Aneurysmal Subarachnoid Hemorrhage with Spinal Subdural Hematoma: A Case Report and Systematic Review of the Literature.

OBJECTIVE: Spinal subdural hematoma (S-SDH) rarely occurs after aneurysmal subarachnoid hemorrhage (SAH). Little information is known regarding the management and prognosis of patients with both S-SDH and SAH. Here, we present an illustrative case and provide a systematic review of S-SDH in the setting of SAH. METHODS: A systematic literature review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines revealed 11 previous cases of concurrent intracranial SAH and spinal SDH, which are presented with our new reported case. RESULTS: Intracranial sources of spontaneous SAH included 8 aneurysms, 1 pseudoaneurysm, and 3 angiogram-negative cases. Hunt Hess grades ranged from 1 to 4, mean time between SAH and S-SDH was 5.8 days, and S-SDH presented most frequently in the lumbar spine. Eight patients showed significant to complete clinical recovery, 2 had continued plegia of the lower extremities, and 2 expired. Modified Rankin scores (mRS) ranged from 0 to 6, with mRS >2 for 4 of 12 patients. Patients with a poor clinical outcome (mRS >2) had an initially negative cerebral angiogram, earlier presentation with less time between SAH and S-SDH (0.8 vs. 7.6 days), use of antithrombotic medication, no diversion of cerebrospinal fluid, and cervical or thoracic S-SDH. CONCLUSION: S-SDH is uncommon in the setting of aneurysmal SAH; better outcomes are associated with lumbar location, delayed presentation, cerebrospinal fluid diversion, and lack of antithrombotic use. Conservative treatment may be sufficient in patients with delayed S-SDH and lack of significant neurologic deficits. More reported cases will allow greater understanding of this clinical entity.

Revision of Chiari decompression for patients with recurrent syrinx.

The management of adult patients with Chiari malformation associated with syrinx remains controversial. Although an abundance of literature exists for the pediatric population, there is an absence of guidelines for the adult population. It is unclear which of the different surgical approaches is appropriate in patients with Chiari I malformations and syringomyelia. A 36-year-old female patient had a posterior fossa decompression 3years prior to recurrence. The patient developed recurrent symptoms with sensory loss and hyperesthesia in the right upper extremity. MRI revealed decreased cerebrospinal fluid flow at the craniocervical junction. The patient was taken to the operating room for revision of the posterior fossa decompression, lysis of adhesions and duraplasty. Re-exploration of a Chiari decompression, lysis of adhesions and revision duraplasty is an effective treatment option for recurrent syringomyelia.

Association of Chiari malformation type I and tethered cord syndrome: preliminary results of sectioning filum terminale.

OBJECTIVE: The pathogenesis of CM-I is incompletely understood. We describe an association of CM-I and TCS that occurs in a subset of patients with normal size of the PCF. METHODS: The prevalence of TCS was determined in a consecutively accrued cohort of 2987 patients with CM-I and 289 patients with low-lying cerebellar tonsils (LLCT). Findings in 74 children and 244 adults undergoing SFT were reviewed retrospectively. Posterior cranial fossa size and volume were measured using reconstructed 2D computed tomographic scans and MR images. Results were compared to those in 155 age- and sex-matched healthy control individuals and 280 patients with generic CM-I. The relationships of neural and osseus structures at the CCJ and TLJ were investigated morphometrically on MR images. Intraoperative CDU was used to measure anatomical structures and CSF flow in the lumbar theca. RESULTS: Tethered cord syndrome was present in 408 patients with CM-I (14%) and 182 patients with LLCT (63%). In 318 patients undergoing SFT, there were no significant differences in the size or volume of the PCF as compared to healthy control individuals. Morphometric measurements demonstrated elongation of the brain stem (mean, 8.3 mm; P < .001), downward displacement of the medulla (mean, 4.6 mm; P < .001), and normal position of the CMD except in very young patients. Compared to patients with generic CM-I, the FM was significantly enlarged (P < .001). The FT was typically thin and taut (mean transverse diameter, 0.8 mm). After SFT, the cut ends of the FT distracted widely (mean, 41.7 mm) and CSF flow in the lumbar theca increased from a mean of 0.7 cm/s to a mean of 3.7 cm/s (P < .001). Symptoms were improved or resolved in 69 children (93%) and 203 adults (83%) and unchanged in 5 children (7%) and 39 adults (16%) and, worse, in 2 adults (1%) over a follow-up period of 6 to 27 months (mean, 16.1 months +/- 4.6 SD). Magnetic resonance imaging 1 to 18 months after surgery (mean, 5.7 months +/- 3.8 SD) revealed upward migration of the CMD (mean, 5.1 mm, P < .001), ascent of the cerebellar tonsils (mean, 3.8 mm, P < .001), reduction of brain stem length (mean, 3.9 mm, P < .001), and improvement of scoliosis or syringomyelia in some cases. CONCLUSIONS: Chiari malformation type I/TCS appears to be a unique clinical entity that occurs as a continuum with LLCT/TCS and is distinguished from generic CM-I by enlargement of the FM and the absence of a small PCF. Distinctive features include elongation and downward displacement of the hindbrain, normal position of the CMD, tight FT, and reduced CSF flow in the lumbar theca. There is preliminary evidence that SFT can reverse moderate degrees of tonsillar ectopia and is appropriate treatment for cerebellar ptosis after Chiari surgery in this cohort.

Intentional partial coil occlusion followed by delayed clip application to wide-necked middle cerebral artery aneurysms in patients presenting with severe vasospasm. Report of two cases.

The treatment of ruptured cerebral aneurysms in patients presenting with vasospasm remains a particular challenge. The authors treated two patients harboring Hunt and Hess Grade 1 subarachnoid hemorrhages from middle cerebral artery (MCA) aneurysms associated with severe local angiographically demonstrated yet asymptomatic vasospasm on presentation. Because both aneurysms had wide necks and were located at the MCA bifurcation, they were believed to be anatomically suitable for microsurgical clip application. Severe M, vasospasm was believed to be a relative contraindication to open surgery, however. An intentionally staged endovascular and microsurgical treatment strategy was planned in each patient. Partial coil occlusion of the aneurysmal dome was performed to prevent the lesion from rebleeding and was followed by balloon angioplasty of the spastic vessel. Early treatment of the severe spasm appeared to prevent significant delayed neurological ischemic deficit. Following resolution of the vasospasm, definitive clipping of the aneurysms was performed on Day 13 post embolization. One patient had a good clinical recovery and was discharged without neurological deficit. The other patient's hospital course was complicated by the occurrence of a postoperative posterior temporal infarct requiring partial temporal lobectomy, although she eventually had a good recovery with only a small visual field deficit. Based on data obtained in these two patients, one can infer that ruptured wide-necked MCA aneurysms associated with severe local vasospasm may best be treated using a staged combined treatment plan. Delayed clip application might be performed more safely 4 to 6 weeks postocclusion, or later, than at 2 weeks.