Subdural Hemorrhage as an Early Presentation in a Case of Sotos Syndrome.

Subdural hemorrhages (SDHs) in the pediatric population are associated with a high mortality and morbidity and may present in the context of abusive head trauma. Diagnostic investigations for such cases often include evaluation for rare genetic and metabolic disorders that can have associated SDH. Sotos syndrome is an overgrowth syndrome associated with macrocephaly and increased subarachnoid spaces and rarely with neurovascular complications. Here, we report two cases of Sotos syndrome, one with SDH during infancy who underwent repeated evaluation for suspected child abuse prior to the Sotos syndrome diagnosis and the other with enlarged extra-axial cerebrospinal fluid spaces, demonstrating a possible mechanism for SDH development in this setting. These cases suggest that some individuals with Sotos syndrome may be at elevated risk of developing SDH in infancy and that Sotos syndrome should be on the differential diagnosis during a medical genetics evaluation in cases of unexplained SDH, especially in the setting of macrocephaly.

The Long-Term Use of Diagnostic Subdural Electroencephalogram Electrodes and Subdural Hematoma: A Prospective Cohort Study.

OBJECTIVES: Seizures and status epilepticus (SE) are frequent complications of acute subdural hematoma (aSDH) associated with increased morbidity and mortality. Therefore, we aimed to evaluate whether invasive subdural electroencephalogram recording leads to earlier seizure detection and treatment initiation in patients with aSDH. DESIGN: Prospective, single-center, cohort trial. SETTING: Neurologic and neurosurgical ICUs of one academic hospital in Germany. PATIENTS: Patients with aSDH undergoing surgical treatment. In total, 76 patients were enrolled in this study, 31 patients (40.8%) were assigned to the invasive electroencephalogram (iEEG) monitoring group and 45 patients (59.2%) to control group. INTERVENTIONS: The electrode group was implanted with a subdural strip electrode providing up to 7 days of real-time electroencephalogram recording in the neurointensive care unit, whereas the control group received regular normal surface electroencephalograms during the 7-day period. The primary outcomes were the prevalence and time to seizures and SE occurrence. Secondary outcomes included neurologic outcomes assessed using the Glasgow Outcome Scale (GOS) at discharge and 6-month follow-up and the prevalence of focal structural epilepsy within 2 years after discharge. MEASUREMENTS AND MAIN RESULTS: The trial was stopped after a study committee meeting when the prespecified criteria were met. The iEEG and control groups were well-matched for clinical characteristics at admission. Frequencies of seizures and SE detection were significantly higher in the iEEG group than in the control group (61% vs 15.6%; p < 0.001 and 38.7% vs 11.1%; p = 0.005). Time to seizure and SE detection was significantly earlier (median 29.2 vs 83.8 hr; p = 0.018 and 17.2 vs 83.8 hr; p = 0.033) in the iEEG group than in the control group. Favorable outcomes (GOS 4-5) were more frequently achieved in the iEEG group than in the control group (58% vs 31%; p = 0.065). No significant differences were detected in long-term mortality or post-traumatic epilepsy. CONCLUSIONS: Invasive subdural electroencephalogram monitoring is valuable and safe for early seizure/SE detection and treatment and might improve outcomes in the neurocritical care of patients with aSDH.

Examining diagnostic variability among pediatric subspecialists using case examples of infant head injury.

BACKGROUND: Although there is research regarding the diagnosis and timing of abusive head trauma, there remains practice variation among pediatric subspecialists. OBJECTIVES: To examine diagnostic variability among pediatric subspecialists using case examples of infant head injury. Secondary objectives were timing variability among subspecialists, and diagnostic and timing variability among Child Abuse Pediatricians (CAPs). PARTICIPANTS AND SETTING: Pediatric subspecialists were recruited from Child Abuse Pediatrics, Hospital Medicine, Emergency Medicine, Critical Care, and Neurosurgery to complete a research instrument. Participants qualified for the study if they evaluated at least 1 case of possible abusive head trauma during their career. METHODS: This multi-institutional, mixed-methods study used a research instrument with 4 case examples of infant head injury: severe retinal hemorrhages (RH), mass-effect subdural hemorrhage (SDH), SDH membrane formation, and sepsis. The response selected by most CAPs was reference and compared across subspecialties and among CAPs using Chi-square or Fisher's exact tests. A Bonferroni correction (p < 0.01) was used for subspecialty comparisons. RESULTS: There were 288 participants who completed at least 1 case example. Diagnostic variability was observed in all case examples. Significantly fewer Hospital Medicine (34.9 % vs. 57.9 %, p < 0.01), Emergency Medicine (28.0 % vs. 57.9 %, p < 0.0001), and Neurosurgery (24.0 % vs. 57.9 %, p < 0.01) participants selected the reference response for the mass-effect SDH case example. Timing variability was statistically significant for all case examples (p < 0.01). Significantly fewer CAPs aged 44-64 years selected the reference response for timing (p < 0.01) for the severe RH case example. CONCLUSIONS: Additional peer review processes and consensus guidelines for challenging issues in abusive head trauma may be beneficial.

Subdural hemorrhages and severe retinal hemorrhages in a short fall with a rotational component.

We present the case of a 5-month-old referred for child abuse investigation with subdural hemorrhages and extensive retinal hemorrhages following a short fall from a swivel chair seen on video footage. Subdural hemorrhages with extensive retinal hemorrhages are not typically seen as the result of short household falls. Reviewing the footage, contributing factors may have included increased rotational and deceleration forces.

Application of deep learning models for detection of subdural hematoma: a systematic review and meta-analysis.

BACKGROUND: This study aimed to investigate the application of deep learning (DL) models for the detection of subdural hematoma (SDH). METHODS: We conducted a comprehensive search using relevant keywords. Articles extracted were original studies in which sensitivity and/or specificity were reported. Two different approaches of frequentist and Bayesian inference were applied. For quality and risk of bias assessment we used Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). RESULTS: We analyzed 22 articles that included 1,997,749 patients. In the first step, the frequentist method showed a pooled sensitivity of 88.8% (95% confidence interval (CI): 83.9% to 92.4%) and a specificity of 97.2% (95% CI 94.6% to 98.6%). In the second step, using Bayesian methods including 11 studies that reported sensitivity and specificity, a sensitivity rate of 86.8% (95% CI: 77.6% to 92.9%) at a specificity level of 86.9% (95% CI: 60.9% to 97.2%) was achieved. The risk of bias assessment was not remarkable using QUADAS-2. CONCLUSION: DL models might be an appropriate tool for detecting SDHs with a reasonably high sensitivity and specificity.

Multisystem inflammatory syndrome in a neonate with severe hemophilia - a diagnostic challenge in COVID times: a case report.

BACKGROUND: Multisystem Inflammatory Syndrome in Neonates (MIS-N) can occur following antenatal COVID- 19 infection in the mother. Here we report a rare case of a neonate with Hemophilia A and MIS-N. CASE PRESENTATION: A 2-day-old baby presented with an intramuscular hematoma, neonatal seizures, and isolated activated partial thromboplastin time (APTT) prolongation. The neurosonogram showed a subdural hematoma. A diagnosis of Hemophilia A was made and was confirmed by factor 8 assay and genetic analysis. Supportive measures and Factor 8 replacement was initiated. A rising trend of inflammatory markers and an ongoing need for mechanical ventilation were noted. As there was a history of COVID-19 in the mother in the third trimester, MIS-N was diagnosed. The baby was treated with intravenous immunoglobulin (IVIG) and steroids, and there was an improvement in the clinical and laboratory markers. However, the baby developed seizures on day 16. There was an increase in the subdural hemorrhage and a further rise in inflammatory markers. A craniostomy and hematoma evacuation was done and the baby improved. CONCLUSION: The concurrent occurrence of hemophilia A with intracranial bleed, and MIS-N in a neonate is a diagnostic challenge. It is important to have a high index of suspicion to ensure timely diagnosis and treatment of MIS-N in this pandemic era.

Pathogenic variant in NFIA associated with subdural hematomas mimicking nonaccidental trauma.

Subdural hematoma (SDH) in infants raises the concern for nonaccidental trauma (NAT), especially when presenting with associated injuries. However, isolated SDH could be caused by multiple etiologies. NFIA (MIM# 600727) encodes nuclear factor I A protein (NFI-A), a transcription factor which plays important roles in gliogenesis. Loss-of-function variants in NFIA are associated with autosomal dominant brain malformations with or without urinary tract defects (MIM# 613735). Intracranial hemorrhage of various types besides SDH has been reported in patients with this condition. Here, we report a patient with a heterozygous novel NFIA pathogenic variant affecting splicing who initially presented with SDH concerning for NAT. We also review previous NFIA-related disorder cases with intracranial hemorrhage. This report emphasizes the importance of genetic evaluation in infants presenting with isolated SDH.

Spontaneous Intracranial Hypotension in the Critical Patient.

Spontaneous intracranial hypotension typically manifests with orthostatic headaches and is caused by spinal dural tears, ruptured meningeal diverticula, or CSF-venous fistulas. While most patients are diagnosed and treated in the outpatient setting, some patients will occasionally present in the emergent ICU setting due to subdural hematomas, coma, or downward brain herniation. In this review paper, we will discuss the diagnostic and treatment steps that intensivists can undertake to coordinate a team approach to successfully manage these patients. A brief general overview of spontaneous intracranial hypotension will also be discussed.

Predictors of Mortality, Withdrawal of Life-Sustaining Measures, and Discharge Disposition in Octogenarians with Subdural Hematomas.

OBJECTIVE: Risk factors for mortality in patients with subdural hematoma (SDH) include poor Glasgow Coma Scale (GCS) score, pupil nonreactivity, and hemodynamic instability on presentation. Little is published regarding prognosticators of SDH in the elderly. This study aims to examine risk factors for hospital mortality and withdrawal of life-sustaining measures in an octogenarian population presenting with SDH. METHODS: A prospectively collected multicenter database of 3279 traumatic brain injury admissions to 45 different U.S. trauma centers between 2017 and 2019 was queried to identify patients aged >79 years old presenting with SDH. Factors collected included baseline demographic data, past medical history, antiplatelet/anticoagulant use, and clinical presentation (GCS, pupil reactivity, injury severity scale [ISS]). Primary outcome data included hospital mortality/discharge to hospice care and withdrawal of life-sustaining measures. Multivariate logistic regression analyses were used to identify factors independently associated with primary outcome variables. RESULTS: A total of 695 patients were isolated for analysis. Of the total cohort, the rate of hospital mortality or discharge to hospice care was 22% (n = 150) and the rate of withdrawal of life-sustaining measures was 10% (n = 66). A multivariate logistic regression model identified GCS <13, pupil nonreactivity, increasing ISS, intraventricular hemorrhage, and neurosurgical intervention as factors independently associated with hospital mortality/hospice. Congestive heart failure (CHF), hypotension, GCS <13, and neurosurgical intervention were independently associated with withdrawal of life-sustaining measures. CONCLUSIONS: Poor GCS, pupil nonreactivity, ISS, and intraventricular hemorrhage are independently associated with hospital mortality or discharge to hospice care in patients >80 years with SDH. Pre-existing CHF may further predict withdrawal of life-sustaining measures.

Hematoma subdural diagnosticado como ingesta medicamentosa en paciente con esquizofrenia / Subdural haematoma diagnosed as drug ingestion in patient with schizophrenia

Objetivo: Subrayar la importancia de una exploración exhaustiva para el diagnóstico de procesos intraparenquimatosos en pacientes con antecedentes de patología psiquiátrica. Caso clínico Varón de 56 años con antecedentes de esquizofrenia ingresado a urgencias por somnolencia, dificultad para la deambulación y temblor de miembro superior derecho. Se sospecha por medicina interna, de secundarismos neurológicos tras intento autolítico mediante ingesta farmacológica. Resultados Tras la exploración del estado mental por psiquiatría, se amplía el estudio mediante tomografía axial computarizada (TC) que revela un hematoma subdural agudo (HSA). La atrofia cortical en pacientes con esquizofrenia predispone a la acumulación de sangre intracerebral y al retardo en los síntomas y el diagnóstico de estos procesos aumentando el riesgo vital. Conclusiones Es fundamental una correcta anamnesis y la inclusión de pruebas de imagen cerebrales para el diagnóstico diferencial del HSA en pacientes con esquizofrenia. (AU)

Objective: To underline the importance of thorough examination in diagnosing intraparenchymal processes in patients with a history of psychiatric disease. Clinical case A 56-year-old male with a history of schizophrenia was taken to the emergency department with somnolence, difficulty in walking and right-arm tremor. The internal medicine department suspected to be secondary neurological symptoms after attempted to self-harm through ingestion of drugs. Results After the psychiatric department had examined the patient's mental state, a CT scan was performed that revealed an acute subdural haematoma (ASH). Cortical atrophy in patients with schizophrenia favours the accumulation of intracerebral blood and a delay in the symptoms and diagnosis of these processes, increasing the risk to life. Conclusions Accurate anamnesis and brain imaging tests are essential for the differential diagnosis of ASH in patients with schizophrenia. (AU)

Outcomes of patients with nonepileptic transient neurologic symptoms after subdural hematoma evacuation.

BACKGROUND: Patients undergoing a subdural hematoma (SDH) evacuation can experience transient neurological symptoms (TNS) postoperatively. Electroencephalography (EEG) is used to rule out seizures. We aim to characterize patients with TNS and negative epileptiform activity on EEG and compare them to those with positive epileptiform EEG findings. METHODS: We performed a retrospective study of adult patients who underwent EEG for evaluation of TNS after undergoing SDH evacuation. Patients were stratified based on SDH type (acute and non-acute) and whether or not their EEG demonstrated positive epileptiform activity. A multivariate analysis was performed to identify predictors of negative EEG findings. RESULTS: One hundred twenty-nine SDH patients were included (45 (34.9%) acute; 84 (65.1%) non-acute). Overall, 45 (24 acute and 21 non-acute SDH patients) had positive epileptiform EEG findings, and 84 (21 acute and 63 non-acute SDH patients) had a negative EEG. Acute and non-acute SDH patients with positive EEG findings were more likely to suffer from greater than five episodes of TNS, impaired awareness, and motor symptoms, while the negative EEG group was more likely to suffer from negative symptoms. Non-acute SDH patients with positive EEG had longer mean ICU stays (14.6 vs. 7.2; p = 0.005). Both acute and non-acute SDH-positive EEG patients had worse disposition upon discharge (p < 0.05), worse modified Rankin score at discharge (p < 0.05), and 3-month follow-up (p < 0.05) and were more likely to be discharged on more than one antiepileptic drug (p < 0.001). CONCLUSION: Postoperative acute and non-acute SDH patients with TNS and negative EEG results are likely to have a favorable clinical picture. This distinction is therapeutically and prognostically important as these patients may not respond to typical antiepileptic drugs and they have better functional outcomes.

Subdural Hematoma Presenting as Psychogenic Nausea.

Psychogenic nausea refers to nausea symptoms that are experienced outside of the context of obvious general medical pathology and presumably as a result of psychiatric etiology. Although this dichotomy between general medical and psychiatric pathology is somewhat dated according to the focus of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) Somatic Symptom Disorders, the psychogenic description of a medically unexplained symptom is still commonly used in the general medical vernacular. This case report involved a 74-year-old man who was presumed to have "psychogenic" nausea symptoms after a negative medical workup. New tremulous symptoms were presumed to be secondary to a benzodiazepine taper. However, the presence of additional focal neurological deficits prompted a computed tomography of the patient's head, which revealed a subdural hematoma. Emergent neurosurgical evacuation and drainage relieved the patient's symptoms and proved to be a life-saving measure. Subdural hematomas are most commonly the result of traumatic tearing of the cortical bridging veins that overlie this subdural space. Subsequent mass effect and ischemia from venous bleeding can cause multiple symptoms, including nausea. This case highlights the importance of ensuring a broad differential for medically unexplained symptoms and close monitoring of symptomatic changes.

[Effectiveness of treatment of elderly patients with traumatic brain injury complicated by subdural hematoma.]

The work is based on the results of a retrospective analysis of the medical records of 56 patients with traumatic brain injury complicated by acute subdural hematoma with a volume of 60-100 cm3. The patients were divided into 2 groups according to their age: the 1st group included 29 patients aged 22-29 years, the 2nd group consisted of 27 patients aged 61-69 years. The degree of impaired consciousness in the victims at admission to the clinic was evaluated on the Glasgow scale, the effectiveness of the treatment at discharge from the hospital was performed on the Rankin scale, assessing the degree of independence and disability. Elderly patients were found to have a more severe condition upon admission to the clinic. Upon discharge from the hospital, the assessment of the degree of independence and disability on the Rankin scale revealed a statistically significant predominance of scores in the group of elderly patients (p<0,01), which indicates less effective treatment in comparison with young patients. The results of this study can serve as a basis for the development of additional recommendations in outpatient practice for the care and care of patients in the older age group and a personalized approach to neurosurgical patients taking into account their age.

Subdural Hygroma in an Infant with Marfan's Syndrome.

Based on a patient encounter in which genetically confirmed Marfan's syndrome (MFS) underlay a spontaneously resolving subdural hygroma (SDHy) diagnosed in infancy, we review the literature of MFS clinically manifest in early life (early-onset MFS [EOMFS]) and of differential diagnoses of SDHy and subdural hemorrhage (SDHe) at this age. We found that rare instances of SDHy in the infant are associated with EOMFS. The most likely triggers are minimal trauma in daily life or spontaneous intracranial hypotension. The differential diagnosis of etiologies of SDHy include abusive and nonabusive head trauma, followed by perinatal events and infections. Incidental SDHy and benign enlargement of the subarachnoid spaces must further be kept in mind. SDHy exceptionally also may accompany orphan diseases. Thus, in the infant, EOMFS should be considered as a cause of SDHe and/or SDHy. Even in the absence of congestive heart failure, the combination of respiratory distress syndrome, muscular hypotonia, and joint hyperflexibility signals EOMFS. If EOMFS is suspected, monitoring is indicated for development of SDHe and SDHy with or without macrocephaly. Close follow-up is mandatory.

Pitfalls in the diagnosis of subdural hemorrhage - Mimics and uncommon causes.

PURPOSE: Subdural hemorrhage (SDH), the accumulation of blood between the dura and arachnoid mater, is one of the most commonly encountered traumatic findings in emergency radiology setting. The purpose of this essay is to review the pitfalls in the diagnosis of SDH including a) mimics on CT imaging and b) etiology other than accidental trauma. We describe several entities that closely mimic SDH on non-contrast CT scans. A knowledge of these mimics is essential in the emergency setting since overdiagnosis of SDH can lead to unnecessary hospital admissions, potentially invasive procedures, or even delay in necessary treatment. The mimics of SDH on non-contrast head CT include: PATHOLOGIC ENTITIES IATROGENIC MIMICS ANATOMIC/PHYSIOLOGIC MIMICS ARTIFACTUAL MIMICSWe also briefly review non-accidental and non-traumatic causes of SDH. Although, the most common cause of SDH is accidental trauma, other routinely encountered causes of SDH include coagulopathy, non-accidental trauma, cranial surgery, vascular malformations etc. CONCLUSION: Clinicians dealing with SDH in the emergency setting should consider SDH mimics and less common etiologies of SDH in order to facilitate appropriate patient management.

Subdural haematoma, the great imitator, mimicking acute spinal cord lesion.

Acute non-traumatic paraparesis is usually caused by vascular, inflammatory or neoplastic myelopathies; however, it is sometimes caused by non-myelopathic pathologies, including polyradiculoneuropathies, myopathies, psychogenic aetiologies or parasagittal cortical pathologies. A 73-year-old woman reported weakness of the bilateral lower limbs and urinary incontinence. Together with the sensory level at the left T6 dermatome, we initially considered thoracic myelopathy as the most likely diagnosis. However, MRI of the cervicothoracic cord was negative and subsequent cranial CT revealed a bilateral subdural haematoma. A parasagittal cortical pathology should not be excluded from differential diagnoses as a rare cause of paraparesis until its possibility is carefully ruled out.

Shaken baby syndrome resulting in death: a case series.

BACKGROUND: The aim of this study was to raise the awareness of all healthcare personnel, primarily Emergency Department physicians, forensic physicians, and paediatricians about cases of shaken baby syndrome (SBS), which can be difficult to diagnose, require a high level of suspicion in diagnosis and there is a high likelihood of missed diagnosis. METHODS: A retrospective examination was made of 3400 forensic cases applied with autopsy between 2012 and 2018 to the Forensic Medicine Institution of Malatya Group Directorate. RESULTS: Of the total cases, 113 were aged < 2 years and head trauma was determined in 35. Eight cases were determined as SBS. Of the 8 cases that resulted in death, 75% were male and the mean age was 8.3 months. The trauma had been perpetrated by the father in 50% of cases. There was a history of seizure in 67.5% of the infants and 75% were taken to the Emergency Department with cardiopulmonary arrest. Subdural hematoma and subarachnoid hemorrhage were determined in 37.5% of the cases, subdural hematoma, subarachnoid hemorrhage and intracranial hemorrhage in 50%, and epidural hemorrhage and subarachnoid hemorrhage in 12.5%. In the microscopic examination of the medulla spinalis, focal subdural fresh bleeding was seen in 50% of cases. Bleeding around the optic nerves was determined in 37.5% of cases bilaterally and in 37.5% unilaterally. Retinal hemorrhage was determined in all the cases, which was bilateral in 75%. CONCLUSIONS: The actual worldwide incidence of SBS is not known, and in Turkey, it is thought to be much higher than has been determined. The most important reason for this is thought to be that the diagnosis of child abuse is difficult and physicians do not have a sufficient level of knowledge.

Neonatal Ureaplasma parvum meningitis complicated with subdural hematoma: a case report and literature review.

BACKGROUND: Neonatal meningitis is a severe infectious disease of the central nervous system with high morbidity and mortality. Ureaplasma parvum is extremely rare in neonatal central nervous system infection. CASE PRESENTATION: We herein report a case of U. parvum meningitis in a full-term neonate who presented with fever and seizure complicated with subdural hematoma. After hematoma evacuation, the seizure disappeared, though the fever remained. Cerebrospinal fluid (CSF) analysis showed inflammation with CSF pleocytosis (1135-1319 leukocytes/µl, mainly lymphocytes), elevated CSF protein levels (1.36-2.259 g/l) and decreased CSF glucose (0.45-1.21 mmol/l). However, no bacterial or viral pathogens in either CSF or blood were detected by routine culture or serology. Additionally, PCR for enteroviruses and herpes simplex virus was negative. Furthermore, the CSF findings did not improve with empirical antibiotics, and the baby experienced repeated fever. Thus, we performed metagenomic next-generation sequencing (mNGS) to identify the etiology of the infection. U. parvum was identified by mNGS in CSF samples and confirmed by culture incubation on mycoplasma identification medium. The patient's condition improved after treatment with erythromycin for approximately 5 weeks. CONCLUSIONS: Considering the difficulty of etiological diagnosis in neonatal U. parvum meningitis, mNGS might offer a new strategy for diagnosing neurological infections.