Fibrosis ; Hematoma, Subdural ; Humans ; Osteogenesis ; Subdural Space ; Tomography, X-Ray Computed

Subarachnoid hemorrhage (SAH) usually occurs due to aneurysmal rupture of intracranial arteries and its typical computed tomography (CT) findings are increased attenuation of cisterns and subarachnoid spaces. However, several CT findings mimicking SAH are feasible in diverse conditions. They are so-called as pseudo-SAH, and this report is a case of pseudo-SAH which is misdiagnosed as aneurysm rupture accompanied by bilateral chronic subdural hematoma (cSDH). A 42-year-old male with severe headache visited our institute. Non-contrast brain CT images showed increased attenuation on basal cistern, and cSDH on both fronto-temporo-parietal convexity with midline shifting. Trans-femoral cerebral angiography was done and we confirmed small aneurysm at right M1 portion of middle cerebral artery. Under diagnosis of SAH, we planned an operation in order to clip aneurysmal neck and remove cSDH. cSDH was removed as planned, however, there was no SAH and we also couldn't find the rupture point of aneurysm. Serial follow-up CT showed mild cumulative cSDH recurrence, but the patient was tolerant and had no neurologic deficit during hospitalization. We have checked the patient via out-patient department for 6 months, there are no significant changes in volume and density of cSDH and the patient also have no neurologic complications.
Adult ; Aneurysm ; Arteries ; Brain ; Brain Edema ; Cerebral Angiography ; Diagnosis ; Follow-Up Studies ; Headache ; Hematoma, Subdural, Chronic ; Hemorrhage ; Hospitalization ; Humans ; Intracranial Hypertension ; Male ; Middle Cerebral Artery ; Neck ; Neurologic Manifestations ; Outpatients ; Recurrence ; Rupture ; Subarachnoid Hemorrhage ; Subarachnoid Space

We report 3 cases of arachnoid cysts (ACs) that completely disappeared after burr hole drainage, without cyst fenestration into the subarachnoid space or cystoperitoneal shunt. The first patient was a 21-year-old female with an AC of the right cerebral convexity, found incidentally. After endoscopic AC fenestration was performed, the patient complained of persistent headache. Two-month postoperative brain imaging revealed reaccumulated AC and associated multi-stage subdural hematoma. Burr hole drainage was performed to resolve the chronic subdural hematoma (CSDH). Three months later, brain computed tomography showed that the CSDH and the AC had disappeared. The second patient was an 11-year-old male who had a history of trauma 1 month prior to presentation at the clinic. Brain magnetic resonance imaging revealed an AC in the left sylvian fissure with CSDH. We performed burr hole drainage to treat the CSDH first. Subsequently, the AC as well as the CSDH disappeared. The third case was an AC of the right parietal convexity, found incidentally. Only burr hole drainage was performed, following which, the AC disappeared. This case series shows that an AC can disappear naturally after rupture into the subdural space by trauma or the burr hole procedure.
Arachnoid Cysts ; Arachnoid ; Brain ; Child ; Drainage ; Female ; Headache ; Hematoma, Subdural ; Hematoma, Subdural, Chronic ; Humans ; Magnetic Resonance Imaging ; Male ; Neuroimaging ; Rabeprazole ; Rupture ; Subarachnoid Space ; Subdural Space ; Trephining ; Young Adult

Treatment of chronic subdural hematoma (CSDH) is relatively straightforward, however, there is still some debate regarding the best strategy for treatment. The most practical recommendations of up to date were identified by a review of literature. The author reviewed the literature on CSDH management from the past to now to identify the best methods. Till 1970s, craniotomy was the most commonly used method. Burr hole (BH) became the most preferred method from 1980s. In 1977, twist drill (TD) craniostomy was introduced. Closed system drainage after a BH or a TD became the most frequently used surgical method. Although nonsurgical treatment is often successful, trephination has more advantages, such as rapid resolution of the symptoms and short period of hospitalization. Nonsurgical treatment is possible in asymptomatic patients with a small CSDH. For the symptomatic patients with CSDH, trephination is the treatment of choice, either by BH or TD. In gray zone between surgery and medical treatment, shared decision making can be an ideal approach. For the recurrent CSDHs, repeated trephination is still effective for patients with a low risk of recurrence. If the risk of recurrence is high, additional management would be helpful. For the refractory CSDHs, it is necessary to obliterate the subdural space.
Craniocerebral Trauma ; Craniotomy ; Decision Making ; Drainage ; Hematoma, Subdural, Chronic ; Hospitalization ; Humans ; Methods ; Recurrence ; Subdural Space ; Trephining

Subdural hematoma (SDH) due to spontaneous rupture of intracranial aneurysm rarely occurs. The prevalence of subarachnoid hemorrhage (SAH) with SDH is approximately 0.5%–10.3% of all aneurysmal SAH. We report a case of aneurysmal rupture with SDH and SAH due to arachnoid defect after aneurysm clipping. The decedent was a 51-year-old woman who underwent brain surgery for SAH a few years ago. Two days before she died, she had nausea and sentinel headache. She was alive in the morning and was found dead at 6 PM. Injuries in the external surface were not found. A fresh SDH, measured approximately 90 mL, was found in the right hemisphere. SAH was diffusely distributed at the base of the brain and the right sylvian fissure. Two aneurysmal clippings were found in the anterior communicating artery and right internal carotid artery. A ruptured de novo aneurysm was also found in the right proximal middle cerebral artery. An uncal herniation was also observed. The cause of death was SAH with SDH due to de novo intracranial aneurysm. The tearing caused by the adhesion between the aneurysm and arachnoid, high blood pressure, and massive bleeding has been thought to be the causative mechanism of aneurysmal SAH with SDH. However, in this case, the arachnoid defect was caused by aneurysmal clipping through pterional approach. This defect served as the passage between the subarachnoid and subdural spaces. The autopsy for recurrent intracranial aneurysm will increase according to the extending life expectancy of patients after aneurysmal clipping.
Aneurysm ; Arachnoid ; Arteries ; Autopsy ; Brain ; Carotid Artery, Internal ; Cause of Death ; Female ; Headache ; Hematoma, Subdural ; Hemorrhage ; Humans ; Hypertension ; Intracranial Aneurysm ; Life Expectancy ; Middle Aged ; Middle Cerebral Artery ; Nausea ; Prevalence ; Rupture ; Rupture, Spontaneous ; Subarachnoid Hemorrhage ; Subdural Space ; Tears

Superficial siderosis results from the deposition of hemosiderin in subpial layers of the central nervous system following hemorrhage in subarachnoid spaces. Infratentorial superficial siderosis (ISS) presents with unique clinical features including progressive hearing loss, ataxia, and myelopathy, and the most common cause of idiopathic ISS is dural abnormality. Here we report a case of idiopathic ISS with radiological findings of spontaneous intracranial hypotension, whose clinical symptoms of ISS including cerebellar dysfunction improved after supine position was maintained for 2 months.
Ataxia ; Central Nervous System ; Cerebellar Diseases ; Hearing Loss ; Hemorrhage ; Hemosiderin ; Intracranial Hypotension ; Siderosis ; Spinal Cord Diseases ; Subarachnoid Space ; Subdural Effusion ; Supine Position

Chronic subdural hematoma (CSDH) and symptomatic subdural hygroma are common diseases that require neurosurgical management. Burr hole trephination is the most popular surgical treatment for CSDH and subdural hygroma because of a low recurrence rate and low morbidity compared with craniotomy with membranectomy, and twist-drill craniotomy. Many reports suggest that placing a catheter in the subdural space for drainage can further reduce the rate of recurrence; however, complications associated with this type of drainage include acute subdural hematoma, cortical injury, and infection. Remote hemorrhage due to overdrainage of cerebrospinal fluid (CSF) is another possible complication of burr hole trephination with catheter drainage that has rarely been reported. Here, we present 2 cases of remote hemorrhages following burr hole trephination with catheter drainage for the treatment of CSDH and symptomatic subdural hygroma. One patient developed intracerebral hemorrhage and subarachnoid hemorrhage in the contralateral hemisphere, while another patient developed remote hemorrhage 3 days after the procedure due to the sudden drainage of a large amount of subdural fluid over a 24-hour period. These findings suggest that catheter drainage should be carefully monitored to avoid overdrainage of CSF after burr hole trephination.
Catheters ; Cerebral Hemorrhage ; Cerebrospinal Fluid ; Craniotomy ; Drainage* ; Hematoma, Subdural, Acute ; Hematoma, Subdural, Chronic* ; Hemorrhage* ; Humans ; Recurrence ; Subarachnoid Hemorrhage ; Subdural Effusion ; Subdural Space ; Trephining

OBJECTIVE: The aim of this study is to analyze the differences in the incidence, predicting factors, and clinical course of chronic subdural hematoma (CSDH) following surgical clipping between unruptured (UIA) and ruptured intracranial aneurysm (RIA). METHODS: We conducted a retrospective analysis of 752 patients (UIA : 368 and RIA : 384) who underwent surgical clipping during 8 years. The incidence and predicting factors of CSDH development in the UIA and RIA were compared according to medical records and radiological data. RESULTS: The incidence of postoperative CSDH was higher in the UIA (10.9%) than in the RIA (3.1%) (p=0.000). In multivariate analysis, a high Hounsfield (HF) unit (blood clots) for subdural fluid collection (SFC), persistence of SFC ≥5 mm and male sex in the UIA and A high HF unit for SFC and SFC ≥5 mm without progression to hydrocephalus in the RIA were identified as the independent predicting factors for CSDH development (p<0.05). CONCLUSION: There were differences in the incidence and predicting factors for CSDH following surgical clipping between UIA and RIA. Blood clots in the subdural space and persistence of SFC ≥5 mm were predicting factors in both UIA and RIA. However, progression to hydrocephalus may have in part contributed to low CSDH development in the RIA. We suggest that cleaning of blood clots in the subdural space and efforts to minimize SFC ≥5 mm at the end of surgery is helpful to prevent CSDH following aneurysmal clipping.
Aneurysm ; Hematoma, Subdural, Chronic* ; Humans ; Hydrocephalus ; Incidence ; Intracranial Aneurysm* ; Male ; Medical Records ; Multivariate Analysis ; Retrospective Studies ; Subdural Space ; Surgical Instruments*

Chronic subdural hematomas (CSHs) are generally regarded to be a traumatic lesion. It was regarded as a stroke in 17th century, an inflammatory disease in 19th century. From 20th century, it became a traumatic lesion. CSH frequently occur after a trauma, however, it cannot occur when there is no enough subdural space even after a severe head injury. CSH may occur without trauma, when there is sufficient subdural space. The author tried to investigate trends in the causation of CSH. By a review of literature, the author suggested a different view on the causation of CSH. CSH usually originated from either a subdural hygroma or an acute subdural hematoma. Development of CSH starts from the separation of the dural border cell (DBC) layer, which induces proliferation of DBCs with production of neomembrane. Capillaries will follow along the neomembrane. Hemorrhage would occur into the subdural fluid either by tearing of bridge veins or repeated microhemorrhage from the neomembrane. That is the mechanism of hematoma enlargement. Trauma or bleeding tendency may precipitate development of CSH, however, it cannot lead CSH, if there is no sufficient subdural space. The key determinant for development of CSH is a sufficient subdural space, in other words, brain atrophy. The most common and universal cause of brain atrophy is the aging. Modifying Virchow's description, CSH is sometimes traumatic, but most often caused by degeneration of the brain. Now, it is reasonable that degeneration of brain might play pivotal role in development of CSH in the aged persons.
Aging ; Atrophy ; Brain ; Capillaries ; Classification ; Craniocerebral Trauma ; Hematoma ; Hematoma, Subdural, Acute ; Hematoma, Subdural, Chronic* ; Hemorrhage ; Humans ; Intracranial Pressure ; Stroke ; Subdural Effusion ; Subdural Space ; Tears ; Veins

Subdural hematoma is a common disease of intracranial hemorrhage that accounts for 11-21% of all head trauma patients. It is defined as a hematoma that develops between dura mater and subarachnoid space. In elder patients, mild trauma may not always be accurately recognized and symptoms may not develop slowly due to the large area of subdural space. Headache is the most common symptom of subdural hematoma and may be associated with hemiplegia, dysarthria, sensation disorder, conscious disorder, and etc. We present, with a literature review, a case of a patient who developed subacute subdural hematoma after performing Brandt-Daroff habituation exercise to treat benign paroxysmal positional vertigo.
Benign Paroxysmal Positional Vertigo ; Craniocerebral Trauma ; Dura Mater ; Dysarthria ; Headache ; Hematoma ; Hematoma, Subdural* ; Hemiplegia ; Humans ; Intracranial Hemorrhages ; Sensation Disorders ; Subarachnoid Space ; Subdural Space