Intracranial rebleeding post spinal anesthesia in pregnant patient with undiagnosed chronic subdural hematoma: case report.

Intracranial hematoma after spinal anesthesia is a rare complication. It generally presents with posture-dependent headache that becomes persistent. We describe the case of patient submitted to spinal anesthesia for cesarean section who presented a non-posture-dependent headache, resistant to clinical treatment, that progressively worsened and with symptoms of intracranial hypertension. The patient had a history of head trauma without symptoms. The CT-scan revealed a chronic bilateral parietal hematoma with a recent bleeding component, treated surgically. We concluded that spinal puncture led to chronic hematoma to rebleed. We have reported the case to draw attention to the importance of investigating atypical headache after spinal anesthesia.

Chronic intracranial subdural hematoma after spinal anesthesia for a cesarean section: a case report.

BACKGROUND: Subdural hematoma is a rare, potentially devastating, yet curable complication of spinal anesthesia. Differentiation between post-dural puncture headache and subdural hematoma can be difficult, resulting in a delay in diagnosis. CASE PRESENTATION: We present a 28-year-old Ethiopian female patient who underwent elective cesarean section under spinal anesthesia and returned to the emergency department after 1 month with a worsening headache. Brain computed tomography revealed a chronic subdural hematoma with a significant midline shift. The patient recovered completely after surgical evacuation. CONCLUSIONS: A high index of suspicion and close attention to the pattern and characteristics of the headache, coupled with a meticulous neurologic examination and neuroimaging, can help to achieve timely diagnosis of this serious entity. Investigation with head computed tomography or magnetic resonance imaging is vital.

Hipotensión intracraneal secundaria a fístula espinal espontánea de líquido cefalorraquídeo: Presentación de tres casos / Intracranial hypotension secondary to spontaneous spinal cerebrospinal fluid fistula: Three case reports

El síndrome de hipotensión intracraneal espontánea (HIE) es una dolencia poco frecuente. El síntoma principal es la cefalea ortostática, si bien pueden aparecer otras manifestaciones como síntomas vegetativos, meningismo o déficits neurológicos focales. La causa más frecuente es una fístula de líquido cefalorraquídeo, generalmente traumática. Las fístulas de líquido cefalorraquídeo espontáneas son poco comunes y se relacionan con la presencia de quistes/divertículos meníngeos o en el contexto de enfermedades del tejido conectivo. El diagnóstico se basa en las pruebas de imagen, tanto para detectar complicaciones intracraneales, como los hematomas subdurales bilaterales y para localizar el punto de fuga a nivel intracraneal o espinal. El tratamiento de la HIE suele ser conservador mediante reposo postural, cafeína y analgésicos. La inyección de un parche hemático epidural es una opción válida cuando persisten los síntomas. La cirugía está indicada en casos refractarios o cuando existe un defecto anatómico evidente y accesible. En el presente artículo se describen tres casos clínicos con síndrome de hipotensión intracraneal secundarios a una fístula de líquido cefalorraquídeo espontánea a nivel espinal (AU)

Spontaneous intracranial hypotension syndrome (SIH) is a rare condition. The main symptom is orthostatic headache, although other symptoms such as vegetative symptoms, meningism, or focal neurological deficits may appear. The most common cause is a cerebrospinal fluid leak, usually traumatic. Spontaneous cerebrospinal fluid leaks are rare and associated with the presence of meningeal cysts / diverticula or in the setting of connective tissue diseases. The diagnosis is based on imaging tests, both to detect intracranial complications and bilateral subdural hematomas and to locate the leak point at the intracranial or spinal level. The treatment of SIH is usually conservative: bed rest, caffeine and analgesics. Epidural blood patch is a good option when symptoms persist. Surgery is indicated in refractory cases or when there is an evident and accessible anatomic defect. This article describes three clinical cases with intracranial hypotension syndrome secondary to a spontaneous spinal cerebrospinal fluid leak (AU)

Optimal surgical indications of endoscopic surgery for traumatic acute subdural hematoma in elderly patients based on a single-institution experience.

Recently, treatment of acute subdural hematoma (ASDH) by minimally invasive surgery with endoscopy has been successfully demonstrated. However, few case series are available on this procedure for ASDH, and the surgical indication has not been established. We retrospectively analyzed the data of patients (n = 26) aged 65 years or older who underwent endoscopic surgery (ES) for ASDH at our institution between January 2011 and March 2019. We then evaluated the surgical outcomes and procedure-related complications in patients who underwent ES. The mean hematoma reduction rate was over 90%. Percentage of favorable outcomes at discharge was 69.2% in ES-treated patients. The presence of a skull fracture, subarachnoid hemorrhage, midline shift/subdural hematoma thickness ratio > 1.0, and early surgery were associated with postoperative IPHs in patients who underwent ES or conventional surgery for ASDH. The present study revealed that ES for elderly patients with ASDH is likely to be an efficient and safe procedure when patients are selected appropriately. However, ES is not recommended in patients with significant IPHs on initial CT scan. Additionally, ES should be carefully considered in cases with the factors, where IPHs may progress following surgery.

Pial arteriovenous fistula with appearance of hemorrhagic tumor: A case report.

INTRODUCTION: Pial arteriovenous fistula (PAVF) is a rare intracranial vascular disease, and its presentation with a huge tumor-resembling thrombus is rarer. PATIENT CONCERNS: A 38-year-old female patient presented with a sudden left-side motor disorder and loss of consciousness. The patient was otherwise in good health and had no history of hypertension or diabetes. During the physical examination, she appeared lethargic and manifested left limb paralysis with level zero muscle strength and a positive pathological reflex. DIAGNOSES: Because imaging failed to rule out a tumor stroke, an intracranial lesion resection was performed immediately. Because the lesion was considered to be a vascular structure, digital subtraction angiography was undertaken before the surgery, and PAVF was diagnosed. INTERVENTIONS: Endovascular embolization was conducted, followed by PAVF and hematoma resection. OUTCOMES: At the 3-month follow up, her left limb muscle strength was level 4, and she could live on her own (Modified Rankin Scale score = 2). CONCLUSIONS: It is noteworthy that PAVF with a large thrombus may appear as a tumor in the initial diagnosis, and therefore it is necessary to perform an intracranial vascular examination in patients with tumor stroke symptoms.

Guillain-Barre Syndrome After Craniocerebral Gunshot Injury: First Report.

BACKGROUND: Guillain-Barre syndrome (GBS) is a rare but serious disorder involving peripheral nerve inflammatory demyelination characterized by acute onset tetraparesis and areflexia. Generally, GBS is preceded by a bacterial or viral infection, and post-traumatic or postsurgical GBS is rarely seen. CASE DESCRIPTION: A 41-year-old man with severe craniocerebral gunshot injury and open depressed occipital bone fracture was operated urgently. Two weeks postoperatively, he suffered from sudden quadriparesis. He had flaccid paralysis of his bilateral muscle lower extremities (0/5), along with bilateral upper extremity weakness (2/5). CONCLUSIONS: We report the first case, to our knowledge, with post-traumatic GBS after craniocerebral gunshot injury. We want to indicate the possibility of post-traumatic GBS in cases of unexplained quadriparesis or quadriplegia after trauma or surgery.

Low Risk of Traumatic Intracranial Hematoma Expansion with Factor Xa Inhibitors without Andexanet Reversal.

BACKGROUND: Andexanet alfa, a novel anticoagulation reversal agent for factor Xa inhibitors, was recently approved. Traumatic intracranial hemorrhage presents a prime target for this drug. The Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors study established the efficacy of andexanet alfa in reversing factor Xa inhibitors. However, the association between anticoagulation reversal and traumatic intracranial hemorrhage progression is not well understood. The objective of this study was to determine progression rates of patients with traumatic intracranial hemorrhage on factor Xa inhibitors prior to hospitalization who were managed without the use of andexanet alfa. METHODS: A retrospective cohort study was performed between 2016 and 2019 at a single institution. An institutional traumatic brain injury (TBI) registry was queried. Patients with recorded use of apixaban or rivaroxaban <18 hours before injury were included. The primary study outcome was <35% increase in hemorrhage volume or thickness on repeated head computed tomography (CT) scans. RESULTS: We identified 25 patients meeting the inclusion criteria. Two patients were excluded because of a lack of necessary CT data. Twelve patients (52%) were receiving apixaban, and 11 were (48%) on rivaroxaban. On admission CT scan, 14 patients had subdural hematoma, 6 had traumatic intraparenchymal hemorrhage, and 3 had subarachnoid hemorrhage. Anticoagulation reversal was attempted in 17 patients (74%), primarily using 4-factor prothrombin complex concentrate. Twenty patients (87%) were adjudicated as having excellent or good hemostasis on repeat imaging. CONCLUSIONS: Our results indicate that patients on factor Xa inhibitors with complicated mild TBI have a similar intracranial hemorrhage progression rate to patients who are not anticoagulated or anticoagulated with a reversible agent. The hemostatic outcomes in our cohort were similar to those reported after andexanet alfa administration.

Traumatic Retroclival Subdural Hematoma in a Child with Hemophilia.

BACKGROUND: Retroclival hematomas are a rare entity and may occur in 3 compartments, namely the epidural, subdural, and subarachnoid spaces. They are frequently secondary to trauma. Hemophilia is a clinical syndrome affecting usually men and characterized by the inherited tendency to bleed excessively after slight injury. Hemophilia is caused by a specific defect of coagulation factor VIII. The main concern associated with the disease is bleeding, especially after trauma and surgeries. The most serious site of bleeding is the central nervous system. CASE PRESENTATION: An 11-year-old boy diagnosed with hemophilia presented after sustaining a fall. On arrival to the emergency department, his vitals where within normal range and he was fully conscious. Neurologic examination was significant for bilateral abducens nerve palsy; the rest of the examination was unremarkable. Imaging studies with computed tomography (CT) scan and brain magnetic resonance imaging showed subacute retroclival subdural hemorrhage with left cerebellar and upper cervical spine extension. Follow-up imaging with CT scan showed progressive resolution of the hematoma, and the patient had a stable clinical course while receiving factor VII replacement. CONCLUSIONS: Retroclival subdural hematomas are rare and may present either spontaneously or after trauma. Conservative treatment is the usual course of treatment. Patients with hemophilia A are under a constant threat from bleeding, either spontaneous or after trivial injury. The most common cause of death in this patient population is intracranial hemorrhage. The most important aspect of intracranial hematoma management is the early replacement therapy of deficient coagulation factors in patients with hemophilia.

Fatal Acute Intracranial Subdural Hematoma After Spinal Anesthesia for Cesarean Delivery: Case Report and Review of the Literature.

The authors report on the autopsy case of a 40-year-old primigravida without either coagulation disorders or anticoagulant/antiplatelet therapy, who developed a fatal intracranial subdural hematoma after spinal anesthesia (SA) for elective cesarean delivery for tocophobia.Intracranial subdural hematoma is the most dreaded complication of SA and is often misdiagnosed with postdural puncture headache.In this article, the authors discuss pathophysiological mechanisms and risk factors for the development of an intracranial subdural hematoma after SA and review the pertinent literature.

Resistant Pseudomeningocele following Craniotomy for Non-Traumatic Acute Intracranial Haematoma in Very Young Children: Report of Four Cases.

BACKGROUND: The incidence of non-traumatic intracranial haemorrhage among neonates is less than among adults. However, the outcomes are generally poor, with high rates of morbidity and mortality. Non-traumatic intracranial haemorrhage can cause a sudden increase in intracranial pressure, requiring emergency craniotomy for evacuation. METHODS: We report 4 cases following craniotomy for non-traumatic acute intracranial haematoma in very young children. The surgical technique and postoperative course are discussed, with emphasis on dural repair to avoid resistant pseudomeningocele. RESULTS: Despite successful management of the acutely raised intracranial pressure, all patients afterwards developed tense pseudomeningoceles and required formal dural repair. This led to a change in institutional practice and modifications to the surgical technique. CONCLUSION: The authors highlight the postoperative occurrence of resistant pseudomeningoceles in young children after clot evacuations and leaving the dura open. They describe the surgical procedures to avoid these pseudomeningoceles.

Intracranial Subdural Hematoma after Spinal Anesthesia: Report of Two Cases with different Outcomes

Spinal anesthesia is a technique commonly used for local anesthesia and in obstetric surgeries. Rarely, the formation of an intracranial subdural hematoma (SDH) may result from spinal anesthesia, constituting a serious condition that often leads to severe neurological deficits. The presentation and course of this pathology may occur in a completely different way, which makes its diagnosis and management difficult. In the present article, the authors report two cases of patients with intracranial SDH after spinal anesthesia with completely different presentations and outcomes, demonstrating the variability of the manifestations of this condition. A quick review of key points of its pathophysiology, symptomatology, diagnosis, and treatment was also performed.

Methodical history taking may help in timely diagnosis of spontaneous intracranial hypotension.

Orthostatic headache (OH) is a key symptom of spontaneous intracranial hypotension (SIH). However, there is no optimal history taking for OH. A 35-year-old man complained of headache that prevented him from performing routine physical activities, which was relieved on lying down. We initially considered migraine as the most likely diagnosis. However, detailed history taking revealed that his headache worsened on standing, and he was finally diagnosed with SIH. Headache relief on lying down is not a specific indicator of OH associated with SIH. Thus, with regard to headache history taking, we suggest it important to confirm headache aggravation on standing.

Is repeat head CT necessary in patients with mild traumatic intracranial hemorrhage.

BACKGROUND: Patients with traumatic intracranial hemorrhage (TIH) frequently receive repeat head CT scans (RHCT) to assess for progression of TIH. The utility of this practice has been brought into question, with some studies suggesting that in the absence of progressive neurologic symptoms, the RHCT does not lead to clinical interventions. METHODS: This was a retrospective review of consecutive patients with CT-documented TIH and GCS ≥ 13 presenting to an academic emergency department from 2009 to 2013. Demographic, historical, and physical exam variables, number of CT scans during admission were collected with primary outcomes of: neurological decline, worsening findings on repeat CT scan, and the need for neurosurgical intervention. RESULTS: Of these 1126 patients with mild traumatic intracranial hemorrhage, 975 had RHCT. Of these, 54 (5.5% (4.2-7.2 95 CI) had neurological decline, 73 (7.5% 5.9-9.3 95 CI) had hemorrhage progression on repeat CT scan, and 58 (5.9% 4.5-7.6 95 CI) required neurosurgical intervention. Only 3 patients (0.3% 0.1-0.9% 95 CI) underwent neurosurgical intervention due to hemorrhage progression on repeat CT scan without neurological decline. In this scenario, the number of RHCT scans needed to be performed to identify this one patient is 305. CONCLUSIONS: RHCT after initial findings of TIH and GCS ≥ 13 leading to a change to operative management in the absence of neurologic progression is a rare event. A protocol that includes selective RHCT including larger subdural hematomas or patients with coagulopathy (vitamin K inhibitors and anti-platelet agents) may be a topic for further study.

Traumatic Subacute Spinal Subdural Hematoma Concomitant with Symptomatic Cranial Subdural Hematoma: Possible Mechanism.

BACKGROUND: Spinal subdural hematoma (SDH) concomitant with cranial SDH is extremely rare. Although some theories have been proposed, the pathophysiology underlying this condition remains unclear. We present a case of traumatic subacute spinal SDH followed by symptomatic subacute cranial SDH. CASE DESCRIPTION: A 56-year-old woman was admitted with severe back pain 2 weeks after sustaining a minor head injury. The pain was worse with walking or standing and was relieved a little bit by sitting. There was no clinical evidence of back injury. There was no neurologic deficit. Magnetic resonance imaging of the spine showed subacute spinal SDH from T12 to S1. Owing to progressive worsening of back pain, bilateral laminectomy of L1-S1 and drainage of subacute spinal SDH were performed. The pain was completely relieved after surgery. On postoperative day 4, the patient was noted to be unconscious with Glasgow Coma Scale score of 10 (E2V3M5). Computed tomography scan of the head showed subacute bilateral cranial SDH. Burr hole drainage was performed. The patient experienced a complete recovery. CONCLUSIONS: This case suggests the possibility that spinal SDH can develop as a result of cranial SDH migration to the most dependent spinal subdural space. The physician should be aware of the possibility of symptomatic cranial SDH developing following spinal SDH evacuation.

Spontaneous intracranial hypotension and its complications.

Spontaneous intracranial hypotension (SIH) is a syndrome that was unknown until the advent of magnetic resonance imaging (MRI). It is a cause of orthostatic headache, which remains underdiagnosed and, rarely, can result in several complications including dural venous sinus thrombosis, subdural hematoma and subarachnoid hemorrhage. Some of these complications are potentially life-threatening and should be recognized promptly, mainly by imaging studies. We reviewed the MRI of nine patients with SIH and describe the complications observed in three of these patients. Two of them had subdural hematoma and one had a dural venous sinus thrombosis detected by computed tomography and MRI. We concluded that MRI findings are of great importance in the diagnosis of SIH and its complications, which often influence the clinical-surgical treatment of the patient.

A delayed-onset intracranial chronic subdural hematoma following a lumbar spinal subdural hematoma: A case report.

RATIONALE: A spinal subdural hematoma (SDH) is rarely complicated with an intracranial SDH. We found only 7 cases of spontaneous concurrent lumbar spinal and cranial SDHs, in which lumbar symptoms occurred before head symptoms. PATIENT CONCERNS: We describe a 77-year-old man with spontaneous concurrent spinal and cranial SDHs, in whom the spinal SDH was identified 30 days before the intracranial chronic SDH. DIAGNOSIS: Magnetic resonance imaging showed a spinal SDH at L4/L5. There was no paralysis, and the patient was managed conservatively. About 30 days after the onset of back pain, he experienced tinnitus and visual hallucination. Brain computed tomography showed a chronic SDH and midline shift. INTERVENTIONS: Burr-hole evacuation was performed, and the patient's condition improved. OUTCOMES: At 5 months of follow-up, there was no recurrence of the spinal or intracranial SDH. LESSONS: It is important to consider the possibility of intracranial hemorrhage when a spinal SDH is identified.