Spinal subdural hygroma.

A spinal subdural hygroma is a rare entity. In this review, we try to contribute to the pooling of current knowledge about spinal subdural hygroma, from embryology and physiology until radiological detection and treatment. The relevant articles in the literature regarding spinal subdural hygroma were reviewed, using a sensitive search strategy on Internet databases. A spinal subdural hygroma is associated with trauma, iatrogenic causes, spontaneous intracranial hypotension headache, and probably meningitis. MR imaging is the golden standard for diagnosis. Treatment of the hygroma is almost always conservative and surgery is seldom necessary, however treating the underlying cause is important. The physiology, in spite of numerous suggestions and hypotheses in literature, remains unclear. The prevalence of spinal subdural hygroma is also still unknown. Only a few articles deal with spinal subdural hygroma, because it is an uncommon entity, without specific symptoms. Probably it is often not diagnosed because of the frequent association with other cranial or spinal pathologies and the need for high-resolution imaging. More research is required to examine the prevalence, importance, and pathophysiology of spinal subdural hygroma.

Symptomatic Postoperative Spinal Subdural Extra-Arachnoid Hygromas: Resolution with Conservative Management: A Report of 2 Cases.

CASE: Two cases of postoperative spinal subdural extra-arachnoid hygromas were successfully treated with bed rest after patients developed symptoms 4 to 5 days following decompressive lumbar surgery. The development of the hygromas as well as the radiological findings are discussed. CONCLUSION: To the best of our knowledge, these comprise the first postoperative cases successfully treated without surgical re-exploration. This demonstrates conservative management may be a safe and effective management choice.

Clinical Features of Patients With Spontaneous Intracranial Hypotension Complicated With Bilateral Subdural Fluid Collections.

BACKGROUND: Subdural hygromas are often found bilaterally in spontaneous intracranial hypotension (SIH). They frequently progress to chronic subdural hematomas (CSDHs), and if the hematomas are formed, it is difficult to consider SIH as an underlying cause. Whether SIH is underlying or not among the patients presenting bilateral subdural fluid collections (hygromas or CSDHs) is clinically important because the treatment strategy should be different between them. OBJECTIVES: We designed a retrospective case-control study to figure out differential clinical features of the patients presenting bilateral symptomatic subdural fluid collections owing to SIH. METHODS: Sixty-two patients with bilateral symptomatic subdural fluid collections were enrolled, and their data on general demographics, clinical courses, radiological findings, treatments, and outcomes were collected. The patients were divided into "SIH" and "Non-SIH" groups, and a simple logistic regression analysis was performed to clarify the differences between the groups. The consequent receiver operating characteristics (ROC) curve analyses were performed with the significant predictors. RESULTS: Eight patients (13%) were diagnosed with SIH. Young age (odds ratio [OR] = 0.831, 95% confidence interval [CI]: 0.743-0.929, P = .0012), no underlying disease (OR = 0.062, 95% CI: 0.007-0.544, P = .0121), radiological features of brain sagging (OR = 10.36, 95% CI: 0.912-93.411, P = .0017), pseudo-subarachnoid hemorrhage (OR = 15.6, 95% CI: 2.088-116.52, P = .0074), and small amount of fluid collections (OR = 0.719, 95% CI: 0.579-0.893, P = .0029) were significantly associated with SIH group. ROC curve analyses were performed in parameters of age and amount of fluid collection and the cut-off values for each parameter were ≤55 years old and ≤22.08 mm, respectively. Patients diagnosed with SIH underwent epidural blood patches and showed good results, except 1 patient who underwent burr-hole trephinations. CONCLUSION: Bilateral subdural fluid collections due to underlying SIH is associated with young age (≤55 years old), no underlying diseases, smaller amount of fluid collections (≤22.08 mm of depth), and radiological findings of brain sagging or pseudo-subarachnoid hemorrhages.

Benign extracerebral fluid collection complicated by subdural hematoma and fluid collection: clinical characteristics and management.

INTRODUCTION: Benign extracerebral fluid collection (bECFC) can be complicated by subdural hematoma (SDH) or subdural fluid collection (SDFC). The etiology, natural history, and management strategy for SDH/SDFC in bECFC are not fully understood. We retrospectively reviewed the cases of bECFC patients complicated with SDH/SDFC and tried (1) to confirm the fact that bECFC children are vulnerable to SDH/SDFC, (2) to investigate the clinical significance of 'trauma history' witnessed by a caregiver, and (3) to determine optimal management for them. METHOD: Among 213 bECFC patients identified from January 2000 to August 2015, 20 patients (male:female = 14:6; median age, 6.5 months; range 1-16 months) complicated by SDH/SDFC documented with brain imaging were evaluated for their clinical manifestations, radiologic features, and management outcomes. The median follow-up period was 9.5 months. They were divided into two groups (traumatic group versus non-traumatic group) according to whether objective radiologic evidence of head injury was present or not, and the two groups were analyzed for any clinical differences between them. We also evaluated the clinical significance of witnessed traumatic events by caregivers as an additional independent variable in the analysis. RESULTS: The incidence of SDH/SDFC in bECFC patients was 9.4% (20/213) in our data. In a comparative analysis, the traumatic group is more likely to have 'acute' stage SDH, whereas the non-traumatic group is more likely to have 'chronic' stage SDH. The trauma history witnessed by caregivers did not show clinical significance in the data analysis when included as an independent variable. The prognosis of SDH/SDFC in bECFC patients was favorable without surgery in most of patients regardless of whether the patient has evidence of head trauma or not. CONCLUSION: Benign ECFC is vulnerable to SDH/SDFC development. For the bECFC patients complicated by SDH/SDFC, the trauma history witnessed by a caregiver did not show any clinical significance. A 'wait and watch' strategy is sufficient for the management of SDH/SDFC in bECFC patients.

The Comparison Between Surgical Procedure and Conservative Treatment in the Management of Traumatic Subdural Effusion.

AIM: Traumatic subdural effusion (TSE) occurs following traumatic brain injury and may be treated by either conservative methods or surgical procedure commonly according to the patients' clinical information. We aimed to compare the effective rate of effusion removal and the standardized morbidity ratio of poor prognosis of the two different treatments, and to discuss the future treatment methods possible. MATERIAL AND METHODS: We reviewed the clinical records of patients who were divided into two groups according to the treatment choices in our center, and the effective rate of effusion removal and the standardized morbidity ratio of poor prognosis were compared. RESULTS: Eighty patients were identified, and divided into two groups: conservative treatment and surgical procedure group. The mean CRASH-CT predicted risk of mortality in two weeks and unfavorable outcome at six months was higher in the surgical procedure group compared with the conservative treatment group. Effective rate of effusion removal was observed in 57.1 % of conservative treatment group versus 88.5% of surgical procedure group (p=0.002). The standardized morbidity ratio of poor prognosis (observed/expected poor prognosis) was 0.56 (95 % CI: 0.32-0.80) for the conservative treatment group versus 0.25 (95 % CI: 18 0.08-0.42) for the surgical procedure group. CONCLUSION: Conservative treatment and surgical procedure are used for the management of traumatic subdural effusion, and the former is used more commonly to treat the mildly affected patients than the latter one, but a surgical procedure may be more effective for the patients in poor clinical condition. Adequate evidence is required to clear the indications.

Lumbar subdural cerebrospinal fluid collection with acute cauda equina syndrome after posterior fossa decompression for Chiari malformation Type I: case report.

This report describes the circumstances of a patient with a cauda equina syndrome due to the development of a lumbar subdural CSF collection with ventral displacement of the cauda equina shortly following posterior fossa decompression for Chiari malformation Type I (CM-I). This unusual, but clinically significant, complication was successfully treated with percutaneous drainage of the extraarachnoid CSF collection. Although there are a few cases of intracranial subdural hygroma developing after surgery for CM-I, often attributed to a pinhole opening in the arachnoid, as far as the authors can determine, a spinal subdural hygroma associated with surgery for CM-I has not been recognized.

Postoperative subdural hygroma and chronic subdural hematoma after unruptured aneurysm surgery: age, sex, and aneurysm location as independent risk factors.

OBJECTIVE: This study investigated the incidence and risk factors for the postoperative occurrence of subdural complications, such as a subdural hygroma and resultant chronic subdural hematoma (CSDH), following surgical clipping of an unruptured aneurysm. The critical age affecting such occurrences and follow-up results were also examined. METHODS: The case series included 364 consecutive patients who underwent aneurysm clipping via a pterional or superciliary keyhole approach for an unruptured saccular aneurysm in the anterior cerebral circulation between 2007 and 2013. The subdural hygromas were identified based on CT scans 6-9 weeks after surgery, and the volumes were measured using volumetry studies. Until their complete resolution, all the subdural hygromas were followed using CT scans every 1-2 months. Meanwhile, the CSDHs were classified as nonoperative or operative lesions that were treated by bur-hole drainage. The age and sex of the patients, aneurysm location, history of a subarachnoid hemorrhage (SAH), and surgical approach (pterional vs superciliary) were all analyzed regarding the postoperative occurrence of a subdural hygroma or CSDH. The follow-up results of the subdural complications were also investigated. RESULTS: Seventy patients (19.2%) developed a subdural hygroma or CSDH. The results of a multivariate analysis showed that advanced age (p = 0.003), male sex (p < 0.001), middle cerebral artery (MCA) aneurysm (p = 0.045), and multiple concomitant aneurysms at the MCA and anterior communicating artery (ACoA) (p < 0.001) were all significant risk factors of a subdural hygroma and CSDH. In addition, a receiver operating characteristic (ROC) curve analysis revealed a cut-off age of > 60 years, which achieved a 70% sensitivity and 69% specificity with regard to predicting such subdural complications. The female patients ≤ 60 years of age showed a negligible incidence of subdural complications for all aneurysm groups, whereas the male patients > 60 years of age showed the highest incidence of subdural complications at 50%-100%, according to the aneurysm location. The subdural hygromas detected 6-9 weeks postoperatively showed different follow-up results, according to the severity. The subdural hygromas that converted to a CSDH were larger in volume than the subdural hygromas that resolved spontaneously (28.4 ± 16.8 ml vs 59.6 ± 38.4 ml, p = 0.003). Conversion to a CSDH was observed in 31.3% (5 of 16), 64.3% (9 of 14), and 83.3% (5 of 6) of the patients with mild, moderate, and severe subdural hygromas, respectively. CONCLUSIONS: Advanced age, male sex, and an aneurysm location requiring extensive arachnoid dissection (MCA aneurysms and multiple concomitant aneurysms at the MCA and ACoA) are all correlated with the occurrence of a subdural hygroma and CSDH after unruptured aneurysm surgery. The critical age affecting such an occurrence is 60 years.

Recurrent, symptomatic, late-onset, contralateral subdural effusion following decompressive craniectomy treated by cranial strapping.

Subdural effusions following decompressive craniotomy for trauma are usually benign, ipsilateral to the craniotomy and resolve spontaneously. Far less common and more dangerous are contralateral subdural effusions causing external cerebral herniation. We report a case of recurrent contralateral effusion and highlight the management dilemmas. Arachnoid tear is probably the cause of these collections. Contralateral subdural effusions should be suspected in patients who have delayed neurological deterioration after an initial improvement particularly in the setting of increased "flap bulge" though they may also be found in patients who remain moribund after initial surgery. There are no clear-cut guidelines on their management due to their rarity. A variety of options like subduro-peritoneal shunt and drainage with simultaneous cranioplasty may be tried. In situations where resources or patient compliance is an issue, tapping the effusion followed by cranial strapping may be tried as was done in our case.

Bilateral subdural hygromas following administration of intrathecal methotrexate chemotherapy.

We report the case of a previously well 58-year-old man who presented with headache and confusion 4 days postadministration of intrathecal methotrexate. He was undergoing intensive chemotherapy (CODOX-M/IVAC, cyclophosphamide, doxorubicin, vincristine, methotrexate, etoposide, ifosfamide, cytarabine) for the treatment of leukaemic phase CD20 negative diffuse large B-cell lymphoma. A CT of the head demonstrated the presence of bilateral subdural hygromas complicated by haemorrhage resulting from coexisting chemotherapy induced thrombocytopenia. Surgical drainage of the hygroma was undertaken but the patient died of overwhelming sepsis. In patients with high-risk lymphoma, directed central nervous system (CNS) therapy is administered either systemically or intrathecally. It is thought that subdural hygromas result from cerebrospinal fluid (CSF) accumulation in the inner dural layers of the cerebral convexities from CSF leak and reduction in CSF pressure post-lumbar puncture. We describe a rare but potentially fatal complication of intrathecal chemotherapy that haemato-oncologists need to be mindful of.

Symptomatic contralateral subdural hygromas after decompressive craniectomy: plausible causes and management protocols.

OBJECT: Contralateral subdural hygromas are occasionally observed after decompressive craniectomies (DCs). Some of these hygromas are symptomatic, and the etiology and management of these symptomatic contralateral subdural collections (CLDCs) present surgical challenges. The authors share their experience with managing symptomatic CLSDCs after a DC. METHODS: During a 10-month period, 306 patients underwent a DC. Of these patients, 266 had a head injury, 25 a middle cerebral artery infarction (that is, a thrombotic stroke), and 15 an infarction due to a vasospasm (resulting from an aneurysmal subarachnoid hemorrhage [SAH]). Seventeen patients (15 with a head injury and 2 with an SAH) developed a CLSDC, and 7 of these patients showed overt symptoms of the fluid collection. These patients were treated with a trial intervention consisting of bur hole drainage followed by cranioplasty. If required, a ventriculo- or thecoperitoneal shunt was inserted at a later time. RESULTS: Seven patients developed a symptomatic CLSDC after a DC, 6 of whom had a head injury and 1 had an SAH. The average length of time between the DC and CLSDC formation was 24 days. Fluid drainage via a bur hole was attempted in the first 5 patients. However, symptoms in these patients improved only temporarily. All 7 patients (including the 5 in whom the bur hole drainage had failed and 2 directly after the DC) underwent a cranioplasty, and the CLSDC resolved in all of these patients. The average time it took for the CLSDC to resolve after the cranioplasty was 34 days. Three patients developed hydrocephalus after the cranioplasty, requiring a diversion procedure, and 1 patient contracted meningitis and died. CONCLUSIONS: Arachnoid tears and blockage of arachnoid villi appear to be the underlying causes of a CLSDC. The absence of sufficient fluid pressure required for CSF absorption after a DC further aggravates such fluid collections. Underlying hydrocephalus may appear as subdural collections in some patients after the DC. Bur hole drainage appears to be only a temporary measure and leads to recurrence of a CLSDC. Therefore, cranioplasty is the definitive treatment for such collections and, if performed early, may even avert CLSDC formation. A temporary ventriculostomy or an external lumbar drainage may be added to aid the cranioplasty and may be removed postoperatively. Ventriculoperitoneal or thecoperitoneal shunting may be required for patients in whom a hydrocephalus manifests after cranioplasty and underlies the CLSDC.

[Prevention and effective treatment of opposite subdural effusion after decompressive cranium].

OBJECTIVE: To explore the prevention and effective treatment of opposite subdural effusion after decompressive cranium. METHODS: Retrospective analyses were conducted for 79 cases of opposite subdural effusion after decompressive cranium. And the efficacies of various methods were compared. RESULTS: Among them, 78 cases were cured by enswathing with elastic bondage. And one case improved through cavity fluid drainage catheter. CONCLUSION: Enswathing with elastic bondage is an effective, simple and economic method of managing opposite subdural effusion after decompressive cranium.

Recurrent subdural hygromas after foramen magnum decompression for Chiari Type I malformation.

A paediatric case of foramen magnum decompression for Chiari Type I malformation complicated by recurrent subdural hygromas (SH) and raised intracranial pressure without ventriculomegaly is described. SH pathogenesis is discussed, with consideration given to arachnoid fenestration. We summarise possibilities for treatment and avoidance of this unusual consequence of foramen magnum decompression.

Management of subdural hygromas associated with arachnoid cysts.

OBJECT: Arachnoid cysts may occasionally be associated with subdural hygromas. The management of these concurrent findings is controversial. METHODS: The authors reviewed their experience with arachnoid cysts and identified 8 patients with intracranial arachnoid cysts and an associated subdural hygroma. The medical records and images for these patients were also examined. RESULTS: In total, 8 patients presented with concurrent subdural hygroma and arachnoid cyst. Of these 8 patients, 6 presented with headaches and 4 had nausea and vomiting. Six patients had a history of trauma. One patient was treated surgically at the time of initial presentation, and 7 patients were managed without surgery. All patients experienced complete resolution of their presenting signs and symptoms. CONCLUSIONS: Subdural hygroma may lead to symptomatic presentation for otherwise asymptomatic arachnoid cysts. The natural course of cyst-associated subdural hygromas, even when symptomatic, is generally benign, and symptom resolution can be expected in most cases. The authors suggest that symptomatic hygroma is not an absolute indication for surgical treatment and that expectant management can result in good outcomes in many cases.

Feasibility of placement of an anterior cervical epidural blood patch for spontaneous intracranial hypotension.

The dorsal epidural blood patch is a commonly used management technique for spontaneous intracranial hypotension from a dural CSF leak, but it may be less efficacious for cervical or ventral leaks. We report the technique of placing an anterior cervical blood patch for a large cervical ventral leak. To our best knowledge, this approach has not been reported. In the appropriately selected patient, an anterior cervical epidural blood patch may be safely used.