Medicine › Neurology

Neurosurgical Procedures and Complications

Works Count: 27983

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Description

This cluster of papers focuses on cerebrospinal fluid disorders, including spontaneous spinal cerebrospinal fluid leaks, intracranial hypotension, and chronic subdural hematoma. It explores the pathophysiology, surgical management, risk factors, recurrence predictors, and potential pharmacotherapies for these conditions. Connective tissue disorders and angiogenesis are also highlighted as relevant factors. The cluster encompasses a wide range of research on diagnosis, treatment, and outcomes related to cerebrospinal fluid disorders and hematomas.

Keywords

Cerebrospinal Fluid Leaks; Intracranial Hypotension; Chronic Subdural Hematoma; Spontaneous CSF Leaks; Connective Tissue Disorders; Middle Meningeal Artery Embolization; Epidural Blood Patch; Anticoagulant Therapy; Angiogenesis; Surgical Management

Chronic subdural hematoma in the elderly: not a benign disease

2010-09-24

Lucas Bernardes Miranda , Ernest Braxton , Joseph Hobbs +1 more

Chronic subdural hematoma (CSDH) is perceived to be a "benign," easily treated condition in the elderly, but reported follow-up periods are brief, usually limited to acute hospitalization.The authors conducted a … Chronic subdural hematoma (CSDH) is perceived to be a "benign," easily treated condition in the elderly, but reported follow-up periods are brief, usually limited to acute hospitalization.The authors conducted a retrospective review of data obtained in a prospectively identified consecutive series of adult patients admitted to their institution between September 2000 and February 2008 and in whom there was a CT diagnosis of CSDH. Survival data were compared to life-table data.Of the 209 cases analyzed, 63% were men and the mean age was 80.6 years (range 65-96 years). Primary surgical interventions performed were bur holes in 21 patients, twist-drill closed-system drainage in 44, and craniotomies in 72. An additional 72 patients were simply observed. Reoperations were recorded in 5 patients-4 who had previously undergone twist-drill drainage and 1 who had previously undergone a bur hole procedure (p = 0.41, chi-square analysis). Thirty-five patients (16.7%) died in hospital, 130 were discharged to rehabilitation or a skilled care facility, and 44 returned home. The follow-up period extended to a maximum of 8.3 years (median 1.45 years). Six-month and 1-year mortality rates were 26.3% and 32%, respectively. In the multivariate analysis (step-wise logistic regression), the sole factor that predicted in-hospital death was neurological status on admission (OR 2.1, p = 0.02, for each step). Following discharge, the median survival in the remaining cohort was 4.4 years. In the Cox proportional hazards model, only age (hazard ratio [HR] 1.06/year, p = 0.02) and discharge to home (HR 0.24, p = 0.01) were related to survival, whereas the type of intervention, whether surgery was performed, size of subdural hematoma, amount of shift, bilateral subdural hematomas, and anticoagulant agent use did not affect the long- or short-term mortality rate. Comparison of postdischarge survival and anticipated actuarial survival demonstrated a markedly increased mortality rate in the CSDH group (median survival 4.4 vs 6 years, respectively; HR 1.94, p = 0.0002, log-rank test). This excess mortality rate was also observed at 6 months postdischarge with evidence of normalization only at 1 year.In this first report of the long-term outcome of elderly patients with CSDH the authors observed persistent excess mortality up to 1 year beyond diagnosis. This belies the notion that CSDH is a benign disease and indicates it is a marker of other underlying chronic diseases similar to hip fracture.

Chronic subdural hematoma: a systematic review and meta-analysis of surgical procedures

2014-07-04

Weiming Liu , Nicolaas A. Bakker , Rob J. M. Groen

Object In this paper the authors systematically evaluate the results of different surgical procedures for chronic subdural hematoma (CSDH). Methods The MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and … Object In this paper the authors systematically evaluate the results of different surgical procedures for chronic subdural hematoma (CSDH). Methods The MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and other databases were scrutinized according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement, after which only randomized controlled trials (RCTs) and quasi-RCTs were included. At least 2 different neurosurgical procedures in the management of chronic subdural hematoma (CSDH) had to be evaluated. Included studies were assessed for the risk of bias. Recurrence rates, complications, and outcome including mortality were taken as outcome measures. Statistical heterogeneity in each meta-analysis was assessed using the T 2 (tau-squared), I 2 , and chi-square tests. The DerSimonian-Laird method was used to calculate the summary estimates using the fixed-effect model in meta-analysis. Results Of the 297 studies identified, 19 RCTs were included. Of them, 7 studies evaluated the use of postoperative drainage, of which the meta-analysis showed a pooled OR of 0.36 (95% CI 0.21–0.60; p < 0.001) in favor of drainage. Four studies compared twist drill and bur hole procedures. No significant differences between the 2 methods were present, but heterogeneity was considered to be significant. Three studies directly compared the use of irrigation before drainage. A fixed-effects meta-analysis showed a pooled OR of 0.49 (95% CI 0.21–1.14; p = 0.10) in favor of irrigation. Two studies evaluated postoperative posture. The available data did not reveal a significant advantage in favor of the postoperative supine posture. Regarding positioning of the catheter used for drainage, it was shown that a frontal catheter led to a better outcome. One study compared duration of drainage, showing that 48 hours of drainage was as effective as 96 hours of drainage. Conclusions Postoperative drainage has the advantage of reducing recurrence without increasing complications. The use of a bur hole or twist drill does not seem to make any significant difference in recurrence rates or other outcome measures. It seems that irrigation may lead to a better outcome. These results may lead to more standardized procedures.

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Painful ophthalmoplegia

1961-01-01

William E. Hunt , John N. Meagher , Harry E. LeFever +1 more

CLINICAL FEATURES OF SPINAL VASCULAR MALFORMATIONS

1974-01-01

M. J. Aminoff , Valentine Logue

Journal Article CLINICAL FEATURES OF SPINAL VASCULAR MALFORMATIONS Get access M. J. AMINOFF, M. J. AMINOFF National Hospital for Nervous Diseases, Maida Vale HospitalLondon W9 Search for other works by … Journal Article CLINICAL FEATURES OF SPINAL VASCULAR MALFORMATIONS Get access M. J. AMINOFF, M. J. AMINOFF National Hospital for Nervous Diseases, Maida Vale HospitalLondon W9 Search for other works by this author on: Oxford Academic PubMed Google Scholar VALENTINE LOGUE VALENTINE LOGUE Institute of NeurologyQueen Square, London WCI Search for other works by this author on: Oxford Academic PubMed Google Scholar Brain, Volume 97, Issue 1, 1974, Pages 197–210, https://doi.org/10.1093/brain/97.1.197 Published: 01 January 1974 Article history Received: 19 July 1973 Published: 01 January 1974

Actual and projected incidence rates for chronic subdural hematomas in United States Veterans Administration and civilian populations

2015-03-20

David Balser , Sameer Farooq , Talha Mehmood +2 more

Chronic subdural hematomas (SDHs) are more common among veterans and elderly persons than among members of the general population; however, precise incidence rates are unknown. The purposes of this study … Chronic subdural hematomas (SDHs) are more common among veterans and elderly persons than among members of the general population; however, precise incidence rates are unknown. The purposes of this study were 1) to determine the current incidence of chronic SDH in a US Veterans Administration (VA) population and 2) to create a mathematical model for determining the current and future incidence of chronic SDH as a function of population age, sex, and comorbidity in the United States VA and civilian populations.To determine the actual number of veterans who received a radiographic diagnosis and surgical treatment for SDH during 2000-2012, the authors used the VISN03 VA database. On the basis of this result and data from outside the United States, they then created a mathematical model accounting for age, sex, and alcohol consumption to predict the incidence of SDH in the VA and civilian populations during 2012-2040.Of 875,842 unique (different patient) visits to a VA hospital during the study period, 695 new SDHs were identified on CT images. Of these 695 SDHs, 203 (29%) required surgical drainage. The incidence rate was 79.4 SDHs per 100,000 persons, and the age-standardized rate was 39.1±4.74 SDHs per 100,000 persons. The authors' model predicts that incidence rates of chronic SDH in aging United States VA and civilian populations will reach 121.4 and 17.4 cases per 100,000 persons, respectively, by 2030, at which time, approximately 60,000 cases of chronic SDH will occur each year in the United States.The incidence of chronic SDH is rising; SDH is projected to become the most common cranial neurosurgical condition among adults by the year 2030.

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Effectiveness of Epidural Blood Patch in the Management of Post–Dural Puncture Headache

2001-08-01

Valérie Safa-Tisseront , F Thormann , P. Malassiné +4 more

Background Lumbar epidural blood patch (EBP) is a common treatment of post-dural puncture headache, but its effectiveness and mode of action remain a matter of debate. The aim of this … Background Lumbar epidural blood patch (EBP) is a common treatment of post-dural puncture headache, but its effectiveness and mode of action remain a matter of debate. The aim of this study was to assess both the effectiveness and the predictive factors of failure of EBP on severe post-dural puncture headache. Methods This prospective observational study includes all patients treated in the authors' hospital with EBP for incapacitating post-dural puncture headache, from 1988 to 2000. The EBP effect was classified into complete relief (disappearance of all symptoms), incomplete relief of symptoms (clinically improved patients who recovered sufficiently to perform normal daily activity), and failure (persistence of severe symptoms). The following data were analyzed using a logistic regression to identify predictive factors of failure of EBP: (1) patient characteristics; (2) circumstances of dural puncture; (3) delay between dural puncture and EBP; and (4) the volume of blood injected for EBP. Results A total of 504 patients were analyzed. The frequency rates of complete relief, incomplete relief of symptoms, and failure after EBP were 75% (n = 377), 18% (n = 93), and 7% (n = 34), respectively. In a multivariate analysis, only the diameter of the needle used to perform dura mater puncture (odds ratio = 5.96; 95% confidence interval, 2.63-13.47; P < 0.001) and a delay in EBP less than 4 days (odds ratio = 2.63; 95% confidence interval, 1.06-6.51; P = 0.037) were independent significant risk factors for a failure of EBP. Conclusions Epidural blood patch is an effective treatment of severe post-dural puncture headache. Its effectiveness is decreased if dura mater puncture is caused by a large bore needle.

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The Monro–Kellie hypothesis

2001-06-26

Bahram Mokri

More than two centuries ago, Alexander Monro applied some of the principles of physics to the intracranial contents and for the first time hypothesized that the blood circulating in the … More than two centuries ago, Alexander Monro applied some of the principles of physics to the intracranial contents and for the first time hypothesized that the blood circulating in the cranium was of constant volume at all times. This hypothesis was supported by experiments by Kellie. In its original form, the hypothesis had shortcomings that prompted modification by others. What finally came to be known as the Monro–Kellie doctrine, or hypothesis, is that the sum of volumes of brain, CSF, and intracranial blood is constant. An increase in one should cause a decrease in one or both of the remaining two. This hypothesis has substantial theoretical implications in increased intracranial pressure and in decreased CSF volume. Many of the MRI abnormalities seen in intracranial hypotension or CSF volume depletion can be explained by the Monro–Kellie hypothesis. These abnormalities include meningeal enhancement, subdural fluid collections, engorgement of cerebral venous sinuses, prominence of the spinal epidural venous plexus, and enlargement of the pituitary gland.

Surgical Management of Acute Subdural Hematomas

2006-03-01

M. Ross Bullock , Randall M. Chesnut , Jamshid Ghajar +6 more

Abstract Indications for Surgery Timing Methods Abstract Indications for Surgery Timing Methods

Subarachnoid and intracerebral hemorrhage

1984-07-01

Ralph L. Sacco , Philip A. Wolf , Nadir E. Bharucha +6 more

No uniformly accepted hypothesis explains the genesis and rupture of intracranial aneurysms. We followed 5,184 men and women prospectively for 26 years; 36 cases of aneurysmal subarachnoid hemorrhage (SAH) accounted … No uniformly accepted hypothesis explains the genesis and rupture of intracranial aneurysms. We followed 5,184 men and women prospectively for 26 years; 36 cases of aneurysmal subarachnoid hemorrhage (SAH) accounted for 62% of all intracranial hemorrhages. Blood pressure before SAH was higher in these patients than in controls. Definite hypertension (2160 mm Hg and/or 295 mm Hg) at entry to the study or at closest exam before SAH was more frequent than in controls. Cigarette smoking, particularly heavy smoking, was also more frequent among cases.

INDEPENDENT PREDICTORS FOR RECURRENCE OF CHRONIC SUBDURAL HEMATOMA

2008-12-01

Koichi Torihashi , Nobutake Sadamasa , Kazumichi Yoshida +3 more

Chronic subdural hematoma (CSDH) is a common form of intracranial hemorrhage with a substantial recurrence rate. We focused on determining independent predictors associated with the recurrence of CSDH.We retrospectively reviewed … Chronic subdural hematoma (CSDH) is a common form of intracranial hemorrhage with a substantial recurrence rate. We focused on determining independent predictors associated with the recurrence of CSDH.We retrospectively reviewed 343 consecutive surgical cases of CSDH. Univariate and multivariate analyses were performed to describe the relationships between recurrence of CSDH and factors such as sex, age, hypertension, diabetes mellitus, heart disease, cerebrovascular disease, atrial fibrillation, antiplatelet or anticoagulant therapy, and bilateral CSDH.Sixty-one patients experienced a recurrence of CSDH. Univariate and multivariate analyses found that bilateral CSDH was an independent risk factor for the recurrence of CSDH. Although antiplatelet and anticoagulant therapy had no significant effect on recurrence of CSDH, the time interval between the injury and the first operation for patients with antiplatelet and/or anticoagulant therapy was shorter than that for patients without it (29.9 versus 44.2 days).Bilateral CSDH was an independent predictor for the recurrence of CSDH. Antiplatelet or anticoagulant drugs might facilitate the growth of CSDH. These results may help to identify patients at high risk for the recurrence of CSDH.

Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension

1996-04-01

Wouter I. Schievink , Fredric B. Meyer , John L.D. Atkinson +1 more

Spinal cerebrospinal fluid (CSF) leaks are often implicated as the cause of the syndrome of spontaneous intracranial hypotension, but they have rarely been demonstrated radiographically or surgically. The authors reviewed … Spinal cerebrospinal fluid (CSF) leaks are often implicated as the cause of the syndrome of spontaneous intracranial hypotension, but they have rarely been demonstrated radiographically or surgically. The authors reviewed their experience with documented cases of spinal CSF leaks of spontaneous onset in 11 patients including their surgical observations in four of the patients. The mean age of the six women and five men included in the study was 38 years (range 22-51 years). All patients presented with a postural headache; however, most had additional symptoms, including nausea, emesis, sixth cranial-nerve paresis, or local back pain at the level of the CSF leak. All patients underwent indium-111 radionucleotide cisternography or computerized tomographic (CT) myelography. The location of the spontaneous CSF leak was in the cervical spine in two patients, the cervicothoracic junction in three patients, the thoracic spine in five patients, and the lumbar spine in one patient. The false negative rate for radionucleotide cisternography was high (30%). Subdural fluid collections, meningeal enhancement, and downward displacement of the cerebellum, resembling a Chiari I malformation, were commonly found on cranial imaging studies. In most patients, the symptoms resolved in response to supportive measures or an epidural blood patch. Leaking meningeal diverticula were found to be the cause of the CSF leak in four patients who underwent surgery. In three patients these diverticula could be ligated with good result but in one patient an extensive complex of meningeal diverticula was found to be inoperable. Two patients had an unusual body habitus and joint hypermobility, and two other patients had suffered a spontaneous retinal detachment at a young age. In conclusion, spontaneous spinal CSF leaks are uncommon, but they are increasingly recognized as a cause of spontaneous intracranial hypotension. Most spinal CSF leaks are located at the cervicothoracic junction or in the thoracic spine, and they may be associated with meningeal diverticula. The radiographic study of choice is CT myelography. The disease is usually self-limiting, but in selected cases our experience with surgical ligation of leaking meningeal diverticula has been satisfactory. An underlying connective tissue disorder may be present in some patients with a spontaneous spinal CSF leak.

Syndrome of Orthostatic Headaches and Diffuse Pachymeningeal Gadolinium Enhancement

1997-05-01

Bahram Mokri , David G. Piepgras , Gary M. Miller

Chronic Subdural Hematoma Management

2013-10-07

Saleh A. Almenawer , Forough Farrokhyar , Chris J. Hong +7 more

To compare the efficacy and safety of multiple treatment modalities for the management of chronic subdural hematoma (CSDH) patients.Current management strategies of CSDHs remain widely controversial. Treatment options vary from … To compare the efficacy and safety of multiple treatment modalities for the management of chronic subdural hematoma (CSDH) patients.Current management strategies of CSDHs remain widely controversial. Treatment options vary from medical therapy and bedside procedures to major operative techniques.We searched MEDLINE (PubMed and Ovid), EMBASE, CINAHL, Google scholar, and the Cochrane library from January 1970 through February 2013 for randomized and observational studies reporting one or more outcome following the management of symptomatic patients with CSDH. Independent reviewers evaluated the quality of studies and abstracted the data on the safety and efficacy of percutaneous bedside twist-drill drainage, single or multiple operating room burr holes, craniotomy, corticosteroids as a main or adjuvant therapy, use of drains, irrigation of the hematoma cavity, bed rest, and treatment of recurrences following CSDH management. Mortality, morbidity, cure, and recurrence rates were examined for each management option. Randomized, prospective, retrospective, and overall observational studies were analyzed separately. Pooled estimates, confidence intervals (CIs), and relative risks (RRs) were calculated for all outcomes using a random-effects model.A total of 34,829 patients from 250 studies met our eligibility criteria. Sixteen trials were randomized, and the remaining 234 were observational. We included our unpublished single center series of 834 patients. When comparing percutaneous bedside drainage to operating room burr hole evacuation, there was no significant difference in mortality (RR, 0.69; 95% CI, 0.46-1.05; P = 0.09), morbidity (RR, 0.45; 95% CI, 0.2-1.01; P = 0.05), cure (RR, 1.05; 95% CI, 0.98-1.11; P = 0.15), and recurrence rates (RR, 1; 95% CI, 0.66-1.52; P = 0.99). Higher morbidity was associated with the adjuvant use of corticosteroids (RR, 1.97; 95% CI, 1.54-2.45; P = 0.005), with no significant improvement in recurrence and cure rates. The use of drains following CSDH drainage resulted in a significant decrease in recurrences (RR, 0.46; 95% CI, 0.27-0.76; P = 0.002). Craniotomy was associated with higher complication rates if considered initially (RR, 1.39; 95% CI, 1.04-1.74; P = 0.01); however, craniotomy was superior to minimally invasive procedures in the management of recurrences (RR, 0.22; 95% CI, 0.05-0.85; P = 0.003).Percutaneous bedside twist-drill drainage is a relatively safe and effective first-line management option. These findings may result in potential health cost savings and eliminate perioperative risks related to general anesthetic.

Chronic subdural haematoma: modern management and emerging therapies

2014-09-16

Angelos G. Kolias , Ajai Chari , Thomas Santarius +1 more

Headache and neck pain in spontaneous internal carotid and vertebral artery dissections

1995-08-01

Peter L. Silbert , Bahram Mokri , Wouter I. Schievink

We studied the characteristics of headaches in 161 consecutive symptomatic patients with spontaneous dissections of the internal carotid artery (n = 135) or the vertebral artery (n = 26). For … We studied the characteristics of headaches in 161 consecutive symptomatic patients with spontaneous dissections of the internal carotid artery (n = 135) or the vertebral artery (n = 26). For patients with internal carotid artery dissection (ICAD), the mean age was 47 years and for those with vertebral artery dissection (VAD), 40.7 years. A history of migraine was present in 18% of the ICAD group and in 23% of the VAD group. Headache was reported by 68% of the patients with ICAD and by 69% of those with VAD, and, when present, it was the initial manifestation in 47% of those with ICAD and in 33% of those with VAD. Ten percent of patients with ICAD had eye, facial, or ear pain without headache. The median interval from onset of headache to development of other neurologic manifestations was 4 days for the ICAD group and 14.5 hours for the VAD group. For all dissections, headaches typically were ipsilateral to the side of dissection. In the ICAD group, headaches were limited to the anterior head in 60% of patients and were steady in 73% and pulsating in 25%. In the VAD group, headaches were distributed posteriorly in 83% of patients and were steady in 56% and pulsating in 44%. Neck pain was present in 26% of patients with ICAD (anterolateral) and in 46% of those with VAD (posterior). The median duration of the headache in patients with VAD and ICAD was 72 hours, but headaches became prolonged, persisting for months to years, in four patients with ICAD.

Spontaneous intracranial hypotension

1992-03-01

Thomas A. Rando , Robert A. Fishman

We report two patients with spontaneous intracranial hypotension. In addition to the cardinal features of a postural headache and a low CSF pressure, the patients also had subdural fluid collections … We report two patients with spontaneous intracranial hypotension. In addition to the cardinal features of a postural headache and a low CSF pressure, the patients also had subdural fluid collections demonstrated by head MRI. In both patients, radionuclide cisternography revealed a CSF leak along the spinal axis and rapid accumulation of radioisotope in the bladder. CSF leakage from spinal meningeal defects may be the most common cause of this syndrome. The headache is a consequence of the low CSF pressure producing displacement of pain-sensitive structures. Associated symptoms, including tinnitus and vertigo, and subdural fluid collections are presumably from hydrostatic changes among intracranial fluid compartments that occur at low CSF pressures. Methods of treatment are identical to those for post-dural puncture headaches. Epidural blood patches and epidural saline infusions have rapidly ameliorated the symptoms of spontaneous intracranial hypotension.

Spontaneous Cerebrospinal Fluid Leaks: From Intracranial Hypotension to Cerebrospinal Fluid Hypovolemia—Evolution of a Concept

1999-11-01

Bahram Mokri

The surgical management of chronic subdural hematoma

2011-09-09

Andrew F. Ducruet , Bartosz T. Grobelny , Brad E. Zacharia +6 more

Chronic subdural hematomas: a review

1981-05-01

Thomas-Marc Markwalder

✓ Present knowledge of the still controversial pathogenetic, ultrastructural, diagnostic, and treatment aspects of chronic subdural hematomas is reviewed. ✓ Present knowledge of the still controversial pathogenetic, ultrastructural, diagnostic, and treatment aspects of chronic subdural hematomas is reviewed.

MRI changes in intracranial hypotension

1993-05-01

Susan C. Pannullo , Jeffrey Reich , George Krol +2 more

We report seven patients with the syndrome of intracranial hypotension who were referred to Memorial Sloan-Kettering, primarily because of suspicion of meningeal tumor or infection raised by the finding of … We report seven patients with the syndrome of intracranial hypotension who were referred to Memorial Sloan-Kettering, primarily because of suspicion of meningeal tumor or infection raised by the finding of meningeal enhancement on MRI. In three patients, symptoms occurred after lumbar puncture; in four, there was no clear precipitating event. Lumbar puncture after MRI in six patients revealed low CSF pressure (six patients) and pleocytosis or high protein, or both (four patients). Three patients had subdural effusions. Six patients had measurable descent of the brain on midsagittal images. Postural headache resolved in all seven patients, six of whom had follow-up MRIs. Meningeal enhancement resolved or diminished in all six. Subdural effusions resolved spontaneously in two and were evacuated (but were not under pressure) in one. Downward brain displacement improved or resolved in all patients. The clinical syndrome and MRI abnormalities generally resolve on their own. An extensive workup is not helpful and may be misleading. Patients should be treated symptomatically.

Relation between Perioperative Hypertension and Intracranial Hemorrhage after Craniotomy

2000-07-01

Ayman Basali , Edward J. Mascha , Iain H. Kalfas +1 more

Background Previous data suggest that systemic hypertension (HTN) is a risk factor for postcraniotomy intracranial hemorrhage (ICH). The authors examined the relation between perioperative blood pressure elevation and postoperative ICH … Background Previous data suggest that systemic hypertension (HTN) is a risk factor for postcraniotomy intracranial hemorrhage (ICH). The authors examined the relation between perioperative blood pressure elevation and postoperative ICH using a retrospective case control design. Methods The hospital's database of all patients undergoing craniotomy from 1976 to 1992 was screened. Coagulopathic and unmatchable patients were excluded. There were 69 evaluable patients who developed ICH postoperatively (n = 69). A 2-to-1 matched (by age, date of surgery, pathologic diagnosis, surgical procedure, and surgeon) control group without postoperative ICH was assembled (n = 138). Preoperative, intraoperative, and postoperative blood pressure records (up to 12 h) were examined. Incidence of perioperative HTN (blood pressure &gt; or = 160/90 mmHg) and odds ratios for ICH were determined. Results Of the 11,214 craniotomy patients, 86 (0.77%) suffered ICH, and 69 fulfilled inclusion criteria. The incidence of preoperative HTN was similar in the ICH (34%) and the control (24%) groups. ICH occurred 21 h (median) postoperatively, with an interquartile range of 4-52 h. Sixty-two percent of ICH patients had intraoperative HTN, compared with only 34% of controls (P &lt; 0.001). Sixty-two percent of the ICH patients had prehemorrhage HTN in the initial 12 postoperative hours versus 25% of controls (P &lt; 0.001), with an odds ratio of 4.6 (P &lt; 0.001) for postoperative ICH. Hospital stay (median, 24.5 vs. 11.0 days), and mortality (18.2 vs. 1.6%) were significantly greater in the ICH than in the control groups. Conclusions ICH after craniotomy is associated with severely prolonged hospital stay and mortality. Acute blood pressure elevations occur frequently prior to postcraniotomy ICH. Patients who develop postcraniotomy ICH are more likely to be hypertensive in the intraoperative and early postoperative periods.

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Assessment: Prevention of post–lumbar puncture headaches

2000-10-10

Randolph W. Evans , Carmel Armon , Elliot M. Frohman +1 more

2][3][4][5][6] In their monograph summarizing the world literature through 1960, Tourtellotte et al. 1 considered separately three principal patient populations: 1) patients undergoing diagnostic LPs (excluding myelography, pneumoencephalography, and cisternal … 2][3][4][5][6] In their monograph summarizing the world literature through 1960, Tourtellotte et al. 1 considered separately three principal patient populations: 1) patients undergoing diagnostic LPs (excluding myelography, pneumoencephalography, and cisternal puncture), excluding also patients whose condition might reduce the reliability to report HA; 2) patients undergoing nonobstetric spinal anesthesia; and 3) patients undergoing obstetric spinal anesthesia.They reported several observations.1.The average frequency of post-LP HAs (PLPHA) in patients after diagnostic LP (excluding myelography, pneumoencephalography, and cisternal puncture), excluding also patients whose condition might reduce the reliability to report HA, was 32%.For nonobstetric spinal anesthesia, the average frequency was 13%.For obstetric spinal anesthesia, the average frequency was 18%. 2. In reports in which patients received special measures to prevent PLPHA, the average frequencies were 6% for diagnostic LPs, 5.5% for nonobstetric spinal anesthesia, and 6.2% for obstetric spinal anesthesia.The actual frequencies in individual series ranged from 0 to 18%. 3. The frequency of PLPHA was 36% in their own series of 105 normal individuals, 30% in 317 patients with diagnostic LPs, and 2% definite and 2% probable in 100 patients undergoing spinal anesthesia (but 30 patients with HAs of other types were excluded from the latter count).In analyzing risk factors for PLPHA, they concluded that the evidence, including their own prospective series, was convincing to consider younger age and female gender as definite risk factors.They attributed the difference of PLPHAs in obstetric and nonobstetric patients undergoing spinal anesthesia at least in part to these factors.They further considered the data fairly convincing that the smaller the needle size, the lower the frequency of PLPHA, but were unable to show this in their prospective series.They commented that the great variability of HA frequency for the same needle size between authors may reduce the reliability of this observation.With regard to all other risk factors, they concluded that the evidence was inconclusive.With regard to all preventive or therapeutic measures, they commented that proponents of a particular treatment, in general, found it to be beneficial; however, some of the reports were uncontrolled and some results could not be replicated by others.Today, we would consider the latter findings a result of publication bias-if one first tried a new approach to reducing the incidence of PLPHA, one would be less likely to publish a failure than a success.They commented on the different frequency of PLPHA in patients undergoing diagnostic LP compared with those undergoing spinal anesthesia, and considered the following factors in their series: age, gender, needle size, fasting, hydration, premedication and postoperative medication, minimal amount of trauma to the meninges, duration of recumbency, and the amount of CSF removed.Even after controlling for age and gender, the frequency of PLPHA in the spinal anesthesia group was low.They speculated that "if patients undergoing an LP for diagnostic purposes were treated like patients undergoing spinal anesthesia the incidence ['frequency'] of PLPHAs could be markedly reduced." 1 The work of Tourtellotte et al. 1 demonstrated the large variability in the frequency of PLPHA in different settings and in different series, and the apparent ability to reduce this frequency, based on uncontrolled reports.The average frequency that they reported in their monograph has been replicated or even exceeded in more recent experience (e.g.,

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Incidence of Subarachnoid Hemorrhage

1996-04-01

F. Linn , G. J. E. Rinkel , Ale Algra +1 more

The incidence of subarachnoid hemorrhage (SAH) has been estimated for many years at 10 to 15 per 100 000 person-years, but the most recent studies yield lower figures, of 6 … The incidence of subarachnoid hemorrhage (SAH) has been estimated for many years at 10 to 15 per 100 000 person-years, but the most recent studies yield lower figures, of 6 to 8 per 100 000 person-years. To investigate the cause of this apparent decline, we studied the influence of year to study, rate of CT,and region.Eighteen studies fulfilled predefined inclusion criteria. In three Finnish studies, the pooled incidence was 21.4 per 100 000 person-years (95% confidence interval [CI], 19.5 to 23.4); in 15 non-Finnish studies, it was 7.8 per 100 000 person-years (95% CI, 7.2 to 8.4). With univariate analysis, in non-Finnish studies the incidence decreased .96% for each percentage point increase of patients investigated with CT (rate ratio, -0.9904; 95% CI, 0.9878 to 0.9930). With 100% CT scanning, the incidence of SAH outside Finland is estimated at 6 per 100 000 person-years. The rate ratio for year of study was 0.952 (95% CI, 0.935 to 0.969) for each later year in the period 1960 to 1994. In multivariate analysis, only the use of CT was independently related to SAH incidence. For the Finnish studies, the rate ratios for use of CT and year to study were not statistically significant. We also found in six studies that incidence for women was 1.6 (95% CI, 1.1 to 2.3) times higher than that for men (7.1 [95% CI, 5.4 to 8.7] and 4.5 [95% CI, 3.1 to 5.8], respectively).The actual incidence of SAH has remained stable over the last three decades; the apparent decline in incidence is entirely explained by the greater proportion of patients investigated with CT. The incidence of SAH in Finland is almost three times as high as in other parts of the world.

Use of drains versus no drains after burr-hole evacuation of chronic subdural haematoma: a randomised controlled trial

2009-09-01

Thomas Santarius , Peter J. Kirkpatrick , Dharmendra Ganesan +7 more

Surgical Treatment of Chronic Subdural Hematoma in 500 Consecutive Cases: Clinical Characteristics, Surgical Outcome, Complications, and Recurrence Rate.

2001-01-01

Kentaro Mori , Minoru Maëda

Chronic subdural hematoma (CSDH) is one of the most common clinical entities in daily neurosurgical practice. The diagnosis and treatment are well established, but recurrence, complications, and factors related to … Chronic subdural hematoma (CSDH) is one of the most common clinical entities in daily neurosurgical practice. The diagnosis and treatment are well established, but recurrence, complications, and factors related to these problems, especially in the elderly, are not completely understood. This study evaluated the clinical features, radiological findings, and surgical results in a large series of the patients treated at the same institution. 500 consecutive patients (359 men and 141 women) with CSDH were treated by burr hole craniostomy with closed system drainage from January 1987 through February 1999. Causes, clinical and computed tomographic findings, surgical results, re-expansion of brain after surgery, and hematoma recurrence were statistically analyzed to elucidate the potential risks of CSDH. Most patients (89.4%) had good recovery, 8.4% showed no change, and 2.2% worsened. Six patients (1.2%) died, three due to disseminated intravascular coagulation. Recurrence of hematoma was recognized in 49 patients (9.8%), at 1 to 8 weeks (3.5 ± 1.9 weeks) after the first operation. The brain re-expansion rate at one week after operation was 45.0 ± 21.4% in patients with hematoma recurrence and significantly lower than 55.3 ± 19.1% in patients without recurrence (p < 0.001). Old age, pre-existing cerebral infarction, and persistence of subdural air after surgery were significantly correlated with poor brain re-expansion (p < 0.001). Twenty-seven patients (5.4%) suffered postoperative complications, of which 13 cases were acute subdural hematoma caused by incomplete hemostasis of the scalp wound and four cases were tension pneumocephalus. Careful hemostasis and complete replacement of subdural hematoma by normal saline to prevent influx of air into the subdural space will further improve the surgical outcome for patients with CSDH.

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Factors in the natural history of chronic subdural hematomas that influence their postoperative recurrence

2001-08-01

Hiroshi Nakaguchi , T Tanishima , Norio Yoshimasu

Factors affecting the postoperative recurrence of chronic subdural hematomas (CSDHs) have not been sufficiently investigated. The authors have attempted to determine features of CSDHs that are associated with a high … Factors affecting the postoperative recurrence of chronic subdural hematomas (CSDHs) have not been sufficiently investigated. The authors have attempted to determine features of CSDHs that are associated with a high or low recurrence rate on the basis of the natural history of these lesions and their intracranial extension.One hundred six patients (82 men and 24 women) harboring 126 CSDHs who were treated at Tokyo Kosei Nenkin Hospital between January 1989 and April 1998 were studied. Types of CSDHs were classified according to hematoma density and internal architecture, and the intracranial extension of the hematomas were investigated. The postoperative recurrence rate was calculated for each factor. Based on the internal architecture and density of each hematoma, the CSDHs were classified into four types, including homogeneous, laminar, separated, and trabecular types. The recurrence rate associated with the separated type was high, whereas that associated with the trabecular type was low. Chronic subdural hematomas are believed to develop initially as the homogeneous type, after which they sometimes progress to the laminar type. A mature CSDH is represented by the separated stage and the hematoma eventually passes through the trabecular stage during absorption. Based on the intracranial extension of each hematoma, CSDHs were classified into three types, including convexity, cranial base, and interhemispheric types. The recurrence rate of cranial base CSDHs was high and that of convexity CSDHs was low.Classification of CSDHs according to the internal architecture and intracranial extension may be useful for predicting the risk of postoperative recurrence.

The course of chronic subdural hematomas after burr-hole craniostomy and closed-system drainage

1981-09-01

Thomas-Marc Markwalder , Klaus F. Steinsiepe , Matthias Rohner +2 more

A consecutive series of 32 adult patients with chronic subdural hematoma was studied in respect to postoperative cerebral reexpansion (reduction in diameter of the subdural space) after burr-hole craniostomy and … A consecutive series of 32 adult patients with chronic subdural hematoma was studied in respect to postoperative cerebral reexpansion (reduction in diameter of the subdural space) after burr-hole craniostomy and closed-system drainage. Patients with high subdural pressure showed the most rapid brain expansion and clinical improvement during the first 2 days. Nevertheless, a computerized tomography (CT) scan performed on the 10th day after surgery demonstrated persisting subdural fluid in 78% of cases. After 40 days, the CT scan was normal in 27 of the 32 patients. There was no mortality and no significant morbidity. Our study suggests that well developed subdural neomembranes are the crucial factors for cerebral reexpansion, a phenomenon that takes at least 10 to 20 days. However, blood vessel dysfunction and impairment of cerebral blood flow may participate in delay of brain reexpansion. It may be argued that additional surgical procedures, such as repeated tapping of the subdural fluid, craniotomy, and membranectomy or even craniectomy, should not be evaluated earlier than 20 days after the initial surgical procedure unless the patient has deteriorated markedly.

Misdiagnosis of Spontaneous Intracranial Hypotension

2003-12-01

Wouter I. Schievink

Spontaneous intracranial hypotension is an important cause of "new daily persistent headaches" but is not a well-recognized entity. The misdiagnosis of spontaneous intracranial hypotension can have serious consequences.The clinical course … Spontaneous intracranial hypotension is an important cause of "new daily persistent headaches" but is not a well-recognized entity. The misdiagnosis of spontaneous intracranial hypotension can have serious consequences.The clinical course in 18 consecutive patients with spontaneous intracranial hypotension who were evaluated for definitive surgical treatment of the underlying spontaneous spinal cerebrospinal fluid leak from January 1, 2001, through June 30, 2002, was investigated by correspondence with the patients and physicians.Seventeen patients (94%) initially received an incorrect diagnosis, and the diagnostic delay ranged from 4 days to 13 years (median, 5 weeks; mean, 13 months). Migraine, meningitis, and psychogenic disorder were the most commonly entertained diagnoses. Diagnostic or therapeutic procedures for disorders that mimicked spontaneous intracranial hypotension included cerebral arteriography in 2 patients, craniotomies for Chiari malformation in 2 patients, craniotomy for evacuation of subdural hematomas in 1 patient, and brain biopsy in 1 patient.Patients with spontaneous intracranial hypotension are commonly misdiagnosed, causing a significant delay in the initiation of effective treatments and exposing patients to the risks associated with treatment for disorders that mimic intracranial hypotension. Increasing the awareness of this spontaneous type of intracranial hypotension is required to decrease the high rate of misdiagnosis.

Detection of subarachnoid haemorrhage on early CT: is lumbar puncture still needed after a negative scan?

1995-03-01

Nic J.A. van der Wee , Gabriël J.E. Rinkel , Djo Hasan +1 more

Computed tomography may be normal in up to 5% of patients who are investigated within one or two days after subarachnoid haemorrhage. This study investigated the need for further diagnostic … Computed tomography may be normal in up to 5% of patients who are investigated within one or two days after subarachnoid haemorrhage. This study investigated the need for further diagnostic evaluation after a normal CT scan was found very early (within 12 hours) in patients suspected of subarachnoid haemorrhage. A consecutive series of 175 patients with sudden headache and a normal neurological examination who had first CT within 12 hours after the onset of headache were investigated. The patients with normal CT underwent lumbar puncture, but not earlier than 12 hours after the event. Computed tomography showed subarachnoid blood in 117 patients, and was normal in 58. Spectrophotometric analysis of CSF gave evidence for a subarachnoid haemorrhage in two of these 58 patients (3%; 95% confidence interval (95% CI) 0.4-12%); a ruptured aneurysm was found in both. Thus CT was normal in two of 119 patients with a definite subarachnoid haemorrhage (2%; 95% CI 0.2-6%). It is concluded that in patients with sudden headache but normal CT a deferred lumbar puncture is necessary to rule out subarachnoid haemorrhage, even if CT is performed within 12 hours after the onset of symptoms.

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Chronic subdural haematoma in the elderly

2002-02-01

Vedamurthy Adhiyaman , Muhammad Asghar , K. N. Ganeshram +1 more

Abstract Chronic subdural haematoma is predominantly a disease of the elderly. It usually follows a minor trauma. A history of direct trauma to the head is absent in up to … Abstract Chronic subdural haematoma is predominantly a disease of the elderly. It usually follows a minor trauma. A history of direct trauma to the head is absent in up to half the cases. The common manifestations are altered mental state and focal neurological deficit. Neurological state at the time of diagnosis is the most important prognostic factor. Morbidity and mortality is higher in the elderly but outcome is good in patients who undergo neurosurgical intervention.

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The efficacy of epidural blood patch in spontaneous CSF leaks

2001-11-27

Drahomira Sencakova , Bahram Mokri , Robyn L. McClelland

Of 25 consecutive patients with spontaneous CSF leaks treated with epidural blood patch (EBP), nine patients (36%) responded well to the first EBP. Of 15 patients who received a second … Of 25 consecutive patients with spontaneous CSF leaks treated with epidural blood patch (EBP), nine patients (36%) responded well to the first EBP. Of 15 patients who received a second EBP, five became asymptomatic (33%). Of eight patients who received three or more EBP (mean 4), four patients (50%) responded well.

Post-dural puncture headache: pathogenesis, prevention and treatment

2003-10-22

D. Turnbull , D. Shepherd

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Post‐Dural Puncture Headache: Part I Diagnosis, Epidemiology, Etiology, and Pathophysiology

2010-06-02

David Bezov , Richard B. Lipton , Sait Ashina

Post-dural puncture headache (PDPH) is a frequent complication of dural puncture whether performed for diagnostic purposes or accidentally, as a complication of anesthesia. Because both procedures are common, clinicians interested … Post-dural puncture headache (PDPH) is a frequent complication of dural puncture whether performed for diagnostic purposes or accidentally, as a complication of anesthesia. Because both procedures are common, clinicians interested in headache should be familiar with this entity. The differential diagnosis of PDPH is broad and includes other complications of dural puncture as well as headaches attributable to the condition which lead to the procedure. The patterns of development of PDPH depend on a number of procedure- and nonprocedure-related risk factors. Knowledge of procedure-related factors supports interventions designed to reduce the incidence of PDPH. Finally, despite best preventive efforts, PDPH may still occur and be associated with significant morbidity. Therefore, it is important to know the management and prognosis of this disorder. In this review, we will highlight diagnosis and clinical characteristics of PDPH, differential diagnosis, frequency, and risk factors as well as pathophysiology of PDPH.

Clinical Trial Registration: A Statement from the International Committee of Medical Journal Editors

2004-09-09

Catherine De Angelis , Jeffrey M. Drazen , Frank Frizelle +7 more

Altruism and trust lie at the heart of research on human subjects. Altruistic individuals volunteer for research because they trust that their participation will contribute to improved health for others … Altruism and trust lie at the heart of research on human subjects. Altruistic individuals volunteer for research because they trust that their participation will contribute to improved health for others and that researchers will minimize risks to participants. In return for the altruism and trust that make clinical research possible, the research enterprise has an obligation to conduct research ethically and to report it honestly. Honest reporting begins with revealing the existence of all clinical studies, even those that reflect unfavorably on a research sponsor's product. Unfortunately, selective reporting of trials does occur, and it distorts the body of evidence . . .

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Incidence and Significance of Early Aneurysmal Rebleeding Before Neurosurgical or Neurological Management

2001-05-01

Hiroki Ohkuma , Hisanobu Tsurutani , Shigeharu Suzuki

Background and Purpose —Rebleeding is a major cause of death and disability in aneurysmal subarachnoid hemorrhage (SAH); however, there has been no report focusing on rebleeding before hospitalization in neurosurgical … Background and Purpose —Rebleeding is a major cause of death and disability in aneurysmal subarachnoid hemorrhage (SAH); however, there has been no report focusing on rebleeding before hospitalization in neurosurgical or neurological institutions. The aim of this study was to clarify the incidence of prehospitalization rebleeding, its impact on the clinical course and prognosis in patients with aneurysmal SAH, and the possible factors inducing it. Methods —In 273 patients who were admitted to our institution within 24 hours after the initial SAH bleeding and whose clinical course before admission could be fully evaluated, the patients’ clinical conditions and CT findings on admission, operability, prognosis, and possible factors inducing rebleeding were comparatively evaluated between the patients with and without an episode of prehospitalization rebleeding. Results —Of the 273 patients, 37 (13.6%) patients suffered from 39 episodes of rebleeding in the ambulance or at the referring hospital before admission to our hospital. The peak time of rebleeding was within 2 hours (77%), in which the incidence was statistically significant compared with that occurring 2 to 8 hours after the initial SAH bleeding ( P <0.01). The group experiencing rebleeding showed more severe Hunt and Hess grades on admission, higher rates of intracerebral hematoma, of intraventricular hematoma, and of subdural hematoma on CT scan on admission, less operability, and poorer prognoses with statistically significant differences compared with the group that did not experience rebleeding. Systolic arterial pressure >160 mm Hg was a possible risk factor of rebleeding (odds ratio 3.1, 95% CI 1.5 to 6.8). Conclusions —Rebleeding during transfer and at the referring hospital is not rare. To improve overall outcome of aneurysmal SAH, the results obtained in this study should be made available to general practitioners and the doctors devoted to emergency medicine.

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Postoperative Hematoma

1994-12-01

James D. Palmer , Owen Sparrow , Fausto Iannotti

This study examines the surgical practice at the Wessex Neurological Centre over the 5-year period from 1989 to 1993 to determine the incidence of postoperative hematoma and to identify risk … This study examines the surgical practice at the Wessex Neurological Centre over the 5-year period from 1989 to 1993 to determine the incidence of postoperative hematoma and to identify risk factors for a perioperative bleeding disorder. The study includes only those postoperative hematomas (at any site) that followed and were related to a neurosurgical operation and were surgically evacuated. The study is prospective for the year 1993 and retrospective for the preceding years. Over the 5 years, 6668 operations were performed and 71 postoperative hematomas were surgically evacuated, accounting for an overall rate of 1.1% of operations. The records were available for 69 cases. The most frequent diagnosis leading to postoperative hematoma was meningioma surgery with a rate of 6.2% of cases (13 of 211); followed by craniotomy for trauma, 3.7% (7 of 192); aneurysm surgery, 2.6% (11 of 428); and intrinsic supratentorial tumors, 2.2% (10 of 451). Postoperative hematomas were intraparenchymal in 43% of cases, subdural in 5%, extradural in 33%, mixed in 8%, and confined to the superficial wound in 11%. The overall mortality was 32% (37% for intraparenchymal and 12% for extradural). Risk factors for a perioperative bleeding disorder were present in two-thirds of the patients. Administration of antiplatelet agents (aspirin and nonsteroidal anti-inflammatory drugs) was the most commonly associated risk factor. At least 75% of these identified risk factors could potentially have been avoided or corrected.

DURAL HEADACHE AND INNERVATION OF THE DURA MATER

1940-07-01

Wilder Penfield

The only adjective which Celsus applied to headache was "intolerabilis." Unless it was intolerable, he said, there was no necessity for a remedy (Vaughan, 1825<sup>1</sup>). Today the same proviso might … The only adjective which Celsus applied to headache was "intolerabilis." Unless it was intolerable, he said, there was no necessity for a remedy (Vaughan, 1825<sup>1</sup>). Today the same proviso might be applied, at least to surgical remedies. But when the ache is intolerable, radical operative treatment should be undertaken. Knowledge of the innervation and sensitivity of intracranial structures is prerequisite to success with such treatment. This study is concerned primarily with the nerve supply and pain reference of the dura mater in man and in the monkey. It is illustrated by clinical cases which cast light on dural sensitivity and on the radical treatment of falcial cicatrix, migraine and other forms of headache. A preliminary anatomic study has already been published by one of us (F. M.).<sup>2</sup> <h3>STRUCTURE AND DEVELOPMENT OF THE CEREBRAL DURA MATER</h3> The cerebral dura is a very tough membrane composed of two closely adherent

Outcome of contemporary surgery for chronic subdural haematoma: evidence based review

2003-06-16

Ralf Weigel

To evaluate the results of surgical treatment options for chronic subdural haematoma in contemporary neurosurgery according to evidence based criteria.A review based on a Medline search from 1981 to October … To evaluate the results of surgical treatment options for chronic subdural haematoma in contemporary neurosurgery according to evidence based criteria.A review based on a Medline search from 1981 to October 2001 using the phrases "subdural haematoma" and "subdural haematoma AND chronic". Articles selected for evaluation had at least 10 patients and less than 10% of patients were lost to follow up. The articles were classified by three classes of evidence according to criteria of the American Academy of Neurology. Strength of recommendation for different treatment options was derived from the resulting degrees of certainty.48 publications were reviewed. There was no article that provided class I evidence. Six articles met criteria for class II evidence and the remainder provided class III evidence. Evaluation of the results showed that twist drill and burr hole craniostomy are safer than craniotomy; burr hole craniostomy and craniotomy are the most effective procedures; and burr hole craniostomy has the best cure to complication ratio (type C recommendation). Irrigation lowers the risk of recurrence in twist drill craniostomy and does not increase the risk of infection (type C recommendation). Drainage reduces the risk of recurrence in burr hole craniostomy, and a frontal position of the drain reduces the risk of recurrence (type B recommendation). Drainage reduces the risk of recurrence in twist drill craniostomy, and the use of a drain does not increase the risk of infection (type C recommendation). Burr hole craniostomy appears to be more effective in treating recurrent haematomas than twist drill craniostomy, and craniotomy should be considered the treatment of last choice for recurrences (type C recommendation).The three principal techniques-twist drill craniostomy, burr hole craniostomy, and craniotomy-used in contemporary neurosurgery for chronic subdural haematoma have different profiles for morbidity, mortality, recurrence rate, and cure rate. Twist drill and burr hole craniostomy can be considered first tier treatment, while craniotomy may be used as second tier treatment. A cumulative summary of data shows that, overall, the postoperative outcome of chronic subdural haematoma has not improved substantially over the past 20 years.

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Spontaneous Spinal Cerebrospinal Fluid Leaks and Intracranial Hypotension

2006-05-16

Wouter I. Schievink

ContextSpontaneous intracranial hypotension is caused by spontaneous spinal cerebrospinal fluid (CSF) leaks and is known for causing orthostatic headaches. It is an important cause of new headaches in young and … ContextSpontaneous intracranial hypotension is caused by spontaneous spinal cerebrospinal fluid (CSF) leaks and is known for causing orthostatic headaches. It is an important cause of new headaches in young and middle-aged individuals, but initial misdiagnosis is common.ObjectiveTo summarize existing evidence regarding the epidemiology, pathophysiology, diagnosis, and management of spontaneous spinal CSF leaks and intracranial hypotension.Evidence AcquisitionMEDLINE (1966-2005) and OLDMEDLINE (1950-1965) were searched using the terms intracranial hypotension, CSF leak, low pressure headache, and CSF hypovolemia. Reference lists of these articles and ongoing investigations in this area were used as well.Evidence SynthesisSpontaneous intracranial hypotension is caused by single or multiple spinal CSF leaks. The incidence has been estimated at 5 per 100 000 per year, with a peak around age 40 years. Women are affected more commonly than men. Mechanical factors combine with an underlying connective tissue disorder to cause the CSF leaks. An orthostatic headache is the prototypical manifestation but other headache patterns occur as well, and associated symptoms are common. Typical magnetic resonance imaging findings include subdural fluid collections, enhancement of the pachymeninges, engorgement of venous structures, pituitary hyperemia, and sagging of the brain (mnemonic: SEEPS). Myelography is the study of choice to identify the spinal CSF leak. Treatments include bed rest, epidural blood patching, percutaneous placement of fibrin sealant, and surgical CSF leak repair, but outcomes have been poorly studied and no management strategies have been studied in properly controlled randomized trials.ConclusionsSpontaneous intracranial hypotension is not rare but it remains underdiagnosed. The spectrum of clinical and radiographic manifestations is varied, with diagnosis largely based on clinical suspicion, cranial magnetic resonance imaging, and myelography. Numerous treatment options are available, but much remains to be learned about this disorder.

Chronic subdural haematoma: surgical treatment and outcome in 1000 cases

2004-11-12

Miguel Gelabert‐González , M. Iglesias-País , A. García-Allut +1 more

Dural enhancement and cerebral displacement secondary to intracranial hypotension

1993-03-01

Robert A. Fishman , William P. Dillon

We studied a patient with spontaneous intracranial hypotension whose gadolinium-enhanced MRI revealed an extraordinary degree of dural enhancement and striking displacement of the optic chiasm, flattening of the pons, and … We studied a patient with spontaneous intracranial hypotension whose gadolinium-enhanced MRI revealed an extraordinary degree of dural enhancement and striking displacement of the optic chiasm, flattening of the pons, and downward displacement of the cerebellar tonsils. These changes were reversed when a CSF leak at the site of a T12-L1 arachnoid cyst was closed following an epidural blood patch. Such diffuse meningeal enhancement results from the dural venous dilatation that accompanies a reduced CSF volume, a consequence of the Monro-Kellie rule.

Patterns of Contrast Enhancement in the Brain and Meninges

2007-03-01

James G. Smirniotopoulos , Frances M. Murphy , E J Rushing +2 more

Contrast material enhancement for cross-sectional imaging has been used since the mid 1970s for computed tomography and the mid 1980s for magnetic resonance imaging. Knowledge of the patterns and mechanisms … Contrast material enhancement for cross-sectional imaging has been used since the mid 1970s for computed tomography and the mid 1980s for magnetic resonance imaging. Knowledge of the patterns and mechanisms of contrast enhancement facilitate radiologic differential diagnosis. Brain and spinal cord enhancement is related to both intravascular and extravascular contrast material. Extraaxial enhancing lesions include primary neoplasms (meningioma), granulomatous disease (sarcoid), and metastases (which often manifest as mass lesions). Linear pachymeningeal (dura-arachnoid) enhancement occurs after surgery and with spontaneous intracranial hypotension. Leptomeningeal (pia-arachnoid) enhancement is present in meningitis and meningoencephalitis. Superficial gyral enhancement is seen after reperfusion in cerebral ischemia, during the healing phase of cerebral infarction, and with encephalitis. Nodular subcortical lesions are typical for hematogenous dissemination and may be neoplastic (metastases) or infectious (septic emboli). Deeper lesions may form rings or affect the ventricular margins. Ring enhancement that is smooth and thin is typical of an organizing abscess, whereas thick irregular rings suggest a necrotic neoplasm. Some low-grade neoplasms are “fluid-secreting,” and they may form heterogeneously enhancing lesions with an incomplete ring sign as well as the classic “cyst-with-nodule” morphology. Demyelinating lesions, including both classic multiple sclerosis and tumefactive demyelination, may also create an open ring or incomplete ring sign. Thick and irregular periventricular enhancement is typical for primary central nervous system lymphoma. Thin enhancement of the ventricular margin occurs with infectious ependymitis. Understanding the classic patterns of lesion enhancement—and the radiologic-pathologic mechanisms that produce them—can improve image assessment and differential diagnosis.

SPREADING DEPRESSION OF ACTIVITY IN THE CEREBRAL CORTEX

1944-11-01

A. A. P. Leão

Avoiding Pitfalls in the Diagnosis of Subarachnoid Hemorrhage

2000-01-06

Jonathan A. Edlow , Louis R. Caplan

"For it happens in this, as the physicians say it happens in hectic fever, that in the beginning of the malady it is easy to cure but difficult to detect, … "For it happens in this, as the physicians say it happens in hectic fever, that in the beginning of the malady it is easy to cure but difficult to detect, but in the course of time, not having been either detected or treated in the beginning, it becomes easy to detect but difficult to cure." — Niccolò Machiavelli, The Prince Patients with headache account for 1 to 2 percent of visits to the emergency department14 and up to 4 percent of visits to physicians' offices.5 Most have primary headache disorders, such as migraine and tension-type headaches. Only a few . . .

A classification system of spontaneous spinal CSF leaks

2016-07-21

Wouter I. Schievink , M. Marcel Maya , Stacey Jean-Pierre +3 more

<h3>Objective:</h3> Spontaneous spinal CSF leaks cause spontaneous intracranial hypotension but no systematic study of the different types of these CSF leaks has been reported. Based on our experience with spontaneous … <h3>Objective:</h3> Spontaneous spinal CSF leaks cause spontaneous intracranial hypotension but no systematic study of the different types of these CSF leaks has been reported. Based on our experience with spontaneous intracranial hypotension, we propose a classification system of spontaneous spinal CSF leaks. <h3>Methods:</h3> We reviewed the medical records, radiographic studies, operative notes, and any intraoperative photographs of a group of consecutive patients with spontaneous intracranial hypotension. <h3>Results:</h3> The mean age of the 568 patients (373 [65.7%] women) was 45.7 years. Three types of CSF leak could be identified. Type 1 CSF leaks consisted of a dural tear (151 patients [26.6%]) and these were almost exclusively associated with an extradural CSF collection. Type 1a represented ventral CSF leaks (96%) and type 1b posterolateral CSF leaks (4%). Type 2 CSF leaks consisted of meningeal diverticula (240 patients [42.3%]) and were the source of an extradural CSF collection in 53 of these patients (22.1%). Type 2a represented simple diverticula (90.8%) and type 2b complex meningeal diverticula/dural ectasia (9.2%). Type 3 CSF leaks consisted of direct CSF-venous fistulas (14 patients [2.5%]) and these were not associated with extradural CSF collections. A total of 163 patients (28.7%) had an indeterminate type and extradural CSF collections were noted in 84 (51.5%) of these patients. <h3>Conclusions:</h3> We identified 3 types of spontaneous spinal CSF leak in this observational study: the dural tear, the meningeal diverticulum, and the CSF-venous fistula. These 3 types and the presence or absence of extradural CSF form the basis of a comprehensive classification system.

Pathophysiology of chronic subdural haematoma: inflammation, angiogenesis and implications for pharmacotherapy

2017-05-30

Ellie Edlmann , Susan Giorgi-Coll , Peter C. Whitfield +2 more

Chronic subdural haematoma (CSDH) is an encapsulated collection of blood and fluid on the surface of the brain. Historically considered a result of head trauma, recent evidence suggests there are … Chronic subdural haematoma (CSDH) is an encapsulated collection of blood and fluid on the surface of the brain. Historically considered a result of head trauma, recent evidence suggests there are more complex processes involved. Trauma may be absent or very minor and does not explain the progressive, chronic course of the condition. This review focuses on several key processes involved in CSDH development: angiogenesis, fibrinolysis and inflammation. The characteristic membrane surrounding the CSDH has been identified as a source of fluid exudation and haemorrhage. Angiogenic stimuli lead to the creation of fragile blood vessels within membrane walls, whilst fibrinolytic processes prevent clot formation resulting in continued haemorrhage. An abundance of inflammatory cells and markers have been identified within the membranes and subdural fluid and are likely to contribute to propagating an inflammatory response which stimulates ongoing membrane growth and fluid accumulation. Currently, the mainstay of treatment for CSDH is surgical drainage, which has associated risks of recurrence requiring repeat surgery. Understanding of the underlying pathophysiological processes has been applied to developing potential drug treatments. Ongoing research is needed to identify if these therapies are successful in controlling the inflammatory and angiogenic disease processes leading to control and resolution of CSDH.

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Middle Meningeal Artery Embolization for Chronic Subdural Hematoma

2017-10-11

Seung Pil Ban , Gyojun Hwang , Hyoung Soo Byoun +7 more

Purpose To evaluate the effect of middle meningeal artery (MMA) embolization on chronic subdural hematoma (CSDH) and compare the treatment outcomes of MMA embolization and conventional treatment. Materials and Methods … Purpose To evaluate the effect of middle meningeal artery (MMA) embolization on chronic subdural hematoma (CSDH) and compare the treatment outcomes of MMA embolization and conventional treatment. Materials and Methods All consecutive patients 20 years or older with CSDH were assessed for eligibility. CSDHs with a focal location, a thickness of 10 mm or less, no mass effect, or underlying conditions were excluded. Seventy-two prospectively enrolled patients with CSDH underwent MMA embolization (embolization group; as the sole treatment in 27 [37.5%] asymptomatic patients and with additional hematoma removal for symptom relief in 45 [62.5%] symptomatic patients). For comparison, 469 patients who underwent conventional treatment were included as a historical control group (conventional treatment group; close, nonsurgical follow-up in 67 [14.3%] and hematoma removal in 402 [85.7%] patients). Primary outcome was treatment failure defined as a composite of incomplete hematoma resolution (remaining or reaccumulated hematoma with thickness > 10 mm) or surgical rescue (hematoma removal for relief of symptoms that developed with continuous growth of initial or reaccumulated hematoma). Secondary outcomes included surgical rescue as a component of the primary outcome and treatment-related complication for safety measure. Six-month outcomes were compared between the study groups with logistic regression analysis. Results Spontaneous hematoma resolution was achieved in all of 27 asymptomatic patients undergoing embolization without direct hematoma removal. Hematoma reaccumulation occurred in one (2.2%) of 45 symptomatic patients receiving embolization with additional hematoma removal. Treatment failure rate in the embolization group was lower than in the conventional treatment group (one of 72 patients [1.4%] vs 129 of 469 patients [27.5%], respectively; adjusted odds ratio [OR], 0.056; 95% confidence interval [CI]: 0.011, 0.286; P = .001). Surgical rescue was less frequent in the embolization group (one of 72 patients [1.4%] vs 88 of 469 patients [18.8%]; adjusted OR, 0.094; 95% CI: 0.018, 0.488; P = .005). Treatment-related complication rate was not different between the two groups (0 of 72 patients vs 20 of 469 patients [4.3%]; adjusted OR, 0.145; 95% CI: 0.009, 2.469; P = .182). Conclusion MMA embolization has a positive therapeutic effect on CSDH and is more effective than conventional treatment. © RSNA, 2017

Subarachnoid haemorrhage

2007-04-01

Rustam Al‐Shahi Salman , W P A N E T H -H H A M , Davenport Richard J +2 more

Pavlovian conditioning: It's not what you think it is.

1988-01-01

Robert A. Rescorla

Current thinking about Pavlovian conditioning differs substantially from that of 20 years ago.Yet the changes that have taken place remain poorly appreciated by psychologists generally.Traditional descriptions of conditioning as the … Current thinking about Pavlovian conditioning differs substantially from that of 20 years ago.Yet the changes that have taken place remain poorly appreciated by psychologists generally.Traditional descriptions of conditioning as the acquired ability of one stimulus to evoke the original response to another because of their pairing are shown to be inadequate.They fail to characterize adequately the circumstances producing learning, the content of that learning, or the manner in which that learning influences performance.Instead, conditioning is now described as the learning of relations among events so as to allow the organism to represent its environment.Within this framework, the study of Pavlovian conditioning continues to be an intellectually active area, full of new discoveries and information relevant to other areas of psychology.

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Huber needle and Tuohy catheter.

1995-05-01

Joseph Eldor

Associations of Refractory Spontaneous Intracranial Hypotension and Chronic Subdural Hematoma with Factor XIII Deficiency: A Case Report

2025-06-23

Takahiro Tsuchiya , Satoru Miyawaki , Keita Saito +7 more | Asian Journal of Neurosurgery

Abstract The co-occurrence of spontaneous intracranial hypotension (SIH) due to thoracic dural tear and factor XIII deficiency (FXIIID) is rare and may result in chronic subdural hematoma (CSDH). CSDH often … Abstract The co-occurrence of spontaneous intracranial hypotension (SIH) due to thoracic dural tear and factor XIII deficiency (FXIIID) is rare and may result in chronic subdural hematoma (CSDH). CSDH often recurs and is difficult to treat, despite appropriate treatment. However, there is no definitive knowledge on the optimal timing of factor XIII (FXIII) supplementation or therapeutic interventions, such as epidural blood patch (EBP) and burr hole drainage (BHD). We present a case of refractory SIH and CSDH associated with FXIIID. Considering an ineffective initial EBP, we performed a second EBP after observing sufficiently high FXIII activity; SIH was cured subsequently. The patient experienced SIH recurrence after 14 months and was treated with a combination of EBP and BHD, with sufficient FXIII supplementation. CSDH disappeared and did not recur for more than 12 months. During the treatment of SIH and CSDH associated with FXIIID, surgical treatment such as EBP appeared ineffective due to low FXIII activity. This necessitates intravenous supplementation of FXIII to maintain sufficient FXIII activity. Regular monitoring of FXIII activity is also necessary to prevent CSDH recurrence.

Active Cerebrospinal Fluid Exchange vs External Ventricular Drainage in the Neurocritical Care Unit: An International, Retrospective Cohort Study

2025-06-23

Behnam Rezai Jahromi , Gracie Monachello , Muhammad Babar Khan +7 more | Neurosurgery

Active cerebrospinal fluid exchange (ACE) through the dual-lumen IRRAflow catheter is a technique that has been used in the treatment of intraventricular hemorrhage and subarachnoid hemorrhage, ventriculitis, and others. Previous … Active cerebrospinal fluid exchange (ACE) through the dual-lumen IRRAflow catheter is a technique that has been used in the treatment of intraventricular hemorrhage and subarachnoid hemorrhage, ventriculitis, and others. Previous reports have consisted of small numbers of patients and focused on particular conditions. Our objective was to complete a multi-institutional retrospective cohort study to evaluate the safety and clinical outcomes of ACE therapy through the IRRAflow catheter. Multiple academic neurocritical care units from the United States and Europe contributed patients treated with either ACE or external ventricular drainage to a retrospective database. Complications including failure to drain, inadvertent removal, infection, cerebrospinal fluid leak, insertional hemorrhage, and early replacement were compared. Shunt dependence and modified Rankin score were also compared. A total of 401 treated with external ventricular drainage and 118 treated with ACE were included. Diagnoses included were subarachnoid hemorrhage, intraventricular hemorrhage, and ventriculitis. ACE therapy showed fewer overall complications (odds ratio [OR] = 0.29, P < .0001), failures to drain (OR = 0.21, P = .0004), infections (OR = 0.2, P < .0001), cerebrospinal fluid leak (OR = 0.26, P = .017), and early replacements (OR = 0.4, P = .036). There was no difference in insertional hemorrhage or inadvertent removal. ACE therapy was associated with a lower rate of shunt dependence (OR = 0.28, P < .0001) and higher likelihood of discharge with an modified Rankin score of 0 to 2 (OR = 2.47, P = .001). ACE therapy with the IRRAflow catheter is associated with fewer complications and improvement in some clinical outcomes. These results need to be confirmed with prospective and randomized trials.

Inpatient neurosurgical mortality in germany: a comprehensive analysis of 2023 in-hospital data

2025-06-23

Marcel A. Kamp , Christine Jungk , Matthias Schneider +5 more | Neurosurgical Review

Abstract Background Neurosurgical conditions and procedures are associated with varying in-hospital mortality rates, which represent one of several quality indicators. This study aims to determine and report in-hospital mortality rates … Abstract Background Neurosurgical conditions and procedures are associated with varying in-hospital mortality rates, which represent one of several quality indicators. This study aims to determine and report in-hospital mortality rates across German neurosurgical departments in 2023. Methods A cross-sectional analysis of all neurosurgical cases treated in Germany in 2023 was conducted using nationwide hospital billing data reported under § 21 of the Hospital Remuneration Act. In-hospital mortality was defined as death during hospitalization (discharge status: deceased). Results Neurosurgical departments treated 222,158 inpatient cases, with 49% female and 48% aged ≥ 65 years. The overall mortality rate was 3.8% (8,338 cases), with significantly lower rates in females (3.3% vs. 4.2%, p < 0.0001). The most common fatal diagnoses included traumatic subdural hematomas (1,278 cases), subcortical intracerebral hemorrhages (611 cases) and traumatic subarachnoid hemorrhages (504 cases). Mortality rates varied by diagnosis: malignant brain tumors (4%), cerebral metastases (6%), benign meningeal tumors (1.3%), non-traumatic subarachnoid hemorrhages (7%), intracerebral hemorrhages (29%), and traumatic subdural hematomas (12%). Mortality for selected procedures was 3% for primary brain tumor resections, 9% for vascular reconstructions, 1% for spinal fusions, 2% for dynamic stabilizations, and 4% for vertebral body replacements. Conclusions This study analyzes and reports neurosurgical in-hospital mortality rates in Germany, providing a national benchmark that may inform clinicians, policymakers, and patients. While the use of administrative billing data imposes inherent limitations — particularly regarding clinical detail and causality — the findings may offer a foundation for future research. Subsequent studies should aim to explore disease- and procedure-specific mortality more granularly and may identify underlying risk factors. Clinical trial number Not applicable.

Endless-Loop Craniotomy for Revision Surgery After the Burr-Hole Evacuation of Chronic Subdural Hematoma—A Technical Note

2025-06-21

Artem Rafaelian , Sae‐Yeon Won , Thomas M. Freiman +2 more | Surgical Techniques Development

Background and Importance: Chronic subdural hematoma (cSDH) is a common and complex neurosurgical problem, particularly in elderly patients. Revision surgery for chronic subdural hematoma can be challenging, particularly in cases … Background and Importance: Chronic subdural hematoma (cSDH) is a common and complex neurosurgical problem, particularly in elderly patients. Revision surgery for chronic subdural hematoma can be challenging, particularly in cases with inhomogeneous, firm consistency and extensive adhesions. Clinical Presentation: In this article, we present our endless-loop craniotomy technique, which offers a novel approach to address these challenges by performing the wide, curved exposure of the subdural space utilizing the already-present burr hole. This technique allows for a wide, unobstructed view of the subdural space, enabling the access and evacuation of this chronic and often adhesive subdural hematoma. Conclusion: We believe that endless-loop craniotomy is a valuable addition to the neurosurgeon’s armamentarium for managing complex cases of revision surgery in chronic subdural hematomas.

Outcomes of CT-Guided Targeted Epidural Patching For Lateral Dural Tears In Spontaneous Intracranial Hypotension: A Multicenter Retrospective Cohort Study

2025-06-20

Andrew L. Callen , Daniel Montes , Debayan Bhaumik +7 more | American Journal of Neuroradiology

Spontaneous intracranial hypotension (SIH) due to lateral dural tears with spinal longitudinal extradural fluid collections (SLECs) can cause disabling orthostatic headaches. While epidural patching is commonly used as first-line treatment, … Spontaneous intracranial hypotension (SIH) due to lateral dural tears with spinal longitudinal extradural fluid collections (SLECs) can cause disabling orthostatic headaches. While epidural patching is commonly used as first-line treatment, outcomes specific to lateral dural tears have not been well characterized. We aimed to evaluate clinical and radiologic outcomes following CT-guided patching for lateral dural tears and assess whether anatomic or procedural factors- including presence of a herniated arachnoid pouch, patch volume, material, or approach-influence treatment success. This was a retrospective multicenter cohort study of patients with lateral dural tears treated with CT-guided epidural patching between December 2013 and March 2025. Demographics, leak characteristics, patching details, and clinical and imaging outcomes were collected. The presence of herniated arachnoid pouches on spine MRI and pre/post-treatment Bern scores were recorded. Associations between clinical resolution, SLEC resolution, and procedural variables were analyzed using univariate methods. Fifty-six patients (mean age 38.7 ± 11.7 years; 80% female) were included. Mean pretreatment Bern score was 6.6 ± 2.3; no patients had superficial siderosis. Clinical resolution occurred in 20/56 (35.7%), and SLEC resolution in 10/40 (25%) on post-patch spine MRI. A herniated arachnoid pouch was present in 69.7% and associated with lower SLEC resolution (30% vs. 80%, p=0.003). Patch type, volume, transforaminal approach, and needle placement into the herniated pouch were not associated with outcomes. Post-patch Bern scores were lower among those with clinical resolution (0.9 ± 1.1 vs. 2.6 ± 2.5, p=0.046). Of 11 patients with complete clinical improvement who had post-patch spine MRI, 5 (45.5%) had persistent SLECs. CT-guided patching led to complete symptom resolution in roughly one-third of patients with lateral dural tears. Herniated arachnoid predicted lower SLEC resolution, while procedural variables were not predictive of outcome. A subset of patients improved clinically despite persistent extradural fluid, emphasizing the need for long-term monitoring.ABBREVIATIONS: SIH＝ spontaneous intracranial hypotension; SLEC = spinal longitudinal extradural fluid collection.

Added Value of Adjunctive Middle Meningeal Embolization to Surgical Evacuation for Chronic Subdural Hematoma: Comprehensive Meta-Analysis Based on Controlling Confounders

2025-06-20

Seyed Farzad Maroufi , Mohammad Sadegh Fallahi , Sahar Afsahi +4 more | Neurosurgery

BACKGROUND AND OBJECTIVES: Chronic subdural hematoma (CSDH) often recurs after surgical evacuation, with rates ranging from 2% to 37%. Middle meningeal artery embolization (MMAE) has emerged as a potential adjunct … BACKGROUND AND OBJECTIVES: Chronic subdural hematoma (CSDH) often recurs after surgical evacuation, with rates ranging from 2% to 37%. Middle meningeal artery embolization (MMAE) has emerged as a potential adjunct to surgery to reduce recurrence. The aim of this study was to systematically review the added value of adjunctive MMAE to surgical treatment (MMAE+S) compared with surgical treatment alone (S) in managing CSDH with consideration to matching and randomization status of the 2 groups. METHODS: A systematic search identified 16 studies encompassing 1814 patients (939 MMAE+S, 1440 S). Five studies were randomized trials, 3 studies were matched studies, and the remaining were unmatched cohorts. Data on recurrence, radiological and functional outcomes, complications, and hospital stay were analyzed using a random-effects meta-analysis. The risk of bias was evaluated using Risk of Bias in Nonrandomized Studies of Interventions and Risk of Bias in Randomized Trials tools. RESULTS: The 2 treatment groups were comparable regarding all preoperative characteristics except for antithrombotic use which was higher in the MMAE+S group ( P = .03). Compared with surgery alone, the MMAE+S group had significantly lower recurrence rates (4.7% vs 17.7%, relative risk [RR] 0.31, P < .01) and reduced postoperative hematoma thickness (standardized mean difference [SMD] −0.17, P = .04), volume (SMD −0.25, P = .01), and midline shift (SMD −0.24, P = .01). Reduced recurrence was also observed in the subgroup of matched/randomized studies (RR 0.28, P < .01) and only randomized studies (RR 0.28, P < .01). Complication rates were comparable between the 2 groups when analyzing all (RR 0.90, P = .46), matched/randomized (RR 1.05, P = .62), and only randomized studies (RR 1.05, P = .63). The outcomes were influenced by the choice of embolic agent and timing of embolization, with liquid agents, and postoperative embolization showing slightly better outcomes compared with other embolization approaches. Functional outcomes, complications, mortality, and length of hospital stay were comparable between groups. CONCLUSION: MMAE combined with surgery effectively reduces CSDH recurrence and improves radiological outcomes without increasing complications. These findings support MMAE as a valuable adjunct to surgical treatment, warranting further research to optimize its clinical application.

How many cranial CT scans does a man need?

2025-06-19

Josef G. Heckmann , Martin Breckner , Michael Reng | Practical Neurology

A 61-year-old man had epilepsy related to chronic alcoholism and occipito-temporal porencephaly. Over a span of 19 years, he had been admitted to our institution 227 times, undergoing 55 CT … A 61-year-old man had epilepsy related to chronic alcoholism and occipito-temporal porencephaly. Over a span of 19 years, he had been admitted to our institution 227 times, undergoing 55 CT scans of the head and 11 CT scans of the cervical spine. His blood alcohol concentrations varied between 1.9 g/L and 5.1 g/L. We discuss the challenges of emergency management of patients with alcoholism and seizures and the overuse of radiological examinations.

Effectiveness of subdural evacuating port system (SEPS) and middle meningeal artery embolization (MMAE) for chronic subdural hematomas – a multicenter experience

2025-06-19

Jaims Lim , Vinay Jaikumar , Alexandra R. Paul +7 more | Journal of NeuroInterventional Surgery

Background Craniotomy for subdural hematoma (SDH) in elderly patients with comorbidities can be challenging. The Subdural Evacuating Port System (SEPS; Medtronic, Minneapolis, MN) offers a less invasive alternative, while middle … Background Craniotomy for subdural hematoma (SDH) in elderly patients with comorbidities can be challenging. The Subdural Evacuating Port System (SEPS; Medtronic, Minneapolis, MN) offers a less invasive alternative, while middle meningeal artery embolization (MMAE) has shown effectiveness in preventing SDH recurrence. We evaluated the combined effectiveness of SEPS+MMAE for chronic SDH (cSDH) treatment. Methods Retrospective database reviews were conducted. Demographic, comorbidity, procedural, and outcomes data were analyzed. cSDH resolution was tracked by measuring hematoma volumes on noncontrast computed tomograms pre-SEPS+MMAE, 24–48 hours post-SEPS+MMAE, and 6–8 weeks afterward (follow-up-SEPS+MMAE). Results Our study included 114 patients (median age: 77 years (interquartile range (IQR): 69–83 years); men: women=74:40) with 134 cSDHs treated with SEPS+MMAE were included. Median pre-SEPS+MMAE cSDH volume was 122.9 mL (88–152.4 mL) with midline shift of 6 mm (3.4–9.5 mm). Most MMAE procedures were performed under general anesthesia (68.7%), utilizing the femoral approach (61.9%) and particle embolic agents (55.2%). In-hospital rescue craniotomy was required after 10 (7.5%) procedures. Median post-SEPS+MMAE and follow-up-SEPS+MMAE cSDH volume reductions were 71.1 mL (54.1–94.8 mL) and 23.4 mL (2–56.3 mL), respectively, resulting in 38.1% (22.1–52.9%) and 79.9% (51–97.8%) reductions, respectively. Of 109 patients with follow-up, 10 (9.2%) were readmitted for cSDH residual/recurrence within 90 days, eight (7.3%) required retreatment: five (4.6%) with craniotomy, three (2.8%) with SEPS. Hyperlipidemia (P=0.002), anticoagulant use (P=0.036), and larger pre-SEPS+MMAE cSDH volume (P<0.001) predicted greater SEPS-mediated clearance. Older age (P=0.03), coronary artery disease (P=0.004), membranes within cSDH (P=0.039), acute/subacute components in cSDH (P=0.047), and unilateral cSDH (P=0.017) predicted less SEPS-mediated clearance. Older age (P=0.006), acute/subacute components in cSDH (P=0.016), and longer follow-up (P=0.013) predicted higher MMAE effectiveness. Higher pre-SEPS+MMAE cSDH volume (P=0.047) and unilateral MMAE for bilateral cSDH (P=0.036) predicted lower MMAE effectiveness. Conclusion SEPS+MMAE was an effective, safe treatment for cSDH.

Phosphodiesterase 4 regulates pyroptosis in subarachnoid hemorrhage

2025-06-19

Jiahe Tan , Yinrui Ma , Rui Song +3 more | Neural Regeneration Research

Abstract Phosphodiesterase 4 is a key enzyme involved in the regulation of cell signal transduction, but its role in subarachnoid hemorrhage remains unclear. Neuronal pyroptosis has been reported to be … Abstract Phosphodiesterase 4 is a key enzyme involved in the regulation of cell signal transduction, but its role in subarachnoid hemorrhage remains unclear. Neuronal pyroptosis has been reported to be involved in early brain injury after subarachnoid hemorrhage. This study aimed to investigate whether phosphodiesterase 4 contributes to early brain injury after subarachnoid hemorrhage by mediating neuronal pyroptosis and its related mechanisms. Endovascular perforation of male C57BL/6J mice was performed to model subarachnoid hemorrhage in vivo , and oxyhemoglobin was added to the culture medium of primary neurons to model subarachnoid hemorrhage in vitro . A phosphodiesterase 4-specific inhibitor, etazolate, was intraperitoneally injected 30 minutes after subarachnoid hemorrhage induction. Small interfering RNA (siRNA) was administered intracerebroventricularly 72 hours before subarachnoid hemorrhage to achieve genetic knockdown of phosphodiesterase 4. To investigate the mechanism, a nucleotide-binding oligomerization domain-like receptor pyrin domain containing 3 (NLRP3)-specific agonist, nigericin, was intracerebroventricularly injected 60 minutes before subarachnoid hemorrhage. Neuronal phosphodiesterase 4 expression increased after subarachnoid hemorrhage and reached the highest point at 24 hours. Etazolate treatment reduced neurological deficits and brain edema in mice, alleviated neuronal pyroptosis and inflammatory response, and improved neuronal injury. Treatment with phosphodiesterase 4 siRNA had the same neuroprotective effects as etazolate. Mechanistically, phosphodiesterase 4 triggered the nuclear factor kappa-B pathway, and simultaneously caused lysosomal and mitochondrial dysfunction after subarachnoid hemorrhage, which promoted NLRP3 inflammasome activation and induced neuronal pyroptosis. Blocking of phosphodiesterase 4 inhibited the nuclear factor kappa-B pathway, and improved lysosome and mitochondrial function. Activation of NLRP3 reversed the neuroprotective effects of etazolate without affecting phosphodiesterase 4 expression. Together, the results indicate that phosphodiesterase 4 regulates NLRP3-mediated neuronal pyroptosis in early brain injury after subarachnoid hemorrhage. Phosphodiesterase 4 may be a potential therapeutic molecular target for subarachnoid hemorrhage.

Systematic Review of the predictive value of negative brain or low probability brain MRIs in patients with CSF venous fistulas

2025-06-18

Angelique Sao‐Mai S. Tay , Marcel Maya , Peter G. Kranz +2 more | American Journal of Neuroradiology

Since the discovery of the cerebrospinal fluid venous fistula, its diagnosis has become more frequent, especially in patients with brain MRIs positive for spontaneous intracranial hypotension (SIH). However, there is … Since the discovery of the cerebrospinal fluid venous fistula, its diagnosis has become more frequent, especially in patients with brain MRIs positive for spontaneous intracranial hypotension (SIH). However, there is a need to understand the likelihood of diagnosis of a cerebrospinal fluid venous fistula in a patient with negative brain imaging. Our aim was to investigate the frequency of cerebrospinal fluid venous fistula in patients suspected of SIH who have negative neuroaxis MRIs. All studies reporting on the incidence of cerebrospinal fluid venous fistula in patients with negative neuroaxis MRIs or low probability scores according to the Bern and Mayo score were searched on PubMed, EMBASE, Scopus, Web of Science and Cochrane. Nine studies comprising of 898 patients suspected of SIH with 80 cerebrospinal fluid venous fistulas were included. Data were collected on patient demographics, number of patients found to have negative neuroaxis MRIs or low probability scores according to the Bern or Mayo scoring systems, type of imaging used, and number of patients diagnosed with cerebrospinal fluid venous fistula. Analysis was performed using the standard method for evaluating the negative predictive value of a diagnostic test. There were 27 (10.7%) patients with a cerebrospinal fluid venous fistula of 252 patients found to have negative brain MRIs, 15 (18.3%) of 82 patients found to have low probability on the Bern score, and 38 (34.8%) of 109 patients found to have low probability on the Mayo score. The negative predictive value of a negative brain MRI was 0.89 (95%CI, 0.86-0.92), 0.81 (95% CI, 0.77-0.87) for the Bern score, and 0.65 (95% CI, 0.58-0.72) for the Mayo score. Our review was limited by heterogeneity of the reference standard and few studies in each subcategory. This review demonstrated that a negative brain MRI is effective in predicting that a patient will not have a CVF, with a high NPV of 89%. However, a patient with a strong clinical suspicion for CSF leak should be considered for more invasive imaging. bMRI-- negative brain magnetic resonance imaging, CTM - computed tomography myelogram, CVF - cerebrospinal fluid venous fistula, dCTM-BT - lateral decubitus dynamic CTM protocol using real-time bolus-tracking, DSM - digital subtraction myelogram, NPV - negative predictive value, PC-CTM - photon-counting detector CT myelography.

Investigation of the frequency of meningothelial hyperplasia and its clinicopathological correlation in patients diagnosed with subdural hematoma

2025-06-18

Fadime Eda Gökalp Satıcı , Gözde Arslan , Hamide Sayar | Annals of Diagnostic Pathology

Upward migration of subduroperitoneal shunt catheters in an infant: a rare complication in the treatment of chronic subdural hematoma

2025-06-18

G.H. Choi , Na Young Jung , Sun Geon Yoon +3 more | Neurofunction

Pulmonary embolism presenting with syncope, complicated by fatal delayed acute subdural hemorrhage

2025-06-18

Guo Li , Mingming Yang , Bo Cheng +1 more | Medicina Clínica Práctica

Case Report of a Rare but Serious Complication in Anesthesia: Arachnoiditis Following an Epidural Blood Patch

2025-06-18

David Kalpers , Jérome Jean | Cureus

Simulation of cerebrospinal fluid (CSF)-venous fistula embolization in a swine model: A technical video

2025-06-18

Esref Alperen Bayraktar , Jonathan Cortese , Julien Ognard +5 more | Interventional Neuroradiology

Cerebrospinal fluid venous fistulas (CSFVF) can lead to spontaneous intracranial hypotension, causing debilitating symptoms in patients. The transvenous embolization technique has been developed to occlude leakage sites via an endovascular … Cerebrospinal fluid venous fistulas (CSFVF) can lead to spontaneous intracranial hypotension, causing debilitating symptoms in patients. The transvenous embolization technique has been developed to occlude leakage sites via an endovascular approach. However, the spinal venous anatomy remains relatively unfamiliar to many neurointerventionalists. This technical video presents a swine model designed to train physicians in navigating the spinal venous system, performing embolization injections, observing their spread, and testing new embolization systems for treating CSFVF. Although there are slight anatomical differences, the spinal venous system in swine closely resembles that of humans, including its navigability and employing liquid embolic agents. We successfully embolized multilevel spinal vasculature that can potentially drain into a fistula formation, without any complications.

Effectiveness of subdural evacuating port system (SEPS) and middle meningeal artery embolization (MMAE) for chronic subdural hematomas

2025-06-18

Vinay Jaikumar , Jaims Lim , Patrick Wahlig +7 more | Interventional Neuroradiology

Background Performing a craniotomy for chronic subdural hematoma (cSDH) in elderly patients with comorbidities can be challenging. The Subdural Evacuating Port System (SEPS; Medtronic, Dublin, Ireland) offers a less-invasive alternative, … Background Performing a craniotomy for chronic subdural hematoma (cSDH) in elderly patients with comorbidities can be challenging. The Subdural Evacuating Port System (SEPS; Medtronic, Dublin, Ireland) offers a less-invasive alternative, while middle meningeal artery embolization (MMAE) has shown effectiveness in preventing cSDH recurrence. However, the combined effectiveness of SEPS and MMAE (SEPS + MMAE) remains unclear. This study reports the outcomes of patients undergoing a combination of these procedures for the treatment of cSDH. Methods A retrospective review of our medical records database was conducted to identify patients with cSDH who were treated with SEPS + MMAE between January 1, 2021, and April 1, 2024. Demographics, comorbidities, procedure, and outcomes data were analyzed. cSDH resolution was tracked by measuring hematoma volumes on noncontrast computed tomography scans pre-SEPS + MMAE, 24–48 h postprocedure, and 6–8 weeks postprocedure. Results A total of 35 patients (median age: 77 years [interquartile range (IQR):69–85.5]; men:woman = 22:13) with 49 cSDH, of which 41 cSDHs receiving combined SEPS + MMAE were included. Notably, 38 (92.7%) of the 41 cSDHs were holohemispheric, and 15 (36.6%) had an acute or subacute component. The median pre-SEPS + MMAE cSDH volume was 121.9 mL [IQR:87.9–153.4 mL] with a median midline shift of 6.6 mm [IQR:3.5–10 mm]. All MMAE procedures were performed under conscious sedation. The femoral approach was utilized in 19 patients (54.3%). Three patients required rescue craniotomy. Median post-SPES + MMAE volume was 71.1 mL [IQR:54.5–93.2], resulting in a 38% [IQR:21.9–53] reduction in cSDH volume; and median follow-up SEPS + MMAE volume was 22 mL [IQR:2–59.2] resulting in an 81% [IQR:50.9–98.1] reduction in cSDH volume, compared to pre-SEPS + MMAE levels. Seven (17.1%) patients required readmission for residual or recurrent cSDH within 90 days. Five of these patients were retreated (12.2%), two of whom required craniotomy (4.9%). Conclusion Our experience suggests that SEPS + MMAE was an effective method of cSDH treatment and was associated with low complication rates.

Surgical evacuation without versus with middle meningeal artery embolization in chronic subdural hematoma: A meta-analysis of randomized controlled trials

2025-06-16

Jun Liu , Can Tang , Lanjun Xie +3 more | Neurological Sciences

Availability, Accessibility, and Utilization of Diagnostics and Therapeutics for Spontaneous Intracranial Hypotension in Asia

2025-06-16

Soyoun Choi , Woo-Seok Ha , Soo‐Jin Cho +7 more | Deleted Journal

Development of spontaneous subarachnoid-cutaneous fistula after the removal of epidural catheter and its management: A case report

2025-06-16

Bhanupreet Kaur , Minnu Panditrao , N.K. Bansal +1 more | Saudi Journal of Anaesthesia

Continuous epidural catheter technique is generally a safe modality. A rare occurrence of development of subarachnoid-cutaneous fistula (SACF), postremoval of epidural catheter, is described. It can be potentially challenging to … Continuous epidural catheter technique is generally a safe modality. A rare occurrence of development of subarachnoid-cutaneous fistula (SACF), postremoval of epidural catheter, is described. It can be potentially challenging to diagnose and treat. A watchful and patient conservative approach is highly recommended for successful outcomes.

The Value of Texture Analysis in Postoperative Recurrence of Chronic Subdural Hematoma

2025-06-16

Yu Yan , Jianchao Wang , Jincai Fang +1 more | Journal of Korean Neurosurgical Society

Texture analysis is widely used in all walks of life, and also in medicine. This paper aims to discuss the value of texture analysis in postoperative recurrence of chronic subdural … Texture analysis is widely used in all walks of life, and also in medicine. This paper aims to discuss the value of texture analysis in postoperative recurrence of chronic subdural hematoma (CSDH). A total of 173 patients with CSDH who were hospitalized in our hospital from January 2018 to August 2023 were selected . All the patients underwent magnetic resonance imaging (MRI) examinations before surgery. According to whether patients with CSDH have relapsed after surgery, the patients are divided into recurrence group and non-recurrence group. FireVoxel software (https://firevoxel.org) was used to manually delineate the region of interest on the largest level of the hematoma cavity during MRI plain scans and measure the texture parameters. The texture parameters with statistical difference were analyzed by receiver operating characteristic curve. Heterogeneity and entropy texture parameters in the recurrence group were statistically different from those in the nonrecurrence group (p<0.05). When the cut-off point of the heterogeneity parameter was 0.284, the sensitivity, specificity, and accuracy of judging whether CSDH relapsed were 83.3%, 80.4%, and 80.7%, respectively. Texture analysis of CSDH can provide a new method to judge the recurrence of patients with CSDH.

Symptomatic cerebral spinal fluid leak (or intracranial hypotension) due to sacral extradural cyst rupture after sacral fracture: illustrative case

2025-06-16

Breanna L. Sheldon , Jerry M. Brown , Hasan Ozgur +1 more | Journal of Neurosurgery Case Lessons

BACKGROUND Intracranial hypotension due to a CSF leak has many possible etiologies including traumatic dural tears, CSF-venous fistulas, iatrogenic causes, and elevated intracranial pressure. An example of traumatic rupture of … BACKGROUND Intracranial hypotension due to a CSF leak has many possible etiologies including traumatic dural tears, CSF-venous fistulas, iatrogenic causes, and elevated intracranial pressure. An example of traumatic rupture of a preexisting congenital spinal cyst (SC) in the sacrum causing a symptomatic CSF leak has not been described in the literature; therefore, the authors present the case of a 13-year-old female with a previously undiagnosed SC (Nabor type IB, sacral meningocele) found to have symptomatic intracranial hypotension following a ground-level fall. OBSERVATIONS Traumatic rupture of SCs may cause a dural tear, resulting in stigmata of intracranial hypotension. LESSONS SCs are rare entities that are often asymptomatic but should be carefully considered in the differential diagnoses for intracranial hypotension, even following low-impact trauma. Symptoms resolve with definitive treatment of dural tear, and recurrence rates are low. https://thejns.org/doi/10.3171/CASE2555

Transdural Approach for Repair of a Spontaneous Ventral Thoracic Cerebrospinal Fluid Leak Using Muscle Plug: 2-Dimensional Operative Video

2025-06-16

Edoardo Centofanti , Evgenii Belykh , Jonathan Pace | Operative Neurosurgery

Tranexamic acid vs. embolization of the meningeal artery as an adjunctive therapeutic regime to reduce the recurrence rate after surgical relief of chronic subdural hematomas (TABASCO)—a randomized controlled trial

2025-06-14

Magnus Scheer , Vanessa Beuchel , Uwe Max Mauer +2 more | Trials

Abstract Background Chronic subdural hematoma is a persistent, bloody to serous fluid retention in the subdural space between the dura mater and arachnoid mater, usually caused by an initial trauma, … Abstract Background Chronic subdural hematoma is a persistent, bloody to serous fluid retention in the subdural space between the dura mater and arachnoid mater, usually caused by an initial trauma, and is one of the most common traumatic intracranial hemorrhages in western industrialized nations. In the event of a compressive effect on the brain, the hematoma is usually relieved by means of a burr hole trephination. In view of the high postoperative recurrence rate, conservative treatment methods have been investigated both as a competitor to surgery alone in cases where the indication for surgery is debatable and as a supportive therapy for surgical hematoma relief. Studies on embolization of the middle meningeal artery during surgery as well as studies on postoperative drug therapy using tranexamic acid have shown the most promise. However, there is currently a lack of studies that randomly compare the effectiveness of these two perioperative treatment strategies regarding to their efficacy in avoiding revision surgery and the safety of the respective procedure. Methods TABASCO is a prospective, randomized, two-arm, multicenter, clinical trial designed to determine whether postoperative treatment of chronic subdural hematomas using adjuvant drug therapy with tranexamic acid (test group) is equivalent to postoperative embolization of the arteria meningea media (control group) in terms of postoperative volume reduction of the hematoma and the need for revision surgery of CSDH. Patients over 18 years of age who have undergone surgery for CSDH for the first time no more than 24 h before inclusion in the study will be randomized 1:1 to the test group or control group. The primary endpoint is the postoperative volume decrease of a primarily surgically relieved CSDH quantitatively and regarding to the time course on the affected side in a study period of 3 months postoperatively. The secondary endpoint of this study is to investigate the extent to which the rate of necessary revision surgery can be influenced by the adjuvant therapy procedures over the course of 3 months. The tertiary endpoint is the neurological outcome of the patients included in the study and assigned to the different treatment arms after a total follow-up period of 3 months as well as the complication rate of the adjuvant procedures used. Assuming a risk difference of 8% for rebleeding and surgical revision, with an applied power of 80%, 276 patients (138 per group) will be included in this study. Discussion The TABASCO study will provide clinical evidence as to whether embolization of the middle meningeal artery in addition to surgery is comparable to postoperative drug therapy using tranexamic acid as an adjuvant treatment method for operated chronic subdural hematomas in terms of hematoma volume reduction, revision rate and safety of the procedures. Trial registration German Clinical Trials Registry (Deutsches Register Klinischer Studien (DRKS)) DRKS00033515. Registered on 05 Feb 2024.

Resolution of subdural hemorrhage following interventional treatment of superior vena cava occlusion in a hemodialysis patient: a case report

2025-06-13

Qiquan Lai , Ling Chen , Xuejing Gao +2 more | Frontiers in Cardiovascular Medicine

Superior vena cava syndrome (SVCS) and nontraumatic subdural hemorrhage (SDH) were rare but severe complications in hemodialysis patients. This case report presented a 73-year-old male with end-stage renal disease (ESRD) … Superior vena cava syndrome (SVCS) and nontraumatic subdural hemorrhage (SDH) were rare but severe complications in hemodialysis patients. This case report presented a 73-year-old male with end-stage renal disease (ESRD) on long-term hemodialysis who developed SVCS due to central venous occlusion, subsequently complicated by SDH. After interventional treatment of SVCS with balloon angioplasty and stent placement in the left brachiocephalic vein and SVC, both the SVCS and SDH were resolved. This case gave hint to the pathophysiological connection between venous congestion and SDH, as the obstruction of the SVC led to increased intracranial venous pressure, contributing to SDH. Additionally, anticoagulation and dialysis-induced hemodynamic fluctuations may exacerbate the condition. This report highlights the need for timely intervention to relieve venous congestion in SVCS, which not only restores vascular access but also prevents severe neurological complications like SDH in hemodialysis patients.

Is Surgery Advocated in M1 Extradural Hematoma, or Is It Not?—A Case Report

2025-06-13

Chetan Kumar Agali | Indian Journal of Neurotrauma

Abstract Pediatric EDH (extradural hematoma) following trauma is a well-known surgical entity with early diagnosis and treatment reducing morbidity and mortality. It is custom not to suggest surgery for a … Abstract Pediatric EDH (extradural hematoma) following trauma is a well-known surgical entity with early diagnosis and treatment reducing morbidity and mortality. It is custom not to suggest surgery for a patient with traumatic EDH with a Glasgow Coma Scale (GCS) of E1M1Vt, with no cough or gauge reflux. Case history: a 5-year-old school-going girl presented with posttraumatic temporo-parietal EDH with GCS of E1M1Vt with fixed dilated right pupil. The patient denied surgery due to poor recovery and a high rate of morbidity and mortality. Hospital course: with the patient being young and just a ray of hope, surgery was performed. To a surprise, she completely recovered and was discharged with residual weakness in her left upper and lower limbs and was able to return to her daily work/school. At follow-up, she was able to perform all the daily routine work with residual weakness and required help from others to perform complex tasks. This rare case is being reported because the patient improved from M1 to M6 and returned to school, which was a rare event, and many had lost hope; even literature is scarce to justify this approach.

Intradural venous engorgement of CSF-venous fistula mimics spinal dural arteriovenous fistula on MRI: A novel case report and review of literature

2025-06-13

Bala McRae‐Posani , Ariana Thakurdyal , Marcus Konner +5 more | The Neuroradiology Journal

Engorgement of spinal intradural veins on MRI has classically been associated with spinal dural arteriovenous fistulas (sdAVF). We report a novel case of a patient who presented with worsening cognitive … Engorgement of spinal intradural veins on MRI has classically been associated with spinal dural arteriovenous fistulas (sdAVF). We report a novel case of a patient who presented with worsening cognitive impairment, whose spinal MRI demonstrated marked intradural venous engorgement in the form of serpiginous perimedullary flow voids akin to sdAVF. Further investigation led to a diagnosis of CSF-venous fistula (CVF), a sub-type of spontaneous spinal CSF leaks without an associated extradural fluid collection. This is the first reported case of CVF mimicking sdAVF on MRI. While clinical presentations of CVF and sdAVF are typically distinct, there may be overlap and/or uncertainty in atypical presentations, such as in our patient. As such, the differential for spinal intradural venous engorgement should be expanded to include spontaneous CSF leaks, including CVF.

Is length of stay for patients admitted with spontaneous subarachnoid haemorrhage an effective quality indicator?

2025-06-12

Daniel Thompson , Adam Williams , Adel Helmy | British Journal of Neurosurgery

The aim of this study is to help better understand whether length of stay (LOS) for patients admitted with spontaneous subarachnoid haemorrhage (SAH) is an appropriate quality indicator of care … The aim of this study is to help better understand whether length of stay (LOS) for patients admitted with spontaneous subarachnoid haemorrhage (SAH) is an appropriate quality indicator of care for comparison of NHS Neurosurgical department performance. We utilised Hospital Episode Statistics (HES) at a unit level to demonstrate the number of spells between 2019 and 2023 for patients presenting with spontaneous SAH as well as those that had an endovascular or microsurgical procedure to secure the aneurysm. We captured data concerning average LOS and average readmission within 30 day rates for each centre throughout the period. We demonstrated a weak relationship between shorter LOS and increased readmission rates; however, when a single outlier institutions data were removed, this relationship disappeared. The mean LOS was 25.7 days with a mean readmission rate of 4.9% for treated spontaneous SAH patients. If each centre reduced LOS to that of the shortest, there is the potential for 10,000 bed days saved per year. LOS for aneurysmal SAH patients has some promise as a quality indicator of care. We support a national quality improvement project going forwards to better understand the reasons for variation in LOS and to help eliminate unnecessary variability.

Twist-drill craniostomy with pressure-controlled fibrinolytic irrigation therapy reduces recurrence of chronic subdural hematomas: Could spontaneous intracranial hypotension be more common during chronic subdural hematomas than we diagnose?

2025-06-06

Nicolas Engrand , G Laurent | Clinical Neurology and Neurosurgery

Meningeal Embolization for Preventing Chronic Subdural Hematoma Recurrence After Surgery

2025-06-05

Eimad Shotar , Bertrand Mathon , Henri Salle +7 more | JAMA

Importance Middle meningeal artery (MMA) embolization has been proposed as a potential treatment for chronic subdural hematoma (CSDH). Objective To assess the efficacy of MMA embolization in reducing the risk … Importance Middle meningeal artery (MMA) embolization has been proposed as a potential treatment for chronic subdural hematoma (CSDH). Objective To assess the efficacy of MMA embolization in reducing the risk of CSDH recurrence at 6 months compared with standard care in patients who underwent an operation and were at high risk of CSDH recurrence. Design, Setting, and Participants Multicenter, open-label, randomized clinical trial with blinded end point assessment. Patients who underwent an operation for CSDH recurrence or a first CSDH episode at high risk of recurrence were recruited from July 2020 to March 2023 in 12 French neurosurgical or comprehensive neurosurgical and interventional neuroradiology centers. Last follow-up took place on November 2, 2023. Intervention Participants were randomized 1:1 to undergo MMA embolization with microparticles within 7 days of surgery (171 patients, intervention group) or standard medical care alone (171 patients, control group). Main Outcomes and Measures The primary end point was the rate of CSDH recurrence at 6 months assessed by an independent, blinded adjudication committee. There were 5 secondary end points, including rates of repeat surgery for homolateral CSDH recurrence during the 6-month follow-up period and embolization procedure–related complications. Results Among 342 randomized patients (median [IQR] age, 77 [68-83] years; 274 [80.1%] male), 308 (90.1%) completed the trial. The primary end point was observed in 24 of 162 (14.8%) and 33 of 157 (21.0%) patients in the intervention and control groups, respectively (after imputation: odds ratio, 0.64 [95% CI, 0.36-1.14]; adjusted absolute difference, −6% [95% CI, −14% to 2%]; P = .13). The groups did not significantly differ in any of the secondary end points. Repeat surgery was performed in 7 of 162 (4.3%) and 13 of 157 (8.3%) patients in the intervention and control groups ( P = .14), respectively. Minor and major embolization procedure–related complications occurred in 3 of 171 (1.8%) and 1 of 171 (0.6%) patients, respectively. Conclusions and Relevance In this randomized clinical trial, among patients who underwent an operation for CSDH recurrence or a first CSDH episode at high risk of recurrence, MMA embolization did not lead to a significantly lower rate of recurrence at 6 months compared with standard medical care alone. However, the magnitude of the effect estimate is consistent with other recent trials, including some that demonstrated the benefit of MMA embolization with nonadhesive liquid embolic agents, and these findings considered together may inform future studies and potential use of this therapeutic approach for CSDH management. Trial Registration ClinicalTrials.gov Identifier: NCT04372147

SPECT/CT as Gatekeeper for Extrathecal Administration on 99mTc-DTPA Cisternography

2025-06-04

Irene García-Megias , Ana María Cabada-del Rio , Jaime-Andrés Bonilla-Plaza +2 more | Clinical Nuclear Medicine

Spontaneous intracranial hypotension is an entity caused by the loss of cerebrospinal fluid (CSF) volume. Cisternography presents an adequate diagnostic performance for the detection of CSF leaks. A 32-year-old woman … Spontaneous intracranial hypotension is an entity caused by the loss of cerebrospinal fluid (CSF) volume. Cisternography presents an adequate diagnostic performance for the detection of CSF leaks. A 32-year-old woman with orthostatic headache of months of evolution, lumbar canal stenosis on magnetic resonance imaging and CSF hypotension suspicious of CSF leakage was referred to our department. Patient underwent 2 cisternographies: first was interpreted erroneously as CSF leakage being necessary procedure repetition and a retrospective review of SPECT/CT images for a correct diagnosis. This case illustrates the importance of checking the correct administration of the radiopharmaceutical with SPECT/CT for avoiding misdiagnosis.

Comparing Different Techniques in the Management of Chronic Subdural Hematoma - What is the Role of Middle Meningeal Artery Embolization?: a Systematic Review and Network Meta-Analysis

2025-06-04

Luis F Fabrini Paleare , Sávio Batista , Raphael Camerotte +7 more | Clinical Neurology and Neurosurgery