Chronic Calcified Subdural Hematoma: Case Report and Review of the Literature

Background: Calcified chronic subdural hematoma is a rare but known entity, estimated to represent 0.3-2.7% of chronic subdural hematomas. Although surgical treatment is unanimous for chronic subdural hematomas, therein lies some doubt on it being applied to calcified chronic subdural hematomas. Case Description: We report a case of a 73‑year‑old male, presenting with deterioration of motor function in his right limbs since 18 months, with computed tomography (CT) scans and magnetic resonance imaging (MRI) documenting a large subdural collection of the left hemisphere, with calcified inner membrane, which was successfully and completely removed, with progressive clinical and radiological improvement. Conclusions: We report a case where this type of rare lesion was removed with a progressive and complete resolution of the patient’s symptoms, restoring his previous neurological condition. From the cases described in the literature and our own experience with this case, we think surgical treatment in these patients, when symptomatic, is necessary and viable, frequently resulting in the patient’s improvement.

Hematoma Subdural em Pediatria Diagnosticar e Tratar Precocemente

Introdução: O hematoma subdural agudo não traumático é uma entidade rara em Pediatria. A presença de sintomas neurológicos de instalação aguda associada a anti coagulação obriga à exclusão desta entidade. Caso clínico: Apresentamos o caso de uma criança, do sexo masculino, de sete anos de idade, com prótese mitral mecânica, medicada com varfarina, que recorreu ao serviço de urgência por cefaleias intensas e progressivas, associadas a alteração no estado de consciência e convulsões. A nível laboratorial o INR (International Normalized Ratio) era de 4,2. Foi admitida na Unidade de Cuidados Intensivos Pediátricos (UCIP) em coma com anisocoria. Iniciou ventilação mecânica, medidas anti-edema cerebral e antiepilépticos. O exame de imagem mostrou hematoma subdural agudo à esquerda, com desvio da linha média. Foi submetida a craniotomia descompressiva, 56 horas após o início da sintomatologia, com recuperação clínica e actualmente sem sequelas. Conclusão: Este caso clínico ilustra a importância da suspeição clínica de hematoma subdural em doentes anti coagulados, bem como a necessidade de optimização das condições cirúrgicas e da utilização das técnicas não invasivas na monitorização do nível de consciência.

Hematoma subdural de medula espinhal associada ao uso de anticoagulante oral

O hematoma subdural de medula espinhal (HSDME) é uma complicação rara decorrente do uso de antagonistas de vitamina K (AVK) e de diagnostico difícil. Este artigo apresenta um caso com complicação ameaçadora à vida: um paciente octogenário portador de fibrilação atrial de início recente em uso de AVK. A história e o exame físico inicialmente se apresentavam normais, associados com a elevação dos valores de coagulograma supraterapêuticos (INR > 10). Após 24 horas da admissão hospitalar, o paciente apresentou tetraparesia progressiva, evidenciando na ressonância nuclear magnética (RNM) de medula espinhal um HSDME (Figura 1). Após reversão completa da hipocoagulação e intervenção neurocirúrgica o paciente obteve melhora do quadro neurológico.

Performance of fixed-pressure valve with antisiphon device SPHERA (R) in hydrocephalus treatment and overdrainage prevention

Patients with hydrocephalus and risk factors for overdrainage may be submitted to ventricular shunt (VS) implant with antisiphon device. The objective of this study was to prospectively evaluate for two years the clinical and tomographic results of the implant of fixed-pressure valves with antisiphon device SPHERA (R) in 35 adult patients, with hydrocephalus and risk factors for overdrainage. Of these, 3 had congenital hydrocephalus in adult patients with very dilated ventricles (Evans index >50%), 3 had symptomatic overdrainage after previous VS implant (subdural hematoma, hygroma or slit ventricle syndrome), 1 had previous chronic subdural hematoma, 15 had normal pressure hydrocephalus with final lumbar pressure <5 cm H2O after tap test (40 mL), 6 had pseudotumor cerebri, and 7 had hydrocephalus due to other causes. Clinical improvement was observed and sustained in 94.3% of the patients during the two-year period with no computed tomography (CT) evidence of hypo or overdrainage, and no immediate early or late significant complications.

Chronic subdural hematoma: epidemiological and prognostic analysis of 176 cases

Objective : To characterize patients with chronic subdural hematoma undergoing surgery and to identify prognostic indicators. Methods : We conducted a retrospective analysis of patients diagnosed with chronic subdural hematoma (CSDH) undergoing surgical treatment. We analyzed: age, period from trauma to diagnostic imaging, pre and postoperative Glasgow coma scale, type of surgery, associated comorbidities, use of postoperative drainage and outpatient treatment. Results : The sample consisted of 176 patients, 126 male and 50 female patients (ratio 2.5 : 1), ages ranged from six months to 97 years, with an average of 59.3 years. CSDH was caused by trauma in 52% of patients, with the time from trauma to imaging averaging 25.05 days; 37.7% were hypertensive patients and 20% had a neurological disease. Eighty-five (48.3%) patients were elderly and altered consciousness was present in 63% of cases. Of the 91 (51.7%) non-elderly patients, 44% presented with headache, altered consciousness occurred in 40% and motor abnormalities in 27.5%. The CSDH was located on the right in 41%, left in 43% and bilaterally in 16% of patients. Conclusion : the change of consciousness was the most common clinical alteration in the elderly and headache in non-elderly. The most associated comorbidity was the arterial hypertension and the most frequent cause, head trauma. The trepanation with two oriffices associated with a closed drainage system was the most used operating, with high efficacy and low complication rate.

Chronic subdural hematomas treated by burr hole trepanation and a subperiostal drainage system.

OBJECTIVE: Most symptomatic chronic subdural hematomas are treated by subdural drainage. However, a subperiostal (i.e., extracranial) passive closed-drainage system in combination with double burr hole trepanation is used at our institution. Therefore, we wanted to analyze our results and compare them with the alternate treatment strategies reported in the current literature. METHODS: In a retrospective single-center study, we analyzed the data of all patients undergoing double burr hole trepanation with a subperiostal passive closed-drainage system. Data analysis included general patient data, complications, postoperative seizure rate, and outcome. RESULTS: One hundred forty-seven patients underwent surgery for 183 symptomatic chronic subdural hematomas. The perioperative mortality rate was 3.4%. Hematoma persistence or recurrence occurred in 13.1% of the cases. The postoperative seizure rate was 6.6%, and the infection rate was 1.6%, including 3 cases of superficial wound infection and 1 case with deep infection. The reintervention rate was 9.3%, including trepanation in 8.2% of the patients and craniotomy in 1.1%. The overall complication rate was 10.9%. CONCLUSION: Double burr hole trepanation combined with a subperiostal passive closed-drainage system is a technically easy, highly effective, safe, and cost-efficient treatment strategy for symptomatic chronic subdural hematomas. The absence of a drain in direct contact with the hematoma capsule may moderate the risk of postoperative seizure and limit the secondary spread of infection to intracranial compartments.

A Standardized Classification for Subdural Hematomas- I

Subdural hematomas are a frequent and highly heterogeneous traumatic disorder, with significant clinical and socioeconomic consequences. In clinical and medicolegal practice, subdural hematomas are classified according to its apparent age, which significantly influences its intrinsic pathogenic behavior, forensic implications, clinical management, and outcome. Although practical, this empirical classification is somewhat arbitrary and scarcely informative, considering the remarkable heterogeneity of this entity. The current research project aims at implementing a comprehensive multifactorial classification of subdural hematomas, allowing a more standardized and coherent assessment and management of this condition. This new method of classification of subdural hematomas takes into account its intrinsic and extrinsic features, using imaging data and histopathological elements, to provide an easily apprehensible and intuitive nomenclature. The proposed classification unifies and organizes all relevant details concerning subdural hematomas, hopefully improving surgical care and forensic systematization.

A Standardized Classification for Subdural Hematomas- I

Subdural hematomas are a frequent and highly heterogeneous traumatic disorder, with significant clinical and socioeconomic consequences. In clinical and medicolegal practice, subdural hematomas are classified according to its apparent age, which significantly influences its intrinsic pathogenic behavior, forensic implications, clinical management, and outcome. Although practical, this empirical classification is somewhat arbitrary and scarcely informative, considering the remarkable heterogeneity of this entity. The current research project aims at implementing a comprehensive multifactorial classification of subdural hematomas, allowing a more standardized and coherent assessment and management of this condition. This new method of classification of subdural hematomas takes into account its intrinsic and extrinsic features, using imaging data and histopathological elements, to provide an easily apprehensible and intuitive nomenclature. The proposed classification unifies and organizes all relevant details concerning subdural hematomas, hopefully improving surgical care and forensic systematization.

Early vitamin K deficiency bleeding after maternal phenobarbital intake: management of massive intracranial haemorrhage by minimal surgical intervention.

Vitamin K deficiency bleeding within the first 24 h of life is caused in most cases by maternal drug intake (e.g. coumarins, anticonvulsants, tuberculostatics) during pregnancy. Haemorrhage is often life-threatening and usually not prevented by vitamin K prophylaxis at birth. We report a case of severe intracranial bleeding at birth secondary to phenobarbital-induced vitamin K deficiency and traumatic delivery. Burr hole trepanations of the skull were performed and the subdural haematoma was evacuated. Despite the severe prognosis, the infant showed an unexpected good recovery. At the age of 3 years, neurological examinations were normal as was the EEG at the age of 9 months. CT showed close to normal intracranial structures. CONCLUSION: This case report stresses the importance of antenatal vitamin K prophylaxis and the consideration of a primary Caesarean section in maternal vitamin K deficiency states and demonstrates the successful management of massive subdural haemorrhage by a limited surgical approach.

Kernohan's notch and misdiagnosis of disorders of consciousness.

A 69-year-old man presented with a sudden headache followed by unconsciousness. There was no head injury. The Glasgow Coma Scale (GCS) score was 3/15 and there was a left mydriasis, unreactive to light. The CT-scan showed a left acute subdural haematoma causing a remarkable mass effect. A supratentorial hemispheric craniotomy was performed. Nevertheless, after several weeks at the intensive care unit (ICU), the patient was still unresponsive to external stimuli and did not show any motor activity. A comfort care attitude was decided on with the family and the patient was extubated. However, a few days later, the patient subsequently showed a surprisingly favourable course, with improved wakefulness. Indeed, the GCS score improved, and the treatment plan was modified so that the patient benefited from rehabilitation. The MRI showed a right cerebral peduncle lesion, consistent with a Kernohan-Woltman notch phenomenon (KWNP). Six months later, the patient was able to walk and live quite normally.

Avaliação da pressão liquórica em pacientes obstétricas submetidas à anestesia subaracnoidea que apresentaram cefaleia pós-punção dural

Pós-graduação em Anestesiologia - FMB

Acute subdural hematoma from ruptured cerebral aneurysm

The combination of ruptured aneurysms with acute subdural hematomas (aSDHs) is a rare presentation. Patients with aSDH associated with aneurysmal bleeding represent a subgroup within the spectrum of aneurysmatic hemorrhage. We summarize the clinical characteristics, diagnostic evaluation, and management of a series of cases presenting with aSDH associated with aneurysmal subarachnoid hemorrhage (SAH).