External Hydrocephalus as a Cause of Infant Subdural Hematoma: Epidemiological and Radiological Investigations of Infants Suspected of Being Abused.

BACKGROUND: Acute subdural hematoma (ASDH) and chronic subdural hematoma (CSDH) in infants have been regarded as highly specific for abuse. Other causes of CSDH have not been investigated in a large population. PURPOSE: The purpose of this study was to investigate to what extent external hydrocephalus is present in infants with ASDH and CSDH undergoing evaluation for abuse. MATERIAL AND METHODS: Eighty-five infants suspected of being abused, with ASDH (n = 16) or CSDH (n = 69), were reviewed regarding age, risk factor profiles, craniocortical width (CCW), sinocortical width (SCW), frontal interhemispheric width (IHW), subarachnoid space width (SSW), and head circumference (HC). In infants with unilateral subdural hematoma (SDH), correlations between contralateral SSW and ipsilateral CCW and SDH width were investigated. RESULTS: Infants with CSDH had significantly lower mortality, were more often premature and male, and had significantly higher CCW, SCW, IHW, and SSW than infants with ASDH (P < 0.05). Ipsilateral CCW (R = 0.92, P < 0.001) and SDH width (R = 0.81, P < 0.01) correlated with contralateral SSW. Increased HC was more prevalent in infants with CSDH (71%) than in infants with ASDH (14%) (P < 0.01). Forty-two infants, all with CSDH, had at least one of CCW, SCW, or IHW ≥95th percentile. Twenty infants, all with CSDH, had CCW, SCW, and IHW >5 mm, in addition to increased HC. CONCLUSION: A substantial proportion of infants with CSDH who had been suspected of being abused had findings suggesting external hydrocephalus.

Decompressive Craniectomy in Traumatic Brain Injury-Craniectomy-Related and Cranioplasty-Related Complications in a Single Center.

OBJECTIVE: Decompressive craniectomy (DC) relieves intracranial hypertension after severe traumatic brain injury (TBI), but it has been associated with poor clinical outcome in 2 recent randomized controlled trials. In this study, we investigated the incidence and explanatory variables for DC-related and cranioplasty (CP)-related complications after TBI. METHODS: In this retrospective study, we identified 61 patients with TBI who were treated with DC in the neurointensive care unit, Uppsala University Hospital, Sweden, between 2008 and 2018. Demography, admission status, radiology, and clinical outcome were analyzed. RESULTS: Eleven patients (18%) were reoperated because of postoperative hemorrhage after DC. Six (10%) developed postoperative infection during neurointensive care. Twenty-eight (46%) developed subdural hygromas and 10 (16%) received a permanent cerebrospinal fluid shunt. Sixteen patients (26%) died before CP. Median time to CP was 7 months (range, 2-19 months) and 32 (71%) were operated on with autologous bone and 13 (29%) with synthetic material primarily. In 9 patients with autologous bone (29%), the CP had to be replaced because of bone resorption/infection, whereas this did not occur after synthetic material (P = 0.04). However, all 4 postoperative hemorrhages after CP occurred when synthetic material was used (P = 0.005). CONCLUSIONS: DC and CP surgery have a high risk for complications, leading to additional neurosurgery in about one third of cases. Synthetic CP materials may decrease the risk of reoperation, but special care with hemostasis is required because of increased risk of postoperative hemorrhage. Future trials need to address these topics to further improve the outcome for these patients.

Management of Concealed Type IV Endoleak and Aortic Sac Hygroma by Prone ContrASt EnHancement Computed Tomography Angiography.

BACKGROUND: Aortic sac hygroma and concealed endoleaks (EL) after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm needs particular attention with aggressive management as they are associated with rapid sac expansion and rupture risk. However, they can be erroneously reported as type IV or V EL with supine computed tomography (CT) scans, leading to delay in management. Therefore, we describe a novel diagnostic technique, 'Prone contrASt enHanced computed tomography Angiography' (PASHA), to document concealed EL METHODS: We present eight case descriptions with continuous sac expansion after primary EVAR. Management began with diagnosis using the PASHA imaging technique. PASHA is a multiphase CTA positional technique for increasing the accuracy of detecting EL after EVAR. Furthermore, the PASHA imaging technique also guides whether the open or endovascular intervention could be used effectively to manage the sac expansion. In synchrony with the PASHA technique, "EVAR GORE SalvAge FAbric Technique" (ARAFAT) was to salvage previous EVAR. RESULTS: The PASHA technique diagnosed all cases of type IIIb EL, as it enhanced the degree of contrast infiltration into the aortic sac when microleaks were present. ARAFAT was effectively used in five elderly patients. Another three had an open conversion; two with double breasting of the aortic sac and one EVAR explantation. CONCLUSIONS: The PASHA protocol helped classify and localize the concealed EL (type IV, V), which were not appropriately diagnosed by supine CT protocols. PASHA and ARAFAT were used as a fully functioning protocol to overcome apparent challenges in accurate diagnosis and subsequent concealed EL management in high-risk patients.

Surgical treatment of cyst of the canal of Nuck and prevention of lymphatic complications: A single-center experience.

The canal of Nuck is a residue of the peritoneal evagination that runs along the round ligament through the inguinal canal in women. Its partial or total patency can lead to a cystic lymphangioma (CL). CL of the canal of Nuck in an adult female is a rare entity and its clinical diagnosis can be difficult or incorrect. Ultrasonography can be useful to identify the nature of groin masses. A potential CL of the canal of Nuck should always be considered in the differential diagnosis of inguinal swelling in adult females. Even if it is possible to consider conservative treatment, the optimal therapeutic option is surgical excision of the cystic mass and closure of the inguinal ring by an anterior approach. In this study, we report a case series of four women affected by a cyst of the canal of Nuck to underline the surgical treatment's therapeutic role of this pathological condition and the importance of preliminary identification of lymphatic vessels with BPV (Blue Patent Violet) in order to prevent lymphatic injuries such as lymphorrea and lymphocele in the groin after surgery due to the disruption of inguinal lymph nodes and lymphatics.

[Hygroma following liposuction and -grafting in the gluteal area].

This case report is of a 24-year-old woman, who was referred to an orthopaedic department with sarcoma in her left thigh. Further investigations revealed, that she had previously undergone an autologous lipografting from her thighs to her gluteal area, and she had developed widespread, severe hygroma formation as a late complication to the procedure. The complication rate to liposuction and -grafting varies 7-10% with seroma being the most abundant. Knowledge of these complications is important in order to diagnose and refer the patients correctly.

Novel clinical phenotype of generalised lymphatic dysplasia in a neonate: a missed diagnosis.

We report a preterm neonate who had a large cervical cystic hygroma and right chylothorax. She was operated on day-21 and a near-complete resection of cystic hygroma was done. She developed refractory hypoxemia and shock post surgery and died after 24 hours. During autopsy, the chest cavity was found to be filled with chyle. Histopathological examination showed dilated lymphatics in the pleura, hepatic capsule, serosa of stomach and intestines, peri-pancreatic regions, peri-renal capsule and peri-adrenal tissues suggestive of generalised lymphatic dysplasia. Clinical exome sequencing did not reveal any pathogenic mutation in the genes involved in primary lymphatic dysplasia, noonan syndrome or rasopathies.

Are Hygromas and Hydrocephalus After Decompressive Craniectomy Caused by Impaired Brain Pulsatility, Cerebrospinal Fluid Hydrodynamics, and Glymphatic Drainage? Literature Overview and Illustrative Cases.

BACKGROUND: Poorly understood cranial fluid accumulations are frequently observed after decompressive craniectomy and often termed "external hydrocephalus." These findings are difficult to explain using traditional models of hydrocephalus. METHODS: Representative cases, clinical management, and literature overview are presented. RESULTS: We present a hypothesis that abnormal cranial fluid accumulations develop after decompressive craniectomy in a vulnerable subset of patients as a result of 1) the large compliant cranial defect with durotomy causing reduced internal brain expansion, ventricular squeezing, and pulsatile cerebrospinal fluid (CSF) circulation; 2) impaired pulsatile CSF flow along major cerebral arteries and the adjoining perivascular spaces (Virchow-Robin spaces); 3) reduced clearance of interstitial fluid by the glymphatic system; and 4) redistribution of CSF from the subarachnoid space into the subdural and subgaleal compartments and the ventricles. CONCLUSION: Closure of the cranial defect with cranioplasty improves cerebral blood flow and CSF pulsatile circulation and is frequently sufficient to resolve the external hydrocephalus.

[Intraperitoneal cystic lymphangioma and Crohn's disease: an exceptional association]. / Kystique intra-péritonéal et maladie de Crohn: à propos d'une association exceptionnelle.

Cystic lymphangioma is a rare benign malformative tumor of the lymphatic vessels which may occur in various locations. Intra-abdominal cystic lymphangioma is less frequent than cervicoaxillary cystic lymphangioma. Clinical presentation is polymorphic. Diagnosis is based on imaging data but it requires histological confirmation. Surgery is the gold standard treatment. We here report a rare case of acquired intraperitoneal cystic lymphangioma secondary to subtotal colectomy in a female patient with severe evolutive Crohn's disease treated with anti-TNF alpha. The patient presented with irreducible right painful paramedian mass with no impulse on coughing, suggesting the diagnosis of strangulated eventration within a surgical scar from midline laparotomy. She underwent emergency surgery. Surgical exploration showed multi-cystic intraperitoneal mass protrunding through the right paramedian eventration. Anatomo-pathological examination helped to confirm the diagnosis of cystic lymphangioma. Postoperatively, the mass was punctured twice to evacuate the fluid, because of incomplete surgical resection. This is the first reported case of cystic lymphangioma in a patient under anti-TNF alpha. It could be caused by disruption of the immune system and more specifically of the lymphocyte population. This association has not hitherto been established and experimental studies are necessary to accept or refuse this hypothesis.

Yield of early postoperative computed tomography after frontal ventriculoperitoneal shunt placement.

Despite being widely used, ventriculoperitoneal (VP) shunt placement is a procedure often associated with complications and revision surgeries. Many neurosurgical centers routinely perform early postoperative cranial computer tomography (CT) to detect postoperative complications (e.g., catheter malposition, postoperative bleed, over-drainage). Because guidelines are lacking, our study aimed to evaluate the yield of early routine postoperative CT after shunt placement for adult hydrocephalus. We retrospectively reviewed 173 patients who underwent frontal VP shunting for various neurosurgical conditions. Radiological outcomes were proximal catheter malposition, and ventricular width in preoperative and postoperative imaging. Clinical outcomes included postoperative neurological outcome, revision surgery because of catheter malposition or other causes, mortality, and finally surgical, non-surgical, and overall morbidity. In only 3 (1.7%) patients did the early routine postoperative CT lead to revision surgery. Diagnostic ratios for CT finding 1 asymptomatic patient who eventually underwent revision surgery per total number to scan were 1:58 for shunt malposition, 1:86 for hygroma, and 1:173 for a cranial bleed. Five (2.9%) patients with clinically asymptomatic shunt malposition or hygroma underwent intervention based on early postoperative CT (diagnostic ratio 1:25). Shunt malposition occurred in no patient with normal pressure hydrocephalus and 2 (40%) patients with stroke. Lower preoperative Evans' Index was a statistically significant predictor for high-grade shunt malposition. We found a rather low yield for early routine postoperative cranial CT after frontal VP-shunt placement. Therefore, careful selection of patients who might benefit, considering the underlying disease and preoperative radiological findings, could reduce unnecessary costs and exposure to radiation.

Post-traumatic Spinal Hygroma Causing Cord Compression in Type III Odontoid Fracture With Vertical Atlantoaxial Instability.

STUDY DESIGN: Case report. OBJECTIVE: To report the first case in the literature of a traumatic cervical spine subdural cerebrospinal fluid (CSF) collection (hygroma) under tension causing cord compression. We suggest etiopathogenesis and modality of treatment. SUMMARY OF BACKGROUND DATA: Hygromas are subdural cranial CSF collection. A literature review showed no previous published case of post-traumatic spinal hygroma. This was a potential life-threatening sequelae of a high cervical injury that warranted early diagnosis and emergency treatment. METHODS: We present a case of a young adult who sustained a traumatic vertical atlantoaxial dislocation associated with a type III odontoid fracture. He was initially scored C6 ASIA D. Magnetic resonance imaging (MRI) demonstrated cord contusion at the craniocervical junction and a small fluid collection anterior to the cervical cord. On day 5 after his injury he developed complete paraplegia and priapism. An urgent MRI of his spine revealed expansion of the intraspinal fluid collection with distortion of the cord. He was treated with an emergency surgical decompression. The cervical fluid collection was found to be subdural extra-arachnoidal CSF. A subdural-pleural shunt was inserted. The atlantoaxial injury was reduced and fixed with posterior instrumentation. RESULTS: At 1 year from the injury the patient was independent and fully ambulant. MRI and computed tomography images of his spine demonstrated complete resolution of the cervical hygroma, appropriate placement of the cervical-pleural shunt, and stability of the atlantoaxial injury. CONCLUSION: We describe a unique case of post-traumatic spinal hygroma causing cord compression in a patient with an unstable craniocervical injury. The early recognition and correction of this dangerous complication is of paramount importance to savage cord function. LEVEL OF EVIDENCE: 5.

Perigraft hygroma - a rare cause of post-EVAR aneurysm growth.

Development of perigraft hygromas following repair of abdominal aortic aneurysms is extremely rare. A case is presented of a patient who was found to have a large hygroma despite two re-interventions on a previous EVAR.

Early urgent cranioplasty for symptomatic hygroma: Report of two cases.

Following craniectomy, hygromas are relatively common. While many cases resolve spontaneously, some patients develop neurologic deficits. Management of symptomatic hygromas often involves shunting or drainage. We present two patients who three weeks after decompressive hemicraniectomy developed declining neurologic status secondary to enlarging hygroma. Failing conservative management, both were treated with urgent cranioplasty and returned to neurologic baseline. Early cranioplasty may be safe and effective for symptomatic collections.

[Gastrocolic omental cyst in an adult: Case presentation and review of literature]. / Quiste omental gastrocólico en un adulto: presentación de un caso y revisión de la bibliografía.

BACKGROUND: Mesenteric lymphangioma are rare tumours. They usually present early on in life, if congenital, or soon after trauma. The usual sites of presentation of lymphangiomas are in the neck, and axillae. In the abdomen they are more common in the mesentery, primarily of the ileum, or retroperitoneal. OBJECTIVE: A rare case is presented of a mesenteric lymphangioma. CLINICAL CASE: It involves an elderly African-American male, many years after trauma, and characterised with early satiety, causing weight loss, but without gastric outlet obstruction or vomiting. Its diagnosis, management and review of literature are presented. CONCLUSIONS: Mesenteric cysts are rare tumours that should be included as differential diagnosis in elderly patients with a history of previous abdominal trauma.

Confirmation of etiology in fetal hydrops by sonographic evaluation of fluid allocation patterns.

OBJECTIVE: To evaluate patterns of fluid allocations in different etiologies of hydrops fetalis. STUDY DESIGN: This report is a retrospective cohort study on 20,395 fetal sonographic evaluations in a single tertiary center from 2000 to 2014. Special emphasis was placed on the exact description of the distinct fluid allocation sites in each fetus. Postmortem/postnatal records were evaluated additionally. Mean follow up of the surviving neonates was 34 days (10-60 days). RESULTS: There seem to be distinctive patterns of fluid allocation in some etiologies leading to fetal hydrops including aneuploidies and Parvovirus B19 related infections. CONCLUSION: Due to the allocation patterns of fluid filled sites in fetuses with hydrops fetalis the spectrum of possible etiologies may be narrowed already during initial ultrasound scan. It can contribute substantially to diagnostic accuracy as well as to parental counseling. This knowledge may also help to omit delay in diagnostic routines.

Acute onset of mediastinal cystic lymphangioma in the puerperium.

Lymphangioma is a benign congenital malformation developing from the prenatal lymphatic vessels. Lymphangiomas are typically slow-growing and asymptomatic, but can occur throughout the body; there are few documented cases of either mediastinal or rapid growing lymphangiomas. Here, we report a case of a 27-year-old female who experienced sudden-onset nocturnal dyspnea 1 month after delivery. Ultrasound and computed tomography revealed a cystic tumor (diameter, 8 cm), which posteriorly displaced the superior vena cava and trachea. Ultrasound-guided aspiration was performed and the tumor disappeared on chest X-ray, only to return on subsequent chest X-ray performed the following day. Therefore, thoracoscopic excision of the mediastinal tumor was performed, and pathological diagnosis confirmed mediastinal cystic lymphangioma. In this report, we discuss the rare nature of this case and the treatment of lymphangioma in pregnancy.