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Concept: Subdural hematoma

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INTRODUCTION: Symptomatic subdural hematoma development is a constant concern for patients who have undergone cerebrospinal fluid shunting procedures to relieve symptoms related to normal-pressure hydrocephalus. Acute subdural hematomas are of particular concern in these patients as even minor head trauma may result in subdural hematoma formation. The presence of a ventricular shunt facilitates further expansion of the subdural hematoma and often necessitates surgical treatment, including subdural hematoma evacuation and shunt ligation. CASE PRESENTATION: We present the case of a 63-year-old North American Caucasian man with normal-pressure hydrocephalus with an adjustable valve ventriculoperitoneal shunt who developed an acute subdural hematoma after sustaining head trauma. Conservative treatment was favored over operative evacuation because our patient was neurologically intact, but simple observation was considered to be too high risk in the setting of a low-pressure ventriculoperitoneal shunt. Thus, the valve setting on the ventriculoperitoneal shunt was increased to its maximum pressure setting in order to reduce flow through the shunt and to mildly increase intracranial pressure in an attempt to tamponade any active bleeding and limit hematoma expansion. A repeat computed tomography scan of the head six days after the valve adjustment revealed complete resolution of the acute subdural hematoma. At this time, the valve pressure was reduced to its original setting to treat symptoms of normal-pressure hydrocephalus. CONCLUSIONS: Programmable shunt valves afford the option for non-operative management of acute subdural hematoma in patients with ventricular shunts for normal-pressure hydrocephalus. As illustrated in this case report, increasing the shunt valve pressure may result in rapid resolution of the acute subdural hematoma in some patients.

Concepts: Traumatic brain injury, Intracranial pressure, Cerebrospinal fluid, Hydrocephalus, Subdural hematoma, Hematoma, Subdural space

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Chronic subdural hematoma (cSDH) is a common neurosurgical disease. It is often considered to be a rather benign entity. In spite of well established surgical procedures cSDH is complicated by a recurrence rate up to 30%. Since glucocorticoids have been used for treatment of cSDH in 1962 their role is still discussed controversially in lack of evident data. On the basis of the ascertained inflammation cycle in cSDH dexamethasone will be an ideal substance for a short lasting, concomitant treatment protocol.

Concepts: Medicine, Epidemiology, Asthma, Randomized controlled trial, Surgery, Efficacy, Subdural hematoma, Subdural space

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ABSTRACT Traumatic brain injury (TBI) is an important health issue with high prevalence. The most common type of TBI is mild TBI (MTBI). MTBI is known as a condition with self-limited symptoms; however, it could cause some structural abnormalities of brain and become complicated. Visible structural brain damage could have an important effect on recovery after MTBI, but the outcome is not fully understood. This study investigated the clinical course of MTBI patients with the existence of contusion in computed tomography (CT) imaging. Fifty patients with MTBI and simultaneous brain contusion in CT scan were enrolled according to specific exclusion criteria in 14 month. Patients were followed up for two weeks after their first arrival for neurosurgical interventions, decreased level of consciousness, and other neurological complications. Presence of neurological symptoms increased duration of hospital stay and number of CT scans. Forty-two percent of MTBI patients with contusion did not have any objective neurological signs. Fifty percent returned to the hospital with neurologic symptoms and signs. Leading causes were headache followed by seizure and dizziness. Rehospitalization was increased in the patients with altered level of consciousness. The size of brain contusion increased in two patients without further need for neurosurgical intervention. Contusion alone did not worsen the prognosis of patients in short-term follow-up and did not cause neurosurgical interventions.

Concepts: Brain, Traumatic brain injury, Tomographic reconstruction, Neurology, Post-concussion syndrome, Subdural hematoma, Neurotrauma, Head injury

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BACKGROUND: Spontaneous intracranial hypotension has become a well-recognized cause of headaches and a wide variety of other manifestations have been reported. Recently, several patients with asymptomatic spontaneous intracranial hypotension were reported. I now report two patients with spontaneous intracranial hypotension who developed multiple arterial strokes associated with death in one patient, illustrating the spectrum of disease severity in spontaneous intracranial hypotension. METHODS: Medical records and radiologic imaging of the two patients were reviewed. RESULTS: Case 1. A 45-year-old man presented with an orthostatic headache. Neurologic examination was normal. MRI showed bilateral subdural fluid collections, brain sagging, and pachymeningeal enhancement. At lumbar puncture, the opening pressure was too low to record. He underwent two epidural blood patches with transient improvement of symptoms. His headaches progressed and a CT-myelogram showed a lower cervical CSF leak. Subsequently, periodic lethargy and confusion was noted and he then rapidly deteriorated. Examination showed coma (GCS: 4 [E1, M2, V1]), a fixed and dilated right pupil, and decerebrate posturing. Bilateral craniotomies were performed for the evacuation of chronic subdural hematomas. Immediate postoperative CT showed bilateral posterior cerebral artery infarcts and a recurrent right subdural hematoma, requiring re-evacuation. Postoperative examination was consistent with brain death and support was withdrawn.  Case 2. A 42-year-old man presented with a non-positional headache. Neurologic examination was normal. CT showed bilateral acute on chronic subdural hematomas and effacement of the basilar cisterns. MRI showed brain sagging, bilateral subdural hematomas, and pachymeningeal enhancement. Bilateral craniotomies were performed and subdural hematomas were evacuated. Postoperatively, the patient became progressively lethargic (GCS: 8 [E2, M4, V2]) and variable degrees of pupillary asymmetry and quadriparesis were noted. MRI now also showed multiple areas of restricted diffusion in the pons and midbrain, consistent with multiple infarcts. CT showed worsening subdural fluid collections with midline shift and increased effacement of the basilar cisterns. Repeat bilateral craniotomies were performed for evacuation of the subdural fluid collections. Neurologic examination was then noted to be fluctuating but clearly improved when lying flat (GCS: 10T [E4, M6, VT]). CT-myelography demonstrated an extensive cervico-thoracic CSF leak. An epidural blood patch was performed. The patient made a good, but incomplete, recovery with residual quadriparesis and dysphagia. CONCLUSIONS: Arterial cerebral infarcts are rare, but potentially life-threatening complications of spontaneous intracranial hypotension. The strokes are due to downward displacement of the brain and can be precipitated by craniotomy for evacuation of associated subdural hematomas.

Concepts: Brain, Traumatic brain injury, Neurology, Subdural hematoma, Hematoma, Headache, Lumbar puncture, Spontaneous cerebrospinal fluid leak

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To compare the efficacy and safety of multiple treatment modalities for the management of chronic subdural hematoma (CSDH) patients.

Concepts: Meta-analysis, Subdural hematoma

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: Postpartum hematomas are a potentially serious obstetric complication for which management options are not standardized. We report successful treatment of a large postpartum hematoma using arterial embolization as primary approach.

Concepts: Surgery, Embolization, Subdural hematoma, Hematoma

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Approximately 75% of traumatic brain injuries (TBI) are classified mild (mTBI). Despite the high frequency of mTBI, it is the least well studied. The prevalence of mTBI among service personnel returning from Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) and the recent reports of an association between repeated mTBI and the early onset of Alzheimer’s and other types of dementias in retired athletes has focused much attention on mTBI. The study of mTBI requires the development and validation of experimental models of mTBI and one of the most basic requirements for an experimental model is that it replicates important features of the injury or disease in humans. mTBI in humans is associated with acute symptoms such as loss of consciousness and pre- and/or posttraumatic amnesia. In addition, although the majority of patients recover within a few months after mTBI, a small but significant number (2.5 - 26%) had Glasgow Outcome Scores in the “moderate disability” range. These mTBI patients experienced long-term effects of mTBI including deficits in speed of information processing, attention and concentration, memory acquisition, retention and retrieval and reasoning and decision-making. Although methods for the diagnosis and evaluation of the acute and chronic effects of mTBI in humans are well established, the same is not the case for rodents, the most widely used animal for TBI studies. Despite the magnitude of the difficulties associated with adapting these methods for experimental mTBI research, they must be surmounted. The identification and testing of treatments for mTBI depends of the development, characterization and validation of reproducible, clinically relevant models of mTBI.

Concepts: Traumatic brain injury, Model organism, Dementia, Injury, Post-concussion syndrome, Subdural hematoma, Concussion, Post-traumatic amnesia

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Concussion in children is frequently related to participation in sports. It requires a traumatic event to occur that transmits acceleration to the brain. Some children may have intrinsic risk factors that place them at greater risk for this type of injury. Comorbidities such as attention-deficit/hyperactivity disorder, migraine headaches, and mood disorders may place athletes at increased risk of more severe injury. A previous concussion is probably the most important influence on risk for future injury. Extrinsic risk factors include coaching techniques, officiating, and choice of sport. Helmet choice does not diminish concussion risk, nor does the use of mouth guards. Education of athletes, coaches, parents, and physicians is very important in improving recognition of potential concussive injury and helping child athletes and their parents understand the risks involved in sport participation. [Pediatr Ann. 2014;43(12):e309-e315.].

Concepts: Risk, Traumatic brain injury, Injury, Mental disorder, Subdural hematoma, Concussion, Head injury

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Neuropsychological follow-up appointments are important for patients who have had intracranial surgery because cognitive deficits are common in this population and prognosis is not always optimistic. Unfortunately some patients cancel or do not show up. The current study attempted to identify predictors of non-attendance in this population. A total of 428 patients recruited over 2 years with a scheduled neuropsychological follow-up appointment after intracranial surgery in the St. Elisabeth Hospital, Tilburg, The Netherlands were included. Demographic, clinical, and other miscellaneous variables were extracted from medical records. Of this total population, 42% were non-attenders. The predictors of non-attendance were as follows: patients who had subdural hematomas and/or malignant tumors (compared to those who had other diagnoses prior to intracranial surgery); those who had been transferred to another hospital (compared to those sent home); those who had been referred for further medical treatment before the appointment; a shorter time interval between discharge and follow-up appointment; and finally, if the patient’s home was further away from the hospital. Patients who undergo intracranial surgery are a very heterogeneous group with different needs. Neuropsychological follow-up after surgery may be important for some patients (the better-functioning and/or those with cognitive complaints) but perhaps not for others (those with more severe prognoses and/or no complaints). We provide suggestions which should increase attendance in those who could benefit from follow-up neuropsychological assessment.

Concepts: Medicine, Cancer, Oncology, Patient, Hospital, Surgery, Physician, Subdural hematoma

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OBJECT This report describes the stereotactic technique, hospitalization, and 90-day perioperative safety of bilateral deep brain stimulation (DBS) of the fornix in patients who underwent DBS for the treatment of mild, probable Alzheimer’s disease (AD). METHODS The ADvance Trial is a multicenter, 12-month, double-blind, randomized, controlled feasibility study being conducted to evaluate the safety, efficacy, and tolerability of DBS of the fornix in patients with mild, probable AD. Intraoperative and perioperative data were collected prospectively. All patients underwent postoperative MRI. Stereotactic analyses were performed in a blinded fashion by a single surgeon. Adverse events (AEs) were reported to an independent clinical events committee and adjudicated to determine the relationship between the AE and the study procedure. RESULTS Between June 6, 2012, and April 28, 2014, a total of 42 patients with mild, probable AD were treated with bilateral fornix DBS (mean age 68.2 ± 7.8 years; range 48.0-79.7 years; 23 men and 19 women). The mean planned target coordinates were x = 5.2 ± 1.0 mm (range 3.0-7.9 mm), y = 9.6 ± 0.9 mm (range 8.0-11.6 mm), z = -7.5 ± 1.2 mm (range -5.4 to -10.0 mm), and the mean postoperative stereotactic radial error on MRI was 1.5 ± 1.0 mm (range 0.2-4.0 mm). The mean length of hospitalization was 1.4 ± 0.8 days. Twenty-six (61.9%) patients experienced 64 AEs related to the study procedure, of which 7 were serious AEs experienced by 5 patients (11.9%). Four (9.5%) patients required return to surgery: 2 patients for explantation due to infection, 1 patient for lead repositioning, and 1 patient for chronic subdural hematoma. No patients experienced neurological deficits as a result of the study, and no deaths were reported. CONCLUSIONS Accurate targeting of DBS to the fornix without direct injury to it is feasible across surgeons and treatment centers. At 90 days after surgery, bilateral fornix DBS was well tolerated by patients with mild, probable AD. Clinical trial registration no.: NCT01608061 ( clinicaltrials.gov ).

Concepts: Alzheimer's disease, Clinical trial, Hospital, Surgery, Physician, Neurology, Deep brain stimulation, Subdural hematoma