherwise benign condition.

Incidental findings on cranial imaging in nonagenarians.

OBJECT: The aim of this article was to report on the nature and prevalence of incidental imaging findings in a consecutive series of patients older than 90 years of age who underwent intracranial imaging for any reason. METHODS: The authors retrospectively reviewed the electronic medical and imaging records of consecutive patients who underwent brain MR imaging at a single institution over a 153-month interval and were at least 90 but less than 100 years of age at the time of the imaging study. The prevalence of lesions by type in this consecutive series of MR imaging evaluations was calculated for all patients. The authors reviewed the medical record to evaluate whether a change in management was recommended based on MR imaging findings. They evaluated patient age at the time of death and the time interval between MR imaging and death. RESULTS: The authors identified 177 patients who met the study criteria. The group included 119 women (67%) and 58 (33%) men. Their mean age was 92.3 ± 1.8 years. Evidence of acute ischemic changes or cerebrovascular accident (CVA) was found in 36 patients (20%). Fifteen patients (8%) had an intracranial tumor. Intracranial aneurysms were incidentally identified in 6 patients (3%). Chronic subdural hematomas were found in 3 patients (2%). Overall, 25 patients (14%) had some change in medical management as a result of the MR imaging findings. The most common MR imaging finding that resulted in a change in medical management was an acute CVA (p < 0.0001). The mean time to death from date of MR imaging was 2.5 ± 2.3 years. CONCLUSIONS: Intracranial imaging is rarely performed in patients older than 90 years. In cases of suspected stroke, MR imaging findings may influence treatment decisions. Brain MR imaging studies ordered for other indications in this age group rarely influence treatment decisions. Incidentally discovered lesions in this age group are generally not treated.

[Cranial subdural hematoma with intracranial hypotension related to epidural anesthesia and Trendelenburg position: a case report].

We report a case of cranial subdural hematoma with intracranial hypotension. A 34-year-old woman had laparoscopic ovarial cysterectomy under general anesthesia combined with epidural anesthesia. Two days later, she developed a severe headache and nausea. She underwent cranial magnetic resonance imaging (MRI) scanning, and was diagnosed with cranial subdural hematoma with intracranial hypotension. The patient had had no anticoagulant therapy before the surgery. She was managed conservatively with bed rest and additional intravenous infusion. Her symptoms gradually improved except a slight headache, and she was discharged on the 38th postoperative day. Intracranial hypotension is a syndrome characterized by orthostatic headaches and hypovolemia of cerebrospinal fluid (CSF). There were typical findings on MRI, which include linear enhancement of the pachymeninges, pituitary hyperemia and subdural hemorrhage. We thought that these were due to epidural anesthesia first, but there was no evidence of dural puncture. It was also considered that it is influenced by change in CSF pressure, and intracranial venous engorgement may be due to Trendelenburg position for several hours. Because cranial subdural hematoma is a life-threatening complication, it is necessary to reconsider application of epidural anesthesia for laparoscopic surgery with Trendelenburg position.

Risk Factors for Urinary Tract Infection or Pneumonia After Admission for Traumatic Subdural Hematoma at a Level I Trauma Center: Large Single-Institution Series.

BACKGROUND: The development of infections such as urinary tract infections (UTIs) or pneumonia after a traumatic subdural hematoma (tSDH) can worsen patient outcomes and increase healthcare costs. We herein identify clinical parameters that influence the risk of infections after tSDH. METHODS: This single-institution retrospective cohort study examined the incidence and risk factors for UTI and pneumonia among tSDH patients from 1990 to 2015. Multivariate logistic regression assessed the impact of various demographic and clinical variables on these outcomes. RESULTS: 3024 patients with tSDHs were identified (73.1% male); Of those, 208 (6.9%) experienced a UTI and 434 (14.4%) experienced pneumonia. Of the 559 patients (18.5%) who underwent a craniotomy and/or craniectomy for evacuation of a tSDH, 62 (11.1%) experienced a UTI and 222 (39.7%) experienced pneumonia. Risk factors for both pneumonia and UTI included length of stay (LOS) ≥7 days (odds ratio [OR] = 6.0, P < 0.001; OR = 11.2, P < 0.001), intensive care unit LOS ≥7 days (OR = 8.1, P < 0.001; OR = 1.7, P = 0.012), and mechanical ventilation ≥14 days (OR = 3.4, P < 0.001; OR = 1.8, P = 0.007). Craniotomy/craniectomy increased the risk of pneumonia (OR = 1.4, P = 0.019) but not UTI. Glasgow Coma Scale (GCS) ≥13 was associated with a decreased pneumonia risk (OR = 0.5, P = 0.003), and male gender (OR = 0.5, P < 0.001) and age <60 (OR = 0.6, P < 0.001) were associated with a decreased UTI risk. CONCLUSIONS: Patients with prolonged hospitalizations and/or intensive care unit stays were more likely to experience UTIs and pneumonia. Male gender and younger age were protective against UTI, and higher GCS was protective against pneumonia. These data may aid the identification and treatment of at-risk populations after admission for a tSDH.

Systematic characterization of the computed tomography angiography spot sign in primary intracerebral hemorrhage identifies patients at highest risk for hematoma expansion: the spot sign score.

BACKGROUND AND PURPOSE: The presence of active contrast extravasation (the spot sign) on computed tomography (CT) angiography has been recognized as a predictor of hematoma expansion in patients with intracerebral hemorrhage. We aim to systematically characterize the spot sign to identify features that are most predictive of hematoma expansion and construct a spot sign scoring system. METHODS: We retrospectively reviewed CT angiograms performed in all patients who presented to our emergency department over a 9-year period with primary intracerebral hemorrhage and had a follow-up noncontrast head CT within 48 hours of the baseline CT angiogram. Three neuroradiologists reviewed the CT angiograms and determined the presence and characteristics of spot signs according to strict radiological criteria. Baseline and follow-up intracerebral hemorrhage volumes were determined by computer-assisted volumetric analysis. RESULTS: We identified spot signs in 71 of 367 CT angiograms (19%), 6 of which were delayed spot signs (8%). The presence of any spot sign increased the risk of significant hematoma expansion (69%, OR=92, P<0.0001). Among the spot sign characteristics examined, the presence of > or =3 spot signs, a maximum axial dimension > or =5 mm, and maximum attenuation > or =180 Hounsfield units were independent predictors of significant hematoma expansion, and these were subsequently used to construct the spot sign score. In multivariate analysis, the spot sign score was the strongest predictor of significant hematoma expansion, independent of time from ictus to CT angiogram evaluation. CONCLUSIONS: The spot sign score predicts significant hematoma expansion in primary intracerebral hemorrhage. If validated in other data sets, it could be used to select patients for early hemostatic therapy.

Traumatic clival subdural hematoma in an adult.

Retroclival hematomas are a rare entity. They are usually associated with significant trauma, and patients frequently have focal neurological deficits, especially cranial nerve palsies. Previous case reports of epidural clival hematomas have been described almost exclusively in the pediatric population. The authors report a unique case of traumatic clival subdural hematoma, which has never been described in an adult except in the context of hemophilia. An 18-year-old man presented with continuing nausea and headaches following a seemingly trivial head injury. He was found to have a posterior fossa retroclival hematoma extending into the spinal subdural space but without any neurological deficits. He was treated conservatively, with a good outcome. The authors discuss the possible mechanisms of injury, management, and complications related to this rare condition, and they review the pertinent literature.

Difficulties diagnosing spinal subdural hemorrhage in a hypo-coagulated patient due to simultaneous symptomatic subdural cranial hemorrhage.

A hypo-coagulated 58-year-old female complained of headaches right after being exposed to the first pressure waves generated during an exhibition of fireworks. The day after she presented with seizures and the CT scan showed subdural hemorrhage over the left frontoparietal sulci. Eight hours after admission she disclosed left lower limb hypo-esthesia, i.e. a finding not attributable to the cranial hemorrhage. Four hours later sphincter dysfunction and paraparesis were also present with a left predominance. This was due to a T12-L1 subdural extramedullary hemorrhage. The patient was operated and showed a favorable outcome. Hypo-coagulated patients with cranial hemorrhage require prolonged surveillance and may harbor spinal hemorrhage as well. This rare combination can be unsuspected in view of the evident cranial event, and may cause severe neurological deficits if not detected.

Abusive head trauma: evidence, obfuscation, and informed management.

Abusive head trauma remains the major cause of serious head injury in infants and young children. A great deal of research has been undertaken to inform the recognition, evaluation, differential diagnosis, management, and legal interventions when children present with findings suggestive of inflicted injury. This paper reviews the evolution of current practices and controversies, both with respect to medical management and to etiological determination of the variable constellations of signs, symptoms, and radiological findings that characterize young injured children presenting for neurosurgical care.

Glutaric aciduria type 1 presenting as bilateral subdural hematomas mimicking nonaccidental trauma. Case report and review of the literature.

Glutaric aciduria type 1 (GA1) is a rare neurometabolic disorder with characteristic neuroimaging and clinicopathological features. The authors describe a case of GA1 in a 7-month-old girl presenting with macrocephaly and bilateral subdural hematomas (SDHs) who was initially evaluated for nonaccidental trauma (NAT). Bilateral subdural drains were placed because of significant mass effect from the chronic SDHs, with subsequent neurological and neuroimaging-documented improvement. Clinical and neuroimaging findings led to further laboratory investigation to confirm the diagnosis of GA1, after which a specialized low-protein diet was initiated. After a thorough investigation, NAT was ruled out. At the follow-up examination, the patient experienced improvement in her symptoms and resolution of the bilateral subdural collections. The presence of bilateral SDHs in an infant raises the suspicion of NAT and presents a difficult diagnostic challenge because of the legal and social implications. Glutaric aciduria type 1 should be considered in the differential diagnosis of bilateral SDHs, and an evaluation should be performed. The authors review the clinical manifestations, diagnosis, medical and surgical management, and specific considerations regarding GA1, including misdiagnosis of NAT.

Traumatic subacute subdural effusion in the posterior fossa associated with secondary acute hydrocephalus in a neonate. Case report.

The authors report on a neonatal patient with traumatic subacute subdural effusion in the posterior fossa associated with secondary acute hydrocephalus. The infant fell from his mother's hand onto the floor, injuring his left parietal region. Computed tomography (CT) scans of the patient's head revealed a linear fracture of the left parietal bone, a small contusion in the right temporal lobe, and a small subdural hematoma in the right posterior fossa with thin subdural effusion. Serial CT scans revealed a progressive increase in subdural effusion bilaterally in the posterior fossa. On Day 7 the anterior fontanelle was tense and CT scans revealed marked hydrocephalus associated with thick subdural effusion in the posterior fossa. External drainage of both the subdural effusion and dilated lateral ventricles improved the patient's condition, and no reaccumulation of subdural effusion has been observed. The origin and treatment of this rare clinical entity is discussed.

Delayed hemorrhage following microvascular decompression. Three case reports.

Postoperative hemorrhage is one of the most dangerous complications following microvascular decompression (MVD), and usually occurs within the first 24 hours after MVD operation, whereas delayed hemorrhage is extremely rare. The possible mechanisms of acute and delayed postoperative hemorrhage following MVD seem to be different. Three of 685 patients treated by MVD developed delayed hematoma more than 24 hours after surgery, including two cases at the operative site and one at a remote site. The possible causes of such delayed hemorrhage are discussed. Postoperative monitoring is extremely important after the MVD procedure. If any hemorrhage can be identified at the early stage, valuable time can be won for treatment and better outcome.

Acute intracranial subdural hematoma after epidural steroid injection: a case report.

OBJECTIVE: Conservative treatment of lumbar radiculopathy includes bed rest, oral medications, physical therapy, spinal manipulation, mobilization, and epidural steroid injections. Intracranial subdural hematoma after accidental dural puncture is a rare and life-threatening complication of epidural steroid injections. In this report, we present a case of subacute intracranial subdural hematoma that developed after epidural steroid injection. CLINICAL FEATURES: A 40-year-old man was admitted to our clinic with severe persistent headache and vomiting for 2 days after epidural steroid injection for right leg pain. INTERVENTION AND OUTCOME: The patient was hospitalized for epidural steroid injection for right leg pain in our pain clinic and was discharged the same day. Twenty-four hours later, he started having a headache. Despite the use of oral analgesics, his headache worsened, and he began to vomit particularly in the upright position. Magnetic resonance imaging of the brain displayed a right frontal subdural hematoma. The headache was relieved after strict bed rest, intravenous hydration, and analgesics. The patient was discharged with full recovery after 1 week. CONCLUSION: Intracranial subdural hematoma after accidental dural puncture during epidural steroid injection is a rare complication. Persistent headache should be evaluated carefully for possible intracranial hematomas.

[Intracranial subdural hematoma following dural puncture].

BACKGROUND: Intracranial subdural hematoma (SDH) following dural puncture (DP) is a life-threatening complication. However, the characteristics and prognosis are little-known. METHODS: Reports documenting intracranial SDH following DP were surveyed by using PubMed and the Igaku-chuou-zassi (Japana Centra Reveuo Medicina) database (1979-2005) and the cases were analyzed to clarify their characteristics and prognoses. RESULTS: Sixty-nine case reports were enrolled. Seventy per cent of patients underwent anesthetic procedures including spinal and epidural anesthesia. Fifty-two per cent of patients, many of whom receiving obstetrical procedures, were under 40 years of age and majority of the rest of over 40 years were male. Eighty per cent of patients had an onset of SDH within 1 month after DP. Patients often showed disappearance of postural headache, associated with various neurological symptoms such as consciousness disorder, vomiting, hemiplegia and diplopia. The eighty-three per cent of patients recovered completely from SDH except 11 patients who died or afflicted with sequelae because of delayed diagnosis. CONCLUSIONS: Seventy per cent of SDH occured following anesthesia related procedures. Most of them had an onset within one month after DP The prognosis was relatively good as long as SDH could be diagnosed at its early stage. It was necessary to observe the disappearance of postural headache and associated symptoms carefully to avoid delayed diagnosis.

Spontaneous retroclival hematoma: a case series.

OBJECTIVE: Retroclival hematomas are rare, appearing mostly as posttraumatic phenomena in children. Spontaneous retroclival hematoma (SRH) in the absence of trauma also has few descriptions in the literature. None of the reported clinical cases features the combination of an SRH and intraventricular hemorrhage (IVH). Nevertheless, despite extensive cases of idiopathic or angiographically negative subarachnoid hemorrhage (SAH) of the posterior fossa, only a single case report of a patient with a unique spontaneous retroclival hematoma has been identified. In this study, the authors reviewed the presentation, management, and clinical outcome of this rare entity. METHODS: The authors performed a retrospective analysis of all patients with diagnosed SRH at their institution over a 3-year period. Collected data included clinical history, laboratory results, treatment, and review of all imaging studies performed. RESULTS: Four patients had SRH. All were appropriately evaluated for coagulopathic and/or traumatic etiologies of hemorrhage, though no etiology could be found. Moreover, all of the patients demonstrated SRH that both clearly crossed the basioccipital synchondrosis and was contained within a nondependent configuration along the retroclival dura mater. CONCLUSIONS: Spontaneous retroclival hematoma, often associated with IVH, is a rare subtype of intracranial hemorrhage frequently recognized only when MRI demonstrates compartmentalization of the posterior fossa hemorrhage. When angiography fails to reveal an underlying lesion, SRH patients, like patients with traditional angiographically negative SAH, enjoy a remarkably good prognosis.

Review of the Management of Infected Subdural Hematoma.

OBJECTIVE: Infection of a subdural hematoma is an unusual cause of subdural empyema, with fewer than 50 cases reported in the literature. The appropriate surgical option for this entity has not been determined because of its rarity. We present a case report of a post-traumatic subdural hematoma infected with Escherichia coli that was successfully treated with craniotomy. In addition, we performed a PubMed search to comprehensively illustrate the causative organism, source of infection, clinical picture, surgical treatment, and outcome for this condition. This article presents an update on the condition. CASE DESCRIPTION: A 55-year-old man was admitted to our hospital complaining of headache, seizure, and urinary incontinence. He had a history of alcoholism and several hospitalizations for mild head trauma. Neuroimaging studies revealed a chronic hematic collection in the left frontal-parietal region. Laboratory tests showed increased C-reactive protein levels. In addition, surgical results revealed an infected subdural hematoma. A bacterial culture of the purulent specimen identified E. coli. In view of the urinary complaint and leukocyturia, the cause of the infected subdural hematoma was postulated as a urinary tract infection. CONCLUSIONS: Infected subdural hematoma is an unusual disorder. We must keep in mind the possibility of this complication when seeing a patient who presents with any of the 3 most common symptoms in this review. In these patients, craniotomy should be the method of surgical drainage, especially in adults. It ensures maximal drainage of the loculated pus and allows the total removal of the infected hematoma capsule.