Perioperative risk factors for major complications after bone replacement in decompressive craniectomy.

INTRODUCTION: Bone flap replacement after a decompressive craniectomy is a low complexity procedure, but with complications that can negatively impact the patient's outcome. A better knowledge of the risk factors for these complications could reduce their incidence. PATIENTS AND METHODS: A retrospective review of a series of 50 patients who underwent bone replacement after decompressive craniectomy at a tertiary center over a 10-year period was performed. Those clinical variables related to complications after replacement were recorded and their risk factors were analyzed. RESULTS: A total of 18 patients (36%) presented complications after bone flap replacement, of which 10 (55.5%) required a new surgery for their treatment. Most of the replacements (95%) were performed in the first 90 days after the craniectomy, with a tendency to present more complications compared to the subsequent period (37.8% vs 20%, p > 0.05). The most frequent complication was subdural hygroma, which appeared later than infection, the second most frequent complication. The need for ventricular drainage or tracheostomy and the mean time on mechanical ventilation, ICU admission, or waiting until bone replacement were greater in patients who presented post-replacement complications. Previous infections outside the nervous system or the surgical wound was the only risk factor for post-bone flap replacement complications (p = 0.031). CONCLUSIONS: Postoperative complications were recorded in more than a third of the patients who underwent cranial bone flap replacement, and at least half of them required a new surgery. A specific protocol aimed at controlling previous infections could reduce the risk of complications and help establish the optimal time for cranial bone flap replacement.

Postoperative Spinal Subdural Extra-arachnoid Hygroma Because of Trauma: Resolution with Lumbar Puncture: A Case Report.

CASE: A 73-year-old woman, after spinal surgery, presented with symptomatic spinal subdural extra-arachnoid hygroma (SSEH) because of a fall on the third postoperative day. The hygroma was diagnosed by magnetic resonance imaging (MRI). Lumbar puncture was performed under local anesthesia, after which the leg pain disappeared immediately. MRI obtained immediately after puncture and 1 week later confirmed disappearance of the hygroma. CONCLUSION: Although dural transection is mentioned in most of the reports on treatment of symptomatic postoperative SSEH, we were able to treat this entity by epidural puncture. In the absence of paraplegia or cystorectal disturbance, puncture can be an effective and minimally invasive treatment option.

Subdural Hygroma After Management of Ruptured Intracranial Aneurysms: Incidence, Associated Factors, Clinical Course, and Management Options.

OBJECTIVE: To evaluate the incidence, associated factors, clinical course, and management options of subdural hygroma in patients treated for aneurysmal subarachnoid hemorrhage (aSAH). METHODS: From January 2013 until June 2022, 336 consecutive patients with aSAH underwent treatment in our center. No one patient was excluded from the study cohort. Computed tomography (CT) examinations were performed at admission, immediately after surgery and on the first postoperative day, and subsequently in case of any neurologic deterioration or, at least, once per week until discharge from the hospital. Thereafter, CT examinations were at the discretion of specialists in the rehabilitation facility, referring physicians, or neurosurgeons at the outpatient clinic. RESULTS: The length of radiologic follow-up starting from CT at admission ranged from 1 to 3286 days (mean, 673 ± 895 days; median, 150 days). Subdural hygromas developed in 84 patients (25%). An average interval until this imaging finding from the initial CT examination was 25 ± 55 days (median, 8 days; range, 0-362 days). Evaluation in the multivariate model showed that patient age ≥72 years (P < 0.0001), cerebrospinal fluid (CSF) shunting (P < 0.0001), and microsurgical clipping of ruptured intracranial aneurysm (RIA; P < 0.0001) are independently associated with the development of subdural hygroma. In 54 of 84 cases (64%), subdural hygromas required observation only. Increase of the lesion size with (5 cases) or without (10 cases) appearance of midline shift was associated with patient age <72 years (P = 0.0398), decompressive craniotomy (P = 0.0192), and CSF shunting (P = 0.0009), whereas evaluation of these factors in the multivariate model confirmed independent association of only CSF shunting (P = 0.0003). Active management of subdural hygromas included adjustment of the shunt programmable valve opening pressure, cranioplasty, external subdural drainage, or their combination. Overall, during follow-up (mean, 531 ± 824 days; median, 119 days; range, 2-3285 days) after the start of observation or applied treatment, subdural hygromas showed either decrease (50 cases) or stabilization (34 cases) of their sizes, and no one lesion showed progression again. CONCLUSIONS: The clinical course of subdural hygromas in patients treated for aSAH is generally favorable, but occasionally these lesions show progressive enlargement with or without the appearance of midline shift, which requires active management.

Cranial vault reduction cranioplasty for severe macrocephaly due to holoprosencephaly and subdural hygroma: a case report.

BACKGROUND: Severe macrocephaly can still be found in developing countries. This condition is usually caused by neglected hydrocephalus and can cause a lot of morbidities. Cranial vault reconstruction cranioplasty is the main treatment option for severe macrocephaly. Holoprosencephaly is often seen with features of microcephaly. Hydrocephalus should be considered as the main cause in HPE patients with features of macrocephaly. In this report, we present a rare case of cranial vault reduction cranioplasty procedure in patient with severe macrocephaly due to holoprosencephaly and subdural hygroma. CASE DESCRIPTION: A 4-year-10-month-old Indonesian boy was admitted with head enlargement since birth. He had a history of VP shunt placement when he was 3 months old. But the condition was neglected. Preoperative head CT showed massive bilateral subdural hygroma that compressed brain parenchyma caudally. From the craniometric calculation, the occipital frontal circumference was 70.5 cm with prominent vertex expansion, the distance between nasion to inion was 11.91 cm and the vertical height was 25.59 cm. The preoperative cranial volume was 24.611 cc. The patient underwent subdural hygroma evacuation and cranial vault reduction cranioplasty. The postoperative cranial volume was 10.468 cc. CONCLUSION: Subdural hygroma can be a rare cause of severe macrocephaly in holoprosencephaly patients. Cranial vault reduction cranioplasty and subdural hygroma evacuation is still the main treatment option. Our procedure successfully reduces significant cranial volume (57.46% volume reduction).

Subdural hygroma as a rare complication after revision spine surgery.

Spinal fusion surgery is the most commonly performed orthopaedic surgical procedure. However, subdural hygroma occurrence is a very rare complication after revision spinal fusion surgery. Here, we report a case of revision lumbar fusion surgery at the L3-4 level. The patient developed acute conus medullaris syndrome at 10 days postoperatively. MRI showed a subdural, extra-arachnoid area fluid collection following the T12-L2, cephalad to the area of revision spinal fusion. When patients have a decreased motor grade, difficulty in voiding urine and neurological abnormalities after lumbar spine surgery, conus medullaris syndrome with a possible occurrence of subdural hygroma should be considered. In this situation, immediate imaging investigations and emergency surgery might be necessary to reduce the pressure on the spinal cord.

Traumatic subdural hygroma and chronic subdural hematoma: A systematic review and meta-analysis.

Recently, a relationship between traumatic subdural hygroma (SDG) and chronic subdural hematoma (CSDH) has been proposed. However, the role of traumatic SDG in development of CSDH has not been well characterized. This systematic review aimed to estimate the rate of evolution of traumatic SDG to CSDH, and to identify risk factors associated with traumatic SDG evolution to CSDH. We searched MEDLINE, EMBASE, and Cochrane Library databases from inception to May 26, 2021, using the combination of the terms "subdural hygroma" and "chronic subdural hematoma." Using a random-effects model, we calculated a pooled estimate of rate of evolution of traumatic SDG to CSDH. In addition, we conducted a systematic review of studies of risk factors for traumatic SDG evolution to CSDH. Nineteen studies with 1,335 patients met the inclusion criteria for meta-analysis. The pooled estimate of evolution rate was 25.0 % (95 % CI, 19.3 %-30.7 %; I2 = 85.6 %), with significant heterogeneity among studies (P < 0.01). Age ≥ 60 years was associated independently with traumatic SDG evolution to CSDH, after adjustment for study design using multivariate meta-regression. Risk factors associated with evolution of traumatic SDG to CSDH were radiological characteristics such as thicker SDG and higher SDG CT value. The rate of traumatic SDGs evolution to CSDH is approximately 25 %. Patients aged 60 or older with traumatic SDGs are at increased risk of CSDH development. Thicker SDG and higher SDG CT value, are commonly reported risk factors for traumatic SDG evolution to CSDH. However, higher quality studies are needed.

Spontaneous acute bleeding within subdural effusion from dural metastasis of gastric cancer: A case report / Sangrado subdural agudo en el seno de una efusión subdural causada por una metástasis de cáncer gástrico: un caso clínico

Dural metastases are uncommon findings and at diagnosis normally appear in disseminated stages of malignant tumors. Usually clinically silent, these could become symptomatic due to mass effect or after developing subdural collections. We present the case of a young woman recently operated from gastric cancer who presented consciousness deterioration and hemiparesis caused by subdural collection. During examination, the patient drastically worsens his neurological status due to an acute subdural bleeding within the subdural collection, which after pathological analysis was diagnosed of dural metastasis of gastric cancer. In malignancies associated with subdural collections it is important to suspect the coexistence of dural metastases and performing a contrast enhanced CT scan or Magnetic Resonance Imaging (MRI) may help in the diagnosis. If surgery is indicated, it is mandatory to evacuate the tumor and involved dura which causes the accumulation of fluid and to coagulate the external tumor membrane to avoid re-bleeding (AU)

Las metástasis durales son hallazgos infrecuentes, y al diagnosticarse, normalmente se encuentran en estadios diseminados de tumores malignos. Generalmente, son clínicamente silentes, pero pueden dar síntomas debido al efecto de masa o tras desarrollar colecciones subdurales. Presentamos el caso de una mujer joven, recientemente intervenida de cáncer gástrico, que presentó deterioro de la conciencia y hemiparesia por colección subdural. Durante la exploración, la paciente empeoró neurológicamente debido a un sangrado subdural agudo dentro de la colección subdural, que tras análisis patológico fue diagnosticada de metástasis dural de cáncer gástrico. En las neoplasias asociadas con colecciones subdurales es importante sospechar la coexistencia de metástasis durales y realizar una tomografía computarizada con contraste o una resonancia magnética puede ayudar en el diagnóstico. Si está indicada la cirugía es obligatorio evacuar el tumor y la duramadre afectada que provoca la acumulación de líquido y coagular la membrana tumoral externa para evitar el resangrado (AU)

Spontaneous acute bleeding within subdural effusion from dural metastasis of gastric cancer: A case report.

Dural metastases are uncommon findings and at diagnosis normally appear in disseminated stages of malignant tumors. Usually clinically silent, these could become symptomatic due to mass effect or after developing subdural collections. We present the case of a young woman recently operated from gastric cancer who presented consciousness deterioration and hemiparesis caused by subdural collection. During examination, the patient drastically worsens his neurological status due to an acute subdural bleeding within the subdural collection, which after pathological analysis was diagnosed of dural metastasis of gastric cancer. In malignancies associated with subdural collections it is important to suspect the coexistence of dural metastases and performing a contrast enhanced CT scan or Magnetic Resonance Imaging (MRI) may help in the diagnosis. If surgery is indicated, it is mandatory to evacuate the tumor and involved dura which causes the accumulation of fluid and to coagulate the external tumor membrane to avoid re-bleeding.

Postoperative Complications of Microscopic Fenestration for Middle Fossa Arachnoid Cysts: A Retrospective Study of 38 Cases and Literature Review.

INTRODUCTION: Middle fossa arachnoid cyst (MFAC) is one of the most common cranial cysts in children, and the various postoperative complications following cyst fenestration represent a major concern. We conducted a retrospective study in our department and performed a systematic review of the literature to identify the risk factors for complications. METHODS: A retrospective survey was conducted in 38 patients with MFAC (<14 years) who underwent microscopic fenestration from January 2019 to December 2020. Postoperative complications, including postoperative hemorrhage/hematoma, subdural hygroma (SH), cranial nerve palsy, postoperative central nervous system infection, and cerebrospinal fluid (CSF) leak, were collected. A systematic PubMed search for cohort studies on surgically treated MFAC published after 1980 was performed. The postoperative complications in the included studies were illustrated. RESULTS: The overall complication rate in our series was 7.9%, among whom, 9 patients (23.7%) developed postoperative SH, one of which required cyst-peritoneal shunting. Patients who developed SH were significantly younger (4.0 ± 1.8 vs. 6.3 ± 3.4 years, p = 0.012). Binary logistic analysis showed that a lower age could be a risk factor for developing SH (odds ratio: 0.738, p = 0.067). One patient developed a subdural hematoma. No cranial nerve palsy or CSF leak was observed. Eighteen studies were included in the systematic review, comprising 649 cases of MFAC. The most common complication was SH (4.9%), and the postoperative complication rates were similar between the microscopic and endoscopic techniques. CONCLUSION: The complication rate of MFAC fenestration is considerable. SH is the most common postoperative complication, and it mostly occurs in young children. Strict surgical indications should be applied for young children.

Campylobacter jejuni subdural hygroma infection in a 2-year old boy: case report and a brief literature review.

BACKGROUND: Campylobacter jejuni is a common cause of acute gastroenteritis, but central nervous system infections are rare manifestations of Campylobacter infection. Therefore, C. jejuni trauma-related subdural hygroma infection in children is poorly described in the literature. CASE PRESENTATION: We described a 2-year old boy with lobar holoprosencephaly presenting with subdural hygroma following head trauma. C. jejuni infection was confirmed from a subdural hygroma sample by culture as well as by DNA sequencing of a broad range 16S rDNA PCR product. Cerebrospinal fluid from the ventriculoperitoneal shunt remained sterile. Combined neurosurgical and antimicrobial treatment led to complete recovery. Review of the literature showed that the most common manifestation of Campylobacter central nervous system infection is meningitis, mostly in neonates, and subdural hygroma infection was described for only one case. CONCLUSIONS: Subdural hygroma infection caused by C. jejuni is a rare clinical condition in children. Molecular methods represent an important tool for the detection of rare or unexpected pathogens. No standard recommendations for antimicrobial treatment of C. jejuni subdural space infection in children are available, but meropenem treatment combined with surgery seems to be an effective approach.

Diabetic ketoacidosis (DKA) induced cerebral edema complicating small chronic subdural hematoma/hygroma/ at Zewuditu memorial hospital: a case report.

BACKGROUND: While both DKA & CSDH/subdural hygroma/ are known to cause significant morbidity and mortality, there is no a study that shows the role & effect of DKA on CSDH/subdural hygroma/ & vice versa to authors' best knowledge; hence this work will show how important relation does exist between DKA & CSDH/ hygroma. This study highlights the diagnostic & management challenges seen for a case of a 44 years old female black Ethiopian woman admitted with a diagnosis of newly diagnosed type 1 DM with DKA + small CSDH/subdural hygroma/ after she presented with sever global headache and a 3 month history of lost to her work. She needed burrhole & evacuation for complete clinical improvement besides DKA's medical treatment. CONCLUSION: DKA induced cerebral edema on the CSDH/subdural hematoma/ can have a role in altering any of the parameters (except the thickness of CSDH) for surgical indication of patients with a diagnosis of both CSDH +DM with DKA. Hence, the treating physicians should be vigilant of different parameters that suggests tight brain &/ cerebral edema (including midline shift, the status of cisterns, fissures & sulci) and should not be deceived of the thickness of the CSDH/subdural hygroma/alone; especially when there is a disproportionately tight brain for the degree of collection. Whether DKA induced cerebral edema causes a subdural hygroma is unknown and needs further study.

Preoperative risk and postoperative outcome from subdural fluid collections in African infants with postinfectious hydrocephalus.

OBJECTIVE: This study investigated the incidence of postoperative subdural collections in a cohort of African infants with postinfectious hydrocephalus. The authors sought to identify preoperative factors associated with increased risk of development of subdural collections and to characterize associations between subdural collections and postoperative outcomes. METHODS: The study was a post hoc analysis of a randomized controlled trial at a single center in Mbale, Uganda, involving infants (age < 180 days) with postinfectious hydrocephalus randomized to receive either an endoscopic third ventriculostomy plus choroid plexus cauterization or a ventriculoperitoneal shunt. Patients underwent assessment with the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III; sometimes referred to as BSID-III) and CT scans preoperatively and then at 6, 12, and 24 months postoperatively. Volumes of brain, CSF, and subdural fluid were calculated, and z-scores from the median were determined from normative curves for CSF accumulation and brain growth. Linear and logistic regression models were used to characterize the association between preoperative CSF volume and the postoperative presence and size of subdural collection 6 and 12 months after surgery. Linear regression and smoothing spline ANOVA were used to describe the relationship between subdural fluid volume and cognitive scores. Causal mediation analysis distinguished between the direct and indirect effects of the presence of a subdural collection on cognitive scores. RESULTS: Subdural collections were more common in shunt-treated patients and those with larger preoperative CSF volumes. Subdural fluid volumes were linearly related to preoperative CSF volumes. In terms of outcomes, the Bayley-III cognitive score was linearly related to subdural fluid volume. The distribution of cognitive scores was significantly different for patients with and those without subdural collections from 11 to 24 months of age. The presence of a subdural collection was associated with lower cognitive scores and smaller brain volume 12 months after surgery. Causal mediation analysis demonstrated evidence supporting both a direct (76%) and indirect (24%) effect (through brain volume) of subdural collections on cognitive scores. CONCLUSIONS: Larger preoperative CSF volume and shunt surgery were found to be risk factors for postoperative subdural collection. The size and presence of a subdural collection were negatively associated with cognitive outcomes and brain volume 12 months after surgery. These results have suggested that preoperative CSF volumes could be used for risk stratification for treatment decision-making and that future clinical trials of alternative shunt technologies to reduce overdrainage should be considered.

The Transformation of Intracranial Subdural Hygroma to Chronic Subdural Hematoma Following Endoscopic Spinal Surgery: A Case Report.

BACKGROUND: We present the case of an intracranial subdural hygroma resulting from intraoperatively undetected dural tear after unilateral biportal endoscopic (UBE) spine surgery for lumbar spinal stenosis. CASE DESCRIPTION: An 80-year-old woman presented with insidious onset, gradually progressing low back pain, and right leg pain of 1-year duration. The pain radiated to the right L4-L5 dermatomes. Neurogenic intermittent claudication was <300 m. Motor function was normal. Lumbar magnetic resonance imaging showed a lateral recess stenosis at the L3-L4 and L4-L5 levels. These lesions were operated on by the UBE decompression technique.No major complications were encountered during the operation. But soon we found out that there was an undiscovered dura tear. We placed the patient under close observation for 2 weeks. After 30 days, we confirmed that subdural hygroma had changed to chronic subdural hematoma. Conservative treatment was continued. On postoperative day 90), the condition was stable and the symptoms improved completely. CONCLUSIONS: We concluded that a spinal cerebrospinal fluid leakage can result in an intracranial subdural hygroma. Intracranial subdural hygromas and hematomas after lumbar spinal surgery should be cautiously assessed and treated.

Ruptured middle cranial fossa arachnoid cysts after minor trauma in adolescent boys presenting with subdural hygroma: two case reports.

BACKGROUND: Intracranial arachnoid cysts are common, cerebrospinal fluid-filled, innocent lesions that are usually detected incidentally on brain imaging. They may rupture and complicate due to subdural hematoma or hygroma after minor trauma. Authors present two cases of ruptured middle cranial fossa arachnoid cysts in adolescent (12-year-old and 15-year-old) Afghan boys presenting with subdural hygroma after minor trauma. CONCLUSION: Imaging work-up is necessary for symptomatic patients following minor head trauma as incidentally detected ruptured intracranial arachnoid cysts can be responsible for the symptoms.

Contralateral subdural effusion after decompressive craniectomy: What is the optimal treatment?

OBJECTIVE: Contralateral subdural effusion after decompressive craniectomy (CSEDC) is rare, and the optimal treatment is not determined. We present 11 cases of CSEDC and give an overview of the English literature pertaining to this disease. METHODS: We searched the database at our institution and performed a search of English literature in PubMed and Google Scholar. Keywords used were as follows (single word or combination): "subdural hygroma"; "subdural effusion"; "decompressive craniectomy". Only patients with CSEDC and contained adequate clinical information pertinent to the analysis were included. RESULTS: 11 cases of CSEDC were recorded at our institution. They comprised ten men and one woman with an average age of 41.9 years. All the 8 symptomatic patients underwent surgery and the CSEDC resolved gradually. 68 cases of CSEDC were found in the literature. Including ours, a total of 79 patients were analyzed. Conservative treatment was effective in the asymptomatic patients. 41.7% of the symptomatic CSEDC underwent burr hole drainage and successfully drained the CSEDC. However, 76% of them received subsequent surgery to manage the reaccumulation of CSEDC. 25% of the symptomatic patients underwent cranioplasty, while 13.3% of them received Ommaya drainage later because of CSEDC recurrence. 18.3% of the symptomatic patients underwent cranioplasty plus subduroperitoneal shunting, and all CSEDC resolved completely. CONCLUSIONS: Burr hole drainage appears to be only a temporary measure. Early cranioplasty should be performed for patients with CSEDC. CSF shunting procedures may be required for patients in whom CSEDC have not been solved or hydrocephalus manifest after cranioplasty.

Subdural Hygroma: A Rare Complication of a Common Brain Malformation.

INTRODUCTION: Arachnoid cysts are a common incidental finding on head imaging. While the natural history of these cysts in poorly described, hemorrhage with subdural hygroma formation is rare. We review the clinical course of a patient who developed a subdural hygroma following trauma. CASE: The patient was a previously healthy 14-month-old male who presented to the Emergency Department with vomiting after a fall and was found to have esotropia without other focal neurological deficits and a CT scan consistent with a subdural cerebrospinal fluid collection with midline shift. The patient was treated conservatively and his symptoms resolved. DISCUSSION: Arachnoid cyst rupture is a rare complication which can lead to increased intracranial pressure with devastating consequences. Clinical manifestation can be similar to that of other intracranial pathologies. Prompt diagnosis is required to avoid life-threatening symptoms. CONCLUSION: Arachnoid cyst rupture should be considered when evaluating patients with non-specific neurological symptoms following trauma.