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.

Subdural contrast effusion during endovascular therapy: case report.

Accumulation of contrast medium in the subdural space after diagnostic intraarterial contrast administration is a rare observation. The authors report the case of a subdural contrast effusion (SCE) presenting during endovascular treatment of an intracranial dural arteriovenous fistula (DAVF) mimicking an acute subdural hematoma. Differentiation between the two by computed tomography (CT) or intraprocedural Dyna CT and early neurological examination can be crucial for patient management. We believe that repeated large-volume contrast injections via large-bore intermediate catheters into the territory of an (even partly) occluded DAVF may induce leakage of contrast medium into the extravascular subdural space thereby causing a SCE.

Understanding Subdural Collections in Pediatric Abusive Head Trauma.

Life-threatening physical abuse of infants and toddlers is frequently correlated with head injuries. A common variant of the abusive head trauma is the shaken baby syndrome. The present review article sheds light on subdural collections in children with abusive head trauma and aims at providing a recent knowledge base for various medical disciplines involved in diagnostic procedures and legal proceedings. To this end, the different subdural collection entities are presented and illustrated. The pathophysiologic background is explained. Differential and age-diagnostic aspects are discussed and summarized by tabular and graphic overviews. Two problematic constellations frequently occurring during initial CT investigations are evaluated: A mixed-density subdural collection does not prove repeated trauma, and hypodense subdural collections are not synonymous with chronicity. The neuroradiologic analysis and assessment of subdural collections may decisively contribute to answering differential diagnostic and forensic questions. In addition to more reference data, a harmonization of terminology and methodology is urgently needed, especially with respect to age-diagnostic aspects.

Quistes aracnoideos e higroma subdural / Arachnoid cysts and subdural hygroma

No disponible

An overlooked cause of subdural effusions.

A middle-aged man presented with progressive confusion. Initial brain CT was misinterpreted to have 'cerebral atrophy and bilateral subdural effusions' by the emergency physician, and the patient was admitted to a medical ward for further investigation. Two days later, the patient experienced acute neurological deterioration, and burr hole drainage was performed to relieve the effusions. It was later confirmed that the effusions were caused by intracranial hypotension secondary to spinal cerebrospinal fluid leakage. The patient improved on conservative treatment with no lasting neurological sequela.

Subdural Fluid Collection and Hydrocephalus After Foramen Magnum Decompression for Chiari Malformation Type I: Management Algorithm of a Rare Complication.

BACKGROUND: Chiari malformation type I is a hindbrain abnormality characterized by descent of the cerebellar tonsils beneath the foramen magnum, frequently associated with symptoms or brainstem compression, impaired cerebrospinal fluid circulation, and syringomyelia. Foramen magnum decompression represents the most common way of treatment. Rarely, subdural fluid collection and hydrocephalus represent postoperative adverse events. The treatment of this complication is still debated, and physicians are sometimes uncertain when to perform diversion surgery and when to perform more conservative management. CASE DESCRIPTION: We report an unusual occurrence of subdural fluid collection and hydrocephalus that developed in a 23-year-old patient after foramen magnum decompression for Chiari malformation type I. Following a management protocol, based on a step-by-step approach, from conservative therapy to diversion surgery, the patient was managed with urgent external ventricular drainage, and then with conservative management and wound revision. CONCLUSIONS: Because of the rarity of this adverse event, previous case reports differ about the form of treatment. In future cases, finding clinical and radiologic features to identify risk factors that are useful in predicting if the patient will benefit from conservative management or will need to undergo diversion surgery is only possible if a uniform form of treatment is used. Therefore, we believe that a management algorithm based on a step-by-step approach will reduce the use of invasive therapies and help to create a standard of care.

Coexistent Supratentorial and Infratentorial Subdural Hygromas with Hydrocephalus After Chiari Decompression Surgery: Review of Literature.

BACKGROUND: Foramen magnum decompression (FMD) is the standard procedure for Chiari I malformation. Although seemingly a straightforward procedure, recent articles have reported an increase in various complications. We describe a rare complication of coexistent supratentorial and infratentorial subdural hygromas (SDHs) with hydrocephalus noted after FMD and provide a detailed review of the literature on this topic. METHODS: A 34-year-old woman presented with strain-related suboccipital headache and myelopathy for 6 months. Imaging revealed tonsillar herniation up to C2 level and cervical syringomyelia. A standard FMD, C1 posterior arch removal, and tonsillar reduction was performed. After an initial uneventful postoperative course, she had 2 readmissions with headache, vomiting, and ataxia. Imaging showed a tense pseudomeningocele and concomitant supratentorial and infratentorial (initially right-sided, followed by left-sided) SDHs with ventriculomegaly. She was conservatively managed with antiedema measures and had excellent relief of symptoms. For the literature review, only cases with concomitant supratentorial and infratentorial SDHs with hydrocephalus were searched online and analyzed. RESULTS: Including ours, 10 cases have been reported. Mean age was 25.3 years. The male-to-female ratio was 1:2.3. Symptoms appeared an average of 12.6 days postoperatively. Treatment was with conservative management in 3 cases, and 3 cases required permanent cerebrospinal fluid diversions. Mean follow-up duration was 9.4 months (range, 1-27 months). CONCLUSIONS: Coexistent supratentorial and infratentorial SDHs with hydrocephalus after Chiari decompression is a very rare occurrence. Treatment needs to be individualized based on the predominant symptomatic lesion, and surgical options need to be judiciously considered. Good prognosis is the rule in most cases.

A calvarial acute subdural hematoma migrating into the spinal canal in a young male.

It is not common for an acute subdural hematoma (SDH) in the supratentorial region to show rapid resolution or migration during the clinical course. In this report, we present a rare case where the SDH in the supratentorial region was observed to rapidly migrate into the lumbar spinal canal, leading to severe radiculopathy. A 20-year-old male patient was admitted to the emergency department with severe headache after head trauma. The patient's overall condition was good, whereas his Glasgow Coma Scale score was 15 and blood pressure was normal. He had vomited 3 times after the onset of pain. No stiff neck was found, and the computed tomography showed an ASDH over the outer layer of the right hemisphere, causing a 7- to 8-mm shift. During the follow-up, the headache regressed and eventually resolved after 12 hours; however, another severe pain occurred in the lumbar region and in both legs. The pain worsened over time, progressing to sciatica in both legs. Acute SDH associated with a minor head trauma may migrate from the supratentorial compartment into the spinal canal by the help of elastic cerebral tissues in young adults and children.

False localizing sign of cervico-thoracic CSF leak in spontaneous intracranial hypotension.

OBJECTIVE: Spontaneous spinal CSF leaks are an important cause of new-onset headaches. Such leaks are reported to be particularly common at the cervico-thoracic junction. The authors undertook a study to determine the significance of these cervico-thoracic CSF leaks. METHODS: The patient population consisted of a consecutive group of 13 patients who underwent surgery for CSF leak repair based on CT myelography showing CSF extravasation at the cervico-thoracic junction but without any evidence of an underlying structural lesion. RESULTS: The mean age of the 9 women and 4 men was 41.2 years. Extensive extrathecal longitudinal CSF collections were demonstrated in 11 patients. At surgery, small leaking arachnoid cysts were found in 2 patients. In the remaining 11 patients, no clear source of CSF leakage could be identified at surgery. Resolution of symptoms was achieved in both patients with leaking arachnoid cysts, but in only 3 of the 11 patients with negative intraoperative findings. Postoperative spinal imaging was performed in 9 of the 11 patients with negative intraoperative findings and showed persistence of the longitudinal intraspinal extradural CSF. Further imaging revealed the site of the CSF leak to be ventral to the thoracic spinal cord. Five of these patients underwent microsurgical repair of the ventral CSF leak with resolution of symptoms in all 5 patients. CONCLUSIONS: Cervico-thoracic extravasation of dye on myelography does not necessarily indicate the site of the CSF leak. Treatment directed at this site should not be expected to have a high probability of sustained improvement of symptoms.

Enhancing subdural effusions mimicking acute subdural hematomas following angiography and endovascular procedures: report of 2 cases.

Hyperdense enhancing subdural effusion due to contrast extravasation has been recently described as a potential mimicker of acute subdural hematoma following a percutaneous coronary procedure. Herein, the authors report on 2 patients who presented with subarachnoid hemorrhage from ruptured cerebral aneurysms and who developed enhancing subdural effusions mimicking acute subdural hematomas after angiography and endovascular coil placement. In 1 case, the subdural effusions completely cleared but recurred after a second angiography. CT attenuation values higher than expected for blood, as well as the evolution of the effusions and density over time, allowed for differentiation of enhancing subdural effusions from acute subdural hematomas.

Neuropsychological examination detects post-operative complications in idiopathic normal pressure hydrocephalus (iNPH): report of two cases.

Subdural fluid collections (SFC) are characteristic complications of shunting for idiopathic normal pressure hydrocephalus (iNPH). This report presents two shunted iNPH patients with clinically silent postoperative SFC, detected after abnormal neuropsychological findings. These cases highlight the value of neuropsychological assessment in the routine postoperative assessment of iNPH.

Imaging of bridging vein thrombosis in infants with abusive head trauma: the "Tadpole Sign".

OBJECTIVES: Abusive head trauma (AHT) in infants is usually diagnosed using a multi-disciplinary approach by investigating the circumstances and identifying morphological indicators, for example, subdural hematomas (SDHs), subdural hygromas (SDHys), retinal haemorrhages and encephalopathy. The present morphological study investigates the incidence, radiological characteristics and non-radiological co-factors of bridging vein thrombosis (BVT) in infants with AHT. METHODS: From 2002 to 2013, computed tomography (CT) and magnetic resonance imaging (MRI) material of 628 infants aged 0-2 years were analysed retrospectively. If available, medicolegal expert opinions were additionally considered. Cases with SDHs and/or SDHys were identified and systematically evaluated as to the presence and characteristics of BVT. RESULTS: SDHs and/or SDHys were present in 29 of the 81 cases exhibiting morphological abnormalities in the initial CT. Among these, 11 cases (40%) had BVT (mean age = 5.0 months). BVT could be best depicted in the T1-weighted spin echo and T2*/susceptibility-weighted MRI. In one case, BVT could be depicted indirectly using time-of-flight MR venography. The predominant (73%) BVT shape was found to be tadpole-like ("Tadpole Sign"). CONCLUSIONS: In the absence of appropriate accidental trauma, BVT appears to be a strong indicator of AHT. Therefore, the BVT/Tadpole Sign represents compelling cause to search for other signs of AHT. KEY POINTS: • BVT is an excellent indicator of AHT in SDH/SDHy cases. • Accidental trauma must be ruled out before diagnosing AHT. • The Tadpole Sign appears to be the most characteristic shape of BVT. • BVT can be depicted using CT, MRI and MR venography. • The Tadpole Sign suggests searching for other signs of AHT.

Sixth cranial nerve palsy due to arachnoid cyst.

Sixth cranial nerve palsy is an extremely rare complication of an arachnoid cyst. A 4-year-old boy who presented with left abducens palsy and a subdural hygroma complicating arachnoid cyst is discussed. Comprehensive review of the world literature revealed only 12 additional cases.

Headache secondary to intracranial hypotension.

Intracranial hypotension is known to occur as a result of spinal cerebrospinal fluid (CSF) leaking, which may be iatrogenic, traumatic, or spontaneous. Headache is usually, but not always, orthostatic. Spontaneous cases are recognized more readily than in previous decades as a result of a greater awareness of clinical presentations and typical cranial magnetic resonance imaging findings. An underlying disorder of connective tissue that predisposes to weakness of the dura is implicated in spontaneous spinal CSF leaks. CT, MR, and digital subtraction myelography are the imaging modalities of choice to identify spinal CSF leakage. Spinal imaging protocols continue to evolve with improved diagnostic sensitivity. Epidural blood patching is the most common initial intervention for those seeking medical attention, and may be repeated several times. Surgery is reserved for cases that fail to respond or relapse after simpler measures. While the prognosis is generally good with intervention, serious complications do occur. More research is needed to better understand the genetics and pathophysiology of dural weakness as well as physiologic compensatory mechanisms, to continue to refine imaging modalities and treatment approaches, and to evaluate short- and long-term clinical outcomes.

Subdural hygroma accompanied by parenchymal and subarachnoid haemorrhage after epidural analgesia in an obstetric patient.

BACKGROUND: Anaesthetists need to know the different causes of persistent headache or a change in level of consciousness following epidural analgesia for labour. Failure to recognise these neurological complications can lead to delayed diagnoses, with subsequent serious implications. METHODS: We present a patient who was re-admitted for postural headache resulting from an unrecognised dural puncture during an epidural for pain relief while in labour. During the interview, the patient confirmed drug use (cocaine), so she was evaluated by a psychiatrist with possible post-partum psychosis or drug withdrawal syndrome. Afterwards, the patient deteriorated neurologically, showing impaired consciousness and seizures. RESULTS: The cranial computed tomography showed bilateral frontoparietal subdural collections with intraparenchymal and subarachnoid haemorrhaging. She improved by burr hole drainage of subdural hygroma and a blood patch. CONCLUSIONS: Neurological signs should alert the clinician to the possibility of subdural collection and other possible complications such as sinking of the brain in order not to delay the request for imaging tests for diagnoses and effective treatments.

Acute aggravation of subdural fluid collection associated with dural metastasis of malignant neoplasms: case report and review of the literature.

A 63-year-old woman was admitted to our hospital with serious headache and vomiting. Five months before admission, she had undergone surgery for a primary advanced gastric cancer. Neuroradiological examinations revealed subdural fluid collection. We twice performed evacuation of the subdural fluid collection. However, aggravation of her state of consciousness progressed and she passed away. Histological examinations demonstrated that the dural veins were infiltrated by numerous tumor cells that produced mucus; however, ruptured vessels were not found. Furthermore, the subdural fluid collection increased shortly after the initial operation. We infer that the cause of the collection, which was associated with the dural metastasis of malignant tumors, was not only mucin secretion by tumor cells but also a rapid increase in perfusion pressure in the vessels of the dura mater, resulting in extravasation of plasma components into the subdural space. Our case demonstrates that the pathogenetic mechanism that is specific for subdural fluid collection caused by dural metastasis of malignant tumors differs from the mechanism of production of subdural hematoma associated with dural metastasis.

Subdural effusions and lack of early pontocerebellar hypoplasia in siblings with RARS2 mutations.

Mutations in the recently described RARS2 gene encoding for mitochondrial arginyl-transfer RNA synthetase give rise to a disorder characterised by early onset seizures, progressive microcephaly and developmental delay. The disorder was named pontocerebellar hypoplasia type 6 (PCH6) based on the corresponding radiological findings observed in the original cases. We report two siblings with the RARS2 mutation who displayed typical clinical features of PCH6, but who had distinct neuroimaging features. Early scans showed marked supratentorial, rather than infratentorial, atrophy, and the pons remained preserved throughout. One sibling also had bilateral subdural effusions at presentation. The deceleration in head growth pointed to an evolving genetic/metabolic process giving rise to cerebral atrophy and secondary subdural effusions. RARS2 mutations should be considered in infants presenting with seizures, subdural effusions, decelerating head growth and evidence of cerebral atrophy even in the absence of pontocerebellar hypoplasia on imaging.

Floating dural sac sign is a sensitive magnetic resonance imaging finding of spinal cerebrospinal fluid leakage.

We would like to propose floating dural sac sign, which is observed as a hyperintense band or rim around the spinal dural sac on axial T2-weighted images, as a sensitive sign to identify cerebrospinal fluid (CSF) leakage. One hundred patients with orthostatic headache were prospectively registered in 11 hospitals. These patients were examined by brain magnetic resonance (MR) imaging (n = 89), radioisotope cisternography (n = 89), MR myelography (n = 86), axial T2-weighted imaging of the spine (n = 70), and computed tomography myelography (n = 2). In this study, we separately evaluated the imaging findings of intracranial hypotension and spinal CSF leakage. Among 100 patients, 16 patients were diagnosed as having spinal CSF leaks. Of 70 patients examined with axial T2-weighted imaging, 14 patients were diagnosed with spinal CSF leaks, and floating dural sac sign was observed in 17 patients, 13 patients with spinal CSF leaks and 4 without CSF leaks (sensitivity 92.9%, specificity 92.9%). Of 86 patients examined by MR myelography, extradural fluid was observed in only 3 patients (sensitivity 21.4%, specificity 100%). The floating dural sac sign was a sensitive sign that can be used to identify CSF leakage. Spinal axial T2-weighted imaging might be a good screening method for spinal CSF leakage that can help to avoid the need for lumbar puncture.